MicroRNAs as master regulators of FOXO transcription factors in cancer management

MicroRNAs are critical regulators of the plethora of genes, including FOXO "forkhead" dependent transcription factors, which are bonafide tumour suppressors. The FOXO family members modulate a hub of cellular processes like apoptosis, cell cycle arrest, differentiation, ROS detoxification, and longevity. Aberrant expression of FOXOs in human cancers has been observed due to their down-regulation by diverse microRNAs, which are predominantly involved in tumour initiation, chemo-resistance and tumour progression. Chemo-resistance is a major obstacle in cancer treatment. Over 90% of casualties in cancer patients are reportedly associated with chemo-resistance. Here, we have primarily discussed the structure, functions of FOXO and also their post-translational modifications which influence the activities of these FOXO family members. Further, we have addressed the role of microRNAs in carcinogenesis by regulating the FOXOs at post-transcriptional level. Therefore, microRNAs-FOXO axis can be exploited as a novel cancer therapy. The administration of microRNA-based cancer therapy is likely to be beneficial to curb chemo-resistance in cancers.

Parental and training coaches' knowledge and attitude towards dental trauma management of children

BACKGROUND

The aim of this study was to evaluate parental and training coaches' knowledge and attitude towards traumatic dental injuries (TDIs) among children.

MATERIAL AND METHODS

A 31-item questionnaire was distributed to the parents and training coaches attending local sporting clubs in Brisbane region, Australia. The questionnaire consisted of five parts (i) demographic and professional information; (ii) TDIs in the primary dentition; (iii) fractures and subluxation of permanent teeth (iv) avulsion of permanent teeth, and (v) information and knowledge related to the management of traumatized teeth. The jamovi (Version 1.6.3) and GraphPad Prism were used for data analysis.

RESULTS

A total of 233 participants were surveyed, 211 parents and 22 coaches. Of all types of injuries, parental knowledge of managing avulsion to permanent teeth was poorest (9.5%), followed by management of injuries of primary teeth (17.5%) and management of fractures or subluxation of permanent teeth (29.4%). Parents in health care occupations had higher satisfaction on self-knowledge in managing TDIs however there was no significant difference in knowledge levels between health care personnel and other professions (P = 0.128). There was a discrepancy between the lack of knowledge and willingness to further self-educate with online platforms being the preferred medium.

CONCLUSION

The study showed a gap in parents' and training coaches' knowledge regarding the management of TDIs among children.

Pedagogical development in local anaesthetic training in paediatric dentistry using virtual reality simulator

PURPOSE

With the advancements in technology, dental pedagogy has also evolved, and new learning technologies have emerged. Virtual reality (VR) as an education tool in dentistry is underutilised. VR as an adjunct in local anaesthesia (LA) teaching in paediatric dentistry has not been investigated. The study aimed to investigate dental student's perception of dental LA VR simulation on a paediatric patient and to determine whether this can improve students learning experience.

METHODS

Seventy-one students participated in a self-administered questionnaire before and after the use of dental LA VR simulator. Descriptive analysis was performed to determine the perceptions of experience gained through VR. The data were tabulated, graphed, and analysed using SPSS and GraphPad Prism software.

RESULTS

The study noted that 89.9% of participants perceived that it would improve their LA skills. After using dental LA VR, 83.1% of participants experienced more engaged in the learning activity, and 55.0% of participants agreed/strongly agreed that it improved their understanding of anatomical landmarks. Around 56.4% of participants agreed/strongly agreed that it added value compared with traditional LA teaching methods.

CONCLUSION

It can be concluded that the use of VR simulation can enhance students engagement and learning experience in paediatric dentistry settings and can be used as an additional means of LA training.

Diabetic patients' knowledge of the bidirectional link: are dental health care professionals effectively conveying the message?

Diabetes mellitus (DM) has emerged as a global public health concern with significant upshots due to its high prevalence, severity and associated complications. The present review aims to evaluate the literature that has investigated the awareness and attitude of diabetic patients about their oral/periodontal health to identify gaps in the dissemination of this critical information. Literature addressing diabetic patient's awareness/knowledge, response to their periodontal health needs, and the source of oral health education was investigated using a computer search of electronic databases. Twenty-six papers were included in the systematic review for analysis. The studies reported data from 13 different countries involving 10 550 participants, 9843 patients with DM and 974 healthy controls. The overall analysis of the studies showed that approximately 73% of the diabetic patients were unaware of the link between their systemic condition (DM) and periodontal health. The results of the study show that a large number of diabetic patients are unaware of the link between oral/periodontal health and DM. There is a strong need to implement the recent guidelines established by the IDF/EFP concerning mutual care of diabetic patients by the medical and dental health care professionals. This will result in improved general and oral health of our diabetic patients.

Salubrinal enhances eIF2α phosphorylation and improves fertility in a mouse model of Classic Galactosemia

Loss of galactose-1 phosphate uridylyltransferase (GALT) activity in humans results in Classic Galactosemia, and the GalT-deficient (GalT^-/-) mouse mimics the patient condition. GalT^-/- ovaries display elevated endoplasmic reticulum (ER) stress marker, BiP, and downregulated canonical phosphatidylinositol 3-kinase (Pi3k)/protein kinase B (Akt) growth/pro-survival signaling. Numbers of primordial follicles are reduced in the mutants, recapitulating the accelerated ovarian aging seen in human patients. We previously found that oral administration of the compound Salubrinal (an eIF2α phosphatase inhibitor), resulted in reduction of ovarian BiP expression, rescued Pi3k/Akt signaling, and a doubling of primordial follicles in GalT^-/- adults. Here, we further characterized galactosemic stress in GalT^-/- mice versus wild-type (WT) controls, and examined whether Salubrinal treatment improved broader reproductive parameters. We assessed the expression levels of factors of the unfolded protein response (UPR), and found that BiP, phospho-Perk, and phospho-eIF2α were all elevated in GalT^-/- ovaries. However, neither IKK activation (NFκB pathway) nor alternative Xbp1 splicing downstream of ER membrane protein Ire1α activation was induced, suggesting an Xbp1-independent UPR in galactosemic stress. Moreover, Salubrinal treatment significantly increased the number of ovulated eggs in mutant animals after gonadotrophic superovulation. Salubrinal treatment also normalized estrus cycle stage lengths and resulted in significantly larger litter sizes than vehicle-treated mutants. Overall, we show that Salubrinal protects against galactosemia-induced primordial follicle loss in a fashion that includes suppressing the de-phosphorylation of eIF2α, and that intervention in this way significantly improves and extends ovarian function, fertility, and fecundity.

Cardioprotective Efficacy of Coriandrum sativum (L.) Seed Extract in Heart Failure Rats Through Modulation of Endothelin Receptors and Antioxidant Potential

The present study aimed to evaluate the therapeutic and prophylactic potential of Coriandrum sativum extract in isoproterenol-induced heart failure (HF) in Wistar rats. Two weeks after the isoproterenol administration, rats developed severe impairment in left ventricular functions, reduced baroreflex sensitivity, and significant alteration in hemodynamic parameters and lipid profile. HF rats also exhibited enhanced lipid peroxidation and increased expression of endothelin receptors (ET_A and ET_B). Therapeutic and prophylactic treatment with C. sativum extract significantly (p < .05) improved the left ventricular functions and hemodynamic parameters and increased baroreflex sensitivity. It also inhibited lipid peroxidation, improved lipid profile, and downregulated the expression of endothelin receptors. Simvastatin treatment showed a similar cardioprotective effect. Our results suggest that C. sativum extract provides significant protection from heart failure possibly due to its ability to improve left ventricular functions and baroreflex sensitivity, attenuate lipid peroxidation, and modulate the expression of endothelin receptors.

Anti-carcinogenic effect of hesperidin against renal cell carcinoma by targeting COX-2/PGE2 pathway in Wistar rats

The present study was designed to evaluate the protective effects of hesperidin, a flavonoid on DEN initiated and Fe-NTA promoted renal carcinogenesis in Wistar rats. Renal cancer was initiated by a single i.p. injection of DEN (200 mg/kg b.wt.) and promoted with Fe-NTA (9 mg Fe/kg b.wt. i.p.) twice a week for 16 weeks. Rats were simultaneously administered with hesperidin (100 and 200 mg/kg b.wt.) for 16 consecutive weeks. The chemopreventive effect of hesperidin was assessed in terms of antioxidant activities, renal function, PGE2 level, and the expressions of COX-2 and VEGF. Hesperidin decreased the DEN and Fe-NTA induced lipid peroxidation, improved the renal function (by decreasing the levels of BUN, creatinine, and KIM-1) and restored the renal antioxidant armory (GSH, GPx, GR, SOD, and catalase). Hesperidin was also found to decrease the level of PGE2 and downregulate the expressions of COX-2 and VEGF. Histological findings further revealed the protective effects of hesperidin against DEN and Fe-NTA induced kidney damage. The result of our present findings suggest that hesperidin may be a promising modulator in preventing renal cancer possibly by virtue of its ability to alleviate oxidative stress and inhibit COX-2/PGE2 pathway.

Effects of Coriandrum Sativum Extract and Simvastatin in Isopreterenol Induced Heart Failure in Rats

Heart failure is a syndrome, caused due to structural and functional cardiac abnormalities, characterized by changes in the hemodynamic and neurohumoral mechanisms. It is becoming a major health burden worldwide. More effective therapies are desperately needed. Coriandrum sativum (C. sativum), a traditional spice crop has been known to possess many biological and medicinal properties. The present study was designed to investigate the cardioprotective efficacy of C. sativum in rat model of isoproterenol induced heart failure. Heart failure was produced by injecting isoproterenol subcutaneously (85 mg/kg twice at an interval of 24 h). Oral efficacy of seed extract was assessed on hemodynamic profile, antioxidant enzyme activities, lipid peroxidation, lipid profile, atherogenic indices, mRNA and protein expression of endothelin receptors (ETA and ETB) and histopathology. Treatment of heart failure rats with C. sativum orally (1g/kg b.wt) improved the altered hemodynamics, restored the cardiac antioxidant enzymes armory, attenuated oxidative stress, improved lipid profile, lowered atherogenic indices, decreased the levels of ETA and ETB receptor mRNA and protein, and restored the cardiac morphology. In conclusion, our results suggest C. sativum to be a cardioprotective agent in heart failure, possibly by the virtue of its ability to alleviate oxidative stress, improve lipid profile and endothelial dysfunction.

Primary well differentiated neuroendocrine tumor of ovary collides with Mucinous borderline tumor in a postmenopausal female: a report of case and review of literature

Collision tumors represent a coexistence of two adjacent but histologically distinct tumors without histologic admixture in an organ. Primary well differentiated neuroendocrine tumor of ovary is rare and coexistent borderline mucinous tumor makes this association extremely rare. Although these tumors have been reported in other organs, its occurrence in ovary is rare. Collision tumor comprising primary neuroendocrine tumor of ovary and mucinous borderline tumor is an extremely rare occurrence. Here we report a case of this collision tumor in a postmenopausal female. H&E and immunohistochemical stains for chromogranin, synaptophysin, CDX-2, CK20, CK7 and Ki-67 were performed to confirm the diagnosis of collision tumor. Extensive search of literature revealed only a couple of cases report so far with this association. Our case is unique for a reason that we have reported trabecular variant of neuroendocrine tumor while the previously reported cases were insular variant. Management depends on patient's age, desire for fertility and disease distribution.

Reversal of aberrant PI3K/Akt signaling by Salubrinal in a GalT-deficient mouse model

Classic Galactosemia is an autosomal recessive disorder caused by deleterious mutations in the GALT gene, which encodes galactose-1 phosphate uridylyltransferase enzyme (GALT: EC 2.7.7.12). Recent studies of primary skin fibroblasts isolated from the GalT-deficient mice demonstrated a slower growth rate, a higher level of endoplasmic reticulum (ER) stress, and down-regulation of the Phosphoinositide 3 kinase/Protein kinase B (PI3K/Akt) signaling pathway. In this study, we compared the expression levels of the PI3K/Akt signaling pathway in normal and GalT-deficient mouse tissues. In mutant mouse ovaries, phospho-Akt [pAkt (Ser473)] and pGsk3β were reduced by 62.5% and 93.5%, respectively (p<0.05 versus normal controls). In mutant cerebella, pAkt (Ser473) and pGsk3β were reduced by 62%, 50%, respectively (p<0.05). To assess the role of ER stress in the down-regulation of PI3K/Akt signaling, we examined if administration of Salubrinal, a chemical compound that alleviates ER stress, to GalT-deficient fibroblasts and animals could normalize the pathway. Our results demonstrated that Salubrinal effectively reversed the down-regulated PI3K/Akt signaling pathway in the mutant cells and animals to levels close to those of their normal counterparts. Moreover, we revealed that Salubrinal can significantly slow down the loss of Purkinje cells in the cerebella, as well as the premature loss of primordial ovarian follicles in young mutant mice. These results open the door for a new therapeutic approach for the patients with Classic Galactosemia.

Pathways for Transformation: Disaster Risk Management to Enhance Resilience to Extreme Events

Disaster risk from extreme events and development are intimately linked. Disaster risk management influences and is affected by local development strategies. Trade-offs made in policy and implementation determine winners and losers on the basis of unequal capacity, susceptibility and hazard exposure. Transformation has been introduced as a concept opening new policy space for fundamental shifts in development trajectories. Though policy neutral, when combined with normative frameworks such as the Sustainable development goals it can open up leverage points for determining development trajectories. There is limited empirical evidence on which to base understanding of transformative disaster risk management policy though some work has been done in sister domains such as climate change mitigation and adaptation. This study asks whether transformation pathways for disaster risk management can be observed, offering an initial qualitative analysis to inform policy development. It is based on five case studies drawn from diverse locations exposed to a range of extreme events, examined through a conceptual framework offering five indicators of transformation to aid analysis: intense interaction between actors; the intervention of external actors; system level change extending beyond efficiency to governance and goals; behavior beyond established coping strategies; and behavior extending beyond established institutions. Core characteristics of transformative pathways for disaster risk reduction are identified, including pathway competition, pathway experimentation, pathway scale effects and pathway lock-in. These characteristics are seen to determine the extent to which the disruption consequent on extreme events leads to either transformatory change or relative stasis. The study concludes that transformative disaster risk management, both intentional and incidental can be observed. It is seen that transformations occur primarily at local level. Where policy level change occurs this generally played out at local level too. The particular insight of the study is to suggest that most often the burden of transformation is carried at the local level through the behavior of individuals, populations and civil society. This observation raises an important question for further work: How can the burden of undertaking transformation be shared across scales?

Inhibition of precancerous lesions development in kidneys by chrysin via regulating hyperproliferation, inflammation and apoptosis at pre clinical stage

Chrysin (CH) is natural, biologically active compound, belongs to flavoniod family and possesses diverse pharmacological activities as anti-inflammatory, anti-oxidant and anti-cancer. It is found in many plants, honey and propolis. In the present study, we investigated the chemopreventive efficacy of CH against N-nitrosodiethylamine (DEN) initiated and Fe-NTA induced precancerous lesions and its role in regulating oxidative injury, hyperproliferation, tumor incidences, histopathological alterations, inflammation, and apoptosis in the kidneys of Wistar rats. Renal cancer was initiated by single intraperitoneal (i.p.) injection of DEN (200 mg/kg bw) and promoted by twice weekly injection of ferric nitrilotriacetate (Fe-NTA) 9 mg Fe/kg bw for 16 weeks. CH attenuated Fe-NTA enhanced renal lipid peroxidation, serum toxicity markers and restored renal anti oxidant armory significantly. CH supplementation suppressed the development of precancerous lesions via down regulation of cell proliferation marker like PCNA; inflammatory mediators like TNF-α, IL-6, NFkB, COX-2, iNOS; tumor incidences. CH up regulated intrinsic apoptotic pathway proteins like bax, caspase-9 and caspase-3 along with down regulation of Bcl-2 triggering apoptosis. Histopathological and ultra structural alterations further confirmed biochemical and immunohistochemical results. These results provide powerful evidence for the chemopreventive efficacy of CH against chemically induced renal carcinogenesis possibly by modulation of multiple molecular pathways.

Developmental vulnerability--don't investigate without a model in mind

Children who are developmentally vulnerable are at risk of a difficult start to school, and ongoing educational challenges which may adversely impact on long term health outcomes. Clinicians, researchers and service providers need a thorough understanding of both risk and protective factors and their complex interplay to understand their impact on early childhood development, in order to plan effective and comprehensive prevention and interventions strategies. In this opinion piece we recommend that investigation of developmental vulnerability should only proceed if underpinned by both a theoretical model through which the interaction between risk and protective factors may be investigated, and analytical models that are appropriate to assess these impacts.

HDM2 antagonist MI-219 (spiro-oxindole), but not Nutlin-3 (cis-imidazoline), regulates p53 through enhanced HDM2 autoubiquitination and degradation in human malignant B-cell lymphomas

Background

Lymphomas frequently retain wild-type (wt) p53 function but overexpress HDM2, thereby compromising p53 activity. Therefore, lymphoma is a suitable model for studying the therapeutic value of disrupting the HDM2-p53 interaction by small-molecule inhibitors (SMIs). HDM2 have been developed and are under various stages of preclinical and clinical investigation. Previously, we examined the anti-lymphoma activity of MI-319, the laboratory grade of a new class of HDM2 SMI, the spiro-oxindole, in follicular lymphoma. Since then, MI-219, the clinical grade has become readily available. This study further examines the preclinical effects and mechanisms of MI-219 in a panel of human lymphoma cell lines as well as a cohort of patient-derived B-lymphcytes for its potential clinical use.

Results

Preclinical assessment of MI-219 was evaluated by means of an in vitro and ex vivo approach and compared to Nutlin-3, the gold standard. Characterization of p53 activity and stability were assessed by quantitative PCR, Western blot, and immunoprecipitation. Biological outcome was measured using Trypan blue exclusion assay, Annexin V/PI, PARP and caspase-3 cleavage. Surprisingly, the overall biological effects of Nutlin-3 were more delayed (48 h) while MI-219 triggered an earlier response (12-24 h), predominantly in the form of apoptotic cell death. Using a cell free autoubiquitination assay, neither agent interfered with HDM2 E3 ligase function. MI-219 was more effective in upregulating wt-p53 stabilization compared to Nutlin-3. MI-219, but not Nutlin-3, enhanced the autoubiquitination and degradation of HDM2.

Conclusions

Our data reveals unexpected differences between MI-219 and the well-studied Nutlin-3 in lymphoma cell lines and patient samples. We suggest a novel mechanism for MI-219 that alters the functional activity of HDM2 through enhanced autoubiquitination and degradation. Additionally, this mechanism appears to correspond to biological outcome. Our results provide evidence that different classes of HDM2 SMIs elicit molecular events that extend beyond HDM2-p53 dissociation which may be of biological and potentially therapeutic importance.

Do the wealthy have a health advantage? Cardiovascular disease risk factors and wealth

The use of wealth as a measure of socioeconomic status (SES) remains uncommon in epidemiological studies. When used, wealth is often measured crudely and at a single point in time. Our study explores the relationship between wealth and three cardiovascular disease (CVD) risk factors (smoking, obesity and hypertension) in a US population. We improve upon existing literature by using a detailed and validated measure of wealth in a longitudinal setting. We used four waves of data from the Panel Study of Income Dynamics (PSID) collected between 1999 and 2005. Inverse probability weights were employed to control for time-varying confounding and to estimate both relative (risk ratio) and absolute (risk difference) measures of effect. Wealth was defined as inflation-adjusted net worth and specified as a six category variable: one category for those with less than or equal to zero wealth and quintiles of positive wealth. After adjusting for income and other time-varying confounders, as well as baseline covariates, the risk of becoming obese was inversely related to wealth. There was a 40%-89% higher risk of becoming obese among the less wealthy relative to the wealthiest quintile and 11 to 25 excess cases (per 1000 persons) among the less wealthy groups over six years of follow up. Smoking initiation had similar but more moderate effects; risk ratios and differences both revealed a smaller magnitude of effect compared to obesity. Of the three CVD risk factors examined here, hypertension incidence had the weakest association with wealth, showing a smaller increased risk and fewer excess cases among the less wealthy groups. In conclusion, this study found a strong inverse association between wealth and obesity incidence, a moderate inverse association between wealth and smoking initiation and a weak inverse association between wealth and hypertension incidence after controlling for income and other time-varying confounders.

Impact of CYP2C9 genetic polymorphism on warfarin dose requirements in Pakistani population

Variations of cytochrome-P450 enzyme system (CYP2CP) are associated with impaired metabolism of warfarin. The objective of our study was to estimate the frequency of genetic and allelic variants of CYP2C9 in Punjabi population of Pakistan and their effects on warfarin dose requirement. One hundred and twenty unrelated Pakistani subjects belong to Punjab province, were randomly included from the registry of National Institute of Heart Disease Rawalpindi, Pakistan. The patients had stable international normalized ratio (INR) of 2 to 3 for last 3 months with warfarin therapy after heart valves replacement. The detection of CYP2C9 variant was done on polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. Total 120 patients (73 males; 47 females) of mean age of 37 years participated in the study. Nine patients had mutant allele CYP2C9*3 (7.5%), one CYP2C9*2 (0.8%) and 110 patients exhibited wild type CYP2C9*1 (91.7%). The frequency of CYP2C9 genotype was *1/*1 (0.858) ; *1/*3 (0.117) ; 2/*20 (0.08 ) and *3/*3 (0.017) in our study population. A high dose of warfarin (42.2+9.56) mg/week is required for patients with *1/*1 genotype as compared to patients with *2/*2 (17.5+1.9) and *1/*3 (16.6+2.3) allele (p<0.001). Individuals with CYP2C9*3/3* need lowest (8.75±1.76 mg/week) daily warfarin dose. In conclusion, the genetic variations in the CYP2C9 occur in 14% of Punjabi ethnic group in Pakistan. Presence of CYP2C9*2 or *3 variants is an independent predictor of low warfarin dose requirement in our patients. CYP2C9 variants assay may be used in high risk groups for appropriate dose adjustment to avoid complications on long term basis.

Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled clinical trial using split-mouth technique

The use of prophylactic antibiotics to reduce postoperative complications in third molar surgery remains controversial. The study was a prospective, randomized, double blind, placebo-controlled clinical trial. 100 patients were randomly assigned to two groups. Each patient acted as their own control using the split-mouth technique. Two unilateral impacted third molars were removed under antibiotic cover and the other two were removed without antibiotic cover. The first group received antibiotics on the first surgical visit. On the second surgical visit (after 3 weeks), placebo capsules were given or vice versa. The second group received antibiotics with continued therapy for 2 days on the first surgical visit and on the second surgical visit (after 3 weeks) placebo capsules were given or vice versa. Pain, swelling, infection, trismus and temperature were recorded on days 3, 7 and 14 after surgery. Of 380 impactions, 6 sockets (2%) became infected. There was no statistically significant difference in the infection rate, pain, swelling, trismus, and temperature between the two groups (p>0.05). Results of the study showed that prophylactic antibiotics did not have a statistically significant effect on postoperative infections in third molar surgery and should not be routinely administered when third molars are removed in non-immunocompromised patients.

Knife inflicted penetrating injuries of the maxillofacial region: a descriptive, record-based study

Penetrating knife injuries of the face are more common in South Africa than the rest of the world. These injuries can be life-threatening, especially where the major blood vessels of the face are involved. The approach to treatment should be multidisciplinary, beginning with the trauma unit to provide airway maintenance and haemodynamic stabilisation. An interventional radiologist may be consulted for angiography. The aim of the present study was to retrospectively analyse all cases of knife-inflicted penetrating injuries to the maxillofacial region with the knife in situ and subsequently develop a management protocol to be used by maxillofacial surgery registrars when presented with such cases.

MATERIALS AND METHODS

It was a retrospective, cross-sectional and record-based study, analysing all penetrating knife injuries reported at various hospitals for a period of 11 years. In this study, 24 cases of knife injuries were analysed.

RESULTS

Twenty-one patients (87.5%) in this series were male and three (12.5%) were female. Of these 24 patients, 13 (54.2%) were coloured and 11 (45.8%) were black. There were no white or Indian patients. Post-surgical recovery of all patients was rapid and uneventful, and there were no fatalities.

CONCLUSION

Patients with knife injuries to the face with no definite signs of vascular injury can thus be safely and accurately managed on the basis of physical examination and plain-film radiography. An angiogram is mandatory if the patient presents with excessive bleeding, an expanding haematoma or if the knife blade is in the region of any large vessels.

Therapeutic drug monitoring of amikacin in preterm and term infants

INTRODUCTION

Amikacin is a commonly-prescribed drug used for the empirical treatment of bacterial infections in neonates. A marked change in the pharmacokinetics of amikacin has been reported during neonatal life. Amikacin has a very narrow therapeutic range and can cause very serious side effects such as nephrotoxicity and ototoxicity. The current therapeutic dose of amikacin, i.e. 15 mg/kg of body weight, may increase the risk of toxicity in preterm infants with immature renal functions. We aimed to determine the frequency of amikacin toxicity in preterm as compared to term infants by measuring its serum trough levels following the administration of the current therapeutic dose.

METHODS

A comparative study was conducted at the neonatal intensive care unit of the Military Hospital, Rawalpindi, Pakistan. A total of 104 infants (52 term and 52 preterm) receiving amikacin at a dose of 15 mg/kg of their body weight, once daily for bacterial infection, were included. After clinical evaluation, serum creatinine levels were measured at admission and on the third day. Amikacin trough levels were taken after 72 hours of therapy and measured on the TDx Abbot Drug Analyser.

RESULTS

The gestational age range was 37-40 weeks in term and 29-36 weeks in preterm infants. The term and preterm infants had a median weight of 2.8 kg and 2.1 kg, respectively. The preterm infants had significantly higher median (range) 11.33 (1.50-42.60) ug/ml levels of serum amikacin as compared to 8.5 (2.8-33.0) ug/ml in term infants (p-value is less than 0.01). The preterm infants had a high frequency of toxic 32 (62 percent) and subtherapeutic 12 (23 percent) levels, as compared to 11 (21 percent) and 5 (10 percent) in term infants, respectively. Serum amikacin levels revealed a positive correlation with post-dose serum creatinine (r equals 0.48; p-value is less than 0.05).

CONCLUSION

This study demonstrated that the current practice of amikacin treatment for bacterial infection needs to be adjusted due to unique pharmacokinetic variability in preterm infants. There is a need for regular therapeutic drug monitoring and renal function assessment in all infants receiving amikacin therapy in order to avoid nephrotoxicity.

The role of radiation therapy in benign diseases

Although adequate prospective data are lacking, radiation therapy seems to be effective for many benign diseases and remains one of the treatment modalities in the armamentarium of medical professionals. Just as medication has potential adverse effects, and surgery has attendant morbidity, irradiation sometimes can be associated with acute and chronic sequelae. In selecting the mode of treatment, most radiation oncologists consider the particular problem to be addressed and the goal of therapy in the individual patient. It is the careful and judicial use of any therapy that identifies the professional. With an understanding of the current clinical data, treatment techniques, cost, and potential detriment, the goal is to provide long-term control of the disease while minimizing unnecessary treatment and potential risks of side effects. The art lies in balancing benefits against risks.

The cost of treating pancreatic cancer: A pilot study

16004

Background: The treatment of pancreatic cancer (PC) is rapidly changing with the approval of new anti-cancer agents. A pilot analysis of twenty five patients treated for PC was performed to determine the cost of PC treatment. Methods: Twenty-five PC patients were selected from 1998–2004 to represent a variety of treatments, both standard and experimental. Charts were reviewed for hospitalizations, clinic visits, and medications greater than $10 in cost. Costs were determined using pharmacy and hospital billing services. Average costs per month were calculated for all 25 patients in the twelve months preceding death. Results: Mean time from diagnosis to death was 13.6 months and mean duration of treatment was 12.6 months. During the period of treatment, mean monthly anti-cancer treatment and additional pharmacotherapy costs were $3,771 and $3,196 respectively. Mean monthly cost of hospitalizations and clinic visits were $2,258 and $213. In the last twelve months of life, months -3, -5, and -2 (death = 0) were most expensive with average spending of $65,557, $58,820, $47,727 respectively. Breakdown of costs in the three most expensive months was: anti-cancer agents (82%), hospitalization (15%), additional pharmacotherapy (3.0%), and clinic visits (0.5%). Conclusions: In this pilot study, we compiled major contributors to the cost of treating PC and then focused on the twelve months preceding death. Anti-cancer agents were determined to be the largest expenditure overall, and were a greater proportion of the cost in the most expensive months before death. This remains an underestimate as surgery, radiation, and indirect costs are not included. As newer agents become incorporated into standard treatment for PC, costs are expected to rise further. This data is being used in designing a larger study comparing costs, quality of life, and survival using newer combination chemotherapy.

No significant financial relationships to disclose.

Pseudomyocardial infarction associated with a retrocaecal gangrenous appendix

The case is presented of a 54 year old man who attended the emergency department with a history of central abdominal pain and electrocardiograpic changes consistent with an anteroseptal myocardial infarction. Myocardial infarction was not confirmed with serial cardiac enzymes and a subsequent laparotomy revealed a gangrenous retrocaecal appendix. This case highlights the rare but recognised association between an acute surgical abdomen and pseudomyocardial infarction. It is, to the authors' knowledge, the first reported case of pseudomyocardial infarction complicating a retrocaecal appendicitis.

Nontypeable Haemophilus influenzae in the lower respiratory tract of patients with chronic bronchitis

The frequency of colonization and intracellular localization of nontypeable Haemophilus influenzae (NTHi) in the lower respiratory tract was determined in healthy adults and in clinically stable and acutely ill chronic bronchitis (CB) patients. NTHi was recovered from bronchial wash or bronchial brush specimens in 6 of 23 (26%) stable CB patients and in 1 of 15 (7%) CB patients with a respiratory exacerbation. No NTHi (0 of 26) was recovered from lower tract specimens of healthy adults undergoing anesthesia for elective surgery. Molecular typing of NTHi strains revealed that five of nine patients with stable CB had different strains in upper respiratory tract and bronchial wash/brush specimens collected simultaneously. Four stable patients with CB had different strains recovered on repeat bronchoscopy. These results demonstrate the frequent colonization of the lower airways of stable CB patients with multiple strains of NTHi. Bronchial biopsies also were examined for intracellular NTHi by in situ hybridization and immunofluorescence microscopy. Intracellular NTHi were found in 0 of 7 healthy adults, 8 of 24 patients with clinically stable CB, and 13 of 15 acutely ill CB patients. This observation suggests a role for intracellular infection by NTHi in the pathogenesis of exacerbations of CB.

The role of 123I-diagnostic imaging in the follow-up of patients with differentiated thyroid carcinoma as compared to 131I-scanning: avoidance of negative therapeutic uptake due to stunning

OBJECTIVE

Some patients with relapsed differentiated thyroid cancer may show rising thyroglobulin (Tg) levels despite a lack of 131I uptake on routine whole body imaging. A significant proportion of these patients, after therapy doses of 131I, may demonstrate positive 131I uptake with a subsequent fall in serum Tg, implying a therapeutic effect. Attempts to identify such patients by increasing the dose of the diagnostic 131I tracer may lead to inhibition of subsequent uptake after the therapy dose, an effect referred to as 'stunning' and associated with a reduction in therapeutic effect. 123I is a short half-life gamma-emitter, thought to be unlikely to cause stunning, which may thus be more suitable than 131I for diagnostic imaging of thyroid cancer.

DESIGN AND PATIENTS

The efficacy of the 123I radionuclide was determined in a longitudinal study of 12 patients who were selected only because they showed elevated serum Tg and a negative diagnostic 131I whole body study prior to therapy with 131I.

RESULTS

There was almost complete concordance in uptake between 123I diagnostic imaging and the final scans carried out after 131I therapy (hereafter known as therapy studies) in 11 out of 12 patients at their first evaluation, in each of four patients receiving 123I at their second evaluation and in a single patient receiving 123I at a third evaluation. One patient had a positive 123I study but a negative 131I therapy study: following therapy Tg declined from 5.5 pg/l to undetectable levels, implying a therapeutic effect, and suggesting that the negative uptake was not the result of stunning. Two negative diagnostic 123I studies were followed by negative therapy studies, and thus there were no false negatives. 123I correctly identified disease in the nine patients with metastases in the lungs, mediastinum and bone at the first evaluation, in all four patients at the second evaluation and in the single patient at the third evaluation. At the end of the study, patients had received up to three 131I therapy doses, Tg had risen in four patients, fallen in eight and become undetectable in one patient.

CONCLUSIONS

123I is highly sensitive in diagnosing local recurrence and metastatic disease, and produces scintigraphic images which concord well with uptake following 131I therapy. It is proposed that 123I imaging, in combination with serum Tg measurements, should replace 131I tracer imaging as an indicator of the potential efficacy of 131I therapy. Stunning, with its detrimental effects on 131I therapy, may thus be avoided. The possibility of false negative images due to the stunning phenomenon must always be borne in mind if there is a discrepancy between positive 131I imaging studies and a surprisingly negative subsequent 131I therapy scan.

Economic growth, income equality, and population health among the Asian Tigers

The "Tiger" economies of Southeast Asia provide examples of developing nations where economic growth and increasing income equality are compatible and, when occurring together, are associated with superior health trends over time. The degree of income inequality in the Asian Tigers declined during the period of rapid economic growth. Traditionally, economists have viewed economic growth and relative parity in income distribution as incompatible, or trade-offs. This poses a public policy dilemma, since a reasonable propensity to increase a nation's overall economic well-being would mean forsaking measures that increase income parity. The Asian Tigers, however, have shown that this need not be viewed as a trade-off. Economic growth and a simultaneous increase in income equality are possible and, with respect to health outcomes, desirable. The authors propose a variety of mechanisms through which income inequality can enhance economic growth, and discuss policies in education, agricultural land reform, and housing that influence the simultaneous attainment of income equality and economic growth.

Health and rapid economic change in the late twentieth century

Rapidly expanding economies, such as the post-war Tiger Economies, are associated with increasing health and rapidly contracting economies, such as Central and Eastern Europe in the early 1990s, are associated with declining health. In Central and Eastern Europe health decline in association with economic contraction has been mediated by changes in income distribution and, also, by health-determining aspects of civil society. The nations of Central and Eastern Europe are an example of swift economic and political transformation occurring concurrently with economic decline; with increasing disparity in income distributions; and with high levels of distrust in civil institutions. Concurrent with these declines was a marked reduction in health status, described here in terms of life expectancy. Conversely, the nations of Southeast Asia experienced rapid economic growth and increasing life expectancies. Though data are scarce, the experience of the Tiger Economies appears to be one of economic growth; a virtuous cycle of increased investment in education and housing; and increasing parity in income distribution based upon a relatively equitable distribution of returns on education.