Morphometric analysis and roosting ecology of bat species Pteropus Medius in Mansehra, Khyber Pakhtunkhwa, Pakistan

Morphometric measurement and roosting ecology of Pteropus medius were aimed to find out in Mansehra district of KP, Pakistan. Total 3149 numbers of bats were found in eight biological spots visited; Baffa Doraha, Darband, Dadar, Jallu, Hazara University, Garhi Habibullah Chattar Plain and Jabori, in total 299 numbers of different species of trees including; Morus alba, Pinus raxburghi, Eucalyptus camaldulensis, Morus nigra, Grevillea robusta, Brousonetia papyrifera, Platanus orientalis, Ailanthus altissima, Hevea brasiliensis and Populus nigra. Morphometric features were measured and found vary according to sex of the bats. The average wing span, wing`s length from tip of wing to neck, from thumb to tip of wing and the body`s length from head and claws were recorded to be 102.98 cm, 49.07cm, 28.7 cm and 22.78 cm respectively in males while 93.67 cm, 44.83cm, 24.78cm and 22.78 cm respectively in female bats. Mean circumference of the body including wings and without wing were measured as 22.78 cm and 17.29 cm in males and that of female were 20.07 cm and 16.9 cm. Average length of thumb 3.64 cm, ear`s length 3.1 cm, snout 5.62cm, eye length were 1.07 cm for both sexes and length between the feet in extended position were16.3 cm. Generally different measurement of males bodies were found to be greater than female such as mean body surface area, mass, volume and pressure were found to be 2691.79 cm2, 855.7gm,1236.4 ml and 295.77 dyne/ c m 3 for male and 2576.46 cm2, 852.71gm,1207 ml and 290.2 dyne/ c m 3 respectively for female. While weight and density for both males and females bats were same with mean of 8.59 newton and 0.701 g/m3. Findings of current reports can add valued information in literature about bats, which can be used for species identification and conservation.

Molecular Approaches for Detection of Rifampin-Resistant Mycobacterium tuberculosis and Its Associated Risk Factors among General Population

GeneXpert MTB/RIF is a molecular technique for the diagnosis of tuberculosis. This method not only detects M. tuberculosis but also identifies the absence or presence of different drug resistant mutations in DNA fragments like rifampicin resistance. In this study, about 200 septum samples were collected from tuberculosis suspected people of Isfandyar Bukhari District Head Quarter Hospital Attock for screening and determination of Mycobacterium tuberculosis and multi-drug-resistant tuberculosis. The samples were screened for the presence of M. tuberculosis using Fluorescence Microscopy staining followed by GeneXpert MTB/RIF assay. The results were further confirmed by Line Probe Assay and Mycobacterium Growth Indicator Tube 960 techniques. In a total of 200 samples, 45(22.5%) were found positive, 155 (77.5%) were classified negative on culture while 38(19%) were positive and 162(81%) were negative on FM, 33(16.5%) were positive and 167(83.5%) were negative on ZN staining microscopy and 47(23.5%) were noted positive and 153 (76.5%) were negative on GeneXpert. The overall sensitivity of GeneXpert was 07% higher than that of smear microscopy and 4.2 % higher than culture.Different risk factors reported for TB are; malnutrition (23.40%), health care workers (14.89%), immunosuppression (12.76%), unimmunized with Bacille Calmette-Guérin (BCG) vaccine and contact with infected persons (10.63%), diabetes mellitus (8.51%), poverty and foreign-born children are (4.2%). It is concluded that the most common risk factor for TB was malnutrition (23.40%) and the foreign-born children (4.2%) were least affected. GeneXpert assay for identification of tuberculosis was found more sensitive than fluorescence microscopy and for isolation of MTB and rifampicin resistance, GeneXpert RIF assay can efficiently be usedwhich is simple, robust and efficient with minimum handling technique.

HPLC-DAD Based Polyphenolic Profiling and Evaluation of Pharmacological Attributes of Putranjiva roxburghii Wall

The current study was intended to explore the phytochemical profiling and therapeutic activities of Putranjiva roxburghii Wall. Crude extracts of different plant parts were subjected to the determination of antioxidant, antimicrobial, antidiabetic, cytotoxic, and protein kinase inhibitory potential by using solvents of varying polarity ranges. Maximum phenolic content was notified in distilled water extracts of the stem (DW-S) and leaf (DW-L) while the highest flavonoid content was obtained in ethyl acetate leaf (EA-L) extract. HPLC-DAD analysis confirmed the presence of various polyphenols, quantified in the range of 0.02 ± 0.36 to 2.05 ± 0.18 μg/mg extract. Maximum DPPH scavenging activity was expressed by methanolic extract of the stem (MeOH-S). The highest antioxidant capacity and reducing power was shown by MeOH-S and leaf methanolic extract (MeOH-L), respectively. Proficient antibacterial activity was shown by EA-L extract against Bacillus subtilis and Escherichia coli. Remarkable α-amylase and α-glucosidase inhibition potential was expressed by ethyl acetate fruit (EA-F) and n-Hexane leaf (nH-L) extracts, respectively. In case of brine shrimp lethality assay, 41.67% of the extracts (LC₅₀ < 50 µg/mL) were considered as extremely cytotoxic. The test extracts also showed mild antifungal and protein kinase inhibition activities. The present study explores the therapeutic potential of P. roxburghii and calls for subsequent studies to isolate new bioactive leads through bioactivity-guided isolation.

Withaferin A: From Ancient Remedy to Potential Drug Candidate

Withaferin A (WA) is a pivotal withanolide that has conquered a conspicuous place in research, owning to its multidimensional biological properties. It is an abundant constituent in Withania somnifera Dunal. (Ashwagandha, WS) that is one of the prehistoric pivotal remedies in Ayurveda. This article reviews the literature about the pharmacological profile of WA with special emphasis on its anticancer aspect. We reviewed research publications concerning WA through four databases and provided a descriptive analysis of literature without statistical or qualitative analysis. WA has been found as an effective remedy with multifaceted mechanisms and a broad spectrum of pharmacological profiles. It has anticancer, anti-inflammatory, antiherpetic, antifibrotic, antiplatelet, profibrinolytic, immunosuppressive, antipigmentation, antileishmanial, and healing potentials. Evidence for wide pharmacological actions of WA has been established by both in vivo and in vitro studies. Further, the scientific literature accentuates the role of WA harboring a variable therapeutic spectrum for integrative cancer chemoprevention and cure. WA is a modern drug from traditional medicine that is necessary to be advanced to clinical trials for advocating its utility as a commercial drug.

Evaluation of Hepato-protective and Nephron-Protective Potential of Euphorbia nivulia Buch.-Ham. Against Carbon Tetrachloride-induced Toxicity in Sprague Dawley Rats

Background: Euphorbia nivulia Buch.-Ham (En) is one of the members of Euphorbiaceae family that is rich in phytochemicals including flavonoids, triterpenes and polyphenolics. Purpose: To evaluate hepato-nephronprotective potential of Euphorbia nivulia. Study Design: Sprague Dawley rats were used as animal models in the study. Methods: En hydro alcoholic extract was standardized and managed in high dose (300 mgkg−1 body weight (BW) and low dose  (150 mgkg−1 BW) to Sprague Dawley rats, administered with CCl4 (1mlkg−1BW). Silymarin (50 mgkg−1 BW) was taken as positive control. The treatments were given thrice a week. Consequently, blood and hepatic homogenates were collected after 4 weeks of treatment. While the situation of kidney was explored through measurement of serum creatinine, serum urea, sodium and albumin levels. Hepatic and renal samples of rats treated with both 150 and 300 mg/kg of the extract were used for tissue pathological study. Results: En extract revealed dose dependent moderate level of shelter against CCl4 intoxicated hepato-nephrotoxicity as directed from the acquired results. The decrease of the albumin levels by the maximum dose of the extract exceeded similar to that attained with Silymarin, and the protecting effects of the extract against oxidative destruction were evaluated. Examination of serum show significant (p < 0.05) elevation in the level of aspartate transaminase(AST), alkaline phosphatase(ALP), alanine transaminase(ALT), whereas decline were noted for albumin in CCl4 treated rats. Histopathological cuts and damages were seen in hepatic cells and kidney of rats managed by CCl4. But, co-administration of En extract, dose dependently, improved the CCl4-carried hepatic harms in these limits. Conclusion: These effects propose that the phyto-ingredients of En extract with known polyphenols were able to improve the oxidative stress brought along with CCl4 and may be a useful healing mediator to manage oxidative stress related disorders like hepato-nephro toxicity.

Report- Antioxidant, cytotoxicity, protein kinase inhibition and antibacterial activities of Fragaria x ananassa leaves

Fragaria × ananassa leaves extracts prepared in different solvents were subject for antioxidative, cytotoxicity, protein kinase inhibition and antibacterial activities. The extracts showed varying activities depending upon solvent used for extraction. Combined effect of methanol and ethyl acetate showed maximum antioxidant and reducing power potential (207.65±6μg AAE/mg and 88.58±20μg AAE/mg, respectively). Maximum DPPH (2,2-diphenyl-1-picryl hydrazyl) free radical scavenging activity was calculated by when methanol: chloroform and acetate fractions were used (87.68% and 86.88% inhibition, respectively). Total phenolics varied from 186 to 1.91μg AAE/mg while total flavonoids also significantly varied among the extracts. The extracts also showed significant activities against brine shrimp larvae and bacterial strains tested. The study concludes that Fragaria × ananassa leaves can be a good source for isolation of active phytochemicals to be used in different industries.

Numerical solution to generalized Burgers'-Fisher equation using Exp-function method hybridized with heuristic computation

In this paper, a new heuristic scheme for the approximate solution of the generalized Burgers'-Fisher equation is proposed. The scheme is based on the hybridization of Exp-function method with nature inspired algorithm. The given nonlinear partial differential equation (NPDE) through substitution is converted into a nonlinear ordinary differential equation (NODE). The travelling wave solution is approximated by the Exp-function method with unknown parameters. The unknown parameters are estimated by transforming the NODE into an equivalent global error minimization problem by using a fitness function. The popular genetic algorithm (GA) is used to solve the minimization problem, and to achieve the unknown parameters. The proposed scheme is successfully implemented to solve the generalized Burgers'-Fisher equation. The comparison of numerical results with the exact solutions, and the solutions obtained using some traditional methods, including adomian decomposition method (ADM), homotopy perturbation method (HPM), and optimal homotopy asymptotic method (OHAM), show that the suggested scheme is fairly accurate and viable for solving such problems.

Evaluation of antioxidant potential and HPLC based identification of phenolics in Polygonum amplexicaule extract and its fractions

There is a growing interest for the plant-based medicines in pharmaceutical industry. Plant derived Antioxidants have gained huge importance regarding their medicinal value. The present study was designed to establish pharmaceutical value of Polygonum amplexicaule for their antioxidant activity using shoot, leaf and rhizome crude methanolic extract along with their n-butanolic, ethanolic, ethyl acetate and aqueous fractions. DPPH assay was used to assess antioxidants, which shows the maximum activity by crude methanolic extract of leaves (CMEL) having IC(50) 1.03 μg/ml where all other fractions showed IC(50) in a range of 1.03-58.2 μg/mL. The DNA plasmid protection assay showed that 10 ppm and 100 ppm concentrations of crude methanolic extracts (rhizome and leaf), aqueous fractions (shoot and leaf extract), n-butanolic fractions (shoot and leaf extract) and ethanolic fraction (rhizome extract) have DNA protection properties. TLC and HPLC based Identification of different antioxidants present in shoot, leaf and rhizome crude extracts and their fractions showed the presence of gallic acid, quercetin, catechin, caffeic acid, rutin, myricetin and kaempferol. This study suggested that this plant have high content of antioxidants, which needs to be investigated further for their medicinal and/cosmaceutical applications.

Agrobacterium-mediated transformation of tomato with rolB gene results in enhancement of fruit quality and foliar resistance against fungal pathogens

Tomato (Solanum lycopersicum L.) is the second most important cultivated crop next to potato, worldwide. Tomato serves as an important source of antioxidants in human diet. Alternaria solani and Fusarium oxysporum cause early blight and vascular wilt of tomato, respectively, resulting in severe crop losses. The foremost objective of the present study was to generate transgenic tomato plants with rolB gene and evaluate its effect on plant morphology, nutritional contents, yield and resistance against fungal infection. Tomato cv. Rio Grande was transformed via Agrobacterium tumefaciens harbouring rolB gene of Agrobacterium rhizogenes. rolB. Biochemical analyses showed considerable improvement in nutritional quality of transgenic tomato fruits as indicated by 62% increase in lycopene content, 225% in ascorbic acid content, 58% in total phenolics and 26% in free radical scavenging activity. Furthermore, rolB gene significantly improved the defence response of leaves of transgenic plants against two pathogenic fungal strains A. solani and F. oxysporum. Contrarily, transformed plants exhibited altered morphology and reduced fruit yield. In conclusion, rolB gene from A. rhizogenes can be used to generate transgenic tomato with increased nutritional contents of fruits as well as improved foliar tolerance against fungal pathogens.

Mood and motor effects of thalamic deep brain stimulation surgery for essential tremor

PURPOSE

The aim of this study was to evaluate the effects of unilateral and bilateral ventralis intermedius (Vim) deep brain stimulation (DBS) on mood and motor function.

METHODS

Thirty-one consecutive medication refractory patients with essential tremor who underwent unilateral or bilateral Vim DBS at University of Florida and returned for at least 6 -month follow-up completed the Visual Analog Mood (VAMS), the Beck Depression Inventory (BDI), and the Tremor Rating Scale (TRS) before and after surgery. We excluded all patients who were implanted at other institutions.

RESULTS

The tense subscale of the VAMS improved significantly in both the unilateral and bilateral DBS groups (P < 0.001). On the VAMS afraid subscale, only the bilateral group trended toward improvement (P = 0.075). There were no significant changes for either group for the happy, confused, sad, angry, energetic or tired VAMS scores. TRS subscale scores all improved after unilateral and bilateral Vim DBS surgery (P < 0.001).

CONCLUSIONS

Feelings of tenseness, tremor severity and ADLs improved following unilateral or bilateral Vim DBS for ET.

Brain penetration effects of microelectrodes and DBS leads in STN or GPi

OBJECTIVE

To determine how intraoperative microelectrode recordings (MER) and intraoperative lead placement acutely influence tremor, rigidity, and bradykinesia. Secondarily, to evaluate whether the longevity of the MER and lead placement effects were influenced by target location (subthalamic nucleus (STN) or globus pallidus interna (GPi)).

BACKGROUND

Currently most groups who perform deep brain stimulation (DBS) for Parkinson disease (PD) use MER, as well as macrostimulation (test stimulation), to refine DBS lead position. Following MER and/or test stimulation, however, there may be a resultant "collision/implantation" or "microlesion" effect, thought to result from disruption of cells and/or fibres within the penetrated region. These effects have not been carefully quantified.

METHODS

47 consecutive patients with PD undergoing unilateral DBS for PD (STN or GPi DBS) were evaluated. Motor function was measured at six time points with a modified motor Unified Parkinson Disease Rating Scale (UPDRS): (1) preoperatively, (2) immediately after MER, (3) immediately after lead implantation/collision, (4) 4 months following surgery-off medications, on DBS (12 h medication washout), (5) 6 months postoperatively-off medication and off DBS (12 h washout) and (6) 6 months-on medication and off DBS (12 h washout).

RESULTS

Significant improvements in motor scores (p<0.05) (tremor, rigidity, bradykinesia) were observed as a result of MER and lead placement. The improvements were similar in magnitude to what was observed at 4 and 6 months post-DBS following programming and medication optimisation. When washed out (medications and DBS) for 12 h, UPDRS motor scores were still improved compared with preoperative testing. There was a larger improvement in STN compared with GPi following MER (p<0.05) and a trend for significance following lead placement (p<0.08) but long term outcome was similar.

CONCLUSION

This study demonstrated significant acute intraoperative penetration effects resulting from MER and lead placement/collision in PD. Clinicians rating patients in the operating suite should be aware of these effects, and should consider pre- and post-lead placement rating scales prior to activating DBS. The collision/implantation effects were greater intraoperatively with STN compared with GPi, and with greater disease duration there was a larger effect.

Serum hormonal, electrolytes and trace element profiles in the rutting and non-rutting one-humped male camel (Camelus dromedarius)

The camel is known to be a seasonal breeder and, in the male camel, the breeding activity maximizes during the rutting period (winter and spring seasons). During the non-rutting period (summer and autumn), however, the breeding activity almost ceases completely. Serum steroid hormonal, electrolytes and trace element profiles were studied in 16 adult male camels aged 5-9 years, slaughtered during the rutting (n=8) and non-rutting periods (n=8). Moreover, testicular and epididymal tissue contents of electrolytes and trace elements were also studied during these two periods. Serum levels of testosterone, progesterone and T(4):T(3) ratio were higher in the rutting animals when compared to the non-rutting ones, while the reverse was true for serum T(3), T(4) and corticosterone levels (p<0.01). Among minerals, serum levels of sodium, calcium, copper and zinc were higher, while those of potassium were lower, in the rutting than non-rutting camels. In the testicular tissue, the levels of sodium, calcium, copper and iron were higher in the rutting group, while magnesium was higher in non-rutting one. In the epididymis, the tissue levels of chloride, iron and zinc were higher in the rutting than non-rutting period. These results demonstrate a clear evidence of the distribution of steroid hormones, electrolytes and trace elements forming and maintaining a certain level at two different physiological states in camels.

Pakistan's maternal and child health policy: analysis, lessons and the way forward

An estimated 400,000 infant and 16,500 maternal deaths occur annually in Pakistan. These translate into an infant mortality rate and maternal mortality ratio that should be unacceptable to any state. Disease states including communicable diseases and reproductive health (RH) problems, which are largely preventable account for over 50% of the disease burden. The analysis of Pakistan's maternal and child health (MCH) and family planning (FP) policy covers the period 1990-2002, and focuses on macroeconomic influences, priority programs and gaps, adequacy of resources, equity and organizational aspects, and the process of policy formulation. The overall MCH/FP policy is well directed. MCH/FP has been a priority in all policies; resource allocation, although unacceptably low, has substantially increased during the last decade; and there is a progressive shift from MCH to the reproductive health (RH) agenda. Areas in need of improvement include greater use of evidence as a basis for policy; increased priority to nutrition programs, measures to reduce neonatal and perinatal mortality, provision of emergency obstetric care, availability of skilled birth attendants, and a clear policy on integrated management of childhood illnesses. Enhanced planning capacity, development of a balanced human resource, improved governance to reduce staff absenteeism and frequent transfers, and a greater role of the private sector in the provision of services are some organizational aspects that need the governments' consideration. There are several lessons to be learnt: (i) Ministries of Health need sustained stewardship and well-documented evidence to protect cuts in resource allocation; (ii) frequent policy announcement sends inappropriate signals to managers and weakens on-going implementation; (iii) MCH/FP policies unless informed by evidence and participation of interest groups are unlikely to address gaps in programs; (iv) distributional and equity objectives of MCH/FP be addressed while setting overall national goals; (v) institutional capacity is a vital ingredient in translating MCH/FP policies into effective services. The suggested strategic directions emphasize, among others, the need for a comprehensive MCH/FP framework; strengthened stewardship in ministry of health, cost-effective strategies to address the gaps identified and doubling of the public sector resource allocation to MCH/FP over the next 5 years. The ability to ensure delivery of quality health services remains the biggest challenge in the Pakistani health sector. Unless sound policies are backed by well-functioning programs they are likely to become a victim of poor implementation.

Effect of volume of culture medium on enhanced citric acid productivity by a mutant culture of Aspergillus niger in stirred fermentor

AIMS

The present study deals with the effect of volume of culture medium on enhanced citric acid productivity by a mutant culture of Aspergillus niger.

METHODS AND RESULTS

A laboratory scale stirred fermentor of 15-l capacity was employed for all microbial cultivations. Blackstrap molasses, a by-product of sugar industries is easily and abundantly available for its exploitation as a carbon source in fermentation processes. The parental culture of A. niger was improved by mutation using ultraviolet radiations and N-methyl N-nitro N-nitroso guanidine, i.e. mutagen MNNG. Six MUV and eight MNNG-treated mutant strains were isolated after extensive screening and optimization. Mutant strain of A. niger MNNG-2 showed enhanced citric productivity (87.60 g l-1) over the parental strain BTL-45 (19.53 g l-1) and other mutant derivatives (49.85 g l-1 citric acid in case of mutant MUV-5 and 76.82 g l-1 in case of mutant MNNG-7). The optimal sugar level was found to be 150 g l-1 (optimum volume of the medium, 60%) after 6 days of inoculation, which is economically significant. Specific productivity of the mutant culture MNNG-2 (qp = 0.057 g/g cells h-1) was several folds higher than other strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results of the present study are of commercial level. All kinetic parameters including yield coefficients and volumetric rates revealed the hyper-producibility of citric acid by mutant MNNG-2 using blackstrap molasses as the basal medium in stirred fermentor.

Statins for primary prevention: at what coronary risk is safety assured?

AIMS

Increasingly HMG CoA reductase inhibitors (statins) are being used for primary prevention of vascular disease in patients with a raised cholesterol but at low absolute risk of coronary heart disease (CHD). This study uses clinical trial results to explore the limits of absolute safety for statin use in such patients.

METHODS

The major placebo controlled statin outcome trials were identified by automated and manual literature searches. Principal results including all cause mortality in placebo and intervention groups and baseline values of standard coronary risk factors were abstracted for each trial. For the trials identified the reduction in overall mortality with statin treatment for each study was regressed against the underlying CHD risk of the population recruited into that trial using a statistically robust method.

RESULTS

The regression line describing the relationship between mortality benefit and risk suggests that statin use could be associated with an increase in mortality of 1% in 10 years. This would be sufficiently large to negate statin's beneficial effect on CHD mortality in patients with a CHD event risk less than 13% over 10 years.

CONCLUSIONS

Absolute safety of statins has not been demonstrated for patients at low risk of CHD. Patients absolute risk of CHD should be calculated before starting statin treatment for primary prevention. Extensions of such treatment to low risk patients should await further evidence of safety.

Crosstalk between p38, Hsp25 and Akt in spinal motor neurons after sciatic nerve injury

The p38 stress-activated protein kinase pathway is involved in regulation of phosphorylation of Hsp25, which in turn regulates actin filament dynamic in non-neuronal cells. We report that p38, Hsp25 and Akt signaling pathways were specifically activated in spinal motor neurons after sciatic nerve axotomy. The activation of the p38 kinase was required for induction of Hsp25 expression. Furthermore, Hsp25 formed a complex with Akt, a member of PI-3 kinase pathway that prevents neuronal cell death. Together, our observations implicate Hsp25 as a central player in a complex system of signaling that may both promote regeneration of nerve fibers and prevent neuronal cell death in the injured spinal cord.

Population implications of lipid lowering for prevention of coronary heart disease: data from the 1995 Scottish health survey

OBJECTIVE

To determine the proportion of the population, firstly, with cholesterol >/= 5.0 mmol/l and, secondly, with any cholesterol concentration, who might benefit from statin treatment for the following: secondary prevention of coronary heart disease (CHD); primary prevention at CHD risk 30%, 20%, 15%, and 6% over 10 years; and primary prevention at projected CHD risk 20% over 10 years (CHD risk at age 60 years if actual age < 60 years).

SUBJECTS

Random stratified sample of 3963 subjects aged 35-64 years from the Scottish health survey 1995.

RESULTS

For secondary prevention 7.8% (95% confidence interval (CI) 6.9% to 8.6%) of the population with cholesterol >/= 5.0 mmol/l would benefit from statins. For primary prevention, the prevalence of people at CHD risk 30%, 20%, 15%, and 6% over 10 years is 1.5% (95% CI 1.2% to 1.9%), 5.4% (95% CI 4.7% to 6.1%), 9.7% (95% CI 8.8% to 10.6%), and 32.9% (95% CI 31.5% to 34.4%), respectively. At projected CHD risk 20% over 10 years, 12.4% (95% CI 11.4% to 13.5%) would be treated with statins. Removing the 5.0 mmol/l cholesterol threshold makes little difference to population prevalence at high CHD risk.

CONCLUSIONS

Statin treatment would be required for 7.8% of the population for secondary prevention. For primary prevention, among other factors, guidelines should take into account the number of patients needing treatment at different levels of CHD risk when choosing the CHD risk to target. The analysis supports a policy of targeting treatment at CHD risk 30% over 10 years as a minimum, as recommended in current British guidelines, with a move to treating at CHD risk 15% over 10 years as resources permit.

Is coronary risk an accurate surrogate for cardiovascular risk for treatment decisions in mild hypertension? A population validation

OBJECTIVE

To examine the relationship between coronary (CHD) and cardiovascular (CVD) risk in patients with uncomplicated mild hypertension and to determine the accuracy of using CHD risk > or = 15% over 10 years to identify for antihypertensive treatment those patients with CVD risk > or = 20% over 10 years as advised in recent British guidelines.

DESIGN

Comparison of decisions made using CHD risk > or = 15% over 10 years calculated by the Framingham risk function and estimated using a simple table with CVD risk > or = 20% over 10 years.

SETTING

British population.

SUBJECTS

People aged 35-64 years with uncomplicated mild systolic hypertension (SBP 140-159 mmHg, n = 624) from the 1995 Scottish Health Survey.

MAIN OUTCOME MEASURES

Relationship between CHD and CVD risk. Sensitivity, specificity, positive and negative predictive values (PPV and NPV).

RESULTS

CHD risk 15% over 10 years was equivalent to CVD risk 21% over 10 years. Exact CHD risk > or = 15% over 10 years had sensitivity 79%, specificity 98%, PPV 94% and NPV 93% in detecting CVD risk > or = 20% over 10 years. Use of the table to estimate CHD risk > or = 15% over 10 years gave sensitivity 88%, specificity 90%, PPV 76% and NPV 95%.

CONCLUSION

CHD risk appears acceptably accurate for targeting treatment in mild hypertension. The risk assessment table, which slightly overestimates CHD risk, was more sensitive in identifying patients with CVD risk > or = 20% over 10 years and may be preferable to using exact CHD risk. European guidelines which suggest targeting treatment for mild hypertension at CHD risk > or = 20% over 10 years are over-conservative compared with British guidelines.

Solitary fibrous tumour of the spinal cord

We report an intramedullary primary solitary fibrous tumour of the cervical spinal cord in a 33-year-old man. The tumour predominantly consisted of monomorphic spindle cells with a storiform pattern. MRI demonstrated an inhomogeneously enhancing cervical intramedullary tumour. The patient was well without recurrence 18 months after surgery.

Implication of recent trials with b-hydroxy-b-methylglutaryl coenzyme A reductase inhibitors for hypertension management

BACKGROUND

There is broad agreement that statin treatment should be targeted at absolute coronary heart disease (CHD) risk but no consensus on the level of risk to target. We have examined the implications of adopting three different treatment policies for the management of hypertensive patients in the UK using data from treated hypertensives aged 35-69 years included in the Health Survey for England (1993).

METHODS

We calculated the proportion of hypertensive patients with existing atherosclerotic cardiovascular disease requiring statin treatment for secondary prevention of CHD. For those without atherosclerotic cardiovascular disease (primary prevention), we estimated CHD risk from the Framingham equation and examined the proportion with CHD risk exceeding thresholds of 4.5, 3 and 1.5% per year.

RESULTS

Twenty-one percent of treated hypertensives would require statin treatment for secondary prevention of CHD. When the CHD event threshold for statin treatment was set at > or =4.5% per year [equivalent to a number needed to treat (NNT) in 5 years of 13] a further 0.6% of hypertensive patients were identified for treatment; at a threshold of 3.0% per year (NNT = 20) 5.5% of patients were identified for primary prevention; and at a threshold of 1.5% per year (NNT = 40) 28.5% of patients were identified for primary prevention.

CONCLUSIONS

Those needing secondary prevention are first priority for statins and 21% of hypertensive patients will require treatment Formulation of guidelines for primary prevention should take into account the NNT; the proportion of patients targeted for treatment; the cost-effectiveness and the total cost of treatment. Current British guidance will entail treating an additional 5.5% of hypertensive patients for primary prevention and therefore 27% of hypertensive patients.

Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment

OBJECTIVES

To estimate the cost effectiveness of statin treatment in preventing coronary heart disease (CHD) and to examine the effect of the CHD risk level targeted and the cost of statins on the cost effectiveness of treatment.

DESIGN

Cohort life table method using data from outcome trials.

MAIN OUTCOME MEASURES

The cost per life year gained for lifelong statin treatment at annual CHD event risks of 4.5% (secondary prevention) and 3.0%, 2.0%, and 1.5% (all primary prevention), with the cost of statins varied from pound 100 to pound 800 per year.

RESULTS

The costs per life year gained according to annual CHD event risk were: for 4.5%, pound 5100; 3.0%, pound 8200; 2.0%, pound 10 700; and 1.5%, pound 12 500. Reducing the cost of statins increases cost effectiveness, and narrows the difference in cost effectiveness across the range of CHD event risks.

CONCLUSIONS

At current prices statin treatment for secondary prevention, and for primary prevention at a CHD event risk 3.0% per year, is as cost effective as many treatments in wide use. Primary prevention at lower CHD event risks (< 3.0% per year) is less cost effective and unlikely to be affordable at current prices and levels of health service funding. As the cost of statins falls, primary prevention at lower risk levels becomes more cost effective. However, the large volume of treatment needed will remain a major problem.

Prediction of coronary risk for primary prevention of coronary heart disease: a comparison of methods

Most recent guidelines advise targeting of lipid lowering for primary prevention at those at high absolute coronary (CHD) risk. We compared the accuracy of five CHD risk assessment methods in identifying such patients: one based on total cholesterol > or = 6.5 mmol/l plus two risk factors, and four based on the Framingham risk function (the European Task Force chart and Sheffield table, both using total cholesterol and the New Zealand chart and modified Sheffield table, both using total: HDL cholesterol ratio) for predicting CHD event risk > or = 2% per year, calculated by an independent risk function, PROCAM, in 126 treated hypertensive men. Cholesterol threshold plus two risk factors had sensitivity 59% and specificity 63%, did not identify some very high-risk patients, and identified very low-risk patients. Framingham-based methods using total cholesterol alone had sensitivity 90-98% and specificity 37-43%, and identified high-risk patients well, but identified some patients at very low risk. Methods based on total: HDL cholesterol ratio had sensitivity 90-98% and specificity 60-63%, and did not identify incorrectly patients at very low CHD risk. Methods based on cholesterol threshold and counting of risk factors are too inaccurate for targeting drug therapy for primary prevention of CHD. Framingham-based methods should incorporate HDL-cholesterol as the total: HDL cholesterol ratio.

Is the Framingham risk function valid for northern European populations? A comparison of methods for estimating absolute coronary risk in high risk men

OBJECTIVE

To examine the validity of estimates of coronary heart disease (CHD) risk by the Framingham risk function, for European populations.

DESIGN

Comparison of CHD risk estimates for individuals derived from the Framingham, prospective cardiovascular Münster (PROCAM), Dundee, and British regional heart (BRHS) risk functions.

SETTING

Sheffield Hypertension Clinic. Patients-206 consecutive hypertensive men aged 35-75 years without preexisting vascular disease.

RESULTS

There was close agreement among the Framingham, PROCAM, and Dundee risk functions for average CHD risk. For individuals the best correlation was between Framingham and PROCAM, both of which use high density lipoprotein (HDL) cholesterol. When Framingham was used to target a CHD event rate > 3% per year, it identified men with mean CHD risk by PROCAM of 4.6% per year and all had CHD event risks > 1.5% per year. Men at lower risk by Framingham had a mean CHD risk by PROCAM of 1.5% per year, with 16% having a CHD event risk > 3.0% per year. BRHS risk function estimates of CHD risk were fourfold lower than those for the other three risk functions, but with moderate correlations, suggesting an important systematic error.

CONCLUSION

There is close agreement between the Framingham, PROCAM, and Dundee risk functions as regards average CHD risk, and moderate agreement for estimates within individuals. Taking PROCAM as the external standard, the Framingham function separates high and low CHD risk groups and is acceptably accurate for northern European populations, at least in men.

Sheffield risk and treatment table for cholesterol lowering for primary prevention of coronary heart disease

When used for the secondary prevention of coronary heart disease, treatment with an inhibitor of hydroxymethylglutaryl-coenzyme-A reductase results in worthwhile benefit that clearly exceeds any risk in patients whose risk of coronary death is 1.5% or more per year. This evidence can be extrapolated logically to primary prevention of coronary disease provided that treatment is targeted at those with similar or higher risk. We present a table that refines previously proposed methods of risk prediction. The table identifies subjects who have the specified degree of coronary risk; shows the serum cholesterol concentration that confers that degree or risk in the individual; and identifies subjects who will not have this degree of risk, irrespective of their cholesterol concentration. It is simple enough for use in ordinary practice. The table highlights the predominant effect of age on coronary risk; a person who is free of vascular disease and younger than 52 years is unlikely to have the specified degree of risk. Even in older people (60-70 years) several risk factors are generally required to attain this degree of risk. Some people are candidates for lipid- lowering drug treatment with serum cholesterol as low as 5.5 mmol/L, whereas others with cholesterol as high as 9.0 mmol/L are not. Although cholesterol lowering is a powerful method for preventing coronary events in people at high risk, cholesterol measurement by itself is not a good way to identify those with high coronary risk. The method can be adapted readily to target a different level of coronary risk as new evidence on the benefit and risk of treatment becomes available.

Might non-pharmacological treatment disadvantage patients with hypertension?

Weight reduction, moderate salt restriction and alcohol reduction are effective in lowering blood pressure (BP), and are feasible interventions for long-term management of hypertension. When used in combination these non-pharmacological measures are significantly inferior to drug therapy in anti-hypertensive effect. When they are implemented as a first step in the treatment of mild hypertension, resorting to drug therapy only if non-pharmacological measures fail, anti-hypertensive drugs can be avoided in about 40% of patients. However, BP control is again significantly inferior with this strategy compared with drug therapy without non-pharmacological advice. Those given advice on non-pharmacological measures may therefore have suboptimal protection against cardiovascular complications. This is particularly so when the threshold for drug treatment is set at a DBP of > or = 100 mmHg, as many patients will be left untreated with DBPs between 90 and 99 mm Hg as a result of non-pharmacological measures. Non-pharmacological treatment may thus stand between patients and anti-hypertensive drug therapy, which nowadays is simple, well-tolerated, safe and proven effective in preventing cardiovascular disease. The role of non-pharmacological therapy needs to be reconsidered.

Should cholesterol be measured in all hypertensives?

Guidelines for the management of hypertension, and those for hyperlipidaemia, advocate measurement of cholesterol in all hypertensive subjects. It is suggested that knowledge of serum cholesterol should influence the choice of anti-hypertensive agent because thiazides and beta-blockers may influence lipids adversely. However, the changes in lipids associated with low-dose thiazides and beta-blockers are small, not sustained and do not appear to affect prognosis adversely. Some believe that knowledge of serum cholesterol may help target the treatment of mild hypertension more accurately by predicting an increased risk of vascular complications of hypertension. However, serum cholesterol does not predict the risk of cardiovascular complications in hypertensive women. It does predict coronary heart disease (but not stroke) in men, but coronary risk can be estimated satisfactorily without knowledge of serum cholesterol. Suggestions that cholesterol should be lowered in hypercholesterolaemic hypertensive patients to reduce the incidence of coronary heart disease are understandable. However, the diet recommended for this has no useful effect on serum cholesterol, and the benefit of lipid-lowering drugs for cholesterol reduction only exceeds the risk in patients at very high risk of coronary mortality, for example those who have had a myocardial infarction. Hypertension alone will not place individuals at high enough risk to warrant drug therapy for cholesterol reduction. We conclude that the current guidelines are incorrect, and that routine measurement of cholesterol in all hypertensive patients is not justified.

Cryodestruction of haemorrhoids

Thirty-seven cases of second and third degree haemorrhoids have been treated by cryosurgery. Although the number of cases treated is small and the follow-up is short, we are greatly encouraged by the early excellent results. It is a simple and effective procedure with minimal complications, and it is especially recommended for those patients who are medically unfit for general anaesthesia. The rapidity of this procedure combined with the painless operative and postoperative course enables the patient to leave hospital the next day. More cases with long-term follow-up are needed before adequate evaluation of this form of treatment can be made.