Comparative appraisal of ghee and common vegetable oils for spectral characteristics in FT-MIR reflectance spectroscopy.

FT-MIR spectra of ghee (anhydrous milk fat) and common vegetable oils were acquired using HATR in 4000-650 cm-1 region. The differences in absorbance by carbon-hydrogen (C-H) stretch in fatty acid chain at 3.48 µm and absorbance by carbonyl (C-O) stretch of ester linkage at 5.7 µm in ghee and that in vegetable oils were studied. The clear differences in the spectra of ghee and that of the vegetable oils were noticed in fingerprint region, which can be very well utilized to develop FT-MIR spectroscopy as a promising tool to detect presence of common vegetable oils mixed in the ghee as an adulterant.

A Comprehensive Review of Thrombocytopenia With a Spotlight on Intensive Care Patients.

Thrombocytopenia is a common entity seen in ICU patients and is associated with increased morbidity such as bleeding and transfusions, and mortality in ICU patients. Various mechanisms such as decreased platelet production, sequestration, destruction, consumption, and sometimes a combination of these factors contribute to thrombocytopenia. An understanding of the mechanism is essential to diagnose the cause of thrombocytopenia and to help provide appropriate management. The management strategies are aimed at treating the underlying disorder, such as platelet transfusion to treat complications like bleeding. Several studies have aimed to provide the threshold for platelet transfusions in various clinical settings and recommend a conservative approach in the appropriate scenario. In this review, we discuss various pathophysiological mechanisms of thrombocytopenia and the diverse scenarios of thrombocytopenia encountered in the ICU setting to shed light on the varied thresholds for platelet transfusion, alternative agents to platelet transfusion, and future directions for the implementation of thromboelastography (TEG) in multiple clinical scenarios to assist in the administration of appropriate blood products to correct coagulopathy.

From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions.

Pleural space infections have been described since the time of Hippocrates and to this day remains a significant pathology. Every year in the USA approximately there are one million hospital admissions for pneumonia with 20%-40% associated with some form of pleural space infections leading to pleural effusions with increased morbidity and mortality. Often, management of these effusions mandate combination of medical treatment and surgical drainage with debridement and decortication. There has been a lot of ongoing research regarding the safety and efficacy of intrapleural fibrinolytics in the management of complicated pleural effusions and empyema. Till this day, areas of debate and controversies exist among clinicians treating pleural space infection. Empyema is historically considered a surgical disease. There have been societies and guidelines for the management of infected parapneumonic effusions with antibiotics and chest tube drainage as an initial empiric treatment modality. With the advances in the use of Intrapleural fibrinolytics and minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS), empyema a surgical disease is now more favoring medical management. Surgical option, such as open thoracotomy, is reserved for patients who failed conservative management and chronic empyema. The aim of this comprehensive review is to shed light on the evolution of various management strategies from the era of Hippocrates to current day practice and how there continues to be a paradigm shift in treating empyema as a surgical condition to a medical disease.

Chronic kidney disease after orthotopic liver transplantation in recipients receiving tacrolimus.

INTRODUCTION: Chronic kidney disease (CKD) is common in liver transplant recipients receiving calcineurin inhibitors. METHOD AND POPULATION: The goals of this case-control study were to identify risk factors associated with CKD and its effect on mortality in 294 liver transplant recipients receiving calcineurin inhibition with tacrolimus. RESULTS: Hepatitis C virus (HCV) was the most common indication (42%) for transplantation. CKD 4 and 5 (estimated glomerular filtration rate (eGFR) of <=29 ml/min/1.73 m2) developed in 10.8% of recipients during a mean follow-up of 52 months. The incidence density of CKD was 2.56 per 100 patient-years. End-stage renal disease developed in 2.7%. By univariate analysis, CKD patients were older (mean±sd, 57±10 vs. 51±11, p<0.05) with hypertension (56 vs. 32%, p<0.05), had lower preoperative hematocrit (31±6 vs. 34±5, p<0.05), alanine aminotransferase (median (95% confidence limit) 46 (34­80) vs. 68 (56­77), <0.05) and eGFR (56±28 vs. 91±35 ml/ min/1.73 m2, p<0.05), had higher preoperative prothrombin time (16.1 (14.6­17.2) vs. 14.8 (14.5­15.1) seconds, p<0.05), and required more perioperative renal replacement therapy (RRT) (41% vs. 6.5%, p<0.05) compared to controls. Perioperative need for RRT (hazard ratio (95% CI) 2.72 (1.05­7.03)) and lower preoperative eGFR: 60­89 (4.08 (1.23­13.5)), 30­59 (4.26 (1.18­15.36)), and<=29 (5.91 ((1.28­27.19)) vs. eGFR>=90 ml/min/1.73 m2 were independently associated with development of CKD adjusting for important covariates. The development of CKD (2.36 (1.22­4.59)) was independently associated with late mortality with an attributable risk of 12.8%. CONCLUSION: Data demonstrate that CKD is an important clinical event associated with increased risk for death after primary liver transplantation.

Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency.

BACKGROUND: Reflux in the ovarian veins, with or without an obstructive venous outflow component, is reported to be the primary cause of pelvic venous insufficiency (PVI). The degree to which venous outflow obstruction plays a role in PVI is currently ill-defined. METHODS: We retrospectively reviewed the charts of 227 women with PVI who presented to the Center for Vascular Medicine from January 2012 to September 2015. Assessments and interventions consisted of an evaluation for other causes of chronic pelvic pain by a gynecologist; preintervention and postintervention visual analog scale (VAS) pain score; complete venous duplex ultrasound examination; and Clinical, Etiology, Anatomy, and Pathophysiology classification. All patients underwent diagnostic venography of their pelvic and left ovarian veins as well as intravascular ultrasound of their iliac veins. Patients were treated in one of six ways: ovarian vein embolization (OVE) alone (chemical ± coils), OVE with staged iliac vein stenting, OVE with simultaneous iliac vein stenting, iliac vein stenting alone, OVE with venoplasty, and venoplasty alone. RESULTS: Of the 227 women treated, the average age and number of pregnancies was 46.4 ± 10.4 years and 3.36 ± 1.99, respectively. Treatment distribution was the following: OVE, n = 39; OVE with staged stenting, n = 94; OVE with simultaneous stenting, n = 33; stenting alone, n = 50; OVE with venoplasty, n = 8; and venoplasty alone, n = 3. Seven patients in the OVE and stenting groups (staged) and one patient in the OVE + venoplasty group required a second embolization of the left ovarian vein. Eighty percent (181/227) of patients demonstrated an iliac stenosis >50% by intravascular ultrasound. Average VAS scores for the entire cohort before and after intervention were 8.45 ± 1.11 and 1.86 ± 1.61 (P ≤ .001). In the staged group, only 9 of 94 patients reported a decrease in the VAS score with OVE alone. VAS score decreased from 8.6 ± 0.89 before OVE to 7.97 ± 2.10 after OVE. After the planned staged stenting, VAS score decreased to 1.33 ± 2.33 (P ≤ .001). Similarly, in the simultaneous group, preintervention scores were 8.63 ± 1.07 and decreased to 2.36 ± 2.67 after OVE + stenting (P ≤ .001). CONCLUSIONS: The majority of patients in our series (80%) demonstrated a significant iliac vein stenosis. These observations indicate that the incidence of iliac vein outflow obstruction in PVI is greater than previously reported. In patients with combined ovarian vein reflux and iliac vein outflow obstruction, our data suggest that pelvic venous outflow lesions should be treated first and that ovarian vein reflux should be treated only if symptoms persist. In women with an outflow lesion, ovarian vein reflux, and a large pelvic reservoir, we recommend simultaneous treatment.

Beta-lactamase-inhibitor combinations in the 21st century: current agents and new developments.

Combinations of beta-lactams and beta-lactamase inhibitors have become one of the most successful antibacterial strategies in our global battle against bacterial infections. The success of these agents is particularly emphasized by the continued efficacy of Augmenting (amoxicillin and clavulanate) after nearly 20 years of clinical use. The clinical situation now dictates that second-generation beta-lactamase inhibitors capable of encompassing both class A and class C beta-lactamases would combat emerging resistance and provide a vital addition to our armory of hospital antibiotics. This realization has generated a renewed interest in beta-lactamase inhibitors and improved the prospects for the delivery of such agents in the future.

Structure-function aspects and inhibitor design of type 5 17beta-hydroxysteroid dehydrogenase (AKR1C3).

17beta-Hydroxysteroid dehydrogenase (17beta-HSD) type 5 has been cloned from human prostate and is identical to type 2 3alpha-HSD and is a member of the aldo-keto reductase (AKR) superfamily; it is formally AKR1C3. In vitro the homogeneous recombinant enzyme expressed in Escherichia coli functions as a 3-keto-, 17-keto- and 20-ketosteroid reductase and as a 3alpha-, 17beta- and 20alpha-hydroxysteroid oxidase. The enzyme will reduce 5alpha-DHT, Delta(4)-androstene-3,17-dione, estrone and progesterone to produce 3alpha-androstanediol, testosterone, 17beta-estradiol and 20alpha-hydroxprogesterone, respectively. It will also oxidize 3alpha-androstanediol, testosterone, 17beta-estradiol and 20alpha-hydroxyprogesterone to produce 5alpha-androstane-3,17-dione, Delta(4)-androstene-3,17-dione, and progesterone, respectively. Many of these properties are shared by the related AKR1C1, AKR1C2 and AKR1C4 isoforms. RT-PCR shows that AKR1C3 is dominantly expressed in the human prostate and mammary gland. Examination of k(cat)/K(m) for these reactions indicates that as a reductase it prefers 5alpha-dihydrotestosterone and 5alpha-androstane-3,17-dione as substrates to Delta(4)-androstene-3,17-dione, suggesting that in the prostate it favors the formation of inactive androgens. Its concerted reductase activity may, however, lead to a pro-estrogenic state in the breast since it will convert estrone to 17beta-estradiol; convert Delta(4)-androstene-3,17-dione to testosterone (which can be aromatized to 17beta-estradiol); and it will reduce progesterone to its inactive metabolite 20alpha-hydroxyprogesterone. Drawing on detailed structure-function analysis of the related rat 3alpha-HSD (AKR1C9), which shares 69% sequence identity with AKR1C3, it is predicted that AKR1C3 catalyzes an ordered bi bi mechanism, that the rate determining step is k(chem), and that an oxyanion prevails in the transition state. Based on these relationships steroidal-based inhibitors that compete with the steroid product would be desirable since they would act as uncompetitive inhibitors. With regards to transition state analogs steroid carboxylates and pyrazoles may be preferred while 3alpha, 17beta or 20alpha-spiro-oxiranes may act as mechanism-based inactivators.

Floor-pattern salt-split skin cannot distinguish bullous pemphigoid from epidermolysis bullosa acquisita. Use of toad skin.

BACKGROUND AND DESIGN: Patients with epidermolysis bullosa acquisita (EBA) and bullous pemphigoid (BP) can present with similar clinical features. These antigens have different phylogenetic origins. It was thought that sodium chloride split-skin immunofluorescence could reliably distinguish between BP and EBA. However, it has now been recognized that both diseases can present with a floor pattern fluorescence on salt-split skin. A simple method is required to distinguish these diseases. RESULTS: Serum specimens from two patients presenting with pruritic blisters showing a floor pattern immunofluorescence on salt-split skin were found to have positive fluorescence on toad skin that has the BP and not the EBA antigen. The diagnosis of BP in these patients was confirmed by a prompt response to treatment with systemic steroids. Electron microscopy showed a split at the lamina lucida. CONCLUSIONS: Bullous pemphigoid can present with a floor pattern immunofluorescence on salt-split skin. The use of the skin from invertebrates like the toad may help in distinguishing BP from EBA.

Leukemia cutis.

Leukemia cutis is an uncommon manifestation of leukemia that is strongly associated with the presence of extramedullary disease at other sites. Patients usually present with leukemia cutis concomitantly with systemic leukemia or after leukemia has been diagnosed. Acute monocytic, myelomonocytic, and the T-cell leukemias show the highest incidence of leukemia cutis. The lesions show varied morphology and can be difficult to distinguish both clinically and histopathologically from nonspecific cutaneous lesions, which occur much more frequently. Immunohistochemistry is useful in making the distinction between them. The prognosis in leukemia cutis is generally poor; the best results have been achieved with a combination of systemic and local therapy.

Effect of sexual practices on T cell subsets and delayed hypersensitivity in transsexuals and female sex workers.

To determine whether ano-receptive unprotected sexual intercourse (SI) practised by transsexuals produces immunological abnormalities we compared delayed hypersensitivity skin tests (DTH) and T cell helper (CD4) and suppressor (CD8) subsets in 57 transsexuals and 69 female sex worker controls. The populations were matched for age, duration of prostitution, number of clients and previous use of antibiotics. Heterosexual males and females and transsexuals who practised protected SI, were also included as controls. All were HIV negative. There were significantly increased absolute CD4 and CD8 counts and decreased DTH and CD4/CD8 ratios in those who practised unprotected ano-receptive SI. These changes were unlikely to be due to any of the microbial agents tested. We conclude that ano-receptive sexual intercourse results in increased immunological abnormalities in these sex workers possibly as a result of rectal exposure to seminal alloantigens. These abnormalities could play an important role as co-factors in disease transmission.

Portal venous pressure and the serum-ascites albumin concentration gradient.

CLINICAL ISSUE: Other investigators have found the serum-ascites albumin concentration gradient to be 1.1 g/dL or greater in the presence of portal hypertension and less than that in its absence. OBJECTIVE: To determine if any correlation exists between the serum-ascites albumin concentration gradient (which reflects the net serum oncotic pressure) and the portal venous pressure. METHODS: The study group comprised 15 patients who had alcoholic cirrhosis. The portal venous pressure was calculated as the difference between the measured hepatic venous wedge and inferior vena cava pressures and was expressed as the hepatic venous pressure gradient. SUMMARY: All patients had portal hypertension; the mean hepatic venous pressure gradient was 14.81 +/- 6.91 (SD) mm Hg. Fourteen of the 15 patients had a serum-ascites albumin concentration gradient of at least 1.1 g/dL; the mean value was 2.168 +/- .709 g/dL. No correlation was found between these variables (r = .0459, P > .05). CONCLUSIONS: Although the serum-ascites albumin concentration gradient is a sensitive indicator of portal hypertension in patients with alcoholic cirrhosis, it does not reflect the portal venous pressure.

Efficacy of health education programme on awareness of AIDS among transsexuals.

A study of the awareness of Acquired Immunodeficiency Syndrome (AIDS) among Transsexual prostitutes attending the Middle Road Hospital was made. The present study involved 71 subjects of a cohort of 100 who were interviewed a year earlier and had subsequently been given intensive health education. The results show that there was now an increased awareness of AIDS in virtually all the subjects studied. In contrast, there has been no significant change in the use of safe sex practices as a direct consequence of this knowledge. The reasons for this are discussed. There may be a need for more intensive behaviour modification programme in this group of individuals.

PIP: 100 Transsexual prostitutes originally interviewed in 1984 and 1985 were recalled in Singapore and interviewed by questionnaire during 1985 and 1986. 71 completed the health education session. They were given a pamphlet about methods of transmission and measures used to decrease risk. Individual verbal counselling on risk factors, transmission, and the etiology of AIDS was administered by the Epidemiological Counselling Unit (ECU). Condoms and the reduction of exchange of body fluids were recommended to decrease risk. Gonococcal smears were taken every 2 weeks, and syphilis serology was done 3 monthly. There were 35 Chinese aged 20-49, 27 Malays aged 20--55, and 9 Indians aged 24-33. THere was a greater awareness of AIDS in the present cohort of 71 subjects as a result of health education sessions conducted by the ECU. However, there was no significant difference in the sexual practices within the 3 ethnic groups. They continued their high risk sexual practices as before, probably because of their socioeconomic status and their educational level. They were avoiding Caucasians and oral sex, as sources of HIV infection. Condom usage did not change significantly, however, their perception that attendance at the hospital protected them from AIDS dropped from 26 (26%) in 1984-85 to 2 (3%) in 1985-86. THese finding show that although there was in increased awareness of AIDS, there was no significant change in the use of safe sex practices. More intensive but simple behavior modification programs are needed to reduce unsafe sex practices.

Awareness of AIDS among transsexual prostitutes in Singapore.

PIP: A study was conducted on 100 Singapore transsexual prostitutes in an attempt to discover AIDS awareness and any precautions which might have been taken by the prostitutes to limit their exposure to the AIDS virus. The results are as follows: the age, race and educational levels of the transsexuals were recorded. 55% of the transsexuals were Chinese, 36% were Malay, and 9% were Indian. The age range of the transsexuals was 20-55; the mean age of the Chinese transsexuals was 30.9; Malay was 33.1; and Indian was 27.0. 46% of the Chinese transsexuals, 64% of the Malay and 77% of the Indian had received only Primary education or were uneducated. 50% of the Chinese, 30% of the Malay and 23% of the Indians had received Secondary education. 4% of the Chinese and 6% of the Malay had received Post Secondary education. When asked, "Have you heard of AIDS?" 67% of the Chinese, 48% of the Malay and 44% of the Indians replied in the affirmative. When asked, "Has knowledge of AIDS altered your sexual practice?" 67% of the Chinese, 48% of the Malays and 44% of the Indians answered in the affirmative. Safe sex methods reported were: use of condoms, avoidance of Caucasians, checking of genitalia, non-penetration, and cleaning after the act.^ieng

Adjuvant therapy of bullous pemphigoid with mycophenolate mofetil: old drug, new use.

Bullous Pemphigoid (BP) is an autoimmune subepidermal blistering disease appearing predominantly in the elderly. The disease is primarily treated with systemic corticosteroids. However, the treatment can be associated with significant morbidity. Adjuvant corticosteroid sparing therapy can also be associated with significant morbidity. In this study a case of BP which was difficult to control with systemic steroids was successfully treated with mycophenolate mofetil as adjuvant therapy. Mycophenolate mofetil used previously in transplantation, has recently been shown to be useful in autoimmune blistering disorders. Further study to confirm this significant finding and to determine if the long term prognosis of BP can be altered by the drug, is required.

Current therapy of HIV associated infections and malignancies.

Drug therapy in AIDS is used to prolong life as there are many infections and malignancies which appear as a consequence of the immunosuppression and these can be fatal. Current anti-virals which specifically inhibit HIV replication are being used earlier to extend quality of life, maintain immune status and reduce the prevalence of opportunisitic infections and malignancies. Some infections cannot yet be treated and new therapies are awaited. It is too early in the epidemic for significant drug resistance to emerge. However, this is to be expected in the future. The prevalence of adverse drug reactions is significantly increased and therefore newer alternatives are keenly awaited. Drug treatment of HIV infected individuals is a formidable task requiring skilled multidisciplinary approach. This review summarises the most current treatment modalities for HIV associated infections and malignancies.

A review of neurological complications in AIDS.

Involvement of the central nervous system is now being recognized as an important aspect of HIV infection. Acting as a sanctuary site, it may pose problems to effective therapeutic strategies. HIV-induced AIDS dementia complex is the commonest mode of presentation. Other causes include opportunistic infections and, more infrequently, malignancies. The precise diagnosis is often difficult to make and requires the judicious use of the CT scan. Treatment has been disappointing and is characterized by frequent relapses.

Cutaneous carcinogenesis: a review of recent advances in pathogenesis.

The clinical spectrum of cutaneous carcinogenesis has not changed substantially. New insights into the pathogenesis of ultraviolet induced lesions have resulted in better understanding of the basic biology of cutaneous tumours. This has evolved into the development of 4 stages in skin carcinogenesis. New problems like Human Immunodeficiency Virus (HIV), associated tumours and ozone depletion are emerging, which will require greater research efforts into preventing a further increase in incidence.

Cutaneous angiofibromas: treatment with the carbon dioxide laser.

A keloid-prone young Chinese patient with multiple facial angiofibromas (incomplete form of tuberous sclerosis) who had been previously treated with liquid nitrogen and electrocautery is presented. He was treated with carbon dioxide laser using low irradiance to vapourize most of the lesions. Postoperative progress was uneventful and results after one-year follow-up showed very satisfactory cosmetic results. There was no recurrence or complication on prolonged follow-up. Carbon dioxide laser is advocated as the treatment of choice for angiofibromas.

Sodium chloride split skin in detecting circulating bullous pemphigoid antibodies.

Sodium chloride split skin is a sensitive and cheap substrate compared to Monkey Oesophagus and cadaveric skin in detecting bullous pemphigoid antibodies. Split skin results in greater exposure of antigen for antibody binding. It is recommended for routine use in immunofluorescence laboratories.

Immunofluorescence studies of pemphigus and pemphigoid in Singapore.

Immunofluorescence studies (direct and indirect) were done on 48 cases of pemphigus and 55 cases of bullous pemphigoid. All cases of pemphigus had in vivo and in vitro IgG intercellular antibodies except for two patients whose sera were not sent for pemphigus antibodies. 47 (85.4%) of our pemphigoid patients had linear C3 deposits on the basement membrane zone while 29 (52.7%) had IgG deposition. Only 17 (30.9%) patients had circulating pemphigoid antibodies. The results were compared and discussed with those reported by other earlier authors.