Anti phospholipid syndrome

Anti Phospholipid Syndrome (APS) is a relatively new conception of syndrome complex first noticed in 1983. It may be primary or secondary to other diseases like SLE, RA, Systemic sclerosis, behchet's syndrome, temporal arteritis, sjogren's syndrome psoriatic arthropathy etc. Clinical manifestations are consequences of vascular thrombosis and embolism like DVT, pulmonary embolism, stroke, TIA, complication of pregnancy with pregnancy loss. We report a 34 years married female housewife who presented with sudden onset of nausea, vomiting, vertigo, dysphagia, dysarthria and ataxia. She had a chronic leg ulcer. Neurological findings were consistent with lateral medullary syndrome due to stroke though she was normotensive, nondiabetic with normal lipid profile. She had history of two abortions in last three years. Investigations were done accordingly and she fulfilled the diagnostic criteria of APS. No secondary cause was detected after thorough clinical examination and laboratory investigations. She was treated symptomatically along with oral anticoagulation. She improved slowly but steadily.

Clinical profile, management and outcome of lupus

Systemic Lupus Erythematosus (SLE) is a disease of many faces and great mimicry. Women of child bearing ages are the potential candidates for this disease though it may occur in any age and sex group and the clinical manifestations do not vary with sex differentiation. Etiology of SLE is still to be defined and it has a prevalence of 27.7/100,000 population with higher rate of incidence in Asian and African women. This is a prospective study done from January, 2002 to December, 2006. The objective of the study was to observe the clinical profile and outcome of patients suffering from SLE. 33 patients were diagnosed following the ARA criteria. All the patients were investigated with ANA, anti ds-DNA antibody, routine blood and urine examination and follow up was done following SLE Disease Activity Index (SLEDAI) scoring system along with routine blood and urine examination. Mean age at presentation was 27.3 years with a standard deviation of 12.5. Among them, constitutional symptoms were present in 91% of the patients, hematological features were also present in 91% of patients where anemia was almost universal, one patient was suffering from autoimmune hemolytic anemia and 4 patients had thrombocytopenia. Mild leucopenia and lymphopenia was also observed in 33% patients. 60% patients show an ESR higher than 100 mm in 1st hour. Musculoskeletal and cutenous features were present in 81% and 75% cases respectively. 36% patients had some degree of renal involvement at the time of diagnosis. 6% patients had severe neuropsychiatric features. After appropriate management 52% patients leading a normal life with medication, 30% patients had a fluctuating course, 9% patients died and 9% lost follow up. Outcome was better in the patients who were diagnosed and treated early.

Bouncing back: is the bipolar rebound phenomenon peculiar to lithium? A retrospective naturalistic study

In bipolar disorder the discontinuation of lithium prophylaxis is associated with early episode precipitation. Is this ;rebound' phenomenon peculiar to lithium? This naturalistic retrospective case note review investigated the frequency of immediate recurrence after discontinuation of any prophylactic treatment. Bipolar patients who stopped at least one medication after at least 6 months of remission were studied. A total of 310 case notes were examined in a systematic search. A total of 53 cases of discontinuation in 48 subjects were found. Discontinued medications included lithium, valproate, carbamazepine, typical and atypical antipsychotics and antidepressants. Recurrence occurred within 3 months of medication withdrawal in 39 cases (74%). Over half of the discontinuation episodes involved lithium: recurrence occurred in 86% of these cases. In the groups stopping other prophylactic agents, a majority of subjects suffered recurrence: anticonvulsants (89%), antipsychotics (64%) and antidepressants (58%). However, these groups were small and the clarity of the data was undermined by the simultaneous withdrawal of other agents. Manic and hypomanic episodes were the most common form of recurrences. Depressive episodes occurred proportionately most frequently following antidepressant withdrawal. More than half of recurrences required hospital admission. This study provides preliminary naturalistic evidence that early episode recurrence in bipolar disorder is not peculiar to lithium withdrawal but may occur following withdrawal of medication from all classes recommended in prophylaxis. These findings, if replicated, have important implications for clinical practice and for research.

Non-mosaic trisomy 22: a report of 2 cases

Non-mosaic trisomy 22 is a common cause of first trimester miscarriage and has a livebirth incidence of 1 in 30,000-50,000. Consequently there is a paucity of information for counselling parents. Detection in the second trimester is rare. It is commonly associated with severe growth retardation and multiple structural abnormalities. Oligohydramnios is frequently seen and can make detection of other abnormalities difficult. The outlook is uniformly poor and survival beyond the first trimester may present management dilemmas. A thorough fetal assessment including high-resolution cytogenetics with or without FISH is required for counselling. Careful plans for intrapartum and neonatal management may be necessary. The recurrence risk is thought to be low but information is very limited as there have been no reported cases of recurrence. We present two case of non-mosaic trisomy 22 including the first to be diagnosed subsequent to investigation for a high serum screening Down's risk.

Identification of quantitative trait loci (QTL) for oil and protein contents and their relationships with other seed quality traits in Brassica juncea

A detailed RFLP-genomic map was used to study the genetics of oil, seed and meal protein and sum of oil and seed/meal protein contents in a recombinant doubled-haploid population developed by crossing black- and yellow-seeded Brassica juncea lines. Two yellow seed color genes (SC-B4, SC-A6) and one QTL for erucic acid content (E(1b)) showed pleiotropic effect for oil, protein and sum of oil and seed/meal protein contents. Six (O-A1, O-A6, O-A9, O-B3, O-B4, O-B5) and five (SP-A1, SP-A9, SP-B4, SP-B6, SP-C) QTLs were significant for oil and seed protein contents, respectively. Tight linkage of three of these QTLs (SP-A1, SP-A9, SP-B4, O-A1, O-A9, O-B4), with opposite effects, poses challenge to the plant breeders for simultaneous improvement of negatively correlated (r = -0.7**) oil and seed protein contents. However, one QTL for oil content (O-B3) and two for seed protein content (SP-B6, SP-C) were found to be unlinked, which offer the possibility for simultaneous improvement of these two traits. QTLs significant for meal protein (MP-A1, MP-A6, MP-A9, MP-B5, MP-B6) were significant at least for oil, seed protein or sum of oil and seed/meal protein contents (T-A6, T-A7, T-B4, T-B5). Sum of oil and seed protein contents and sum of oil and meal protein contents had a perfect correlation, as well as same epistatic interactions and QTLs with similar additive effect. This indicates that protein in seed or meal has practically the same meaning for breeding purposes. Epistatic interactions were significant for the quality traits, and their linkage reflected association among the traits.

Nutrient homeostasis, metabolism of reserves, and seedling vigor as affected by seed priming in coarse rice

The influence of seed priming on germination, seedling vigor, ion homeostasis, and starch metabolism in coarse rice was studied. Priming treatments included pregermination (a traditional soaking method being used for rice nursery preparation), hydropriming for 48 h, osmohardening with KCl or CaCl2 (ψs –1.25 MPa solution) for 24 h, ascorbate priming (10 mg·L–1) for 48 h, and hardening for 24 h. Compared with controls, all priming treatments (except pregermination) reduced the time to start germination, improved the rate of germination and synchronization, and the length of shoot and root, seedling fresh and dry mass, number of secondary roots, the concentration of reducing sugars, and α-amylase activity, although the extent of these changes was different in seeds subjected to different treatments. These seed treatments resulted in higher germination that might be due to overcoming dormancy. Osmohardening with KCl was more effective than CaCl2 for these parameters. Nitrogen concentration remained unaffected in seedlings; however, Ca2+ concentrations in both seeds and seedlings were greater in seeds osmohardenerd with CaCl2 than with all other treatments, including the control. Seed priming enhanced K+ concentration in both seeds and seedlings, leading to improved α-amylase activity. There were positive correlations between seed K+ concentration and amylase activity, and the concentration of reducing sugars with amylase activity, seedling dry mass, or number of secondary roots. Osmohardening with KCl performed better than all other treatments including control. Priming improved the K+ balance that activates α-amylase, a basis for seed invigoration.

A comparison between glass/polyimide and titanium/polyimide microjoint performances in cerebrospinal fluid

Assessment of neural biocompatibility requires that materials be tested with exposure in neural fluids. Laser bonded microjoint samples made from Ti coated glass substrate and polyimide film (GPI) and titanium foil and polyimide film (TIPI) were evaluated for mechanical performance before and after exposure in artificial cerebrospinal fluid (CSF) for two, four, and 12 weeks at 37 degrees C. These samples represent a critical feature, i.e., the microjoint-a major weakness in the bioencapsulation system. Both material systems showed initial degradation up to 4 weeks which then stabilized afterwards and retained similar strength until 12 weeks. The TIPI system appears to exhibit better overall performance with less degradation compared to its as-received strength. The CSF exposed TIPI samples predominantly failed at the interface, while GPI samples had mixed glass and polyimide substrate and interface failure. The amount of glass failure decreases and interface failure increases with increase in CSF exposure time. The failure mechanism of the as-received (not exposed to CSF) GPI samples under tension was predominantly flexure type failure of the glass substrate.

Molecular markers for seed colour in Brassica juncea

A detailed RFLP map was used to map QTLs associated with seed colour in Brassica juncea using a doubled-haploid population derived from a cross between a black/brown-seeded cultivar and a yellow-seeded breeding line. Segregation analysis suggested that seed colour was under control of 2 unlinked loci with duplicate gene action. However, QTL analysis revealed 3 QTLs, SC-B4, SC-A10 and SC-A6, affecting seed colour. The QTLs were consistent across environments, and individually explained 43%, 31%, and 16%, respectively, and collectively 62% of the phenotypic variation in the population. Digenic interaction analysis showed that closest flanking locus of QTL SC-B4, wg7b6cNM, had strong epistasis with the locus wg5a1a, which is tightly linked to QTL SC-A6. The interaction of these 2 loci explained 27% of the phenotypic variation in the population, while the whole model explained 84%. In a multiple regression model, the effects of QTL SC-A10, as well as its interaction with other loci, were non-significant, whereas the effects of loci wg7b6cNM and wg5a1a and their interaction were significant. Ninety-eight percent of the DH lines carried the expected alleles of loci wg7b6cNM and wg5a1a for seed colour, confirming that only these 2 loci were linked to seed colour in B. juncea. Four additional digenic interactions significantly affected seed colour, and all 5 digenic interactions were consistent across environments.

Molecular mapping of seed aliphatic glucosinolates in Brassica juncea

An RFLP genomic map with 316 loci was used to study the inheritance of aliphatic glucosinolates in Brassica juncea using doubled-haploid (DH) populations developed from a cross between RLM-514, an agronomically superior non-canola quality B. juncea (high erucic acid and high glucosinolates), and an agronomically poor canola quality B. juncea breeding line. Two QTLs (GSL-A2a and GSL-A2b) associated with 3-butenyl were consistent across years and locations, and explained 75% of the phenotypic variance in the population. Three QTLs (GSL-A2a, GSL-F, GSL-B3) affected 2-propenyl and explained 78% of the phenotypic variance in the population. For total aliphatic glucosinolates, five QTLs explained 30% to 45% of the total phenotypic variance in the population in different environments. Several QTLs (GSL-A7 and GSL-A3) were highly inconsistent in different environments. Major QTLs (GSL-A2a and GSL-A2b) associated with individual glucosinolates were non-significant for total aliphatic glucosinolates. A marker-assisted selection strategy based on QTLs associated with individual glucosinolates rather than total aliphatic glucosinolates is proposed for B. juncea.

The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning

BACKGROUND

The hypothesis of this study is that working on the simulator without a structured feedback does not change performance; hence, any effects shown after structured feedback would amount to useful learning of the procedure. The aim was to investigate the learning curve for the HT Immersion Medical Colonoscopy Simulator without any structured feedback. This could then be potentially applied to validate the learning curve on the simulator when structured feedback is provided. There are no previous studies on this matter.

METHODS

Candidates were asked to perform colonoscopy on the HT Immersion Medical Colonoscopy Simulator. Modules 3 and 4 were used at random. In total, each candidate was asked to perform five consecutive virtual colonoscopies on the same module. These five episodes were collectively referred to as one trial. A time result of 3,600 sec (1 h) was used to denote perforation. No guidance or feedback was given to candidates before, during, or after each procedure. A total of 26 postgraduate doctors were recruited, including nine research fellows, five preregistration house officers, six specialist registrars, and six consultants. Fourteen candidates recorded five attempts each (i.e., one trial each) on the same module of the colonoscopy simulator (14 trials over 70 episodes). Another 12 candidates recorded five attempts (i.e., one trial each) on two modules of the colonoscopy simulator (24 trials over 120 episodes). Hence, 190 episodes were recorded in total, representing 38 trials.

RESULTS

There was no improvement in performance on the simulator from first attempt to the fifth in the absence of feedback. If there was any initial gain in any measurable outcome, this was lost in subsequent attempts indicating lack of learning. The outcomes measured included time taken to complete the test, percentage of the mucosa visualized, depth of the instrument inserted, and the path length used. The results were statistically significant for all outcomes.

CONCLUSIONS

This study demonstrates that in the absence of feedback, it is not possible to improve performance on the HT Immersion Medical Colonoscopy Simulator. Thus, there is no learning curve for the machine. The information from this study is vital for using the simulators in training and assessment because any improvement in learning curves shown after training on simulators can be presumed to be due to learning the procedure and not the simulator.

Genetic analysis of quantitative traits in rice (Oryza sativa L.) exposed to salinity

Abstract The release of rice cultivars with improved performance in saline environments is reliant on an understanding of the genetic control of plant and panicle characters in plants exposed to salinity. The regulation of agro-physiological characters of rice plants grown in a saline environment was thus investigated. A complete diallel cross was prepared from 8 parental rice accessions with a range of tolerances to salinity. F1 hybrids and parents were grown in saline-sodic soil in artificially constructed salinity blocks. At maturity, the plant height, productive tiller number per plant, panicle length, primary branch number per panicle, panicle fertility, time to maturity, shoot dry weight, shoot Na, Ca, and K concentrations, and paddy yield were recorded. Additive and dominant genetic effects contributed significantly to the total heritable variation observed for plant height, panicle length, and sodium and potassium shoot concentrations. Additive genetic effects were important for the expression of variation of productive tiller number per plant and the number of primary branches per panicle, while dominant genetic effects were important for the expression of variation of the number of days to maturity. Plant height and primary branch number per panicle are traits that may be readily improved by selection in saline environments.

A study to validate the colonoscopy simulator

BACKGROUND

The aim of this study was to investigate the relation between clinical experience and performance with regard to colonoscopic procedures performed on the HT Immersion Medical Colonoscopy Simulator. The hypothesis is that the performance of novice, intermediate, and experienced operators is different on simulators, just as it is on real patients.

METHODS

25 Postgraduate doctors were recruited and divided into three groups according to their level of colonoscopic experience. Candidates were asked at random to perform colonoscopy on module 3 or 4 of the HT Immersion Medical Colonoscopy Simulator. Modules 3 and 4 have built-in complex loops, and can demonstrate the candidate's ability either to avoid or undo the loop. Candidates in the first group, termed "novice," each had performed fewer than 10 colonoscopies and included four preregistration house officers (PRHOs), five specialist trainee resistrars (SpRs) and two consultants. This novice group had completed 80 episodes among them. In the second group, termed "intermediate," each candidate had performed between 11 and 100 colonoscopies, and the candidates included five SpRs and two research fellows. This intermediate group had completed 65 episodes. Members of the third group, termed "experienced" each had performed more than 101 colonoscopies, and included one SpR and six consultants. This experienced group had completed 45 episodes between them. A time result of 3,600 s (1 h) was used to denote perforation.

RESULTS

The experienced group were shown to perform better than the intermediate group, which in turn performed better than the novice group. The assessment was based on multiple factors including time taken to complete the test, percentage of the colonic mucosa visualized, incidence of colonic perforations, and path length used. The results were highly significant statistically for all these factors ( p < 0.000) except in path length used.

CONCLUSIONS

This study demonstrated that operators who differ in terms of their clinical experience and technical ability also differ in their performance of simulated colonoscopy. Thus, the findings have shown the simulator technology to be a powerful discriminator of manipulative skills in colonoscopy. The clinical differences that exist between novices and experts in terms of experience and technical expertise in endoscopic procedures are reflected by statistically significant differences in performance on the simulator. It is therefore reasonable to argue that improving proficiency on the simulator may translate into improvements in clinical practice. This study has validated the use of the HT Medical Immersion Colonoscopy Simulator to discriminate among subjects with different levels of experience.

RFLP linkage analysis and mapping genes controlling the fatty acid profile of Brassica juncea using reciprocal DH populations

An RFLP linkage map, comprising 300 linked and 16 unlinked loci, was constructed using reciprocal DH populations of Brassica juncea. The linked loci were organized into 18 linkage groups and seven unlinked segments, covering a total map distance of 1,564 cM. The A and B genomes were identified. The chi(2) test showed that 96.1% of the common intervals in the two populations differed non-significantly for recombination fractions, thus strongly suggesting the absence of sex-based differences for recombination fractions in B. juncea. Two QTLs, E(1a) and E(1b), significantly affected erucic acid content, and individually explained 53.7% and 32.1%, respectively, and collectively 85.8% of the phenotypic variation in the population. The QTLs E(1a) and E(1b) showed epistasis, and the full model including epistasis explained nearly all of the phenotypic variation in the population. The QTLs E(1a) and E(1b) were also associated with contents of oleic, linoleic and linolenic acids. Three additional QTLs (LN(2), LN(3) and LN(4)) significantly influenced linolenic acid content. The QTL LN(2) accounted for 35.4% of the phenotypic variation in the population. Epistatic interactions were observed between the QTLs E1a and LN(2). The stability of the detected QTLs across years and locations, and breeding strategies for improving the fatty acid profile of B. juncea, are discussed.

Amoebic versus pyogenic liver abscess

OBJECTIVES

To study the differences between the clinical presentation and complications of amoebic and pyogenic liver abscess. To correlate the diagnostic significance of Entamoeba Indirect Haemagglutination test (E.IHA) in establishing the diagnosis of amoebic liver abscess.

DESIGN

Open cohort observational study.

SETTING

Department of Medicine (Medical Unit II) Jinnah Postgraduate Medical Centre, Karachi.

PARTICIPANTS

Fifty two patients aged 13-70 years admitted in Medical Unit II and diagnosed to have liver abscess.

INTERVENTIONS

Group A comprised of patients clinically diagnosed to have amoebic liver abscess and received Metronidazole 500mg iv x 8 hourly for atleast 10 days or more if patient developed complications. Group B comprised of patients diagnosed to have pyogenic abscess and received Cefotaxime 1g iv x 8 hourly for the same duration or more if complicated (antibiotic reviewed in accordance with culture and sensitivity report).

MAIN OUTCOME MEASURES

Differences in the clinical presentation, complications and diagnostic parameters between the two groups of patients.

RESULTS

It was not possible to differentiate between amoebic and pyogenic liver abscess on clinical grounds, routine investigations and imaging techniques. Aspiration of pus, especially if the abscess was multiple, was most helpful in differentiating the two types of abscesses. Serological test of E.IHA was highly specific and sensitive for amoebic liver abscess.

CONCLUSION

Majority of liver abscesses in Karachi are due to Entamoeba Histolytica. Pyogenic abscess though less frequent, must be excluded by pus aspiration and culture and sensitivity. E.IHA is a good rapid method of discriminating between the two types of abscesses.

Effect of angiotensin II on ion transport across human Fallopian tube epithelial cells in vitro

Angiotensin II type 1 receptors have been identified in Fallopian tube epithelia. Polarized confluent human Fallopian tube epithelial cell cultures were used under short-circuit conditions to study the actions of angiotensin II on electrogenic ion transport. The results demonstrate that angiotensin II increases baseline short-circuit current, implying a net transport of negatively charged ions from a basal to apical direction. This effect was inhibited by the selective angiotensin II type 1 receptor antagonist losartan. The effects of angiotensin II on short-circuit current were rapid in onset, brief in duration, and although less than those achieved with ATP, similar in amplitude to those described for other epithelia with angiotensin II. These findings reflect a significant retention of function for these cells in monolayer culture. Immunohistochemistry using the antibody 6313/G2, which is directed against a specific sequence in the extracellular domain of the angiotensin II type 1 receptor, confirmed that the receptor was retained in cultured cells. The results indicate that angiotensin II plays a role in regulating the composition of Fallopian tube secretions.

Role of dexamethasone in acute bacterial meningitis in adults

OBJECTIVE

To evaluate the role of dexamethasone as adjunctive therapy in adult acute bacterial meningitis (ABM) in two groups of patients treated with antibiotics alone or a combination of antibiotics and dexamethasone.

DESIGN

Systematic sampling interventional open cohort study.

SETTING

Department of Medicine (Medical Unit II), Jinnah Postgraduate Medical Centre, Karachi.

PATIENTS

Sixty eight patients aged 12-85 years admitted in Medical Unit II and diagnosed to have ABM. Patients were divided into two groups. Group A received anti-microbial therapy for 14 days (a combination of benzyl penicillin 6 million units I/V 6 hourly and chloramphenicol 1 gm I/V 6 hourly) and group B received the same antimicrobial therapy with dexamethasone 0.6 mg/kg/day in 3 divided doses for 4 days.

MAIN OUTCOME MEASURES

Differences in mortality and morbidity in the two groups and differences in the CSF inflammatory parameters between the two groups of patients.

RESULTS

There was early resolution of fever, headache and altered consciousness in group B as compared to group A. Cranial nerves involvement was lower in group B. There was no difference in the occurrence of other focal neurological deficits between the two groups. CSF inflammatory parameters (glucose, protein and WBC count) were significantly better in group B by day 5. No complications attributable to dexamethasone were seen in group B.

CONCLUSION

There was early resolution of symptoms and CSF inflammatory parameters in the group that received dexamethasone as adjuvant therapy. Mortality was lower in the group treated with dexamethasone but the difference was not statistically significant. Dexamethasone should be administered to all adults patients with ABM.

Fallopian tube ciliary beat frequency in relation to the stage of menstrual cycle and anatomical site

BACKGROUND

The cyclical changes in ciliary structure and motion within the human Fallopian tube are well documented. Previous investigators have studied ciliary beat frequency (CBF) in relation to menstrual cycle and anatomical site, but with conflicting results.

METHODS

Using a technique that records variations in light intensity, we have studied the changes in CBF in relation to the menstrual cycle and anatomical site. Fallopian tubes were collected from 26 women who underwent hysterectomy for benign conditions. Menstrual history, hormone profile and endometrial biopsy results were used to determine the stage of the cycle. Fourteen women were in the proliferative phase, and 12 women in the secretory phase.

RESULTS

Mean CBF for all subjects was 5.3 plus minus 0.2 Hz. There was no significant difference in CBF in relation to anatomical site. In the fimbrial region the ciliary beat was faster in the secretory (5.8 plus minus 0.3 Hz) as compared with the proliferative phase (4.9 plus minus 0.2 Hz), P < 0.02.

CONCLUSIONS

It is possible that this increase in fimbrial CBF may contribute to ovum retrieval and transport after ovulation. However, the reproductive significance of the changes in CBF in relation to the menstrual cycle needs further investigation.

Sumatriptan challenge in bipolar patients with and without migraine: a neuroendocrine study of 5-HT1D receptor function

An association between bipolar disorder and migraine has been lately recognized and an abnormality of central serotonergic function is suggested as the underlying neurophysiological disturbance. To examine the role of serotonin in bipolar disorder and migraine, we used the neuroendocrine challenge paradigm, and we chose sumatriptan, a 5HT1D agonist, as the pharmacological probe. We studied nine bipolar patients with migraine, nine bipolar patients without it, seven migraine patients, and nine matched normal controls. A post-hoc analysis showed subsensitivity of serotonergic function, reflected in a blunted growth hormone response to sumatriptan challenge in bipolar patients who also suffered from migraine.