Quality of life in newly diagnosed patients with lung cancer in a developing country: is it important?

There are no data regarding quality of life (QoL) assessments in lung cancer in developing countries like India. Quality of life was evaluated in 76 newly diagnosed lung cancer patients by using the World Health Organization Quality of Life questionnaire in Hindi (WHOQoL-Bref) (men 87%). The mean age was 55 years (SD = 10). Cough, dyspnoea, chest pain and haemoptysis were present in 83%, 72%, 66% and 43% of patients respectively. The median duration of symptoms was 5.9 months (range 1-13). Eighty-nine per cent had non-small cell lung cancer. The median pack-years smoked was 23 (range 0.5-88). Most patients (53%) had a Karnofsky's Performance Status (KPS) of 70 and 83% had stage III or IV disease. Quality of life did not correlate with age, gender, presence or duration of symptoms, histological type, stage of disease or degree of smoking. The physical and psychological domains of QoL correlated significantly with the KPS (P = 0.001 and P = 0.01 respectively). Patients with a KPS of 80 had better physical (P < 0.001), psychological (P < 0.01) and social (P < 0.05) QoL than those with a KPS of 70. In conclusion, patients with lung cancer in a developing country like India have an unsatisfactory QoL. The Karnofsky's Performance Scale is a simple and reliable surrogate marker for assessing QoL in these patients. Larger multi-centric studies may help in providing a more comprehensive evaluation of the effect of various demographic and clinical variables on QoL in this setting.

Effect of antioxidants on STAT3, cell survival gene products, apoptosis and chemoresistance in lung cancer cells

20067

Background: We had earlier demonstrated that antioxidants (beta carotene, vitamins C and E) enhance the apoptotic effect of paclitaxel and carboplatin in vitro and there was a suggestion that when used as an adjunct to the above chemotherapeutic agents in patients with NSCLC, they might enhance the efficacy of the latter. To elucidate the mechanism underlying the synergistic effect between antioxidants and chemotherapy, in the present study we evaluated the effect of antioxidants on STAT3 activation in NSCLC cells. Since this transcription factor has been shown to regulate multiple oncogenic pathways, including pathways regulating tumor cell survival, we further studied how STAT3 modulation relates to apoptosis and downstream apoptosis regulatory proteins. Methods: H520 cells were treated with antioxidants. STAT3 proteins were assessed by western blotting and their nuclear localization was evaluated by immunocytochemistry. Antiapoptotic proteins (survivin, Bcl-2, Bcl-xl and cyclin D1) were evaluated by Western blotting. To assess the interaction, cells were treated with chemotherapy (Paclitaxel and Carboplatin) with or without antioxidants and the effect was assessed by Live & Dead assay, MTT assay and flowcytometry. Results: Antioxidants inhibited STAT3 phosphorylation in a dose and time dependent manner before the initiation of cell death and depleted the nuclear pool of STAT3. This effect was specific since there was no effect on STAT5 phosphorylation and was reversible since STAT 3 reverted back to its constitutively activated state after the removal of antioxidants. Antioxidants suppressed the expression of antiapoptotic proteins Bcl -2, Bcl-xl, cyclin D1 and survivin. This resulted in the inhibition of proliferation of cells and induction of apoptosis as evident on caspase 3 activation and PARP cleavage. Antioxidants arrested the cells in G0/G1 phase of cell cycle making them more vulnerable to the cytotoxic effects of chemotherapy. This synergy was evident on live and dead assay. Conclusions: Our results demonstrate that antioxidants are potent inhibitors of STAT3 phosphorylation and can have a potential role as an adjunct to chemotherapy in lung cancer.

No significant financial relationships to disclose.

Cardiac sarcoidosis: an uncommon presentation of sarcoidosis in India

Cardiac involvement in sarcoidosis is uncommon. The manifestations of cardiac sarcoidosis are protean and vary from benign ectopics to life threatening ventricular tachycardias. High index of suspcion and early aggressive intervention is required for the diagnosis and treatment of this condition. Early diagnosis is essential since ventricular tachycardia is the most common terminal event in these patients if left untreated. Corticosteroids are needed early in these patients which along with other antiarrhythmic management strategies including intracardiac defibrillator form the backbone of treatment. We describe four patients who were diagnosed to have pulmonary and cardiac sarcoidosis. Their varied presentations highlight the difficulties that may occur in the diagnosis. Furthermore, the need for proper management is stressed, as a delay in diagnosis may be fatal.

Predictors of development and outcome in patients with acute respiratory distress syndrome due to tuberculosis

OBJECTIVE

To study the predictors of development and determinants of outcome in patients with acute respiratory distress syndrome (ARDS) due to tuberculosis (TB).

METHODS

Retrospective case-control study of demographic, clinical and laboratory data of hospitalised adult patients with active TB.

RESULTS

Of 2733 TB patients treated during 1980-2003, 29 (1.06%; 1.21 patients/year; mean age 31.6 +/- 10.9 years; 16 males) developed ARDS (cases). Seven had pulmonary TB and 22 had miliary TB (MTB); 298 (mean age 32.0 +/- 14.2 years; 110 males) who did not develop ARDS constituted controls. Presence of MTB (OR 4.6, 95%CI 1.2-17.8; P = 0.02), duration of illness beyond 30 days at presentation (OR 177.9, 95%CI 39-811.7; P < 0.001), absolute lymphocyte count < 1625/ mm3 (OR 4.5, 95%CI 1.1-19.3; P = 0.04) and serum ALT > 100 IU (OR 15.7, 95%CI 3.0-81.1, P < 0.001) were independent predictors of ARDS development. Twelve cases died (41.4%). Patients with APACHE II score >18; those with APACHE II score <18 in the presence of hyponatraemia and PaO2/FIO2 ratio <108.5 were likely to die.

CONCLUSIONS

In patients with TB, prolonged illness, MTB, absolute lymphocytopaenia and elevated ALT are independently associated with ARDS development. APACHE II score, serum sodium and PaO2/FIO2 ratio are determinants of outcome.

Stem cell markers: ABCG2 and MCM2 expression in retinoblastoma

BACKGROUND/AIM

The authors studied the expression of cancer stem cell surface marker, ABCG2, and neural stem cell marker, MCM2, in retinoblastoma and correlated clinicopathologically.

METHODS

Among 39 retinoblastomas, 18 tumours were not subjected to preoperative/postoperative chemotherapy, 15 tumours underwent postoperative chemotherapy, and six tumours had preoperative chemotherapy. There were 20 tumours with no invasion and 19 tumours with invasion of choroid/optic nerve. ABCG2 and MCM2 expression was studied by immunohistochemistry.

RESULTS

ABCG2 was positive in six of six and MCM2 was positive in five of six tumours that had recurred in the orbit or metastasised. ABCG2 was positive in 15/19 tumours with invasion. MCM2 was positive in 16/19 tumours with invasion. Invasive tumours showed higher expression of ABCG2 (p < 0.01) and MCM2 (p < 0.01) proteins. There was no correlation with differentiation and laterality of the tumours. Non-neoplastic retina was positive for ABCG2 and MCM2.

CONCLUSION

ABCG2 and MCM2 were expressed more in invasive tumours. Further studies are needed to understand the significance of ABCG2 and MCM2 expression in retinoblastoma.

Survival in small cell lung cancer in India: Prognostic utility of clinical features, laboratory parameters and response to treatment

BACKGROUND

Predictors of survival and response to treatment in patients with small cell lung cancer (SCLC) are ill-defined and unclear. In an attempt to assess the impact of common presenting symptoms and laboratory values on survival, we undertook this retrospective review of patients with SCLC. To our knowledge, there is no study on survival in SCLC patients from the Indian subcontinent.

DESIGN

Retrospective Cohort study.

MATERIALS AND METHODS

All newly diagnosed small cell lung cancer cases from December 2001 through December 2004, were identified and clinical data on presenting symptoms and laboratory findings from their hospital records, noted. The influence of various pretreatment factors on survival was investigated using Kaplan-Meier plots and Cox multivariate regression model.

RESULTS

76 subjects were included (84% males, 91% smokers). 57% patients had five or more symptoms at presentation. Cumulative symptom burden was strongly associated with survival (P =0.02). Survival was also significantly related with Karnofsky performance status (KPS) (P =0.04), disease extent (P =0.03) and symptomatic response to treatment (P< 0.001). Patients with higher hemoglobin (P =0.02), serum sodium (P =0.04) and serum globulin (P =0.02), survived significantly longer. By multivariate regression analysis, hemoglobin, KPS and brain metastases, were significant predictors of survival (P =0.01, P =0.02, P< 0.01 respectively).

CONCLUSION

Cumulative symptom burden, KPS, disease extent and symptomatic assessment of improvement after treatment, are useful predictors of survival. This has important clinical implications, keeping in view, the infrastructure and cost involved in more objective tests like CT scan, for evaluation of disease extent and prognosis. These findings can provide a simple basis for predicting prognosis in small cell lung cancer, especially in developing countries like ours.

A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study

BACKGROUND AND PURPOSE

Prevalence of obstructive sleep apnea (OSA) is high in obese subjects, many of whom may not be overtly symptomatic. Polysomnography (PSG) is a costly and time-consuming investigation. Since it is not feasible to subject all obese individuals to PSG, it is useful to define predictors of OSA among these subjects.

PATIENTS AND METHODS

One hundred and eighteen obese subjects [body mass index (BMI)> or =25 kg/m(2)] presenting to the hospital with non-sleep related complaints were included, of which 53 subjects with PSG evidence of OSA [apnea-hypopnea index (AHI)> or =15/h] were defined as cases and 65 subjects without any evidence of OSA (AHI<15/h) were defined as controls. Anthropometry, biochemical investigations, blood gas analysis, pulmonary function tests, and PSG were performed for all subjects.

RESULTS

Waist hip ratio (WHR) (as percentage of a standard) [odds ratio (95% CI): 1.07 (1.00-1.14); P = 0.049] male gender [odds ratio (95% CI): 3.97 (0.99-15.81); P = 0.046] and neck circumference (NC) [odds ratio (95% CI): 1.23 (1.03-1.47); P = 0.023] were found to be independent predictors of OSA. Overnight oxygen desaturation data were evaluated in patients selected as having OSA on the basis of these clinical markers, and the best cut-off for level of desaturation (10%) was defined. The stepped approach had a specificity, sensitivity, positive and negative predictive value of 89.2, 88.5, 86.8 and 90.6%, respectively, for the diagnosis of OSA.

CONCLUSIONS

Male gender, WHR and NC are independent predictors of OSA in overtly asymptomatic obese subjects. A stepped approach to diagnose OSA should be used, as it is accurate and cost-effective.

Unilateral pulmonary agenesis: an uncommon cause of lower zone lung opacity

Congenital abnormalities of the lung are rare and are often misdiagnosed. We report the case of a young girl who was initially diagnosed to have pleural effusion with collapse. After detailed evaluation including computerised tomographic (CT) scan and fiberoptic bronchoscopy, a final diagnosis of unilateral pulmonary agenesis was made. This condition must be suspected in differential diagnosis in a young person presenting with features of lung collapse.

Clinical and echocardiographic findings in patients with myocardial toxicity due to scorpion sting

BACKGROUND

Myocardial toxicity following a sting by the Indian red scorpion (Mesobuthus tamulus) is a life-threatening medical emergency. A perusal of the published literature suggests that this problem has seldom been studied systematically.

METHODS

We retrospectively studied the clinical presentation and echocardiographic findings in 24 patients (mean [SD] age 23.2 [11.7] years; 19 males) with myocardial toxicity caused by the sting of an Indian red scorpion (Mesobuthus tamulus). They were treated with inotropic support and diuretics depending on the requirement. At admission, oral L-carnitine was administered in a dose of 1980 mg/day in three divided doses till the left ventricular (LV) function normalized. None of the patients received digitalis, prazosin, hydrocortisone or antivenin.

RESULTS

Extreme anxiety and severe pain at the site of sting were present in all the patients. Hypotension (n = 19), pulmonary oedema (n= 15) and acute renal failure (n=8) were the other presenting features. Chest X-ray revealed cardiomegaly in 8 and pulmonary oedema in 13 patients. Serum creatinine phosphokinase levels were elevated more than two times the upper limit of normal (200 IU/L) in 22 patients (92%). The mean duration of hospitalization was 5 days (range 3- 11 days). L-carnitine treatment resulted in significant reduction in the LV diameter (mm) in diastole (47.6 [6.2] v. 42 [6.1], p < 0.01) and systole (42 [7.1] v. 28.2 [4], p<0.001); end-diastolic volume (ml) (108.7 [31.9] v. 81 [26.7], p <0.01) and end-systolic volume (ml) (81.3 [30.9] v. 31.1 [10.7], p < 0.001); and significant improvement in the stroke volume (ml) 27.8 [13.2] v. 61.7 [6.2], p<0.001) and ejection fraction (%) (25.5 [12.8] v. 61.2 [6.5], p<0.001). All the patients responded well to treatment and none died.

CONCLUSION

Our initial observations suggest a potential benefit with additional oral L-carnitine treatment in patients with myocardial toxicity caused by scorpion sting presenting with hypotension and severe LV dysfunction. These findings merit further study.

Laser bronchoscopy--current status

The majority of patients with lung cancer have advanced disease with severe endobronchial symptoms such as cough, dyspnea, and hemoptysis for which palliation is required. Laser resection of endobronchial lesions located in the trachea, mainstem or proximal lower lobe bronchi provides significant and rapid improvement in the patient's symptoms. Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser is gaining popularity due to efficient photocoagulation, good penetration and excellent hemostasis. Complications are rare and can be minimized by following standardized techniques and safety guidelines. Laser resection is equally effective with the rigid and flexible bronchoscope. The future may see combinations of laser with other palliative modalities to improve the chances of a symptom-free life for lung cancer patients.

Multidrug-resistant tuberculosis

Multidrug-resistant tuberculosis (MDR-TB) caused by Mycobacterium tuberculosis resistant to both isoniazid and rifampicin with or without resistance to other drugs is among the most worrisome elements of the pandemic of antibiotic resistance. Globally, about three per cent of all newly diagnosed patients have MDR-TB. The proportion is higher in patients who have previously received antituberculosis treatment reflecting the failure of programmes designed to ensure complete cure of patients with tuberculosis. While host genetic factors may probably contribute, incomplete and inadequate treatment is the most important factor leading to the development of MDR-TB. The definitive diagnosis of MDR-TB is difficult in resource poor low income countries because of non-availability of reliable laboratory facilities. Efficiently run tuberculosis control programmes based on directly observed treatment, short-course (DOTS) policy is essential for preventing the emergence of MDR-TB. Management of MDR-TB is a challenge which should be undertaken by experienced clinicians at centres equipped with reliable laboratory service for mycobacterial culture and in vitro sensitivity testing as it requires prolonged use of expensive second-line drugs with a significant potential for toxicity. Judicious use of drugs, supervised individualised treatment, focussed clinical, radiological and bacteriological follow up, use of surgery at the appropriate juncture are key factors in the successful management of these patients. In certain areas, currently available programme approach may not be adequate and innovative approaches such as DOTS-plus may have to be employed to effectively control MDR-TB.

Extrapulmonary tuberculosis

Extrapulmonary involvement can occur in isolation or along with a pulmonary focus as in the case of patients with disseminated tuberculosis (TB). The recent human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) pandemic has resulted in changing epidemiology and has once again brought extrapulmonary tuberculosis (EPTB) into focus. EPTB constitutes about 15 to 20 per cent of all cases of tuberculosis in immunocompetent patients and accounts for more than 50 per cent of the cases in HIV-positive individuals. Lymph nodes are the most common site of involvement followed by pleural effusion and virtually every site of the body can be affected. Since the clinical presentation of EPTB is atypical, tissue samples for the confirmation of diagnostic can sometimes be difficult to procure, and the conventional diagnostic methods have a poor yield, the diagnosis is often delayed. Availability of computerised tomographic scan, magnetic resonance imaging laparoscopy, endoscopy have tremendously helped in anatomical localisation of EPTB. The disease usually responds to standard antituberculosis drug treatment. Biopsy and/or surgery is required to procure tissue samples for diagnosis and for managing complications. Further research is required for evolving the most suitable treatment regimens, optimal duration of treatment and safety when used with highly active antiretroviral treatment (HAART).

Non small cell lung cancer (NSCLC): current status and future prospects

The incidence of lung cancer is rising dramatically and it is now the commonest cause of mortality and morbidity not only in the industrialised countries, but in developing nations like India as well. Tobacco smoking has consistently been demonstrated to be an important aetiological factor, though lung cancer occurs in non-smokers also. In spite of great advances in radiological and molecular diagnostic techniques, the ideal screening marker for early detection of lung cancer has still not been found. Histological diagnosis and staging is essential for selecting the mode of therapy in patients with lung cancer. Stages I and II are amenable to surgery. However, advanced stage III and IV need an individualised combination of surgery, chemotherapy and radiotherapy. With a better understanding of the cellular mechanisms operating in carcinogenesis, newer target specific modalities are being developed and tested in order to stem this disease, which threatens to assume epidemic proportions.

Uncommon manifestations of sarcoidosis

OBJECTIVE

To study the uncommon manifestations in patients of sarcoidosis.

METHODS

This is a prospective study of uncommon manifestations observed in 93 of the 210 biopsy proved patients (mean age 43.8 +/- 6.4 years; 58 males) of sarcoidosis seen by us over the last 22 years at the All India Institute of Medical Sciences, New Delhi.

RESULTS

Clinical presentation of acute sarcoidosis in the form of Löfgren's syndrome (n = 5) was uncommonly observed. Rare pulmonary manifestations included seasonal dyspnoea with audible wheezing mimicking bronchial asthma (n = 30); narrowing of main bronchi, fixed upper airways obstruction (n = 1); pleural involvement (n = 7); bullous lung disease (n = 2); chronic respiratory failure (n = 2); and vocal cord involvement (n = 4). Other notable features were glaucoma (n = 4); digital clubbing (n = 3); sarcoid nephritis (n = 1); and sicca syndrome (n = 1). Uncommon neurological manifestations included bilateral sequential facial nerve palsy (n = 2); optic atrophy (n = 2); optic neuritis, proximal myopathy, multiple brainstem lesions, pituitary stalk lesion (one patient each). Cardiac involvement occurred in 15 patients. This included complete heart block (n = 2); congestive heart failure (n = 4); supraventricular ectopics (n = 6); ventricular ectopics (n = 2); and recurrent ventricular tachycardia requiring radiofrequency ablation (n = 1). Contrast-enhanced computerised tomographic scan (CECT scan) of the abdomen revealed intrabdominal lymphadenopathy (n = 5); infiltrates in the liver and spleen (n = 3). Portal hypertension was observed in four patients with grade IV (n = 2) and grade II oesophageal varices (n = 2). One of the patients with grade IV oesophageal varices had recurrent haematemesis and successfully underwent endoscopic sclerotherapy while another patient with grade IV varices succumbed to massive haematemesis. CECT scan was found to be useful in localising the lesions in patients with extrapulmonary sarcoidosis.

CONCLUSION

Awareness regarding uncommon manifestations of sarcoidosis will facilitate early confirmation of diagnosis.

Does routine home visiting improve the return rate and outcome of DOTS patients who delay treatment?

Overa period of 6 months the effect of home visits on compliance with directly observed therapy, short course [DOTS], was studied on 480 new smear-positive tuberculosis patients who had delayed collecting their drugs on one occasion. Patients registered at 15 tuberculosis treatment centers in Baghdad, Iraq, were randomized to an intervention group [receiving home visits from trained personnel] or a control group. Home visits were highly effective in improving the return to treatment of patients who were late for treatment [231/240, 96.3%]. The intervention group showed a higher treatment success rate [94.2% versus 76.7%], lower default rate [0.8% versus 10.0%] and higher smear conversion rate after the end of treatment [92.9% versus 75.0%] than controls. Home visiting by trained personnel significantly improves patient compliance with DOTS

Does routine home visiting improve the return rate and outcome of DOTS patients who delay treatment?

Over a period of 6 months the effect of home visits on compliance with directly observed therapy, short course (DOTS), was studied on 480 new smear-positive tuberculosis patients who had delayed collecting their drugs on one occasion. Patients registered at 15 tuberculosis treatment centres in Baghdad, Iraq, were randomized to an intervention group (receiving home visits from trained personnel) or a control group. Home visits were highly effective in improving the return to treatment of patients who were late for treatment (231/240, 96.3%). The intervention group showed a higher treatment success rate (94.2% versus 76.7%), lower default rate (0.8% versus 10.0%) and higher smear conversion rate after the end of treatment (92.9% versus 75.0%) than controls. Home visiting by trained personnel significantly improves patient compliance with DOTS.

Eosinophilic pleural effusion and presence of filariform larva of Strongyloides stercoralis in a patient with metastatic squamous cell carcinoma deposits in the pleura

A 58-year-old, human immunodeficiency virus (HIV) negative, male farmer presented with a right-sided hemorrhagic, exudative, eosinophilic, rapidly reaccumulating pleural effusion. Pleural biopsy revealed secondary deposits from a squamous cell carcinoma. Wet mount film of pleural fluid unexpectedly showed filariform larvae of Strongyloides stercoralis. Our observation suggests that strongyloidiasis should be considered as the etiological cause for pleural effusion of obscure etiology. The threshold for suspicion should be high if the pleural effusion is exudative and eosinophil rich.

Scientific basis of directly observed treatment, short-course (DOTS)

The introduction of rifampicin, pyrazinamide and ethambutol ushered in the era of "short course chemotherapy". Multidrug resistance TB (MDR-TB) is threatening to destabilise the best efforts of TB control. Treatment of MDR-TB is difficult, expensive and toxic and is often unsuccessful. DOTS is an interventional strategy designed to effectively diagnose and treat TB. The fundamental principles in the DOTS strategy are: Polititical will, diagnosis by sputum microscopy, directly observed standardised short-course treatment, adequate supply of good quality drugs, systematic monitoring and accountability. Patients with HIV infection and TB disease respond well to antituberculosis treatment if they are given short-course chemotherapy in the programme of DOTS.

Sarcoidosis: global scenario & Indian perspective

Sarcoidosis is now recognised as a member of a large family of granulomatous disorders and has been reported from all parts of the world. Current evidence points to genetic predisposition and exposure to yet unknown transmissible agent(s) and/or environmental factors as etiological agents. Depending on the organ systems involved, patients with sarcoidosis present themselves to various specialities; pulmonary involvement is by far the commonest and occurs in about 90 per cent of the patients. The diagnosis is based on a compatible clinical and/or radiological picture, histopathological evidence of non-caseating granulomas in tissue biopsy specimens and exclusion of other diseases capable of producing similar clinical or histopathological appearances. Sarcoidosis is an underdiagnosed disease in India. However, owing to the increasing awareness, it is being diagnosed more frequently than a few decades ago. Most Indian patients with sarcoidosis are males and present in the fourth or fifth decade of life. The disease runs a benign course with spontaneous remission of the activity though some degree of residual pulmonary function abnormality persists. Only a minority of the patients develop complicated disease. Corticosteroids remain the mainstay of treatment. For asymptomatic patients with pulmonary sarcoidosis, no therapy is required. Corticosteroid treatment should be considered in symptomatic patients with evidence of radiological or pulmonary function deterioration. Treatment under close clinical monitoring should be tailored to suit the needs of the individual patient. Sometimes steroid-sparing alternative treatments may be beneficial. In this review, the current understanding of the global scenario and Indian perspective of sarcoidosis are critically reviewed.

Abdominal tuberculosis: diagnosis by laparoscopy and colonoscopy

BACKGROUND

Histopathological confirmation in abdominal tuberculosis is difficult due to suboptimal noninvasive access to the involved area. Peritoneoscopy and colonoscopy provide semi-invasive access to the peritoneum, large intestine and ileocecal area. Information on the diagnostic yield of these two investigation in abdominal tuberculosis is scarce.

OBJECTIVE

To evaluate the role of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis.

PATIENTS AND METHODS

Between January 1998 and July 2001, 34 patients were diagnosed to have abdominal tuberculosis on the basis of laparoscopy or colonoscopy. The case records of these patients were retrospectively reviewed to assess the usefulness of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis.

RESULTS

Laparoscopy was performed in 23 patients. Peritoneal tuberculosis was diagnosed in 19 of them, characterized by presence of ascites, multiple whitish tubercles, fibrous bands and adhesions, hyperaemic edematous bowel loops or dense adhesions without ascites. Multiple jejunoileal hyperemic short segments with serosal neovascularization was noticed in three patients. One patient had cecal mass with pericecal inflammatory adhesions. In three patients, laparoscopy was converted to open laparotomy due to bowel injury, extensive adhesions, and difficulty in assessing lymph nodal mass in one patient each. Peritoneal biopsy confirmed the diagnosis in 10 of the 15 (67%) patients. In one patient pericecal tissue biopsy confirmed the diagnosis. The remaining patients received therapeutic trial with anti tuberculosis treatment. All patients showed good response. Thus laparoscopy provided positive diagnosis of tuberculosis in 20/23 (87%) and positive histology in 10 of the 15 (67%) patients with peritoneal lesions. Thirteen patients underwent colonoscopy. Mucosal lesions involving terminal ileum, cecum and colon was noted in 11 patients. Colonoscopic biopsy confirmed the diagnosis in six of the 11 patients (54%). Non of these patients had any complication related to colonoscopy.

CONCLUSION

Laparoscopy was safe and helped in the diagnosis of peritoneal as well as intestinal tuberculosis in 87% of patients. Colonoscopy is useful for colonic and terminal ileal lesion with a positive diagnostic yield of 54%.

Sleep disordered breathing in chronic obstructive pulmonary disease

We prospectively studied sleep disordered breathing in 50 consecutive patients (39 males) with chronic obstructive pulmonary disease (COPD) with chronic respiratory failure (CRF) (n=33) and without CRF (n=17) by performing polysomnography. Patients with CRF had a lower mean nocturnal oxygen saturation (SaO2 %) (88.6+/-6.7 vs. 96.3+/-0.8; p=0.0001) and a lower minimal nocturnal SaO2 (73.6+/-12.0 vs. 84.3+/-7.3; p=0.002) compared to those without CRF, suggesting that patients with CRF tend to have more severe drops in nocturnal SaO2. Patients with CRF also had a lower FEV1 (% predicted) (p=0.01) and PEFR (% predicted) (p=0.031) compared to those without CRF suggesting an indirect relation to the oxygen saturation. Other pulmonary functions were comparable between both the groups. Among patients with and without CRF, the total sleep time (minutes); the rapid eye movement (REM) stage (% of total sleep time); the non-rapid eye movement (NREM) stage (% of total sleep time) were comparable (p=NS). Only three of the 50 patients with COPD had a significant (>5) apnea-hypopnea index (AHI) (total no. of apneas + total no. of hypopneas/ total sleep time [(hours) = AHI] and these three patients had a mean BMI = 27.7 which was higher than the mean BMI of the whole group (21.1). The AHI was comparable in patients with and without respiratory failure. Multiple regression analysis revealed a positive correlation between AHI and the neck circumference (r=0.41; p=0.005) and BMI (r=0.31; p=NS). There was a small but statistically insignificant negative correlation between AHI and neck length (r= -0.28; p=NS). We conclude that, BMI per se contributes to the AHI and nocturnal desaturation in patients with COPD.

Effect of cytokines and growth factors on the secretion of inhibin A, activin A and follistatin by term placental villous trophoblasts in culture

OBJECTIVE

Maternal serum inhibin A and activin A are higher in pre-eclampsia than in normal pregnancy. The placenta is a source of these proteins in pregnancy. The aim of this study was to investigate the effect of growth factors and proinflammatory cytokines that are raised in pre-eclampsia on the secretion of dimeric inhibin A, activin A and follistatin by villous cytotrophoblasts in culture.

DESIGN AND METHODS

Villous cytotrophoblasts were prepared from term placentae and cultured in serum-free media. Cells were treated with increasing concentrations of tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, transforming growth factor (TGF)-beta1, granulocyte and monocyte colony-stimulating factor (GMCSF), inhibin A, activin A and follistatin for 2 days. Culture supernatants were assayed for human chorionic gonadotrophin (hCG), inhibin A, activin A and follistatin as appropriate. Experiments were repeated at least three times with each cytokine or growth factor and the data pooled.

RESULTS

Cytotrophoblasts syncytialise and spontaneously secrete hCG, inhibin A and activin A in culture. Follistatin levels were <20 pg/ml in most experiments. Activin A secretion was increased in culture in a dose-dependent manner by IL-1beta (approximately 150%, P<0.05), TNF-alpha (approximately 35%, P=0.02) and GMCSF (approximately 100%, P<0.01). hCG secretion was inhibited in a dose-dependent manner by TNF-alpha (50%, P<0.05). Inhibin A was stimulated by IL-1beta ( approximately 30%, P=0.05). Inhibin A, activin A, follistatin or TGF-beta1 did not have a significant effect on any measured parameters.

CONCLUSIONS

These data show that inflammatory cytokines increase the secretion of activin A by trophoblasts in culture. The presence of very low levels, or no follistatin (<20 pg/ml) in the culture media suggests 'free' activin A could have autocrine/paracrine effects on cytotrophoblasts. Inhibin A secretion was stimulated by IL-1beta. However, absence of an effect by the other cytokines investigated on inhibin A in this study suggests that the mechanism(s) involved in increasing maternal circulating levels of inhibin A and activin A in pre-eclampsia are controlled differentially.

Transfer and interference of motor skills in people with intellectual disability

Atypical laterality (i.e. the lack of a clear pattern of lateralization) has been found to be a characteristic feature of individuals with intellectual disability (ID). The evidence for this has been based on 'handedness' studies which have contained little information about the ability of people with ID to carry out interhemispheric tasks reflecting bilateral transfer or interference. The present study examined this capacity in individuals with ID by utilizing bilateral transfer and interference paradigms. Right-handed subjects with ID (IQ = 55-76) and controls matched for age and sex were tested for bilateral transfer of motor skill in contralateral hands with a mirror-drawing task. The subjects were also tested for their ability to perform a finger-tapping task while processing verbal and non-verbal stimuli. The findings indicated that people with ID are significantly deficient relative to matched controls in bilateral transfer of motor skills from their non-preferred (left) hand to their preferred (right) one. The effect of interference during performance of the dual task was significantly greater in individuals with ID. Subjects with ID were found to perform better with their non-preferred than with their preferred hand. A within-group comparison revealed that right-handed performance was more affected by interference than left in these subjects.

A prospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculosis pleural effusion

We prospectively evaluated the usefulness of adenosine deaminase [ADA] estimation in the diagnosis of tuberculosis [TB] pleural effusion. Seventy five subjects with pleural effusion were studied. Forty eight of them had TB pleural effusion [M:F: 37:11; mean age 33 +/- 14.4 years range 17-76] and the remaining 27 had pleural effusion due to causes other than TB [non-TB group] [M:F: 19:8; mean age 47.3 +/- 16.5 years; range 17-75]. Pleural fluid [PF] ADA levels were significantly higher in TB (n=48; mean 95.8 +/- 57.5 IU/L) compared with non-TB group (n=27; mean 30.7 +/- 27.2 IU/L) [p<0.001]. Serum ADA [S-ADA] levels were also significantly higher in TB (n=45; mean 39.6 +/- 18.3 IU/L) compared with non-TB group (n=26; mean 18.0 +/- 13.7 IU/L) [p<0.001]. PF-ADA levels were higher compared to S-SDA in TB (p <0.001) and non-TB groups [p<0.01]. Using a cut off of 35 IU/L, the sensitivity and specificity of PF-ADA in the diagnosis of TB was computed to be 83.3% and 66.6% respectively. At a cut-off level of 100 IU/L, PF-ADA was found to have a sensitivity 40% and specificity 100%. From this study it is concluded that, using 100 IU/L as the cut-off, it is possible to avoid pleural biopsy to ascertain the diagnosis of TB in as much as 40% of the patients.

Clinical characteristics, pulmonary function abnormalities and outcome of prednisolone treatment in 106 patients with sarcoidosis

The clinical profile of one hundred and six biopsy proved patients with sarcoidosis is reported from New Delhi. The disease occurred more frequently in males (68 of the 106; 64%) in their fifth decade. Dry cough (83%), exertional dyspnoea (61%), fever (56%) and joint pains (44%) were frequent symptoms. Hepatomegaly (45%), peripheral lymphadenopathy (45%), cutaneous involvement (42%), presence of crepitations (36%) were frequent signs. In addition, ocular symptoms (18%), parotid gland enlargement (12%), facial nerve palsy (8%) were observed. Audible wheeze was present in nine patients. Radiologically, 25 (24%), 67 (63%) and 14 (13%) of patients belonged to stage I, II and III respectively at presentation. More than one sibling was involved in six families. Pulmonary functions revealed mixed obstructive and restrictive ventilatory defect. However, obstructive ventilatory defect was predominant. Systemic steroids were used in 81 patients who regularly followed up. Frequent relapses occurred on tapering off or stopping the corticosteroids in 21 patients. History of malaise (p < 0.05), presence of crepitations (p < 0.05), wheezing (p < 0.05), peripheral blood eosinophilia (p < 0.05) and FEV1/FVC (%) < 65% of the predicted value (p < 0.05), were independent predictors of relapse. Hyperuricaemia, hitherto unreported in patients with sarcoidosis was observed in 41% of patients for whom values were available. Two patients died; one from cardiomyopathy and another from stroke. In summary, constitutional symptoms such as fever, weight loss and pulmonary infiltrates, were more frequently encountered in Indian patients with sarcoidosis as compared to western studies. A high index of clinical suspicion and histopathological confirmation early in the illness are required to ascertain the diagnosis lest these patients will get treated as tuberculosis with potentially hepatotoxic drugs.

Ehlers-Danlos syndrome with bladder diverticula

We describe an Indian man with the unusual association of classical cutaneous features of Ehlers-Danlos syndrome, a marfanoid habitus, bladder diverticula and multiple emphysematous bullae.

A synthetic, structural, magnetic, and spectral study of several [Fe[tris(pyrazolyl)methane]2](BF4)2 complexes: observation of an unusual spin-state crossover

The complexes [Fe[HC(3,5-Me2pz)3]2](BF4)2 (1), [Fe[HC(pz)3]2](BF4)2 (2), and [Fe[PhC(pz)2(py)]2](BF4)2 (3) (pz = 1-pyrazolyl ring, py = pyridyl ring) have been synthesized by the reaction of the appropriate ligand with Fe(BF4)2.6H2O. Complex 1 is high-spin in the solid state and in solution at 298 K. In the solid phase, it undergoes a decrease in magnetic moment at lower temperatures, changing at ca. 206 K to a mixture of high-spin and low-spin forms, a spin-state mixture that does not change upon subsequent cooling to 5 K. Crystallographically, there is only one iron(II) site in the ambient-temperature solid-state structure, a structure that clearly shows the complex is high-spin. Mössbauer spectral studies show conclusively that the magnetic moment change observed at lower temperatures arises from the complex changing from a high-spin state at higher temperatures to a 50:50 mixture of high-spin and low-spin states at lower temperatures. Complexes 2 and 3 are low-spin in the solid phase at room temperature. Complex 2 in the solid phase gradually changes over to the high-spin state upon heating above 295 K and is completely high-spin at ca. 470 K. In solution, variable-temperature 1H NMR spectra of 2 show both high-spin and low-spin forms are present, with the percentage of the paramagnetic form increasing as the temperature increases. Complex 3 is low-spin at all temperatures studied in both the solid phase and solution. An X-ray absorption spectral study has been undertaken to investigate the electronic spin states of [Fe[HC(3,5-Me2pz)3]2](BF4)2 and [Fe[HC(pz)3]2](BF4)2. Crystallographic information: 2 is monoclinic, P2(1)/n, a = 10.1891(2) A, b = 7.6223(2) A, c = 17.2411(4) A, beta = 100.7733(12) degrees, Z = 2; 3 is triclinic, P1, a = 12.4769(2) A, b = 12.7449(2) A, c = 13.0215(2) A, alpha = 83.0105(8) degrees, beta = 84.5554(7) degrees, gamma = 62.5797(2) degrees, Z = 2.

Recognition of cyclooxygenase-2 (COX-2) active site by NSAIDs: a computer modelling study

The energetics and models of COX-2 complexed with nonsteroidal anti-inflammatory drugs (NSAIDs) having different degrees of selectivity for two isoforms of COX (COX-2 and COX-1) have been studied using computer modelling approach. The models are obtained for complexes of NS398 (NS), a selective COX-2 inhibitor; indoprofen (Ind), a non-selective inhibitor; di-tert-butylbenzofurans (DHDMBFs) with substituents at the 5th position: CONH(CH2)2OMe (BF1), CONH-c-Pr (BF2), 3-methylene-gamma-butyrolactonyl (BF3) and oxicams namely, meloxicam (Mel), piroxicam (Pir) and tenoxicam (Ten). These were optimized using molecular mechanics (MM) and molecular dynamics (MD) techniques. The binding energies and structures were compared with pharmacological parameters and available results with COX-1. In case of NS a larger difference in the binding energies between COX-2 and COX-1 was noticed as compared to that of Ind. It also had stronger interaction with His90 and Tyr355 which is considered important for COX-2 selectivity. There was a difference in the compactness at the channel entrance between COX-2 selective and non-selective ligands. Models with DHDMBFs and oxicams showed a similar correlation. The results were used to design a peptide inhibitor, Tyr-Arg-Cys-Ala-delta Phe-Cys (Pept) which could fit better in the COX-2 cavity. As per our MD simulation results this peptide inhibitor showed both higher activity and COX-2 selectivity.

The effects of matrices of paired substitutions in mid-acceptor stem on Drosophila tRNA(His) structure and end-processing

End-maturation reactions, in which the 5' end leader and 3' end trailer of precursor tRNA are removed by RNase P and 3'-tRNase, respectively, are early, essential steps in eukaryotic precursor tRNA processing. End-processing enzymes may be expected to contact the acceptor stem of tRNA due to its proximity to both cleavage sites. We constructed matrices of pair-wise substitutions in mid-acceptor stem at nt 3/70 and 4/69 of Drosophila tRNA(His) and analyzed their ability to be processed by Drosophila RNase P and 3'-tRNase. In accord with our earlier study of D/T loop processing matrices, we find that tRNA end processing enzymes respond to sequence changes differently. More processing defects were observed with 3'-tRNase than with RNase P, and substitutions at 4/69 reduced processing more than those at 3/70. We evaluated tRNA folding using structure probing nucleases and investigated the contribution of K(M) and V(Max) to the processing efficiency of selected variants. In one substitution (C3A), mis-folding correlates with processing defects. In another (C69A), a disruption of structure appears to be transmitted laterally to both ends of the acceptor stem. Poor processing of C69A by RNase P is due entirely to a reduction in V(Max), but for 3'-tRNase, it is due to an increase in K(M).

Association between isolated hypercholesterolemia, isolated hypertriglyceridemia and coronary artery disease in south Indian type 2 diabetic patients

Very high prevalence rates of coronary artery disease have been reported among Indians. The aim of this study was to determine the relative importance of isolated hypercholesterolemia, isolated hypertriglyceridemia, isolated high low-density lipoprotein and isolated low high-density lipoprotein in coronary artery disease among South Indian type 2 diabetic subjects. The study group comprised of 17,885 type 2 diabetic patients attending our institute. A history of documented myocardial infarction was considered as the diagnostic criteria for coronary artery disease. Isolated hypercholesterolemia was defined as serum cholesterol over 200 mg/dL with normal serum triglyceride levels (< or = 200 mg/dL); isolated hypertriglyceridemia was defined as serum triglyceride level over 200 mg/dL with normal serum cholesterol levels (< or = 200 mg/dL). Isolated low high-density lipoprotein was defined as one below 35 mg/dL with normal serum triglyceride levels. Isolated high low-density lipoprotein cholesterol was defined as one over 150 mg/dL with normal serum triglyceride levels. Normolipidemia was defined as serum cholesterol and serum triglyceride both upto 200 mg/dL, high-density lipoprotein 35 mg/dL or above and low-density lipoprotein upto 150 mg/dL. The prevalence of coronary artery disease was significantly high among patients with isolated hypercholesterolemia (4.1%; p < 0.001), isolated high low-density lipoprotein (4.5%; p < 0.001) and isolated low high-density lipoprotein (3.9%; p = 0.005) compared to normolipidemic individuals (2.8%), but not in those with isolated hypertriglyceridemia (3.4%). The odds ratios for coronary artery disease increased with each quartiles of isolated cholesterol, isolated low-density lipoprotein cholesterol and total cholesterol to high-density lipoprotein ratio and reached statistical significance in the last quartile (p < 0.05). There was no significant increase in the odds ratios for coronary artery disease in relation to quartiles of isolated triglycerides. For isolated low high-density lipoprotein, when the last quartile was taken as the reference, the odds ratio for coronary artery disease in the first quartile reached statistical significance (p = 0.03). Multivariate regression analysis revealed age (odds ratio 1.06; p < 0.001), male sex (odds ratio 1.7; p < 0.001), hypercholesterolemia (odds ratio 1.26; p = 0.07) and high low-density lipoprotein levels (odds ratio 1.22; p = 0.043) to be strongly associated with coronary artery disease. Among South Indian type 2 diabetic subjects, serum isolated hypercholesterolemia and high low-density lipoprotein cholesterol but not isolated hypertriglyceridemia appear to be associated with coronary artery disease.

Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review. II. Lymphomas and multiple myeloma

We review studies on hair dyes and lymphomas and multiple myeloma (MM). A computerized literature search for the years 1966 through 1996 was conducted. Data were extracted using a standardized form that recorded study design, study population, type of cases, comparison group, sources of data on personal exposure to hair dyes, method of data collection, type of exposure data collected, covariates, and results. This review identified 10 epidemiologic studies published in the English literature that examined personal use of hair dyes and lymphomas or MM. These studies include three evaluations of Hodgkin's disease, five of non-Hodgkin's lymphoma (NHL), two of lymphomas with type not specified, and six of MM. For Hodgkin's disease, one case-control study reported some positive associations with use of permanent hair dyes, whereas two cohort studies found no associations with ever use of hair dyes. For NHL and MM, several evaluations suggest associations with use of permanent dyes, particularly with duration, frequency, age at first use, and dark colors. However, these associations are not consistent within and between studies. For lymphomas with type not specified, one study was superseded by a more recent report with NHL specific data and a second study was limited by small numbers of exposed subjects. At this time, it is not possible to determine if the inconsistent associations between permanent hair dyes and NHL and MM reflect sampling variability or differences in methods between studies. Because an appreciable fraction of the population has potential exposure to permanent hair dyes, elucidation of such issues may be warranted with studies that include adequate numbers of exposed subjects and that elicit information on personal use of hair dyes over time.