Spina bifida occulta with the persistent spinous process in living: A three-dimensionally reconstructed sacrum from computed tomographic imaging.

Background: Here we aim to report the persistent spinous process in the 'pan sacral type' of spina bifida occulta in an asymptomatic male and discuss its clinical significance. The presence of this type of dorsal wall defect with a bony spur attached to it has never been described in the literature to the best of our knowledge after extensive literature search. Our work presents the first anatomic description where the spinous and paraspinous cleft are seen in a sacrum of a live subject. Case Report: During a morphometric study of the sacra, normal subject computed tomography imaging (CT) was procured from the Department of Radio-diagnosis. A three-dimensional (3D) image of the sacrum was created using Dicom to Print and Geomagic freeform plus software. A complete dorsal wall defect was observed in a 3D reconstructed sacrum of an adult male. The sacral canal was converted into a groove with a bony spur hanging in the centre. The longitudinal bony spur attached to the lamina was the persistent spinous process. Conclusion: Such congenital defects are clinically significant for the anaesthetist during caudal epidural block and for orthopaedic surgeons before any surgical procedure. It may be misdiagnosed as an abnormal bony injury on CT. Thus, it is essential to ensure that patients with congenital anomalies are not treated unnecessarily for spinal fractures.

Vertebral arteries bilaterally passing through stellate (cervicothoracic) ganglion.

Vertebral artery is a branch of the first part of subclavian artery. Vertebral artery arising from the aortic arch most commonly presents on the left side. The cervical part of sympathetic trunk is closely related to the vertebral artery in the cervical region. Though lots of variations regarding anomalous origin, course of vertebral artery is reported in the literature, here we present a rare anomaly in which vertebral artery after originating from aortic arch is passing through stellate ganglia and it enters into the transverse foramina of higher cervical vertebra (C5). Such variation should be kept in mind by anaesthetist during stellate ganglion block in order to relieve intractable pain in central nervous system lesion. Surgeons should keep this anomaly in mind during cervical spine surgery otherwise vertebral artery may get injured leading to haemorrhage.

A Study on Mortality Profile among Fifty Plus- (50+-) Population (FPP) of India: A 5-Year Retrospective Study at New Delhi District.

Objectives. To find out the mortality profile vis-a-vis different epidemiological factors at the time of autopsy among the 50+-Population. Material and Method. A five-year retrospective evaluation of medicolegal records between 2006 and 2010 was done at Lady Hardinge Medical College, New Delhi. Results. A total of 493 (17.78%) cases belonged to 50+-Population age group out of total 2773 autopsies performed. The proportion of unidentified/unknown persons among this age group was 36.51%. The unnatural and natural causes constituted 44.62% and 55.38% cases, respectively. The unspecified pneumonitis (50.18%) was reported as the commonest cause followed by coronary artery disease and respiratory tuberculosis among natural ones and the transport accident (57.27%) followed by accidental and intentional self-poisoning and exposure to noxious substances and falls among the unnatural ones. Conclusion. The findings reveal that this age group most commonly dies of natural causes rather than the unnatural ones even in autopsy cases. They have definite cure with timely interventions. The study also points out the need to devise the road and home safety measures to reduce mortality among the study population.

Gymnemic Acid Stimulates In Vitro Splenic Lymphocyte Proliferation.

Gymnemic acid is a mixture of triterpenoid saponins of oleanane class, isolated from Gymnema sylvestre Wild R.Br (family: Asclepidaceae), an herbal plant used in traditional medicine to treat diabetes. Effect of gymnemic acid (0.1-20 µg/mL) on in vitro mitogen (concanavalin A and lipopolysaccharide)-induced splenic lymphocyte proliferation was studied using rat as model. Significant (p < 0.05) stimulation of lymphoproliferation was observed in cultures treated with 10 and 20 µg/mL concentration of gymnemic acid in the absence or presence of mitogens. The present study suggests that gymnemic acid has immunomodulatory property, stimulating lymphoid components of immune system, and the traditional knowledge of anti-diabetic property of G. sylvestre is scientifically supplemented with its immunomodulatory properties.

Immunomodulatory Effect of Gymnema sylvestre (R.Br.) Leaf Extract: An In Vitro Study in Rat Model.

Gymnema sylvestre Wild R.Br (family: Asclepidaceae) is a valuable medicinal plant used in folk medicine to treat diabetes, obesity, asthma etc. in India for antiquity. Diabetes mellitus is a syndrome characterized immunologically by lymphocyte apoptosis and reduced cell-mediated and humoral immunity. Modulation of immune responses to alleviate diseases has been of interest, and traditional herbal medicines may play an important role in this regard. In this study, we aim to evaluate the immunomodulatory potential of methanolic extract of G. sylvestre leaf using rat model. HPLC analysis of leaf extract was carried out for gymnemic acid. The method involves the initial hydrolysis of gymnemic acids, the active ingredients, to a common aglycone followed by the quantitative estimation of gymnemagenin, using gymnemagenin as reference standard. Gymnemic acid content was 2.40% (w/w) in G. sylvestre leaf extract. In vitro immunomodulatory activity of the methanolic extract of G. sylvestre leaf (1-200µg/ml) was evaluated by gauging its effects on nitroblue tetrazolium reduction and nitrite release in rat peritoneal macrophages and on mitogen (ConA, PHA and LPS) induced splenic lymphocyte proliferation. G. sylvestre leaf extract showed significant (<0.05) enhancement in NO and ROS generation in macrophages and in proliferation of lymphocytes in dose dependent manner. EC50 value was 3.10, 3.75 and 2.68 µg/ml for NBT reduction, nitrite release and lymphoproliferation, respectively. Potential effect was observed at 100 µg/ml in NO and ROS generation in macrophages and 20 µg/ml in lymphocyte proliferation. G. sylvestre leaf extract stimulates macrophage reactivity, increasing the level of activity even higher when combined with PMA or LPS. These findings suggest the presence of active compounds, gymnemic acid, in methanolic extract of G. sylvestre leaf that stimulates both myeloid and lymphoid components of immune system, and therefore can restore the innate immune function. Through this study, the traditional knowledge of anti-diabetic property of G. sylvestre is scientifically supplemented with its immunomodulatory properties.

Lymphocytic hypophysitis in males.

Lymphocytic hypophysitis (LH) is a rare inflammatory disorder of the pituitary gland that typically affects women in the peripartum period. We describe two male patients (ages 43 years and 36 years), who presented with headaches, visual disturbance and hypopituitarism. MRI revealed a heterogeneous pituitary lesion that extended into the suprasellar region and with a thickened pituitary stalk. In both patients a histopathological diagnosis of LH was made after endoscopic transsphenoidal surgery. LH in males, although rare, should be considered as a differential diagnosis in those with hypopituitarism and a heterogeneous pituitary fossa mass, extending into pituitary stalk.

Comparison of single-incision laparoscopic high anterior resection with standard laparoscopic high anterior resection.

AIM: Single-incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS). METHOD: Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS. RESULTS: Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three-port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2-24) h for SILS vs 18 (2-96) h for StdLS] and were discharged faster [1 (1-8) days for SILS vs 3 (1-24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30-day mortality. CONCLUSION: SILS for high anterior resection is feasible, safe and quicker to perform than standard three-port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.

Formulation development and optimization of polyox based quick dissolving film of quetiapine.

Quick dissolving film prepared by various grades of polyox like Polyox N10, N80, N750 and N205. Polyox having excellent film forming capacity with rapid hydration power which leads to rapid disintegration of film upon contact with saliva. Film is optimized for concentration of polymer and plasticizer using CCD design. The tensile Strength, folding Endurance, % drug released at 10 min (Y10) and disintegration time were selected as dependent variables. The data revealed that 2% of polyox N 750 and 15% of PEG 400 showed excellent film forming property with rapid drug release profile.

A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation.

AIM: Despite advances in surgical technique, parastomal herniation is common. This systematic review aims to assess the efficacy of prophylactic mesh at primary operation in reducing the incidence of parastomal hernia. METHOD: Medline, EMBASE and CENTRAL were searched for relevant publications between January 1980 and January 2010. The search strategy included text terms and MESH headings for parastomal hernia, mesh and prevention and/or prophylaxis of hernia. No language restrictions were applied. Bibliographies from the papers requested in full were manually checked. All randomized controlled trials were included regardless of the language of publication. Results were extracted from the papers by two observers independently on a predefined data sheet. Disagreements were resolved by discussion. REVMAN 5 was used for statistical analysis. RESULTS: Of 27 possible studies three randomized controlled trials fulfilled the criteria for systematic review, with a total of 128 patients (mesh 64, no mesh 64). The two study groups were well matched demographically. The incidence of parastomal hernia in the mesh group was 12.5% (8/64) compared with 53% (34/64) in the control group (P < 0.0001). There was no difference in mesh related morbidity in the two groups. CONCLUSION: Although only three trials with 128 patients fulfilled the criteria for this systematic review, the data suggest that the use of prophylactic prosthetic mesh at the time of primary stoma formation reduces the incidence of parastomal hernia.

Short-term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians.

AIM: The 30-day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied. METHOD: An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded. RESULTS: In all, 173 patients (80 men) of median age 84 (80-93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14-45) kg/m(2). Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty-three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1-37) days. Three (1.7%) patients died within 30 days of surgery. CONCLUSION: This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.

An FTO variant is associated with Type 2 diabetes in South Asian populations after accounting for body mass index and waist circumference.

AIMS: A common variant, rs9939609, in the FTO (fat mass and obesity) gene is associated with adiposity in Europeans, explaining its relationship with diabetes. However, data are inconsistent in South Asians. Our aim was to investigate the association of the FTO rs9939609 variant with obesity, obesity-related traits and Type 2 diabetes in South Asian individuals, and to use meta-analyses to attempt to clarify to what extent BMI influences the association of FTO variants with diabetes in South Asians. METHODS: We analysed rs9939609 in two studies of Pakistani individuals: 1666 adults aged ≥40 years from the Karachi population-based Control of Blood Pressure and Risk Attenuation (COBRA) study and 2745 individuals of Punjabi ancestry who were part of a Type 2 diabetes case-control study (UK Asian Diabetes Study/Diabetes Genetics in Pakistan; UKADS/DGP). The main outcomes were BMI, waist circumference and diabetes. Regression analyses were performed to determine associations between FTO alleles and outcomes. Summary estimates were combined in a meta-analysis of 8091 South Asian individuals (3919 patients with Type 2 diabetes and 4172 control subjects), including those from two previous studies. RESULTS: In the 4411 Pakistani individuals from this study, the age-, sex- and diabetes-adjusted association of FTO variant rs9939609 with BMI was 0.45 (95%CI 0.24-0.67) kg/m(2) per A-allele (P=3.0 × 10(-5) ) and with waist circumference was 0.88 (95% CI 0.36-1.41) cm per A-allele (P=0.001). The A-allele (30% frequency) was also significantly associated with Type 2 diabetes [per A-allele odds ratio (95%CI) 1.18 (1.07-1.30); P=0.0009]. A meta-analysis of four South Asian studies with 8091 subjects showed that the FTO A-allele predisposes to Type 2 diabetes [1.22 (95%CI 1.14-1.31); P=1.07 × 10(-8) ] even after adjusting for BMI [1.18 (95%CI 1.10-1.27); P=1.02 × 10(-5) ] or waist circumference [1.18 (95%CI 1.10-1.27); P=3.97 × 10(-5) ]. CONCLUSIONS: The strong association between FTO genotype and BMI and waist circumference in South Asians is similar to that observed in Europeans. In contrast, the strong association of FTO genotype with diabetes is only partly accounted for by BMI.

Laparoscopic surgery for recurrent ileocolic Crohn's disease is as safe and effective as primary resection.

AIM: The safety and short-term outcome of laparoscopic surgery for recurrent ileocolic Crohn's disease was compared with the outcome following primary resection. METHOD: Between June 2002 and June 2010, 59 consecutive unselected patients (30 of whom had recurrent disease) underwent laparoscopic ileocolic resection. Four primary resections and one revision were performed as a single incision laparoscopic surgery (SILS) procedure. RESULTS: There was no difference between the two groups in terms of age, body mass index, American Society of Anesthesiology (ASA) grade or the presence or absence of fistulating disease. The median operating time was significantly longer for the revision group (125 min vs 85 min; P < 0.001). The rate of conversion was 8.5%, morbidity was 20% and mortality was 0% (P = not significant between groups). Risk factors for conversion included a complex fistula, fibrosis and the need to carry out multiple stricturoplasty. Patients in whom surgery was converted had a longer hospital stay and a higher morbidity (40%). The median hospital stay was 3 days, the return to theatre rate was 5% and the re-admission rate was 5% (P = not significant between groups). CONCLUSION: Laparoscopic surgery for recurrent ileocolic Crohn's disease is safe and can lead to significant short-term benefit, including earlier discharge. Conversion increases the length of stay in hospital and the overall morbidity.