Non-invasive quantification of hepatic steatosis in living, related liver donors using dual-echo Dixon imaging and single-voxel proton spectroscopy.

AIM: To evaluate the diagnostic implications of hepatic fat fraction calculated using dual-echo Dixon imaging and (1)H magnetic resonance spectroscopy (MRS) to detect hepatic steatosis in potential liver donors using histopathology as the reference standard. MATERIALS AND METHODS: One hundred and forty-five potential liver donors were included in the study. Magnetic resonance imaging (MRI) was performed using a 1.5 T system using a three-dimensional dual-echo MRI sequence with automated reconstruction of in-phase (IP), out-of-phase (OP), fat-signal-only, and water-signal-only images. Hepatic fat fraction was calculated by drawing 15 regions of interest on the IP, OP, fat-only, and water-only images. Single-voxel MRS was performed at echo times (TEs) of 30 ms in the right and left lobes of liver. Liver fat fraction was calculated from water and fat peaks. One hundred and forty-five biopsies were prospectively evaluated for steatosis by a pathologist using traditional determination of the cell-count fraction. MRI and pathology values of steatosis were correlated using Pearson's correlation coefficient. The sensitivity and specificity of each of these methods was calculated using histopathology as the reference standard. Reproducibility was assessed in 40 patients who had repeat scanning within 4-40 days. Measurement error was calculated from the coefficient of variation (CoV) with histopathologically proven <5% fat (n=112). RESULTS: The Bland-Altman limits of agreement with 95% confidence intervals (CI) was -2.9 to 5.3%. The intraclass correlation coefficient (ICC) for interobserver variability and reproducibility was 0.94 (95% CI: 0.91-0.97), 0.92 (95% CI: 0.91-0.97). The CoV was 7.6% (95% CI: 3.4-11.85). The area under the receiver operating characteristic (ROC) curve (AUC) for Dixon imaging 0.89 (95% CI: 0.87-0.91), for MRS 0.88 (95% CI: 0.86-0.90). The sensitivity for detecting <5% fat was 84% and specificity was 90%. CONCLUSION: Combination of dual-echo Dixon imaging and proton MRS is a useful tool for the preoperative diagnosis of hepatic steatosis in potential living liver donors. This can help avoid unnecessary biopsies in these patients.

Persistent Trophoblastic Disease at Cesarean Scar.

Pregnancy over the cesarean scar is the rarest cause of ectopic pregnancy and development of persistent trophoblastic disease at the scar site is extremely rare. A high index of suspicion is needed for early diagnosis and management of cesarean scar molar pregnancy. This condition is difficult to diagnose and must be considered in the patient with a history of cesarean section who has persistent vaginal bleeding or symptoms of pregnancy after suction evacuation. Diagnosis can be confirmedby measuring ß Human Chorionic Gonadotropin levels, transvaginal ultrasound with doppler flow evaluation. As this is an uncommon condition, this case report with conservative non surgical approach will add up to its clinical spectrum.

Low-dose short-term hepatitis B immunoglobulin with high genetic barrier antivirals: the ideal post-transplant hepatitis B virus prophylaxis?

BACKGROUND: Low-dose hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogs (lamivudine/adefovir) used for the prevention of hepatitis B virus (HBV) recurrence after liver transplantation (LT) are associated with some risk of HBV recurrence and antiviral resistance. METHODS: The study cohort included 176 patients (at least >12 months follow-up) with HBV cirrhosis/hepatocellular carcinoma who received secondary prophylaxis with indefinite entecavir/tenofovir after living-donor LT (LDLT). All patients received 10,000 IU intravenous HBIG in anhepatic phase followed by 600-1000 IU intramuscularly daily for 7 days, weekly for 3 weeks, and then monthly, to keep antiHBs levels >100 mIU/mL for 1 year. Hepatitis B surface antigen (HBsAg) and HBV DNA were tested every 6 months. RESULTS: The study cohort is composed of 157 men and 19 women, mean age 47.9 ± 10.1 years, all HBsAg positive, 35 (19.8%) had HBV DNA >2000 IU/mL before LT. After LT, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and tenofovir (n = 30, 17% for 3 months), followed by entecavir alone. During follow-up of 43 (12-117) months, 2 patients (including 1 with non-compliance) had HBV recurrence. CONCLUSION: In a large cohort of LDLT recipients for HBV-related liver disease, use of low-dose short-term HBIG with high genetic barrier drugs results in a substantially lower incidence of HBV recurrence, even in high-risk patients.

Abdominal wall reconstruction (AWR) for post-trauma laparotomy ventral hernia and follow-up assessment of functional quality of life (QOL): experience of a level-1 trauma centre in India.

PURPOSE: The aim of this study was to examine the postoperative outcomes and follow-up QOL of patients after AWR at a level-1 trauma centre in India. METHODS: The study cohort included AWR patients treated between January 2011 and July 2022. The Activities Assessment Scale (AAS) was used to measure QOL, and the Ventral Hernia Recurrence Inventory (VHRI) was used to determine the occurrence of recurrence. In patients suspected of having recurrence, thorough clinical examination and relevant imaging were performed to confirm or rule out recurrence. RESULTS: Out of 89 patients, 35 patients whose complete perioperative and follow-up data were available were enrolled. The mean age of the patients was 28 (SD, 9) years. The mean defect size was 14. 9 (SD, 7) cm. The mean time from laparotomy to AWR surgery was 21 months. During the postoperative course, 37% of patients developed complications, such as SSI and seroma. The mean follow-up time was 53 (SD, 43) months. Upon comparing procedures involving the mesh placed in the sublay position with procedures involving the mesh placed in other positions, no statistically significant difference in the recurrence rate (one in each group, p = 0.99), surgical complication rate (33% v/s 66%, p = 0.6), or mean AAS QOL score (94.7 v/s 98, p = 0.4) was observed. The specificity of the VHRI for diagnosing recurrence was 79%. CONCLUSION: Overall, the recurrence rate was low in these patients despite the presence of large hernia defects. Long-term QOL was not affected by the specific procedure used. Timely planning and execution are more important than the specific repair approach for post-trauma laparotomy ventral hernia.

Mutational analysis of hemoglobin binding and heme utilization by a bacterial hemoglobin receptor.

Iron is an essential nutrient for most living organisms. To acquire iron from their environment, Gram-negative bacteria use TonB-dependent transporters that bind host proteins at the bacterial surface and transport iron or heme to the periplasm via the Ton machinery. TonB-dependent transporters are barrel-shaped outer membrane proteins with 22 transmembrane domains, 11 surface-exposed loops, and a plug domain that occludes the pore. To identify key residues of TonB-dependent transporters involved in hemoglobin binding and heme transport and thereby locate putative protective epitopes, the hemoglobin receptor of Haemophilus ducreyi HgbA was used as a model of iron/heme acquisition from hemoglobin. Although all extracellular loops of HgbA are required by H. ducreyi to use hemoglobin as a source of iron/heme, we previously demonstrated that hemoglobin binding by HgbA only involves loops 5 and 7. Using deletion, substitution, and site-directed mutagenesis, we were able to differentiate hemoglobin binding and heme acquisition by HgbA. Deletion or substitution of the GYEAYNRQWWA region of loop 5 and alanine replacement of selected histidines affected hemoglobin binding by HgbA. Conversely, mutation of the phenylalanine in the loop 7 FRAP domain or substitution of the NRQWWA motif of loop 5 significantly abrogated utilization of heme from hemoglobin. Our findings show that hemoglobin binding and heme utilization by a bacterial hemoglobin receptor involve specific motifs of HgbA.

Development of Primers and Probes for Genus and Species Specific Detection of 'Candidatus Liberibacter Species' by Real-Time PCR.

Huanglongbing (HLB), also known as citrus greening, is currently the most devastating disease impacting citrus production. The disease is associated with three different 'Candidatus Liberibacter species', 'Ca. Liberibacter asiaticus', 'Ca. Liberibacter americanus', and 'Ca. Liberibacter africanus', which induce similar and overlapping symptoms. When HLB-symptomatic trees are tested, one of the Candidatus Liberibacters is normally detected by conventional or real-time PCR (qPCR). The most widely used assays use primers and probes based on the 16S ribosomal RNA (rRNA) gene. The 16S rRNA-based assays to detect the three species are species-specific and must be performed sequentially. We describe a single assay that detected all species of 'Ca. Liberibacter' at the genus level, providing increased convenience. Recent molecular analyses of 'Ca. Liberibacter species' and other bacteria suggest that the rpoB gene (encoding the ß-subunit of RNA polymerase) provides an alternative target for bacterial identification. We report here the design of a single pair of degenerate primers and a hybridization probe corresponding to the rpoB region and their application for the detection of all three citrus 'Ca. Liberibacter species', enabling detection of 'Ca. Liberibacter' at the genus level. In addition, species-specific primers and probes based on the rplJ/rplK genes were designed and used for detection at the species level in a multiplexed format. Both the genus- and species-specific assays were validated in both SYBR Green I and TaqMan formats, and with both plant and insect extracts that contained the pathogen. These one-step qPCR diagnostic methods are useful for the detection of all species of Liberibacter infecting citrus. In addition, the degenerate genus-specific primers and probe successfully detected 'Ca. Liberibacter solanacearum', a psyllid-transmitted pathogen associated with disease in tomato, carrot, and potato.

Noradrenaline vs. terlipressin in the treatment of hepatorenal syndrome: a randomized study.

BACKGROUND & AIMS: Various vasoconstrictors are useful in the management of hepatorenal syndrome (HRS). Terlipressin is the drug of choice; however, it is expensive. In this study, we evaluated safety and efficacy of terlipressin and noradrenaline in the treatment of HRS. METHODS: Forty-six patients with HRS type 1 were managed with terlipressin (group A, N=23) or noradrenaline (Group B, N=23) with albumin in a randomized controlled trial at a tertiary center. RESULTS: HRS reversal could be achieved in 9 (39.1%) patients in group A and 10 (43.4%) patients in group B (p=0.764). Univariate analysis showed baseline Child Turcotte Pugh score (CTP), model of end stage liver disease (MELD), urine output on day 1(D1), albumin, and mean arterial pressure (MAP) were associated with response. However, on multivariate analysis only CTP score was associated with response. Fourteen patients in group A and 12 in group B died at day 15 (p>0.05). Noradrenaline was less expensive than terlipressin (p<0.05). No major adverse effects were seen. CONCLUSIONS: The results of this randomized study suggest that noradrenaline is as safe and effective as terlipressin, but less expensive in the treatment of HRS and baseline CTP score is predictive of response.

Hepatic osteodystrophy is common in patients with noncholestatic liver disease.

BACKGROUND: Patients with cirrhosis are more prone to develop metabolic bone disease. Scanty literature data are available on osteodystrophy in patients from India with noncholestatic liver diseases. METHODS: Patients diagnosed with cirrhosis were prospectively evaluated for bone mineral density (BMD) as measured by dual-energy X-ray absorptiometry at the femoral neck, lumbar spine, and left forearm (distal radius). Correlation of BMD with age, sex, etiology of cirrhosis, Child's class, serum bilirubin, alkaline phosphatase (ALP), albumin, calcium, phosphate, 25-hydroxyvitamin D (25(OH)D), and parathyroid hormone (PTH) was studied. RESULTS: The study group comprised 115 cirrhotic patients (107 males and 8 females). Etiology of cirrhosis was alcohol in 67 (58.2%) and viral in 48 (41.7%). Hepatitis B was diagnosed in 29 (25.2%) and hepatitis C in 19 (16.5%). Mean age was 49 (± 5.5) years. Prevalence of osteodystrophy was significantly higher in males than in females; 97.1% and 75% respectively (P = .038). Both alcoholic and viral groups had similar baseline characteristics except albumin levels. Child's class was B in 72 patients and C in 43. Low BMD was present in 97% of patients with alcoholic cirrhosis and 93.7% with viral cirrhosis (P > .05). Low BMD was present at the femoral neck in 80.8% of patients, lumbar spine in 77.3%, and forearm in 59.9%. PTH correlated negatively with BMD. CONCLUSION: Osteodystrophy is common in alcoholic and viral cirrhosis patients.

First and second trimester induced abortions in women with cardiac disorders: a 12-year analysis from a developing country.

This was a retrospective analysis of induced abortions (1st and 2nd trimester) in women with cardiac disease over a 12-year period (September 1994-December 2006). Of the 3,096 women who underwent an induced abortion during this period, 65 (2.1%) had an associated cardiac disease (NYHA class I or II = 58, class III or IV = 7). Their mean age was 29.6 years and 48/65 (73.9%) had opted for concurrent sterilisation. Nearly all 1st trimester abortions (52/53) were performed by suction evacuation. Among the 12 women undergoing 2nd trimester abortions, seven received vaginal misoprostol with or without oral mifepristone, four received varying combinations of intracervical dinoprostone, extra-amniotic saline (EAS) and oxytocin and elective hysterotomy was performed in one. Complications observed among the 1st trimester terminations were incomplete abortion in 1/53 (1.8%) and prolonged bleeding in 3/53 (5.6%). Method failure was the only complication seen in 2/12 (16.6%) 2nd trimester abortions. There was no major morbidity or mortality. Mifepristone and misoprostol used for 2nd trimester induced abortions were found to be safe in the few women so treated.

Abortion procedures in a tertiary care institution in India.

OBJECTIVE: To determine the complications rate of termination of pregnancy (TOP) and the risk factors for complications following TOP. METHODS: Retrospective observational study of the records of 1287 women who underwent TOP in the Department of Obstetrics and Gynaecology of the Postgraduate Institute of Medical Education and Research, Chandigarh, India, between 1997 and 2001. First-trimester abortion was performed in 1088 women (85%) and second-trimester abortion in 199 women (15%). Most women (76%) were aged between 26 and 30 years; they were educated and requested TOP primarily to limit the number of their children or to space their births. A malformed fetus was the indication for TOP in 5.9% cases, and 16% of the women had medical disorders associated with the pregnancy. Suction evacuation was the method of choice for first-trimester abortion (88%); dinoprostone gel and extra-amniotic saline solution plus oxytocin infusion were the primary methods (71%) for second-trimester abortion. RESULTS: Uterine perforation occurred in 1 patient (0.09%) after a first-trimester abortion. The total rate of complications was 3.79% after first-trimester and 4.0% after second-trimester abortions. Excessive hemorrhage and retained placenta were chief complications associated with second-trimester abortion. Incomplete abortion (1.5%) and minor infection were seen in 2.3% patients. The rate of complications was higher among parous women. Postabortion insertion of a CuT intrauterine device increased the need for a second course of antibiotics. CONCLUSION: Termination of pregnancy is safe if adequate care is taken while performing the procedure.

Expression of delta1-pyrroline-5-carboxylate synthetase gene during drought in rice (Oryza sativa L.).

The 45-days-old seedlings of drought resistant (N-22, CR143-2-2) and susceptible rice (Oryza sativa L.) genotypes (Panidhan, Pusa-169) were subjected to osmotic stress in PEG-6000 solution of -10 and -16 bar and the relative water content (RWC), proline content, and pyrroline-5-carboxylate synthetase (P5CS) activity and its P5CS expression were studied. A gradual decrease in RWC was observed in tolerant genotypes, whereas the decrease was drastic in susceptible ones. Proline content and P5CS activity increased both in susceptible and tolerant genotypes; the increase was higher in tolerant genotypes. Higher proline levels in tolerant genotypes were due to increased P5CS activity. The EcoRI, BamHI and XbaI restricted DNA of N-22 and Panidhan genotypes were hybridized with Arabidopsis P5CS sequence and a single band (approx 2.4 kb) was observed, however, P5CS expression was more in N-22 as compared to Panidhan.

Chlamydia pneumoniae exposure and inflammatory markers in acute coronary syndrome (CIMACS).

Previous studies have shown higher levels of Chlamydia pneumoniae (C. pneumoniae, CP) antibody titers (CPIgG), C-reactive protein (CRP), and fibrinogen in patients with coronary artery disease. The role of these infectious and inflammatory markers in precipitating acute coronary syndrome (ACS) is unclear. We conducted a cross-sectional study on patients (n = 830, mean age 63 +/- 15 years, 57% male) admitted to the chest pain center of our institution. The differences in the CPIgG, CRP, and fibrinogen levels in patients who were diagnosed with ACS versus those who were not (non-ACS) were evaluated. CPIgG titers tended to be higher in the ACS group than in the non-ACS group. However, when different titers were used to define seropositivity, the difference achieved statistical significance only at the titer of > or =1:1,024 (35% vs 26%, p = 0.004). CRP (median 0.48 vs 0.33 mg/dl, p <0.0001), fibrinogen (median 317 vs 293 mg/dl, p <0.0001), and leukocyte count (median 7.7 vs 6.9 10(9)/L, p <0.0001) were higher in the ACS group. On multivariate analysis, CPIgG > or =1:1,024 (odds ratio [OR] 1.62), diabetes (OR 1.91), hypertension (OR 1.46), prior myocardial infarction (OR 1.78), smoking (OR 1.70), Caucasian race (OR 1.7), high-density lipoprotein (OR 0.98), and elevated troponin-T (OR 12.44) were the only factors independently associated with ACS. Thus, we found a strong association between high level seropositivity to CP and ACS. This may indicate recent re-infection or an exaggerated immune response to CP as an etiologic factor for ACS. This study also suggests that therapeutic interventions may need to be specifically targeted to these patients.

Clinical profile of polymyositis in Kashmir valley.

OBJECTIVES: The present study is a retrospective and prospective study of 24 cases of idiopathic inflammatory myopathies from Kashmir valley. The study was conducted to depict the clinical profile of polymyositis from this part of the world. METHODS: The diagnosis of polymyositis/dermatomyositis was established by following the criteria of Bohan and Peter (1975). Besides relevant clinical examination, investigations like complete blood count, ESR, muscle enzymes, LE cell phenomenon, antinuclear antibodies and rheumatoid factor were also done. Electrophysiological study and open muscle biopsy was performed in 21 and 24 cases respectively. RESULTS: The mean age at presentation was 34 years with 62.5% cases presenting in fourth decade. Pelvic girdle weakness was observed in all the 24 cases. Male:Female ratio was 1:1.4. Four (16.8%) cases had associated collagen vascular disease. No case was associated with malignancy or childhood vasculitis. Raynauds' phenomenon was seen in seven (29.1%) cases. Creatine phosphokinase and lactic dehydrogenase was elevated in 22 (91.6%) and 12 (50%) cases respectively. Electromyography revealed myopathic features in 74.3% cases. Muscle biopsy revealed features of inflammatory myopathy in 22 (91%) cases. CONCLUSIONS: The conclusions drawn from this study are as follows: a. Younger age at presentation b. Shorter duration of illness at presentation c. Increased frequency of Raynaud's phenomenon as compared to other Indian series. d. No case of polymyositis/dermatomyositis associated with malignancy or childhood vasculitis was seen. e. Biochemical, electrophysiological and histopathological features suggestive of shorter duration of illness were observed.

AIDS and transfusion practice.

PIP: AIDS has reached epidemic proportions in many regions of the world and is rapidly spreading. Among other modes of transmission, HIV may be transmitted through the transfusion of blood and blood products. The potential for such transmission warrants and has sparked the screening of donor blood and blood products for antibodies to HIV. Safe practices for transfusion services would include promoting voluntary donors, motivating and recruiting donors from low-risk groups, encouraging high-risk donors to exclude themselves from the donor pool, obtaining trained donor pool, obtaining trained donor recruiters, and linking programs with AIDS education campaigns. Further, the Blood Safety Initiative of the World Health Organization stresses the importance of transfusing blood and its products only when required to prevent mortality or major morbidity. 4082 of 589,824 individuals screened in India over the period 1985-90 were identified as HIV-seropositive. Of these individuals, 2068 were heterosexually promiscuous, 6 were homosexual, 600 sold blood professionally, 64 were recipients of blood and blood products, and 861 were IV drug users. To help control the spread of HIV, known seropositive donors should be told of their status and permanently barred from giving blood. Since HIV seroprevalence in samples of professional blood sellers has been shown to be comparatively higher than that among voluntary donors, the professional sale of blood should be discouraged in favor of increased the voluntary supplies. ELISA and Western blot tests are used to screen blood for antibodies to HIV, while serum neopterin estimation is also helpful. Viricidal techniques for blood parasites plasma include the application of dry heat of 600 degrees Celsius for 24 hours, heptane, or treatment with solvent-detergents. Viricidal techniques for cellular components of blood remain experimental.^ieng

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India.

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Electrophysiological characteristics of seizure clusters.

The phenomenon of temporal clustering of seizures is well known, but its effect on seizure localization has not been rigorously analyzed. The aim of our study was to assess electrophysiological localization during Video EEG (VEEG) monitoring in patients with intractable epilepsy demonstrating a cluster of seizures. The study was conducted on 203 intractable epilepsy patients, aged 2 to 60 years (19.96 +/- 10.87). Patients with unilateral temporal lobe epilepsy having clusters were compared with patients not having clusters, and the effect of clustering on concordance was addressed. Fully consistent localization was observed in 116 patients, partially consistent localization in 18 patients, and inconsistent localization in 19 patients. ANOVA did not reveal any significant difference in these groups (p=0.65). A total of 770 seizures recorded from 149 patients was analyzed for clustering effect. Clustering was present in 603/770 seizures pairs (78.31%). In the cluster group, 483 (80.09%) seizure pairs were concordant for seizure onset, while 98 (16.25%) were discordant and 22 (3.65%) were indeterminate. In the noncluster group, 134 (80.24%) seizure pairs were concordant for seizure onset, while 23 (13.77%) were discordant and 10 (5.98%) were indeterminate. The study found that cluster seizures occurring within an interseizure interval (ISI) less than 8 hours are independent and have the same localizing value as those seizures with longer ISIs.

Ribonuclease, deoxyribonuclease, and antiviral activity of Escherichia coli-expressed Bougainvillea xbuttiana antiviral protein 1.

A full-length cDNA encoding ribosome-inactivating/antiviral protein from the leaves of Bougainvillea xbuttiana was recently isolated. The coding region of cDNA was cloned and expressed in Escherichia coli, and the protein product was designated as BBAP1 (Bougainvillea xbuttiana antiviral protein 1). BBAP1 showed ribonuclease activity against Torula yeast RNA. It also exhibited depurination activity against supercoiled pBlueScript SK+ plasmid DNA in a concentration dependent manner, and was found to convert nicked circular DNA into linear form only at higher concentration. On bioassay, BBAP1 exhibited antiviral activity against sunnhemp rosette virus infecting Cyamopsis tetragonoloba leaves in which 95% inhibition of local lesion formation was observed.