Balaglitazone: a second generation peroxisome proliferator-activated receptor (PPAR) gamma (γ) agonist

Balaglitazone (DRF-2593) is a novel partial agonist of PPAR-gamma (γ), which is developed by Dr. Reddy's laboratories India. Balaglitazone is a second generation peroxisome proliferator-activated receptor (PPAR) gamma agonist with only partial agonistic properties. Balaglitazone is currently being evaluated in phase III clinical trial in United States and Europe. Selective PPAR-γ modulators bind in distinct manners to the ligand-binding pocket of PPAR-γ, leading to alternative receptor conformations, differential cofactor recruitment/displacement, differential gene expression, and ultimately differential biological responses. Based on this concept, new and improved novel antidiabetic agents are in current development. Clinical studies conducted with 409 subjects of randomized, double blind, parallel-group placebo and active comparator-controlled subject groups to determine the efficacy and safety of Balaglitazone. The study showed that the trial met its primary endpoint. Balaglitazone treated groups shown significantly reduce of HbA1c (%), FSG (mmol/L), postprandial glucose as comparison to pioglitazone. Phase III clinical studies data clearly shows that Balaglitazone provides robust glycemic control as an add-on to insulin therapy. Balaglitazone 10 mg and 20 mg show the similar magnitudes of the effects which comparable to the effects seen in the pioglitazone 45 mg group. The incidence of fluid retention and fat accumulation fewer than those observed with pioglitazone 45 mg. Hence, Balaglitazone is prominent candidate of new glitazone which requires fewer doses as comparison pioglitazone and shows better safety profile less incidence of special adverse effect like heart failure, peripheral oedema, and myocardial infarction. Unlike other marketed PPAR gamma agonists, Balaglitazone shows less fluid retention, less heart enlargement and no reduction of bone formation than full PPAR gamma agonists in preclinical studies. In present review, we have tried to cover classification PPARs various ligands, chemistry, physical properties, commercial synthesis, current patent status, polymorphic information, receptor interaction, pharmacophore rational, mechanism, adverse effect and clinical status of Balaglitazone, giving emphasis on medicinal chemistry aspect.

Trigeminal neuralgia secondary to posterior fossa tumor

Trigeminal neuralgia (TN) is by no means an uncommon entity presenting as typical or atypical pain syndrome with a standard treatment protocol consisting of medical and surgical therapies. The diagnosis of TN is mainly dependent on the characteristics of symptoms conveyed by the patient and the clinical presentation. Careful history taking, proper interpretation of the signs and symptoms and cranial nerve assessment are necessary for proper diagnosis. Here, we report a case of TN, treated for dental problems and then for neuralgia with only short-term relief. Subsequently, the patient underwent neuroimaging and was found to be having an uncommon space-occupying lesion in the posterior cranial fossa.

Polyelectrolyte coated polymeric nanoparticles for controlled release of docetaxel

Polyelectrolyte coatings are effective means of minimizing the rate of release of small molecules from a nanoparticle system. The current investigation aim at developing biodegradable drug delivery carriers composed of three types of polymers viz poly(lactide-co-glycolic) acid [PLGA], poly(lactide-co-glycolic) acid-polyethylene imine [PLGA-PEI] and poly lactic acid [PLA]. The PLGA and PLGA-PEI nanoparticles were in the size range approximately 150 nm while PLA nanoparticles were approximately 80 nm in size respectively. The nanoparticles were found to encapsulate 66%, 62% and 65% of the hydrophobic drug, Docetaxel (DOCE) respectively. "Layer by Layer (LbL)" self assembly technique was then performed to coat these particles with polyelectrolyte thin films (PEs). DLS studies showed hydrodynamic diameter of 330 nm, 350 nm and 310 nm for the coated PLGA, PLGA-PEI and PLA nanoparticles respectively, while SEM and TEM studies demonstrated that after coating the particle sizes were approximately 200 nm for all the three nanoparticles. In vitro drug release studies demonstrated that at the end of 24 hours, about 83%, 90% and 88% of drug was released from uncoated PLA, PLGA-PEI and PLGA nanoparticles respectively. Using LbL coating, the same amount of the drug was found to be released in a sustained way for up to 7 days for PLGA and up to 6 days for PLGA-PEI and PLA nanoparticles. In vitro cytocompatibility studies were carried out with each system and the cell viability at end of 48 hours was found to be in the range of 70% to 100%. Current approach of sustained drug delivery can help in improving the therapeutic efficiency of the breast cancer drug, DOCE.

Randomized trial of marker-directed versus standard schedule zoledronic acid for bone metastases from breast cancer

511

Background: Zoledronic acid (ZOL) reduces skeletal morbidity associated with metastatic bone disease by 30-50%. Current recommendations are for indefinite administration of intravenous 3-4 weekly (w) ZOL 4mg. Over recent years it has become clear that the risk of skeletal morbidity is related to the rate of bone resorption. We have compared a marker directed schedule of ZOL (M-ZOL), using measurements of urinary n-telopeptide of type I collagen (NTX), to a standard treatment schedule (S-ZOL) in patients with bone metastases from breast cancer. Methods: The primary endpoint was skeletal related events (SRE). A non-inferiority study was designed with 80% power and (one-sided) 5% alpha to demonstrate that M-ZOL retained 67% of the efficacy of S-ZOL. This required 1500 patients, assuming a SRE rate of 0.7/year. Following minimisation for known prognostic factors, patients were randomised to receive S-ZOL 3-4 w or M-ZOL (15-16w; 8-9 w or 3-4w if NTX levels were <50, 50-100, >100 nmol/mmol creatinine respectively), with the schedule adjusted according to NTX measured every 16 weeks. The study duration was 24 months. Results: Due to lower than expected recruitment, the study closed in 2009 following recruitment of 289 patients. 90% of patients had received >4 cycles of ZOL or pamidronate prior to randomisation. The median number of ZOL infusions administered to S-ZOL patients was >2x that received on M-ZOL. 46 (32%) S-ZOL and 55 (38%) M-ZOL patients experienced an SRE. The numbers of SRE were 94 and 138 in the S-ZOL and M-ZOL arms, with the excess in SRE being largely due to more patients on M-ZOL experiencing ≥2 SRE. Multivariate analysis adjusting for key minimisation factors and baseline NTX for all SRE showed a hazard ratio for M-ZOL vs. S-ZOL of 1.41 (90%CI 0.98-2.02, p=.12). NTX levels were significantly higher at all time points in the M-ZOL treated patients. Osteonecrosis of the jaw was uncommon with 3 cases with S-ZOL and 1 with M-ZOL. Conclusions: The study is underpowered to demonstrate non-inferiority in SRE outcome between the treatment strategies. However, the results suggest that the adjustment of ZOL schedule based on NTX values alone may represent sub-optimal management.

Webbed penis: a rare case

Webbed penis belongs to a rare and little-known defect of the external genitalia. The term denotes the penis of normal size for age hidden in the adjacent scrotal and pubic tissues. Though rare, it can be treated easily by surgery. A case of webbed penis is presented with brief review of literature.

The enlarged translabyrinthine and transapical extension type I approach for large vestibular schwannomas

To evaluate the results obtained by performing the enlarged translabyrinthine and transapical extension type I approaches for removal of large vestibular schwannomas and those with anterior extensions. An academic tertiary referral centre at Mumbai, India. Retrospective case review. 35 patients of vestibular schwannomas having size greater than 3 cm in extrameatal diameter with extension anterior to the internal auditory canal who underwent the enlarged translabyrinthine or transapical extension type I approach and with a minimum follow up of 1 year are considered. Other subjects who underwent translabyrinthine approach but did not fulfill the above criteria were excluded. Tumor was removed completely in 34 subjects (97.1%). Anatomic interruption of facial nerve occured in 4 cases (11.4%); 3 subjects underwent end to end anastomosis and 1 subject required a cable graft, these were done during the primary procedure itself. At 1 year follow up 28 subjects (80%) had good facial function (Grade I and II, House Brackmann Grading). Postoperative cerebrospinal fluid leak was encountered in 1 subject (2.9%). 34 subjects (97.1%) had a normal albeit slow gait by the sixth post-operative day. Complete tumor removal with a very low morbidity in our series suggest that the enlarged translabyrinthine and transapical extension type I approach offers excellent control of the neurovascular structures in the cerebellopontine angle as also of the large vestibular schwannoma itself aiding complete removal. It also offers the advantage of management of the interrupted facial nerve at the primary procedure itself since the proximal and distal segments are in the operative field.

Abstract P5-10-07: TACT2 Randomised Adjuvant Trial in Early Breast Cancer (EBC): Tolerability and Toxicity of Standard 3 Weekly Epirubicin (E) Versus Accelerated Epirubicin (aE) Followed by Capecitabine (X) or CMF in 129 UK Hospitals (CRUK/05/019)

Introduction: TACT2, a multicentre phase III trial with E-CMF as control (NEAT Poole NEJM 2006), tests 2 hypotheses in a 2x2 factorial design: A) accelerating chemotherapy (CT) offers superior benefits (CALGB9741 Citron JCO 2003); B) the oral 5FU prodrug X gives similar efficacy but preferential side-effect profile to CMF. Here, focus is on hypothesis B with results for compliance, QL & acute toxicities (physician & patient (pt) reported) during CMF vs. X

Materials &

Methods: 4391 pts (4371 women, 20 men) with node+ve/high risk node-ve invasive EBC were recruited between Dec 2005-08. Treatment was E(100mg/m2 x 4) q3wk vs q2wk aE(100mg/m2 x 4 + pegfilgrastim 6mg d2) followed by classical CMF q4wk x 4 vs X(2500mg/m2/day x 14) q3wk x 4. Detailed CTCAE toxicity was assessed in a subset (38 centres, 2086 pts receiving ≥1 cycle CMF or X). 1279/2086 also participated in substudy of pt-reported outcomes (EORTC QLQ-C30 and TACT2-specific toxicities). 826 had complete dataset (baseline, cycles 4&8). P-values are trend tests across all grades & %grade 3+ are reported. QL assessed via linear regression models adjusted for baseline, end cycle 4 score, & aE vs E. P&lt;0.01 classed as significant

QL in cycles 5-8 was better with X than CMF for global QL& fatigue (P&lt;0.001). Pts reporting clinically meaningful deterioration (&gt;10 points): global QL CMF 106/398 (27%), X 79/428 (18%); fatigue CMF 164/398 (41%), X 122/428 (29%)).

Conclusion: TACT2, the largest adjuvant EBC trial with X, confirms that X has preferential side-effect profile and global QL compared to CMF, with no evidence that prior aE compromised treatment delivery. Dose delivery data are consistent with advanced disease observations that for some pts, 2000mg/m2/day may be correct dose.

Results: 4264 (97%) pts continued on CT beyond cycle 4. 3726 completed all 8 cycles (E-CMF 951 (85%), aE-CMF 938 (86%), E-X 932 (84%), aE-X 905 (83%). For cycles 5-8, %RDI &gt; 85% was 69% after E and 68% after aE. Cycles delivered on time CMF 59%, X 63%; cycles without dose reduction CMF 75%, X 62%. 15 deaths in total within 30 days of CT: 9 on CMF, 6 on X. Worst grade toxicities which differed between CMF & X during cycles 5-8:

Characterization of lactate dehydrogenase enzyme in seminal plasma of Japanese quail (Coturnix coturnix japonica)

Lactate dehydrogenase enzyme present in quail seminal plasma has been characterized. Polyacrylamide gel electrophoresis and subsequently with LDH specific staining of seminal plasma revealed a single isozyme in quail semen. Studies on substrate inhibition, pH for optimum activity and inhibitor (urea) indicated the isozyme present in the quail semen has catalytic properties like LDH-1 viz. H-type. Furthermore, unlike other mammalian species, electrophoretic and kinetic investigations did not support the existence of semen specific LDH-X isozyme in quail semen. The effect of exogenous lactate and pyruvate on sperm metabolic activity was also studied. The addition of 1 mM lactate or pyruvate to quail semen increased sperm metabolic activity. Our results suggested that both pyruvate and lactate could be used by quail spermatozoa to maintain their basic functions. Since the H-type isozyme is important for conversion of lactate to pyruvate under anaerobic conditions it was postulated that exogenous lactate being converted into pyruvate via LDH present in semen may be used by sperm mitochondria to generate ATP. During conversion of lactate to pyruvate NADH is being generated that may be useful for maintaining sperm mitochondrial membrane potential.

Presurgical nasoalveolar molding for correction of cleft lip nasal deformity: experience from northern India

CONTEXT

The cleft lip type nasal deformity presents one of the most complex surgical challenges. The long-term postoperative results are still not satisfactory despite an emphasis on primary nasal correction. This is attributed to tissue memory and healing. Nasoalveolar molding is used effectively to reshape the nasal cartilage and to mold the maxillary arch before cleft lip repair.

AIMS

This study was undertaken to evaluate the role of presurgical nasoalveolar molding in correction of cleft lip nasal deformity for patients with unilateral and bilateral clefts of the lip.

SETTINGS AND DESIGN

Twenty-three cases of clefts of lip and palate with nasal deformity were subjected to present study from May 2004 to May 2006. These cases were initially treated on outpatient basis, and they were admitted at the time of operation. All of these patients were children of less than 1 year of age, belonging to north Indian population.

MATERIAL AND METHODS

Study consisted of patients of cleft lip and palate who were given presurgical nasoalveolar splints at early age. Lip repair was done after at least 2 months of molding. These patients along with control group (without presurgical nasoalveolar molding) were followed up for 1 year. Measurements were taken at different intervals in study over dental cast and on patients. Data obtained from comparison of 2 groups were analyzed using "MSTAT" analysis software (developed by Dr Russel Freed, Professor & Director, Crop & Soil Sciences Department, Michigan State University, East Lansing, Michigan).

RESULTS

In our study, we found that nostril height was more in patients of experimental group (P = .18), while nostril width and alar perimeter were not changed significantly. Children with nasoalveolar molding had significant lengthening of columella (P = .02). Patients of unilateral cleft lip had more reduction in alveolar gap (P = .08) than bilateral group (P = .15).

CONCLUSIONS

Nasoalveolar molding can be a useful adjunct for treatment of cleft lip nasal deformity. It is a cost-effective technique that can reduce the number of future surgeries such as alveolar bone grafting and secondary rhinoplasties.

[Magnetcardiographic detection of abnormal intraventricular activation in patients with ischemic heart disease with and without tachycardia]

Fragmented and delayed activation of ventricular myocardium can cause malignant tachyarrhythmias. By detection of ventricular late potentials only a severely delayed depolarisation is registered, but not the intra QRS-activation. The aim of this study was to examine the complete phase of ventricular depolarisation, to detect and to quantify abnormal electrical activation by magnetocardiography and to estimate in a small group of patients with coronary heart disease the prognostic significance.In 26 healthy subjects, 32 patients after myocardial infarction without malignant ventricular arrhythmias and 10 patients with coronary heart disease and a history of sustained, monomorph ventricular tachycardia magnetocardiography was performed in a magnetically shielded room. To quantify the fragmentation of QRS a fragmentation-index (FI) was calculated. Besides signal averaged ECG, in patients with coronary heart disease cardiac catheterisation and in patients with arrhythmias electrophysiological testing was performed. The FI for the three groups was significantly different (p<0,005). The mean FI in the group of healthy subjects was 20,4+/-5,4, in the group of postinfarction-patients without arrhythmias 27+/-12,1 and in the group of patients with coronary heart disease and ventricular arrhythmias 49,5+/-17,9. Dichotomized at 36 the sensitivity was 80%, the specifity 93%, the positive predictive value was 66% and the negative predictive value 96%. The FI was correlated to the extent of regional wall-motion-irregularity and global ejection fraction.Analyzing late potentials, the values for sensitivity and positive predictive value were surprisingly low (20% and 50%, respectively). The specifity was 96%, the negative predictive value was 88%. Calculating the FI on the basis of electrical signals only an insufficient discrimination of the groups was possible.In the follow-up period of two years one post-infarctional patient was resusciated because of ventricular fibrillation. The FI of this patient was 17.One patient with coronary 3-vessel-disease and left ventricular ejection fraction of 50% died due to acute myocardial infarction, his FI was 39.

CONCLUSION

By means of magnetocardiography fragmented ventricular activation in patients with coronary heart disease was demonstrated even within the QRS-complex and could be correlated to ventricular tachyarrhythmias.

Magnetocardiographic mapping of QRS fragmentation in patients with a history of malignant tachyarrhythmias

BACKGROUND

The identification of patients at increased risk for ventricular tachycardia or ventricular fibrillation (VT/VF) and sudden cardiac death has consequences for therapeutic options and thus may reduce mortality in patients with coronary artery disease (CAD).

HYPOTHESIS

We hypothesized that the intra-QRS fragmentation in magnetocardiographic recordings is increased in patients with CAD and with a history of VT/VF.

METHODS

Multichannel magnetocardiography (MCG) was carried out in 34 healthy controls, 42 patients with CAD without a history of VT/VF, and 43 patients with CAD and with a history of VT/VF. The intra-QRS fragmentation was quantified by a new fragmentation score. Its spatial distribution was investigated using two-dimensional (2-D) contour maps according to the sensor position of the 49-channel magnetogradiometer.

RESULTS

Patients with CAD and with a history of VT/VF had significantly increased QRS fragmentation compared with patients with CAD without VT/VF or controls (72.9+/-37.5, 48.5+/-14.3, and 42.5+/-7.8, respectively: p <0.05). The area of high fragmentation in 2-D contour maps was twice as large in patients with than in those without a history of VT/VF (represented by the number of MCG channels with high fragmentation: 26.3+/-15.5 vs. 12.4+/-9.9, p<0.0001). Patients prone to VT/VF could be identified with a sensitivity of 64% and a specificity of 90%.

CONCLUSION

In patients with CAD and with a history of VT/VF, intra-QRS fragmentation is increased and the area of high fragmentation in 2-D contour maps is enlarged. These findings may be helpful in identifying patients with CAD at risk for malignant tachyarrhythmias.

Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH

Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides a conduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia. Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter. In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery. The incidence of accidental dural puncture was 4%(34/846). Two patients 5.88% (2/34) had transient paresthesia during spinal catheter insertion. Post dural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects. Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.

On the thermal elevation of a 60-electrode epiretinal prosthesis for the blind

In this paper, the thermal elevation in the human body due to the operation of a dual-unit epiretinal prosthesis to restore partial vision to the blind affected by irreversible retinal degeneration is presented. An accurate computational model of a 60-electrode device dissipating 97 mW power, currently under clinical trials is developed and positioned in a 0.25 mm resolution, heterogeneous model of the human head to resemble actual conditions of operation of the prosthesis. A novel simple finite difference scheme combining the explicit and the alternating-direction implicit (ADI) method has been developed and validated with existing methods. Simulation speed improvement up to 11 times was obtained for the the head model considered in this work with very good accuracy. Using this method, solutions of the bioheat equation were obtained for different placements of the implant. Comparison with in-vivo experimental measurements showed good agreement.

Penetrating foreign body neck: a case report

Penetrating neck wounds are potentially dangerous and require emergency management because of the presence of vital structures in the neck. Organic foreign bodies further carries a risk of wound infection. We present a case of penetrating broken branch of a tree traversing from zone II to zone III without any neurovascular injury. Neck exploration was done with midline mandibulotomy approach and foreign body was removed without any complication.

Anglo-Celtic IV: First results of a UK National Cancer Research Network randomized phase III pharmacogenetic trial of weekly compared to 3 weekly paclitaxel in patients with locally advanced or metastatic breast cancer (ABC)

LBA1005

Background: Phase II studies of weekly paclitaxel (P) confirm this to be a well tolerated regimen in ABC with potentially superior efficacy to standard q3w schedules. This was tested in the phase III CALGB 9840 trial, which used a “patient resource conserving” design, combining randomised patients with imported control data from a previous CALGB study of predominantly 2nd line treatment. This and the higher total dose of P in the weekly arm, left many unsure if there really was superior activity for the weekly schedule. Methods: The primary efficacy objective was to detect a 2 month improvement (6 to 8 months, HR = 1.33) in time to progression (TTP) by the giving the same total dose of P weekly (wP) vs. 3 weekly (3wP). 560 randomised patients were required to give 90% power to detect this difference at the 0.05 significance level. A single analysis was planned six months after study closure. Secondary endpoints include overall survival, toxicity and quality of life. The primary translational endpoint is a pharmacogenetic (PG) study of the effect of MDR and CYP single nucleotide polymorphisms. Between Sept. 2002 and July 2006, 569 patients were randomized to receive either wP 90 mg/m2 for 12 weeks or 3wP 175 mg/m2 for 6 cycles. Patients were stratified for measurable disease, prior treatment for ABC and Trastuzumab use. Results: The investigator reported response rates were 27% (3wP) and 42% (wP), p=0.002. Median TTP was 22.0 weeks for 3wP (95% CI 19.7–24.6) and 23.9 weeks for wP (95% CI 20.7–26.7), HR=0.92, p=0.06. Both schedules were well tolerated. PG samples from 325 patients are being matched to the unblinded efficacy data. Conclusions: This phase III trial shows that, for a matched total dose, wP produces a higher response rate than 3wP. This confirms the result from CALGB 9840. The mismatch in treatment duration in this trial may explain why TTP with wP was superior in CALGB 9840 while in the current study we have failed to detect superiority despite a higher response rate. Combining the trial results supports the hypothesis that total dose and schedule of P are important. Our results support the widespread adoption of wP as the standard schedule.

No significant financial relationships to disclose.

Nationwide efficacy-safety study of nebivolol in mildly hypertensive patients

Nebivolol has been adequately tested in clinical efficacy trials of patients with mild hypertension. Clinical efficacy trials or their meta-analyses did not accurately predict the outcome of subsequent large studies. The primary objective was to assess the efficacy/safety of nebivolol 5-10 mg daily in a nationwide study of patients with mild hypertension. Secondary objectives were (1) to compare efficacy/safety as monotherapy versus add-on therapy and (2) to assess the effect of nebivolol on ISH. This was an open-label, 6-week follow-up study of 6,356 patients with mild hypertension or ISH, as defined by the 1999 World Health Organization guidelines, recruited from 2,700 facilities. Previous monotherapies were continued except for beta-blockers. Results are reported as means+/-SDs. Intention-to-treat analysis is given. A total of 5,740 patients completed the study; of the withdrawals, 90% were lost for follow-up or were noncompliant, 38% were untreated before, 23% had beta-blockers. In the accumulated data, mean systolic and diastolic blood pressures fell by 24+/-14 and 13+/-9 mm Hg (both P<0.001). The differences between the blood pressure-reducing effects of nebivolol monotherapy and add-on therapy were not statistically significant: 28+/-16 and 22+/-14 mm Hg for systolic and 15+/-11 and 11+/-8 mm Hg for diastolic blood pressures. Adverse events were limited to 0.5% of the patients, no serious adverse events were observed. In the ISH patients, diastolic blood pressure fell by 4+/-6 mm Hg compared with 15+/-10 mm Hg in the no-ISH patients (P<0.01). Efficacy-safety effects of nebivolol in patients with mild hypertension can be generalized in a nationwide assessment. The efficacy of nebivolol as monotherapy and as the efficacy as add-on therapy are very similar. Nebivolol is highly efficacious in patients with ISH.

Nebivolol: a review of its clinical and pharmacological characteristics

Nebivolol is a cardioselective lipophilic beta-blocker devoid of intrinsic sympathomimetic and membrane-stabilizing actions. The pharmacological profile differs from that of conventional cardioselective beta3-blockers in that it displays nitric oxide- (NO) mediated vasodilator activity. The net hemodynamic effect of nebivolol is the result of a balance between the depressant effects of beta3-blockade and an action that tends to maintain cardiac output, presumably connected with its afterload reducing vasodilator effect. Recent studies suggest that nebivolol may also restore endothelial dysfunction. Long-term follow-up studies indicate that the compound is efficacious and safe both in patients with mild hypertension and those with stable angina. An interesting effect of chronic nebivolol therapy in elderly patients with mild hypertension is the reversal of a depressor effect into a pressor effect on standing. This action indicates that nebivolol has advantages over other antihypertensive drugs and that it may protect elderly hypertensive patients from orthostatic complaints. The observation that nebivolol improves exercise capacity in non-claudicant hypertensives is also of clinical interest. Nebivolol resembles serotonin reuptake inhibitors in that it is metabolized by CYP450 2D6 and, therefore, concomitant treatment with serotonin uptake inhibitors may lead to overdosing. Nebivolol compared to placebo does not significantly reduce the mortality risk in elderly subjects. The effects of biological age and comorbidities may be responsible for this finding. In conclusion, clinical studies suggest that nebivolol is effective and safe in patients with hypertension, angina pectoris and heart failure. The beneficial effects on endothelial function, autonomic control and exercise capacity are of considerable clinical interest.

The effect of bismuth subgallate as haemostatic agent in tonsillectomy

Tonsillectomy is one of the frequent operations performed by Otolaryngologists world over: Otolaryngologists are in search of a technique of tonsillectomy where the operation time and operative blood loss is less. This study was carried out to evaluate the effect of bismuth subgallate (BSG) and adrenaline on tonsillectomy time blood loss during the surgery as well as on the number of ties used. A prospective randomized trial of 60 patients was carried out, in which 30 had a tonsillectomy performed using BSG as haemostatic agent and in the remaining no heamostatic agent was used. Application of BSG in the tonsillar fossae reduces the operation time by 31.49%, the operative blood loss by 33.28% and also reduces the number of ties used by 53.33%. All these results are statistically significant.

Ectopic multinodular Goitre-An unusual case

Ectopic thyroid tissue is usually found in the midline along the path of descent of the thyroid gland, such as in the tongue, larynx, trachea, oesophagus, etc. Initially, laterally placed thyroid tissues were found to contain malignant tissue and hence the term lateral aberrant thyroid tumours. Some attributed these to metastatic deposits of primary thyroid carcinoma while others felt that these were primary tumours of aberrant thyroid tissue. In later years, benign ectopic thyroid tissues were described in the lateral neck. It was felt that ectopic thyroid tissues are derived from thyroid cell rests that have failed to fuse with the main thyroid tissue during development. They are subjected to the same goitrogenic stimulation as the normally placed thyroid tissue. Our case supports the view that not all laterally placed thyroid tissues are malignant and also presents an unusual subplatysmal location of ectopic thyroid tissue.

Distribution of malignancies in head and neck regions and their management

A retrospective, cross sectional, series of cases were currently studied in the department of ENT-Head & Neck Surgery of Tribhuvan University Teaching Hospital (TUTH) Kathmandu, Nepal to find out the distribution of different malignancies in head and neck regions and to identify their treatment modalities during the period of one year from January 2003 to December 2003. Altogether 159 new cases of histopathologically/cytopathologically confirmed malignancies of head and neck regions and their treatment modalities were analyzed. Out of 159 cases, malignancies of larynx (41), pharynx (31) and oral cavity (30) were found to be the commonest head and neck malignancies where as malignancies of ear (1), and salivary glands (4) were found to be the least common. Likewise surgery with or without radiotherapy and/or chemotherapy was found to be the commonest treatment modality. Of the 159 cases seven were occult primary. As the laryngo-pharyngo-oral malignancies are the commonest malignancies and surgery with or without radiotherapy and/or chemotherapy the commonest treatment modalities for these head and neck malignancies. A well equipped head and neck unit is needed at TUTH along with proposed radiotherapy and medical oncology support for better management of these malignancies.

A rare cause of steatohepatitis

We present a rare case of steatohepatitis due to neutral lipid storage disorder in a 1.5-year-old male presenting with intermittent fever, hepatomegaly and dark-coloured urine. On examination, there was ichthyosis involving both the limbs. Liver biopsy showed steatohepatitis. The peripheral blood smear revealed fat vacuoles in the cytoplasm of leucocytes, characteristic of the Dorfman-Chanarin syndrome. Awareness of this condition helps in prompt diagnosis and avoids unnecessary further investigations.

Production of verbenol, a high valued food flavourant from a fusant strain of Aspergillus niger

A hyperperformer for the production of verbenol was produced from the fusion of two improved strains of Aspergillus niger. A 2-deoxy glucose de-repressed mutant [high sporulation (50%), viability (80%) showing a conversion of 15.6% of initial alpha-pinene to verbenol in 6 h under the conditions used] was fused with another strain enriched with alpha-pinene (26.4% of alpha pinene converted to verbenol) to obtain a final verbenol conversion yield of 48.6% of initial alpha pinene.

Release of iron from ferritin by metabolites of benzene and superoxide radical generating agents

The release of iron from ferritin in the presence of benzene metabolites, viz. phenol (P), catechol (CT), hydroquinone (HQ) and superoxide radical generating compounds, viz. pyrogallol (PL), phloroglucinol (PG), phenylhydrazine (PH) or phenylenediamine (PD) was studied in acetate buffer, pH 5.6. Monitoring the formation of the iron-ferrozine complex quantitated the release of iron from ferritin. The presence of P (125 microM) did not result in the release of iron from ferritin, whereas the same concentration of CT, HQ, PL, PH or PD resulted in the release of significant amounts of iron from ferritin and a marginal amount of iron in the presence of PG, CT, HQ, PL, PH or PD concentration and time-dependent increase in iron release from ferritin were observed although the increase was not linear as a function of time and concentration of the compounds studied. The presence of superoxide dismutase inhibited significantly the release of iron from ferritin by CT, HQ, PL, PH or PD. The iron released from ferritin by CT, HQ, PL, PH or PD enhanced lipid peroxidation in rat brain homogenate and released aldehydic products from bleomycin-dependent degradation of DNA and also caused single strand nicks to pUC18 DNA. These studies indicate that CT and HQ, the two principal polyphenolic metabolites of benzene and PL, PH or PD, the superoxide radical generating compounds were capable of reducing ferric iron from ferritin and also mobilizing and releasing iron from ferritin core. The release of iron from ferritin by these compounds is a result of direct reduction of ferritin iron by electron transfer and also reduction via superoxide radical. The release of iron from ferritin by CT and HQ may have toxicological implications in relation to benzene toxicity. The release of iron by superoxide radical generating agents suggests that oxidative stress may play a role as this could lead to disruption of intracellular iron homeostasis.

Jaundice in the newborn

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5-10% of all newborns require intervention for pathological jaundice. Neonates on exclusive breast-feeding have a different pattern of physiological jaundice as compared to artificially fed babies. Guidelines from American Academy of Pediatrics (AAP) for management of jaundice in a normal term newborn have been included in the protocol. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies, for jaundice secondary to hemolysis and for prolonged hyperbilirubinemia. Although hour specific bilirubin charts are available, these have to be validated in Indian infants before they are accepted for widespread use.

Integrated effects of the vasodilating beta-blocker nebivolol on exercise performance, energy metabolism, cardiovascular and neurohormonal parameters in physically active patients with arterial hypertension

OBJECTIVE

The present study was designed to investigate the integrated effects of the beta-1-selective blocker with vasodilator properties, nebivolol, on systemic haemodynamics, neurohormones and energy metabolism as well as oxygen uptake and exercise performance in physically active patients with moderate essential hypertension (EH).

DESIGN AND METHODS

Eighteen physically active patients with moderate EH were included: age: 46.9 +/- 2.38 years, weight: 83.9 +/- 2.81 kg, blood pressure (BP): 155.8 +/- 3.90/102.5 +/- 1.86 mm Hg, heart rate: 73.6 +/- 2.98 min(-1). After a 14-day wash-out period a bicycle spiroergometry until exhaustion (WHO) was performed followed by a 45-min submaximal exercise test on the 2.5 mmol/l lactate-level 48 h later. Before, during and directly after exercise testing blood samples were taken. An identical protocol was repeated after a 6-week treatment period with 5 mg nebivolol/day.

RESULTS

Nebivolol treatment resulted in a significant (P < 0.01) decrease in systolic and diastolic BP and heart rate at rest and during maximal and submaximal exercise. Maximal physical work performance, blood lactate and rel. oxygen uptake (rel. VO(2)) before and after nebivolol treatment at rest and during maximal and submaximal exercise remained unaltered. Free fatty acid, free glycerol, plasma catecholamines, beta-endorphines and atrial natriuretic peptide (ANP) increased before and after treatment during maximal and submaximal exercise but remained unaltered by nebivolol treatment. In contrast, plasma ANP levels at rest were significantly higher in the presence of nebivolol, endothelin-1 levels were unchanged.

CONCLUSIONS

Nebivolol was effective in the control of BP at rest and during exercise in patients with EH. Furthermore, nebivolol did not negatively affect lipid and carbohydrate metabolism and substrate flow. The explanation for the effects on ANP at rest remain elusive. This pharmacodynamic profile of nebivolol is potentially suitable in physically active patients with EH.

Parathyroid carcinoma

INTRODUCTION

Parathyroid carcinoma is a rare tumor with an incidence of 0.5 to 4%. Preoperative differentiation from benign adenoma is very difficult. Several features, though nonspecific, have been used in differentiating parathyroid carcinoma from the adenoma.

MATERIAL AND METHOD

A retrospective analysis during the period of nine years, four cases of parathyroid carcinoma were diagnosed on the basis of per-operative local invasion and on histological evidence of capsular invasion and vascular invasion.

RESULT

We have different observations to make. Diagnosis of parathyroid carcinoma which was done on the basis of intra operative suspicion only. One patient died on 6th post operative day due to development of pancreatitis. At the follow-up of two years there was no local recurrence or distant metastasis.

CONCLUSION

It is preferable to have a high index of suspicion for parathyroid carcinoma when these features are present than to miss the opportunity for surgical cure by failing to consider it in the differential diagnosis.

Phased chest and abdominal compression-decompression versus conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BACKGROUND

Several methods have been developed to improve the efficacy of mechanical resuscitation, because organ perfusion achieved with conventional manual resuscitation is often insufficient. In animal studies, phased chest and abdominal compression-decompression resuscitation by use of the Lifestick device has resulted in a better outcome compared with that of conventional resuscitation. In end-of-life patients, an increased coronary perfusion pressure was achieved. The aim of the present study was to determine the feasibility, safety, and efficacy of the Lifestick compared with conventional resuscitation in patients with sudden nontraumatic out-of-hospital cardiac arrest.

METHODS AND RESULTS

The crews of 4 mobile intensive care units, staffed by an emergency physician and a paramedic, were trained to use the device. Fifty patients were randomized by sealed envelopes to either Lifestick (n=24) or conventional (n=26) resuscitation. No differences were found regarding demographic and logistical conditions between the groups. Nineteen of the patients (73%) with conventional resuscitation had ventricular fibrillation, 13 of whom survived to hospital admission (no survivals with other arrhythmias) and 7 were discharged. In contrast, in the Lifestick-CPR group, only 9 patients had ventricular fibrillation (38%; P=<0.02; OR, 2.5; 95% CI, 0.6 to 10.6). Four of these 9 patients and 5 of 15 patients with other arrhythmias survived to hospital admission, but none survived to hospital discharge. Autopsy in a subgroup of patients who died at the scene revealed less injuries with Lifestick than with conventional resuscitation.

CONCLUSION

Lifestick resuscitation is feasible and safe and may be advantageous in patients with asystole or pulseless electric activity.