A129 CYP2C19 PHARMACOGENETIC TESTING IN PAEDIATRIC PATIENTS WITH EOSINOPHILIC ESOPHAGITIS INFLUENCES DOSING OF PROTON-PUMP-INHIBITORS AND RESPONSE TO THERAPY

Background

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder that can be treated with a proton pump inhibitor (PPI). Pharmacogenetics (PGx) is the study of how variations in an individual’s genome influences drug response. Genetic variation in the metabolism gene CYP2C19 can produce differences in enzyme activity which is known to be a contributing factor for therapeutic failure with PPI treatment. Use of 2^nd generation PPI (rabeprazole) can be beneficial in some as this PPI is less effected by CYP2C19 metabolism. PGx has been studied in PPI therapy for peptic ulcer disease but has not been demonstrated in patients with EoE.

Aims

To describe the CYP2C19 metabolism in patients with EoE on PPI and to estimate the clinical utility of PGx testing in directing subsequent changes in therapy with improvement in remission rates.

Methods

Interim analyses of a single centre, non-interventional, ongoing descriptive pilot study investigating CYP2C19 metabolism in patients with EoE, as part of a larger PGx pilot study and EoE- AHEAD Registry Study at SickKids. Patients with EoE that were newly diagnosed and started PPI or those not in remission on current non-PPI therapy or not in remission on dose PPI (2 mg/kg/day, max 30 mg lansoprazole BID) were included. Active disease was defined as a peak eosinophil count >15/hpf.

Results

37 patients met the inclusion criteria with completed PGx test; mean age was 13 years, 29(78%) were male, and 13(35%) had concurrent atopic disease. PGx testing showed that 12(32%) and 4(11%) were rapid (RM) and ultrarapid metabolizers (URM) respectively (Fig.1), which is significantly higher than the population average. Of this subgroup, 9 started rabeprazole, 3 had a lansoprazole dose increase, and 4 had no changes. Overall, changes in therapy based on PGx testing were made in 29(78%) patients, 8 are awaiting follow-up (Fig 2). Currently, the patients with available repeat biopsy results after PGx test-guided therapy changes is limited due COVID-19 related delays in endoscopies.

Conclusions

The preliminary findings of our study using PGx to guide PPI dosing in pediatric patients with EoE demonstrate that PGx test results lead to a change in clinical management in most patients. In RM and URM, PGx results trigger an adjustment of PPI dose or type could lead to earlier disease remission in PPI-responsive patients, thereby optimizing PPI efficacy. PGx may support dose reduction in poor metabolizers aiming to avoid long-term adverse events.

Further correlation with endoscopy and histology findings of patients after PGx-guided therapy changes will follow. Furthermore, it is important to examine if CYP2C19 variant information available before PPI therapy further streamlines an initial phase of the treatment.

Funding Agencies

Dr. Marcon: J Garfield Campbell Fund, Dr. Hulst: Start-up Funds from the Department of Pediatrics at SickKids

A128 PATIENT CHARACTERIZATION AND ASSESSMENT OF REMISSION RATES IN CHILDREN WITH EOSINOPHILIC ESOPHAGITIS AFTER INITIAL TREATMENT AND 1-YEAR POST-DIAGNOSIS

Background

Eosinophilic esophagitis (EoE) is a chronic immune- or antigen-mediated esophageal disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. With incidence rates rapidly increasing, EoE is the leading cause of food bolus impaction and the second leading cause of chronic esophagitis. The treatment of EoE includes both induction and maintenance therapy to prevent complications including esophageal fibrosis and strictures. Despite significant advances in the diagnosis and treatment of EoE, the natural history and long-term management of the disease remains poorly understood.

Aims

To describe the clinical characterization of children with EoE, and to assess remission rates after initial treatment and 1-year post-diagnosis.

Methods

In this ongoing, single-center retrospective study, the electronic medical charts of children newly diagnosed with EoE between January 2017-March 2021 participating in the EoE-AHEAD Registry study were reviewed. Children aged 6 months-18 years with a confirmed diagnosis of EoE based on consensus guidelines and receiving outpatient care at the SickKids EoE clinic were included.

Results

A total of 37 children with a median age of 11 years (IQR: 4.5, 12.5) were included, the majority of which were male (86.5%). Demographic and clinical characteristics are shown in Table 1. On initial treatment, 2.7% of children were on an elemental diet, 18.9% on a food elimination diet, 40.5% on proton-pump inhibitor (PPI) therapy, 16.2% on topical steroids, 8.1% on systemic steroids, and 13.5% on a combination therapy. Of the 30 children with a second endoscopy (mean interval since diagnosis of 6.1 months (3.9)), 30% achieved histological remission after the initial treatment (see Figure 1). Of the 14 children with a one-year follow-up endoscopy, 14.2% were in remission, 3 of which had relapsed. No significant differences in treatment modality were found between those who achieved remission and those who did not.

Conclusions

This is the first Canadian registry study to examine the longitudinal outcomes of EoE in a pediatric setting. Our preliminary results show that only 30% of children achieved histological remission following first-line treatment. The choice of initial therapy varied, although the majority of patients (62.2%) were prescribed a PPI and/or a topical steroid. Our findings highlight the importance of identifying different disease phenotypes to develop personalized therapeutic approaches for the management of EoE.

Funding Agencies

SickKids start-up funds (JM Hulst) and the Comprehensive Research Experience for Medical Students (CREMS) Program

Immunohistochemical Analysis Of Breast Cancer Subtypes And Their Correlation With Ki 67 Index

BACKGROUND

Breast cancer is the second most common cancer in females including Pakistan. Nowadays immunohistochemistry has revolutionized management of breast cancer. In this study, we determined the frequency of various subtypes of breast cancer on the basis of immunohistochemical staining and their correlation with ki 67 index.

METHODS

Fifty consecutive diagnosed breast cancers cases received during the period February 2014 to February 2016, at Ayub Medical College, Pathology Department were included in this cross-sectional study. Immunohistochemistry for Oestrogen receptor (ER), Progesterone receptor (PgR), Her2neu and ki 67 index were applied and the results were recorded.

RESULTS

Out of 50 cases, 34 (68%) were positive for ER and PgR, 6 (12%) were positive for her 2 neu while 6 (12%) were triple positive and 4 (8%) were triple negative.

CONCLUSIONS

Low risk Luminal A was the most frequently encountered breast cancer category.

EXPRESSION OF PEROXISOME-PROLIFERATOR ACTIVATED RECEPTORS-γ IN DIABETICS, OBESE AND NORMAL SUBJECTS

BACKGROUND

Current researcn in type 2 diabetes mellitus focuses on the role of Peroxisome- Proliferator Activated Receptors (PPARs) in the pathogenesis of the Insulin Resistance Syndrome (IRS), which are pre-diabetic lesion and the hallmark of fully developed type 2 diabetes mellitus. This study aims at identifying the abnormal status of the PPAR-γ in adipose tissues of type 2 diabetes mellitus patients, when compared with matched normal controls.

METHODS

This cross-sectional study was conducted in Ayub Medical College, Abbottabad, from 2012 to 2014. Sample included three equal groups of patients. Group-1 with diagnosed type 2 diabetes mellitus, aged 40-65 years, acting as the test group, Group-2 included non-diabetic obese, and Group-3 with normal subjects. Transcription Factor Assay for Peroxisome Proliferator Activated Receptor Gamma (gamma PPAR) was done on ELISA Technique from Nuclear Extract procured from Adipose Tissue of the subjects.

RESULTS

Mean age of enrolled participants was 48.93 SD ± 6.52 years. Patients ranged between ages of 40 years to 67 years. The mean values of PPAR in normal, obese and diabetic group were 1.72 SD ± 0.28, 1.282 SE ± 0.18 and 1.283 SE ± 0.18 respectively. The difference in mean values of PPAR was significant p < 0.05:

CONCLUSION

The levels of PPAR-γ in patients with type 2 Diabetes Mellitus and Obese cases are significantly lower than normal controls.

RESUSCITATION OF NEWBORNS IN HIGH RISK DELIVERIES

BACKGROUND

High risk deliveries are usually associated with increased neonatal mortality and morbidity. Neonatal resuscitation can appreciably affect the outcome in these types of deliveries. Presence of personnel trained in basic neonatal resuscitation at the time of delivery can play an important role in reducing perinatal complications in neonates at risk. The study was carried out to evaluate the effects of newborn resuscitation on neonatal outcome in high risk deliveries.

METHODS

This descriptive case series was carried out at the Department of Obstetrics and Gynecology, Jinnah Hospital, Lahore. Ninety consecutive high risk deliveries were included and attended by paediatricians trained in newborn resuscitation. Babies delivered by elective Caesarean section, normal spontaneous vaginal deliveries and still births were excluded. Neonatal resuscitation was performed in babies who failed to initiate breathing in the first minute after birth. Data was analyzed using SPSS-16.0.

RESULTS

A total of 90 high risk deliveries were included in the study. Emergency. caesarean section was the mode of delivery in 94.4% (n=85) cases and spontaneous vaginal delivery in 5.6% (n=5). Preterm pregnancy was the major high risk factor. Newborn resuscitation was required in 37.8% (n=34) of all high risk deliveries (p=0.013). All the new-borns who required resuscitation survived.

CONCLUSION

New-born resuscitation is required in high risk pregnancies and personnel trained in newborn resuscitation should be available at the time of delivery.

Insulin deficiency among newly diagnosed type 2 diabetics

BACKGROUND

Any patient above the age of 40 years, coming with the symptoms of diabetes is labelled as type 2 diabetic. If insulin levels are included in the protocol for initial investigations of diabetic patients, they can be differentiated as having insulin deficiency or insulin resistance. They can thus be treated accordingly. This study was conducted to see the prevalence of insulin resistance and insulin deficiency in newly diagnosed type 2 diabetics.

METHODS

This study was conducted on 75 newly diagnosed diabetic subjects, and 75 control subjects for comparison. Fasting serum insulin was assayed by ELISA and HOMA-IR index was calculated. The diabetic subjects with fasting hyperglycaemia and serum insulin level below 20 microIU/ml and HOMA-IR index below 3.5 were grouped as insulin deficient (Group-A), and the diabetic subjects with fasting insulin level above 20 microIU/ml and HOMA-IR index above 3.5 were grouped as insulin resistant (Group-B).

RESULTS

Twenty-eight percent subjects were found to have insulin level below 20 microIU/ml while 72% subjects had insulin resistance. When gender was taken into consideration, it was seen that 18.7% males had fasting insulin level of 6.98 +/- 0.737 microIU/ml and 9.3% females had fasting insulin level of 5.21 +/- 0.885 microIU/ml while 32% males and 40% females had insulin resistance. The mean age of male subjects with insulin resistance was significantly higher compared to the male subjects with insulin deficiency. Mean weight and body mass index of the male and female subjects having insulin resistance was significantly higher than their respective control groups and also higher than the subjects with insulin deficiency. Pearson coefficient of correlation was calculated for fasting serum insulin level with age and BMI. A significant positive correlation was observed between fasting serum insulin and age of females with insulin resistance.

CONCLUSION

A considerable number of persons who develop diabetes after 40 years of age but are not insulin resistant. Twenty-eight percent subjects have relative insulin deficiency, and 72% subjects have insulin resistance.

Changing haematological parameters in dengue viral infections

BACKGROUND

Dengue Fever is the most common arboviral disease in the world, and presents cyclically in tropical and subtropical regions of the world. The four serotypes of dengue virus, 1, 2, 3, and 4, form an antigenic subgroup of the flaviviruses (Group B arboviruses). Transmission to humans of any of these serotypes initiates a spectrum of host responses, from in apparent to severe and sometimes lethal infections. Complete Blood count (CBC) is an important part of the diagnostic workup of patients. Comparison of various finding in CBC including peripheral smear can help the physician in better management of the patient.

MATERIAL AND METHODS

This cross sectional study was carried out on a series of suspected patients of Dengue viral infection reporting in Ittefaq Hospital (Trust). All were investigated for serological markers of acute infection.

RESULTS

Out of 341 acute cases 166 (48.7%) were confirmed by IgM against Dengue virus. IgG anti-dengue was used on 200 suspected re-infected patients. Seventy-one (39.5%) were positive and 118 (59%) were negative. Among 245 confirmed dengue fever patients 43 (17.6%) were considered having dengue hemorrhagic fever on the basis of lab and clinical findings. Raised haematocrit, Leukopenia with relative Lymphocytosis and presence atypical lymphocytes along with plasmacytoid cells was consistent finding at presentation in both the patterns of disease, i.e., Dengue Haemorrhagic fever (DHF) and Dengue fever (DF).

CONCLUSION

Changes in relative percentage of cells appear with improvement in the symptoms and recovery from the disease. These findings indicate that in the course of the disease, there are major shifts within cellular component of blood.

Effect of body mass index on serum leptin levels

BACKGROUND

Leptin is product of ob gene, an adipose tissue derived hormone that plays a key role in the regulation of body fat mass by regulating appetite and metabolism while balancing energy intake and energy expenditure. The objective of the study was to evaluate possible association between serum Leptin levels and Body Mass Index (BMI) of gender in adult age group.

METHODS

Two-hundred-seventy subjects aged 20-50 years were randomly selected from general population of Abbottabad. After complete evaluation, demographic data was recorded and BMI calculated. The subjects were grouped on the basis on BMI. Non-fasting venous blood samples were drawn to measure serum Leptin and serum glucose levels. The data were analysed using SPSS-15.

RESULTS

Serum Leptin levels and differences between genders were significant in all body mass indices. For normal BMI group the mean values for leptin were 2.6 +/- 1.5 etag/ml in men, and 17.3 +/- 10.2 etag/ml in women. For Group-2 mean leptin levels were 9.9 +/- 6.8 etag/ml in men, and 34.8 +/- 13.6 etag/ml in women. For Group-3 BMI comprising obese subjects mean values were 21.3 +/- 14.2 etag/ml in men, and 48.21 +/- 21.2 etag/ml in women (p<0.001).

CONCLUSION

A progressive increase in serum leptin concentration was observed with an increase in BMI. Significant difference between leptin concentrations in either gender was found in normal, overweight and obese subjects.

Affect of silymarin on serum levels of ALT and GGT in ethanol induced hepatotoxicity in albino rats

BACKGROUND

Alcoholic liver disease is a worldwide health problem. At least 80% of heavy drinkers have been reported to develop steatosis, 10-35% alcoholic hepatitis, and approximately 10% liver cirrhosis. The objective of this study was to determine the affect of silymarin on the levels of serum ALT and GGT in ethanol induced hepatotoxicity in albino rats. This study was an experimental Randomised Control Trial (RCT), and was conducted at the experimental research laboratory of University of Health Sciences, Lahore, from January 2007 to December 2007.

METHODS

Eighteen male albino rats of 6-8 weeks age, weighing 150-200 gm each were divided into 3 groups of 6 rats each. Group A served as control, Group B was given ethanol at a dose of 0.6 ml (0.5 gm)/100 gm/day and group C was given ethanol and silymarin at a dose of 0.5 gm/100 gm/day, and 20 mg/100 gm/day respectively for 8 weeks. At the end of the experiment, each animal was euthenised with chloroform. Blood was drawn from each animal by cardiac puncture for liver function tests (ALT and GGT). After taking blood sample, each euthenised animal was sacrificed and then its liver was removed for gross and histological examination.

RESULTS

The mean values of serum alanine-aminotransferase (ALT) in groups A, B and C were 28.16 +/- 7.13, 82.33 +/- 10.89 and 49.66 +/- 6.12 U/L respectively, whereas, the mean values of gamma-glutamyl transferase (GGT) in groups A, B and C were 27.33 +/- 3.05, 79.33 +/- 4.37 and 45.66 +/- 1.85 U/L respectively. ANOVA showed significant (p < 0.05) difference in mean value of these serum enzymes among groups. Post Hoc test, using the Tukey honestly significant difference (HSD) showed that there was significant (p < 0.05) increase in mean value of ALT and GGT in group B as compared to group A and C. This test also showed that there was significant (p < 0.05) decrease in mean value of these enzymes in-group C as compared to group B.

CONCLUSION

Silymarin tends to normalise liver function test in alcoholic liver disease.

Ethno-botanical studies from Northern Pakistan

BACKGROUND

In this research paper efforts have been made to document the ethno-botanical knowledge of important plant species found in Northern Pakistan. It includes Thandiani, Galiat, Kaghan, Swat, Buner, Dir, Chitral and Northern Areas of Pakistan. The area has many climatic and vegetation zones or biomes. Locals residing in mountainous areas belonging to various ethnic groups are traditionally utilizing plants over many generations; these ethnic groups have their distinct life style, belief, traditions and cultural heritage.

METHODS

Plant collection and data regarding traditional uses in various areas of Northern Pakistan has been done periodically in different flowering /fruiting seasons. Locals of old age belonging to various ethnic groups were personally interviewed for establishing uses of plants. Photography is done for easy identification and habitat recognition. Collected plant specimens and seeds were preserved. Plant species were dried, mounted, identified and authenticated.

RESULT

135 genera belonging from 66 families of angiosperms and gymnosperms were studied and described.76 species were known to have traditional and ethno botanical uses. Plants have been utilized for many generations. Ethnic groups have distinct life style and have different economic uses for these plants. Due to unsustainable exploitation of natural habitats scarcity of drug plants has occurred. As consequence some species are depleting and may become extinct in near future, e.g. Morchella esculenta, Colchicum lueteum and Viola serpens are just a few of these.

CONCLUSION

Although some sporadic information is available about the flora of this region but very little documented record of the ethno-botanically important plants has been established. It is expected that this research paper will be beneficial for students, researchers, farmers, foresters and general public. On the basis of data obtained it is concluded that ethno-botanical Flora of Northern Pakistan is quite rich and is diverse, due to the difference in altitude, climate and other topographic conditions.

Antioxidant status in coronary heart disease (CHD) patients with type 2 diabetes mellitus

BACKGROUND

The present study was carried out to see the levels of vitamin C, vitamin E and total antioxidant (AO) in Coronary Heart Disease (CHD) patients with and without Type-2 Diabetes Mellitus (T2DM). In various previous studies it has been reported that, diabetes, hypertension and smoking are risk factors for CHD and all risk factors were common in these patients.

METHODS

Serum was tested from 80 CHD patients and 21 healthy controls, matched for age, height, and weight.

RESULTS

No significant difference was seen between the age, height and weight of the subjects and controls. CHD patients were mostly male, smokers, over 40 year of age and belonging upper class families. The mean plasma glucose was significantly higher (p < 0.05) in CHD patients having T2DM as compare to CHD patient with out T2DM. Risk factors for CHD, like diabetes, hypertension and smoking were common in these patients. No significant difference was seen in vitamin C level of patients of CHD. Vitamin E level was significantly (p < 0.05) low among the CHD patients as compared to controls and a significant (p < 0.05) decrease in mean vitamin E level was observed among smoker CHD patients as compared to non-smoker CHD patients. But no significant difference in vitamin C and vitamin E levels of CHD patients with diabetes and hypertension were observed when compared with CHD patients having no such complaints. The CHD patients' total antioxidant level was significantly (p < 0.05) decreased as compared to controls.

CONCLUSION

The total AO (Vit. C and E) were not significantly higher in CHD patients with hypertension and diabetes as compared to those patients of CHD having no hypertension and diabetes.

Study of lipoprotein patterns as an atherogenic factor in T2DM patients and their FDRs

BACKGROUND

The present study was carried out to determine the lipoprotein patterns as an atherogenic factor in T2DM (Type 2 Diabetes Mellitus) patients and their FDRS (First Degree Relatives). In various previous studies it has been reported that hyperinsulinemia and hyperlipidemia frequently coexist in T2DM patients which indicate that the diabetic state it self is associated with atherogenic lipid disorders.

METHOD

The present study included 26 Type 2DM (T2DM) patients and 21 apparently healthy First Degree Relative (FDRs) of T2DM patients. Twenty three age matched control not related to diabetics were also included in the study.

RESULTS

The BMI in male patients and FDRs were significantly higher as compared to controls but no significant difference was seen among the BMI of female FDRs. Fasting plasma glucose (FPG) levels of T2DM patients were significantly higher but no significant difference was observed among the FDRs and controls. FPG did not show any significant correlation with the BMI in diabetic patients, FDRs and controls. The lipid profile of patients showed no significant difference, except the mean LDL-Chol of female patients was significantly higher as compared to female controls. HDL-Chol of males FDRs was significantly lower as compared to male controls. LDL-Chol of female FDRs was significantly lower than the female controls. No significant difference was observed in the total cholesterol and the triglycerides level of the patients of T2DM and FDRs but those cases in which pre-beta band appear upon lipoprotein electrophoresis had significantly higher triglyceride levels as compared to those patients in which pre-beta band did not appear.

CONCLUSION

Lipoproteins of the T2DM patients and FDRs group were found to be highly disturbed as compared to the control group and they show a trend of developing atherogenic states in future.

Topical application of mitomycin-C in oesophageal strictures

BACKGROUND

Benign oesophageal strictures may occur as a complication of caustic ingestion or severe gastro-oesophageal reflux or as a sequela of oesophageal surgery and other fibrosing conditions. The traditional initial treatment of oesophageal strictures is intraluminal dilation; however, even if frequent, this occasionally may not provide adequate oesophageal lumen capacity or give significant symptom-free intervals, and restricturing after dilation is difficult and challenging. Topical postdilation application of an antifibrotic agent, mitomycin-C, in the treatment of an oesophageal stricture has been described.

PATIENTS AND METHODS

Eight centres participated, with a total of 16 patients (4 girls), median age 48 (range 0-276) months. The causes of stricture were as follows: caustic (10), post-trachea-oesophageal fistula repair (2), peptic (2), Crohn disease (1), and dystrophic epidermolysis bullosa (1). The median (range) length and diameter of the strictures were as follows: 22 mm (8-50 mm) and 1.5 mm (1-6 mm). Of the 16 patients, 15 had undergone repeated dilations varying from 3 to more than 1000 (daily self-bouginage) before mitomycin-C, and the median interval between dilations was 4 weeks. Mitomycin-C 0.1 mg/mL was applied after dilation for a median time of 3.5 minutes and a median of 3 (1-12) times.

RESULTS

Major success, both endoscopic and clinical improvement or cure, occurred in 10 of 16 patients. In 3 of 16 patients the interval period between dilations increased dramatically. Failure of therapy was considered in 3 of 16. All of the patients remained symptom free for a follow-up time of as long as 5 years.

CONCLUSIONS

Postdilation application of topical mitomycin-C resulted in major success in 62.5% of patients and partial success in 19%, and it may be a useful strategy in oesophageal strictures of differing causes that are refractory to repeated perendoscopic dilation.

Release of vasopressin during suppression of oestrous cycle in rat by zoladex and hypovolemic challenge

BACKGROUND

The vasopressin (AVP) response to hypovolemia has been compared in intact and chemically castrated rats. This functional ovariectomy was done to confirm the findings in surgical ovariectomy of how gonadal steroids modulate the release of AVP under hypo-volemic challenge.

METHODS

Twenty female Sprague Dawley rats were checked for oestrous over two consecutive cycles. The ten control rats were given sub-cutaneous puncture only whereas the experimental were given Zoladex implant. On the fifteenth day all the rats were given intra-peitoneal injection of poly-ehylene glycol. All the rats were de-capitated after an hour.

RESULTS

The uterine weight was significantly decreased in experimental group. The plasma AVP level was also significantly decreased in the experimental group. The pituitary AVP level was significantly increased in the experimental group.

CONCLUSION

The chemical castration effected the AVP secretion, this proves that the sex steroids modulate the release of AVP secretion inspite of hypo-volemic challenge.

An index of depression in patients with chronic nonspecific musculoskeletal pain

BACKGROUND

The present study was undertaken to derive an index of depression in patients with chronic non-specific musculoskeletal pain and to determine correlation between these two parameters.

METHOD

The study was carried out at the Shaikh Zayed Hospital Lahore from November 2001 to May 2002 and included 36 patients with pain for at least 4-24 weeks duration; an equal number of healthy people acted as controls. Depression was assessed among subjects by administering the General Health Questionnaire (GHQ) to patients and controls and obtaining their GHQ scores. Pain assessment was performed in patients by scoring the total number of pain sites on digital palpation to provide a Total Pain Score (TPS).

RESULTS

Patients differed significantly from controls in their GHQ scores (patients 20.47 +/- 7.19, controls 3.11 +/- 1.89 respectively, p<0.001). The GHQ score and the TPS score correlated significantly in patients (r=0.517, p=0.001).

CONCLUSIONS

Patients with chronic non-specific musculoskeletal pain suffer from significant levels of depression, in direct correlation to their pain.

Endoluminal gastroplication in children with significant gastro-oesophageal reflux disease

AIMS

To describe paediatric experience, and to assess complications and therapeutic effectiveness of the use of endoluminal gastroplication in children with gastro-oesophageal reflux disease (GORD) refractory to, or dependent on, proton pump inhibitors.

METHODS

Seventeen (five male) consecutive children/adolescents (median (range) age 12.4 (6.1-15.9) years, median (range) weight 46.0 (16.5-87.5) kg) with GORD either dependent for more than 12 months on proton pump inhibitors or non-responsive to medical treatment underwent endoscopic gastroplication using a flexible endoscopic sewing device (EndoCinch). Three plications were placed in gastric tissue below the lower oesophageal sphincter. Drug dose requirement, pH measurements, daily symptom severity and frequency, and validated reflux (QOLRAD) and general gastrointestinal (GSRS) quality of life scores were compared before and after endoscopic gastroplication.

RESULTS

All patients showed post-treatment improvement in symptom severity, frequency, and quality of life scores (p<0.0001). Three patients with recurrent symptomatic GORD had a repeat procedure within six weeks and did well subsequently. At up to 33 months of follow up (median 23), 14/17 patients remained off all antireflux medications, and 14/17 had maintained their symptomatic improvement. All pH parameters improved and had returned to normal values in 14/16 patients post-treatment and in 6/9 after one year of follow-up: in particular the reflux index had decreased from a median of 16.6% (0.9-67%) to 2.5% (0.7-15.7%) (p<0.0001) six weeks and 4.3% (2.2-20.6) (p<0.02) 12 months post-procedure. The only complication observed was gastric bleeding in one patient due to previously undiagnosed coagulopathy, which spontaneously resolved.

CONCLUSIONS

Endoluminal gastroplication is an effective and safe procedure in children/adolescents with significant GORD refractory to, or dependent on, medical anti-GORD therapy.

Uric acid profile in patients with chronic nonspecific musculoskeletal pain

BACKGROUND

The present study was undertaken to determine the uric acid profile in patients with unexplained chronic musculoskeletal complaints, and to establish any possible causal role for altered uric acid profile in such patients.

METHOD

A comparative study of 36 patients and 36 controls of both sexes and ages between 25-60 years was carried out at Shaikh Zayed Hospital, Lahore from November 2001-May 2002. Patient included were those who had at least 4-24 weeks duration of complaints. Uric acid profile for serum uric acid, uric acid excretion, uric acid clearance and total uric acid production was done. Additional tests included renal functions test, liver function test, cardiac enzymes, haematology and serology to exclude other underlying causes of complaints.

RESULTS

Mean serum uric acid levels were higher in patients as compared to controls (p = 0.05), with 9 (25%) patients showing hyperuricemia. Uric acid clearance (female patients 5.86 +/- 0.42 ml/min, female controls 8.06 +/- 0.24 ml/min) and daily uric acid excretion (female patients 412.38 +/- 28.52 mg/24 hours, female controls 487.79 +/- 18.64 mg/24 hours) in female patients was significantly lower than control females (P = 0.034 and P < 0.001 respectively). Twenty patients (55.55%, 3 males and 17 females) were classified as under excretors of uric acid, while there were no under excretors in the control group (p < 0.001).

CONCLUSION

We conclude that abnormalities of uric acid profile, particularly under excretor status may be an underlying biochemical abnormality in a significant number of patients. Female patients appear more predisposed to abnormal uric acid profile such as hyperuricemia and under excretor status.

Cortisol response to a cognitive stress challenge in posttraumatic stress disorder (PTSD) related to childhood abuse

Preclinical studies show that animals with a history of chronic stress exposure have increased hypothalamic-pituitary-adrenal (HPA) axis reactivity following reexposure to stress. Patients with posttraumatic stress disorder (PTSD) have been found to have normal or decreased function of the HPA axis, however no studies have looked at the HPA response to stress in PTSD. The purpose of this study was to assess cortisol responsivity to a stressful cognitive challenge in patients with PTSD related to childhood abuse. Salivary cortisol levels, as well as heart rate and blood pressure, were measured before and after a stressful cognitive challenge in patients with abuse-related PTSD (N=23) and healthy comparison subjects (N=18). PTSD patients had 61% higher group mean cortisol levels in the time period leading up to the cognitive challenge, and 46% higher cortisol levels during the time period of the cognitive challenge, compared to controls. Both PTSD patients and controls had a similar 66-68% increase in cortisol levels from their own baseline with the cognitive challenge. Following the cognitive challenge, cortisol levels fell in both groups and were similar in PTSD and control groups. PTSD patients appeared to have an increased cortisol response in anticipation of a cognitive challenge relative to controls. Although cortisol has been found to be low at baseline, there does not appear to be an impairment in cortisol response to stressors in PTSD.

Portal Vein Thrombosis and Pancreatic Failure

We report a case of a child with portal vein thrombosis presenting with protein losing enteropathy. Helater developed exocrine and endocrine pancreatic failure. This association has not been reported before.

Is preoperative donation of autologous blood rational for radical retropubic prostatectomy?

PURPOSE

We investigated differences in the rate of homologous blood transfusion and the degree of anemia to determine whether it is rational to have patients donate autologous blood before radical prostatectomy.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 221 consecutive men who underwent radical retropubic prostatectomy performed by 1 surgeon in a 14-month period. About half of the patients donated autologous blood preoperatively. We evaluated perioperative hemoglobin, and the rate of autologous and homologous transfusion.

RESULTS

The groups did not significantly differ in terms of demographic data, co-morbid conditions, clinical variables or hospitalization. Preoperatively mean hemoglobin plus or minus standard deviation was 13.4 +/- 1 and 14.7 +/- 1 gm./dl. in patients who did and did not donate blood, while homologous transfusion was required in 1 (1%) and 4 (3.5%), respectively (p = 0. 18). At hospital discharge anemia was more prevalent in nondonors. Of the men who did versus did not donate blood hemoglobin was less than 10 and less than 9 gm./dl. in 8.4% versus 34% (p <0.0001), and 12.5% versus 0% (p <0.0004), respectively.

CONCLUSIONS

Our retrospective review of a cohort of patients who underwent radical retropubic prostatectomy showed no difference in homologous blood transfusion based on preoperative autologous donation status. Autologous donors had lower hemoglobin preoperatively, a higher rate of transfused units and higher hemoglobin at hospital discharge. Preoperative donation of autologous blood may not decrease the need for homologous transfusion in healthy patients undergoing radical retropubic prostatectomy.

Molecular analysis of a null mutant for pea (Pisum sativum L.) seed lipoxygenase-2

A mutant line of Pisum fulvum was identified that lacked seed lipoxygenase-2 (LOX-2). The mutant phenotype was introgressed into a standard Pisum sativum cv. Birte to provide near-isogenic lines with or without seed LOX-2. Genetic analyses showed the mutation to behave as a single, recessive Mendelian gene. Northern and dot-blot analyses showed a large reduction in LOX-2 mRNA from developing seeds of the LOX-2-null mutant. A restriction fragment length polymorphism associated with the 5' end of the LOX-2 gene(s) co-segregated with the null phenotype, indicating that the reduction of LOX-2 mRNA was neither a consequence of deletion of the LOX genes nor a consequence of the action of a genetically distant regulatory gene. Analysis of the 5'-flanking sequences of LOX-2 genes from Birte and the near-isogenic LOX-2-null mutant revealed a number of insertions, deletions and substitutions within the promoter from the LOX-2-null mutant that could be responsible for the null phenotype. Incubation of crude seed LOX preparations from Birte and the LOX-2-null mutant showed that the latter generated relatively less 13-hydroperoxides and also produced relatively more hydroxy- and ketoacid compounds that have implications for the fresh-frozen pea industry.

Correlation of transrectal ultrasound measurements of prostate and transition zone size with symptom score, bother score, urinary flow rate, and post-void residual volume

OBJECTIVES

To assess the correlation of total prostatic size and prostate transition zone dimensions with various measurements of the severity of bladder outlet obstruction secondary to benign prostatic hyperplasia.

METHODS

Prostate-specific antigen, creatinine, American Urological Association symptom score, bother score, urinary history, uroflowmetry, and post-void residual urine volume determination was followed by measurement of the prostate gland and transition zone on transrectal ultrasound images in 136 men undergoing systematic prostate biopsies. Patients were divided into five groups based on past urinary tract treatment history and the presence of prostate cancer on the biopsies. The total prostate and transition zone dimensions, as well as calculated prostate and transition zone volumes, were compared by Pearson correlation with both the subjective and objective voiding parameters in each patient group.

RESULTS

The transition zone dimensions correlated positively with American Urological Association symptom score, bother score, and post-void residual urine volume and correlated negatively with maximum and mean flow rates, particularly in patients with no history of prostate surgery, alpha-blocker administration, urinary infections, irritative voiding symptoms, or prostate cancer.

CONCLUSIONS

Transrectal ultrasound measurements of transition zone dimensions correlate better than total prostatic dimensions or calculated prostatic or transition zone volumes with the severity of benign prostatic hyperplasia. Of these, the transverse transition zone dimension demonstrated the best correlation; however, this correlation is probably not adequate for clinical utility.

Identification of changes in cardiac phospholipase C activity in congestive heart failure

Although phosphoinositide-specific phospholipase C (PLC) is involved in signal transduction mechanisms of the myocardial cell. very little is known about its status in congestive heart failure (CHF). We have examined the PLC activity in sarcolemmal and cytosolic fractions isolated from the viable left ventricle of rats at 8 weeks (moderate stage of CHF) and 16 weeks (severe stage of CHF) after occlusion of the left anterior descending coronary artery; the hypertrophied right ventricle was used for comparison. At 8 weeks, the hydrolysis of phosphatidylinositol 4,5-bisphosphate by sarcolemmal PLC was reduced by 37% of sham control values only in the left ventricle, whereas at 16 weeks, PLC-mediated hydrolysis was depressed in both left and right ventricles by 25% and 30%, respectively. The hydrolysis of phosphatidylinositol 4-monophosphate (PIP) was reduced by 25% of control value only in the severely failing left ventricle, while the phosphatidylinositol (PI) hydrolysis remained unaltered. Kinetic studies of PLC activity in the left ventricle showed a depression of V(max) at moderate and severe failure stages, whereas the affinity for the substrate was increased in the left ventricle at 8 weeks and decreased in the right ventricle at 16 weeks. The only difference observed between experimental and control groups at the cytosolic level, was a significant enhancement of PLC activity in the severely failing left ventricle when PIP was given as a substrate, and in the corresponding right ventricle when PI was the substrate. The results of this study identify time-related defects in sarcolemmal PLC in right and left ventricles during the development of CHF due to myocardial infarction.

Decreased expression of cardiac sarcoplasmic reticulum Ca(2+)-pump ATPase in congestive heart failure due to myocardial infarction

Myocardial infarction in rats induced by occluding the left coronary artery for 4, 8 and 16 weeks has been shown to result in congestive heart failure (CHF) characterized by hypertrophy of the viable ventricular myocardial tissue. We have previously demonstrated a decreased calcium transport activity in the sarcoplasmic reticulum (SR) of post-myocardial infarction failing rat hearts. In this study we have measured the steady state levels of the cardiac SR Ca(2+)-pump ATPase (SERCA2) mRNA using Northern blot and slot blot analyses. The relative amounts of SERCA2 mRNA were decreased with respect to GAPDH mRNA and 28 S rRNA in experimental failing hearts at 4 and 8 weeks post myocardial infarction by about 20% whereas those at 16 weeks declined by about 35% of control values. The results obtained by Western blot analysis, revealed that the immunodetectable levels of SERCA2 protein in 8 and 16 weeks postinfarcted animals were decreased by about 20% and 30%, respectively. The left ventricular SR Ca(2+)-pump ATPase specific activity was depressed in the SR preparations of failing hearts as early as 4 weeks post myocardial infarction and declined by about 65% at 16 weeks compared to control. These results indicate that the depressed SR Ca(2+)-pump ATPase activity in CHF may partly be due to decreased steady state amounts of SERCA2 mRNA and SERCA2 protein in the failing myocardium.

Sarcoplasmic reticular Ca2+ pump ATPase activity in congestive heart failure due to myocardial infarction

OBJECTIVE

Earlier studies have shown a depression in the sarcoplasmic reticular (SR) Ca2+ uptake and gene expression in Ca2+ pump ATPase protein in congestive heart failure subsequent to myocardial infarction. It is the objective of this study to understand further the mechanisms of depressed SR Ca2+ pump activity in the failing heart.

METHODS

Heart failure in rats was induced by occluding the left coronary artery for 16 weeks and the viable left ventricle was processed for the isolation of SR membranes. Sham-operated animals were used as control. The characteristics of SR Ca2+ pump ATPase in the presence of different concentrations of K+, Ca2+ and ATP were examined and the purity of these membranes was monitored by determining the marker enzyme activities. In addition to measuring changes in cyclic adenosine monophosphate (cAMP) protein kinase and Ca(2+)-calmodulin induced phosphorylation, alterations in SR phospholipid composition as well as sulfhydryl (SH) group content were investigated.

RESULTS

Ca(2+)-stimulated ATPase activity, unlike Mg(2+)-ATPase activity, was depressed in the left ventricular SR from failing hearts as compared to control. The decrease in Ca(2+)-stimulated ATPase activity was seen at different concentrations of Ca2+, K+ and ATP but no changes in the affinities of the enzyme for Ca2+ and ATP were evident. The SR Ca(2+)-stimulated ATPase activities in the presence of both cAMP-dependent protein kinase and Ca(2+)-calmodulin were markedly decreased in the failing hearts when compared to control preparations. Furthermore, the 32P incorporation in the presence of cAMP-dependent protein kinase or Ca(2+)-calmodulin was also reduced in the experimental heart SR membranes. The phospholipid composition of the SR membranes from the failing heart was markedly altered. No changes in SH-group or the degree of cross contamination with other membranes were apparent in the failing heart SR.

CONCLUSIONS

These results suggest that abnormalities in membrane phospholipid composition and phosphorylation of the enzyme may partly explain the observed depression in SR Ca2+ pump ATPase activity in heart failure following myocardial infarction.

Pathophysiology of cardiac dysfunction in congestive heart failure

Although various factors, such as myocardial infarction, pressure overload and volume overload, result in the development of congestive heart failure (CHF), the pathogenesis of contractile dysfunction in this situation is poorly understood. Loss of cardiac muscle due to myocardial infarction appears to activate several humoral and hormonal pathways, including the renin-angiotensin and sympathetic systems which serve as adaptive mechanisms to maintain cardiovascular performance at early stages of failure. However, under chronic conditions, an altered hormonal profile produces deleterious effects and permits transition from the compensated heart to the failing heart. Since several risk factors--such as hypertension, hypercholesteremia, stress, diabetes, smoking, ageing, obesity and lack of exercise--precipitate ischemic heart disease, it is possible that development of CHF due to myocardial infarction may vary according to the nature of these pathogenetic entities. While a great deal of research work remains in this area of investigation, it is becoming evident that cardiac dysfunction is intimately associated with calcium handling abnormalities of cardiac cells. In view of the role of sarcolemma, sarcoplasmic reticulum and mitochondria in regulating the intracellular concentration of Ca2+ and the importance of myofibrillar interaction with Ca2+, it appears that Ca2+ handling and Ca2+ interaction abnormalities in the failing heart are due to remodelling of different subcellular organelles. Such a remodelling of the subcellular organelles may be due to changes in gene expression for different protein components or the interactions of proteins with phospholipids. Accordingly, it is proposed that new interventions, which could prevent the remodelling of subcellular organelles, be developed for improving the therapy of CHF.

Differential changes in left and right ventricular SR calcium transport in congestive heart failure

To examine the status of sarcoplasmic reticulum (SR) with respect to Ca2+ transport in congestive heart failure due to myocardial infarction, the left coronary artery in rats was ligated for 4, 8, and 16 wk. The left heart function was assessed with an intraventricular pressure transducer, and SR membrane fractions from the right ventricle and the viable left ventricle were isolated for measuring the ATP-dependent Ca2+ uptake activities. In comparison to sham-operated controls, SR Ca2+ uptake activity was decreased in viable left ventricle of the experimental animals at 4, 8, and 16 wk. On the other hand, SR Ca2+ uptake activity in the right ventricle was increased at 4 and 8 wk, but no change was apparent at 16 wk of coronary occlusion. The decrease in SR Ca2+ uptake in left ventricle and increase in right ventricle were associated with corresponding changes in maximal velocity values without any alterations in the affinity for Ca2+. These opposite changes in the right and left ventricles were dependent on the scar size as well as time after inducing the myocardial infarction. The SR Ca(2+)-stimulated adenosinetriphosphatase activity was decreased in left ventricle and increased in the right ventricle from 4 wk experimental animals. The results suggest differential remodeling of the SR membranes with respect to Ca(2+)-pump mechanisms in left and right ventricles during the development of congestive heart failure.

Detection of HIV-antibody evaluation of four commercially available enzyme immunoassays

We evaluated 550 serum samples with four commercially available enzyme immunoassays and Western Blot was used as the confirmatory test for antibodies against human immunodeficiency virus (HIV). The Wellcozyme (Wellcome), Flow HIV-TEK G, and Behring test kits identified all 50 Western Blot positive samples correctly, whereas DuPont failed to detect one sample. None of the kit was able to pickup one sample that showed a faint P24 band on Western Blot strip. The frequency of false positive reaction in the 500 negative serum samples were Wellcome 0%, Behring and DuPont 0.2% and Flow HIV-TEK 0.4%.

Cataract formation is prevented by administration of verapamil to diabetic rats

The purpose of the present study was to examine the effects on cataractogenesis of daily sc administration of the Ca2+ antagonist drug verapamil to diabetic rats. Streptozotocin-induced diabetic rats were given verapamil half-way through the 8-week experimental period or during the full 8 weeks of diabetes. Verapamil administration had no effect on the high blood glucose values, low circulating insulin levels, or elevated triglyceride and cholesterol concentrations in the diabetic rats. Untreated diabetic rats had a 90% incidence of cataracts. Four weeks of verapamil administration reduced this incidence to 41%, and a full 8 weeks of drug treatment further lowered the incidence to 20%. Diltiazem, another Ca2+ antagonist, lowered the incidence of cataracts in the diabetic rats to a similar extent. Verapamil administration to the diabetic animals also partially protected against the presence of retinal microangiopathy in the diabetic animals. Lenticular hydration and lipid accumulation were only indirectly related to cataractogenesis in the diabetic rats and its protection by verapamil treatment. Lenticular electrolyte imbalance, particularly Ca2+, in the diabetic animals was closely correlated with cataract formation, and verapamil significantly reduced the alterations in these ion concentrations. The present results demonstrate the efficacy of verapamil as a protective agent against cataractogenesis and some retinal damage in diabetic animals. Most importantly, this occurs in the absence of any change in the glycemic status of the diabetic animals. The findings strongly support a role for lenticular Ca2+ imbalance in cataract development in diabetes and provide initial evidence to suggest its clinical use in the diabetic population at risk for blindness.

Influence of verapamil on some subcellular defects in diabetic cardiomyopathy

The effects of verapamil on cardiac myofibrillar adenosinetriphosphatase (ATPase) activity, myosin ATPase, and myosin isoenzyme profile as well as sarcoplasmic reticular Ca2+ uptake and ATPase activities were examined in Sprague-Dawley rats made diabetic with a single injection of streptozotocin (65 mg/kg). Myofibrillar ATPase activity and myosin Ca2+ ATPase activity as well as Ca2+ uptake and Ca2+-stimulated ATPase activities of the sarcoplasmic reticulum were significantly decreased in diabetic hearts in comparison to the control values. The myosin isoenzyme component V3 was prominent in diabetic hearts, whereas V1 isoenzyme was the major myosin component in control hearts. Chronic treatment of diabetic rats with verapamil (8 mg/kg daily for 4-8 wk) resulted in an improvement of the altered myofibrillar ATPase activity, myosin ATPase, myosin isoenzyme distribution, and sarcoplasmic reticular Ca2+-pump activities in ventricular tissue. The ability of verapamil to normalize the observed defects in the subcellular organelles in diabetic cardiomyopathy may be related to its effects in controlling the entry of Ca2+ into the cardiac cell.

Long term care of AIDS patients

Institutional long term care (LTC) can be important for AIDS patients because they frequently survive acute illness episodes yet remain severely incapacitated. Many of them are also homeless, or their families or friends are unwilling or unable to care for them. In three years of providing LTC for AIDS patients, staff at Coler Memorial Hospital in New York City have learned that accommodating the patients' fluctuating care needs is one of the program's greatest challenges. Some differences from other chronic care programs are the patients' needs for medically intensive services, their more frequent contagious infections, and their experimental drug regimens.

Beneficial effects of verapamil in diabetic cardiomyopathy

It has been suggested that the occurrence of an intracellular Ca2+ overload may result in the development of diabetic cardiomyopathy, which is associated with depletion of high-energy phosphate stores and a derangement of ultrastructure and cardiac dysfunction. Accordingly, the effects of verapamil, a Ca2+ antagonist, on cardiac function, ultrastructure, and high-energy phosphate stores in the myocardium were evaluated in rats made diabetic by an intravenous injection of streptozocin (65 mg/kg). Four weeks after the induction of diabetes, the animals were treated with three doses (2, 4, or 8 mg.kg-1.day-1) of verapamil for 4 wk until they were used for the measurement of different parameters. Untreated diabetic animals had slower heart rates, depressed rate of contraction and rate of relaxation, lower peak left ventricular systolic pressure, and elevated left ventricular diastolic pressure. All of these changes were significantly improved in diabetic rats receiving verapamil treatment. The beneficial effects of verapamil were more evident with higher doses (8 mg.kg-1.day-1) than with the lower doses (2 mg.kg-1.day-1). The diabetic animals also showed alterations in myocardial high-energy phosphate stores and exhibited evidence of ultrastructural damage; these abnormalities were improved by verapamil treatment without affecting their hyperglycemic status. Our results demonstrate that verapamil is capable of preventing diabetes-induced myocardial changes and support the involvement of Ca2+ in the cardiac pathology during diabetes.