Reactive oxygen species (ROS)-mediated oxidative stress in chronic liver diseases and its mitigation by medicinal plants.

Reactive oxygen species (ROS) play a crucial role in cell survival regulation, and its low levels may act as indicators to encourage cellular proliferation. In contrast, elevated levels of ROS may lead to apoptosis. Stability between generating and eliminating ROS allows the retention of effective functioning of redox-sensitive signaling proteins under physiologic conditions. Cells typically maintain redox homeostasis to guarantee appropriate responses to internal and external stimuli. However, oxidative stress occurs when the oxidation product level exceeds the number of standard antioxidant systems. ROS can cause harm to all types of hepatic cells, including endothelial cells, hepatocytes, Kupffer cells, and stellate cells. High levels of ROS may lead to tissue edema, ischemia, fibrosis, cell death, or malignant transformation and may eventually lead to complete tissue damage. Antioxidants in our body exist in a homeostatic balance with other enzymes involved in the repair of cellular functions in addition to the non-enzymatic molecules such as urate, bilirubin, several vitamins, and reduced glutathione to maintain the levels of ROS in the interest of cellular homeostasis. This balance may, however, get disturbed in case of acute or chronic liver injury due to the accumulation of ROS. In the current manuscript, we aim to review the relevance of oxidative stress and its indicator of liver injury in chronic liver diseases such as alcoholic and non-alcoholic fatty liver diseases and hepatitis. Since reactive oxidation species may also lead to lipid peroxidation and promote ferroptosis, we have also evaluated their impact on epigenetic modifications, such as oxidative damage to histone proteins and DNA methylation, and the differential expression of genes related to cellular injury. We also want to highlight the potential of traditional herbal medicines as redox regulators for managing chronic liver diseases.

Effect of herbal extracts and Saroglitazar on high-fat diet-induced obesity, insulin resistance, dyslipidemia, and hepatic lipidome in C57BL/6J mice.

We evaluated the effects of select herbal extracts (Tinospora cordifolia [TC], Tinospora cordifolia with Piper longum [TC + PL], Withania somnifera [WS], Glycyrrhiza glabra [GG], AYUSH-64 [AY-64], and Saroglitazar [S]) on various parameters in a diet-induced obesity mouse model. After 12 weeks of oral administration of the herbal extracts in high-fat diet (HFD)-fed C57BL/6J mice, we analyzed plasma biochemical parameters, insulin resistance (IR), liver histology, and the expression of inflammatory and fibrosis markers, along with hepatic lipidome. We also used a 3D hepatic spheroid model to assess their impact on profibrotic gene expression. Among the extracts, TC + PL showed a significant reduction in IR, liver weight, TNF-α, IL4, IL10 expression, and hepatic lipid levels (saturated triglycerides, ceramides, lysophosphocholines, acylcarnitines, diglycerides, and phosphatidylinositol levels). Saroglitazar reversed changes in body weight, IR, plasma triglycerides, glucose, insulin, and various hepatic lipid species (fatty acids, phospholipids, glycerophospholipids, sphingolipids, and triglycerides). With the exception of GG, Saroglitazar, and other extracts protected against palmitic acid-induced fibrosis marker gene expression in the 3D spheroids. TC + PL and Saroglitazar also effectively prevented HFD-induced insulin resistance, inflammation, and specific harmful lipid species in the liver.

The aqueous root extract of Withania somnifera ameliorates LPS-induced inflammatory changes in the in vitro cell-based and mice models of inflammation.

Introduction: Most critically ill COVID-19 patients have bronchitis, pneumonia, and acute respiratory distress syndrome (ARDS) due to excessive inflammatory conditions. Corticosteroids have largely been prescribed for the management of inflammation in these patients. However, long-term use of corticosteroids in patients with comorbidities such as metabolic, cardiovascular, and other inflammatory disorders is ideally not recommended due to safety issues. A potential and safer anti-inflammatory therapy is therefore the need of the hour. Withania somnifera (WS), a well-known herbal medicine used during the pandemic in India to prevent SARS-CoV2 infection, also possesses anti-inflammatory properties. Methods: In the present study, we, therefore, evaluated the effect of the aqueous extract of the roots of W. somnifera in the cell-based assays and in the experimental animal models of LPS-induced inflammation. Results: In the NCI-H460, A549 cells and human peripheral blood mononuclear cells (PBMCs) pre-treatment with W. somnifera reduced the LPS-induced expression of the pro-inflammatory cytokines. In addition, W. somnifera extract also showed potent anti-inflammatory activity in the lung tissues of BALB/c mice challenged intranasally with LPS. We observed a marked reduction in the neutrophil counts in the broncho-alveolar lavage (BAL) fluid, inflammatory cytokines, and fibrosis in the mice lungs pre-treated with W. somnifera. Results obtained thus suggest the potential utility of W. somnifera extract in reducing airway inflammation and recommend the clinical evaluation of W. somnifera extract in COVID-19 patients with a high propensity for lung inflammation.

Cyclic ß-hydroxy-α-nitrosulfone isomers readily interconvert via open-chain aldehyde forms.

Two structurally diverse cyclic ß-hydroxy-α-nitrosulfones have been prepared and their isomerisation reactions studied. These cyclic ß-hydroxy-α-nitrosulfones undergo isomer equilibration via open-chain aldehyde forms under a variety of mild conditions. Michael condensation of 1,1'-[(1,3-dinitro-1,3-propanediyl)bis(sulfonyl)]bis(benzene) with propenal and subsequent cyclisation afforded 2,4-dinitro-2,4-bis(phenylsulfonyl)cyclohexanol in 98% yield as a mixture of four diastereomers. Sequential chromatography and recrystallization afford pure (1R,2R,4S)-rel-2,4-dinitro-2,4-bis(phenylsulfonyl)cyclohexanol based on spectroscopic and X-ray crystallographic data. This diastereomer equilibrates with the other three possible diastereomers under a variety of mild conditions: during silica gel chromatography, when dissolved in basic solution, and when dissolved in neutral polar solvents. Open-chain aldehyde forms are implicated as intermediates in isomer interconversion. Condensation of 1-methyl-4-[(nitromethyl)sulfonyl]benzene and pentanedial gives 2-(4-methylphenylsulfonyl)-2-nitrocyclohexane-1,3-diol as predominantly two diastereomers. Purification affords pure racemic diastereomer in 55% yield. This racemic diastereomer interconverts with several other isomers during silica gel chromatography. These isomers were identified as one, likely two, diastereomeric meso 2-(4-methylphenylsulfonyl)-2-nitrocyclohexane-1,3-diol isomers and four cyclic hemiacetal constitutional isomers. When dissolved in neutral polar solvents, the racemic diastereomer also interconverts with meso diastereomers and cyclic hemiacetals showing a marked solvent dependence. Reaction of the racemic diastereomer with triethylamine in dichloromethane results in isomerisation as well as substantial reversion to 1-methyl-4-[(nitromethyl)sulfonyl]benzene and pentanedial. Reaction with triethylamine in DMSO as well as simply warming in DMSO results in ring opening and concomitant dehydration to afford (E)-6-(4-methylphenylsulfonyl)-6-nitrohex-4-enal.

Recent advances in critical care: Part II.

With the increasing number of critically ill patients being admitted to intensive care units (ICUs), newer techniques and treatment modalities continue to evolve for their adequate management. Thus, it has become imperative to understand existing tools and resources, and utilise or repurpose them to achieve better results that can decrease morbidity and mortality. In this writeup, we chose five areas of interest, including analgosedation, role of colloids, recent advancements in the management of respiratory failure, the role of extracorporeal membrane oxygenation, and newer antimicrobials. The role of analgosedation in the critically ill has gained importance with focus on post-ICU syndromes, and albumin has re-entered the fray as a possible repairer of the injured glycocalyx. The coronavirus disease 2019 (COVID-19) pandemic forced us to relook at various ventilator strategies and mechanical support for the failing circulation has now become more common with clear end-points. Rising microbial antibiotic resistance has opened up the research on newer antibiotics.

2-{N-[(2,4,5-trichlorophenoxy) acetyl]-N-methylamino}-3-pyrrolidinepropanamide analogs as potential antagonists of Urotensin II receptor.

THE PURPOSE OF THE ARTICLE: To identify novel small molecule antagonists of Urotensin II receptor with acceptable pharmacological profile. MATERIALS AND METHODS: Structure-activity-relationship (SAR) studies on 2-{N-[(2,4,5-trichlorophenoxy) acetyl]-N-methylamino}-3-pyrrolidinepropanamide series were conducted and shortlisted compounds were synthesized and evaluated in in vitro cell-based assays. Human and mouse Urotensin II receptor overexpressing CHO cells were used for calcium release and radioligand binding assays. Initial molecules in this series had solubility and inter-species variability issue in the calcium release assay. We, therefore, conducted SAR to overcome these 2 issues and molecules with accepted in vitro profile were evaluated further in mouse pressor response model to generate the in vivo proof of concept for UII receptor antagonization. RESULTS AND CONCLUSIONS: We report herewith identification of 2-{N-[(2,4,5-trichlorophenoxy)acetyl]-N-methylamino}-3-pyrrolidinepropanamides series to obtain novel small molecule antagonists of Urotensin II receptor with acceptable pharmacological profile.

Pathogenesis of Fistulating Crohn's Disease: A Review.

Sustained, transmural inflammation of the bowel wall may result in the development of a fistula in Crohn's disease (CD). Fistula formation is a recognized complication and cause of morbidity, occurring in 40% of patients with CD. Despite advanced treatment, one-third of patients experience recurrent fistulae. Development of targeting treatment for fistulae will be dependent on a more in depth understanding of its pathogenesis. Presently, pathogenesis of CD-associated fistulae remains poorly defined, in part due to the lack of accepted in vitro tissue models recapitulating the pathogenic cellular lesions linked to fistulae and limited in vivo models. This review provides a synthesis of the existing knowledge of the histopathological, immune, cellular, genetic, and microbial contributions to the pathogenesis of CD-associated fistulae including the widely accredited contribution of epithelial-to-mesenchymal transition, upregulation of matrix metalloproteinases, and overexpression of invasive molecules, resulting in tissue remodeling and subsequent fistula formation. We conclude by exploring how we might utilize advancing technologies to verify and broaden our current understanding while exploring novel causal pathways to provide further inroads to future therapeutic targets.

Diagnostic Performance of Magnetic Resonance Enterography Disease Activity Indices Compared with a Histological Reference Standard for Adult Terminal Ileal Crohn's Disease: Experience from the METRIC Trial.

BACKGROUND AND AIMS: The simplified magnetic resonance enterography [MRE] index of activity [sMARIA], London, and 'extended' London, scoring systems are widely used in Crohn's disease [CD] to assess disease activity, although validation studies have usually been single-centre, retrospective, and/or used few readers. Here, we evaluated these MRE indices within a prospective, multicentre, multireader, diagnostic accuracy trial. METHODS: A subset of participants [newly diagnosed or suspected of relapse] recruited to the METRIC trial with available terminal ileal [TI] biopsies was included. Using pre-specified thresholds, the sensitivity and specificity of sMARIA, London, and 'extended' London scores for active and severe [sMARIA] TI CD were calculated using different thresholds for the histological activity index [HAI]. RESULTS: We studied 111 patients [median age 29 years, interquartile range 21-41, 75 newly diagnosed, 36 suspected relapse] from seven centres, of whom 22 had no active TI CD [HAI = 0], 39 mild [HAI = 1], 13 moderate [HAI = 2], and 37 severe CD activity [HAI = 3]. In total, 26 radiologists prospectively scored MRE datasets as per their usual clinical practice. Sensitivity and specificity for active disease [HAI >0] were 83% [95% confidence interval 74% to 90%] and 41% [23% to 61%] for sMARIA, 76% [67% to 84%] and 64% [43% to 80%] for the London score, and 81% [72% to 88%] and 41% [23% to 61%] for the 'extended' London score, respectively. The sMARIA had 84% [69-92%] sensitivity and 53% [41-64%] specificity for severe CD. CONCLUSIONS: When tested at their proposed cut-offs in a real-world setting, sMARIA, London, and 'extended' London indices achieve high sensitivity for active TI disease against a histological reference standard, but specificity is low.

IL-1-driven stromal-neutrophil interactions define a subset of patients with inflammatory bowel disease that does not respond to therapies.

Current inflammatory bowel disease (IBD) therapies are ineffective in a high proportion of patients. Combining bulk and single-cell transcriptomics, quantitative histopathology and in situ localization across three cohorts of patients with IBD (total n = 376), we identify coexpressed gene modules within the heterogeneous tissular inflammatory response in IBD that map to distinct histopathological and cellular features (pathotypes). One of these pathotypes is defined by high neutrophil infiltration, activation of fibroblasts and vascular remodeling at sites of deep ulceration. Activated fibroblasts in the ulcer bed display neutrophil-chemoattractant properties that are IL-1R, but not TNF, dependent. Pathotype-associated neutrophil and fibroblast signatures are increased in nonresponders to several therapies across four independent cohorts (total n = 343). The identification of distinct, localized, tissular pathotypes will aid precision targeting of current therapeutics and provides a biological rationale for IL-1 signaling blockade in ulcerating disease.

Identification of novel Urotensin-II receptor antagonists with potent inhibition of U-II induced pressor response in mice.

Urotensin II (U-II) has been found to be one of the most potent vasoconstrictor (Ames et al., 1999; Bohm et al., 2002) reported till date. U-II exerts its response via activation of a G-protein coupled receptor, Urotensin II receptor(UT). Binding of U-II to UT leads to an instant increase in the inositol phosphate turnover and intracellular Ca2+. Such an instant Ca2+ release and potent vasoconstriction exerted by U-II is expected to have an important role in the progression of cardiac diseases. We have previously shown that UT antagonist DS37001789 prevents U-II induced blood pressure elevation in mice (Nishi et al., 2019) in a dose dependent manner, with potent efficacy at 30 and 100 mg/kg. Further to this, we have also shown that DS37001789 ameliorates mortality in pressure-overload mice with heart failure (Nishi et al., 2020). We therefore conducted an extensive structure-activity relationship studies to identify molecules with superior efficacy. In the present manuscript, we report the identification of two potent, non-peptide small molecule antagonists of Urotensin II receptor (UT), RCI-0879 and RCI-0298 which blocked the action of U-II, both in vitro and in vivo. These molecules were found to be very potent in in vitro Ca2+ and radioligand binding assays using human and mouse UT over-expressing CHO cells. RCI-0879 and RCI-0298 also exhibited superior efficacy in in vivo mouse pressor response model using C57BL/6 mice, compared to our initial molecules (Nishi et al., 2019) and demonstrated ED50 values of 3.2 mg/kg and 6.8 mg/kg respectively. Our findings reported herewith, further strengthen our concept and belief in UT antagonization as a potential therapeutic approach for the management of chronic heart failure.

The Difficult Paediatric Airway: Two Cases of large Cystic Hygroma.

This is a report of a two cases of difficult intubation experienced in paediatric surgical cases. Both the infants, aged one and three-month-old respectively, had very large cystic hygroma of the neck area. Prior hematological and radiological investigations (USG and CT scan of the swelling) and preanaesthesia check up was done and cases were posted for surgical excision. Case I had difficult airway due to pressure of the tumour/cystic hygroma over the airway and posed difficulty for intubation, but was managed well. Case II had respiratory distress during preoperative period. She had been postponed for surgical excision of the cystic hygroma of neck twice due to the difficulties experienced during intubation. Needle aspiration of hygroma fluid helped to reduce the respiratory distress, and the size of the tumour as well, which further helped in the smooth intubation after a week. The postoperative period was uneventful in both the infants.

Congenital fibroepithelial polyp: a case report of difficult airway.

A 9 month old child presented with a growth in the oropharynx for removal. Only complaint was distressed breathing on crying. It turned out to be a case of difficult paediatric airway that was managed well. A diagnoses of oesophageal fibro-epithelial polyp was made after histopathological examination.

A review on leukotrienes and their receptors with reference to asthma.

OBJECTIVE AND METHODS: Leukotrienes (LTs) including cysteinyl leukotrienes (CysLTs) and LTB4 are the most potent inflammatory lipid mediators and play a central role in the pathophysiology of asthma and other inflammatory diseases. These biological molecules mediate a plethora of contractile and inflammatory responses through specific interaction with distinct G protein-coupled receptors (GPCRs). The main objective of this review is to present an overview of the biological effects of CysLTs and their receptors, along with the current knowledge of mechanisms and role of LTs in the pathogenesis of asthma. RESULTS: CysLTs including LTC4, LTD4 and LTE4 are ligands for CysLT1 and CysLT2 receptors, and LTB4 is the agonist for BLT1 and BLT2 receptors. The role of CysLT1 receptor is well established, and most of the pathophysiological effects of CysLTs in asthma are mediated by CysLT1 receptor. Several CysLT1 antagonists have been developed to date and are currently in clinical practice. Most common among them are classical CysLT1 receptor antagonists such as montelukast, zafirlukast, pranlukast, pobilukast, iralukast, cinalukast and MK571. The pharmacological role of CysLT2 receptor, however, is less defined and there is no specific antagonist available so far. The recent demonstration that mice lacking both known CysLT receptors exhibit full/augmented response to CysLT points to the existence of additional subtypes of CysLT receptors. LTB4, on the other hand, is another potent inflammatory leukotriene, which acts as a strong chemoattractant for neutrophils, but weaker for eosinophils. LTB4 is known to play an important role in the development of airway hyper-responsiveness in severe asthma. However there is no LTB4 antagonist available in clinic to date. CONCLUSION: This review gives a recent update on the LTs including their biosynthesis, biological effects and the role of anti-LTs in the treatment of asthma. It also discusses about the possible existence of additional subtypes of CysLT receptors.

RBx10080307, a dual EGFR/IGF-1R inhibitor for anticancer therapy.

Pharmacological intervention of epidermal growth factor receptor (EGFR) family members by antibodies or small molecule inhibitors has been one of the most successful approaches for anticancer therapy. However this therapy has its own limitations due to the development of resistance, over a period of time. One of the possible causes of the development of resistance to the therapy with EGFR inhibitors could be the simultaneous activation of parallel pathways. Both EGFR and insulin like growth factor-1 receptor (IGF-1R) pathways are reported to act reciprocal to each other and converge into the mitogen activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways. Inhibiting one pathway alone may therefore not be sufficient and could be a cause of development of resistance. The other cause could be mutations of EGFR which would be less sensitive to the inhibitors. We, therefore, suggest that co-targeting IGF-1R and EGFR kinases by dual inhibitors can lead to improved efficacy and address the problems of resistance. In the present manuscript, we report the identification of a novel, small molecule dual EGFR/IGF-1R inhibitor, RBx10080307 which displayed in vitro activity at the molecular level and oral efficacy in mouse xenograft model. The compound also showed in vitro activity in an EGFR mutant cell line and may thus have the potential to show activity in resistant conditions. Additional efficacy studies are needed in EGFR resistant mouse cancer model and if found efficacious, this can be a major advantage over standalone erlotinib and other existing therapies.

Dual epidermal growth factor receptor (EGFR)/insulin-like growth factor-1 receptor (IGF-1R) inhibitor: a novel approach for overcoming resistance in anticancer treatment.

Small molecule inhibitors of epidermal growth factor receptors (EGFR) have been found to show a good initial response in cancer patients but during the course of treatment, patients develop resistance after a few weeks of time. Development of secondary mutations or over-activation of insulin like growth factor (IGF-1R) pathway are a few of the several mechanisms proposed to explain the resistance. To study the effect of dual inhibition of EGFR and IGF-1R in overcoming the resistance, three strategies were envisaged and are reported in this manuscript: 1) a virtual predictive tumor model, 2) in vitro experimental data using a combination of EGFR and IGF-1R inhibitors and 3) in vitro experimental data using in house dual inhibitors. Findings reported in this manuscript suggest that simultaneous inhibition of IGF-1R and EGFR either by combination of two inhibitors or by dual kinase inhibitors is more efficacious compared to single agents. In vitro cell based experiments conducted using epidermoid cancer cell line, A431 and an EGFR mutant cell line, H1975 along with virtual predictions reported here suggests that dual inhibition of EGFR and IGF-1R is a viable approach to overcome EGFR resistance.

Enhanced expression of recombinant proteins utilizing a modified baculovirus expression vector.

The baculovirus expression vector system (BEVS) has been widely used for over-expressing eukaryotic proteins due to a close resemblance in post-translational modification, processing, and transportation properties of the expressed protein, to that of the mammalian cells. In comparison to the bacterial expression system, protein yield from BEVS is relatively low, resulting in higher cost of production. To improve the existing recombinant protein expression levels, baculovirus homologous region1 (hr1) was strategically integrated into the bacmid-based transfer vectors. Luciferase reporter, human Protein Kinase B-alpha (PKB-A), and N-terminal-modified CYP-1A2 genes were independently cloned in non-hr1 and hr1 constructs for generating respective bacmids and baculoviruses. These recombinant baculoviruses were utilized for comparing the expression levels at varying multiplicity of infections (MOI) and time intervals in Spodoptera frugiperda (Sf21) or Trichoplusia ni (Tni) insect cell lines. Targeted insertion of hr1 upstream to CYP-1A2, PKB-A, and Luciferase genes, compared to the non-hr1 sets, led to 3-, 3.5-, and 4.5-fold increase in the resultant protein levels, respectively. Moreover, at equal protein concentration, the corresponding activity and inhibition characteristics of these high expression hr1 sets were comparable to that of the respective non-hr1 sets. Utilization of this modified baculovirus expression construct offers significant advantage of producing recombinant proteins in a cost-effective manner for various biotechnological and therapeutic applications.

Cinnamic acid, from the bark of Cinnamomum cassia, regulates glucose transport via activation of GLUT4 on L6 myotubes in a phosphatidylinositol 3-kinase-independent manner.

BACKGROUND: Cinnamomum cassia (Family: Lauraceae) is an Ayurvedic medicinal plant used traditionally for the treatment of a number of diseases, including diabetes. The hypoglycemic effect of this plant has been established in vivo. However, the effects of cinnamic acid, isolated from C. cassia, on the insulin signaling cascade in an in vitro model have not been elucidated. Hence, the aim of the present study was to evaluate the anti-diabetic effect of cinnamic acid on glucose transport by L6 myotubes. METHODS: The mechanism of action of cinnamic acid was determined using specific targets in the insulin signaling pathway, including protein tyrosine phosphatase (PTP) 1B, phosphatidylinositol 3-kinase (PI3-K) and the glucose transporter GLUT4. After differentiation of myoblast to myotubes, the cells were serum deprived for 5 h and then treated with 1 ng/mL cinnamic acid and 50 µmol/L rosiglitazone for 18 h and 100 nmol/L insulin for 20 min for gene expression studies. RESULTS: Expression of GLUT4 mRNA was increased following treatment of L6 myotubes with 1 ng/mL cinnamic acid. Furthermore, cinnamic acid inhibited PTP1B activity (by 96.5%), but had no significant effect on PI3-K activity. CONCLUSION: On the basis of the results of the present study, we postulate that cinnamic acid isolated from the hydro-alcoholic extract of Cinnamomum cassia activates glucose transport by a PI3-K-independent pathway. However, the detailed mechanism of action requires further analysis.

Essential role of PSM/SH2-B variants in insulin receptor catalytic activation and the resulting cellular responses.

The positive regulatory role of PSM/SH2-B downstream of various mitogenic receptor tyrosine kinases or gene disruption experiments in mice support a role of PSM in the regulation of insulin action. Here, four alternative PSM splice variants and individual functional domains were compared for their role in the regulation of specific metabolic insulin responses. We found that individual PSM variants in 3T3-L1 adipocytes potentiated insulin-mediated glucose and amino acid transport, glycogenesis, lipogenesis, and key components in the metabolic insulin response including p70 S6 kinase, glycogen synthase, glycogen synthase kinase 3 (GSK3), Akt, Cbl, and IRS-1. Highest activity was consistently observed for PSM alpha, followed by beta, delta, and gamma with decreasing activity. In contrast, dominant-negative peptide mimetics of the PSM Pro-rich, pleckstrin homology (PH), or src homology 2 (SH2) domains inhibited any tested insulin response. Potentiation of the insulin response originated at the insulin receptor (IR) kinase level by PSM variant-specific regulation of the Km (ATP) whereas the Vmax remained unaffected. IR catalytic activation was inhibited by peptide mimetics of the PSM SH2 or dimerization domain (DD). Either peptide should disrupt the complex of a PSM dimer linked to IR via SH2 domains as proposed for PSM activation of tyrosine kinase JAK2. Either peptide abolished downstream insulin responses indistinguishable from PSM siRNA knockdown. Our results implicate an essential role of the PSM variants in the activation of the IR kinase and the resulting metabolic insulin response. PSM variants act as internal IR ligands that in addition to potentiating the insulin response stimulate IR catalytic activation even in the absence of insulin.

Congenital epulis of the newborn: a case report with review of literature.

Congenital epulis, also known as congenital gingival granular cell tumor, is a rare benign intraoral tumor found only in the new born. It can be solitary or multiple and may occur in the mandible, maxilla or tongue and may or may not be associated with other congenital anomalies. The size of the mass varies and if very large may interfere with respiration and feeding at birth, thus necessitating the immediate surgical resection at birth to maintain patency of the airways. Antepartum detection by careful imaging and coordination of multidisciplinary team of maternal-fetal medicine, neonatal-perinatal medicine, anesthesiology and otolaryngology and finally the histopathologists who confirm the diagnosis is essential as the histology differentiates it from other congenital intraoral masses like haemangioma, fibroma, rhabdomyoma, rhabdomyosarcoma, lymphangioma, osteogenic and chondrogenic sarcomas.