Outcomes of Desidustat Treatment in People with Anemia and Chronic Kidney Disease: A Phase 2 Study

BACKGROUND

Desidustat (ZYAN1) is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) that stimulates erythropoiesis. Stabilizing HIF via PHI is developing as a new therapeutic approach to treat anemia secondary to chronic kidney disease (CKD). This trial evaluated the safety, tolerability, and efficacy of Desidustat in adult CKD patients with anemia, who were not on dialysis.

METHODS

This was a Phase 2, randomized, double-blind, 6-week, placebo-controlled, dose-ranging, safety and efficacy study. A total of 117 eligible patients were randomized to 4 arms: 100, 150, 200 mg, or placebo. The investigational product was administered every alternate day for 6 weeks in fasting conditions. The primary endpoint was change in hemoglobin (Hb) from baseline to week 6.

RESULTS

Baseline demographics were well balanced among all the treatment arms. In the modified intent-to-treat (mITT) population, a mean Hb increase of 1.57, 2.22, and 2.92 g/dL in Desidustat 100, 150, and 200 mg arms, respectively, was observed post 6 weeks treatment. The responder rate (≥1 g/dL increase) was 66% in 100 mg, 75% in 150 mg, and 83% in 200 mg treatment arms, in the mITT population. Eighteen patients had at least one treatment emergent adverse event (TEAE), and 5 patients reported at least one drug-related mild TEAE. No death or serious adverse event was reported during the trial.

CONCLUSION

There was dose-related increase in Hb across all doses compared to placebo in mITT and per-protocol populations. Desidustat also increased pharmacokinetic parameters Cmax and AUC in dose-related manner. There was no significant change in vital signs, electrocardiographic parameters, or safety laboratory values. Clinical Trial Registration Number CTRI/2017/05/008534 (registered on May 11, 2017).

Detection of evoked acetylcholine release in mouse brain slices

The study of transmitter interactions in reward and motor pathways in the brain, including the striatum, requires methodology to detect stimulus-driven neurotransmitter release events. Such methods exist for dopamine, and have contributed to the understanding of local and behavioral factors that regulate dopamine release. However, factors that regulate release of another key transmitter in these pathways, acetylcholine (ACh), are unresolved, in part because of limited temporal and spatial resolution of current detection methods. We have optimized a voltammetric method for detection of local stimulus-evoked ACh release using enzyme-coated carbon-fiber microelectrodes and fast-scan cyclic voltammetry. These electrodes are based on the detection of H₂O₂ generated by the actions of acetylcholine esterase and choline oxidase, and reliably respond to ACh in a concentration-dependent manner. Methods for enzyme coating were optimized for mechanical stability that allowed for their use in ex vivo brain slices. We report here the first quantitative assessment of extracellular ACh concentration after local electrical stimulation in dorsal striatum in slices from control mice. The selective detection of ACh under these conditions was confirmed by showing that the response detected in the control slices was absent in slices from mice bred to lack ACh synthesis in the forebrain. These electrodes represent a new tool to study ACh and ACh-dopamine interactions with micrometer spatial resolution.

Anemia Offers Stronger Protection Than Sickle Cell Trait Against the Erythrocytic Stage of Falciparum Malaria and This Protection Is Reversed by Iron Supplementation

Background

Iron deficiency causes long-term adverse consequences for children and is the most common nutritional deficiency worldwide. Observational studies suggest that iron deficiency anemia protects against Plasmodium falciparum malaria and several intervention trials have indicated that iron supplementation increases malaria risk through unknown mechanism(s). This poses a major challenge for health policy. We investigated how anemia inhibits blood stage malaria infection and how iron supplementation abrogates this protection.

Methods

This observational cohort study occurred in a malaria-endemic region where sickle-cell trait is also common. We studied fresh RBCs from anemic children (135 children; age 6–24 months; hemoglobin < 11 g/dl) participating in an iron supplementation trial (ISRCTN registry, number ISRCTN07210906) in which they received iron (12 mg/day) as part of a micronutrient powder for 84 days. Children donated RBCs at baseline, Day 49, and Day 84 for use in flow cytometry-based in vitro growth and invasion assays with P. falciparum laboratory and field strains. In vitro parasite growth in subject RBCs was the primary endpoint.

Findings

Anemia substantially reduced the invasion and growth of both laboratory and field strains of P. falciparum in vitro (~ 10% growth reduction per standard deviation shift in hemoglobin). The population level impact against erythrocytic stage malaria was 15.9% from anemia compared to 3.5% for sickle-cell trait. Parasite growth was 2.4 fold higher after 49 days of iron supplementation relative to baseline (p < 0.001), paralleling increases in erythropoiesis.

Interpretation

These results confirm and quantify a plausible mechanism by which anemia protects African children against falciparum malaria, an effect that is substantially greater than the protection offered by sickle-cell trait. Iron supplementation completely reversed the observed protection and hence should be accompanied by malaria prophylaxis. Lower hemoglobin levels typically seen in populations of African descent may reflect past genetic selection by malaria.

Funding

National Institute of Child Health and Development, Bill and Melinda Gates Foundation, UK Medical Research Council (MRC) and Department for International Development (DFID) under the MRC/DFID Concordat.

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P. falciparum laboratory and field strains invade and grow less efficiently in RBCs from anemic children.

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Deficits in invasion and growth for erythrocytic stage P. falciparum are reversed when RBCs are used from anemic children receiving iron supplementation for 49 and 84 days.

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The population level impact of protection against malaria from anemia was greater than that for sickle-cell trait.

The long-term consequences of anemia are severe, and it is easily treatable. However, concerns remain about the safety of iron supplements, particularly for children in malaria-endemic countries lacking adequate access to health services. We used RBCs from Gambian children before, during, and after 12 weeks of daily iron supplementation for in vitro P. falciparum assays. P. falciparum invasion and growth was decreased in anemic RBCs and increased after 49 days of iron supplementation relative to baseline (p < 0.001), paralleling increases in young RBCs, which the parasite prefers. The parasite growth protection from anemia was substantial, providing greater population level impact than sickle-cell trait.

Cntnap4 differentially contributes to GABAergic and dopaminergic synaptic transmission

Although considerable evidence suggests that the chemical synapse is a lynchpin underlying affective disorders, how molecular insults differentially affect specific synaptic connections remains poorly understood. For instance, Neurexin 1a and 2 (NRXN1 and NRXN2) and CNTNAP2 (also known as CASPR2), all members of the neurexin superfamily of transmembrane molecules, have been implicated in neuropsychiatric disorders. However, their loss leads to deficits that have been best characterized with regard to their effect on excitatory cells. Notably, other disease-associated genes such as BDNF and ERBB4 implicate specific interneuron synapses in psychiatric disorders. Consistent with this, cortical interneuron dysfunction has been linked to epilepsy, schizophrenia and autism. Using a microarray screen that focused upon synapse-associated molecules, we identified Cntnap4 (contactin associated protein-like 4, also known as Caspr4) as highly enriched in developing murine interneurons. In this study we show that Cntnap4 is localized presynaptically and its loss leads to a reduction in the output of cortical parvalbumin (PV)-positive GABAergic (γ-aminobutyric acid producing) basket cells. Paradoxically, the loss of Cntnap4 augments midbrain dopaminergic release in the nucleus accumbens. In Cntnap4 mutant mice, synaptic defects in these disease-relevant neuronal populations are mirrored by sensory-motor gating and grooming endophenotypes; these symptoms could be pharmacologically reversed, providing promise for therapeutic intervention in psychiatric disorders.

Neuromuscular blocking effect of fluoxetine and its interaction with rocuronium

As selective serotonin reuptake inhibitors have an inhibitory effect on nicotinic acetylcholine receptors, they may affect the neuromuscular transmission and interact with neuromuscular blockers. This study was designed to observe the effect of fluoxetine on neuromuscular transmission and its interaction with rocuronium using the rat phrenic nerve hemidiaphragm and rabbit head drop methods. Rat phrenic nerve hemidiaphragms were mounted and stimulated using a train of four pulses (TOF). The effect of fluoxetine was studied on both indirectly and directly stimulated basal twitch responses by plotting cumulative dose response curves (DRCs). DRCs of rocuronium were obtained in the absence, and presence of 5 μm and 20 μm fluoxetine to study its interaction. ED5 , ED50 and ED95 values of rocuronium DRCs in absence and presence of fluoxetine were calculated. Fluoxetine significantly inhibited twitch responses in both indirect and directly stimulated preparations. Fluoxetine (20 μm) caused an increase in the potency of rocuronium such that the ED50 and ED95 values of rocuronium DRCs were significantly decreased. Partially inhibited twitch responses by fluoxetine (100 μm) were not reversed by neostigmine (3.3 μm) or 3,4 diaminopyridine (0.25 μm). Rabbits were given fluoxetine 0.25 mg kg(-1) and 1 mg kg(-1) orally for 15 days, and on 15th day, rocuronium infusion was given, and time for head drop was recorded. The time of head drop was significantly reduced in fluoxetine pretreated as compared to control group. Fluoxetine blocks the neuromuscular transmission and increases the potency of rocuronium-induced neuromuscular block.

Dopamine release in the basal ganglia

Dopamine (DA) is a key transmitter in the basal ganglia, yet DA transmission does not conform to several aspects of the classic synaptic doctrine. Axonal DA release occurs through vesicular exocytosis and is action potential- and Ca²⁺-dependent. However, in addition to axonal release, DA neurons in midbrain exhibit somatodendritic release by an incompletely understood, but apparently exocytotic, mechanism. Even in striatum, axonal release sites are controversial, with evidence for DA varicosities that lack postsynaptic specialization, and largely extrasynaptic DA receptors and transporters. Moreover, DA release is often assumed to reflect a global response to a population of activities in midbrain DA neurons, whether tonic or phasic, with precise timing and specificity of action governed by other basal ganglia circuits. This view has been reinforced by anatomical evidence showing dense axonal DA arbors throughout striatum, and a lattice network formed by DA axons and glutamatergic input from cortex and thalamus. Nonetheless, localized DA transients are seen in vivo using voltammetric methods with high spatial and temporal resolution. Mechanistic studies using similar methods in vitro have revealed local regulation of DA release by other transmitters and modulators, as well as by proteins known to be disrupted in Parkinson's disease and other movement disorders. Notably, the actions of most other striatal transmitters on DA release also do not conform to the synaptic doctrine, with the absence of direct synaptic contacts for glutamate, GABA, and acetylcholine (ACh) on striatal DA axons. Overall, the findings reviewed here indicate that DA signaling in the basal ganglia is sculpted by cooperation between the timing and pattern of DA input and those of local regulatory factors.

Immunocytochemical identification of proteins involved in dopamine release from the somatodendritic compartment of nigral dopaminergic neurons

We examined the somatodendritic compartment of nigral dopaminergic neurons by immunocytochemistry and confocal microscopy, with the aim of identifying proteins that participate in dopamine packaging and release. Nigral dopaminergic neurons were identified by location, cellular features and tyrosine hydroxylase immunoreactivity. Immunoreactive puncta of vesicular monoamine transporter type 2 and proton ATPase, both involved in the packaging of dopamine for release, were located primarily in dopaminergic cell bodies, but were absent in distal dopaminergic dendrites. Many presynaptic proteins associated with transmitter release at fast synapses were absent in nigral dopaminergic neurons, including synaptotagmin 1, syntaxin1, synaptic vesicle proteins 2a and 2b, synaptophysin and synaptobrevin 1 (VAMP 1). On the other hand, syntaxin 3, synaptobrevin 2 (VAMP 2) and SNAP-25-immunoreactivities were found in dopaminergic somata and dendrites Our data imply that the storage and exocytosis of dopamine from the somatodendritic compartment of nigral dopaminergic neurons is mechanistically distinct from transmitter release at axon terminals utilizing amino acid neurotransmitters.

Sinus of Valsalva fistula with quadricuspid aortic valve, a first reported association

Quadricuspid aortic valve and sinus of Valsalva fistula are rare congenital anomalies. We report the first case of association of these two congenital anomalies in an adult patient and the important role of Magnetic Resonance Imaging (MRI) in establishing and confirming the correct diagnosis and helping in planning the treatment.

Masquerade: a malignant arrhythmia masquerading as benign

Pseudoatrial flutter has been reported to have benign causes, but this is the first report of a malignant arrhythmia presenting as a benign arrhythmia. An 82 year old patient presented with ventricular tachycardia and electrical artefact appearing as atrial flutter. In this case, comparing the morphology of the QRS complexes in the rhythm strip with those in lead II showed the arrhythmia to be ventricular in origin and points to the importance of comparing all leads of the ECG before arriving at a diagnosis.

Follow up of 318 cases of diabetes mellitus

Ignorance, apathy, desire to get free advice, investigation and treatment is prevalent in diabetics. Most diabetics (69.63%) are uncontrolled whether on diet, single oral drug or combination of oral drugs or insulin. Ischemic heart disease was commonest complication. Neuritis was present in the one fourth of the followed up cases and was more prevalent in uncontrolled cases. Hypertension increases with the duration of diabetes and was twice more prevalent after duration of more than 5 years. Eye changes were present in about 50% of the people examined. Abnormality increases with the duration of diabetes.

GERD like symptoms as seen in a village

Twenty cases of protozoal infection presented with symptoms suggesting GERD. Treatment with antacids and H2 blockers was unsuccessful in giving them relief. As they had also protozoal infection, treatment with anti-protozoal drugs gave them complete relief in the follow up period of one year after the end of treatment. Hence we have named these conditions simulating peptic ulcer GERD as pseodogerd or protozoal GERD. It is suggested that the person presenting with the symptoms of GERD in our area should be investigated for protozoal infection or should be given treatment of protozoal infection rather than that of peptic ulcers. It is also suggested that the length of treatment of protozoal infection should not be less than one month and not for three or 7 days as suggested in western text books.

Cirrhosis of liver with ascites treatment based on principles of ayurved

A case of ascites with cirrhosis of liver due to chronic malaria and nutritional deficiency was treated with 20 ml of imferron with improvement and is alive for a period of six years after first treatment with iron.

Pediatric cervical spine injuries: defining the disease

BACKGROUND/PURPOSE

Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate.

METHODS

All children with cervical spine injury entered into the National Pediatric Trauma Registry over a consecutive 10-year period were identified. Patients were stratified by age, mortality, presence or absence of bony injury, level of cervical spine injury, and presence of neurologic deficit. Data were analyzed utilizing Student's t test for continuous variables and chi(2) analysis for categorical variables. Statistical significance was accepted at the P less than .05 level.

RESULTS

From a database of 75,172 injured children, 1,098 were identified with cervical spine injury, overall incidence 1.5%. The mean age of the study group was 11 +/- 5 years, and 61% were boys. Nine hundred eight children (83%) had bony spine injury. Distribution of bony injury among upper cervical spine, lower cervical spine, or both was 52%, 28%, and 7%, respectively. The remaining 13% comprised unspecified levels of injury. Upper cervical spine injuries were prevalent among all age groups (42%, age < or = 8; 58%, age > 8), whereas lower spine injuries predominated in older children (85%, age > 8). One third of children in the study group had neurologic injury, and half of these had no radiographic evidence of bony injury. Ninety-four children (24%) had a complete cord injury, and the remaining 76% had an incomplete spinal cord injury. One hundred eleven children (23%) with upper spine injury died compared with 11 children (4%) with lower spine injury. Mortality rate was highest (48%) in those with atlanto-occipital dislocation.

CONCLUSIONS

From this, the largest experience with pediatric cervical spine injury, several conclusions can be drawn. (1) Cervical spine injury occurs in 1.5% of injured children. (2) Upper cervical spine injuries are not limited to younger children but are equally prevalent in both age groups. (3) Associated mortality rate is nearly 6-fold higher in patients with upper cervical injury. (4) Seventeen percent of children with cervical spine trauma show no radiologic anomaly, yet 50% of children with cervical spinal cord injury have no initial radiologic abnormalities. (5) Of those in whom cervical spine injury is associated with a neurologic deficit, the deficit is complete in 24% of children.

Obesity. Effective and safe management

Rapidly rising prevalence of weight in Indians in cities and upper strata of society in villages and towns is a problem of health in India. It also adds substantially to future morbidity and mortality and will increase the health costs. It is a public health problem. In other countries it is a national problem. It increase cost of treatment of the nation. It is individual matter in India. Hence the treatment of chronic diseases like hypertension diabetes, hyperlipidemia is not being effectively carried out in India due to burden of cost of treatment on individual. Lack of education and funds prevent continuous treatment. It is problem of education of public and a support from authorities. Those who are aware should not neglect their own health. Prevention of obesity should be the goal in life.

Nosocomial pneumonia in the pediatric trauma patient: a single center's experience

OBJECTIVES

To evaluate a single center's experience with the frequency rate, patterns of occurrence, and impact on outcome of nosocomial pneumonia in the critically injured child.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Level I university trauma center with a pediatric trauma intensive care unit.

PATIENTS

A total of 523 consecutive critically injured children admitted to the pediatric intensive care unit during an 80-month interval.

MEASUREMENTS AND RESULTS

Thirty-five episodes of nosocomial pneumonia were identified in 29 children (frequency rate of 5.5%). The mean age of the children was 9.2 yrs, and the mean Injury Severity Score was 27 +/- 9. In 91% of patients (26 children), nosocomial pneumonia was associated with mechanical ventilation. This represented a 13% frequency rate in injured children who were ventilated during the study period. The most common organisms recovered were Staphylococcus aureus (21%), Haemophilus influenzae (19%), Pseudomonas (11%), and Enterobacter (11%). Early pneumonia (diagnosed < or = 7 days after injury) was predominantly caused by Haemophilus species. In contrast, Enterobacter and/or Pseudomonas were isolated primarily in late pneumonia (diagnosed >7 days after injury). Staphylococcus was prominent throughout the hospitalization. Overall, children with nosocomial pneumonia were more severely injured (Injury Severity Score 27 vs. 17, p < .001) and had a longer hospital stay (26 vs. 7 days, p < .001). Despite this, mortality (6.9% vs. 7.9%, p = NS) was not significantly different from injured children without pneumonia.

CONCLUSIONS

In this study of a single pediatric trauma center, nosocomial pneumonia occurred in a small but significant percentage of injured children. The frequency rate increased two- to three-fold with mechanical ventilation. Microbiology varied with day of onset. In contrast to the adult, mortality did not seem to be significantly altered by this complication. Analysis of additional pediatric trauma centers is encouraged to confirm these characteristics of nosocomial pneumonia in the injured child.

Prevalence of hypertension in Mumbai

There are few reports on prevalence of hypertension in India. We are presenting a study of its incidence in OPD of hospital patients in Mumbai. Prevalence of hypertension was 7.82% in all subjects, however, it was higher in females 10.5% than in males 6.1%.

Infectious complications in critically injured children

PURPOSE

Infection will complicate the care of a significant number of injured adults. Trauma is the leading cause of mortality in the pediatric population, yet little information is available regarding the incidence of infection in this group. This study evaluates infectious complications in the critically injured child.

METHODS

All children admitted to the pediatric intensive care unit from an urban level-1 trauma center during an 80-consecutive-month period were studied. Infection was defined by Centers for Disease Control criteria and was identified by a retrospective review of the medical records. Demographic and clinical information, including microbiologic data, were compiled for all study patients. Data were analyzed using Student's (t)test or chi2 analysis where appropriate.

RESULTS

Five hundred twenty-three children were at risk for infection during the study period. Seventy-eight infections were documented in 53 children (incidence, 10.1%). Nosocomial infections accounted for 78% of these with a majority (85%) being device associated. Common infections in this group included lower respiratory (n = 35), primary bloodstream (n = 10), and urinary tract (n = 7). Trauma-related infections were primarily wound (n = 9), intraabdominal (n = 3), or central nervous system (n = 3). Bacterial pathogens predominated, and the most frequent microorganisms recovered were Staphylococcus aureus, Pseudomonas sp, and Haemophilus sp. Children with infectious complications were more severely injured (injury severity score [ISS] 24 versus 17, P < .001) and had a longer hospital stay (21 days v 6 days, P < .001) compared with children without infection during the same period. Overall mortality rate for the study group was 5.7% and was not significantly different from children without infection.

CONCLUSIONS

Infection is a significant source of morbidity in the critically injured child. Nosocomial infections predominate, and a majority of these are device related, emphasizing the need for continued vigilance toward prevention in this high-risk group.

Falls in elderly

Falls are common in elderly. They cause morbidily, mortality and financial hardship. They can be prevented with minimum cost. All steps should be taken. Remove the cause or causes as far as it is possible in the environment.

Hypertension in elderly

Treatment of hypertension is necessary to prevent morbidity i.e. complications and early mortality. Adherence to the treatment is imperative. Education of the patient is a must on the part of the physician. Continuous regular treatment is economical than that of its complications.

Pharmacomechanical thrombolysis with use of the brush catheter in canine thrombosed femoropopliteal arterial PTFE bypass grafts

PURPOSE

To assess the efficacy, acute endothelial changes, and distal arterial emboli after use of the Cragg thrombolytic brush catheter in mature thrombosed polytetrafluoroethylene (PTFE) femoropopliteal arterial grafts in canines.

MATERIALS AND METHODS

PTFE femoropopliteal arterial grafts were implanted in 10 canines and were allowed to mature for approximately 4 weeks. The grafts were thrombosed by mechanical means and allowed to remain thrombosed for 24-72 hours. Through a left carotid cut-down, standard Seldinger arterial puncture was performed, followed by catheterization of the thrombosed graft. A soft, low-speed, brush (6 mm in diameter) aided by preprocedure pulse-spray urokinase infusion was utilized for thrombolysis. The native vessels, just proximal and distal to the anastomosis, were evaluated microscopically for endothelial damage. Arteriography was used for assessment of distal embolus.

RESULTS

All grafts were successfully thrombosed before thrombolysis. One graft could not be traversed with a wire and catheter and was, therefore, not treated. Immediate preprocedure pulse-spray urokinase infusion in the remaining nine grafts did not reconstitute antegrade flow in any instance and left significant amounts of residual thrombus in all treated grafts. Mechanical brush thrombolysis reconstituted antegrade flow in all nine treated grafts and complete graft thrombolysis was obtained in most. This was accomplished in a mean time of less than 4 minutes. Emboli were noted angiographically in 67% of cases. Histologic studies showed vessel wall damage limited to the intima or media in 67% of anastomoses.

CONCLUSION

This method offers a simple and rapid means of recanalizing thrombosed PTFE femoropopliteal arterial grafts in the studied model. This technique provides a means of rapidly "debulking" most intragraft thrombi. This may result in a shorter course of thrombolytic infusion. Potential benefits may include shortening the total treatment time and decreasing morbidity and cost associated with percutaneous thrombolysis. The occurrence of distal emboli in a majority of cases is a concerning limitation of this technique.

Levels of lactic acid, normal level & its relation to food, glucose, cholesterol, raised blood urea and phenformin therapy

1. The level of lactic acid was found to be 25 mg percent in 95 percent of 186 normal Indians. There was no difference due to sex and age. 2. Level of lactic acid was estimated in blood of normal persons and diabetics Type II patients to observe the effects of food and glucose. There was no change except the level of lactic acid was in higher but in normal range. 3. Hyperglycemia of over 300 mg raised the blood lactic acid in 25 percent of patients. 4. Lactic acid was not affected by hypercholesteremia but was raised in 60 percent of cases with raised blood urea. 5. Lactic acid was found to remain within normal limits in 48 type II diabetics treated with phenformin dose varying from 50 mg to 225 mg per day. The duration of treatment varied from one year to seven years.

Can the surface electrocardiogram be used to predict myocardial viability?

OBJECTIVE

To investigate whether QRS morphology on the surface ECG can be used to predict myocardial viability.

DESIGN

ECGs of 58 patients with left ventricular impairment undergoing positron emission tomography (PET) were studied. (13)N-Ammonia (NH(3)) and (18)F-fluorodeoxyglucose (FDG) were the perfusion and the metabolic markers, respectively. The myocardium is scarred when the uptake of both markers is reduced (matched defect). Reduced NH(3) uptake with persistent FDG uptake (mismatched defect) represents hibernating myocardium. First, the relation between pathological Q waves and myocardial scarring was investigated. Second, the significance of QR and QS complexes in predicting hibernating myocardium was determined.

RESULTS

As a marker of matched PET defects, Q waves were specific (79%) but not sensitive (41%), with a 77% positive predictive accuracy and a poor (43%) negative predictive accuracy. The mean size of the matched PET defect associated with Q waves was 20% of the left ventricle. This was not significantly different from the size of the matched PET defects associated with no Q waves (18%). Among the regions associated with Q waves on the ECG, there were 16 regions with QR pattern (group A) and 23 regions with QS pattern (group B). The incidence of mismatched PET defects was 19% of group A and 30% of group B (NS).

CONCLUSIONS

Q waves are specific but not sensitive markers of matched defects representing scarred myocardium. Q waves followed by R waves are not more likely to be associated with hibernating myocardium than QS complexes.

Tetanus: study of 8,697 cases

Records of 8,697 cases of tetanus seen over a period of 14 years are analysed. Overall mortality was 48.0%. Mortality in neonatal group was 86.38% whereas that in non-neonatal group it was 40.18%. Disease was seen more frequently in male than in female. Mortality in male was lower than in female. Incidence was highest in the first decade of life. Mortality was lowest (about 33%) in first two decades (excluding neonatal group). Mortality in neonatal group was highest (86.38%). Mortality was inversely related to length of incubation period. In cases with incubation period of 7 days or less, mortality was 58.26% in non-neonates and 94.15% in neonates. Mortality was very low (2.14%) in 2,100 cases who did not develop spasms. In cases with spasms mortality was inversely related to the length of period of onset. Temperature of 100 degrees F within first 24 hours of admission was an adverse factor and these cases had higher mortality. Cases were divided into five grades according to the severity. Mortality in each grade was significantly different from that in the other. Mortality was lower in otogenic tetanus while it was higher in post-abortion and post-injection tetanus. Tetanus following penetrating injury carried higher mortality whereas tetanus following abrasions had lower mortality. With head and face as the site of infection, mortality was low while it was high when the site of infection was a trunk. Results were similar with dose of A.T.S. ranging between 5,000 and 60,000 i.u. and tetanus immune globulin, whereas mortality was high with higher and lower dose of A.T.S. or with no A.T.S. Respiratory spasms, respiratory failure, respiratory complications and circulatory failure were the common causes of death.

The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children

PURPOSE

Focused abdominal sonography for trauma (FAST) is rapidly gaining acceptance as an effective and accurate way to determine significant abdominal injury. The authors analyzed their experience in 94 children with blunt torso trauma (BTT) to assess FAST accuracy in identifying operative lesions and utility in avoiding additional diagnostic studies.

METHODS

The authors' pediatric trauma registry was queried to identify all children with BTT who underwent FAST as part of their initial trauma assessment. Accuracy was determined by calculating sensitivity and specificity using as true positives those children with lesions requiring operative intervention. Utility was analyzed by reviewing the need for additional diagnostic or therapeutic intervention in those patients with negative FAST findings and negative clinical examination findings.

RESULTS

Three of these 94 children had lesions that required laparotomy. One was FAST positive (sensitivity, 33.3%). One of two FAST-negative patients was a child in extremis from a suspected thoracic aortic disruption, and the other was a child with an intestinal disruption in whom peritoneal signs developed 24 hours after injury. Of 89 FAST-negative children, 20 underwent abdominal computed tomography (CT) at the surgeon's request. Eight of these patients were found to have minor visceral injury that required no further treatment. The remaining 69 included the child with the aortic disruption and 68 patients whose hospital course was uneventful and required no additional intervention.

CONCLUSIONS

From the practical perspective of indicating need for operative intervention in BTT, FAST has a high specificity (95%); however, it is not particularly sensitive (33%). This excellent specificity in combination with clinical examination underscores FAST utility by avoiding unnecessary diagnostic intervention in 72% of the patients in this study.

Prevalence of hibernating myocardium in patients with severely impaired ischaemic left ventricles

OBJECTIVE

Severe impairment of left ventricular (LV) contraction is associated with an adverse prognosis in patients with ischaemic heart disease. Revascularisation may improve the impaired LV contraction if hibernating myocardium is present. The proportion of patients likely to benefit from this intervention is unknown. Therefore, the prevalence of hibernating myocardium in patients with ischaemic heart disease and severe impairment of LV contraction was assessed.

DESIGN

From a consecutive series of patients undergoing coronary angiography for the investigation of chest pain or LV impairment, all patients with ischaemic heart disease and an LV ejection fraction (LVEF) < or = 30% were identified. These patients underwent positron emission tomography (PET) to detect hibernating myocardium, identified by perfusion metabolism mismatch.

SETTING

A teaching hospital directly serving 500,000 people.

RESULTS

Of a total of 301 patients, 36 had ischaemic heart disease and an LVEF < or = 30%. Twenty-seven patients had PET images, while nine patients were not imaged because of emergency revascularisation (three), loss to follow up (one), inability to give consent (four), and age < 50 years (one, ethics committee guidelines). Imaged and non-imaged groups were similar in LV impairment, demographic characteristics, and risk factor profile. Fourteen patients (52% of the imaged or 39% of all patients with ischaemic heart disease and LVEF < or = 30%) had significant areas of hibernating myocardium on PET.

CONCLUSION

It is possible that up to 50% of patients with ischaemic heart disease and severely impaired left ventricles have hibernating myocardium.

New thrombolytic brush catheter in thrombosed polytetrafluoroethylene dialysis grafts: preclinical animal study

PURPOSE

To assess the safety, efficacy, endothelial changes, and risks of pulmonary embolic events after the use of a new thrombolytic brush catheter in mature thrombosed polytetrafluoroethylene (PTFE) dialysis grafts in an animal model.

MATERIALS AND METHODS

Loop configuration PTFE grafts were implanted in the femoral vessels of 12 canines 4 weeks before mechanical thrombosis was performed. The thrombus was allowed to consolidate for 24 hours in 10 animals, 72 hours in one animal, and 7 days in one animal. Standard percutaneous criss-cross catheter access was performed, and a soft, low-speed, brush (6 mm in diameter), aided by 250,000 U of periprocedural urokinase, was utilized for thrombolysis. The native vessels, just distal to the anastomosis, and lungs were evaluated macro- and microscopically.

RESULTS

Thrombolysis was complete in all grafts with the exception of a small segment between the crossing of the access vascular sheaths. The total thrombolysis time ranged from 8 to 12 minutes; this included 5 minutes of pulse-spray lacing. No difference in thrombolysis time was found with regard to the age or amount of thrombus. Minimal endothelial changes were noted and no evidence of acute pulmonary embolus was found on necropsy or histologic studies.

CONCLUSION

This method offers a simple, safe, and efficient means of recanalization of thrombosed PTFE dialysis grafts in this canine model.

Neonatal necrotizing enterocolitis: the long-term perspective

Ten years' experience with neonatal necrotizing enterocolitis (NNEC) was reviewed retrospectively to determine long-term survival and quality of life and to analyze risk factors associated with in-hospital mortality. Institutional records were queried to identify all neonates who required emergent surgical intervention for NNEC. These records were then reviewed and survivors' families interviewed by phone to determine patient status, persistent gastrointestinal problems, and overall quality of life. Once identified, long-term survivors (LTSs) were compared to in-hospital deaths by the analysis of birth weight, gestational age, time interval from birth to diagnosis, indications for laparotomy, and extent of intestinal involvement. Between 1986 and 1996, 69 patients required surgical intervention for NNEC. Eleven patients were lost to follow-up. Of the remaining 58 patients, 31 were ultimately discharged home, with 28 patients having survived an average of 4.18 years. The acute, or in-hospital, mortality rate was 39.1 per cent. Infants who died did so within an average of 23 days postoperatively, and those who were discharged home required an average of 121 days of inpatient convalescence. Twenty-one of the 28 LTSs achieved a normal quality of life with no persistent health problems. One patient required a hepatic-intestinal transplant, and another six had minor problems with frequent diarrhea. Average birth weight, age at NNEC diagnosis, and gestational age were not significantly different between LTSs and those with acute deaths. Aggressive in-hospital care is warranted for infants with NNEC. The excellent quality of life achieved in 75 per cent of survivors implies that the expense of heroic surgical care for these seriously ill premature infants is a worthwhile investment.

Relationship of trauma patient volume to outcome experience: can a relationship be defined?

OBJECTIVES

Five years experience recorded in a multi-institutional pediatric trauma registry was analyzed to define the relationship between case volume and outcome as measured by mortality.

METHODS

A total of 30,930 records with complete data were categorized by contributing hospital. Patients with fatal injury as indicated by an injury severity score of 75 or any abbreviated injury scale of 6 were excluded. Each center's experience was stratified by injury severity using injury severity score > or = 15 as indicative of severe injury. Centers were then classified as low volume (LV, 100-500 cases), mid volume (MV, 501-1,000 cases), or high volume (HV, > 1,000 cases). Proportion of patients with severe injury (injury severity score > 15) and mortality were compared among groups using the chi(2) test with significance accepted at p < 0.05. Using the Pediatric Risk Indicator to adjust for mortality risk, the combined hospital experience of each volume group was further analyzed to assess performance with specific levels of increasing injury severity.

RESULTS

Findings demonstrated a trend of increasing mortality with increasing volume, despite a consistent proportion of severe injury. Risk adjusted mortality for each volume class indicates best outcome in the mid level group.

CONCLUSIONS

Regardless of overall volume of patients encountered, there is a consistent proportion of severe injury. The increasing mortality with the most severe injuries seen in the high volume centers may reflect overdemand on resources.

Percutaneous transthoracic needle biopsy of the lung: review of 612 lesions

PURPOSE

The results and complications of 651 pulmonary fine-needle aspiration biopsies (FNABs) were reviewed. The number of needle passes and needle size were correlated to pneumothorax and chest tube placement rates.

MATERIALS AND METHODS

FNAB of the lung was performed on 651 occasions in 612 patients with 18- to 22-gauge Franseen needles. Diagnostic rates were calculated. The number of needle passes performed and needle size used were evaluated for their association with pneumothorax and subsequent chest tube placement.

RESULTS

Diagnostic accuracy was 94% with sensitivity for malignancy of 95%. Positive and negative predictive values were 99.5% and 90%, respectively. Pneumothorax occurred in 26.9% of patients with 9.2% requiring chest tube placement. Increasing numbers of needle passes and larger needle sizes did not increase the rates of pneumothorax or chest tube placement.

CONCLUSIONS

FNAB of the lung has excellent diagnostic rates and remains the procedure of choice for diagnosing pulmonary lesions. This large study contradicts perceptions that pneumothorax and chest tube placement rates decrease with thinner needles and fewer passes.

A survey of the effectiveness of the assessment of the welfare of the child in UK in-vitro fertilization units

Seventy-one clinics in the UK offering in-vitro fertilization (IVF) treatment were surveyed for their protocols on the assessment of the welfare of the children produced. A total of 44 (62%) responded. Of these, five (12%) did not have operational protocols, seven (16%) declined to provide their protocols, and 32 (73%) provided information used in the survey. The information was in the form of a protocol for only 16 (50%) of these clinics. The remaining clinics submitted as their 'protocols' letters to general practitioners, patient information, patient questionnaires and/or a copy of their policy on the assessment of child welfare. From the submitted material, it was possible to determine that 94% of clinics seek information on aspects of child welfare assessment, 78% have a procedure for making further enquiries where there is any cause for concern, 44 % include counselling opportunities explicitly in protocols, 30-38% of clinics see a full medical and social history from each prospective parent as part of the child welfare assessment, 16% include explicit consideration of the impact of multiple births on the welfare of the child, and 3% include consideration of the issue of disclosure of the mode of conception of the child on its welfare. Most clinics did not have clearly defined procedures on how to reach a decision on whether or not to treat. Eight clinics (25%) made explicit in their protocols any exclusion criteria. It is concluded that clinics are not currently producing completely effective protocols. Two possible reasons for this are considered: lack of technical knowledge about what constitutes an effective protocol, and lack of clear policy development and propagation underlying protocols within clinics. Possible approaches to improving the situation are considered.

Heat shock increases the association of binding protein-1 with initiation factor 4E

The effects of heat shock on the regulation of the cap-binding initiation factor 4E (eIF4E) and its inhibitory binding protein, 4E-BP1, have been examined in Chinese hamster ovary cells and in cardiac myocytes. Heat shock increased the association between eIF4E and 4E-BP1, and this was associated with a dephosphorylation of 4E-BP1. These effects did not appear to be due wholly to decreased activity of the p70 S6 kinase pathway, which is implicated in the control of 4E-BP1, and they were not mediated by the stress-activated p38 microtubule-associated protein kinase pathway. Increased binding of 4E-BP1 to eIF4E correlated with a decrease in the amount of eIF4G which co-purified with the latter. This could account for the previously observed impairment of eIF4F function during heat shock, and, since heat shock protein mRNAs are believed to be relatively cap-independent, could provide a mechanism for the selective up-regulation of the synthesis of heat shock proteins and other stress proteins during heat shock.

[Gallstone ileus: plea for simultaneous treatment of obstruction and gallstone disease]

All patients with gallstone ileus admitted to our institution between 1985 and 1995, were retrospectively analysed, to determine, whether a one stage procedure (removal of impacted gallstone, fistula repair and cholecystectomy) is a more valid option than enterotomy. There were 10 patients (8 women, 2 men) in the study group (age range: 63-86 ans), representing 3.7% of small bowel obstruction and 1.4% of patients who underwent biliary surgery during the same period. Bowel occlusion was present in 8 patients and a correct preoperative diagnosis was made in only 2 cases (20%). Eight patients had a one-stage procedure, with no mortality but complications occurred in 2 cases. Enterotomy was the only surgical treatment in 2 cases, with no morbidity. During follow-up period, one patient died 3 years after enterotomy from a biliary complication. We believe that a one-step procedure, is a valid option and should be undertaken to prevent future recurrence, later biliary complications and reoperations in these elderly patients, who have serious concomitant diseases.

Peptide substrates suitable for assaying glycogen synthase kinase-3 in crude cell extracts

In this study we describe the characterization and use of new peptide substrates for assaying glycogen synthase kinase-3 (GSK-3) which are based on the sequence around the single GSK-3 phosphorylation site in the translation factor eIF2B. The new peptides offer important advantages over previous substrates, which were based on the sequence around the multiple GSK-3 phosphorylation sites in glycogen synthase (GS), for the assay of GSK-3 in cell extracts. In particular, decreases in GSK-3 activity following, e.g., insulin treatment, are partially or completely masked when the GS-based peptides are used but are readily measured using the new, eIF2B-based, peptides. The new peptides, unlike those based on GS, are therefore suitable for the assay of changes in GSK-3 activity in cell extracts without the need for prior immunoprecipitation or ion-exchange chromatography.