Buparvaquone Induces Ultrastructural and Physiological Alterations Leading to Mitochondrial Dysfunction and Caspase-Independent Apoptotic Cell Death in Leishmania donovani.

Leishmaniasis is a neglected tropical disease (endemic in 99 countries) caused by parasitic protozoa of the genus Leishmania. As treatment options are limited, there is an unmet need for new drugs. The hydroxynaphthoquinone class of compounds demonstrates broad-spectrum activity against protozoan parasites. Buparvaquone (BPQ), a member of this class, is the only drug licensed for the treatment of theileriosis. BPQ has shown promising antileishmanial activity but its mode of action is largely unknown. The aim of this study was to evaluate the ultrastructural and physiological effects of BPQ for elucidating the mechanisms underlying the in vitro antiproliferative activity in Leishmania donovani. Transmission and scanning electron microscopy analyses of BPQ-treated parasites revealed ultrastructural effects characteristic of apoptosis-like cell death, which include alterations in the nucleus, mitochondrion, kinetoplast, flagella, and the flagellar pocket. Using flow cytometry, laser scanning confocal microscopy, and fluorometry, we found that BPQ induced caspase-independent apoptosis-like cell death by losing plasma membrane phospholipid asymmetry and cell cycle arrest at sub-G0/G1 phase. Depolarization of the mitochondrial membrane leads to the generation of oxidative stress and impaired ATP synthesis followed by disruption of intracellular calcium homeostasis. Collectively, these findings provide valuable mechanistic insights and demonstrate BPQ's potential for development as an antileishmanial agent.

10-degree reverse Trendelenburg position on hemodynamic parameters and block characteristics in unilateral spinal anesthesia in below knee orthopedic surgeries - can head up position do the trick?

Unilateral spinal anesthesia (USpA) is a technique used to restrict the effect of the spinal block on the operative side. 10-15 degrees reverse Trendelenburg position has been used to control the height of the spinal block using hyperbaric drugs. We aimed to study the effect of the 10-degree reverse Trendelenburg position on the quality of block and hemodynamic stability in unilateral spinal anesthesia in this hospital-based, double-blind, randomized clinical trial. 60 patients of both sexes between 20-60 years of age, undergoing below-knee orthopedic surgeries, were randomized into 2 groups. In both groups, spinal anesthesia was given with 2 mL bupivacaine heavy (0.5%), and the lateral position was maintained for 10 mins. Group 2 patients were kept in a 10-degree reverse Trendelenburg position throughout the surgery. The hemodynamic parameters and block characteristics of the two groups were compared using Epi Info statistical software. The onset of sensory block was faster in Group 1 (recumbent) compared to Group 2 (reverse Trendelenburg). The two-segment regression time was longer in the second group. In group 2, 73.3% of patients reached a level at T8 or below T8, compared to 46.7% in Group 1. The duration of sensory block and anesthesia was longer in Group 2. We conclude that reverse Trendelenburg of 10 degrees immediately after spinal anesthesia significantly limits the level of sensory block and prolongs the duration of unilateral spinal anesthesia.

Investigating the Effect of the 10° Reverse Trendelenburg Position on Spinal Block Characteristics and Hemodynamic Parameters in Lower Limb Surgeries.

INTRODUCTION: The primary goal of spinal anesthesia in lower limb surgeries is to achieve a successful sensory and motor block. Adequate level of spinal block for lower limb orthopedic surgery is T10. Due to multiple factors affecting the level of spinal anesthesia, it is not always easy to control the level of spinal anesthesia.We proposed that maintaining patients in a 10° reverse Trendelenburg position after spinal anesthesia can significantly control the height of the sensory block, resulting in stable hemodynamics. MATERIALS AND METHODS: This study is a single centric, prospective, single-blinded randomized clinical trial (CTRI/2018/08/015455) conducted in a tertiary care center in Sub-Himalayan region in India from July 2018 to June 2019. Total 60 patients fulfilling our inclusion and exclusion criteria were recruited in the study and were divided into two groups. In the supine group, patients were positioned in the supine position, and in the Trendelenburg group, patients were positioned in a 10° reverse Trendelenburg position after administering spinal anesthesia with 12.5 mg bupivacaine heavy. The two groups were compared in terms of sensory block, motor block, and analgesia duration. Heart rate, blood pressure, mean arterial pressure, and hypotension were also compared between the two groups. RESULTS: Duration of sensory block, motor block, and analgesia were significantly higher in patients of the reverse Trendelenburg group (group T) compared to the supine group (group S). In group T, 26.6% had a sensory block level above T8, whereas in group S, 86.6% of patients had a sensory block level above T8. No hypotension was observed in the Trendelenburg group, which was present in 33% of patients in the supine group (group S). CONCLUSION: Ten-degree reverse Trendelenburg position immediately after giving spinal anesthesia significantly limits the level of sensory block and provides better hemodynamic stability, and can be more beneficial, especially in geriatric patients and other high-risk patients for lower limb surgeries.

Morphometric Study of Lower End Femur by Using Helical Computed Tomography.

BACKGROUND: A mismatch between the prosthesis size and bone may result in a number of complications. Keeping this in view, it is essential to analyze the morphological differences of the knee observed across various ethnic groups to improve the performance of total knee arthroplasty (TKA). The current study was aimed at studying the computed tomography (CT) profile of distal femur in Indian population and evaluates it morphologically. MATERIALS AND METHODS: This descriptive study was conducted on 62 patients presenting to the Department of Orthopedics in a tertiary care center in rural north-west India for features suggestive of osteoarthritis and trauma of knee from September 17, 2015 to September 16, 2016. Helical CT of both knees was done, and the data were analyzed using Statistical Package for Social Sciences Version 17.0 statistical significance was assessed with the help of t-test and the value of P < 0.05 was considered to be statistically significant. RESULTS: The mean mediolateral (ML) value in male patients was 72.74 ± 4.45 while the mean ML value in female patients was lower (63.59 ± 2.61). The mean anteroposterior (AP) value in male patients was significantly (statistically) higher (49.62 ± 3.86) in comparison to mean AP value in female patients (45.11 ± 4.4). The mean anterior lateral condylar height (ALCH) value in male patients was higher (17.53 ± 2.72) in comparison to mean ALCH value in female patients (14.63 ± 3.42). CONCLUSIONS: The current study highlights the need to develop components and implants for use in TKA and fractures of distal femur keeping the age- and sex-specific anatomical features of people of different ethnic origins in view.

Game change in Indian Health Care System through reforms in medical education curriculum focusing on primary care- Recommendations of a joint working group.

Despite the stated aim of Medical Council of India (body regulating medical education in India) to produce an Indian Medical Graduate with requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a doctor of first contact of the community while being globally relevant, it appears that we failed. The joint working group extensively consisting of medical teachers have come up with suggestions which may work as the game changer in Indian Health care system. The key is to dedicate medical education towards primary care.

In vitro leishmanicidal effects of the anti-fungal drug natamycin are mediated through disruption of calcium homeostasis and mitochondrial dysfunction.

Natamycin, a Food and Drug Administration approved anti-fungal drug, and also used as a food additive was evaluated for anti-leishmanial activity since it is known to specifically bind to ergosterol, which is essential to these parasites but absent in mammals. Promising anti-proliferative activity was observed in both promastigote and amastigote forms of the parasite with IC50 values of 15 and 8 µM respectively and a selective index of 12.5. The ultrastructural effects of natamycin on both forms of the parasite and physiological effects on promastigotes were studied in detail for the first time. Electron microscopic observations in treated cells revealed sub-cellular changes like plasma membrane alterations, accumulation of vesicles in the flagellar pocket and extensive mitochondrial damage. Natamycin treatment in promastigotes resulted in elevation of cytosolic calcium (Ca2+) levels which caused irreversible loss of mitochondrial membrane potential. This resulted in depletion of cellular ATP levels along with ROS generation finally leading to apoptosis-like and necrotic cell death. In view of our observations along with the safety profile of an existing anti-fungal drug, natamycin may be further investigated for repurposing it as a promising drug candidate against Leishmaniasis.

Anterior Glenohumeral Dislocation with Ipsilateral Shaft humerus fracture- A Rare Co-Occurence; Case Report from Hills of North-India.

INTRODUCTION: Combination of Anterior Glenohumeral Dislocation with Ipsilateral Shaft humerus fracture is an rare co-occurrence and guidelines of its management are lacking. It is a rare opportunity for orthopaedic surgeon to observe simultaneous shoulder dislocation with ipsilateral humeral shaft fracture. There has been a total of around twenty cases reported since 1940. CASE PRESENTATION: A case of elderly female with medical co-morbidities who sustained this injury while working in wheat farms. She presented with complaints of pain and swelling in right arm with inability to move right arm. She was diagnosed as a case of ipsilateral fracture of proximal humerus with anterior glenohumeral dislocation. She was successfully treated with open reduction and internal fixation (ORIF) for fracture shaft humerus with long proximal humerus locking plate, because of proximal extension of long oblique fracture line using standard delto-pectoral approach with anterolateral distal extension of surgical approach after visualising radial nerve. Following fixation of shaft, close reduction was carried out for anterior shoulder dislocation under image intensifier. Patient was put on regular physiotherapy and follow up at 4 weekly interval for a period of 3 months and subsequently bimonthly interval upto 1 year. Patient achieved near normal and pain- free range of motion at 1 year. CONCLUSION: Anterior Glenohumeral Dislocation with Ipsilateral Shaft humerus fracture, can be easily missed clinically in obese patients. Close reduction is possible after attaining adequate lever arm by fixing shaft followed by attempt to reduce dislocation. Meticulous surgical technique coupled with dedicated and supervised physiotherapy is essential to bring out good functional outcome.

New visible light excitable donor-acceptor 7-hydroxy-coumarins as blue fluorescent probes for selective staining of vacuoles in yeasts and L. donovani.

In order to address the existing limitations of the commercially available fluorescent probe CMAC (7-amino-4-chloromethylcoumarin), a new series of highly fluorescent donor-acceptor 7-hydroxy-coumarin derivatives was prepared and these derivatives were used as vacuole specific fluorescent probes for live cell imaging of unicellular parasitic protozoa L. donovani promastigotes and yeast cells S. pombe and S. cerevisiae. The synthesized 7-hydroxy-coumarins exhibited interesting photophysical properties and have advantages such as excitation in the visible region, good water solubility, photo-stability, good quantum yield and low cytotoxicity.

Outcome Analysis of Hemiarthroplasty vs. Total Hip Replacement in Displaced Femoral Neck Fractures in the Elderly.

INTRODUCTION: Management of displaced fracture neck femur in the elderly population is frequently done by Hemiarthroplasty or Total Hip Replacement (THR). It avoids high rates of nonunion and avascular necrosis which usually occur after internal fixation of neck femur fractures in this age group. AIM: The present study aimed to evaluate patient function and complications following hemiarthroplasty and total hip replacement in elderly population with displaced femoral neck fractures. MATERIALS AND METHODS: Patients above 60 years of age with displaced fracture neck femur were studied over the period of four years. All the clinical parameters and co-morbid conditions were noted at the time of presentation. The patients associated with co-morbid conditions and underlying pathology were excluded from study. Garden's classification was used for classification of neck femur fractures. After due informed consent patients of displaced fracture neck femur were randomized by simple randomization and allocated for hemiarthroplasty or THR. Antibiotics were given preoperatively at the time of induction and postoperatively for 5-7 days. Surgery was carried out by Modified Gibson approach. Any complications during pre and postoperative period were noted. Follow-up of patients was done 1 month, 3 months, 6 months and 1 year interval with the help of Harris hip score. RESULTS: Total 80 patients were enrolled in the study group, with 40 patients in each group. The mean age of patients was 73 years in hemiarthroplasty group and 78 years in THR group. Female to male ratio was 55:45. Mean operative time was 35 minutes in hemiarthroplasty group and 45 minutes in THR. Average intraoperative blood loss was 200cc and 300cc in hemiarthroplasty and THR respectively. The mean hospital stay was 14 days in both the groups. Superficial wound infection was noted in hemiarthroplasty group while in THR group deep wound infection (n=1) and prolonged ICU stay (n=1) were noted. The mean Harris hip score was better in THR group as compared to Hemiarthroplasty group at one year follow-up. CONCLUSION: In elderly patients with fracture neck femur hemiarthroplasty takes less operative time, less blood loss per operatively and few complications postoperatively as compared to THR. The functional outcome at one year is better with THR as compared to hemiarthroplasty.

Plumbagin, a plant-derived naphthoquinone metabolite induces mitochondria mediated apoptosis-like cell death in Leishmania donovani: an ultrastructural and physiological study.

Naphthoquinones are known to exhibit a broad range of biological activities against microbes, cancer and parasitic diseases and have been widely used in Indian traditional medicine. Plumbagin is a plant-derived naphthoquinone metabolite (5-hydroxy-2-methyl-1,4-naphthoquinone) reported to inhibit trypanothione reductase, the principal enzyme and a validated drug target involved in detoxification of oxidative stress in Leishmania. Here, we report the mechanistic aspects of cell death induced by plumbagin including physiological effects in the promastigote form and ultrastructural alterations in both promastigote and amastigote forms of Leishmania donovani which till now remained largely unknown. Our observations show that oxidative stress induced by plumbagin resulted in depolarization of the mitochondrial membrane, depletion in ATP levels, elevation of cytosolic calcium, increase in caspase 3/7-like protease activity and lipid peroxidation in promastigotes. Apoptosis-like cell death induction post plumbagin treatment was confirmed by biochemical assays like Annexin V/FITC staining, TUNEL as well as morphological and ultrastructural studies. These findings collectively highlight the mode of action and importance of oxidative stress inducing agents in effectively killing both forms of the Leishmania parasite and opens up the possibility of exploring plumbagin and its derivatives as promising candidates in the chemotherapy of Leishmaniasis.

A Very Rare Presentation of Type 1 Monteggia Equivalent Fracture with Ipsilateral Fracture of Distal Forearm-approach with Outcome: Case Report.

INTRODUCTION: We report a case of Type 1 Monteggia equivalent injury with intact radio-capitellar congruity, associated with epiphyseal fracture of distal radius and distal ulna shaft in an 11-year-old boy. There are only a few cases of Monteggia or Monteggia equivalent injury with ipsilateral forearm fractures in children, and injury pattern being reported by us is not only rare but also the only case reported thus far to the best of our knowledge, Sood et al. described Type 1 equivalent with epiphyseal injuries of both radius and ulna Osada et al. also described injury pattern same as Sood et al. with epiphyseal separation in both distal radius and ulna. Our case was slightly different than above two in that distally, there was ulna shaft fracture with Salter Harris Type 2 epiphyseal separation in the radius. CASE REPORT: An 11-year-old, right-hand dominant boy presented in casualty with a history of fall one day back with pain, swelling and deformity in the left forearm with bleeding from left forearm and loss of movement of fingers and thumb of the left hand. On examination, there was a wound of size one centimeter on mid-forearm over the ulnar aspect. Extension of fingers and thumb at metacarpophalangeal joints was lost with intact sensations suggestive of posterior interosseus nerve involvement. No vascular was deficit was present. X-rays were performed which suggested type two epiphyseal separation proximal radius with fracture shaft ulna with lateral angulation in elbow and proximal forearm. Radiocapitellar joint congruity was maintained in the views performed. X-rays of wrist suggested fracture both bones distal forearm epiphysis in distal radius and distal shaft in ulna. The patient was operated with toileting, debridement, and open reduction of proximal ulnar fracture with K-wire. Proximal radius epiphyseal separation was approached by Kocher approach and fixed with two K-wires, while for distal radius epiphyseal separation open reduction and internal fixation was performed. Follow-up of the patient showed posterior interosseus nerve recovery and subsequent union of all fractures with good functional outcome. CONCLUSION: This type of lesion is rare in children probably because the annular ligament is relatively lax and the radial head dislocates more easily anteriorly, rather than occurrence of fracture as seen in our case, and associated fracture of distal forearm is a very rare injury.

A very rare Presentation of Bifocal Non Union Radius with Ipsilateral Ulnar Shaft Non Union: Case Report.

INTRODUCTION: A bifocal non-union of shaft of radius associated with ipsilateral non-union shaft of ulna in an adult has not been reported in the literature till date to the best of our knowledge, though few similar cases of fresh fractures have been reported. The case being reported by us is the first of its kind. CASE PRESENTATION: We report a case of bifocal non-union of shaft radius with non-union ipsilateral shaft of ulna in a 48-year-old right handed male along with discussion of alternative treatment options. CONCLUSION: We describe an extremely rare and complicated non-union in which our patient got excellent results along with satisfactory functional recovery as a result of appropriate surgical treatment.

Synchronous Lipoma arborescens of bilateral wrist: An extremely rare manifestation and a new perspective on etiopathogenesis.

Lipoma arborescens is a rare lesion wherein abnormal proliferation of adipocytes in the subsynovial region is seen. Whether it is neoplastic or not is still not entirely clear. Usually, Lipoma arborescens is seen unilaterally around knee joint but it can also be seen around tendon sheaths or bursa in adults. Multiple lesions are also reported. Involvement of wrist is extremely rare. We are presenting a case with bilateral wrist involvement by Lipoma arborescens which to the best of our knowledge is first one in English literature. There are a host of co-morbid/associated conditions reported with Lipoma arborescens out of which chronic irritation and inflammation appears to be most significant. We are proposing a novel perspective on etiopathogenesis of Lipoma arborescens based on extant understanding of cellular differentiation and information gleaned from fetal autopsies. The new perspective also explains the predilection for knee joint.

Formative assessment in postgraduate medical education - Perceptions of students and teachers.

CONTEXT: One of the most important factors of medical education that can revolutionize the learning process in postgraduate students (PGs) is assessment for learning by means of formative assessment (FA). FA is directed at steering and fostering learning of the students by providing feedback to the learner. However, though theoretically well suited to postgraduate training, evidence are emerging that engaging stakeholders in FA in daily clinical practice is quite complex. AIMS: To explore perceptions of PGs and teachers (Ts) about factors that determines active engagement in FA. SUBJECTS AND METHODS: It was a descriptive qualitative study involving focus group discussions (FGDs) with PGs and Ts from Departments of Pediatrics and Orthopedics. FGDs data were processed through points/remarks, data reduction, data display, coding followed by theme generation for content analysis. RESULTS: Four higher order themes emerged: Harsh reality of present summative assessment structure, individual perspectives on feedback, supportiveness of the learning environment, and the credibility of feedback and/or feedback giver. CONCLUSIONS: Engaging in FA with a genuine impact on learning is complex and quite a challenge to both students and Ts. Increased acceptability along with the effective implementation of FA structure, individual perspectives on feedback, a supportive learning environment and credibility of feedback are all important in this process. Every one of these should be taken into account when the utility of FA in postgraduate medical training is evaluated.

Sacral Agenesis with Neurogenic Bladder Dysfunction-A Case Report and Review of the Literature.

Sacral agenesis (part of the caudal regression syndrome) is a rare and severe sacral developmental abnormality. It is a congenital malformation of unknown aetiology with possible involvement of genetic and teratogenic factors. It is described by various degrees of developmental failure, the most extreme and rare being sirenomelia or mermaid syndrome. The associated malformations comprise anorectal, vertebral, urological, genital, and lower limb anomalies. Approximately 15-20% mothers of these children have insulin dependent diabetes mellitus. The case is being reported for its rarity and educative value because prognosis is good in isolated sacral agenesis.

Giant Cell Tumor of Bone in Skeletally Immature Patients - A Clinical Perspective.

INTRODUCTION: Giant cell tumors of skeleton are very rare in pediatric and adolescent population. Here we report two cases-one a fifteen year old child with swelling distal humerus and another a case of a thirteen year old child with pain and swelling proximal tibia. CASE REPORT: A fifteen year old child presented to department of orthopedics of our institute with complaint of difficulty in moving upper limb and swelling distal humerus. Another patient who was a 13 years old male had painful ambulation and swelling in upper tibia. MRI followed by core needle biopsy was done in both the patients confirming the mass to be giant cell tumor which is quite rare in this age group. First patient was managed by wide excision and total elbow replacement and second one by curettage, cementation and augmentation with plate-screw construct. CONCLUSION: Giant cell tumour of skeleton is highly uncommon in pediatric age group. It should be considered as one of the differential diagnosis of epiphyseo metaphyseal lesions in pediatric population in spite of its rarity.

Radiation-free Insertion of Distal Interlocking Screw in Tibial and Femur Nailing: A Simple Technique.

BACKGROUND: Distal interlocking screw insertion in intramedullary nailing of long-bone fracture is a challenging task for orthopedic surgeons. It is difficult particularly when the surgeon is in his learning stage or when image intensifier is not available. We describe a radiation-free technique of distal interlocking screw insertion which is easy and practicable. MATERIALS AND METHODS: In this technique, a same length nail is placed over the skin (outer nail) and through its distal-most screw hole, a 3.2 mm drill bit is inserted to drill the distal locking screw hole of the intramedullary nail (inner nail). With a small skin incision over the distal screw holes, the distal-most screw hole is identified; the bone window overlying the screw hole is widened with an awl and a locking bolt is inserted with a washer under direct visualization. The other distal interlocking screw is simply drilled by matching the other three holes of the outer and inner nails. We have operated 86 patients (39 femoral shaft fracture and 47 tibial shaft fracture) in 1 year where this technique was used. There were 41 open fracture and 45 closed fracture. RESULTS: Within 6 months of follow-up, bony union was achieved in 36 of 39 femur fractures and 45 of 47 tibial fractures. No unwanted complications were observed during the postoperative period and in follow-up. CONCLUSION: This method of radiation-free distal interlocking screw insertion is simple and can be used in third world country where image intensifier facility is not available. However, surgeons are encouraged to use image intensifier facility where the facility is available.