The enigma of the clandestine association between chloroquine and HIV-1 infection

OBJECTIVES

The antimalarial drug chloroquine (CQ) dampens the immune system and is used in the treatment of autoimmune disorders. CQ also shows antiviral activity against nonenveloped and enveloped viruses, including HIV-1. Persistent immune activation in chronic HIV-1infection leads to CD4 T-cell depletion. CQ is envisioned to attenuate immune activation and virus activity in HIV-1-infected patients. The role of CQ in immune activation and virus activity is discussed here.

METHODS

To elucidate the effect of CQ on immune activation, a retrospective review of published clinical trials, in vivo experimental studies in animals, and the most relevant in vitro observations in HIV-1-infected cells, together with observations from our own laboratory studies, was carried out and the findings discussed.

RESULTS

In a few clinical studies and animal experiments, CQ was ineffective in decreasing immune activation and HIV-1 infection. In vitro, CQ markedly increased HIV-1 infection in astrocytes and other non-CD4 cells.

CONCLUSIONS

The use of CQ in HIV-1-infected patients is questionable. The evidence for a dampening of immune activation by CQ is inconclusive.

IN VITRO CHEMOTHERAPY PROFILING OF WELL-DIFFERENTIATED MIDGUT NEUROENDOCRINE TUMORS (NETS) BASED ON INDIVIDUAL PATIENT TUMOR BIOMARKERS ANALYSIS

BACKGROUND

Midgut neuroendocrine tumors (NETs) are rare malignancies with indolent clinical courses. In general, they are well-differentiated with most tumor cells in the G0 phase of the cell cycle, consistent with the poor response rate of NETs to chemotherapy in vivo. We hypothesize that insults, such as surgery, can drive NET cells from G0 into S phase and that biomarker analysis of individual patient tumors harvested and grown in the lab will provide useful practical guide for future intra and post-operative adjuvant therapy.

METHODS

97 well-differentiated midgut NET patients underwent cytoreductive surgery at our institution between May/2012 and October/2012. 148 surgical specimens were collected and submitted to a single commercial lab for processing. Primary tumors, lymph nodes and liver metastases were harvested and cultured. Their ribonucleic acids (RNA) were then extracted to analyze the expressivity, a total of 88 different biomarkers. Based on our patients' specific tumor biomarker expressivity and known correlations between 36 anti-neoplastic agents with their linked biomarkers, recommendations were reported as clinically beneficial or non-beneficial.

RESULTS

A total of 148 specimens from 97 patients were tested. In four of the 97 patients, no clinically beneficial chemotherapy agent could be identified. Among the remaining 93 patients, the top three agents that are most likely to be clinically beneficial are: fluorouracil, cisplatin and carboplatin. These were reported to be clinically beneficial in 135/148 (91.2%), 103/148 (69.6%), and 103/148 (69.6%) patients respectively.

CONCLUSIONS

Midgut NETs are slow growing tumors which are chemotherapeutically inert owing to the fact that most of the tumor cells are in G0 cell cycle. Surgical insult drives NET cells into active synthetic phase where they begin to express biomarkers specific to their tumor cells. Analysis of these biomarkers guides further potential beneficial therapy based on the current known associations among biomarkers and chemotherapy agents. These results must then be compared and confirmed against a direct in-vitro chemo sensitivity assessment conducted simultaneously on the same patients.

An active atmospheric methane sink in high Arctic mineral cryosols

Methane (CH4) emission by carbon-rich cryosols at the high latitudes in Northern Hemisphere has been studied extensively. In contrast, data on the CH4 emission potential of carbon-poor cryosols is limited, despite their spatial predominance. This work employs CH4 flux measurements in the field and under laboratory conditions to show that the mineral cryosols at Axel Heiberg Island in the Canadian high Arctic consistently consume atmospheric CH4. Omics analyses present the first molecular evidence of active atmospheric CH4-oxidizing bacteria (atmMOB) in permafrost-affected cryosols, with the prevalent atmMOB genotype in our acidic mineral cryosols being closely related to Upland Soil Cluster α. The atmospheric (atm) CH4 uptake at the study site increases with ground temperature between 0 °C and 18 °C. Consequently, the atm CH4 sink strength is predicted to increase by a factor of 5-30 as the Arctic warms by 5-15 °C over a century. We demonstrate that acidic mineral cryosols are a previously unrecognized potential of CH4 sink that requires further investigation to determine its potential impact on larger scales. This study also calls attention to the poleward distribution of atmMOB, as well as to the potential influence of microbial atm CH4 oxidation, in the context of regional CH4 flux models and global warming.

Quality by design approach for simultaneous estimation of doxycycline hyclate and curcumin by RP-HPLC method

A simple, rapid, reliable, robust and optimized reversed phase high performance liquid chromatographic method for simultaneous estimation of doxycycline hyclate and curcumin was successfully developed and validated as per International Conference on Harmonization guidelines. The objective was achieved in terms of well separated peaks within 10 min on a Waters Sunfire C8 column with dimensions of 250×4.6 mm, particle size 5.0 μm using mobile phase consisting of 30 volumes of potassium dihydrogen phosphate buffer (50 mM) adjusted to pH 6.5±0.1 with triethylamine and 70 volumes of methanol at flow rate of 0.85 ml/min. The column effluents were monitored at 400 nm maintained at ambient column temperature (28^o). The developed method was found linear over the concentration range of 200-700 μg/ml for doxycycline hyclate and 8-28 μg/ml for curcumin, the detection and quantitation limit was found to be 26.063 and 78.97 μg/ml for doxycycline hyclate; 0.795 and 2.13 μg/ml for curcumin, respectively. The developed method was optimized using Minitab software version 16 to meet the current quality by design requirements. The method validation was done for linearity, range, detection and quantitation limit, accuracy, precision, specificity, system suitability testing, and robustness.

Alterations in mitochondrial DNA copy number and the activities of electron transport chain complexes and pyruvate dehydrogenase in the frontal cortex from subjects with autism

Autism is a neurodevelopmental disorder associated with social deficits and behavioral abnormalities. Recent evidence suggests that mitochondrial dysfunction and oxidative stress may contribute to the etiology of autism. This is the first study to compare the activities of mitochondrial electron transport chain (ETC) complexes (I-V) and pyruvate dehydrogenase (PDH), as well as mitochondrial DNA (mtDNA) copy number in the frontal cortex tissues from autistic and age-matched control subjects. The activities of complexes I, V and PDH were most affected in autism (n=14) being significantly reduced by 31%, 36% and 35%, respectively. When 99% confidence interval (CI) of control group was taken as a reference range, impaired activities of complexes I, III and V were observed in 43%, 29% and 43% of autistic subjects, respectively. Reduced activities of all five ETC complexes were observed in 14% of autistic cases, and the activities of multiple complexes were decreased in 29% of autistic subjects. These results suggest that defects in complexes I and III (sites of mitochondrial free radical generation) and complex V (adenosine triphosphate synthase) are more prevalent in autism. PDH activity was also reduced in 57% of autistic subjects. The ratios of mtDNA of three mitochondrial genes ND1, ND4 and Cyt B (that encode for subunits of complexes I and III) to nuclear DNA were significantly increased in autism, suggesting a higher mtDNA copy number in autism. Compared with the 95% CI of the control group, 44% of autistic children showed higher copy numbers of all three mitochondrial genes examined. Furthermore, ND4 and Cyt B deletions were observed in 44% and 33% of autistic children, respectively. This study indicates that autism is associated with mitochondrial dysfunction in the brain.

First Report of Bacterial Leaf Spot of Coriander Caused by Pseudomonas syringae pv. coriandricola in India

A new disease was observed during the early spring of 2011 and 2012 on coriander (Coriandrum sativum L.) in the Himachal Pradesh state of India. Disease incidence was estimated as 10% in approximately 5 ha. Symptoms were observed as brown leaf spots (1 to 2 × 3 to 5 mm) surrounded by a water soaked area. The leaf spots were often angular, being limited by veins. Leaf spots merged to cause a more extensive blight. Symptomatic leaf tissues were surface sterilized in 0.1% HgCl₂ for 30 sec followed by three successive rinses in sterilized water. Small sections of tissue were excised aseptically from leaf spot margins and transferred to several drops of sterile distilled water in a petri dish for 30 min. The diffusate was streaked onto King's B medium and incubated at 25°C for 24 to 48 h. Six representative strains of bacteria were isolated from five infected leaves. The bacteria were characterized as Gram negative, rod shaped, with few polar flagella and nonfluorescent on KB, and positive for levan production and tobacco hypersensitivity reaction but negative for oxidase reaction, rot of potato slices, and arginine dihydrolase. Preliminary identification of bacterial isolates was made on the basis of morphological and biochemical characters (3) and confirmed for one isolate by partial 16S rRNA gene sequencing. Using primers PF:5'AACTGAAGAGTTTGATCCTGGCTC3' and PR:5'TACGGTTACCTTGTTACGACTT3', a 1,265-bp DNA fragment of the 16S rDNA region was amplified. A BLAST search of this sequence (JX 156334) in the NCBI database placed the isolate in the genus Pseudomonas, with 99% similarity to accession P. syringae GRFHYTP52 (GQ160904). The sequence also showed 97% similarity to P. syringae pv. apii and P. syringae pv. coriandricola isolates from California (1). Identification of the bacterium to pathovar was based on host symptoms, fulfillment of Koch's postulates, cultural characteristics, physiological and determinative tests, and specificity of host range (2). Host range studies were conducted on celery, carrot, fennel, parsley, and parsnip, and no symptoms developed on any of these hosts. Pathogenicity was confirmed by artificial inoculation of five 1-month-old coriander plants with all isolates. A bacterial suspension (10⁸ CFU ml^-1) was injected into four leaves for each isolate with a hypodermic syringe and inoculated plants were placed in growth chamber at 25°C and 80% relative humidity. Initial symptoms were observed on leaves within 5 days of inoculation. No symptoms were observed on control plants inoculated with sterile water. Reisolation was performed on dark brown lesions surrounded by yellow haloes on the inoculated leaves and the identity of isolated bacteria was confirmed using the biochemical, pathogenicity, and molecular techniques stated above. All tests were performed three times. To our knowledge, this is the first report of P. syringae pv. coriandricola causing leaf spot disease on coriander in India. References: (1) Bull et al., Phytopathology 101:847, 2011. (2) Cerkauskas, Can. J. Plant Pathol. 31:16, 2009. (3) R. A. Lelliott and D. E. Stead, Methods for the Diagnosis of Bacterial Diseases of Plants, Blackwell Scientific, Sussex, UK, 1988.

Seasonal Variation in Essential Oil Content and Composition of Thyme, Thymus serpyllum L. Cultivated in Uttarakhand Hills

Thymus serpyllum L. grown in Kumaon region of Western Himalaya was investigated for essential oil content and composition in different seasons. The oils of fresh samples were obtained by hydrodistillation. The yield of essential oil (% v/w) during different seasons varied from 0.07 to 0.28% with the highest in summer season, at vegetative stage. The oils were analyzed by GC and GC-MS. Major components of all the samples were thymol (19.4-60.1%), γ-terpinene (0.3-13.8%) and p-cymene (3.5-10.4%). The results clearly indicated that season has significant effect on quality and quantity of thyme oil.

Insulin initiation and management in people with Type 2 diabetes in an ethnically diverse population: the healthcare provider perspective

AIM

To explore barriers to prescribing of insulin, particularly delays in initiation, from the perspective of healthcare professionals involved in managing Type 2 diabetes in a multi-ethnic setting.

METHODS

The study was carried out in a UK population with high numbers of people of South Asian (mainly Indian) origin. Semi-structured interviews were conducted with 14 healthcare professionals from primary and secondary care. Analysis involved exploring interview transcripts in terms of themes and sub-themes identified through a process of progressive focusing.

RESULTS

Initiation of insulin therapy was described as challenging in all patients irrespective of ethnicity, but some barriers were perceived to be accentuated because of language needs and lower levels of understanding about diabetes and insulin. Additionally, some South Asians were viewed as more likely than their white European counterparts to be influenced by negative observations and experiences about insulin therapy within community networks. Time restrictions were seen as a barrier that was accentuated in the management of South Asian patients. Participants suggested strategies for overcoming patient barriers; with South Asians these included involvement of families and patient peers and availability of South Asian healthcare providers.

CONCLUSION

The challenge for healthcare providers is to how to address the tension between the optimal clinical time for commencing insulin therapy and the time when the patient feels psychologically ready. To help make these two time points coincide, our findings suggest the need to adopt a holistic approach involving consideration of the cultural context of patients, including their ethnic background.

Effect of thyroxine on fibrinolytic system in rat

Thyroid hormones have many effects on the cardiovascular system. Thyroid dysfunction accelerates atherosclerosis not only through conventional risk factors (dyslipidemia) but they also show a very close relationship with hemodynamic parameters. Thyroxine is determinant of the several components of fibrinolytic system even though the exact relationship is far from clear. Present study was carried out to determine the effect of thyroxine on fibrinolytic parameters such as plasminogen activators (PA) in rat heart, levels of PA and plasminogen activator inhibitor (PAI), glucose in plasma and serum lipid profile. Rats were injected with 50 ug eltroxine/100 gm(-1) body weight intraperitoneally for one week. Compared with controls, thyroxine treatment increased PA activity significantly in rat heart. No changes were seen in PA, PAI and glucose in plasma of two groups of rats. A significant decrease in total cholesterol and LDL-cholesterol levels was seen in serum of treated group resulting in the decrease of LDL/HDL and Total cholesterol/HDL-cholesterol ratios. These results suggest that thyroxine treatment may have considerable clinical significance. It raised PA activity in heart as well as reduced cholesterol content in blood. It is possible that thyroxine treatment may confer a beneficial effect on cardiovascular risk.

Cervical mediastinoscopy: re-evaluation of an old technique in era of new imaging technology

CONTEXT

With the advent of modern anatomical and functional imaging technologies, application of cervical mediastinoscopy has decreased in diagnosis and staging of mediastinal diseases.

AIM

To evaluate the usefulness of cervical mediastinoscopy in assessing the mediastinal disease when imaging modalities are non-diagnostic.

SETTINGS AND DESIGN

Retrospective analysis of records of a tertiary care hospital.

PATIENTS AND METHODS

Thirty-nine patients with mediastinal pathology of varied aetiologies underwent cervical mediastinoscopy. Pre- and post-operative diagnosis was compared.

RESULTS

In 34 out of 39 cases (87.5%), cervical mediastinoscopy provided a confirmatory final diagnosis. One case had a major complication in the form of recurrent laryngeal nerve palsy.

CONCLUSION

Cervical mediastinoscopy is useful, minimally invasive modality in a scenario where anatomical and functional imaging tools are non-diagnostic.

Presentations of pyogenic liver abscess in one UK centre over a 15-year period

BACKGROUND AND AIM

Pyogenic liver abscess (PLA) has been a condition of high mortality, improving over recent decades with combined antibiotic and percutaneous drainage. We aimed to identify the presenting features, diagnosis, microbiology, treatment and outcome for patients over a 15-year period at an inner-city hospital.

METHODS

Patients with an appropriate discharge diagnosis were identified and case records retrospectively analysed.

RESULTS

A total of 73 patient records were analysed. Common presenting features were anorexia, abdominal pain, fever, vomiting and weight loss with raised white cell count, C-reactive protein, alkaline phosphatase and hypoalbuminaemia. The delay following symptom onset to presentation was a mean of 17.3 days. The inclusion of PLA as a possible diagnosis on admission was only considered in 1% of cases. Positive blood or abscess culture was achieved in 63% of cases. We recorded a hospital mortality rate of 11%.

CONCLUSIONS

In this sample, PLA was rarely considered as a possible diagnosis at presentation. There are common presenting features, which should prompt early investigation. Our microbiological yield was lower than in some studies and may be due to the early empirical use of antibiotics, without microbiological guidance. Percutaneous drainage and antibiotic treatment remain the mainstay of management. The underlying cause for PLA is often not identified. Emerging septicaemia or underlying malignancy were strong predictors of mortality.

Chemical investigation of the essential oil of Thymus linearis (Benth. ex Benth) from western Himalaya, India

Thymus linearis (Benth. ex Benth) was collected from five distinct locations of western Himalaya (India) during the summer season. The hydro-distilled essential oil (yield 0.84-0.95%) was analysed by gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS). A total of 56 constituents, representing 81.55% to 98.11% of the total oil composition, were identified. Thymol (52.28-66.65%), p-cymene (1.81-21.60%) and γ-terpinene (1.94-12.48%) were the major constituents in all populations. Other constituents identified in significant amounts were carvacrol, p-cymen-8-ol, borneol, terpinen-4-ol and thymol methyl ether. The presence of high phenol and essential oil contents in this species make it a suitable substitute for common thyme oil.

A rare coronary anatomy comprising dual (Type IV) left anterior descending arteries and an anomalous left circumflex artery from the right coronary artery

We present the case of a rare coronary anomaly in a 64-year-old male who presented with exertional angina. The right coronary artery (RCA) was dominant, giving origin proximally to an anomalous left circumflex (LCX) artery and a left anterior descending (LAD) artery which supplied the conventional mid and distal LAD territory. The left main artery (LM) arose from the left coronary sinus and branched into a large first septal and an intermediate artery. There was associated non-critical atherosclerotic disease. We report this because of the rare division of the LAD area of supply by arteries from both coronary sinuses (dual LAD) with an anomalous LCX also arising from the proximal RCA. The clinical implications are discussed.

Tonsillectomy and adenoidectomy for obstructive sleep apnea in sickle cell anemia

OBJECTIVE

To evaluate the effects of Tonsillectomy and Adenoidectomy (T&A) on Obstructive Sleep Apnea (OSA) secondary to Upper Airway Obstruction (UAO) in children with Sickle Cell Disease (SCD).

METHODS

Twenty eight children with SCD and history of snoring, with or without adeno tonsillar hypertrophy, were evaluated for UAO and OSA.

RESULTS

Eight children were confirmed to have OSA by multichannel polysomnography and underwent T&A. Follow up examination showed symptomatic clinical and objective improvement in sleep study parameters in OSA.

CONCLUSIONS

T&A appears to be a safe, effective option to treat selected patients with OSA due to UAO in SCD children.

Tracheal necrosis with surgical emphysema following thyroidectomy

Tracheal necrosis after thyroidectomy is an extremely rare event with only a few published reports. We present a case of a 65-year-old male who developed rapidly progressive surgical emphysema of face and upper thorax on the seventh day following total thyroidectomy. Prompt surgical exploration of neck revealed a tracheal rent at the level of the second tracheal ring. This hole was then refashioned into a formal tracheostomy. Patient had an eventful recovery. Tracheostomy was closed by the 14th day. The complication was probably related to tracheal injury sustained due to electro-coagulation and subsequent secondary infection.

The Effect of Water Hydraulic Permeability on the Settling of a Soft Contact Lens on the Eye

PURPOSE

Silicone-elastomer soft contact lenses (SCLs) adhere to the cornea during wear, whereas silicone-hydrogel soft contact lenses exhibit adequate on-eye movement. One explanation for the observed immunity to binding of silicone-hydrogel lenses is that some interstitial water is expelled during blinking, therefore maintaining a more stable post-lens tear film (PoLTF). We examine quantitatively whether or not water can be squeezed by hydrodynamic flow through a silicone-hydrogel membrane driven by the applied lid force during a blink.

METHODS

A rigid, porous-disk model of a contact lens was devised to calculate the relative settling rates of a permeable versus a completely impermeable SCL. The settling rate depended strongly on the value of the hydraulic permeability for pressure-driven water flow through the lens. Because the hydraulic permeability of water through silicone-hydrogel materials is not well-known, we measured this value. At steady state, water was forced through flat membranes of representative lens materials under known pressure drops. The resulting volumetric flows were measured by following the transient rise height of water in a vertical, precision-bore glass capillary. Darcy's law permitted calculation of the hydrodynamic permeability.

RESULTS

The settling-rate model indicated that tear can be squeezed through a SCL only when the Darcy-law hydrodynamic permeability is greater than about 10 microm2 (i.e., greater than 10 Darcy). Our measurements for silicone and HEMA hydrogel membranes reveal hydrodynamic permeabilities of the order 10(-8) microm2, almost 9 orders of magnitude smaller than that necessary to initiate hydrodynamic flow through a SCL.

CONCLUSIONS

We conclude that the squeeze-through mechanism cannot quantitatively account for the observed on-eye movement of silicone-hydrogel lenses. Also, we find that the lid-applied pressure cannot squeeze enough water out of a SCL during a blink to stabilize the PoLTF. Neither a squeeze-through nor a squeeze-out mechanism can maintain a stable PoLTF and prevent adherence.

Comparison of internal sphincterotomy with topical diltiazem for post-hemorrhoidectomy pain relief: a prospective randomized trial

AIM

To assess the efficacy of internal sphincterotomy compared with application of topical 2% Diltiazem ointment after hemorrhoidectomy for pain relief.

SETTINGS AND DESIGN

Prospective randomized study.

MATERIALS AND METHODS

In an 18-month period, 108 subjects with uncomplicated Grade 3/ 4 hemorrhoids were enrolled in the study and were randomized into two equal groups: Subjects in Group A underwent internal sphincterotomy at time of primary surgery while those in Group B received 1 g of 2% Diltiazem ointment locally, thrice daily for seven days. Postoperative pain perception was measured using visual analog score (VAS) and on the basis of number of analgesic tablets (Tab tramadol 50 mg) required in each group. Time to discharge, time to return to work and incidence of complications measured and compared.

STATISTICAL ANALYSIS USED

Statistical techniques applied were Student T test, Chi-square and Fisher's Exact Test.

RESULTS

There were 102 analyzable subjects (Group A: 50 and Group B: 52). The mean VAS score was significantly less in the internal sphincterotomy group from the fourth postoperative day onwards compared to topical Diltiazem (2.23 vs. 3.72; P =0.031). Similarly, the mean requirement of analgesic tablets [10.54 vs. 15.40; P =0.01] was much lower in Group A. There was no significant difference in terms of time to discharge and time to return to work between the two groups. The incidence of complications was more with the internal sphincterotomy group (11.5% vs. 3 %; P =0.488).

CONCLUSIONS

In patients undergoing hemorrhoidectomy, addition of surgical internal sphincterotomy results in lesser pain in the postoperative period as compared to those receiving topical application of Diltiazem.

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer

BACKGROUND

Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available.

METHOD

Patients with primary or secondary lung cancer and a Dyspnoea Exertion Scale score of >or=3 were recruited. Following familiarisation, patients received either nebulised furosemide 40 mg or nebulised 0.9% saline under double blind conditions or no treatment, in random order on 3 consecutive days. Patients undertook number reading and arm exercise tests to assess breathlessness and its impact, and were asked to report subjective benefit and any preference between nebulised treatments.

RESULTS

15 patients took part. There were no differences between furosemide, saline and no treatment in the outcomes of the number reading test (eg, mean number read per breath was 6.7, 6.4 and 6.7, respectively) or arm exercise test (eg, mean Borg score at maximum equivalent workload was 2.3, 2.5 and 2.7, respectively). No adverse effects were reported, although there was a small fall in forced expiratory volume in 1 s and forced vital capacity following saline. Six patients considered that their breathlessness improved with nebulised treatment, three preferring saline, one furosemide and two reporting they were of equal benefit.

CONCLUSIONS

Our findings do not support a beneficial effect from nebulised furosemide in patients with cancer related breathlessness. Listed on the National Research Register (N0170118249) and the UK Clinical Research Network Portfolio Database (1428).

Day care laparoscopic cholecystectomy: a feasibility study in a public health service hospital in a developing country

BACKGROUND

Day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centers with adequate infrastructure for day care surgery in economically advanced countries. However, the feasibility of applying this concept in public health service hospitals in less developed and developing nation needs to studied. Unique protocols need to be developed and tested, taking into account local conditions and infrastructural constraints.

PATIENTS AND METHODS

Patients less than 60 years old, graded I and II on the American Society of Anesthesiologists (ASA) physical status score, living within one hour traveling time and willing to make their own arrangements for a return to hospital in case of problems, were selected for DCLC.

RESULTS

291 cases (78%) out of 373 laparoscopic cholecystectomies done in one calendar year were found suitable for DCLC. The most common cause for omitting from DCLC was that the patient lived out of the defined area (57%). Four of 291 (1.3%) cases were cancelled due to medical condition; 270/287 (96.1%) were discharged the same evening as surgery; 6 patients were converted to open surgery; and 11 did not meet the necessary discharge criteria. Eight of 270 (2.9%) required readmission out of which 3 (1.1%) required intervention. Overall, incidence of complication rate was 3.4%. Analysis of data showed that results were comparable to previously published studies, hence extrapolating that inclusion and discharge criteria used in the study are valid. However, there are certain social constraints which hinder truly universal application of DCLC.

CONCLUSIONS

DCLC is a safe and technically feasible concept, even in public health service centers without dedicated ambulatory surgery units. It has potential for much economical and social benefit in these countries.

Syntrophic-archaeal associations in a nutrient-impacted freshwater marsh

AIMS

Evaluation of the composition, distribution and activities of syntrophic bacteria and methanogens in soils from eutrophic and low nutrient regions of a freshwater marsh, and to compare these results with those obtained from a similar study in the Florida Everglades.

METHODS AND RESULTS

Culture dependent and independent approaches were employed to study consortia of syntrophs and methanogens in a freshwater marsh. Methanogenesis from butyrate oxidation was fourfold higher in microcosms containing soil from eutrophic regions of the marsh than from low nutrient regions. Propionate was oxidized in eutrophic microcosms at lower rates than butyrate and with lower yields of methane. Sequence analysis of 16S rRNA gene clone libraries from DNA extracted from microcosms and soils revealed differences such that the dominant restriction fragment length polymorphism (RFLP) phylotypes (representing 82-88% of clone libraries) from eutrophic soils clustered with fatty acid oxidizing Syntrophomonas spp. The four dominant RFLP phylotypes (representing 11-24%) from microcosms containing soils from low nutrient regions were sequenced, and clustered with micro-organisms having the potential for fermentative and syntrophic metabolism. Archaeal 16S rRNA sequence analysis showed that methanogens from eutrophic regions were from diverse families, including Methanomicrobiaceae, Methanosarcinaceae, and Methanocorpusculaceae, but clone libraries from low nutrient soils revealed only members of Methanosarcinaceae.

CONCLUSIONS

These findings indicate that syntroph-methanogen consortia differed with nutrient levels in a freshwater marsh.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is one of few studies addressing the distribution of fatty acid consuming-hydrogen producing bacteria (syntrophs) and their methanogenic partners in wetland soils, and the effects of eutrophication on the ecology these groups.

Percutaneous coronary intervention: recommendations for good practice and training

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.

Tumour necrosis factor (TNFalpha) as a novel therapeutic target in symptomatic corticosteroid dependent asthma

BACKGROUND

Tumour necrosis factor alpha (TNFalpha) is a major therapeutic target in a range of chronic inflammatory disorders characterised by a Th1 type immune response in which TNFalpha is generated in excess. By contrast, asthma is regarded as a Th2 type disorder, especially when associated with atopy. However, as asthma becomes more severe and chronic, it adopts additional characteristics including corticosteroid refractoriness and involvement of neutrophils suggestive of an altered inflammatory profile towards a Th1 type response, incriminating cytokines such as TNFalpha.

METHODS

TNFalpha levels in bronchoalveolar lavage (BAL) fluid of 26 healthy controls, 42 subjects with mild asthma and 20 with severe asthma were measured by immunoassay, and TNFalpha gene expression was determined in endobronchial biopsy specimens from 14 patients with mild asthma and 14 with severe asthma. The cellular localisation of TNFalpha was assessed by immunohistochemistry. An open label uncontrolled clinical study was then undertaken in 17 subjects with severe asthma to evaluate the effect of 12 weeks of treatment with the soluble TNFalpha receptor-IgG1Fc fusion protein, etanercept.

RESULTS

TNFalpha levels in BAL fluid, TNFalpha gene expression and TNFalpha immunoreative cells were increased in subjects with severe corticosteroid dependent asthma. Etanercept treatment was associated with improvement in asthma symptoms, lung function, and bronchial hyperresponsiveness.

CONCLUSIONS

These findings may be of clinical significance in identifying TNFalpha as a new therapeutic target in subjects with severe asthma. The effects of anti-TNF treatment now require confirmation in placebo controlled studies.

Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England

OBJECTIVE

To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry.

SETTING

All NHS centres undertaking adult PCIs in north west England.

METHODS

Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling.

MAIN OUTCOME MEASURES

MACE, which were in-hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents.

RESULTS

Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable.

CONCLUSIONS

A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators.