Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit

AIM

To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes.

MATERIALS AND METHODS

Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022.

RESULTS

Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002).

CONCLUSIONS

The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Application of Noggin-Coated Electrospun Scaffold in Corneal Wound Healing

Purpose

The objective of this study is to develop and characterize electrospun corneal bandage infused with Noggin protein and evaluate its therapeutic potential in the treatment of superficial nonhealing corneal ulceration.

Methods

Electrospun nanofibrous scaffolds were created with different blend ratios of polycaprolactone and gelatin and coated with different concentrations of Noggin protein. Morphologic, mechanical, degradation, and surface chemistry of the developed scaffold was assessed. Biocompatibility of the developed scaffold with corneal epithelial cells was evaluated by looking at cell viability, proliferation, and immunostaining. In vitro wound healing in the presence of Noggin-coated scaffold was evaluated by measuring wound closure rate after scratch.

Results

Uniform nanofibrous scaffolds coated with Noggin were constructed through optimization of electrospinning parameters and demonstrated mechanical properties better than or similar to commercially available contact lenses used in corneal wound healing. In the presence of Noggin-coated scaffold, corneal epithelial cells showed higher proliferation and wound-healing rate.

Conclusions

This Noggin-coated electrospun scaffold represents a step toward, expanding treatment options for patients with indolent corneal ulcers.

Translational Relevance

In this study, the feasibility of Noggin-coated electrospun scaffold as a therapeutic for indolent corneal ulcer was evaluated. This study also provides a better perspective for understanding electrospun scaffolds as a tunable platform to infuse topical therapeutics and use as a corneal bandage.

Development of a Pneumatic-Driven Fiber-Shaped Robot Scaffold for Use as a Complex 3D Dynamic Culture System

Cells can sense and respond to different kinds of continuous mechanical strain in the human body. Mechanical stimulation needs to be included within the in vitro culture system to better mimic the existing complexity of in vivo biological systems. Existing commercial dynamic culture systems are generally two-dimensional (2D) which fail to mimic the three-dimensional (3D) native microenvironment. In this study, a pneumatically driven fiber robot has been developed as a platform for 3D dynamic cell culture. The fiber robot can generate tunable contractions upon stimulation. The surface of the fiber robot is formed by a braiding structure, which provides promising surface contact and adequate space for cell culture. An in-house dynamic stimulation using the fiber robot was set up to maintain NIH3T3 cells in a controlled environment. The biocompatibility of the developed dynamic culture systems was analyzed using LIVE/DEAD™ and alamarBlue™ assays. The results showed that the dynamic culture system was able to support cell proliferation with minimal cytotoxicity similar to static cultures. However, we observed a decrease in cell viability in the case of a high strain rate in dynamic cultures. Differences in cell arrangement and proliferation were observed between braided sleeves made of different materials (nylon and ultra-high molecular weight polyethylene). In summary, a simple and cost-effective 3D dynamic culture system has been proposed, which can be easily implemented to study complex biological phenomena in vitro.

Electrospun Carbon Nanotube-Based Scaffolds Exhibit High Conductivity and Cytocompatibility for Tissue Engineering Applications

Carbon nanotubes (CNTs) are known for their excellent conductive properties. Here, we present two novel methods, "sandwich" (sCNT) and dual deposition (DD CNT), for incorporating CNTs into electrospun polycaprolactone (PCL) and gelatin scaffolds to increase their conductance. Based on CNT percentage, the DD CNT scaffolds contain significantly higher quantities of CNTs than the sCNT scaffolds. The inclusion of CNTs increased the electrical conductance of scaffolds from 0.0 ± 0.00 kS (non-CNT) to 0.54 ± 0.10 kS (sCNT) and 5.22 ± 0.49 kS (DD CNT) when measured parallel to CNT arrays and to 0.25 ± 0.003 kS (sCNT) and 2.85 ± 1.12 (DD CNT) when measured orthogonally to CNT arrays. The inclusion of CNTs increased fiber diameter and pore size, promoting cellular migration into the scaffolds. CNT inclusion also decreased the degradation rate and increased hydrophobicity of scaffolds. Additionally, CNT inclusion increased Young's modulus and failure load of scaffolds, increasing their mechanical robustness. Murine fibroblasts were maintained on the scaffolds for 30 days, demonstrating high cytocompatibility. The increased conductivity and high cytocompatibility of the CNT-incorporated scaffolds make them appropriate candidates for future use in cardiac and neural tissue engineering.

Liquid metals: fundamentals and applications in chemistry

Post-transition elements, together with zinc-group metals and their alloys belong to an emerging class of materials with fascinating characteristics originating from their simultaneous metallic and liquid natures. These metals and alloys are characterised by having low melting points (i.e. between room temperature and 300 °C), making their liquid state accessible to practical applications in various fields of physical chemistry and synthesis. These materials can offer extraordinary capabilities in the synthesis of new materials, catalysis and can also enable novel applications including microfluidics, flexible electronics and drug delivery. However, surprisingly liquid metals have been somewhat neglected by the wider research community. In this review, we provide a comprehensive overview of the fundamentals underlying liquid metal research, including liquid metal synthesis, surface functionalisation and liquid metal enabled chemistry. Furthermore, we discuss phenomena that warrant further investigations in relevant fields and outline how liquid metals can contribute to exciting future applications.

Evolution of 2D tin oxides on the surface of molten tin

The exfoliation of two dimensional (2D) oxides, established on the surface of specific liquid metals, has recently been introduced.

Gastric specimens for diagnosing tuberculosis in adults unable to expectorate in Rawalpindi, Pakistan

Setting: Adult pulmonary tuberculosis (TB) patients unable to expectorate quality sputum represent a diagnostic challenge. A private hospital in Pakistan routinely performs gastric aspiration in adults with difficulties expectorating. Objective: To assess the usefulness of gastric specimens (GS) in diagnosing pulmonary TB (PTB) and drug-resistant TB in adult presumptive TB patients unable to expectorate, and to compare the diagnostic yield and sensitivity of smear, culture and the Xpert^® MTB/RIF assay. Design: This was a comparative cross-sectional study based on retrospective record review. Results: Of 900, 885 and 877 GS tested by smear, Xpert and culture, respectively, interpretable results were obtained for respectively 900 (100%), 859 (97.1%) and 754 (86.0%), with a diagnostic yield of respectively 23.6%, 30.3% and 24.9%. The yield was significantly higher for Xpert in previously treated patients. There were 313 patients with definite TB, defined as positive on Xpert and/or culture. The 82.8% sensitivity of Xpert was significantly higher than that of smear (61.0%) and culture (67.8%). Conclusion: GS obtained by aspiration under routine programme conditions is useful for detecting TB and drug-resistant TB in adult patients unable to expectorate. Xpert, with its rapid testing, high proportion of interpretable results and better sensitivity, can substantially improve the diagnosis of bacteriologically confirmed TB and rifampicin resistance.

Antibiotic susceptibility in Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes in Pakistan: a review of results from the Survey of Antibiotic Resistance (SOAR) 2002-15

OBJECTIVES

To investigate changes in the antibiotic susceptibility of Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2015 in Pakistan.

METHODS

This is a review based on previously published studies from 2002-03, 2004-06 and 2007-09 and also new data from 2014-15. Susceptibility was determined by Etest(®) or disc diffusion according to CLSI and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 706 isolates from CA-RTIs comprising 381 S. pneumoniae, 230 H. influenzae and 95 S. pyogenes were collected between 2002 and 2015 and tested against a range of antibiotics. Antibiotic resistance in S. pneumoniae rose steeply from 2002 to 2009, with isolates non-susceptible to penicillin and macrolides increasing from 10% to 34.1% and from 13%-14% to 29.7%, respectively. Susceptibility to amoxicillin/clavulanic acid (and by inference amoxicillin) remained between 99.4% and 100% from 2002 to 2015. Over the years, the prevalence of susceptibility to cefuroxime was 98%-100% among S. pneumoniae. Resistance in S. pneumoniae to some older antibiotics between 2007 and 2009 was high (86.8% for trimethoprim/sulfamethoxazole and 57.2% for tetracycline). Between 2002 and 2015, ampicillin resistance (β-lactamase-positive strains) among H. influenzae has remained low (between 2.6% and 3.2%) and almost unchanged over the years (H. influenzae was not tested during 2004-06). For S. pyogenes isolates, macrolide resistance reached 22%; however, susceptibility to penicillin, amoxicillin/clavulanic acid and cefuroxime remained stable at 100%.

CONCLUSIONS

In S. pneumoniae from Pakistan, there has been a clear reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (amoxicillin) or cefuroxime. However, susceptibility in H. influenzae has remained stable. Local antibiotic susceptibility/resistance data are essential to support informed prescribing for CA-RTIs and other infections.

Constituents of Cuscuto Reflexa are anti-HIV Agents

Crude water extracts of Cuscuta reflexa exhibited anti-HIV activity. Fractionation of the crude extract led to the isolation of nine pure compounds with closely related structures, showing interesting structure activity relationships. 3,5,7,4′-Tetrahydroxyflavanone (aromadendrin) inhibited infection by binding to V3 loop of gp 120 and inhibiting its interaction with CD4, whereas 3,5,7,3′,4′-pentahydroxyflavanone (taxifolin), with an extra OH group in the 3′ position in ring B was less specific and exhibited less selectivity in cell cultures. In general, flavanones containing an extra OH group in the 3′ position (taxifolin, taxifolin-7-O-β-D-glucopyranoside and coccinoside B) were less specific and inhibited viral protease, reverse transcriptase, CD4 /gp120 interaction in vitro and bound to non specific proteins. Other compounds isolated from C reflexa were derivatives of quinic acids; 3,4-O-dicaffeoylquinic acid was more active than 3-O-caffeoyl quinic acid. The anti-HIV activity of crude extract may be the result of combinatory effects with compounds of different modes of action.

Alkyl Hydrogen Phosphonate Derivatives of the anti-HIV Agent AZT may be Less Toxic than the Parent Nucleoside Analogue

Novel alkyl hydrogen phosphonate derivatives of the anti-HIV nucleoside analogue AZT have been prepared by phosphorochloridite chemistry. These materials are designed to act as labile membrane-soluble prodrugs of the bioactive free nucleotides. In vitro evaluation has revealed the compounds to have a pronounced and selective antiviral action. Short-chain (C1-C7) alkyl derivatives are more potent than the parent hydrogen phosphonate, whilst one long-chain (C18) compound is less active. In an assay that demonstrates the toxicity of the parent drug AZT, the alkyl H-phosphonates appear to be less cytotoxic, whilst retaining full antiviral activity. Lastly, the compounds are all poorly active in a cell line (JM) that is poorly responsive to AZT, indicating that they act as depot forms of the nucleoside rather than of the free nucleotide.

Inhibitory Effects of Novel Mannose-Binding Lectins on HIV-Infectivity and Syncytium Formation

Several new lectins were isolated and characterized with respect to their composition and sugar binding specificities and their ability to prevent HIV-1 infection. Twelve of the 13 mannose-specific lectins were inhibitory to varying degrees. The most effective were Machaerium biovulatum agglutinin (MBA) and M. lunatus agglutinin (MLA) which at 0.4 μg ml−1 prevented the cytopathic effect of the virus. Lower protection was obtained with Bowringia mildbraedii agglutinin (BMA), Galanthus nivalis agglutinin (GNA), Lablab niger agglutinin (LNA) and Dolichos lablab agglutinin (DLA). All these lectins are more protective than Con A while MBA is nearly 10 times more potent than any previously reported lectin. In each case the selective antiviral activity appears to be due to interaction with virus and not with some component on the target cell. MBA and GNA immobilized on Sepharose specifically bound gp120.

Studies of binding to glycoproteins confirmed the recognition of particular isomers of high mannose oligosaccharides Man9 to Man7GlcNAc2 by BMA and of Man5GlcNAc2 glycopeptides by GNA. By contrast, MBA did not bind oligomannosidic structures but did interact with ovalbumin, a glycoprotein rich in hybrid-type glycans.

Inhibition of the Production of HIV-1 from Chronically Infected H9 Cells by Metal Compounds and Their Complexes with L-cysteine or N-acetyl-L-cysteine

A number of metal compounds and their complexes with cysteine and N-acetyl-cysteine (NAC) were tested for their ability to inhibit HIV replication in vitro, specifically in chronically infected H9 cells (which produce virus continuously). Out of seven metal compounds tested, only bismuth nitrate and bismuth sodium tartrate inhibited virus production in chronically infected H9 cells. The complexes made with metals and cysteine or NAC had slightly improved selective indices.

Synthesis and Evaluation of Some Symmetrical Phosphate Dimer Derivatives of 3′-Modified Nucleosides as Potential anti-HIV Agents

Novel symmetrical nucIeotide-(5′,5′)-dimers of 3′-O-acetylthymidine, 3′-O-methylthymidine, 3′-O-ethylthymidine, 3′-O-n-propylthymidine and 3′-azido-3′-deoxythymidine (AZT) were synthesized as membrane soluble pro-drugs. These were prepared using phosphorodichloridate chemistry and were characterised by spectroscopic and analytical data. In-vitro evaluation of the derivatives in cells acutely infected with the human immunodeficiency virus (HIV-1) demonstrated a range of activities. These derivatives were generally found to display poor inhibition of HIV proliferation. Derivatives containing AZT moieties were found to be potent, but such compounds were less active than the parent nucleoside. The data indicated that the AZT-containing compounds act primarily via the release of the free nucleoside. However, in some cases, the dimers of certain inactive nucleoside analogues were found to be active. In these cases, release of the nucleoside alone cannot account for the activity.

Inhibition of HIV Infection by Caffeoylquinic Acid Derivatives

The caffeoylquinic acids 3,4,5-tri-O-caffeoylquinic acid (1) and 4,5-di-O-caffeoylquinic acid (2), as well as caffeic acid (4) and synapoic acid (5) were isolated from the plant Securidaka longipedunculata (polygalaceae). 1 exhibited a greater selective inhibition of HIV replication than 2 which had an anti-HIV activity similar to that of 3,4,5-tri-O-galloylquinic acid (3), isolated from Guiera senegalensis (combretaceae); 4 and 5 were ineffective and the structurally related compound rosmarinic acid (6) had only slight anti-HIV activity. Studies of the actions of these compounds suggest that inhibition of the viral reverse transcriptase in vitro is non-specific and that they act by specific binding to gp120 which prevents its interaction with CD4 on T-lymphocytes and thus inactivates virus infectivity.

Antiviral Activity of 2-Hydroxy Fatty Acids

Following an earlier demonstration of an antiviral effect against varicella-zoster virus (VZV, human herpesvirus 3) using 2-hydroxymyristic acid (2-hydroxytetradecanoic acid; 2-HM), an inhibitor of protein myristoylation, both 2-HM and 2-hydroxypalmitic acid (2-hydroxyhexadecanoic acid; 2-HP) have been tested against a range of viruses. Although both compounds inhibit the replication of varicella-zoster virus (VZV; human herpesvirus 3) they do not inhibit the replication of closely related herpesviruses. They do, however, inhibit the replication of both poliovirus (a member of the Picornaviridae) and the human immunodeficiency virus type 1 (HIV-1; a member of the Retroviridae). Neither compound is toxic to adherent cells by dye uptake assay, although limited toxicity is apparent to non-adherent cell lines at high concentrations. The mechanisms underlying these effects are discussed. A diminished effect of 2-hydroxymyristic acid when the compound is dissolved in dimethyl sulphoxide (DMSO) rather than ethanol is reported, and the implications for the use of DMSO as a ‘universal solvent’ for compound screening noted. Finally, it is suggested that targeting of ‘virus-essential’ cellular functions may provide an alternative route for inhibiting viral replication.

Antiviral Activity of N4-Aminocytidine Derivatives Related to AZT

A number of N4-hydroxy and N4-amino derivatives of 3′-azido-2′,3′-dideoxy-5-methylcytidine have been synthesized and tested for antiviral activity against HIV-1 and HIV-2. The N4-phenylamino and N4-dimethylamino analogues show marked anti-HIV activity which is comparable to that of AZT.

Screening of Compounds for Activity against HIV: A Collaborative Study

The collaborative study was undertaken to examine the sensitivity of a range of tests used in assessing the antiviral activities of compounds against human immunodeficiency virus (HIV). A panel of 20 compounds with diverse antiviral activities against HIV were tested under code at three antiviral testing centres supported by the Medical Research Council's AIDS Directed Programme and at the European Community Centralised Facility (ECCF) for New Antiviral Compounds against AIDS in Belgium. Compounds known to have major anti-HIV activity ranked high in all assays, with the exception of the glucosidase inhibitors and certain nucleoside analogues. Results of two assays based on MT4 cells (centre IV) showed a high degree of similarity, despite the use of distinct HIV-1 (HTLV-IIIB) and HIV-2 (ROD) viruses. Considerable similarity was also observed between the assays based on HTLV-IIIRF in C8166 cells (centres I and II). Other assays performed at centre II and at centre III had enhanced sensitivity for glycosidase inhibitors. The differences in anti-HIV activity that were observed may be attributable to specific properties of the cell lines used and particular testing methodologies. The use of more than one type of assay is advisable in order not to miss compounds with low to moderate activity against HIV.

The Enzymatic Synthesis and Anti-HIV Activity of 9-β-D-2-Deoxy and 9-β-D-2′,3′-Dideoxynucleossdes of 2-Aminopurine

The 9-β-D-2′-deoxy and 9-β-D-2′,3′-dideoxyribonucleosides of 2-aminopurine have been prepared using crude nucleoside N-deoxyribosyltransferases (E.C. 2.4.2.6) from Lactobacillus leichmannii in the presence of 10% ethylene glycol to inhibit degradation of the product nucleosides. The 2′,3′-dideoxynucleoside of 2-aminopurine is an inhibitor of the replication of HIV-1, HIV-2, and SIV with EC50 values in the range 8–100 μM depending on the cell line used and has low in vitro toxicity at its effective concentrations.

Antiviral Activity of Bicyclic Pyrimidine Nucleosides

A number of pyrimidine nucleosides, which may show two hydrogen bonding modes, have been prepared and tested for antiviral activity against a series of viruses. Whilst none of the compounds described showed significant activity against human immunodeficiency virus (HIV), the bicyclic 2′-deoxynucleoside, [2], derived from the base 6H,8H-3,4-dihydropyrimido[4,5-c][1,2]oxazin-7-one, was shown to inhibit herpes simplex virus type 1 (HSV-1) at similar concentrations as BVDU1 and ACV. Compounds 13, 6-(2-deoxyribofuranosyl)-6H,8H-2-methyl-3,4-dihydropyrimido[4,5-c][1,2]oxazin-7-one, and 14, N4-hydroxy-5-(2-chloroethyl)-2′-deoxyuridine, were as active as ACV against varicella-zoster virus (VZV).

IL-10 gene promoter and intron polymorphisms and changes in IL-10 secretion in women with idiopathic recurrent miscarriage

STUDY QUESTION

Is recurrent pregnancy loss (RPL) associated with polymorphisms in the promoter and intron regions of the interleukin-10 (IL-10) gene?

SUMMARY ANSWER

IL-10 rs1518111 was found to be associated with RPL but the commonly studied promoter variants rs1800872, rs1800871 and 1800896 were not.

WHAT IS KNOWN ALREADY

Reduced expression of IL-10 is implicated in RPL, due to defective maternal immune tolerance (causing early miscarriages) or placental vascular insufficiency (causing late losses). IL-10 production is in part inherited, and IL-10 gene variants associated with reduced IL-10 expression have been analyzed for their association with RPL, often with inconclusive results.

STUDY DESIGN, SIZE, DURATION

A retrospective case-control study was performed between January 2011 and April 2012. The subjects comprised 296 RPL cases and 305 control women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Genotyping of the IL-10 intron (rs1878672, rs3024492, rs1554286, rs1518111, rs3024491, rs3024490) and promoter (rs1800872, rs1800871, rs1800896) variants was done by real-time PCR, with defined clusters.

MAIN RESULTS AND THE ROLE OF CHANCE

A higher minor allele frequency (MAF) of rs1518111 (P = 0.03) was in seen RPL cases; but the MAFs of the remaining SNPs were comparable between cases and controls. Setting the homozygous major allele genotype (1/1) as the reference, significantly higher frequencies of heterozygous rs1554286 and rs1800872, and homozygous rs1800896 genotype carriers, and a reduced frequency of homozygous rs1518111 genotype carriers, were seen in RPL cases, while the distribution of the remaining genotypes were comparable between cases and controls. Serum IL-10 levels were significantly reduced in RPL cases compared with control women (P = 0.002), and this correlated with rs1518111 and rs1800871 genotypes in both groups, and with the rs1800872 genotype among control women. A nine-locus (rs1878672, rs3024492, rs1554286, rs1518111, rs3024491, rs3024490, rs1800872, rs1800871 and rs1800896) haploview analysis demonstrated an increased frequency of haplotype 112112121 in RPL cases, thus conferring a disease susceptibility nature to this haplotype.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of this study was that it was limited to Bahraini Arabs, thereby necessitating parallel studies of other ethnic groups. Another limitation is the study design, which prompts speculation on whether it is a cause-effect relationship.

WIDER IMPLICATIONS OF THE FINDINGS

While the lack of association of the various IL-10 promoter variants with RPL was in agreement with reports from varied ethnic groups, this is the first study to confirm the association between IL-10 rs151811 intronic variant and RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by grants from the Arabian Gulf University Research Fund. None of the authors report any competing interests.

Abstract P6-07-13: Local relapse and survival

Aim: Local recurrence may precede distant relapse and death. Many factors which predict local recurrence also predict death. Few studies have investigated the contribution of local recurrence to mortality independent of prior prognostic factors such as nodal status. We wished to estimate the extent to which overall survival is affected specifically by local recurrence.

Methods: 114 of of 2945 patients aged 19 to 94 years (mean 58.3) who had either mastectomy or breast conservation for breast cancer between 1991 and 2011 subsequently suffered an ipsilateral local recurrence. We matched, with one exception (due to extreme young age), each patient who had a local recurrence with 2 controls matched for calendar year of presentation, age, nodal status, grade, and tumour size. A Cox regression analysis of survival from the first therapeutic operation was done on the case matched subset with local recurrence coded dichotomously and age coded continuously as the absolute deviation from the population mean (as both young and old age affect survival adversely) as predictors. To confirm independence of the effect of local recurrence on the hazard of death a further Cox regression analysis of survival as above was done for the whole series with local recurrence, Grade 3, &gt;3 nodes involved, tumour diameter &gt;40mm, coded dichotomously, and age coded as above as independent variables.

Results: The results of the analyses are given in the table below.

Anti-HIV activity of dibenzylbutyrolactone-type lignans from Phenax species endemic in Costa Rica

Previously, we isolated two new dibenzylbutyrolactone-type lignans, named phenaxolactones and, from the leaves of Phenax angustifolius Wedd. (Urticaceae). In this investigation three new dibenzylbutyrolactone lignans (phenaxolactones), together with phenaxolactone, and flavones vitexin, isovitexin, were isolated from Phenax rugosus Wedd. leaves collected in Santa Ana, Costa Rica. The structures were elucidated using 1D and 2D NMR spectroscopy as well as mass spectrometry. Phenaxolactones and flavones and were evaluated for their inhibitory activity against HIV-1MN in infected C8166 cells. The most promising compound was phenaxolactone with an EC50 value of 3.0 microM, no cytotoxicity at 112 microM and a therapeutic index value of 37.3.

Literacy transition and female nuptiality: implications for fertility in Pakistan

"This paper is an attempt to examine trends and differentials in education and age at marriage of males and females [in Pakistan] and then relate the two variables to one important aspect of demographic behaviour, namely fertility, and evaluate the implication of these relationships on reduction of fertility in Pakistan." The data are from the 1981 census and the 1979-1980 Population, Labour Force and Migration (PLM) Survey. "Given the limitations of the survey data which pertain to a sample of ever-married women between the ages of 15 and 49 years, the main conclusions of the study are that a rise in female age at marriage and education at secondary and higher levels are important in affecting fertility levels." Policy implications of the findings are discussed. Comments by Akhtar Hasan Khan are included (pp. 601-3).

Suicidal nonfatal impalement injury of the thorax

We treated an impalement injury of the thorax resulting from a suicide attempt in the form of a road traffic accident. The patient survived and was discharged 5 weeks after his injury. The surgical management of thoracic impalement injuries and the rationale behind a multidisciplinary approach are discussed.

Naphthopyranone glycosides from Paepalanthus microphyllus

Three new naphthopyranone glycosides, paepalantine-9-O-beta-D-glucopyranosyl-(1-->6)-beta-D-glucopyranoside (1), paepalantine-9-O-alpha-L-arabinopyranosyl-(1-->6)-beta-D-glucopyranoside (2), and paepalantine-9-O-alpha-L-rhamnopyranosyl-(1-->6)-beta-D-glucopyranoside (3), along with the known paepalantine-9-O-beta-D-glucopyranoside (4) were isolated from aerial parts of Paepalanthus microphyllus. These compounds were characterized by spectrometric methods, including electrospray mass spectrometry and 1D and 2D NMR experiments. As a part of our program for screening natural compounds for anti-HIV activity, compounds 1-4 were tested in C8166 cells infected with HIV-1MN.

Protection against oxidative damage and cell death by the natural antioxidant ergothioneine

The natural antioxidant ergothioneine (EGT) was tested for its ability to inhibit cell death caused by hydrogen peroxide (H2O2) and to inhibit DNA oxidation by peroxynitrite (ONOO-) in human neuronal hybridoma cell line (N-18-RE-105). High concentrations of EGT (5 mM) were tolerated by the N-18-RE-105 cells. N-acetylcysteine (NAC) was not well tolerated by the cells at concentrations greater than 3 mM (cell viability averaged 50%). Increasing concentrations of EGT increases cell viability in the presence of NAC. EGT at concentrations up to 2 mM weakly improved cell viability in the presence of H2O2. NAC at concentrations up to 2 mM weakly decreased, but not significantly, the viability of the cells. At a higher concentration of 5 mM, NAC weakly protected the neuronal cells against the H2O2-induced cell death. The protection was significantly enhanced by preincubation with EGT. Ergothioneine inhibited ONOO(-)-induced oxidative damage in isolated calf thymus DNA and DNA in N-18-RE-105 cells. The concentration of EGT in human and mammalian tissue has been estimated to be 1-2 mM, which suggests that EGT may serve as a non-toxic thiol buffering antioxidant in vivo and may find applications in pharmaceutical preparations where oxidative stability is desired.

The patients perspective of extracorporeal shock wave lithotripsy

We studied the effect of a single analgesic regime for outpatient lithotripsy on the patient's perception of pain and the disruption of their normal activities by sending a postal questionnaire to 200 patients. Results showed that 15% of patients received insufficient analgesia during ESWL, 25% considered treatment painful, 6.8% had side effects from analgesia, 18% had delayed return to their normal activities and 33% contacted their doctor within a week of lithotripsy with problems related to it. This study shows that analgesic requirements of patients treated with modern lithotriptors are underestimated. This can be avoided by tailoring analgesia to individual needs and better patient communication.

Aspiration pneumonia in pediatric age group: etiology, predisposing factors and clinical outcome

INTRODUCTION

Aspiration pneumonia in children is an important disease in terms of the morbidity and mortality associated with it. The objective of this study is to characterize the cases of aspiration pneumonia on the basis of the predisposing factors, types of aspiration syndromes, materials aspirated and their clinical outcome.

METHODS

A total of 107 patients diagnosed as having aspiration pneumonia, were included in this study. Cases were between 0-15 years of age, admitted to the Aga Khan University Hospital (AKUH) over five years.

RESULTS

The most common form of aspiration syndrome seen was chemical pneumonitis (52.1%). The three most common factors predisposing to pulmonary aspiration were accidental ingestion (37.4%), altered consciousness (34.6%) and neurologic disorders (29%). Children who aspirated oropharyngeal flora were at higher odds to require mechanical ventilation than those aspirating inert fluids and particulate matter (OR = 6.4, 95% CI: 1.5-29.2, p = 0.003). Milk (31.8%), kerosene (21.5%) and oral secretions (19.6%) were the most common materials aspirated. Betel nuts were the most commonly aspirated foreign body. Patients aspirating oral secretions and milk were seen to have a relatively worse clinical outcome than those aspirating kerosene oil.

CONCLUSION

Aspiration pneumonia is a relatively uncommon clinical entity at AKUH in children. However, it does cause significant morbidity and mortality.

Expression of cytokeratin 20 redefines urothelial papillomas of the bladder

BACKGROUND

Most non-invasive urothelial tumours of the bladder are diagnosed as papillary carcinomas in accordance with the WHO classification and because the identification of papillomas is difficult by routine histology; some patients are therefore misdiagnosed. This practice is associated with psychological morbidity for the patient and may also skew cancer statistics. Cytokeratin 20 (CK20) is a sensitive marker of urothelial differentiation. We investigated whether this marker could be used in the identification of urothelial papillomas and used the rate of recurrence as an indicator to assess the biological behaviour of such tumours.

METHODS

In a prospective study, immunocytochemistry for CK20 was done on tumours of all patients who presented for the first time with non-invasive papillary bladder tumours. We classified the expression pattern of CK20 as normal or abnormal at the time of initial diagnosis. We recorded time to first biopsy-proven recurrence or length of follow-up when no recurrence was observed.

FINDINGS

Of 58 consecutive patients, ten had tumours with a normal pattern of CK20 expression. No patients developed further tumours during the follow-up (median 18 [range 13-28] months). By contrast, 30 (73%) of the 41 evaluable patients with tumours that showed abnormal CK20 expression developed further tumours; the median time to a second tumour was 6 (2-24) months. The only factor that had a significant effect on the outcome of patients in terms of recurrence was expression of CK20 (p<0.0001).

INTERPRETATION

Normal urothelial differentiation, as evidenced by a normal pattern of CK20 expression, is retained in a proportion of non-invasive papillary urothelial tumours and thus justifies use of the term urothelial papilloma. A large-scale study is needed to investigate the outcome of patients with such tumours.

Synthesis and anti-HIV activity of C4-modified pyrimidine nucleosides

One-pot syntheses provided a series of triazole- and pentafluorophenyloxy-substituted pyrimidine nucleosides. Most of the compounds in the series displayed anti-HIV activities but none as potent as AZT 2. 1-(beta-D-Erythro-pentofuranosyl)-4-pentafluorophenyloxy-2(1H)-pyr imidinone 14 was the most potent and the most selective compound in the series with EC50 = 1.6 microM.

[S]-AR-R 15896AR-A novel anticonvulsant: acute safety, pharmacokinetic and pharmacodynamic properties

A rational, chemical, synthetic effort to identify promising low-affinity uncompetitive N-methyl-D-aspartic acid receptor antagonists for use as antiepileptic drugs led to the discovery of AR-R 15035AR, or [RS]-alpha-phenyl-2-pyridine-ethanamine.2HCl. Chiral separation followed by intensive in vivo screening resulted in the selection of the [S] enantiomer, AR-R 15896AR, as the best compound for further preclinical development. AR-R 15896AR prevented tonic seizures in rodents for up to 6 to 8 h in response to maximal electroshock (MES), 4-aminopyridine, bicuculline, or strychnine, as well as characteristic seizures following injections of N-methyl-DL-aspartic or kainic acids. AR-R 15896AR was ineffective in two kindling models of epilepsy, did not produce tolerance to MES, and was devoid of proconvulsant and phencyclidine-like properties in mice and rats, respectively. Therapeutic indices for AR-R 15896AR were comparable to or exceeded those for standard anticonvulsants. Orally administered AR-R 15896AR rapidly entered the rat brain and was eliminated in parallel from the plasma and plasma-free compartment. A dose-response relationship between plasma and brain levels after p.o. or i.v. administration of AR-R 15896AR and protection against MES was highly correlative. The time course for loss of protection against MES mirrored the elimination of the compound from brain and plasma. The total brain concentration (25 microM) of drug at the ED50 value (approximately 3 mg/kg) for protection against MES seizures was consistent with the reported affinity of AR-R 15896AR at the N-methyl-D- aspartic acid binding site (IC50 value = 1.3 microM). The present findings demonstrated the attractiveness of AR-R 15896AR as a candidate for further development to treat epilepsy.

Anti-HIV activity and mechanism of action of macrocyclic diamide SRR-SB3

The importance of cyclic compounds as anti-cancer and anti-viral agents has been recognized for some time. We have studied a series of macrocyclic amide derivatives for activity against HIV infection of T lymphocytes in-vitro. Compounds containing aromatic rings and sulphur atoms were generally active, however the selectivity was greatly enhanced when two benzene rings were bridged by a disulphide linkage to produce 7-methyl-6,7,8,9-tetrahydrodibenzo[c,k][1,2,6,9]-dithiadiazacyc lododecine-5,10-dione (SRR-SB3). This compound was studied in detail with different cell and virus infections including macrophages and chronically infected H9 cells. It was active with an EC50 (the dose affording 50% inhibition of infection) of 0.05-01 microg mL(-1) and a TC50 (concentration reducing uninfected cell growth by 50%) of 50 microg mL(-1). The compound did not inhibit protease, but seemed to act by inhibiting maturation of progeny virus, by interfering with precursor protein processing. It was synergistic with AZT (3'-azido-3'-deoxythymidine; zidovudine) when tested in-vitro. The unusual mode of action and potent anti-HIV activity in T lymphocytes and macrophages makes this compound a potential candidate for clinical trials.

Mechanism of asbestos-mediated DNA damage: role of heme and heme proteins

Several observations, including studies from this laboratory, demonstrate that asbestos generates free radicals in the biological system that may play a role in the manifestation of asbestos-related cytotoxicity and carcinogenicity. It has also been demonstrated that iron associated with asbestos plays an important role in the asbestos-mediated generation of reactive oxygen species. Exposure to asbestos leads to degradation of heme proteins such as cytochrome P450-releasing heme in cytosol. Our simulation experiments in the presence of heme show that such asbestos-released heme may increase lipid peroxidation and can cause DNA damage. Further, heme and horseradish peroxidase (HRP) can cause extensive DNA damage in the presence of asbestos and hydrogen peroxide/organic peroxide/hydroperoxides. HRP catalyzes oxidation reactions in a manner similar to that of prostaglandin H synthetase. Iron released from asbestos is only partially responsible for DNA damage. However, our studies indicate that DNA damage mediated by asbestos in vivo may be caused by a combination of effects such as the release and participation of iron, heme, and heme moiety of prostaglandin H synthetase in free radical generation from peroxides and hydroperoxides.