Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial

BACKGROUND AND PURPOSE

Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size.

MATERIALS AND METHODS

Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group.

RESULTS

We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor.

CONCLUSIONS

The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.

Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement

BACKGROUND AND PURPOSE

There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement.

MATERIALS AND METHODS

We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback.

RESULTS

A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period.

CONCLUSIONS

More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.

Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI Consensus Statement

BACKGROUND AND PURPOSE

There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies.

MATERIALS AND METHODS

The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society.

RESULTS

Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure.

CONCLUSIONS

More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.

Screening of Different Extracts of Marine Macro Green Algae for Larvicidal Activity against Dengue Fever Mosquito, <i>Aedes aegypti</i> (Diptera: Culiadae)

The present study larvicidal activities of hexane, chloroform, ethyl acetate, acetone and methanol extracts of Halimeda macroloba, Decsne, Caulerpa racemosa (Frosk) Weber-Van-Bosses and Ulva lactuca Lin, (Chlorophyceae) against Aedes aegypti. The marine macro green algae extracts were tested against early 4th instar larvae of A. aegypti using WHO protocol and concentrations of 200, 400, 600, 800 and 1000 ppm. The observed mortality was made 24 and 48 h after treatment, data was subjected to probit analysis to determine the lethal concentration (LC50 and LC90) of the treated larvae of the tested species.Among the tested extracts the maximum efficicacy was observed in the ethyl acetate extracts. The ethyl acetate extracts of the seaweeds showed the presence of terpenoids, tannins and phenolic compounds stronger than the other extracts. The results revealed that all the extracts showed varied levels of larvicidal activity against A. aegypti tested. However, the ethyl acetate extract of C. racemosa showed remarkable larvicidal activity against A. aegypti (LC50=579.9 and LC90=1255.4 ppm values at 24 h and LC50 =495.4 and LC90 =1073.9 ppm at 48 h) followed by U. lactuca (LC50=588.1 and LC90=1290.7 ppm values at 24 h, and LC50= 530.8 and LC90= 1160.0 ppm at 48 h), respectively. The lowest larval mortality was observed with hexane extract of H. macroloba against A. aegypti with values of LC50=1116.8 and LC90= 1824.5 ppm (after 24 h) and LC50=1059.9 and LC90=1768.3 ppm (after 24 h). The present studies indicate that the larvicidal activity and phytochemicals derived from the ethyl acetate extract of C. racemosa have the potential to be used as an ideal eco-friendly approach and effective mosquito vector control agent.

Screening of Different Extracts of Marine Macro Green Algae for Larvicidal Activity against Dengue Fever Mosquito, <i>Aedes aegypti</i> (Diptera: Culiadae)

The present study larvicidal activities of hexane, chloroform, ethyl acetate, acetone and methanol extracts of Halimeda macroloba, Decsne, Caulerpa racemosa (Frosk) Weber-Van-Bosses and Ulva lactuca Lin, (Chlorophyceae) against Aedes aegypti. The marine macro green algae extracts were tested against early 4th instar larvae of A. aegypti using WHO protocol and concentrations of 200, 400, 600, 800 and 1000 ppm. The observed mortality was made 24 and 48 h after treatment, data was subjected to probit analysis to determine the lethal concentration (LC50 and LC90) of the treated larvae of the tested species.Among the tested extracts the maximum efficicacy was observed in the ethyl acetate extracts. The ethyl acetate extracts of the seaweeds showed the presence of terpenoids, tannins and phenolic compounds stronger than the other extracts. The results revealed that all the extracts showed varied levels of larvicidal activity against A. aegypti tested. However, the ethyl acetate extract of C. racemosa showed remarkable larvicidal activity against A. aegypti (LC50=579.9 and LC90=1255.4 ppm values at 24 h and LC50 =495.4 and LC90 =1073.9 ppm at 48 h) followed by U. lactuca (LC50=588.1 and LC90=1290.7 ppm values at 24 h, and LC50= 530.8 and LC90= 1160.0 ppm at 48 h), respectively. The lowest larval mortality was observed with hexane extract of H. macroloba against A. aegypti with values of LC50=1116.8 and LC90= 1824.5 ppm (after 24 h) and LC50=1059.9 and LC90=1768.3 ppm (after 24 h). The present studies indicate that the larvicidal activity and phytochemicals derived from the ethyl acetate extract of C. racemosa have the potential to be used as an ideal eco-friendly approach and effective mosquito vector control agent.

Genetic selection pressure in TLR9 gene may enforce risk for SLE in Indian Tamils

Objectives Lupus is a classical systemic autoimmune disease with genetics as one of the well known causative factors for the disease pathogenesis. Toll-like receptors are the major pattern recognition receptors associated with innate immunity and also act as an interface with the adaptive immunity. Genetic polymorphisms in genes encoding TLRs were implicated in the development of infections, malignancies and autoimmune diseases. TLR9 is a member of TLR family, and recognizes the CpG DNA motifs of pathogens. Though the incidence rate of lupus in Asians was reported to be low (30 - 50/100,000 population), poor disease prognosis due to higher incidence of renal complications and aggressive disease worsens the scenario. The ability of TLR9 to detect and elicit an immune response against double-stranded DNA makes TLR9 a relevant factor to be tested for its association with the clinical and serological phenotypes of lupus. However, lack of relevant genetic data on normative frequencies of the TLR9 (rs187084) polymorphism may serve as a constraint to derive the sample size to conduct case control association studies. Hence this study was conducted to establish the normative frequency of TLR9 (rs187084) polymorphism in Indian Tamils. Materials and methods The TLR9 (rs187084) polymorphism was screened in South Indian Tamils ( n = 208) by PCR-RFLP. Results and discussion We observed a higher occurrence of the mutant allele (65%) in South Indian Tamils. No gender disparity with respect to the mutant allele frequency was observed. The higher incidence of mutant allele in both genders suggests that this population had undergone a genetic selection pressure as an evolutionary genetic measure to withstand the prevailing endemic infections like TB and malaria. Though the enhanced expression of TLR9 was protective against infections, it may also influence the development of autoimmune diseases. Conclusion The higher incidence of theTLR9 (rs187084) over-expression mutation in Indian Tamils is suggestive of a genetic adaptation or selection pressure to withstand the prevailing endemic infectious and parasitic diseases. However, this genetic adaptation poses a greater risk to develop autoimmune diseases like SLE etc through complex gene environment interactions. The normative frequency of the TLR9 (rs187084) polymorphism established in our population could now be used to define the sample size for future case control studies.

Evaluation of some aromatic plant extracts for mosquito larvicidal potential against Culex quinquefasciatus, Aedes aegypti, and Anopheles stephensi

In the present investigation, larvicidal potential of hexane, choloroform, ethyl acetate, acetone, and methanol extracts of seven aromatic plants, viz., Blumea mollis, Chloroxylon swietenia, Clausena anisata, Feronia limnonia, Lantana camera, Plectranthus amboinicus, and Tagetes erecta were screened against Culex quinquefasciatus, Aedes aegypti, and Anopheles stephensi. The larval mortality was observed after 12 and 24 h of exposure period. The results revealed that all the extracts showed varied levels of larvicidal activity against the mosquito species tested. However, the ethyl acetate extract of Chloroxylon swietenia showed the remarkable larvicidal activity against C. quinquefasciatus, Ae. aegypti, and An. stephensi. After 12 h of exposure period, the larvicidal activity was LC50 = 194.22 and LC90 = 458.83 ppm (C. quinquefasciatus), LC50 = 173.04 and LC90 = 442.73 ppm (Ae. aegypti), and LC50 = 167.28 and LC90 = 433.07 ppm (An. stephensi), and the larvicidal activity after 24-h exposure period was LC50 = 94.12 and LC90 = 249.83 ppm (C. quinquefasciatus), LC50 = 80.58 and LC90 = 200.96 ppm (Ae. aegypti), and LC50 = 76.24 and LC90 = 194.51 ppm (An. stephensi). The larvicidal potential of other plant extracts were in order of ethyl acetate extract of Clausena anisata > methanol extract of P. amboinicus > acetone extract of F. limonia > methanol extract of T. erecta > methanol extract of B. mollis > and methanol extract of L. camera. The results of the present study offer a possible way for further investigations to find out the active molecule responsible for the activity.

Direct costs associated with chronic kidney disease among type 2 diabetic patients in India

The aim of this study was to estimate the direct costs of medical care among hospitalized type 2 diabetic patients with chronic kidney disease (CKD). A total of 209 (M:F, 133:76) patients were divided into groups based on the severity of kidney disease. Group 1 subjects had undergone renal transplantation (n = 12), group 2 was CKD patients on hemodialysis (n = 45), group 3 was patients with CKD, prior to end-stage renal disease (ESRD) (n = 66), and group 4 (n = 86) consisted of subjects without any complications. Details about expenditure per hospitalization, length of stay during admission, direct medical and nonmedical cost, expenditure for the previous two years, and source of bearing the expenditure were recorded in a questionnaire. Diabetic patients with CKD prior to ESRD spend more per hospitalization than patients without any complications. [Median ₹ 12,664 vs. 3,214]. The total median cost of CKD patients on hemodialysis was significantly higher than other CKD patients (INR 61,170 vs. 12,664). The median cost involved in kidney transplantation was ₹ 392,920. The total expenditure for hospital admissions in two years was significantly higher for dialysis than transplantation. Patients on hemodialysis or kidney transplantation tend to stay longer as inpatient admissions. The source of funds for the expenditure was mainly personal savings (46%). The expenditure on hospital admissions for CKD was considerably higher, and so, there is a need to develop a protocol on a cost-effective strategy for the treatment of CKD.

Endovascular therapy of acute ischemic stroke: report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery

OBJECTIVE

To summarize and classify the evidence for the use of endovascular techniques in the treatment of patients with acute ischemic stroke.

METHODS

Recommendations previously published by the American Heart Association (AHA) (Guidelines for the early management of adults with ischemic stroke (Circulation 2007) and Scientific statement indications for the performance of intracranial endovascular neurointerventional procedures (Circulation 2009)) were vetted and used as a foundation for the current process. Building on this foundation, a critical review of the literature was performed to evaluate evidence supporting the endovascular treatment of acute ischemic stroke. The assessment was based on guidelines for evidence based medicine proposed by the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM). Procedural safety, technical efficacy and impact on patient outcomes were specifically examined.

Postnatal induction and localization of R7BP, a membrane-anchoring protein for regulator of G protein signaling 7 family-Gbeta5 complexes in brain

Members of the regulator of G protein signaling 7 (RGS7) (R7) family and Gbeta5 form obligate heterodimers that are expressed predominantly in the nervous system. R7-Gbeta5 heterodimers are GTPase-activating proteins (GAPs) specific for Gi/o-class Galpha subunits, which mediate phototransduction in retina and the action of many modulatory G protein-coupled receptors (GPCRs) in brain. Here we have focused on the R7-family binding protein (R7BP), a recently identified palmitoylated protein that can bind R7-Gbeta5 complexes and is hypothesized to control the intracellular localization and function of the resultant heterotrimeric complexes. We show that: 1) R7-Gbeta5 complexes are obligate binding partners for R7BP in brain because they co-immunoprecipitate and exhibit similar expression patterns. Furthermore, R7BP and R7 protein accumulation in vivo requires Gbeta5. 2) Expression of R7BP in Neuro2A cells at levels approximating those in brain recruits endogenous RGS7-Gbeta5 complexes to the plasma membrane. 3) R7BP immunoreactivity in brain concentrates in neuronal soma, dendrites, spines or unmyelinated axons, and is absent or low in glia, myelinated axons, or axon terminals. 4) RGS7-Gbeta5-R7BP complexes in brain extracts associate inefficiently with detergent-resistant lipid raft fractions with or without G protein activation. 5) R7BP and Gbeta5 protein levels are upregulated strikingly during the first 2-3 weeks of postnatal brain development. Accordingly, we suggest that R7-Gbeta5-R7BP complexes in the mouse or rat could regulate signaling by modulatory Gi/o-coupled GPCRs in the developing and adult nervous systems.

Synthesis of 6- and 7- hydroxy-8-azabicyclo[3.2.1]octanes and their binding affinity for the dopamine and serotonin transporters

Cocaine is a potent stimulant of the central nervous system. Its reinforcing and stimulant effects are related to its ability to inhibit the membrane bound dopamine transporter (DAT). Inhibition of the DAT causes an increase of dopamine in the synapse with a resultant activation of postsynaptic receptors. The rapid onset and short duration of action of cocaine contribute to its high addictive potential. Consequently, the design of tropane analogues of cocaine that display longer onset times on the DAT and extended duration of action is driven by the need to develop cocaine medication. This study extends the exploration of bridge hydroxylated azabicyclo[3.2.1]octanes (tropanes). A series of 6- and 7-hydroxylated tropanes was prepared and evaluated biologically. Structure activity relationships lead to the following conclusions. Bridge hydroxylated tropanes retain biological enantioselectivity but display higher DAT versus SERT selectivity, particularly for the 3 alpha-aryl compounds as compared with the 3beta-aryl compounds, than the bridge unsubstituted analogues. The 7-hydroxyl compounds are more potent at the DAT than their 6-hydroxyl counterparts. The general SAR of the tropanes is maintained and the rank order of potencies based on substitution at the C3 position remains 3,4-dichloro > 2-naphthyl > 4-fluoro > phenyl.

Association between ACE gene polymorphism and diabetic nephropathy in South Indian patients

OBJECTIVE

To study the association of ACE gene polymorphism and diabetic nephropathy in South Indian subjects.

SETTING

Outpatient clinic of a specialized hospital.

PATIENTS

The study included 109 South Indian type 2 diabetic patients (72 males and 37 females; age 56.7 plus/minus 9.0 years, mean plus/minus SD). The patients were subdivided into two groups: nephropathic (n=86) and normoalbuminuric patients (n=23).

INTERVENTIONS

Genomic DNA was isolated from the peripheral blood leukocytes. To determine the ACE genotype, genomic DNA was amplified by PCR initially using a flanking primer pair and, subsequently when necessary, with a primer pair that recognizes the insertion specific sequence for confirmation of the specificity of the amplification reactions.

MAIN OUTCOME MEASURES

ACE genotype distribution in the two study groups.

RESULTS

In the nephropathic patients, ID and DD genotypes were present in 52.3% and 27.9% of the patients, respectively as compared to 34.8% and 21.7% respectively in those with normoalbuminuria. The D allele was present in 80.2% of the nephropathic patients and 56.5% of the normoalbuminuric patients (chi-squared=4.28, P=0.039; odds ratio 3.12). Therefore, the higher percentage of II genotype in the normoalbuminuric group was 43.5% as compared to the 19.8% in nephropathic patients.

CONCLUSIONS

This study showed a positive association between the D allele (ID and DD genotype) of the ACE polymorphism and diabetic proteinuria in South Indian type 2 diabetic patients. Our findings are in keeping with several earlier studies showing a strong association of the D allele of the ACE gene with diabetic nephropathy.

Tufted angioma in a case of neurofibromatosis type I

Tufted angiomas are rare benign tumours with a characteristic histopathological appearance. Their occurrence in neurofibromatosis type 1, a genodermatosis in which vascular malformations are not uncommon, has hitherto not been reported. Some of the characteristic features of tufted angiomas are discussed.

Interface dermatitis in a patient with AIDS

Interface dermatitis is a histological reaction pattern which is seen in a number of conditions. One of the recent associations of the histology is in Acquired Immune Deficiency Syndrome. There are differentiating factors between interface dermatitis occurring in AIDS and those occurring in other conditions. These are discussed in detail.

Synthesis of new indeno[1,2-c]isoquinolines: cytotoxic non-camptothecin topoisomerase I inhibitors

In an attempt to design and synthesize potential anticancer agents acting by inhibition of topoisomerase I (top1), a new series of indenoisoquinolines was prepared and tested for cytotoxicity in human cancer cell cultures and for activity against top1. The synthesis relied on the condensation of substituted Schiff bases with homophthalic anhydrides to produce cis-3-aryl-4-carboxyisoquinolones that were cyclized to indenoisoquinolines in the presence of thionyl chloride. Both top1 inhibitory activity and cytotoxicity maximized in a single compound, 6-[3-(2-hydroxyethyl)aminopropyl]-5,6-dihydro-2,3-dimethoxy-8, 9-methylenedioxy-5,11-dioxo-11H-indeno[1,2-c]isoquinoline hydrochloride (19a), which proved to be a very potent top1 inhibitor having a 110 nM mean graph midpoint (MGM) when tested for cytotoxicity in 55 human cancer cell cultures. A number of structurally related indenoisoquinolines were also obtained that had both potent cytotoxicity as well as top1 inhibitory activity. The key feature of the more potent compounds was the presence of an aminoalkyl side chain on the indenoisoquinoline nitrogen atom. The DNA cleavage patterns induced by top1 in the presence of the indenoisoquinolines were different from those seen with camptothecin. Some of the cleavage sites induced by the indenoisoquinolines were different from those seen with camptothecin, and conversely, camptothecin induced unique cleavage sites not apparent with the indenoisoquinolines. However, both camptothecin and the indenoisoquinolines also induced DNA cleavage sites that were the same in both series but varied in intensity. In addition, some of the DNA cleavages seen with the free base of 19a (compound 18c) in the presence of top1 were inhibited at higher drug concentrations, suggesting either a direct inhibition of the enzyme or an alternative mechanism involving DNA intercalation. Consistent with intercalation, compound 18c did unwind DNA.

Epidermolysis bullosa pruriginosa

Epidermolysis bullosa pruriginosa is a recently described variant of epidermolysis bullosa dystrophica. It is characterised by pruritic nodular prurigo like lesions, milia and with a histopathology of a subepidermal blister. We report 3 cases of this new variant.

Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs

BACKGROUND

In response to the dramatic emergence of resistant pneumococci, more judicious use of antibiotics has been advocated. Physician beliefs, their prescribing practices, and the attitudes of patients have been evaluated previously in separate studies.

METHODS

This 3-part study included a statewide mailed survey, office chart reviews, and parent telephone interviews. We compared survey responses of 366 licensed pediatricians and family physicians in Georgia to recently published recommendations on diagnosis and treatment of upper respiratory infections (URIs). We further evaluated 25 randomly selected pediatricians from 119 surveyed in the Atlanta metropolitan area. For each, charts from the first 30 patients between the ages of 12 and 72 months seen on a randomly selected date were reviewed for encounters during the preceding year. A sample of parents from each practice were interviewed by telephone.

RESULTS

In the survey, physicians agreed that overuse of antibiotics is a major factor contributing to the development of antibiotic resistance (97%), and that they should consider selective pressure for resistance in their decisions on providing antibiotic treatment for URIs in children in their practices (83%). However, many reported practices do not conform to the recently published principles for judicious antibiotic use. For example, 69% of physicians considered purulent rhinitis a diagnostic finding for sinusitis; 86% prescribed antibiotics for bronchitis regardless of the duration of cough; and 42% prescribed antibiotics for the common cold. Reported practices by family physicians were more often at odds with the published principles: they were significantly more likely than pediatricians to omit pneumatic otoscopy (46% vs 25%); to omit the requirement for prolonged symptoms to diagnose sinusitis (median 4 vs 10 days); and to omit laboratory testing for pharyngitis (27% vs 14%). Of the 7531 encounters analyzed in the chart review, 43% resulted in an antibiotic prescription, including 11% of checkups, 18% of telephone calls, and 72% of visits for URIs. There was wide variability in the overall antibiotic use rates among the 25 physicians (1-10 courses per child per year). There was an even wider variability in some diagnosis-specific rates; bronchitis and sinusitis in particular. Those with the highest antibiotic prescribing rates had up to 30% more return office visits. Physicians who prescribed antibiotics for purulent rhinitis were more likely to see parents who believed that their children should be evaluated for cold symptoms.

CONCLUSIONS

Physicians recognize the problem of antibiotic resistance but their reported practices are not in line with recently published recommendations for most pediatric URIs. The actual prescribing practices of pediatricians are often considerably different from their close colleagues. Patient beliefs are correlated with their own physician's practices.

Synthesis of cytotoxic indenoisoquinoline topoisomerase I poisons

A number of indenoisoquinolines were prepared and evaluated for cytotoxicity in human cancer cell cultures and for activity vs topoisomerase 1 (top1). The two most cytotoxic indenoisoquinolines proved to be cis-6-ethyl-5,6,12,13-tetrahydro-2,3-dimethoxy-8, 9-(methylenedioxy)-5,11-dioxo-11H-indeno[1,2-c]isoquinoline (21) and cis-6-allyl-5,6,12,13-tetrahydro-2,3-dimethoxy-8, 9-(methylenedioxy)-5,11-dioxo-11H-indeno[1,2-c]isoquinoline (22), both of which displayed submicromolar mean graph midpoints when tested in 55 human cancer cell cultures. Two of the most potent top1 inhibitors were 6-(3-carboxy-1-propyl)-5,6-dihydro-5, 11-dioxo-11H-indeno[1,2-c]isoquinoline (26) and 6-ethyl-2, 3-dimethoxy-8,9-(methylenedioxy)-11H-indeno[1,2-c]isoquinolinium chloride (27), both of which also inhibited top2, unwound DNA, and are assumed to be DNA intercalators. However, two additional potent top1 inhibitors, 6-allyl-5,6-dihydro-2,3-dimethoxy-8, 9-(methylenedioxy)-5,11-dioxo-11H-indeno[1,2-c]isoquinoline (13c) and 5,6-dihydro-6-(4-hydroxybut-1-yl)-2,3-dimethoxy-8, 9-methylenedioxy-5,11-dioxo-11H-indeno[1,2-c]isoquinoline (19a), did not unwind DNA and did not affect top2. Some of the DNA cleavage sites detected in the presence of the indenoisoquinolines were different from those seen with the camptothecins. The cleavage sites induced by the indenoisoquinolines were reversed by salt treatment, which is consistent with the reversible trapping of top1 cleavable complexes by the indenoisoquinolines. In general, the potencies of the indenoisoquinolines as top1 inhibitors did not correlate with their potencies as cytotoxic agents, as some of the most cytotoxic agents had little if any effect on top1. On the other hand, the most potent of the indenoisoquinolines vs top1 were not the most cytotoxic. In several cases, moderate activity was observed for both cytotoxicity and activity vs top1.

Cardio vascular morbidity in proteinuric south Indian NIDDM patients

Proteinuria is a well known risk factor for cardiovascular morbidity. There has been no report on cardiovascular morbidity in Indian NIDDM patients with proteinuria. Hence this study has been undertaken to estimate the prevalence of cardiovascular diseases (CVD) in South Indian NIDDM with proteinuria. We studied two groups of NIDDM patients with diabetes for > or = 5 years: group PR with persistent proteinuria of > 500 mg/day (n = 297) and group NPR with normoalbuminuria (albuminuria < or = 30 micrograms/mg creatinine)(n = 296), who reported for review during the study period. They were matched for age, duration of diabetes and BMI. The prevalence of cardiovascular diseases, namely myocardial infarction, the presence of ischaemic heart disease and the history of coronary bypass surgery were compared in the two groups. The prevalence of hypertension was higher among the PR than the NPR patients (56.5 vs 24.7%, chi 2 = 61.3, P < 0.01). CVD were detected in 39.2% (n = 116) of the PR and 13.2% (n = 39) of the NPR groups. (chi 2 = 54.85, P < 0.001). The risk was thus three-fold higher in the PR group. Univariate analysis showed that in the proteinuric group, the prevalence of complications was higher in association with hypertension (45.8% vs 30.2%, chi 2 = 6.82, P = 0.009). Multiple logistic regression analysis showed that the factors associated with CVD were proteinuria (odds ratio 5.03), age (OR 1.08) and BMI (OR 1.07) while sex, age at onset of diabetes, duration of diabetes, hypertension, smoking, HbA1, serum creatinine, cholesterol and triglycerides did not show independent contribution. The study, highlights the high risk conferred by macroproteinuria in Indian NIDDM patients. This risk is found to be independent of the presence of associated hypertension.

Malignant blue nevus

Blue nevus represents an aberrant collection of functioning benign dermal melanocytes. Its malignant degeneration is rare and is regarded as a form of malignant melanoma. We report a case of 35-year old male with this rare condition whose primary lesion over left foot ulcerated and patient later succumbed to multiple metastases.

Acantholytic dyskeratotic epidermal naevus

A 43-year old male presented with unilateral warty papular eruptions of 20 years duration, involving the left side of trunk, left upper and lower limbs. There were also whitish macules intermingled with them. Histological features were compatible with Darier's disease. There was no evidence of any family history or palmar pits and nail changes typical of Darier's disease. We are reporting this case as acantholytic dyskeratotic epidermal naevus representing a mosaic form of Darier's disease.

Postpemphigus acanthomata: a sign of clinical activity?

BACKGROUND

Pemphigus is a group of vesiculobullous disorders in which the blisters usually heal with hyper or hypopigmentation. The appearance of acanthomata at sites of previous blisters has been noted in some cases.

METHODS

All cases of pemphigus admitted to the Madras Medical College hospitals during a 2-year period from March 1993 to March 1995 were taken into the study and screened for the presence of acanthomata.

RESULTS

Fifty-two cases of pemphigus were identified, 47 of pemphigus vulgaris and five of pemphigus foliaceus; and of these 13 developed acanthomata when the blisters healed. Ten of these cases were of pemphigus vulgaris and three were of pemphigus foliaceus; biopsy of these lesions showed hyperkeratosis, acanthosis, papillomatosis, and intraepidermal clefting. Immunofluorescence carried out in two of these acanthomata also showed intercellular fluorescence.

CONCLUSIONS

The occurrence of acanthomata in healed lesions of pemphigus is not uncommon; because histopathologic and immunofluorescence evidence of disease activity is present, cases of this sort require careful follow-up.

Neurofibroma occurring in patients with rheumatoid arthritis

Two female patients suffering from rheumatoid arthritis presented with the complaint of papular skin lesions over the dorsal aspect of hands. Histopathological examination of papules showed the features of neurofibroma.

Atypical dyskeratosis congenita

Dyskeratosis congenita is a syndrome characterised mainly by pigmentation and atrophy of skin, nail dystrophy and oral leucoplakia. We report a patient who had features consistent with this syndrome including skin atrophy and pigmentation, oral leucoplakia, oesophageal stricture, but with normal finger and toe nails. Even though many variants have been described in the literature sparing of the nails as in our patient is extremely uncommon.

Eccrine poroma

Eccrine poroma is a benign tumour, usually found over palms and soles. A 35-year-old lady presented with a raised nodule of 0.75 cm over the right palm. On excision biopsy it showed tumour masses consisting anastomosing bands with ductal lumina lined by an eosinophilic cuticle. A diagnosis of eccrine poroma was made. Due to paucity of reports in Indian literature we are reporting this case.

Unilateral atrophoderma vermiculatum

Atrophoderma vermiculatum is an autosomal dominant disorder with small pitted scars over cheek and forehead. A 25-year-old male had multiple 1-2 mm sized pitted scars with ridges producing a reticulated honeycomb appearance on the left cheek since childhood. The lesions were unilateral and there was no other family member with similar lesions.

Atypical fibroxanthoma in tuberous sclerosis

Atypical fibroxanthoma is not an uncommon condition occurring in elderly on the sun exposed areas. We report a case of atypical fibroxanthoma in a patient with tuberous sclerosis. The lesion was excised surgically. There was no evidence of any metastasis.

Aggressive infantile fibromatosis

An 8-month-old infant presented with 2 ulcerated indurated plaques in the right lower limb. The lesions grew rapidly initially but for the last 2 months, they have been stationary. Biopsy showed proliferation of fusiform fibroblasts some of which were arranged in whorls. The clinical picture and the histopathology suggested the diagnosis of an aggressive infantile fibromatosis. This is one of the types of juvenile fibromatoses, a group of tumours characterised by fibrous tissue proliferation present at birth or acquired early in childhood.

Tuberous sclerosis

Although tuberous sclerosis has been described with a diagnostic triad, it is not present consistently in all cases. Variety of skin manifestations were reported in tuberous sclerosis. This studay was undertaken to assess the frequency of various skin changes in tuberous sclerosis. Ten consecutive cases of tuberous sclerosis were studied. Angiofibroma was the commonest cutaneous manifestation. Atypical fibroxanthoma, dermatofibroma and neurofibroma were also noticed as interesting associations.

Mutilating acral keratoderma

A 15-year-old male, born of non-consanguineous marriage started developing thickening of skin of sole of the both feet at the age of 7 which progressed to involve whole of both feet by 11th year. Patient later developed painful autoamputation of little toes of both feet due to pseudoainhum. Involvement of the palms was limited to a localised area over palmar aspect of right middle finger and was non-progressive. No other family member was affected. This may represent a variant of Vohwinkel's syndrome or the rarer form of acral keratoderma.

Chloroquine-induced photosensitive dermatoses

Two female patients suffering from rheumatoid arthritis were put on chloroquine 250 mg bid. After a period of 4 weeks, both of them developed photosensitive dermatitis. Following withdrawal of chloroqunie, both of them showed improvement in dermatitis gradually over a period of 3-4 months.