A curious case of expanded dengue syndrome

Dengue fever (DF) primarily presents with fever, headache, malaise, bleeding manifestations and haemoconcentration. World Health Organization (WHO) classifies DF according to levels of severity: (a) without warning signs; (b) with warning signs, such as abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing haematocrit and thrombocytopenia; and (c) severe dengue with severe plasma leakage, severe bleeding or organ failure. Atypical clinical presentations of DF are defined as expanded dengue syndrome: this includes renal, cardiac, hepatic or cerebral damage. We report such a severe case where a young man developed acute kidney injury, acute fulminant liver failure and acute pancreatitis secondary to DF, but recovered.

Extensively drug-resistant Salmonella Typhi leading to relapsed urinary tract infection: A case report

Salmonella enterica serotype Typhi (S Typhi) associated urinary tract infections are exceedingly rare, accounting for less than 1% of cases. Such infections have known to occur in immune-compromised or individuals with urogenital structural abnormalities. With the emergence of extensively drug resistant S Typhi strains in Pakistan, the management of its various unique presentations poses therapeutic challenges. We report the first documented case of a 74 years old male patient presenting with relapsed urinary tract infection secondary to extensively drug resistant S Typhi.

Geographic variation in heart failure with reduced ejection fraction: insights from the VICTORIA trial

Background

Geographic differences and background therapy have not been explored in the global VICTORIA trial, which enrolled high-risk patients with recent worsening heart failure with reduced ejection fraction (HFrEF).

Methods and results

Among 5050 patients enrolled in 5 pre-specified geographic regions, 34% were from Eastern Europe, 18% Western Europe, 23% Asia Pacific, 14% Latin and South America, and 11% North America (Table 1). Patients from Western Europe were older, had more atrial fibrillation, and lower glomerular filtration rates. Patients from Eastern Europe had more coronary artery disease and exhibited more advanced symptoms (∼50% New York Heart Association [NYHA] class III), whereas those from Latin and South America were less symptomatic (∼70% NYHA class II). North American patients had the largest body mass index as well as more diabetes and hypertension. Levels of NT-proBNP at randomization and MAGGIC risk scores were highest in Western European patients. Evidence-based triple medication therapy was used most frequently in Latin and South America and less frequently in North America; conversely, cardiac resynchronization therapy and implantable cardioverter defibrillators were most frequently used in North America and least frequently in Latin and South America. The overall primary composite event rate (cardiovascular death or HF hospitalization) in the placebo arm was 36.6/100 person-years over a median of 10.8 months and after adjusting for the MAGGIC score. When examined by region, these event rates were nominally highest in North America and lowest in Western Europe.

Conclusion

Substantial regional differences exist in characteristics and treatments among patients in this global trial of patients with HFrEF and a recent worsening event. These findings demonstrate the continuing unmet needs and opportunities for enhancing care in HFrEF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): VICTORIA was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and Bayer AG, Wuppertal, Germany.

Increased frequency of fibromyalgia among patients with chronic pain presenting to internal medicine clinics of a tertiary care hospital: a cross sectional study

Objective: To estimate the frequency of patients with fibromyalgia (by using the 2010 Modified Criteria for Fibromyalgia by American College of Rheumatology ( ACR ) presenting to Internal Medicine clinics  Methods: A cross-sectional study conducted in the department of Internal Medicine, the Indus Hospital, khi, Pakistan between December 2016 and March 2018. Patients who visited internal medicine clinics, met the selection criteria, were included in the study. After taking informed consent patients were assessed for fibromyalgia according to the new 2010 Fibromyalgia Diagnostic criteria questionnaire. The patients were asked the questions in the national language, Urdu. Data analyzed using SPSS version 21. P value of < 0.05 was considered significant. Results: Of the 267 patients presenting to the internal medicine clinics and consenting for participating in the study 149 (55.80%) met at least one of the 2010 Fibromyalgia Criteria. The prevalence of fibromyalgia as estimated in this study was 56% with no difference in gender. Mean age of patients with fibromyalgia was 42.3 ± 14.6 and patients without fibromyalgia was 38.9 ± 13.7 which was statistically significant (p-value = 0.05, 10% level of significance). Of the 267 patient 197 (73.8%) were female and 70 (26.2%) were males, a male to female ratio of 1:2.81.  Conclusion: All patients with generalized pain should be evaluated for fibromyalgia and a diagnosis made to reduce the cost of further referrals and investigations and delay in the management of this debilitating disorder. Keywords: Fibromyalgia, Chronic fatigue, Generalized Pain  

Epidemiology of in-hospital cardiac arrest in a Pakistani tertiary care hospital pre- and during COVID-19 pandemic

Objectives:

To determine epidemiology of in-hospital cardiac arrest (IHCA) in a tertiary care hospital, pre- and during pandemic.

Methods:

This is a cross-sectional study of inpatients who experienced an in-hospital-cardiac arrest at a tertiary care hospital in Karachi between August 2019 and August 2020. Outcome variables were return of spontaneous circulation (ROSC) and survival to discharge (StD) and analysis was also done comparing pre- and during pandemic period.

Results:

A total of 77 patients experienced at least one IHCA event during the 1-year study period. Comparing pre- and during pandemic, ROSC for women was higher during the pandemic albeit not significant (43% vs 50%) in comparison to men (54% vs 10%, p<0.001). During the pandemic, women with IHCA were significantly younger than men (μ ± sd; 36.8 ± 15.3 vs 55.9 ± 12.7, p=0.001,) whereas pre-pandemic, there was no gender differences in mean age. Non-shockable rhythm was more common (92.2%) than shockable rhythm (6.5%). Pre- and during pandemic, there were significant differences in the cause of IHCA for 4H4T (87% vs 100%) and cardiac (36% vs 9%). The proportion of hypoxic patients increased from 50% during pre-pandemic to 91% during the pandemic period, whereas hypo/hyperkalemia decreased from 53% to 34%.

Conclusion:

Despite the limitation of a small sample size, our study has provided important information regarding the epidemiology and outcomes of IHCA pre- and during pandemic in a busy Pakistani tertiary care hospital. Our finding that gender differences exist in survival pre- and during pandemic needs to be explored further with more hospitals doing comparative studies.

Knowledge and perception of Sepsis among Doctors in Karachi Pakistan

Objectives: To assess knowledge and perception among Pakistani physicians towards sepsis. Methods: This cross-sectional study was conducted in Indus Hospital and Health Networks from September 2020 to March 2021. The International Sepsis Survey questionnaire was adapted, and its link was sent to trainee physicians as well as specialists, and consultants practicing in various hospitals via social media. Knowledge and perception were scored and 50% was considered the cut-off score for adequacy. Data was analyzed using SPSS version 26. Results: Analysis was done on 222 respondents who completed the survey. 37.9% of the participants had adequate knowledge. Knowledge regarding sepsis was significantly associated with specialty, ICU/CCU/HDU, and work experience (P-value <0.0001). More recent trainee physicians and those with more experience in critical care areas demonstrated better knowledge. Over 2/3rd of the respondents strongly agreed that sepsis remains one of the unmet needs in critical care today. Conclusion: A common belief exists that sepsis remains a challenge to treat among doctors. Moreover, there is consensus that it is the most frequently miss diagnosed condition in critical care and a dire need exists for its early diagnosis. Additionally, prompt management of presumed sepsis is imperative to improve outcomes. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5775 How to cite this:Ahmed F, Abbasi L, Herekar F, Jiwani A, Patel MJ. Knowledge and perception of Sepsis among Doctors in Karachi Pakistan. Pak J Med Sci. 2022;38(2):380-386. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5775 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Evaluation of Results of Open Reduction and Internal Fixation (ORIF) of Fracture of Distal End of Femur with Intra-Articular Extension

INTRODUCTION

Fractures of the distal femur account for 0.4% of all fractures. They involve about 7% of all femur fractures, with bimodal age distribution, commonly occur during high-velocity trauma of motor vehicle accidents in the younger group of patients and are frequently associated with other skeletal injuries. The treatment of distal femoral fractures has evolved from conservative treatment to more aggressive operative treatment. The aim is to achieve and maintain a good reduction of the joint to allow early active mobilisation, thus minimising the joint stiffness and severe muscular atrophy encountered in the conservative treatment.

MATERIALS AND METHODS

This is a retrospective study of 25 patients with distal femur fracture with intra-articular extension treated with open reduction and internal fixation with DFLP, admitted at our institute between 2016 to 2019, with a minimum follow-up of six months.

RESULTS

In our study, 19 (76%) patients had excellent to good results. Three (12%) patients had fair outcomes, and three (12%) patients had poor outcomes according to Neer's score. The average time for bone union in closed fractures was earlier (4.25 months) than open fractures, averaging 5.86 months. The outcome was almost similar between closed and open fractures. There were 2 (8%) cases of infection in the early post-operative period, 7 (12%) patients suffered from knee stiffness, and there were 3 (12%) cases with a pre-operative bone loss that required bone grafting.

CONCLUSION

Management of complex intra-articular distal femur fracture has always been a challenge. Anatomical reduction of articular fragments and rigid fixation of these fractures are a must. DFLP provides angular stability with multiple options to secure fixation of both metaphyseal and articular fragments with the restoration of the joint congruity, limb length, alignment and rotation, allowing early mobilisation and aggressive physiotherapy without loss of fixation, resulting in gratifying functional outcome and low complication rate.

The Frequency of Poor Sleep Quality in Patients With Diabetes Mellitus and Its Association With Glycemic Control

Background and objective

Emerging evidence suggests that sleep problems are more common among individuals with diabetes mellitus (DM) than in the general population; these sleep issues are associated with poor glycemic control and they negatively affect the overall prognosis of the disease by increasing cardiometabolic risk. Our study aimed to determine the frequency of poor sleep quality and its association with glycemic control among Pakistani adult patients with DM.

Methods

This prospective cross-sectional study was conducted at the outpatient department (OPD) of The Indus Hospital (TIH), Karachi, and included 329 participants. To be eligible, participants had to be 14 years or older, should have been visiting the OPD at TIH for six months or more to seek treatment for DM, and had to give informed consent. Participants were assessed for poor sleep quality using the Pittsburgh Sleep Quality Index (PSQI) score and glycemic control using HbA1C levels ascertained through electronic health record review, with higher HbA1C levels reflecting poorer glycemic control.

Results

Two-thirds of the participants were females (n=212; 64.4%), and approximately 90% of the participants were married (n=292; 88.8%); 57% (n=188) of the participants were found to have poor sleep quality (PSQI of >5) and 233 (70.82%) had poor glycemic control (HbA1C of >7). Interestingly, no significant difference was observed in the PSQI scores between participants with controlled diabetes and those with uncontrolled diabetes.

Conclusion

Based on our findings, there is a high prevalence of sleep disturbance among Pakistani adults with DM, and we believe this necessitates the fostering of sleep-promoting interventional research in the country, as it might be highly rewarding and would positively affect the overall prognosis for diabetes by improving cardiometabolic risks. However, our results did not indicate any significant association between sleep quality and glycemic control. Further research should be conducted to explore the association between sleep disturbance and DM in Pakistani adults, by employing objective measures of sleep quality and involving a larger sample of individuals with DM to determine if these results hold true.

Frequency and Etiology of Pancytopenia in Patients Admitted to a Tertiary Care Hospital in Karachi

Introduction

Pancytopenia is an important hematologic problem encountered frequently in clinical practice characterized by a reduction in all three peripheral blood cell lineages, i.e., anemia, leucopenia, and thrombocytopenia, caused by myriad disease processes. Our study aimed to determine the frequency and etiology of pancytopenia in patients admitted under internal medicine services in a tertiary care hospital.

Method

This cross-sectional study was conducted in the in-patient internal medicine department, The Indus Hospital (TIH), Karachi, included 258 patients. To be eligible, participants had to give informed consent, be 14 years or older, and of either sex. The study involved a 20-30-minute interaction with the patient, involving an interview and physical examination, and access to electronic health record data.

Results

Out of 258 patients studied, 24 (9.3%) were diagnosed with pancytopenia, the male to female ratio was 1:1, no significant difference was observed in the proportion of ethnicity, religion, previous treatment, known infectious disease, and personal and occupational exposure among pancytopenic patients and other non-pancytopenic patients. Fever (n=14, 58.3%) was most common presenting complaint followed by fatigue (n=13, 54.2%) and weight loss (n=7, 29.2%) while most common signs were pallor (87.5% n=21), hepatomegaly (29.2%, n=7), and splenomegaly (25%, n=6). The most common cause of pancytopenia was megaloblastic anemia (n=10, 41.7%), followed by hypersplenism (n=4, 16.6%), acute infectious diseases (n=3, 12.5%), and autoimmune diseases (n=3, 12.5%).

Conclusion

Our study suggests that pancytopenia is a common finding among our patient population and a larger proportion has a treatable cause, thus carrying a favorable prognosis.

Diabetes Self-care Activities and Their Relation with Glycemic Control in Patients Presenting to The Indus Hospital, Karachi

Introduction Nowadays, chronic conditions are increasing globally, stressing on self-management and patients' responsibility toward recognizing and resolving issues related to their illness. Diabetes is also a chronic illness, and diabetes-related self-care activities have been shown to be promising towards preventing its complications and achieving optimal glycemic control. Objective 1) To assess the association between glycemic control and diabetes-related self-care activities 2) To evaluate the association of patients' sociodemographic characteristics with diabetes-related self-care activities 3) To examine the impact of patients' sociodemographic characteristics on glycemic control Materials and methods This cross-sectional study was conducted at The Indus Hospital Karachi from February 2019 to July 2019. A total of 288 patients of both genders, age ≥18 years, having type 2 diabetes mellitus with glycated hemoglobin (HbA1c) done within the last three months from the interview date were enrolled in the study using a non-probability consecutive sampling technique. Whereas patients not giving consent for participation in the study, ICU admitted patients, critically ill patients, pregnant women, comatose, patients with type 1 diabetes mellitus, Alzheimer's disease, dementia, coexisting and chronic liver disease were excluded from the study. Results Majority of the patients were female (n=209; 72.6%) and had uncontrolled glycemic control (n=235; 81.6%). Furthermore, less than half of the patients had inadequate diabetes-related self-care activities (n=140; 48.6%). The Mean ± SD of age was 51.9±10.2 years. The significantly higher proportion of patients who have had a duration of illness and treatment ≥3 years had uncontrolled diabetes but adequate diabetes-related self-care activities. Moreover, there was no association between diabetes-related self-care activities and glycemic control. Conclusion There was no significant relationship between diabetes-related self-care activities and glycemic control. Moreover, a higher proportion of patients with a longer duration of diabetes (≥3 years) had poor glycemic control but adequate diabetes-related self-care activities.

Prevalence of Metabolic Syndrome in Overweight and Obese Patients and Their Measurement of Neck Circumference: A Cross-sectional Study

Background The utilization of neck circumference (NC) as a valuable tool to evaluate metabolic syndrome (MetS) is still unclear. MetS has been extensively reported worldwide mainly due to the increasing trend of central obesity and the risk of developing coronary artery disease. In Pakistan, its incidence is reported to be between 18% and 49% among the urban population. Methods This cross-sectional study was conducted at the Indus Hospital, Karachi, Pakistan; in total, 392 patients (body mass index [BMI] >23 kg/m², age ≥18 years, both genders) were recruited through consecutive sampling, and informed consent was obtained. Results The majority of patients were females (n = 344, 87.8%), and the mean ± SD of age and NC of all patients was 50.5 ± 9.6 years and 38 ± 4.6 cm, respectively. The majority (n = 375, 95.7%) of patients were found to have MetS, with 90% of both males and females having NC ≥38 cm and 34 cm, respectively. Conclusion The prevalence of MetS was found to be very high in overweight and obese patients. Moreover, the majority of patients with MetS were found to have higher NC.

Hypertension-related Knowledge and Its Relationship with Blood Pressure Control in Hypertensive Patients Visiting a Semi-private Tertiary-care Charity Hospital in Karachi, Pakistan

Introduction

Hypertension is one of the leading causes of mortality worldwide. Fifty-four percent of strokes and forty-seven percent of cardiovascular deaths are caused by suboptimal control of blood pressure. Economically developing countries like Pakistan are heavily burdened with an ever-rising epidemic of cardiovascular disease and stroke morbidity and mortality. Therefore, urgent steps are required to treat, as well as modify, risk factors for cardiovascular disease, including hypertension.

Purpose

The objective of this study was to ascertain the knowledge of hypertension and other sociodemographic variables and their impact on controlling blood pressures in the hypertensive population belonging to the low socioeconomic strata.

Methods

This cross-sectional study was conducted in the general medicine and cardiology outpatient clinics of a tertiary care charity hospital. Three-hundred thirty-five hypertensive patients of age >24 years were selected and informed consent was obtained. Hypertension-related knowledge was assessed using the Modified "Hypertensive Knowledge-Level Scale (HK-LS)" via a 15-20 min interview. Secondary variables in the questionnaire included social demographics, medical history, and assessment of body mass index (BMI) and blood pressure average values, which were measured during the interview. Knowledge was recorded based on the 33-point modified HK-LS scale, whereas secondary variables were not counted toward the assessment of knowledge.

Results

The frequencies of low, moderate, and high levels of hypertension-related knowledge were recorded as 2.1%, 79.4%, and 62%, respectively. Among 335 patients, (57.3%) were male, the mean age was 52.5 ± 11.5 years, and 63.6% were professionally active. Median systolic blood pressure (SBP) and diastolic blood pressure (DBP) in hypertensive patients were 140 and 86 mmHg, respectively. Sixty-nine percent of patients reported existing comorbidities, 54% had diabetes, 20.7% had cardiovascular disease, and 24% reported renal disease. No significant association was observed between the levels of knowledge of hypertension and gender, blood pressure (BP) status, professional activity, and age groups (p=0.877, p=0.863, p=0.125, and p=0.400, respectively).

Conclusion

The majority had adequate knowledge of hypertension but only 64.8% had controlled BP status. This depicts not a lack of knowledge and awareness but rather a lack of prevention of risk factors related to hypertension. Thus, further studies are advised to look into the preventive strategies employed by patients to control their BP and assess their effectiveness.

Effects of polypharmacy on adverse drug reactions among geriatric outpatients at a tertiary care hospital in Karachi: a prospective cohort study

BACKGROUND

Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, "concurrent use of five or more different prescription medication". Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center.

METHODS

A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University Hospital April 2012 to March 2013. One thousand geriatrics patients (age ≥ 65 years) visiting ambulatory clinics were identified. They were divided on the basis of exposure (polypharmacy vs. no polypharmacy). We followed them from the time of their enrollment (day zero) to six weeks, checking up on them once a week. Incidence was calculated and Cox Proportional Hazard Model estimates were used.

RESULTS

The final analysis was performed on 1000 elderly patients. The occurrence of polypharmacy was 70% and the incidence of ADRs was 10.5% among the study cohort. The majority (30%) of patients were unable to read or write. The use of herbal medicine was reported by 3.2% of the patients and homeopathic by 3%. Our Cox adjusted model shows that polypharmacy was 2.3 times more associated with ADRs, con-current complementary and alternative medicine (CAM) was 7.4 times and those who cannot read and write were 1.5 times more associated with ADRs.

CONCLUSION

The incidence of ADRs due to poly pharmacy is alarmingly high. The factors associated with ADRs are modifiable. Policies are needed to design and strengthen the prescription pattern.

Patients' insight of interpreting prescriptions and drug labels--a cross sectional study

BACKGROUND

Errors in consuming drugs are associated with significant morbidity and mortality, besides an impact on the already overburdened health-care system. Misunderstanding drug labels and prescriptions plays an important role in contributing to adverse drug events.

OBJECTIVE

To evaluate abilities to understand prescriptions and drug labels among patients attending tertiary care hospital in Karachi.

METHODS

A cross sectional study was conducted at the Aga Khan University Hospital (AKUH), from January to March 2009. After informed consent, 181 adult patients and their healthy attendants were interviewed at AKUH using a standardized questionnaire, which ascertained patient demographics, factors that might increase exposure to health-care personnel as well as the basic knowledge and understanding of prescriptions and drug labels.

RESULTS

Out of 181, majority 137(76%) had received graduate or post-graduate degrees. 16 (9%) had received no formal education; of which all were females and 89(84%) of the total females were housewives. Overall, 130(72%) followed only a single doctor's prescription. Majority failed to understand various medical terminologies related to dosage. In the high literacy group, 45(33%) understood once daily OD (p = 0.003), 27(20%) thrice daily TID (p = 0.05), 29(21%) twice daily BD (p = 0.01), 31(23%) thrice daily TDS (p = 0.002) and 43(31%) as needed SOS (p = 0.003) as compared to the group with no formal education, who were unable to comprehend the terms. The most common reason for using more than one prescription was decreased satisfaction with the doctor in 19(39%) and multiple co-morbids as responded by 17(35%) of patients. Knowledge regarding various medical terminologies used for dosage and routes of drug administration were also understood more frequently among the English medium respondents. The elderly identified medicine through color (47%, p<0.001), and were less likely to understand drug indications (p = 0.05) compared to younger subjects.

CONCLUSION

Understanding of drug prescriptions is alarmingly low in the community, even amongst the educated. Care givers need to revisit this often ignored aspect of patient care.

Benzodiazepine use in medical out-patient clinics: a study from a developing country

OBJECTIVE

To estimate the prevalence of Benzodiazepine use in the outpatient setting of general medicine clinics at a single tertiary care centre.

METHODS

The prospective prevalence study was conducted in the outpatient setting of Internal Medicine Clinics at Aga Khan University Hospital, Karachi, from November to December 2009. All subjects were interviewed after informed consent and variables were recorded on a specially-designed proforma. Apart from basic demographics and comorbid conditions, duration, frequency and route of benzodiazepine use, as well as the reason and who initiated it was noted. Chi-square test and t test was applied to see the association of socio demographic or clinical factors with the use of benzodiazepine.

RESULTS

Of the 355 patients, 129 (36.33%) reported using the drug. The majority (n=86; 24.2%) were taking it on a daily basis. The highest numbers of patients using the drug were suffering from cardiovascular problems, 32 (25%) followed by 22 (17%) from endocrinology. Diazepam equivalent dose was around 7.04+4, with a inter-quartile range of 3-96 weeks. Alprazolam (9%) was the most frequently prescribed Benzodiazepine.

CONCLUSION

Benzodiazepine use is alarmingly high in the outpatient clinics of General Internal Medicine Department. There is no implementation of law to prevent its hazardous sale. In this regard all concerned should work collectively for awareness and irrational drug sale and use.

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: Evidence from a tertiary care institute in a low-income country

Aim:

The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation (CPR) outcome in hospitalized patients.

Methods:

A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR.

Results:

Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 (AOR: 4.6, 95% CI: 2.4-9.0). Also, shorter duration of CPR (AOR: 2.9, 95% CI: 1.9-4.4), evening shift (AOR: 2.1, 95% CI: 1.3-3.5) and Male patients (AOR: 0.6, 95% CI: (0.4-0.9) compared to females were other significant predictors of CPR outcome.

Conclusion:

APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration.

Clinical characteristics and predictors of positive stool culture in adult patients with acute gastroenteritis

OBJECTIVE

To identify the presenting features and spectrum of pathogens in adult patients with acute diarrhoea and to determine the predictors of stool culture positivity.

METHODS

A descriptive study was conducted in a tertiary care hospital from April 1, 2005 to March 31, 2006. Medical records of all consecutive adult patients with history of acute diarrhoea were reviewed between June 2006 to December 2006 for clinical characteristics and laboratory investigations.

RESULTS

A total of 454 patients were admitted from April 1, 2005 to March 31, 2006. Stool cultures were performed in 233 (50%) patients, 96 (42%) had positive results. Patients with positive stool culture compared to a negative Culture were found to have a younger mean age (43 vs. 53), greater number of unformed stools (16 vs. 11) and low serum bicarbonate level (16 vs. 20). Vibrio cholerae (86%) was found to be the most prevalent organism followed by Salmonella spp (6%), Campylobacter spp (5.2%), Shigella spp (2%). Ciprofloxacin was given to 97% patients along with fluid administration, and 78% were found to be resistant to quinolones. Most patients recovered before the finalized stool culture results.

CONCLUSION

Careful selection of the patients based on their clinical presentation and initial laboratory work up can help to decide ordering of stool culture in adults with diarrhoea. Fluid resuscitation remains the main stay of treatment.

Clinical research and diagnostic efficacy studies in the oral and maxillofacial radiology literature: 1996-2005

OBJECTIVES

The aim of this study was to determine the level of evidence that is published in the oral and maxillofacial radiology (OMR) literature.

METHODS

OMR papers published in Dentomaxillofacial Radiology and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology between 1996 and 2005 were classified using epidemiological study design and diagnostic efficacy hierarchies. The country of origin and number of authors were noted.

RESULTS

Of the 725 articles, 384 could be classified with the epidemiological study design hierarchy: 155 (40%) case reports/series and 207 (54%) cross-sectional studies. The distribution of study designs was not statistically significant across time (Fisher's exact test, P = 0.06) or regions (P = 0.89). The diagnostic efficacy hierarchy was applicable to 246 articles: 71 (29%) technical efficacy and 166 (67%) diagnostic accuracy studies. The distribution of efficacy levels was not statistically significant across time (P = 0.22) but was significant across regions (P < 0.01). Authors from Japan produced 26% of the papers with a mean ± standard deviation of 5.78 ± 1.98 authors per paper (APP); American authors, 23% (3.78 ± 1.72 APP); and all others, 51% (3.76 ± 1.51 APP).

CONCLUSION

The OMR literature consisted mostly of case reports/series, cross-sectional, technical efficacy and diagnostic accuracy studies. Such studies do not provide strong evidence for clinical decision making nor do they address the impact of diagnostic imaging on patient care. More studies at the higher end of the study design and efficacy hierarchies are needed in order to make wise choices regarding clinical decisions and resource allocations.

Melanoma in solid organ transplant recipients

This manuscript outlines estimated risk and clinical course of pretransplant MM, donor-transmitted MM and de novo MM posttransplantation and includes an analysis of risk factors for metastasis, data from clinical studies and current and proposed management. MM in situ and thin melanoma (<1 mm) in the transplant population has similar recurrence and survival estimates to those in the general population. A minimum wait time of 2 years prior to transplantation is suggested for MM with a Breslow depth <1 mm and no clinical evidence of metastasis. More advanced MM may adopt a more aggressive course in transplant recipients. Sentinel lymph node biopsy may be of additional prognostic benefit. Revision of immunosuppression in the management of de novo melanoma in collaboration with the transplant team should be considered. Larger studies utilizing uniform staging criteria or at minimum Breslow depth, are required to assess true risk and outcome of MM in the immunosuppressed transplant population. Emphasis remains on patient education and regular screening to provide early detection of MM.

Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study

BACKGROUND

Skin cancers represent a major challenge within the ever growing group of long time surviving organ transplant recipients (OTR) world wide. Especially UV-induced non-melanoma skin cancers (NMSC) like invasive squamous cell carcinomas (SCC) and actinic keratoses (AK), and basal cell carcinoma (BCC), outnumber every other form of cancer in organ transplant recipients. Despite encouraging reports of protective effects of broad-spectrum sunscreens in immunocompetent patients, evidence for the prevention of NMSC in immunocompromised patients is still missing.

OBJECTIVES

To assess preventive effects of regular sun-screen use on AK, SCC and BCC in chronically immunocompromised organ transplant recipients.

METHODS

Hundred and twenty matched (age, sex, skin type, graft, transplant duration, previous post-transplant skin malignancies) organ transplant recipients (40 heart, 40 kidney, 40 liver grafted) were recruited for this prospective, single-center study. Both groups received equally written and oral information on sun protection measures. Sixty patients were provided with a free broad spectrum study-sunscreen (SPF>50, high-UVA absorption) for daily application of 2 mg cm(-2) to the head, neck, forearms, and hands.

RESULTS

All 120 patients completed the 24 months study. Within this 24 month study interval 42 of the 120 patients developed 82 new AK (-102 sunscreen group vs. +82 control; P<0.01), 8 new invasive SCC (0 vs. 8; P<0.01) and 11 BCC (2 vs. 9; ns). In spite of equal numbers of AK at baseline, a marked difference in favor of the intent-to-treat sunscreen group was recorded after 24 months (89 vs. 273; P<0.01, mean difference 3.07 [1.76-4.36]) and the lesion count was significantly lower as compared to the initial visit (89 vs. 191; P<0.01, mean difference 1.7 [0.68-2.72]). With an average of 5.6 applications per week throughout the 24 months the study sunscreen was generally well tolerated. Serum 25-hydroxy vitamin D levels as marker for vitamin D status were decreased in all patients without adequate substitution and 25(OH)D was found to be lower in the sunscreen-group as compared to the control group (mean value 53 ng mL(-1) vs. 60 ng mL(-1)).

INTERPRETATION

Regular use of sunscreens, as part of a consequent UV-protection strategy, may prevent the development of further AK and invasive SCC and, to a lesser degree, BCC in immune-compromised organ transplant recipients.

Career goals of trainee physicians in internal medicine

OBJECTIVE

To survey Internal Medicine trainees' future career choices and factors influencing their decision-making.

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital, Karachi, from November 2006 to January 2007.

SUBJECTS AND METHODS

A standard questionnaire was administered to the residents and Interns working in the Department of Internal Medicine of The Aga Khan University Hospital. The questionnaire covered demographic details, specialty choice, work-time distribution and factors influencing career choice. Descriptive statistics were applied.

RESULTS

A total of 49 doctors participated with 57% females; and 43% males, having 33% interns and 67% residents. A minority (22%) opted for internal medicine, while 78% selected sub-specialties with cardiology (20%) being the most sought- after sub-specialty. Majority (69%) wanted to spend more time in clinical activities compared to administration (18%) or research (13%). Majority (92%) wanted to work in an academic setting. Availability of a structured training program (61%), ability to practice broad area of medicine (41%) and prestige of the specialty (41%) highly influenced their career choices. Forty one (82%) wanted to proceed abroad for further training and 80% wanted to eventually practice in Pakistan.

CONCLUSION

Most of the interviewed under-training physicians wanted to pursue sub-specialty. Clinical work was more attractive compared to research. A structured training program was detrimental in affecting their choices. Majority wanted further training abroad but eventual settlement in Pakistan. The study results can help us create the basis for reforming the current training programs.

Syncope: experience at a tertiary care hospital in Karachi, Pakistan

Introduction

Our aim was to determine the characteristics of patients presenting with syncope at a tertiary care hospital in Karachi, Pakistan.

Methods

A review of medical records was conducted retrospectively at the Department of Medicine, Aga Khan University Hospital, Karachi. Patients aged 16 and above, admitted from January 2000 to December 2005 with the diagnosis of syncope made by the attending physician were included.

Results

A total of 269 patients were included (75% males, mean age: 57.4 years). Neurogenic (vasovagal) syncope was the most common cause (47%), followed by cardiogenic syncope (18%) and orthostatic syncope (9%). A total of 24% were discharged undiagnosed. Twenty patients (7.4%) did not have any prodrome. Common prodromal symptoms included dizziness (61%), sweating (25%), palpitations (19%), nausea/vomiting (19%) and visual symptoms (17%). The distribution of symptoms according to cause of syncope revealed only breathlessness to be significantly associated with cardiogenic syncope (p = 0.002). Most patients with cardiogenic syncope were aged above 40 (98%, p < 0.001), had coronary artery disease (72%, p < 0.001) and abnormal electrocardiogram at presentation (92%, p < 0.001).

Conclusion

Despite differences in burden of diseases, our findings were similar to those of published syncope literature. Further studies are needed to develop a protocol to expedite the evaluation and limit the work-up and admission in low-risk patients.

Drug overdose: a wake up call! Experience at a tertiary care centre in Karachi, Pakistan

OBJECTIVE

To study the characteristics of patients admitted with drug overdose caused either by accidental overdose of the prescribed medications or as an act of deliberate self harm (DSH) at a tertiary care hospital in Karachi, Pakistan.

METHODS

A retrospective case series review was conducted at the Aga Khan University Hospital from January 2002 to October 2006. Three hundred and twenty four adult patients admitted with drug overdose were included in the study.

RESULTS

Our sample group revealed mean age of 36.2 +/- 17.0 years, more females (59%), housewives (34%), and students (20%). Fifty six percent of patients committing DSH were married (p = 0.001), 81% needed in-patient psychiatric services (p = 0.016) of whom a significantly high number (38%) refused it. Domestic and social issues were rated highest among DSH group (p = 0.003), depression among females was common (p = 0.028) and Benzodiazepines (41%) was the most frequently used drug (p = 0.021). Sub-group analysis of accidental overdoses revealed mean age of 45.6 +/- 19.6 years, single (75.4%) and males (54.1%). Drugs used were mainly Benzodiazepines (18%) followed by Opioids (11%), Antiepileptics (10%) and Warfarin (10%).

CONCLUSION

Our study showed that depressed housewives are at greater risk for DSH. Domestic and social issues were rated highest and Benzodiazepines were the most commonly used agents. Most of our patients refused inpatient psychiatric treatment leading us to believe that general awareness of psychiatric illnesses is imperative in our community. High number of accidental overdoses is alarming in older, single males convincing us to believe that existing pharmacy system needs further evaluation and modification.

Actinic keratosis is an early in situ squamous cell carcinoma: a proposal for reclassification

The term actinic keratosis (AK) describes a sun-induced, clinical erythematous lesion covered with scale, but does not provide an understanding of the biology or histopathology of the lesion. Consequently, several classification systems for AK have been suggested, but as yet no consensus has been reached. These systems strive to correlate the pathological and clinical features to better provide physicians with the most accurate information to enable correct decisions to be made regarding treatments, Prognosis and metastatic potential. AK is a clinical description that has a histological diagnosis consistent with squamous cell carcinoma (SCC) in situ. We recommend an AK classification system that describes these lesions as squamous cell carcinomas (SCCs), using the terminology 'early in situ SCC Type AK I', 'early in situ SCC type AK II' and 'in situ SCC Type AK III', there by giving clinicians better guidance for diagnosis and specific treatment recommendations.

Genetically determined susceptibility to COX-2 inhibitors: a report of exaggerated responders to diclofenac 3% gel in the treatment of actinic keratoses

Diclofenac 3% gel is an effective treatment for actinic keratoses (AKs) and is reported to be generally well tolerated with only mild local reactions. However, there is a subset of patients that seem to be susceptible to developing severe local reactions following application of diclofenac 3% gel. Although some of these reactions can be explained as being allergic contact dermatitis and/or photoallergic contact dermatitis, others cannot. We report a series of 10 patients who all developed severe local reactions following application of diclofenac 3% gel, despite negative diclofenac patch testing. This raises the question as to whether there is a subset of patients with skin cancer or AK lesions that are highly/more susceptible to local reactions caused by cyclo-oxygenase-2 (COX-2) inhibitors and peroxisome proliferator-activated receptor (PPAR) agonists? We speculate that underlying molecular differences exist in these patients that make the skin more susceptible to COX-2 inhibitors.

Does progression from actinic keratosis and Bowen's disease end with treatment: diclofenac 3% gel, an old drug in a new environment?

Progression from actinic keratosis (AK) and Bowen's disease (BD) to invasive disease involves a complex cascade of events. The preparation of diclofenac 3% gel (Solaraze; Shire Pharmaceuticals) has been shown to be efficacious and well tolerated in AK. The inhibition of the COX enzymes results in a decrease in downstream by-products of arachidonic acid metabolism. These metabolites have been shown to play a pivotal role in promoting epithelial tumour growth. Given its mechanism of action, we hypothosize that diclofenac 3% gel may have potential to halt the progression of actinic keratoses (AKs) in the setting of field cancerisation and BD. We report a series of five patients with BD, all treated with diclofenac 3% gel with clinical and histological clearance.

Liquid phase migration in the extrusion and squeezing of microcrystalline cellulose pastes

Extensive movement of the liquid phase relative to the solids in solid-liquid pastes during extrusion forming is an undesirable process phenomenon. The impact of formulation and flow pattern on liquid phase migration (LPM) during extrusion of model pharmaceutical pastes (40-50 wt% microcrystalline cellulose/water) has been investigated by ram extrusion through square-entry and 45 degrees conical-entry dies, and by lubricated squeeze flow (extensional flow). Threshold velocities for LPM were observed in both configurations. Squeeze flow testing showed that dilation during extension can cause LPM, while ram extrusion featured both dilation effects and drainage due to compaction. The threshold velocities observed in the two configurations agreed when presented as characteristic shear rates. The threshold velocity increased with paste solids content.

From embryos to embryonic stem cells: biopolitics and therapeutic potential

The inner cell mass of the preimplantation blastocyst, from which all the cells of the body develop, is a source of embryonic stem cells. These cells can be maintained in their undifferentiated state over long periods in culture and yet retain their pluripotency. The generation of human stem cells capable of differentiating into all the cell types of the human body opens the way for the use of these cells in therapeutic transplantation for a myriad of diseases. However, as discussed here, there are a number of logistical, biological, and clinical hurdles that must be overcome prior to the use of these cells in routine clinical practice.

Skin manifestations in vasculitis and erythema nodosum

Cutaneous lesions are frequent in medium-sized and small vessel systemic vasculitides. The classic cutaneous manifestation of vasculitis is palpable purpura; however the clinical manifestations greatly depend on the size of the vessels affected. They usually do not affect prognosis but relapsing or intractable forms have been described. When skin manifestations are only one of the clinical signs of vasculitis, treatment with corticosteroids and, when indicated, an immunosuppressant, is mandatory, which usually leads to the rapid disappearance of cutaneous lesions. Conversely, when skin lesions are isolated, the diagnosis can be more challenging, but initial treatment may be less aggressive, e.g., dapsone or colchicine, reserving corticosteroids only for those patients in whom the former are ineffective. Erythema nodosum (EN) is the most frequent septal panniculitis. In general it is characterized by the sudden eruption of one or more erythematous and tender nodules or plaques located mainly over the extensor sides of lower extremities. EN resolves with complete "restitutio ad integrum" of the skin in 3-6 weeks. Relapses are uncommon but in patients with idiophatic, streptococcal or EN associated with other upper respiratory tract infections they are more frequent. The main treatment of EN is that of the underlying associated conditions, if demonstrated. Aspirin and other NSAIDs in full doses are often sufficient.

Use of the Self-Administered Eczema Area and Severity Index by parent caregivers: results of a validation study

BACKGROUND

The Eczema Area and Severity Index (EASI) is used by dermatological investigators world-wide to assess eczema disease severity. EASI measures are, however, time-consuming and require trained personnel, thereby limiting its application to large-scale epidemiological studies. Additionally, the use of self-assessed severity indices in dermatology is restricted to adult subjects and conditions, thereby not addressing the needs of paediatric patients.

OBJECTIVES

To develop and validate an instrument for a caregiver's self-assessment of the severity of his/her child's atopic dermatitis (AD), the Self-Administered EASI (SA-EASI).

METHODS

Trained investigators performed a modified EASI assessment on the same day as an SA-EASI was obtained from 47 caregivers of children with AD.

RESULTS

The SA-EASI was found to be a valid measure of the severity of AD. Total, acute and chronic SA-EASI scores predicted total, acute and chronic modified EASI scores (P < 0.0001). SA-EASI body surface area (BSA) scores predicted EASI BSA scores (P < 0.0001). SA-EASI pruritus scores correlated with the acute, chronic and total EASI scores (P = 0.0001).

CONCLUSIONS

The SA-EASI may provide caregivers the means to report the severity of their child's skin disease objectively. The high correlation with the EASI score observed in this sample implies that statistical inferences with the SA-EASI will be valid for large populations. In future studies, this will permit analysis of the relationship of skin disease severity to such measures as quality of life, disability, patient satisfaction and the costs of various therapies. Moreover, this SA-EASI instrument may allow older children, over 12 years old, to assess the severity of their AD.

Comparative efficacy and pharmacokinetics of racemic bupivacaine and S-bupivacaine in third molar surgery

PURPOSE

To compare the efficacy and pharmacokinetics of racemic bupivacaine (rac-bupivacaine) with S-bupivacaine as primary local anesthetic agent in bilateral impacted third molar extractions.

METHOD

A randomised, double blind, two period cross-over design was employed. Six subjects (2 males, 4 females; age 19-25 years; weight 69.2+/-9.4 kg) received bupivacaine hydrochloride injection (6.6 ml) as rac-bupivacaine (0.5% as salt) or S-bupivacaine (0.5% as base) prior to extraction of impacted third molars on one side and three weeks later on the other side. Anesthesia, blood loss associated with surgery and post-operative pain experience were evaluated. Plasma samples were analysed for bupivacaine enantiomers by chiral HPLC.

RESULTS

In 7/12 operations, anesthesia adequate for surgery was delayed (>10 min) or unsatisfactory requiring lidocaine rescue medication. Despite this, there were no significant differences in onset and duration of anesthesia, blood loss or post-operative pain experience between the two arms of the study. Pharmacokinetic parameters were not significantly different and there was no evidence of chiral inversion after dosing with S-bupivacaine.

CONCLUSIONS

Both study drugs were inadequate as single anesthetic agent for third molar surgery. Any decision to use S-bupivacaine for oral surgery must rest on evidence that it is less toxic than the racemic drug.

Bone and joint complications related to Gaucher disease

There is a broad spectrum of Gaucher disease-related skeletal complications, ranging from asymptomatic osteopenia to osteonecrosis (of the shoulders and hips) with secondary degenerative joint disease. Characterization of the pattern and severity of bone involvement in the individual patient requires the application of conventional and advanced radiographic techniques. The introduction of enzyme replacement therapy (ERT) for this inborn error of glycosphingolipid metabolism has focused great interest in determining the nature and extent of the bone responses with this mode of treatment. The multifactorial etiology of the bone complications necessitates a multifaceted approach, combining pharmacologic strategies with physical therapy and orthopedic intervention. As bone disease can lead to chronic pain and debility with a resultant adverse impact on quality of life, it is important that patients be monitored closely and that early intervention with ERT prior to established bone disease (infarction and fibrosis) be considered.

Analysis of cross-linked human hemoglobin by conventional isoelectric focusing, immobilized pH gradients, capillary electrophoresis, and mass spectrometry

Diaspirin cross-linked hemoglobin (DCLHb), a hemoglobin-based oxygen carrier exhibiting near physiological oxygen binding capability and devoid of nephrotoxic side effects, was previously found, by gel permeation, reversed-phase high performance liquid chromatography (RP-HPLC) and mass spectrometry, to consist of ca. 94% cross-linked product (reacted on the Lys 99 of two alpha-chains), accompanied by ca. 6% cross-linked Hb, which also reacted on the Lys 132 and/or Lys-144 of the beta-chains and a small amount of intermolecularly cross-linked dimers. However, conventional isoelectric focusing in carrier ampholyte buffers (CA-IEF) gave an unexpected spectrum of four major, almost equally represented, pI species in the pH range of 6.82-7.01, a band of mid-intensity with a pI of 7.11, and two minor components with pls of 6.73 and 6.77. This extraordinary polydispersity was reevaluated by other surface charge probes, such as immobilized pH gradients (IPG) and capillary zone electrophoresis (CZE) of native and denatured globin chains. IPGs of DCLHb gave the expected spectrum of bands, consisting of a main component (92%) with pl 7.337 and three additional minor bands, with lower pIs, representing ca. 8% of the total. These data were in agreement with CZE profiles of native DCLHb, which resolved, in addition to the main DCLHb peak, 3-4 minor components representing ca. 10% of the total. Also, CZE of denatured, heme-free globin chains gave the expected pattern with only traces of minor, extrareacted species. The latter technique, in addition to resolving alpha- and beta-globin chains in a 1:1 ratio in control Hb, resolved a free beta- and the alpha-alpha-dimer in DCLHb. In a 1:1 mixture of control and DCLHb, three peaks were observed, eluting in the order alpha-, alpha-alpha- and beta-globin chains. The identity of the major DCLHb and of the minor species was ascertained by mass spectrometry.

Absence of immunogenicity of diaspirin cross-linked hemoglobin in humans

Diaspirin cross-linked hemoglobin (DCLHb) is an intramolecularly cross-linked hemoglobin-based oxygen carrier being developed as a therapy for acute blood loss. We report here the absence of immunogenicity of DCLHb in patients enrolled in phase II and III clinical trials of DCLHb. Two very sensitive immunoassays, an enzyme-linked immunosorbent assay (ELISA) and a Western blot assay, were developed and validated for this assessment. The DCLHb-antibodies used in these assays were raised in monkeys, had similar affinities for DCLHb and native human hemoglobin (SFHb), and showed cross-reactivity for subunits of DCLHb and SFHb on the Western blot, suggesting that these antibodies were elicited as a xenogenic response to the protein. In the ELISA, the optical density of a patient sample exposed to DCLHb-coated wells was compared with that of the patient sample exposed to carbonate buffer-coated wells; an optical density ratio of 1.4 was established for discriminating between a positive (reactive) or negative DCLHb antibody response. To date, all of the more than 300 patient specimens (preinfusion and postinfusion) from clinical trials have exhibited a ratio of less than 1.4, confirming the lack of preexisting antibodies to DCLHb and clearly showing the absence of DCLHb antibodies after exposure to this new biologic entity. There has been no requirement for use of the confirmatory Western blot assay. Taken together, the results from this study indicate DCLHb is not immunogenic in humans at doses evaluated clinically.

Structural characterization of human hemoglobin crosslinked by bis(3,5-dibromosalicyl) fumarate using mass spectrometric techniques

Diaspirin crosslinked hemoglobin (DCLHb) was analyzed by mass spectrometric-based techniques to identify the protein modifications effected by the crosslinking reaction with bis(3,5-dibromosalicyl) fumarate. DCLHb consists of two principal components. These components were isolated by size-exclusion chromatography and identified by measurement of their molecular weight using electrospray mass spectrometry and subsequent peptide mass mapping and mass spectrometric sequence analysis of their individual digests. Three major RP-HPLC fractions were observed from the major hemoglobin in DCLHb. Their MWs matched the MW of heme, intact hemoglobin beta-chain, and two hemoglobin alpha-chains crosslinked by a fumarate moiety, respectively. The minor HPLC peaks of DCLHb were also separated, and characterized by mass spectrometric methods. These minor components revealed additional details of the structural nature of covalent modification of DCLHb.

Spinal leptomeningeal hemangioblastomatosis in von Hippel-Lindau disease: magnetic resonance and pathological findings

A 55-year-old man with von Hippel-Lindau disease presented with quadriparesis. Multiple enhancing cervical and thoracic spinal masses were seen on magnetic resonance imaging (MRI). A rim of diffuse, nodular enhancement linking all of the discrete masses was apparent on the surface of the cervical and thoracic regions of the cord. Surgical exploration revealed multiple extramedullary-intradural and intramedullary masses, extending to and infiltrating the cord; the leptomeninges contained numerous small tumor seeds at several levels. The excised spinal masses were diagnosed as capillary hemangioblastomas, which infiltrated the pia mater. Diffuse, intense, spinal leptomeningeal enhancement on MRI associated with multiple hemangioblastomas has not been previously reported and may be referred to as spinal "leptomeningeal hemangioblastomatosis."

Secretion of cyclic GMP by cultured epithelial and fibroblast cell lines in response to nitric oxide

LLC-PK1 epithelial cells and RFL-6 fibroblasts secreted both cyclic AMP (cAMP) and cyclic GMP (cGMP) when costimulated with forskolin and 3-morpholinosydnonimine (a chemical nitric oxide generator). Intracellular cAMP levels as high as 1100 and 12,000 pmol/10(6) cells were achieved for the two cell types, respectively. These levels were high enough to reach approximately 50% saturation of the cAMP transporter and inhibited transport of cGMP to an equal extent, suggesting that the two cyclic nucleotides compete for a common transport system. The rates of secretion of cGMP and cAMP from LLC-PK1 cells increased in proportion to their rates of synthesis as concentrations of stimulant were varied, but increased only 25% relative to intracellular concentrations in response to inhibition of phosphodiesterases by 3-isobutylmethylxanthine. It is proposed that secretion of cyclic nucleotides is not simply proportional to the total intracellular pool in these cells, but rather is coupled to synthesis. In support of this model, oxyhemoglobin was used to trap nitric oxide and block activity of guanylate cyclase in cells treated with 3-morpholinosydnonimine. As a result, secretion of cGMP ceased within 1 min, whereas intracellular levels decreased slowly over 60 min. Probenecid [p-(dipropylsulfamoyl)benzoic acid] is a nonselective antagonist of anion transport that inhibited secretion of cAMP in both cell types but, unexpectedly, blocked synthesis of cGMP, and this was reflected in direct inhibition of soluble guanylate cyclase in cell lysates. Two heat-stable, high molecular weight factors that confer sensitivity to probenecid were identified, and these factors increased the sensitivity of guanylate cyclase to nitric acid by an order of magnitude.

Serum immunoglobulin status of psychiatric in-patients

In view of the fact that substantial evidence today links psyche, brain, stress and immune system, the serum immunoglobulin (viz. IgG, IgA, IgM) levels in 40 patients with psychiatric disorders (viz. Schizophrenia, Affective disorder and generalized Anxiety disorders) have been investigated. With the exception of IgA, all psychiatric patients had significantly elevated IgG, IgM levels (p less than 0.001) when compared with healthy controls. Surprisingly these immunoglobulin levels irrespective of prevalent psychiatric disorder were almost similar to those of the hospitalized surgical patients pre-operatively (preferable controls), suggestive of no direct linear causal relationship between the psychiatric disorder and serum immunoglobulin levels. Factors affecting immunoglobulins have been discussed. Considering a probable viral association in Schizophrenia it is felt that simultaneous monitoring of viruses (affecting the nervous system) in the form of antigen/antibodies may be more informative.

Alkyl and aromatic isocyanide binding to haem complexes

Equilibrium constants for the binding of ethyl (EIC), n-butyl (BIC), p-toluenesulphonylmethyl (TMIC) and 2,6-dimethylphenyl isocyanides (DIMPI) to an imidazole-haem complex in toluene and aqueous detergent micelle solutions were determined. In contrast to an earlier study, which indicated that the large affinities of myoglobin for binding DIMPI and 2,6-diethylphenylisocyanide (DEPI) relative to EIC were due to an electronic effect, the present study shows a similarity in binding constants for EIC, BIC, and DIMPI to the imidazole-haem complex in toluene, suggesting no such electronic effect is present. The measured hydrophobic effect (KDIMPI/KEIC = 11) cannot account for the large binding constant reported for DIMPI relative to the binding of EIC to myoglobin. Based on the results of these model studies, the equilibrium binding constant for DIMPI to myoglobin has been re-measured and the standard free energy of binding has been analysed by a more recent method.

Macroscopic and scanning electron microscopic appearance and hardness values of developmental defects in human permanent tooth enamel

Defects present in 12 human permanent teeth were classified on the basis of their macroscopic appearance as hypoplasia (three teeth), diffuse opacities (three teeth), white demarcated opacities (one tooth but two defects), or yellow demarcated opacities (five teeth but six defects). The hardness values and SEM appearance of the defective enamel were determined after the teeth were sectioned through the lesion(s) and were distinctive for each type of defect. The thin enamel of the hypoplastic lesions was either opaque (with reduced hardness values) or translucent (with near-normal hardness values and sometimes a change in prism orientation external to an incremental line). The enamel of the diffuse and demarcated opacities was of normal thickness. The changes in the macroscopic and SEM appearance, and the reduced hardness values of the diffuse patchy opacities, were restricted to the outer 150 microns of the enamel. The demarcated opacities varied in position and depth, and in places had a clearly marked boundary with the adjacent normal enamel. Hardness values were related to color change, with yellow lesions being softer than white. Although prism direction was normal within demarcated opacities, prism outlines were less distinct. The findings suggest that temporary and permanent dysfunction of ameloblasts can occur in both secretory and maturation phases, influencing the final appearance of the lesion.

Steric and hydrophobic effects in alkyl isocyanide binding to Rhodospirillum molischianum cytochrome c'

Equilibrium constants for the binding of a series of alkyl isocyanides to ferrous cytochrome c' from Rhodospirillum molischianum have been measured spectrophotometrically. The equilibrium constants range from 3.3 M-1 to 2.6 x 10(2) M-1 and follow the order methyl greater than ethyl less than n-propyl less than tert-butyl less than n-butyl less than amyl less than cyclohexyl less than n-hexyl. The decrease in equilibrium constant from methyl to ethyl isocyanide provides evidence for a steric interaction between the ligand and the protein. The increase in equilibrium constant from ethyl to n-hexyl isocyanide is accounted for by a favorable partitioning of the ligand into a hydrophobic heme coordination site. The effect of steric interactions on the differences in the binding constants has been further evaluated by comparing the alkyl isocyanide and CO binding constants for the ferrous cytochrome c' to those of a sterically unconstrained model heme complex in a detergent micelle. The results indicate that the heme coordination site of the ferrous cytochrome c' is severely sterically hindered, similar to that of the reported crystal structure of Rs. molischianum ferric cytochrome c'.