Platelet indices as prognostic markers of ischemic stroke and their correlation with lipid profile.

OBJECTIVE: Stroke is the cause of one in eight deaths and adds a dreadful burden of disability for the patients. Ischemic stroke is caused by a loss of blood supply to brain due to sudden occlusion of the arterial system, caused by an emboli or thrombus. Our aim was to correlate platelet indices, total cholesterol ratio, and various comorbidities with stroke. METHODS: A cross-sectional study was performed from 2020-2022 with 132 stroke patients admitted to the SRM Medical College Hospital and Research Center, India. Detailed clinical examination was performed. Venous blood samples were drawn at the time of admission to estimate platelet count, mean platelet volume (MPV), platelet distribution width (PDW), and platelet crit (PCT). Overnight fasting serum samples were obtained for lipid profiling. RESULTS: Among the participants in our study, maximum belonged to the age group 50 to 59 years (34.1%) and majority were males (79.5%). In terms of comorbidities, 85.6% of the participants had diabetes, 42.4% had hypertension and 22% had dyslipaedemia. All platelet and lipid parameters were found to be similar between patients with and without comorbidities. While all platelet indices increased with the increase in severity of stroke, we found that PDW is most reliable in predicting stroke with an area under the receiver operator curve of 0.942, with a sensitivity and specificity of 92.1% at cut-off value 14. All platelet parameters also significantly increased in patients with severe lipid dysfuction, establishing a correlation between lipid profile, platelet indices and stroke. CONCULSION: We found a significant relationship between all platelet parameters and stroke. Thus, we believe that patients with risk factors for atherosclerosis should have their platelet indices assessed periodically before the development of cerebrovascular events. Furthermore, dyslipidemia if properly treated, is a modifiable risk factor for stroke, which can decrease morbidity and mortality leading to a healthier society.

Left Inferior Vena Cava from the Perspective of Laparoscopic Donor Surgeon: Anatomic Considerations and Surgical Implications.

Renal vascular aberrations are not uncommon cause for rejection of living kidney donors. While screening a donor for laparoscopic nephrectomy, we encountered a rare, yet important aberration in the form of left-sided inferior vena cava (IVC). There was an initial dilemma regarding the acceptability of the donor and which side kidney to select for donation. Scant literature is available on this particular clinical scenario, and only after a detailed study of the embryology and anatomy of IVC, were we able to make an informed choice. This article highlights the surgical anatomy and clinical implications of this rare condition from the perspective of laparoscopic donor surgeon.

A systematic review of interventions and outcomes in lung cancer metastases to the spine.

Seventy percent of cancer patients will have metastatic bone disease, most commonly in the vertebra. Prognosis of metastatic lung cancer is poor and treatment is mostly palliative. To-date, there is no systematic review on the ideal treatment for lung cancer with spinal metastases in regards to mortality. Literature searches were performed based on PRISMA guidelines for systematic review. Thirty-nine studies comprising 1925 patients treated for spinal metastases of lung cancer met inclusion criteria. All analyses were performed using SAS and SPSS. Data were analyzed for meaningful comparisons of baseline patient characteristics, primary cancer type, metastatic lesion characteristics, treatment modality, and clinical and radiologic outcomes. Significantly greater mean survival length was seen in the non-surgical group (8.5 months, SD 6.6, SEM 0.17) compared to the surgical group (7.5 months, SD 4.5, SEM 0.25; p = 0.013). There was no statistically significant survival difference between different types of primary lung cancer: NSCLC (8.3 months, SD 13.8, SEM 0.91) and SCLC (7.0 months, SD 4.6, SEM 0.46; p = 0.36). Number of vertebral levels involved per lesion also did not exhibit significant difference: single lesion (11.3 months, SD 6.8, SEM 2.2) and multiple lesions (13.8 months, SD 15.7, SEM 3.6; p = 0.64). For patients with symptomatic spinal metastases from lung cancer, non-operative approaches experience significantly better survival outcomes (p = 0.013). Future clinical studies are needed to determine the best treatment algorithm to help maximize outcomes and minimize mortality in metastatic lung cancer.

Role of Coronary Angiography in Pre-Liver Transplantation Cardiac Evaluation: Experience From an Asian Transplant Institution.

BACKGROUND: Liver transplant (LT) patients with significant coronary artery disease (CAD) have poorer outcomes. Pre-LT coronary angiography (CA) is associated with significant complications in cirrhotic patients. METHODS: This study aimed to identify predictors of abnormal CA in pre-LT cardiac assessment and to develop a predictive model to reduce unnecessary CA. From January 2006 to June 2013, 122 patients underwent CA based on the current institutional protocol. RESULTS: Forty-one (33.6%) patients had abnormal CA. Univariate analysis showed age ≥65 years (P = .001), cryptogenic cirrhosis (P = .046), cardiac comorbidities (P = .027), ischemic heart disease (IHD; P = .002), left ventricular hypertrophy (LVH; P = .004), hypertension (P = .002), diabetes mellitus (P = .017), dyslipidemia (P < .001), metabolic syndrome (P = .003), ≥2 CAD risk factors (P = .001), and high Framingham risk score (hard CAD risk, P = .018; cardiovascular disease: lipids, P = .002; body mass index, P < .001) to be significant predictors of abnormal CA. A predictive model was developed with the use of multivariable logistic regression and included diabetes, dyslipidemia, IHD, age ≥65 years, and LVH, achieving a specificity of 55.1% and sensitivity of 90.0%. This would reduce unnecessary CA by up to one-half in our study population (from 81 to 35) while maintaining a false negative rate of only 8.5%. CONCLUSIONS: Diabetes, dyslipidemia, IHD, age ≥65 years, and LVH appear to be predictors of abnormal CA in pre-LT patients. Our predictive model may help to better select patients for CA, although further validation is required.

Predictors of Non-adherence to Immunosuppressive Therapy in Asian Liver Transplant Recipients.

BACKGROUND: Adherence to immunosuppressive medications has been shown to affect post-transplant outcomes. We aimed to determine the level of adherence to immunosuppressive therapy in liver transplant (LT) recipients and to elucidate factors associated with it, as well as patient preferences on the dosing schedule. METHODS: LT recipients were recruited during transplant clinic follow-up. A validated Morisky 8-item questionnaire was completed by patients to assess their adherence to immunosuppressive therapy. Adherence was determined by the sum of the responses to the questionnaire. Low, medium, and high adherence were defined by a Morisky score of >2, 1 to 2, and 0, respectively. Data on the patient's socio-economic and clinical background, dosing schedule of immunosuppressant medications, and patient preferences were included in the questionnaire. RESULTS: A total of 107 LT recipients were approached and 75 completed the questionnaire. The majority of patients (48/74, 64.9%) preferred a once-daily medication regimen. The proportion of high adherence was 24/75 (32.0%), medium adherence was 51/75 (42.7%), and low adherence was 19/75 (25.3%). Multivariate analysis showed younger age and post-transplant duration >5 years as independent predictors for low adherence. Among low-adherence patients, 16/19 (84.2%) patients were on a twice-daily regimen, and, of these, 14/16 (87.5%) preferred their medications to be reduced to once daily. CONCLUSIONS: A significant proportion (68%) of LT recipients had low to moderate adherence to medications, with younger age and longer post-transplant duration of >5 years as independent predictors. Early identification of at-risk patients is essential to allow implementation of measures to improve adherence. Simplifying medication regimens to once daily is a potential way to improve adherence.

Eicosapentaenoic acid inhibits intestinal ß-carotene absorption by downregulation of lipid transporter expression via PPAR-α dependent mechanism.

The involvement of lipid transporters, the scavenger receptor class B, type I (SR-BI) and Niemann-Pick type C1 Like 1 protein (NPC1L1) in carotenoid absorption is demonstrated in intestinal cells and animal models. Dietary ω-3 fatty acids are known to possess antilipidemic properties, which could be mediated by activation of PPAR family transcription factors. The present study was conducted to determine the effect of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), on intestinal ß-carotene absorption. ß-carotene uptake in Caco-2/TC7 cells was inhibited by EPA (p < 0.01) and PPARα agonist (P < 0.01), but not by DHA, PPARγ or PPARδ agonists. Despite unaltered ß-carotene uptake, both DHA and PPARδ agonists inhibited the NPC1L1 expression. Further, EPA also induced the expression of carnitine palmitoyl transferase 1A (CPT1A) expression, a PPARα target gene. Interestingly, EPA induced inhibition of ß-carotene uptake and SR B1 expression were abrogated by specific PPARα antagonist, but not by PPARδ antagonist. EPA and PPARα agonist also inhibited the basolateral secretion of ß-carotene from Caco-2 cells grown on permeable supports. These results suggest that EPA inhibits intestinal ß-carotene absorption by down regulation of SR B1 expression via PPARα dependent mechanism and provide an evidence for dietary modulation of intestinal ß-carotene absorption.

Food-Based Interventions to Modify Diet Quality and Diversity to Address Multiple Micronutrient Deficiency.

Global data indicate a high prevalence of hidden hunger among population. Deficiencies of certain micronutrients such as folic acid, iodine, iron, and vitamin A have long lasting effects on growth and development and therefore have been a National priority from many decades. The strategy implemented so far limits to the use of supplemental sources or fortified foods in alleviating the burden of deficiencies. These approaches however undermine the food-based strategies involving dietary diversification as the long-term sustainable strategy. There is lack of understanding on the level of evidence needed to implement such strategies and the level of monitoring required for impact evaluation. Dietary diversity concerns how to ensure access for each individual to a quality and safe diet with adequate macro- and micronutrients. The key to success in using dietary diversity as a strategy to tackle hidden hunger is in integrating it with the principles of bioavailability, translated to efficient food synergies with due emphasis on food accessibility, affordability, and outdoor physical activity/life style modifications. Promoting enabling environment and sustainable agriculture is crucial for practicing dietary diversification with behavior change communication as an integral segment. It can be concluded that food-based strategies require careful understanding of the factors associated with it and moderate it to form an effective strategy for controlling multiple micronutrient deficiencies.

Surgical salvage of partial pancreatic allograft thrombosis presenting as ruptured pancreatic cyst: a case report.

INTRODUCTION: Vascular thrombosis is an important cause of pancreatic graft loss, and the vast majority is managed using graft pancreatectomy. There are limited reports and case series of successful salvage of the pancreas allograft. We describe a case of partial pancreatic allograft thrombosis presenting as ruptured pancreatic cyst successfully salvaged using a graft distal pancreatectomy. METHODS: We used descriptive retrospective analysis. RESULTS: A 29-year-old patient with type 1 diabetes and end-stage renal failure underwent a simultaneous pancreas kidney transplantation with immediate graft function. The cadaveric pancreas allograft was placed head up in the right iliac fossa with enteric exocrine drainage and standard vascular anastomosis. He presented with compressive symptoms on his bladder 5 months later, and a computed tomography (CT) showed a 4-cm cystic lesion in the body and tail of the pancreas allograft. Spontaneous rupture of the cyst occurred 3 weeks after the initial onset of symptoms with generalized abdominal pain. He underwent graft distal pancreatectomy with good recovery. He remains euglycemic, insulin-free with a normal renal function. Histology of the resected unhealthy graft showed an arterial thrombus with xanthogranulomatous inflammation and necrosis. CONCLUSION: Surgical salvage with graft distal pancreatectomy is feasible for partial pancreatic allograft thrombosis. Cystic lesion in the pancreas is a possible presentation of vascular thrombosis.

Vegetation response and landscape dynamics of Indian Summer Monsoon variations during Holocene: an eco-geomorphological appraisal of tropical evergreen forest subfossil logs.

The high rainfall and low sea level during Early Holocene had a significant impact on the development and sustenance of dense forest and swamp-marsh cover along the southwest coast of India. This heavy rainfall flooded the coastal plains, forest flourishing in the abandoned river channels and other low-lying areas in midland.The coastline and other areas in lowland of southwestern India supply sufficient evidence of tree trunks of wet evergreen forests getting buried during the Holocene period under varying thickness of clay, silty-clay and even in sand sequences. This preserved subfossil log assemblage forms an excellent proxy for eco-geomorphological and palaeoclimate appraisal reported hitherto from Indian subcontinent, and complements the available palynological data. The bulk of the subfossil logs and partially carbonized wood remains have yielded age prior to the Holocene transgression of 6.5 k yrs BP, suggesting therein that flooding due to heavy rainfall drowned the forest cover, even extending to parts of the present shelf. These preserved logs represent a unique palaeoenvironmental database as they contain observable cellular structure. Some of them can even be compared to modern analogues. As these woods belong to the Late Pleistocene and Holocene, they form a valuable source of climate data that alleviates the lack of contemporaneous meteorological records. These palaeoforests along with pollen proxies depict the warmer environment in this region, which is consistent with a Mid Holocene Thermal Maximum often referred to as Holocene Climate Optimum. Thus, the subfossil logs of tropical evergreen forests constitute new indices of Asian palaeomonsoon, while their occurrence and preservation are attributed to eco-geomorphology and hydrological regimes associated with the intensified Asian Summer Monsoon, as recorded elsewhere.

A case report of an intracaval extrathoracic solitary fibrous tumour.

Solitary fibrous tumours are infrequent neoplasms based in the pleura that are predominantly benign with malignant pathology and behaviour described in 10-36% of cases. Extrathoracic solitary fibrous tumours (ESFTs) have been considered separately to their intrathoracic counterparts and comprise a third of all solitary fibrous tumours. The extrathoracic location was identified as an adverse prognostic factor for local recurrence but not for metastatic disease. So far, there have not been any reports of solitary fibrous tumours demonstrating caval infiltration. We present a case of a benign ESFT infiltrating into the perirenal inferior vena cava. Together with extrauterine leiomyomas, ESFTs should also be considered as a differential diagnosis for the rare benign lesions invading the inferior vena cava.

Value of alpha-foetoprotein for screening of recurrence in hepatocellular carcinoma post resection.

INTRODUCTION: The aim of this study was to establish the value of alpha-foetoprotein (AFP) for the screening of recurrences in hepatocellular carcinoma (HCC) in patients who have undergone curative hepatic resection. METHODS: 72 HCC patients who had curative resection/liver transplant in 2000-2006 were monitored for recurrence by evaluating the three- or six-monthly AFP and computed tomography images. Patients without recurrence were followed up for a mean duration of 7.27 years. RESULTS: Out of the 72 patients, 34 (47.2%) suffered from HCC recurrence. 65.4% of recurrent cases had AFP values showing an upward trend. Patients with recurrence had higher AFP values than those without at last follow-up (119.45 µg/L vs. 3.1 µg/L, p < 0.001). AFP at recurrence was independent of gender, race, history of alcohol consumption and hepatitis C or cirrhosis status. Patient with hepatitis B or those with tumours larger than 5 cm had higher AFP values. The best cut-off AFP indicative of HCC recurrence was 5.45 µg/L (sensitivity 84.4%; specificity 77.1%). High preoperative AFP was associated with high AFP at recurrence (correlation coefficient 0.553, p = 0.01). CONCLUSION: AFP alone is an inadequate screening test for HCC recurrence since only about two-thirds of patients showed upward AFP trend on recurrence. Our study found a relatively low cut-off point for detection of recurrence (5.54 µg/L). Patients with high preoperative AFP tended to have high AFP on recurrence. Imaging is recommended for patients with AFP levels > 5.45 µg/L, especially when AFP shows a rising trend.

Prevalence of ocular signs and subclinical vitamin A deficiency and its determinants among rural pre-school children in India.

OBJECTIVE: To assess the magnitude and determinants of vitamin A deficiency (VAD) and coverage of vitamin A supplementation (VAS) among pre-school children. DESIGN: A community-based cross-sectional study was carried out by adopting a multistage, stratified, random sampling procedure. SETTING: Rural areas of eight states in India. SUBJECTS: Pre-school children and their mothers were covered. RESULTS: A total of 71,591 pre-school children were clinically examined for ocular signs of VAD. Serum retinol concentrations in dried blood spots were assessed in a sub-sample of 3954 children using HPLC. The prevalence of Bitot spots was 0·8%. The total ocular signs were significantly higher (P < 0·001) among boys (2·6%) compared with girls (1·9%) and in older children (3-4 years) compared (P < 0·001) with younger (1-2 years), and were also high in children of labourers, scheduled castes and illiterate mothers. The odds of having Bitot spots was highest in children of scheduled caste (OR = 3·8; 95% CI 2·9, 5·0), labourers (OR = 2·9; 95% CI 2·1, 3·9), illiterate mothers (OR = 2·7; 95% CI 2·2, 2·3) and households without a sanitary latrine (OR = 5·9; 95% CI 4·0, 8·7). Subclinical VAD (serum retinol level <20 µg/dl) was observed in 62% of children. This was also relatively high among scheduled caste and scheduled tribe children. The rate of coverage of VAS was 58%. CONCLUSIONS: The study revealed that VAD is a major nutritional problem and coverage of VAS was poor. The important determinants of VAD were illiteracy, low socio-economic status, occupation and poor sanitation. Strengthening the existing VAS programme and focused attention on dietary diversification are essential for prevention of VAD.

Hypopituitarism as unusual sequelae to central nervous system tuberculosis.

Neurological tuberculosis can very rarely involve the hypophysis cerebri. We report a case of an eighteen year old female who presented with five months duration of generalised apathy, secondary amenorrhea and weight gain. She was on irregular treatment for tuberculosis of the central nervous system for the last five months. Neuroimaging revealed sellar and suprasellar tuberculomas and communicating hydrocephalus requiring emergency decompression. Endocrinological investigation showed hypopituitarism manifesting as pituitary hypothyroidism, hypocortisolism, hypogonadotropic hypogonadism, and hyperprolactinemia. Restarting anti-tuberculosis treatment, hormone replacement therapy, and a ventriculo-peritoneal shunt surgery led to remarkable improvement in the general condition of the patient.

Successful living donor liver transplantation in portomesenteric thrombosis.

Chronic portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to the risks involved and higher morbidity. In this report, we describe a surgical strategy for living donor liver transplant in patient with complete PVT using venovenous bypass from the inferior mesenteric vein (IMV) and then using a jump graft from the IMV for portal inflow into the graft. IMV is a potential source for portal inflow in orthotopic liver transplant.

Screening for distress (the sixth vital sign) in a global recession: sustainable approach to maintain patient-centered care.

A substantial volume of research on the psychosocial impact of cancer clearly indicates that patients are likely to experience emotional distress. There is also evidence that psychosocial interventions aimed at decreasing distress provide tangible cost offsets to cancer patients, caregivers and treating institutions. One seemingly major drawback in the setup and delivery of a fully fledged screening program for distress is the extensive pecuniary requirements. Given that the categorical need for distress screening may be confounded by financial limitations, especially in a time of global recession, a cost-effective alternative seems appropriate. The model proposed herein is not a substitute screening program, nor does it eliminate the need to allocate resources to address the identified risks. It does, however, offer a cost-effective alternative to implement a high-risk distress patient identifying process, quite similar to algorithms used in screening for prostate cancer.

Binding and stabilization of transthyretin by curcumin.

Biophysical evidences suggest that transthyretin (TTR) tetramer dissociation to the monomeric intermediate and subsequent polymerization leads to amyloid fibril formation, which is implicated in the pathogenesis of familial amyloid polyneuropathy (FAP) and senile systemic amyloidosis (SSA). Hence, inhibition of fibril formation is considered a potential therapeutic strategy. Here in we demonstrate that curcumin, a phenolic constituent of curry spice turmeric, binds to the active site of TTR through fluorescence quenching and ANS displacement studies. Binding of curcumin appears to inhibit the denaturant induced tertiary and quaternary structural changes in TTR as monitored by intrinsic emission fluorescence and glutaraldehyde cross-linking studies. However, curcumin did not bind to TTR at acidic pH. Protonation/ isomerization of the side chain oxygen atoms of curcumin at low pH might hamper the binding. These results suggest that curcumin binds to and stabilizes TTR thereby highlight the importance of the side chain conformations of the ligand in binding to TTR.

The selective use of magnetic resonance cholangiopancreatography in the imaging of the axial biliary tree in patients with acute gallstone pancreatitis.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit. METHODS: Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis. RESULTS: 249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18-204) vs. MRCP 39 mmol/l (24-180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3-14) vs. ERCP 9 days (range: 4-20), p < 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p < 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94). CONCLUSIONS: MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital stay. and IAP.

Liver resection and transplantation in the management of iatrogenic biliary injury.

BACKGROUND: Biliary injury during cholecystectomy can be managed successfully by biliary reconstruction in the majority of patients; however, a proportion of patients may require hepatic resection or even liver transplantation. METHODS: Data on all patients referred with biliary injuries were recorded prospectively. The details of patients who required hepatic resection or transplantation were analyzed and compared to those patients managed with biliary reconstruction alone. RESULTS: From November 1984 until November 2003 there were 119 patients referred with Strasberg grade E injuries to the biliary tree, 14 of whom (9 women, 5 men) required hepatic resection or transplantation. The median age of these 14 patients was 48 (range: 30-81) years. Nine patients were considered for hepatic resection, and of these six underwent right hepatectomy, two had a left lateral sectionectomy, and one patient was deemed unfit for surgery and underwent metal stenting of the right hepatic duct. All patients are alive and remain well. Five patients developed hepatic failure and were considered for liver transplantation. Two patients who were unfit for transplantation died, and another died while on the waiting list for transplantation. The remaining two patients underwent liver transplantation, and one of them died from overwhelming sepsis. Concomitant vascular injury was demonstrated in 8 of the 14 patients (57%), and in 3 of the 4 (75%) patients that died. CONCLUSIONS: Hepatic atrophy or sepsis after biliary injury can be managed successfully with hepatic resection. Liver transplantation is required occasionally for patients with secondary biliary cirrhosis, but is rarely successful for early hepatic failure following iatrogenic biliary injury.