SAFE USE OF INTRA-OPERATIVE TOURNIQUETS IN A DISTRICT HOSPITAL IN THE UK-AN AUDIT STUDY IN ORTHOPAEDIC THEATRES AND REVIEW OF CURRENT LITERATURE.

The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.

IMPORTANCE OF JOINT LINE RESTORATION IN TOTAL KNEE ARTHROPLASTY.

The restoration of the joint line is important for a good functional outcome after a Total Knee Arthroplasty(TKA). Knee joint biomechanics need to be restored as near normal as possible. Joint line elevation leads to anterior knee pain, decrease in range of motion, patella baja ,mid-flexion instability and impingement of patellar tendon. Joint line depression on the other hand leads to patella alta, risk of patellar subluxation and mid-flexion instability of the knee. Various studies have demonstrated various range of acceptable joint line variation but there is no clear acceptable range of joint line variation. More studies are required for establishing the acceptable range of joint line variation and standard practices should be established for arthroplasty surgeons for preventing variation of joint line.

CURRENT CONCEPTS IN THE MANAGEMENT OF BOXER'S FRACTURE.

Fractures of the metacarpal particularly the 5th metacarpal is quite common among all hand fractures and has a high incidence in male adult population. Proper management of these fractures plays a key role in rehabilitation and early return to work thus reducing the economic burden. Treatment of these injuries depends on the type of injury: whether it is a closed/open fracture, degree of angulation at the fracture site and also mal-rotation and shortening of the finger. Non-operative management is suitable for fractures which are closed, non-displaced and without angulation or rotation. Open fractures, fractures with angulation and/or mal-rotation and fractures with neuro-vascular injury are more suitable for operative management. The acceptable angulation for conservative management for most studies is 70 degrees. Buddy strapping with a Futura splint provides good functional results. In fractures requiring operative intervention, K-wire fixation is a minimally invasive method of fixation, which in most cases has good functional results. Plate and screw fixation, however, is preferred for cases with significant comminution or multiple metacarpal fractures.

THE ROLE OF DISTAL LOCKING IN INTRAMEDULLARY NAILS FOR HIP FRACTURE FIXATION: A REVIEW OF CURRENT LITERATURE.

Traditionally, it was believed that both proximal and distal locking are essential for achieving stability during intra-medullary fixation for extra-capsular hip fractures. However, recent literature has presented varying perspectives on the necessity of distal locking. Distal locking plays a significant role in managing hip fractures with uncertainties regarding longitudinal and rotational stability. This includes cases of comminuted intertrochanteric fractures with subtrochanteric extension, reverse oblique and high oblique fractures, broad medullary canals, comminution of the lateral wall, diaphyseal fractures, and large posteromedial fragments extending below the level of the lesser trochanter. In stable pertrochanteric fractures, with the lag screw passing through the lateral cortex of the distal fragment, may not require a distal locking screw. Distal locking has been associated with potential complications, including irritation of the fascia lata, prolonged operation time, increased radiation exposure, greater blood loss, implant loosening, secondary femoral stress fractures, and damage to the femoral artery. Thus, although distal locking is of doubtful significance in stable pertrochanteric fractures it is essential in unstable fracture patterns.

CRISPR/Cas9: Nature's gift to prokaryotes and an auspicious tool in genome editing.

Clustered regularly interspaced short palindromic repeats (CRISPR) is a family of DNA direct repeats found in many prokaryotic genomes. It was discovered in bacteria as their (adaptive) immune system against invading viruses. Cas9 is an endonuclease enzyme linked with the CRISPR system in bacteria. Bacteria use the Cas9 enzyme to chop viral DNA sequences by unwinding it and then finding the complementary base pairs to the guide RNA. CRISPR/Cas9 is a modern and powerful molecular biology approach that is widely used in genome engineering (to activate/repress gene expression). It can be used in vivo to cause targeted genome modifications with better efficiency as compared to meganucleases, zinc-finger nucleases and transcription activator-like effector nucleases. CRISPR/Cas9 is a simple, reliable, and rapid method for causing gene alterations that open new horizons of gene editing in a variety of living organisms, including humans, for the treatment of several diseases. In this short review, we explored the basic mechanisms underlying its working principles along with some of its current applications in a number of diverse fields.

Mode of action and anti-Candida activity of Artemisia annua mediated-synthesized silver nanoparticles.

Candida albicans is a polymorphic opportunistic commensal that causes both superficial and systemic fungal infections especially in immunocompromised patients. Biologically synthesized silver nanoparticles (AgNPs) have emerged as potential antifungal agents. The present work evaluates the antifungal activity of Artemisia annua synthesized AgNPs against three Candida species (C. albicans ATCC 90028, C. tropicalis ATCC 750 and C. glabrata ATCC 90030). The in vitro effect of AgNPs was investigated for fungal growth, sterol content, secretion of hydrolytic enzymes and yeast-to-hyphal transition. The green synthesized AgNPs were effective against all the three species with minimum inhibitory concentration (MIC) in the range 80-120µgml-1. Candida glabrata showed greater sensitivity for AgNPs followed by Candida tropicalis and C. albicans. AgNPs at 4MIC were as effective as fluconazole (FLC) and caused only 5% haemolysis while FLC caused 50% haemolysis at the same concentration. The secretion of hydrolytic enzymes was the lowest in case of AgNP exposed C. glabrata. Yeast-to-hyphal transition was significantly reduced in treated C. albicans cells and showed disfigured morphology in SEM images. The decrease in ergosterol content was slightly higher (94%) in both C. glabrata and C. tropicalis in comparison to C. albicans (69%). Green synthesized AgNPs thus have immense potential as an antifungal and can play a crucial role in the management of Candida infections especially those caused by C. glabrata.

Mathematical modelling of ciliary propulsion of an electrically-conducting Johnson-Segalman physiological fluid in a channel with slip.

Bionic systems frequently feature electromagnetic pumping and offer significant advantages over conventional designs via intelligent bio-inspired properties. Complex wall features observed in nature also provide efficient mechanisms which can be utilized in biomimetic designs. The characteristics of biological fluids are frequently non-Newtonian in nature. In many natural systems super-hydrophobic slip is witnessed. Motivated by these phenomena, in this paper, we discussed a mathematical model for the cilia-generated propulsion of an electrically-conducting viscoelastic physiological fluid in a ciliated channel under the action of magnetic field. The rheological behavior of the fluid is simulated with the Johnson-Segalman constitutive model which allows internal wall slip. The regular or coordinated movement of the ciliated edges (which line the internal walls of the channel) is represented by a metachronal wave motion in the horizontal direction which generates a two-dimensional velocity profile. This mechanism is imposed by a periodic boundary condition which generates propulsion in the channel flow. Under the classical lubrication approximation, the boundary value problem is non-dimensionalized and solved analytically with a perturbation technique. The influence of the geometric, rheological (slip and Weissenberg number) and magnetic parameters on velocity, pressure gradient and the pressure rise (evaluated via the stream function in symbolic software) are presented graphically and interpreted at length.

Evidence of activity-dependent plasticity in the dorsal cochlear nucleus, in vivo, induced by brief sound exposure.

The purpose of the present study was to investigate the immediate effects of acute exposure to intense sound on spontaneous and stimulus-driven activity in the dorsal cochlear nucleus (DCN). We examined the levels of multi- and single-unit spontaneous activity before and immediately following brief exposure (2 min) to tones at levels of either 109 or 85 dB SPL. Exposure frequency was selected to either correspond to the units' best frequency (BF) or fall within the borders of its inhibitory side band. The results demonstrate that these exposure conditions caused significant alterations in spontaneous activity and responses to BF tones. The induced changes have a fast onset (minutes) and are persistent for durations of at least 20 min. The directions of the change were found to depend on the frequency of exposure relative to BF. Transient decreases followed by more sustained increases in spontaneous activity were induced when the exposure frequency was at or near the units' BF, while sustained decreases of activity resulted when the exposure frequency fell inside the inhibitory side band. Follow-up studies at the single unit level revealed that the observed activity changes were found on unit types having properties which have previously been found to represent fusiform cells. The changes in spontaneous activity occurred despite only minor changes in response thresholds. Noteworthy changes also occurred in the strength of responses to BF tones, although these changes tended to be in the direction opposite those of the spontaneous rate changes. We discuss the possible role of activity-dependent plasticity as a mechanism underlying the rapid emergence of increased spontaneous activity after tone exposure and suggest that these changes may represent a neural correlate of acute noise-induced tinnitus.

Anti-Candida activity of geraniol involves disruption of cell membrane integrity and function.

Candidiasis is a major problem in immunocompromised patients. Candida, an opportunistic fungal pathogen, is a major health concern today as conventional drugs are highly toxic with undesirable side effects. Their fungistatic nature is responsible for drug resistance in continuously evolving strains. Geraniol, an acyclic monoterpene alcohol, is a component of several plant essential oils. In the present study, an attempt has been made to understand the antifungal activity of geraniol at the cell membrane level in three Candida species. With an MIC of 30-130µg/mL, this natural compound was fungicidal at concentrations 2×MIC. There was complete suppression of fungal growth at MIC values (growth curves) and encouragingly geraniol is non-toxic even at the concentrations approaching 5×MIC (hemolysis assay). Exposed cells showed altered morphology, wherein the cells appeared either broken or shrivelled up (SEM studies). Significant reduction was seen in ergosterol levels at sub-MIC and glucose-induced H(+) efflux at concentrations>MIC values. Our results suggest that geraniol disrupts cell membrane integrity by interfering with ergosterol biosynthesis and inhibiting the very crucial PM-ATPase. It may hence be used in the management and treatment of both superficial and invasive candidiasis but further studies are required to elaborate its mode of action.

Suppression of noise-induced hyperactivity in the dorsal cochlear nucleus following application of the cholinergic agonist, carbachol.

Increased spontaneous firing (hyperactivity) is induced in fusiform cells of the dorsal cochlear nucleus (DCN) following intense sound exposure and is implicated as a possible neural correlate of noise-induced tinnitus. Previous studies have shown that in normal hearing animals, fusiform cell activity can be modulated by activation of parallel fibers, which represent the axons of granule cells. The modulation consists of a transient excitation followed by a more prolonged period of inhibition, presumably reflecting direct excitatory inputs to fusiform cells and an indirect inhibitory input to fusiform cells from the granule cell-cartwheel cell system. We hypothesized that since granule cells can be activated by cholinergic inputs, it might be possible to suppress tinnitus-related hyperactivity of fusiform cells using the cholinergic agonist, carbachol. To test this hypothesis, we recorded multiunit spontaneous activity in the fusiform soma layer (FSL) of the DCN in control and tone-exposed hamsters (10 kHz, 115 dB SPL, 4h) before and after application of carbachol to the DCN surface. In both exposed and control animals, 100 µM carbachol had a transient excitatory effect on spontaneous activity followed by a rapid weakening of activity to near or below normal levels. In exposed animals, the weakening of activity was powerful enough to completely abolish the hyperactivity induced by intense sound exposure. This suppressive effect was partially reversed by application of atropine and was usually not associated with significant changes in neural best frequencies (BF) or BF thresholds. These findings demonstrate that noise-induced hyperactivity can be pharmacologically controlled and raise the possibility that attenuation of tinnitus may be achievable by using an agonist of the cholinergic system.

Behavioral evidence for possible simultaneous induction of hyperacusis and tinnitus following intense sound exposure.

Many human subjects suffering from chronic tinnitus also suffer from hyperacusis, a heightened perception of loudness at moderate to intense sound levels. While numerous studies suggest that animals develop chronic tinnitus following intense noise exposure, it is not yet clear whether sound exposure also induces chronic hyperacusis-like responses in animals. We addressed this question by examining the chronic effects of intense sound exposure on the acoustic startle response (ASR) and its suppression by background noise containing brief gaps. We compared startle amplitudes in intense tone-exposed (10 kHz, 115 dB SPL, 4 h) and age-matched controls at 2-28 weeks post-exposure. While both groups showed similar startle thresholds, exposed animals showed a hyperacusis-like augmentation of ASR at high stimulus levels. Addition of background noise had little effect on ASR in controls but had a strong suppressive effect on startle in exposed animals, indicating a sensitization to background noise. When the background noise contained a gap preceding the startle stimulus, ASR was suppressed in control animals, but exposed animals showed a marked weakening of gap-induced suppression of ASR. This weakening of gap-induced startle suppression is consistent with the interpretation that the gap may have been masked by tinnitus. The associated hyper-responsiveness to startle stimuli presented alone and the sensitization to background noise suggest that hyperacusis may have also been induced. The results indicate that noise exposure leads to increases in the gain of auditory responsiveness and may offer a model of the association of hyperacusis with tinnitus.

Comparison and contrast of noise-induced hyperactivity in the dorsal cochlear nucleus and inferior colliculus.

Induction of hyperactivity in the central auditory system is one of the major physiological hallmarks of animal models of noise-induced tinnitus. Although hyperactivity occurs at various levels of the auditory system, it is not clear to what extent hyperactivity originating in one nucleus contributes to hyperactivity at higher levels of the auditory system. In this study we compared the time courses and tonotopic distribution patterns of hyperactivity in the dorsal cochlear nucleus (DCN) and inferior colliculus (IC). A model of acquisition of hyperactivity in the IC by passive relay from the DCN would predict that the two nuclei show similar time courses and tonotopic profiles of hyperactivity. A model of acquisition of hyperactivity in the IC by compensatory plasticity mechanisms would predict that the IC and DCN would show differences in these features, since each adjusts to changes of spontaneous activity of opposite polarity. To test the role of these two mechanisms, animals were exposed to an intense hyperactivity-inducing tone (10 kHz, 115 dB SPL, 4 h) then studied electrophysiologically at three different post-exposure recovery times (from 1 to 6 weeks after exposure). For each time frame, multiunit spontaneous activity was mapped as a function of location along the tonotopic gradient in the DCN and IC. Comparison of activity profiles from the two nuclei showed a similar progression toward increased activity over time and culminated in the development of a central peak of hyperactivity at a similar tonotopic location. These similarities suggest that the shape of the activity profile is determined primarily by passive relay from the cochlear nucleus. However, the absolute levels of activity were generally much lower in the IC than in the DCN, suggesting that the magnitude of hyperactivity is greatly attenuated by inhibition.

Rapid culture diagnosis of tuberculous lymphadenitis from a tertiary care centre in an endemic nation: potential and pitfalls.

In spite of low sensitivity and specificity, standard diagnostic algorithm recommends fine needle aspiration cytology (FNAC) and direct microscopic screening for acid-fast bacilli (AFB) for the routine diagnosis of tuberculous lymphadenopathy (LNTB). In this study, the diagnostic utility of liquid broth based automated culture (BacT/ALERT 3D) technique was assessed in comparison with conventional techniques in 89 clinically suspected tubercular lymphadenitis patients. 60% (n = 53) were positive by FNAC and 38.4% (n = 34) demonstrated AFB in smear examination. BacT/ALERT yielded isolation in 43.1% (n = 38) aspirates, confirming tubercular aetiology. We also found six paediatric culture-positive cases which showed negative outcome by both FNAC and smear. Thus, we conclude that culture by BacT/ALERT, may be used for faster yield of Mycobacteria in LNTB, especially in children. Additionally, this could also be used as a platform for further differentiation of Mycobacterium tuberculosis from non-tuberculous mycobacteria (NTM) infection and for testing of anti-tubercular chemotherapeutic agents whenever drug resistance is suspected.

Noise-induced hyperactivity in the inferior colliculus: its relationship with hyperactivity in the dorsal cochlear nucleus.

Intense noise exposure causes hyperactivity to develop in the mammalian dorsal cochlear nucleus (DCN) and inferior colliculus (IC). It has not yet been established whether the IC hyperactivity is driven by hyperactivity from extrinsic sources that include the DCN or instead is maintained independently of this input. We have investigated the extent to which IC hyperactivity is dependent on input from the contralateral DCN by comparing recordings of spontaneous activity in the IC of noise-exposed and control hamsters before and after ablation of the contralateral DCN. One group of animals was binaurally exposed to intense sound (10 kHz, 115 dB SPL, 4 h), whereas the control group was not. Both groups were studied electrophysiologically 2-3 wk later by first mapping spontaneous activity along the tonotopic axis of the IC to confirm induction of hyperactivity. Spontaneous activity was then recorded at a hyperactive IC locus over two 30-min periods, one with DCNs intact and the other after ablation of the contralateral DCN. In a subset of animals, activity was again mapped along the tonotopic axis after the time course of the activity was recorded before and after DCN ablation. Following recordings, the brains were fixed, and histological evaluations were performed to assess the extent of DCN ablation. Ablation of the DCN resulted in major reductions of IC hyperactivity. Levels of postablation activity in exposed animals were similar to the levels of activity in the IC of control animals, indicating an almost complete loss of hyperactivity in exposed animals. The results suggest that hyperactivity in the IC is dependent on support from extrinsic sources that include and may even begin with the DCN. This finding does not rule out longer term compensatory or homeostatic adjustments that might restore hyperactivity in the IC over time.

Assessment of trends of ofloxacin resistance in Mycobacterium tuberculosis.

PURPOSE: Ofloxacin (OFX) is one of the potent fluoroquinolone (FQ) recommended to treat MDR-TB. Over a decade, the preexposure of this drug for the treatment of other bacterial infections has resulted in acquisition of FQ resistance among Mycobacterium tuberculosis strains. Considering this possibility, a study was undertaken in a tertiary care center in the capital city (India) to assess the drug resistance trends of OFX among susceptible and multidrug resistant (MDR) strains of M. tuberculosis. MATERIALS AND METHODS: A total of 102 M. tuberculosis isolates (47 susceptible to first-line drugs and 55 MDR isolates) were screened for susceptibility testing of OFX with a critical concentration of 2 µg/ml by Lowenstein Jensen (LJ) proportion method. RESULTS: The results showed 40 (85.1%) isolates among 47 susceptible isolates and 34 (61.8%) isolates among 55 MDR isolates, were found to be susceptible to OFX. Fisher's exact test showed significant P-value (0.0136) demonstrating 1.377 fold (95% confidence interval) increased risk to become resistant to OFX than susceptible isolates. These finding shows decreased OFX susceptibility is not only limited to MDR isolates but also increasingly seen in susceptible strains as a result of drug abuse. CONCLUSIONS: Our finding were not alarming, but highlights the general risk of acquiring resistance to OFX, jeopardizing the potential for these drugs to be used as second-line anti-TB agents in the management of drug-resistant TB and creating incurable TB strains .

Fungicidal activity of thymol and carvacrol by disrupting ergosterol biosynthesis and membrane integrity against Candida.

Natural isopropyl cresols have been reported to have antifungal activity. This work is an attempt to examine thymol and carvacrol against 111 fluconazole-sensitive and -resistant Candida isolates. Insight into the mechanism of action was elucidated by flow cytometric analysis, confocal imaging and ergosterol biosynthesis studies. The susceptibility tests for the test compounds were carried out in terms of minimum inhibitory concentrations (MICs), disc diffusion assays and time-kill curves against all Candida isolates by employing standard protocols. Propidium iodide (PI) cell sorting has been investigated by flow cytometric analysis and confocal imaging. Haemolytic activity on human erythrocytes was studied to exclude the possibility of further associated cytotoxicity. Both compounds were found to be effective to varying extents against all isolates, including the resistant strains. In contrast to the fungistatic nature of fluconazole, our compounds were found to exhibit fungicidal nature. Significant impairment of ergosterol biosynthesis was pronouncedly induced by the test entities. Negligible cytoxicity was observed for the same compounds. Furthermore, it was observed that the positional difference of the hydroxyl group in carvacrol slightly changes its antifungal activity. Carvacrol and thymol show strong fungicidal effect against all of the Candida isolates. The mechanisms of action of these natural isopropyl cresols appear to originate from the inhibition of ergosterol biosynthesis and the disruption of membrane integrity.

Evaluation of nucleic acid probe for rapid identification of Mycobacterium tuberculosis complex in extra-pulmonary culture isolates.

Patients infected with Non-tuberculous mycobacteria (NTM) usually do not respond to conventional anti-tubercular treatment and are misdiagnosed as infection with multi-drug resistant strains of mycobacterium tuberculosis (M.tb) due to lack of correct species identification, particularly in the developing countries like India. One of the challenges faced by clinicians in the treatment of tuberculosis is the absence of an easy, reliable and rapid identification tool that can accurately differentiate disease caused by M.tb complex from NTM. Keeping this in consideration, the performance of species specific nucleic acid probe i.e. Accuprobe was assessed and compared with conventional niacin production, nitrate reductase assay techniques for identification of M.tb complex in 80 mycobacterial isolates obtained from different extra-pulmonary sites. Accuprobe identified 62 isolates (77.5%) as M. tuberculosis complex and remaining 18 isolates (22.5%) as NTM whereas 64 isolates (80%) were identified as M.tb and rest 16 (20%) were interpreted as NTM by conventional biochemical techniques. The overall agreement between both techniques was 96.9% The sensitivity, specificity, positive predictive value(PPV) and negative predictive value (NPV) shown by accuprobe were 96.9%, 100%, 96.9%, and 88.9% respectively. Thus, accuprobe has showed impressive sensitivity and specificity giving results in < 3 hrs from culture-positive isolates and have sure edge over conventional biochemical methods which are, nonetheless, labour intensive and cumbersome to perform thus delaying prompt mycobacterial identification.

Pre-steady state kinetic studies on H(+)-ATPase from Candida albicans.

The mechanism of ATP hydrolysis by plasma membrane H(+)-ATPase from Candida albicans has been investigated by following the kinetics of H(+) liberation/absorption and the UV difference spectrum in a stopped flow spectrophotometer. A distinct pre-steady state phase of ATP hydrolysis could be defined. While the rapid mixing of P(i) and ATPase produced no transient pH changes, the mixing of ADP leads to the release of 1 H(+) per molecule of ATPase. Rapid mixing of ATP with ATPase releases about 2 H(+) per molecule of ATPase, of which around 1.3 H(+) are reabsorbed. The magnitudes of both H(+) release and absorption were found to be independent of ATP concentration. The rate of H(+) release (k(f)) shows ATP dependence while the rate of H(+) absorption is independent of ATP concentration. The rate of H(+) liberation with ADP, on a concentration basis, was far less as compared with ATP, indicating a low affinity of the ATPase for ADP. No change in the difference spectrum was observed with ADP. The stoichiometry of ATP binding to PM-ATPase was found to be unity from UV-difference spectrum studies. The k(f) values for H(+) release and for the appearance of a difference spectrum following the addition of ATP were found to be similar beyond a 1:1 ratio of ATP:ATPase. The results obtained lead us to propose a 4-step kinetic scheme for the mechanism of ATP hydrolysis.