The objectives of this study were to determine the biofilm microbial activity and bacterial community structure and successions in greywater treatment filters and to relate the treatment efficiency to the bacterial community parameters. This 10-month study was performed in a newly established experimental system for domestic greywater treatment that consisted of three parallel vertical flow filters (VFs) followed by a horizontal flow filter (HF). A rapid increase in the bacterial community abundance occurred during the first 85 days of filter operations, followed by a short-term decrease and the stabilization of the 16S rRNA gene copy numbers at average levels of 1.2 × 109 and 3.2 × 108 copies/g dw in VFs and HF, respectively, until the end of the experiment. The dominant bacterial phyla and genera differed between the VFs and HF. The temporal variation in the bacterial community structure was primarily related to the species replacement, and it was significantly affected by the influent organic carbon and nitrogen compounds in the VFs and the ammonia and organic carbon in the HF filters. Despite the differences in the community structure and assembly mechanisms, the temporal dynamics of the bacterial community showed high congruence between the filter types. The treatment efficiency was related to the biofilm bacterial community diversity and abundance and the abundance of certain bacterial genera in the VF filters. The results suggest that the dominant pathway of nitrogen removal by greywater treatment VFs occurs via coupled heterotrophic nitrification and denitrification, while the contribution of aerobic denitrification is temporally variable in these filters.
Body contouring surgery following massive weight loss positively affects patient quality of life. However, the procedure is prone to complications. Here, we stratified complications time-wise. Furthermore, we examined whether the weight loss method — bariatric surgery or lifestyle changes — affected the frequency or severity of complications. In this single-centre retrospective analysis, we included 158 massive weight loss patients undergoing body contouring surgery between 2009 and 2015. We recorded 96 complications in 80 patients, with an overall rate of 51%.
Nerve transfer has become a vital method in the reconstruction of hand function. Reconstructing the motor function to the thenar musculature has proven to be difficult and is rarely satisfactory following direct anatomic repair. Aim of this investigation was to describe the anatomic results obtained by transferring the anterior interosseous nerve to the thenar branch of the median nerve and analyze the histomorphometric results.
The authors need to be congratulated for their fine study on the use of Laser Speckle Contrast Imaging (LSCI) to predict flap necrosis in an experimental setting with a porcine pedicled flap model. LSCI has been repeatedly described for perfusion analysis in flap surgery. There has always been a demand to simplify or optimize intra- and postoperative flap monitoring, especially in free flap surgery. However, the individual techniques to postoperatively monitor free flaps vary considerably. In former studies from the early 1990ies with questionnaires ninety percent of microsurgeons reported to routinely use monitoring devices, with external and laser doppler having achieved greatest popularity.
We read with interest the article by Dr. Henderson "Updated guidelines on complex regional pain syndrome in adults." 1 The article provides an elegant summary of the Royal College of Physicians (RCP) current guidelines in the diagnosis and treatment of complex regional pain syndrome (CRPS) and recommends surgical intervention for the treatment of Type 2 CRPS (i.e. CRPS with a recognized nerve injury). However, it fails to identify the timing of such interventions. This is important considering the emerging paradigm shift in concepts of nerve pain, specifically 'centralization' of pain in neuroma patients with delayed presentations.
Several operative approaches and various implants for osseous fixation have been described to achieve four-corner fusion of the wrist. Given the discordance and to aid in further standardizing the technique, this study directly compares the outcomes of K-wire-, fusion-plate, and headless retrograde compressive screw-fixation to achieve four-corner arthrodesis.
In the wake of call for retractions of papers from Harvard University heart stem cell research lab, the public concerns had been raised about stem cell researches, including adipose-derived stem cells (ADSCs).
I thank Drs Zeiderman and Pereira for their kind words and constructive comments. The Royal College of Physicians guidelines do not absolutely recommend surgery for all cases of type II CRPS, but recognize that it might be appropriate where nerve injury or entrapment are confidently diagnosed (e.g. with nerve conduction tests).
Sanjuan-Cervero et al. 1 report that patients undergoing collagenase injections for the treatment of Dupuytren's contracture report less pain if a wrist block is performed first. Unfortunately the authors did not account for the pain of 10mls of mepivacaine being injected through two injections at the wrist.
Burn scars are usually characterised by a combination of hypertrophic and keloid scars that are often very challenging to treat. They are a consequence of abnormal collagen deposition by fibroblasts exhibiting a hypersensitive response to growth factors.1 These scars can have a profound effect on patients both functionally and psychologically due to their poor cosmesis and debilitating symptoms.2 Currently there is no reliable or satisfactory treatment available to address the long-term sequelae of burns, however, more recently the use of laser-based treatments has been attributed to a paradigm shift in the management of burn scarring.
Saliva is a bodily fluid transuded from gingival crevice fluid and blood and contains many proteins. Proteins in saliva have been studied as markers for periodontal diseases. Mass spectrometric analysis is applied to investigate biomarker proteins that are related to periodontitis.
Material and methods
Saliva samples were collected from 207 participants including 36 pairs matched for age, sex, and smoking who joined Yangpyeong health cohort. Periodontitis was defined by 2005 5th European guideline. Shotgun proteomics was applied to detect proteins from saliva samples. Principal component analysis and Ingenuity Pathway Analysis for canonical pathway and protein pathway were applied. Protein-protein interaction was also applied. Enzyme-linked immunosorbent assay (ELISA) was used to verify the candidate protein markers among another matched participants (n = 80).
Results
Shotgun proteomics indicated that salivary S100A8 and S100A9 were candidate biomarkers for periodontitis. ELISA confirmed that both salivary S100A8 and S100A9 were higher in those with periodontitis compared to those without periodontitis (paired-t test, p < 0.05).
Conclusion
Our proteomics data showed that S100A8 and S100A9 in saliva could be candidate biomarkers for periodontitis. The rapid-test-kit using salivary S100A8 and S100A9 will be a practical tool for reducing the risk of periodontitis and promotion of periodontal health.
Clinical relevance
A rapid-test-kit using salivary biomarkers, S100A8 and S100A9, could be utilized by clinicians and individuals for screening periodontitis, which might reduce the morbidity of periodontitis and promote periodontal health.
The overall objective of the guideline is to provide up‐to‐date, evidence‐based recommendations for the management of hidradenitis suppurativa (HS). The document aims to:.
offer an appraisal of all relevant literature up to July 2018, focusing on any key developments.
address important, practical clinical questions relating to the primary guideline objective.
provide guideline recommendations and if appropriate research recommendations.
This article is protected by copyright. All rights reserved.
Worldwide, large amounts of food are wasted every year. Reducing of food waste at European level is taken very seriously and it has been adopted even a target of reducing the amount of food waste in half until 2030. In many countries of the European Union, food wastes are composted, while in countries like Romania, the composting is too little used or not at all, but efforts are being made to apply this process. Food waste composting should take place both at the composting plants and housing level. An important step before starting the composting process is to establish an appropriate recipe. Therefore, the aim of this paper is to develop a composting recipe starting from investigation of food waste like peel and pomace of fruits (apple, banana, orange, and kiwi) and vegetables (potato, cabbage, and carrots) which are very common in waste generated at the housing level. The most important physical-chemical parameters were investigated in this study. Results show that pH of fruit waste is acid (4.0–5.0), while for vegetable waste, the pH is slightly higher (between 6.0 and 6.5). For all types of food waste, a very high moisture content (80–90%) was registered, while the nitrogen content is below 1%. Considering that C/N ratio is one of the most essential parameters, for the process to be carried out in good conditions, we have used regression analysis in order to determine the amounts of fruits and vegetable waste necessary to obtain different C/N ratios.
Organic matter (OM), a complex entity with diverse functional groups and molecular sizes, has important effects on aquatic systems. We studied the optical compositions and sources of dissolved organic matter (DOM) and particulate organic matter (POM) in Lake Taihu, a large, shallow and eutrophic lake in China. Significant differences in optical compositions and sources occurred between the POM and DOM. The temporal–spatial distribution of the fluorescence indices suggested that the POM in Lake Taihu was mainly from autochthonous sources, but more exogenous characteristics were shown in POM in the river mouths compared with other regions. The chromophoric DOM in Lake Taihu mainly displayed autochthonous characteristics. The POM–DOM PARAFAC model was used to examine OM optical composition and five components were identified, which contained three protein-like components (C1, C2, and C5), a microbial humic-like component (C3), and a terrestrial humic-like component (C4). The POM was dominated by C5 in summer and autumn and C3 in winter and spring, and the DOM was dominated by protein-like components (C1, C2, and C5) through the entire year. The algae-dominated region had a relative higher contribution of tryptophan-like components of POM compared with the macrophyte-dominated region. A conceptual model based on the theory of "four phases of cyanobacteria bloom development" was proposed to fully describe the relationship between POM–DOM exchanges and cyanobacteria bloom development.
Greenhouse gas emissions from agricultural soils contribute substantially to global atmospheric composition. Nitrous oxide (N2O) is one important greenhouse gas induces global warming. Nitrification inhibitors (NI) or biochar can be effective soil N2O emission mitigation strategies for agricultural soils. However, due to differences in crop physiological traits or agricultural management, the effectiveness of mitigation strategies varies among agricultural systems. Camellia oleifera is a woody oil plant widely grown and requires intensive N input, which will potentially increase N2O emissions. Thereby, mitigation of N2O emissions from C. oleifera field soil is vital for sustainable C. oleifera development. Besides NI, incorporation of C. oleifera fruit shell-derived biochar into its soil will benefit waste management and simultaneous mitigation of N2O emissions but this has not been investigated. Here, we conducted two studies to examine effects of biochar addition and NI (dicyandiamide, DCD) application on N2O emissions from C. oleifera field soil with different N (urea or NH4NO3) and incubation temperatures. Biochar effects on nitrification rates varied among N treatments. Biochar applied in combination with DCD further reduced nitrification rates (for urea treatment, decreased from 1.1 to 0.3 mg kg−1 day−1). Biochar addition consistently increased soil N2O emissions (for urea treatment, increased from 0.03 to 0.08 ng g−1 h−1) and their temperature sensitivity. DCD application reduced soil N2O emissions with greater reductions with urea application. In future cultivation of intensively managed C. oleifera gardens, NI should be applied to mitigate N2O emissions if biochar is added, especially when urea is used.
Publication date: Available online 14 December 2018
Source: Trends in Endocrinology & Metabolism
Author(s): Ilja L. Kruglikov, Zhuzhen Zhang, Philipp E. Scherer
Hair follicles (HFs) strongly interact with adipocytes within the dermal white adipose tissue (dWAT), suggesting a strong physiological dependence on the content of immature and mature adipocytes in this layer. This content is regulated by the proliferation and differentiation of adipocyte precursors, as well as by dedifferentiation of mature existing adipocytes. Spatially, long-range interactions between HFs and dWAT involve the exchange of extracellular vesicles which are differentially released by precursors, preadipocytes, and mature adipocytes. Different exogenous factors, including light irradiation, are likely to modify the release of adipocyte-derived exosomes in dWAT, which can lead to aberrations of the HF cycle. Consequently, dWAT should be considered as a potential target for the modulation of hair growth.
Ehlers–Danlos syndrome (EDS) is an emerging cause of skeletal fragility. Mechanism of bone damage are probably multifactorial in line with the different skeletal phenotypes that can be found in clinical practice. A structured approach to clinical management of bone metabolic complication in EDS is proposed.
Ehlers–Danlos syndrome (EDS) is an emerging cause of skeletal fragility. Mechanism of bone damage are probably multifactorial in line with the different skeletal phenotypes that can be found in clinical practice. A structured approach to clinical management of bone metabolic complication in EDS is proposed.
Publication date: Available online 14 December 2018
Source: Journal of the American Academy of Dermatology
Author(s): Emanual Maverakis, Stephanie T. Le, Jeffrey Callen, Uwe Wollina, Angelo Valerio Marzano, Daniel Wallach, Courtney Schadt, Yocasta C. Martinez-Alvardao, Michelle Y. Cheng, Chelsea Ma, Alexander Merleev, Anthony Ormerod, Fiona Craig, Finja Jockenhofer, Joachim Dissemond, Katrin Salva, Hywel C. Williams, David Fiorentino
Clear cell acanthoma (CCA) of the nipple/areola has been reported. The CCA-like histology more likely represents a feature of eczematous dermatitis of the nipple/areola.
Objective
We reviewed cases of CCA-like lesions of the nipple/areola and compared them with classic CCA to clarify their relationship.
Methods
The clinicopathological features of 12 cases of CCA-like lesions of the nipple/areola were compared with classic CCA. The literature on this condition was reviewed, and the results of various treatments were analyzed.
Results
CCA-like lesions of the nipple/areola were clinically different from those of classic CCA. Although they shared the glycogen-rich clear epidermal cells with neutrophilic exocytosis, dermal eosinophils appeared to be a distinctive feature. The anatomic site and association with atopic dermatitis suggested that CCA-like lesions of nipple/areola might represent a manifestation of atopic eczema involving nipple/areola. Topical steroids could be effective.
Limitations
This was a retrospective study with limited cases.
Conclusions
Although CCA-like lesions of the nipple/areola shared histopathological features with classic CCA, their clinical changes were consistent with dermatitis. We propose to name this condition CCA-like eczematous dermatitis of the nipple/areola.
Understanding the intrinsic mechanism behind changes on energy intensity provides insights about reducing carbon emissions and promoting the sustainable development of Beijing-Tianjin-Hebei (BTH) region. Although various studies have found a causal relationship between energy intensity and energy-related carbon emissions, the internal mechanisms are still unclear. This paper presents a comprehensive analysis of the impact of energy intensity on carbon emissions from 2005 to 2015. With an association established between logarithmic mean Divisia index (LMDI) and generalized Fisher index (GFI), two-layer factor decomposition model is proposed to explore the factor analysis in-depth. (1) LMDI method proves that energy intensity is the main contributor that reduces carbon emissions in BTH. (2) GFI model further decomposes energy intensity into five effects, namely energy substitution, technology progress, labor productivity, capital substitution, and labor-capital resources allocation. (3) The results reveal that the effect of capital-energy substitution in declining energy intensity surpasses technology progress. (4) Energy-labor substitution has increased energy intensity, while energy-energy substitution is negligible. For the coordinate development of BTH, the government should aim at energy intensity and attach importance to encouraging entrepreneurship, accelerating the construction of carbon trading market, allocating resources rationally, and guiding the capital flow into energy-efficient direction.
Staphylococcus aureus Decolonization of Mice With Monoclonal Antibody Neutralizing Protein A.
J Infect Dis. 2018 Dec 15;:
Authors: Chen X, Sun Y, Missiakas D, Schneewind O
Abstract Staphylococcusaureus persistently colonizes the nasopharynx of about one-third of the human population, a key risk factor for community- and hospital-acquired invasive infections. Current strategies for S. aureus decolonization include topical and systemic administration of antibiotics, which is associated with selection for antibiotic resistance and posttreatment recolonization. Using a mouse model for S. aureus colonization, we show here that systemic administration of a recombinant monoclonal antibody neutralizing staphylococcal protein A (SpA) can stimulate antibacterial immunoglobulin G and immunoglobulin A responses and promote S. aureus decolonization. These results suggest that antibody neutralizing SpA, a B-cell superantigen, may also be useful for S. aureus decolonization in humans.
PMID: 30551184 [PubMed - as supplied by publisher]
The management of severe hidradenitis suppurativa with destruction of the perianal region can be challenging; local tissue may not be available for closure.
Methods
Patients were managed by proctectomy and reconstruction with musculocutaneous flaps based on the rectus abdominis muscle (RAM).
Results
Three patients were managed using this approach achieving closure without recurrence.
Conclusion
RAM-based flaps provide a good reconstructive option in the management of patients with severe therapy-refractory hidradenitis suppurativa in the gluteal region, combined with severe perianal destruction.
Recent neuropsychological evidence put forward impaired ability in processing particular aspects of time, such as Mental Time Travel (MTT), in brain damaged patients exhibiting a deficit of spatial attention (i.e., neglect) and the possibility to recover this MTT deficit through a manipulation of spatial attention by prism adaptation (PA). The aim of the present study was twofold. First, we explored whether the neglect patients' impairment in MTT is linked with an impairment in functional competences, such as processing temporal duration of everyday activities, motor abilities and independence in daily living. Second, we focused on rehabilitation, investigating the long-term duration of the benefits induced by a PA treatment on both mental time travel and the above-mentioned functional abilities.
To these aims, neglect patients were submitted to a MTT task, as well as to a battery of tests assessing spatial attention, estimation of time duration, motor competence and independence in activities of daily living. All tests were performed before, at the end, and one week after 10 daily sessions of PA treatment inducing a leftward shift of spatial attention.
Results suggest that neglect patients' impairment in MTT ability correlates with spatial attention deficit and with difficulties in producing reasonable temporal estimation of daily life activities. Crucially, the PA treatment induces a long-lasting and stable amelioration of MTT, spatial attention and functional competences.
Eye tracking is an effective tool for identifying behavioural aspects of unilateral spatial neglect (USN), which is a common neurological syndrome that develops after a right hemisphere lesion. Here, we attempted to elucidate how the neglect symptom affects the symmetry of the gaze pattern, by performing an analysis of gaze distribution during the free viewing of a pair of horizontally flipped images. Based on their Behavioural Inattention Test (BIT) scores, 41 patients with right-hemisphere damage were classified into those with USN (n=27) and those without USN (right hemisphere damaged [RHD]; n=14). Eye movement was recorded while the patients viewed six pairs of horizontally flipped images on a computer display. A pair of flipped images has both similar and consistent elements, as well as a reversed spatial location of objects (right-left). We calculated the gaze distribution, extent of gaze shift, total gaze distance, and gaze velocity in each direction. Our results demonstrated a significantly larger rightward gaze shift in the USN group, which showed a significant correlation with the BIT score. More importantly, the extent of gaze shift and total gaze distance were similarly modulated by the contents of the displayed images in both the USN and RHD groups. Our findings suggest that analyses of gaze distribution during the free viewing of a pair of horizontally flipped images have the potential to precisely reveal neglect behaviour, and our results provide important implications for rehabilitation.
Publication date: Available online 15 December 2018
Source: Journal of Autoimmunity
Author(s): Teontor Simakou, John P. Butcher, Stuart Reid, Fiona L. Henriquez
Abstract
Alopecia areata is an autoimmune disease that results in non-scarring hair loss, and it is clinically characterised by small patches of baldness on the scalp and/or around the body. It can later progress to total loss of scalp hair (Alopecia totalis) and/or total loss of all body hair (Alopecia universalis). The rapid rate of hair loss and disfiguration caused by the condition causes anxiety on patients and increases the risks of developing psychological and psychiatric complications. Hair loss in alopecia areata is caused by lymphocytic infiltrations around the hair follicles and IFN-γ. IgG antibodies against the hair follicle cells are also found in alopecia areata sufferers. In addition, the disease coexists with other autoimmune disorders and can come secondary to infections or inflammation. However, despite the growing knowledge about alopecia areata, the aetiology and pathophysiology of disease are not well defined. In this review we discuss various genetic and environmental factors that cause autoimmunity and describe the immune mechanisms that lead to hair loss in alopecia areata patients.
High resolution CT is the most commonly used radiological method for differentiating benign from malignant peripheral solid pulmonary masses, however, some of them are not easily diagnosed by morphology alone. Furthermore, due to the radiation dose, it is unsuitable for patients with disorders requiring repeated examinations over prolonged periods. The aims of this study were to evaluate whether a combination of diffusion-weighted images (DWI) and free-breathing radial 3D fat-suppressed T1-weighted gradient echo (radial volumetric interpolated breath-hold examination, radial VIBE) sequence can enable discrimination between benign from malignant peripheral solid pulmonary masses.
Materials and methods
Both chest CT scan and MR imaging with radial VIBE and DWI were obtained from 47 patients; 30 males and 17 females (mean age 64 years old; age range 48–83 years old). Benign and malignant peripheral solid pulmonary masses were conclusively identified by pathology results. Two radiologists independently reviewed all the images and record radiological features including morphological signs on radial VIBE, CT images, and ADC value. Receiver operating characteristic (ROC) was used to analyze the capability of radial VIBE as well as DWI to distinguish malignant from benign peripheral solid pulmonary masses.
Results
In 77% of patients, malignant peripheral solid pulmonary masses were found. Morphological signs of mediastinal lymph node enlargement and lobulation were more easily found in malignant masses in both radial VIBE (mediastinal lymph node enlargement: p = 0.033, lobulation: p = 0.039) and CT (mediastinal lymph node enlargement: p = 0.004, lobulation: p = 0.012). The ADC value were also significant difference between benign and malignant groups (p = 0.001). Combined ADC value with radial VIBE was a most specific test than routine-dose CT (86.1% vs 75%, p < 0.001), but less sensitive than routine-dose CT (81.8% vs 90.9%; p < 0.001) for malignant peripheral solid pulmonary masses detection. Diagnostic accuracy was 89% for combining ADC value with radial VIBE, and 85% for routine-dose CT.
Conclusions
Combination of morphological signs and ADC value seems to improve differentiating malignant from benign peripheral solid pulmonary masses. Especially in patients unable to endure radiation exposure, suspend respiration, radial VIBE provides similar morphological signs displaying to those on routine-dose CT.
Authors: Alessia Bino Chiara Beatrice Vicentini Silvia Vertuani Ilaria Lampronti Roberto Gambari Elisa Durini Stefano Manfredini Anna Baldisserotto
Hesperidin is one of the most important natural flavonoids, known for its antioxidant, anti-inflammatory, anti-mutagenic, and anti-hypertensive properties. Despite its various biological activities, hesperidin is rarely used in the dermo-cosmetic field because of its poor solubility in both water and oil phases that makes difficult formulation, distribution and bioavailability through the skin layers. Moreover, hesperidin is still underestimated in skin care products, and literature data on its stability into a topical formulation are not yet available. In this paper we report the synthesis of five different derivatives of hesperidin and their evaluation in terms of antioxidant, antifungal, antiproliferative, and apoptotic effects on human leukemic K562 cells. Preliminary antiproliferative effects were considered since hyper-proliferation is involved in several cutaneous problems particularly in the case of photo-exposition and environmental pollution. Esp4 and Esp5 were found to be more active in inhibiting K562 cell growth than parent hesperidin. Esp3 exhibited different biological properties, i.e., antioxidant activity in the absence of antiproliferative effects.
In the largest-ever randomized trial testing vitamin D for cancer prevention, the supplement did not lower the risk of developing cancer. The Vitamin D and Omega-3 Trial (VITAL) includes a nationally representative sample of nearly 26,000 participants.
Epidemiology and outcomes of acute kidney injury in critically ill: Experience from a tertiary care center
p. 413
PS Priyamvada, R Jayasurya, Vijay Shankar, S Parameswaran DOI:10.4103/ijn.IJN_191_17
There is only limited information on the epidemiology and outcomes of acute kidney injury (AKI) in critically ill patients from low- and middle-income countries. This study aims to identify the etiology, short-term outcomes, and determinants of mortality in patients with AKI admitted to multiple medical and surgical Intensive Care Units (ICU's) in a tertiary care center. The study also aims to compare the clinical characteristics and outcomes of community-acquired AKI (CAAKI) and hospital-acquired AKI (HAAKI). A prospective, observational study was done from June 2013 to October 2015. All patients over 18 years with AKI admitted in various medical and surgical ICU's seeking nephrology referral were included. AKI was defined according to KDIGO criteria. The follow-up period was 30 days. A total of 236 patients were recruited from five medical and nine surgical ICU's. Majority (73.3%) were males. About 53.38% patients had CAAKI, whereas 46.61% had HAAKI. The predominant etiologies for AKI were sepsis (22.4%), trauma due to road traffic accidents (21.18%), acute abdomen (perforation, acute pancreatitis, bowel gangrene, intestinal obstruction and cholangitis) (18.64%), and cardiac diseases (10.59%). Sepsis and acute abdomen were the most common causes of CAAKI, whereas trauma and cardiac causes were the predominant causes of HAAKI (P < 0.05). Patients with HAAKI were younger, admitted in surgical units, had lower SOFA scores, lower serum creatinine, lesser need for dialysis, longer hospital stay, and earlier stages of AKI compared to patients with CAAKI (P < 0.05). The 30-day mortality was 52.54%. The mortality was not different between CAAKI and HAAKI (56.3% vs. 48.18%; relative risk = 0.86: 95% confidence interval 0.67–1.1). The mortality was similar across different stages of AKI.
Skin microcirculatory changes in relation to arteriovenous fistula maturation
p. 421
Siew Cheng Chai, Wan Azman Wan Sulaiman, Arman Zaharil Mat Saad, Aida Hanum Rasool, Amran Ahmed Shokri DOI:10.4103/ijn.IJN_402_17
Maturation of arteriovenous fistula (AVF) involves complex vascular remodeling. In this study, we evaluated the changes of skin microvascular perfusion over the extremity with AVF maturation using the laser Doppler fluximetry (LDF). A total of 45 patients with chronic kidney disease, Stages IV–V, were included; they had undergone AVF creation from July 2014 to June 2016 at our institute. The measurement of skin microvascular perfusion was accomplished proximal and distal to the fistula anastomosis site: pre- and post-operative day 1, week 2, week 6, and week 12. Thirty-two patients with mean age of 55.6 had achieved AVF maturation. There were 40.6% radial-based and 59.4% brachial-based AVF. There was a 32.8% reduction of mean skin perfusion distal to the fistula by day 1 compared to the baseline perfusion; however, perfusion increased 47% by week 2 compared to day 1 and no dramatic change was subsequently noted. There was an increase of mean skin perfusion, proximal to fistula anastomosis, over 12 weeks with 35.8% at day 1 from the baseline. However, the changes of the mean skin perfusion were not statistically significant. There was no significant relation of skin perfusion changes with the type of fistula, diabetes mellitus, hypertension, and hyperlipidemia. LDF successfully detected the subclinical change of skin microvascular perfusion in relation to AVF creation. Reduction of skin perfusion distal to the fistula suggests that in patients with existing perfusion inadequacy of extremities, they may experience ischemic symptoms as early as day 1 postoperation, and require close monitoring for distal limb ischemic-related complications.
Urinary neutrophil gelatinase-associated lipocalin and urinary soluble CXCL16 as biomarkers of activity in pediatric lupus nephritis
p. 427
MA El-Gamasy, W El-Naghy DOI:10.4103/ijn.IJN_265_17
One of the challenges of treating patients with lupus nephritis (LN) is to assess disease activity. The aim of this study was to measure the urinary neutrophil gelatinase-associated lipocalin (uNGAL) and urinary soluble chemokine (C-X-C motif) ligand 16 (CXCL16) levels in children and adolescents with systemic lupus erythematosus (SLE) and investigate whether they are elevated in active LN. This study was conducted on 80 patients diagnosed as SLE by the Systemic Lupus International Collaborating Clinics criteria and 60 apparently healthy individuals as controls. Global and renal disease activities were evaluated by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and renal SLEDAI, respectively. uNGAL and urinary CXCL16 were measured for all participants by ELISA. Renal biopsy was done for all cases at initial diagnosis and was graded using ISN/RPS classification. uNGAL and CXCL16 were higher in patients than in the controls (8.9 ± 3.56 ng/dl and 1067 ± 367 ug/L vs. 2.26 ± 1.95 ng/dl and 471 ± 106 ug/L, respectively). uNGAL had higher sensitivity and specificity than urinary CXCL16 as predictor of LN (95% and 90% vs. 85% and 80%, respectively). There was significant positive correlations between uNGAL levels, 24-h urinary proteins (r = 0.732, P = 0.001), and SLEDAI (r = 0.359, P = 0.001). There was also significant positive correlations between urinary CXCL16 levels, 24-h urinary proteins (r = 0.47, P = 0.001), and SLEDAI (r = 0.17, P = 0.001). uNGAL and CXCL16 were reliable indicators of the activity of LN.
Optimization of treatment modality in elderly end-stage renal disease population: Peritoneal dialysis versus transplant
p. 433
A Kaul, MR Behera, R Kishore, B Karthikeyan, DS Bhadauria, P Mishra, N Prasad, A Gupta, RK Sharma DOI:10.4103/ijn.IJN_305_17
Despite kidney transplantation (KT) being considered as the best treatment modality for end-stage renal disease (ESRD), patient and graft survival in the elderly population is poorer than younger individuals. Many authors argue that prolonged life expectancy outweighs the risk of remaining on dialysis, but few studies had compared the treatment modalities, especially with peritoneal dialysis (PD). A retrospective study was conducted at a tertiary care institute to compare outcome of elderly ESRD patients, who received KT with those continued on PD; and to evaluate the predictors of patient survival. Patient survival at 1 year was (76.2% vs. 91.1%); 5 years (53.7% vs. 21.8%); and 10 years (35.6% vs. 0.00%) among KT and PD population, respectively. Infection was the most common cause of death among KT group (35 [41.2%] vs. 34 [28.2%]) while cardiovascular mortality in PD group (55 [46.2%] vs. 7 [8.2%]). Technique survival at 1, 5, and 10 years in PD group was 92.8%, 58.5%, and 0%, respectively. Similarly, graft survival at 1, 5, and 10 years in KT group was 98.7%, 90.2%, and 90.2%, respectively. Multivariate analysis showed body mass index (BMI) (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82–0.93, p < 0.001), and albumin (HR 0.55, 95% CI 0.37–0.80, p = 0.002) were significant predictors of survival. In the 1st year, patient survival was better in PD than KT, but after adjustment for BMI and albumin, both short-term and long-term survival in elderly KT group was better than that of PD. Hence, elderly ESRD patients should not be barred from KT just because of age.
Early graft dysfunction after renal transplantation manifests as acute rejection (AR) or acute tubular necrosis (ATN). Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method of assessing tissue oxygenation, which may be useful for predicting acute allograft dysfunction. This was a prospective study involving 40 patients scheduled for renal transplantation from August 2012 to August 2014. In addition, 15 healthy donors were also enrolled in this study. All recipients underwent BOLD MR imaging (MRI) and R2* mapping 10–20 days after transplant, and additionally within 48 h of biopsy if there was any evidence of graft dysfunction. The healthy donors underwent BOLD MRI 1–2 days before surgery. The biopsies were grouped into AR, ATN, and no evidence of AR or ATN. The mean medullary R2*, cortical R2*, corticomedullary gradient, and medullary: cortical R2* ratio were compared between groups using one-way analysis of variance. Spearman's correlation and multinomial linear regression were applied to determine the influence factors of R2* value. Overall, nine patients had graft dysfunction. Six were reported as AR, two as ATN, and one as no evidence of ATN or rejection. The mean medullary and cortical R2* were significantly higher in ATN group compared with AR and normal group, whereas the mean medullary and cortical R2* of AR group were significantly lower than normal group. The corticomedullary gradient of AR group was significantly lower compared with ATN and normal group. Medullary R2*:cortical R2* ratio was significantly lower in AR group compared with normal group. No significant difference was noted between the 15 donors and patients with normal graft function. R2* values on BOLD MRI are significantly decreased in AR allografts and increased in an early stage of ATN allografts, suggesting that BOLD MRI can become a valuable tool for discriminating between AR and ATN.
Prevalence and clinical correlates of white coat effect in patients with chronic kidney disease and the role of automated blood pressure device in its assessment
p. 448
Srinivas Shenoy, Shankar Prasad Nagaraju, Nileshwar R Rau, Ravindra A Prabhu, Uday Venkat Mateti, Dharshan Rangaswamy, Indu R Rao, Karan Saraf DOI:10.4103/ijn.IJN_418_17
Context: Hypertension in chronic kidney disease (CKD) is an important modifiable cardiovascular risk factor. Patients with CKD can have clinically significant white coat effect (WCE), making routine clinic blood pressure (BP) measurements an unreliable indicator of actual BP control. Automated BP monitoring is useful in identifying WCE. The utility of automated BP monitoring has seldom been part of clinical practice in developing countries. Aim: The goal of this study was to estimate the prevalence and determinants of WCE in adult patients with CKD in an outpatient setting using an automated BP device. Materials and Method: In this prospective observational study, patients with CKD attending the nephrology clinic over a period of 6 months (January 2016 to July 2016), who were suspected to have WCE by the treating physician, were assigned to measurement of BP by both the standardized manual BP recording by a single nephrologist and with automated machine as per a defined protocol. Clinical, demographic characters that would influence outcomes were also studied. Results: Among 118 patients with CKD with suspected WCE, 57.6% showed WCE. The mean systolic and diastolic BPs were significantly lower with automated machine when compared with manual BP recordings in patients with WCE (p = 0.04). WCE was seen in all stages of CKD. Occurrence of WCE in CKD was not dependent on factors such as old age, sex, diabetes mellitus, or smoking status in our study. Conclusion:WCE is a highly prevalent and underdiagnosed entity in patients with CKD. Automated machine is a useful and time-saving tool in detection of WCE in patients with CKD attending the outpatient clinic and guide management.
L Umesha, SM Shivaprasad, EN Rajiv, MM Satish Kumar, V Leelavathy, CG Sreedhara, MR Niranjan DOI:10.4103/ijn.IJN_219_16
Acute pyelonephritis (APN), although a common clinical entity, still not much is known about the clinical profile in the Indian scenario. We prospectively collected clinical, biochemical, and radiological data of patients hospitalized with a diagnosis of APN from March 2014 to June 2016. A total of 296 cases were included in the study. Mean age was 53.85 ± 9.78 years. Male to females ratio was 1.93:1. Among the risk factors recognized for complicated pyelonephritis (PN), diabetes mellitus (DM) (54.4%) was the most common factor followed by renal calculi (14.4%), benign prostatic hyperplasia (6.7%), immunocompromised state (3.3%), stricture urethra and meatal stenosis (3.3%), and neurogenic bladder (2%). Urinary culture was negative in 153 (51.7%) and positive in 143 patient (48.3%). Most common organism isolated was Escherichia coli (29.7%), followed by Klebsiella pneumoniae (5.4%), pseudomonas (5.4%), Enterococcus (4.4%), and Proteus in 10 (3.4%). Serum creatinine of more than 1.5 mg/dl at admission was seen in 96.3% patients; 40% of them had underlying chronic kidney disease with DM being the most common. Multiorgan dysfunction either at admission or during the course in hospital stay was seen in 31.8% patients. Twelve (2%) had emphysematous PN. Six patients had Class II, 4 had Class III, 1 with Class I, and another with Class IV. A total of 18 deaths were noted (6.1%). Hemoglobin <10 g/dl, serum creatinine at admission >1.5 mg/dl, HbA1c% >10%, and immunosuppression had statistically significant association with the development of multiorgan dysfunction on univariate analysis, but on multivariate analysis, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance. Even with attributable risk of mortality, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance on multivariate analysis. HbA1c% adds to the predictive parameters to recognize at-risk patients to intensify the treatment and avoid complications.
Hepatitis C virus-associated membranoproliferative glomerulonephritis treated with directly acting antiviral therapy
p. 462
S Nayak, A Kataria, MK Sharma, A Rastogi, E Gupta, A Singh, SC Tiwari DOI:10.4103/ijn.IJN_235_17
Hepatitis C virus (HCV) infection has been shown to affect kidneys with various histopathological pattern on the kidney biopsy. These commonly include a membranoproliferative glomerulonephritis (MPGN) pattern with mixed cryoglobulinemia (CG), thrombotic microangiopathy, membranous nephropathy, and vasculitis affecting medium and small vessels of the kidneys causing polyarteritis nodosa. It has been rarely associated with MPGN without detectable CG. We present one such patient who presented to us with HCV-associated MPGN without detectable CG, who recovered completely with directly acting antiviral therapy without any immunosuppression.
Systemic lupus erythematosus with linear IgA bullous dermatosis and renal vascular lesions: An extremely rare association
p. 465
R Malipatel, V Gnanapriya, A Manocha, YK Inchara DOI:10.4103/ijn.IJN_200_17
We report a rare case of systemic lupus erythematosus presenting initially with cutaneous manifestations of linear IgA bullous dermatosis. Later the patient developed renal abnormalities due to thrombotic microangiopathy and lupus nephritis with inflammatory necrotizing vasculitis. Paucity of immune deposits was observed on Immunofluorescence. This association of SLE with these cutaneous and renal lesions is rarely reported in the literature.
Xanthogranulomatous pyelonephritis: Intrahepatic and intrathoracic extension
p. 468
U Anandh, N Birajdar, R Kumar, S Babu DOI:10.4103/ijn.IJN_213_17
A 32-year-old female presented to us with worsening cough and expectoration, low-grade fever, and malaise for 3 months. She gave a history of pregnancy loss secondary to urinary tract infection (UTI) a year back. At that time, she was told to have an obstructive right renal calculus. She also had a history of recurrent UTI in the past 1 year. She had no other comorbidities. Her clinical evaluation revealed an enlarged right kidney and reduced air entry in the right hemithorax. Radiological investigations revealed a large right kidney invading into the inferior surface of the right lobe of the liver and the right pleural space. A clinical diagnosis of xanthogranulomatous pyelonephritis was made, and she was advised nephrectomy. Intraoperatively, the right kidney was found to invade both the right lobe of the liver and the right pleural cavity through a right diaphragmatic defect. Histopathology of the kidney revealed the presence of foamy histiocytes suggestive of xanthogranulomatous pyelonephritis. Invasive xanthogranulomatous pyelonephritis is known, however, invasion into the extra-abdominal structures has not been reported in the literature. Our case is a rare manifestation of a rare clinical entity – xanthogranulomatous pyelonephritis.
Crystalline nephropathy in renal transplant: A series of 4 cases
p. 472
K Mnif, S Yaich, M Mars, K Kammoun, F Fendri, K Charfeddine, F Jarraya, T Boudawara, J Hachicha DOI:10.4103/ijn.IJN_76_17
Crystals are particles of endogenous inorganic or organic composition that can trigger kidney injury when deposited or formed inside the kidney. The most common forms of crystalline nephropathies (CNs) are nephrocalcinosis and oxalate nephropathy. The causes of early allograft dysfunction are changing constantly, and recently calcium oxalate (CaOx) crystal deposition has been added to this list. CaOx deposition in renal allograft is important and probably under-recognized cause of delayed graft function that requires adequate awareness with early intervention to improve the allograft outcome. Here, we describe four cases of irreversible renal graft injury due to CNs.
Allopurinol-induced drug reactions with eosinophilia and systemic symptoms syndrome with interstitial nephritis
p. 477
T Aatif, J Fatihi, H El Annaz, O Qamouss DOI:10.4103/ijn.IJN_166_17
Allopurinol-induced drug reactions with eosinophilia and systemic symptoms (DRESS) is a severe illness related to hypersensitivity syndrome characterized by fever, skin rash, lymph node enlargement, hematological abnormalities, especially eosinophilia and atypical lymphocytosis, and single or multiple organ involvement. The syndrome is difficult to diagnose in view of its clinical heterogeneity and long latency period within 8 weeks after start treatment. We report a case of DRESS syndrome in a 64-year-old man, induced by allopurinol treatment for asymptomatic hyperuricemia, started 8 weeks earlier but stopped only 3 days after because of the onset of rash. The diagnosis was retained due to combining of interstitial nephritis with the clinical findings of fever, skin rash, cervical lymphadenopathy, eosinophilia, and reactivation of human herpesviruses specifically HHV-6. The glucocorticoids were started to relieve hypersensitivity. Five days later, the patient became afebrile, and the rash improved significantly. However, interstitial nephritis with renal function impairment progressed to severe azotemia, and even anuria requiring hemodialysis. Allopurinol-induced DRESS syndrome is associated with significant mortality, and care must, therefore, be exercised when given this drug.
Autosomal dominant polycystic kidney disease: Presence of hypomorphic alleles in PKD1 Gene
p. 482
S Pandita, D Khullar, R Saxena, IC Verma DOI:10.4103/ijn.IJN_236_17
Autosomal dominant polycystic kidney disease is characterized by multiple cysts in both kidneys manifesting in adult life. In general, the disorder is caused by a pathogenic variant in one allele of PKD1 or PKD2 genes, while the other allele is normal. Pathogenic variants in both the alleles are rare and have variable phenotypes, from lethal or perinatal presentation to a mild form in later adulthood, depending on the type of variant. Here, we describe a proband with two variants (p.Thr1773Ile and p.Ala1871Thr in trans) in PKD1 gene, who presented with disease at age 24 years. Both the parents and one brother had a variant in one allele, the other being wild type only and had normal ultrasound findings. Segregation studies suggest that both the variants may act as "hypomorphic" or "incompletely penetrant" alleles and acting together resulted in haploinsufficiency of protein PC1 in renal cells, leading to cystogenesis in the proband. The consequences of the presence of two hypomorphic variants have been poorly documented in literature. We reviewed the few published cases having two hypomorphic variants and the data conform to the conclusions that we reached by study of the family described. It is emphasized that to resolve the significance of suspected hypomorphic variants, segregation studies in the parents and siblings are essential.
An unusual association of renal cell carcinoma and renal malakoplakia with focal segmental glomerulosclerosis in an elderly patient
p. 485
M Vijayan, P Koshy, R Parthasarathy, M Mathew, G Abraham DOI:10.4103/ijn.IJN_289_17
The association of malignancy and glomerulonephritis may be missed, especially in elderly patients. Here, we report a case of eosinophilic variant of renal cell carcinoma and renal parenchymal malakoplakia discovered on renal biopsy in a patient with steroid-dependent nephrotic syndrome. The presence of malakoplakia in our biopsy was probably due to systemic steroid therapy for glomerulonephritis, presence of concomitant asymptomatic urinary tract infection, and/or history of diabetes mellitus. The patient had remission of proteinuria following laparoscopic removal of the tumor, indicating probable remission of glomerulonephritis.
Kidney transplantation from a hepatitis C virus-positive donor to a hepatitis C virus-negative recipient
p. 488
M Kamalkiran, V Ravikiran, C Shashidhar, K. V. R Prasad, V Yeldandi DOI:10.4103/ijn.IJN_267_17
Kidney transplantation from a hepatitis C virus (HCV)-positive donor to an HCV-negative recipient till recently has been a contraindication. In view of the excellent sustained virological response (SVR) rates with directly acting antiviral agents, HCV-positive donors are being considered for the HCV-negative recipients in a few centers. We report the successful transplantation of an HCV-negative recipient transplanted with an HCV-positive donor kidney. Donor was treated with sofosbuvir and ribavirin for 12 weeks. At 10th and 16th weeks of starting treatment, her HCV-RNA PCR was negative. Three weeks later, transplantation was performed with basiliximab induction and triple immunosuppression with tacrolimus, mycophenolate, and prednisolone. The recipient was administered sofosbuvir and ribavirin for 12 weeks. He attained good graft function with a stable creatinine. His serial alanine transaminases were normal on 3rd, 6th, and 12th months, respectively. Six months posttransplant his anti-HCV antibody, and HCV-RNA PCR were negative.
