Total temporomandibular joint reconstruction prosthesis in hemifacial microsomia: A systematic review

Hypoplastic asymmetry due to hemifacial microsomia (HFM) often represents the most difficult reconstruction in the craniomaxillofacial clinic. Although autogenous grafts are generally used for temporomandibular joint reconstruction (TMJR), the use of TMJR prostheses is not well established. The aim of this review was to identify, collect and analyse the use of extended TMJR (eTMJR) prostheses in patients with HFM, describing clinical features, surgical procedures and postoperative complications. Online searches of all major databases were performed according to PRISMA guidelines. All studies with HFM patients treated with the eTMJR prostheses were included. Descriptive statistics were used for data analysis. A total of 19 studies, including 08 case studies, 06 case series and 05 retrospective cohort studies, met the inclusion criteria, where a total of 42 HFM patients were reported from 18 countries, mostly from the United States (05; 26%). Fifteen of the 42 cases (~36%) were male. The mean ± SD (range) age of patients in all studies was 19.79 ± 5.81 (9-36) years. The mean ± SD (range) of patient follow-up was 41.30 ± 35.50 (6-136) months. A total of 5 (10.6%) patients were implanted with bilateral eTMJR prostheses. The Pruzansky classification was used in 18 (~89.5%) studies, OMENS classification in 01 (~5%) study, whereas no classification was reported in one study. Only 01 (7.1%) study had documented the eTMJR classification for the prosthesis used. In growing patients with or without a history of failed autogenous tissues, TMJR prostheses may provide a viable alternative. Randomized studies with large cohorts are warranted to validate these preliminary results.

Remineralization potential of phosphorylated chitosan and silver diamine fluoride in comparison to sodium fluoride varnish: invitro study

PURPOSE

The purpose of this study was to evaluate and compare the remineralization potential of phosphorylated chitosan nanoparticles (Pchi) and silver diamine fluoride (SDF) compared to sodium fluoride varnish (NaF) on microhardness of artificial carious lesions in a biomimetic minimally invasive approach that is being regarded as the future of preventive dentistry.

METHODS

The sample size included 40 intact extracted maxillary anterior human teeth. Baseline microhardness was recorded using Vickers hardness test and energy-dispersive X-ray spectroscopy (EDX). Artificial caries-like lesions were created on the exposed enamel by suspending all teeth in demineralizing solution for 10 days in a temperature of 37 °C and then the hardness and EDX were remeasured. Samples were then divided into four main groups: Group A (positive control group) n = 10, treated with NaF, Group B n = 10, treated with SDF, Group C n = 10, treated with Pchi and Group D (negative control group) n = 10 that received no treatment. After treatment, samples were incubated in artificial saliva solution at 37 °C in for 10 days and then reassessed. Data were then recorded, tabulated, and statistically analyzed using Kruskal-Wallis test and Wilcoxon signed test. Scanning electron microscope (SEM) was used to analyze the morphological changes of enamel surface after treatment.

RESULTS

Groups B and C showed the highest calcium (Ca) and phosphate (P) content as well as hardness values, while group B had the highest percentage of fluoride. SEM revealed a smooth layer of mineral formed on the surface of enamel for both groups.

CONCLUSION

Pchi and SDF showed the highest increase in enamel microhardness and remineralization potential.

CLINICAL RELEVANCE

The minimally invasive approach for remineralization could be enhanced using SDF and Pchi.

Clinical Profiles and Outcomes of Cytomegalovirus Positive Renal Transplant Patients in Early Post-Transplant Period

Cytomegalovirus infection can cause increased mortality and morbidity in renal transplant recipient. The purpose of the present study was to observe the clinical profiles and outcomes of Cytomegalovirus positive renal transplant patients in early post-transplant period. This prospective cohort study was conducted in the Department of Nephrology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from September 2016 to August 2017. Adult patients who had undergone renal transplantation were selected as study population. CMV serology (CMV IgM and CMV IgG) of both donor and recipient were detected before renal transplantation. Cytomegalovirus viral DNA was extracted from both serum by using a commercially available DNA extraction kit and PCR was done by the StepOne™ PCR machine using real time PCR kit in all patient during the early post-transplant period. During this period, sign symptoms of patients with cytomegalovirus infection as well as clinical outcomes were also noted. Total number of 32 patients was included in this study with the mean age of 31.15±11.56 years. Cytomegalovirus was found positive in 11(34.4%) patients and negative in 21(65.6%) patients. Anorexia was the most common presentation which was found in 81.8% cases followed by renal impairment, fever, diarrhea, cough and weight loss which were present in 6(54.5%), 3(27.3%), 2(18.2%), 2(18.2%) and 2(18.2%) cases respectively. The outcomes of cytomegalovirus positive patients in first 6 months after renal transplantation revealed 25.0% patients had cytomegalovirus infection; 6.2% patients had cytomegalovirus disease and 6.2% patients were died. However, 9.4% patients had co-infection in the form of UTI and 6.2% patients had re activation of hepatitis C infection associated with cytomegalovirus infection. Cytomegalovirus was found positive in approximately one third of renal transplant recipients in early post-transplant period. Careful clinical evaluation and appropriate laboratory parameters should be looked over for timely diagnosis and management of these cases.

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis

AIMS

Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period.

METHODS AND RESULTS

Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference -17.73 mmHg, (95% confidence intervals -34.50 to -0.96); I2 = 94%] and lower cardiac output [mean difference -0.75 l/min, (-1.11 to -0.39); I2 = 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I2 = 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I2 = 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension.

CONCLUSION

Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.

Effect of slow-release amylase on extraction of peach peel phenolics and their antioxidant activities

The present manuscript demonstrates the work undertaken to optimise and validate a slow-release amylase-assisted extraction of polyphenols from peach fruit peel. A careful investigation and optimisation revealed that peach peel when hydrolysed with 1.50% (w/w) of SRA containing enzyme formulation at 40 °C and 6.1 pH, for 35 min significantly (P < 0.05) increased the extraction yield, levels of polyphenol contents (242.89 ± 1.56 mg gallic acid equivalents – GAE), and coumaric, chlorogenic, ferulic acids or their conjugate esters in extracts. Moreover, the extracts produced through SRA-assisted extraction exhibited ample level of free radical scavenging capacity (DPPH IC50 2.67 ± 0.03 μg mL−1), Trolox equivalent (TE) antioxidant capacity (450.52 ± 24.58 µmol of TE g−1), inhibition of peroxides in linoleic acid (85.68 ± 0.21%), and ferric reducing power of 3.11 ± 0.20 ppm gallic acid equivalents. The results suggested that the incorporation of SRA containing enzyme formulation may enhance the recovery of peach peel polyphenols while hydrolysing the glycosidic linkages without deteriorating their antioxidant character.

Feasibility of establishing a Canadian Obstetric Survey System (CanOSS) for severe maternal morbidity: a study protocol

INTRODUCTION

Severe maternal morbidity (SMM)-an unexpected pregnancy-associated maternal outcome resulting in severe illness, prolonged hospitalisation or long-term disability-is recognised by many, as the preferred indicator of the quality of maternity care, especially in high-income countries. Obtaining comprehensive details on events and circumstances leading to SMM, obtained through maternity units, could complement data from large epidemiological studies and enable targeted interventions to improve maternal health. The aim of this study is to assess the feasibility of gathering such data from maternity units across Canadian provinces and territories, with the goal of establishing a national obstetric survey system for SMM in Canada.

METHODS AND ANALYSIS

We propose a sequential explanatory mixed-methods study. We will first distribute a cross-sectional survey to leads of all maternity units across Canada to gather information on (1) Whether the unit has a system for reviewing SMM and the nature and format of this system, (2) Willingness to share anonymised data on SMM by direct entry using a web-based platform and (3) Respondents' perception on the definition and leading causes of SMM at a local level. This will be followed by semistructured interviews with respondent groups defined a priori, to identify barriers and facilitators for data sharing. We will perform an integrated analysis to determine feasibility outcomes, a narrative description of barriers and facilitators for data-sharing and resource implications for data acquisition on an annual basis, and variations in top-5 causes of SMM.

ETHICS AND DISSEMINATION

The study has been approved by the Mount Sinai and Hamilton Integrated Research Ethics Boards. The study findings will be presented at annual scientific meetings of the Society of Obstetricians and Gynaecologists of Canada, North American Society of Obstetric Medicine, and International Network of Obstetric Survey Systems and published in an open-access peer-reviewed Obstetrics and Gynaecology or General Internal Medicine journal.

Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review

Background

The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction.

Method

Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations.

Results

We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options.

Interpretation

There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04409-4.

Induction of labour in pregnant individuals with obesity

People with obesity may require induction of labour (IoL) due to a higher incidence of pre-existing comorbidities and pregnancy complications, as well as to prevent post-term pregnancies and late-term stillbirths. IoL at 39-40 weeks is associated with fewer caesarean births and lower morbidity for the pregnant person and neonate when compared with expectant management. Ensuring the success and safety of IoL in people with obesity requires adherence to evidence-based protocols for the management of labour induction and augmentation. Cervical ripening as well as the latent and active phases of labour in people with obesity may be considerably prolonged, requiring higher cumulative doses of oxytocin. This should be guided by intrauterine pressure catheters and early provision of neuraxial analgesia, where possible. There is insufficient evidence to recommend one method of IoL over another. The need for higher doses of prostaglandins and concurrent agents for cervical ripening should be studied in prospective studies.

Increased Household Income Improves Nutrient Consumption in Pakistan: A Cross-Sectional Study

The provision of high-quality food is a primary factor in ensuring adequate nourishment and preventing malnourishment-related diseases in Pakistan. This study, therefore, aimed to quantify the impact of income on nutrient consumption in Pakistan, with the hypothesis that income has a primary role in reducing malnourishment in the developing world. To do this, we estimated nutrient–income elasticity—defined as the proportion of change in nutrient consumption in response to a change in income—for total calories, macronutrients, and micronutrients, using the nationally representative Household Integrated Economic Survey data (2010–2011) for Pakistan. Nutrient–income elasticity values were derived using several parametric regression approaches. We also assessed the non-linearity and endogeneity of the relationship. Calorie–income elasticity was found to be significantly different from zero, irrespective of the estimation technique used. Income elasticity for macronutrients and micronutrients was also found to be significantly different from zero, ranging from 0.29 to 0.65. This study, therefore, supports the hypothesis that increased household income likely improves nutrient consumption.

P–149 Calcium ionophores as an aid to surgically retrieved sperms in male factor infertility for increasing cumulative live birth rate

Study question

Does the addition of calcium ionophores for artificial oocyte activation(AOA) help in improving Cumulative Live Birth Rate in surgically retrieved sperms for male factor infertility?

Summary answer

AOA significantly improved cumulative live birth rate in Micro-TESE (M-TESE), TESA for non- azoospermia (TESTICULAR) and Non-Obstructive Azoospermia(NOA)-TESA but not in Obstructive Azoospermia (OA)-TESA.

What is known already

The main cause of Total Fertilization Failure after ICSI is thought to be due to oocyte activation deficiency (OAD) because of oocyte-related or sperm-related factors. Studies have shown that artificial oocyte activation (AOA) is helpful in these situations, but is most effective in couples who have clear sperm-related OAD. Oocyte activation, by Phospholipase- C- Zeta (PLCζ) present in the sperm, leads to series of events resulting in calcium oscillation, oocyte activation and fertilization. AOA increases the free intracellular calcium thereby mimicking physiologic cell signaling mechanisms that result in oocyte activation and fertilization.

Study design, size, duration

This is a retrospective cohort study done in an academic private ART center, in which patient’s records were analyzed, from January 2016 to December 2019 (total 4 years’ duration) and all ICSI cycles with surgically retrieved sperms were included (n = 365). Study subjects were divided into 4 groups- M-TESE (n = 143), NOA-TESA (n = 38), OA-TESA (n = 62) and TESTICULAR (n = 92). Subdivision was done into cases if AOA was done and control were with conventional ICSI without AOA.

Participants/materials, setting, methods

Method- Immediately after ICSI, in case group (AOA), all metaphase II oocytes were treated with calcium ionophore (GM508- CultActive) for 15 minutes, then thoroughly washed and incubated under standard conditions.

Primary outcome measured was cumulative live birth rate(CLBR) and Secondary outcomes were fertilization rate (Fert. rate), Cleavage rate, clinical pregnancy rate (CPR) and miscarriage rate (MA). Statistical analysis was performed with Chi-square and Mann-Whitney- U test, with significance at P &lt; 0.05. Institutional committee clearance was obtained.

Main results and the role of chance

The CLBR was significantly higher with AOA- M-TESE (55.8% vs 33.3%, p- 0.008), AOA-NOA-TESA (55.55% vs 15%, p- 0.027) and AOA-TESTICULAR (62.9% vs 32.3%, p- 0.006) group. Fert. rate was significantly higher with AOA-M-TESE (81 ± 0.84 vs 64 ± 0.97, p- 0.001), AOA-NOA-TESA (86 ± 0.76 vs 64 ± 0.13, p- 0.001) and AOA-TESTICULAR (72 ± 0.12 vs 57 ± 0.11, p- 0.001). Cleavage rate, CPR also showed similar significant differences while MA was comparable. However, significant differences were not observed in any of the outcome measured in OA-TESA group between cases and controls - CBLR (51.6% vs 41.9%, p- 0.611), Fert.rate (0.77±0.14 vs 0.75±0.11, p- 0.539), CPR and MA, p- value &gt; 0.05.

It may be hypothesized that surgically retrieved sperms in cases of NOA or non- azoospermia where TESTICULAR sperms are taken have reduced or absent capacity to cause Calcium oscillations due to deficient or inadequate PLCζ or there may be some chromatin level abnormalities in these sperms, leading to lesser fertilization and lesser good quality embryos in control group in which AOA was not done.

Limitations, reasons for caution

This study is retrospective in nature. Sibling oocytes were not compared. The study neither looked at obstetrics complication nor the neonatal outcomes. Further studies are required for long term impact on children born from AOA cycles.

Wider implications of the findings: To our knowledge, this is the first study in the literature evaluating the efficacy of calcium ionophores for NOA (M-TESE, TESA), OA (TESA) and TESTICULAR sperms. Further research is needed for use of calcium ionophores in cases of unexplained infertility and recurrent implantation failure.

Trial registration number

Not applicable

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy and Neuromyelitis Optica Spectrum Disorder - Reciprocal Effects and Practical Recommendations: A Systematic Review

Introduction: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system characterized by severe, antibody-mediated astrocyte loss with secondary demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord. Recent publications have alluded to increased disease activity during pregnancy, and adverse maternal and fetal outcomes in patients with NMOSD. Our objective was to systematically review published literature to help counsel and manage women with NMOSD contemplating pregnancy. Methods: We searched five databases including MEDLINE and EMBASE, for English-language publications describing pregnancies in women with NMOSD. Article selection, data extraction, and risk-of-bias assessment using Joanna Briggs' critical appraisal tool for case reports and case series, were performed in duplicate. Pooled incidences were calculated where possible, and a narrative summary was provided. Results: Of 2,118 identified titles, 22 case reports and seven case series, representing 595 pregnancies in 389 women, were included. The mean maternal age was 28.12 ± 5.19 years. At least 20% of cases were first diagnosed during pregnancy. There were no maternal deaths. Pooled estimates for clinical outcomes could not be obtained due to inadequate reporting. NMOSD-related disability and relapses increased considerably during pregnancy and especially in the immediate postpartum period. Although a high proportion of early pregnancy losses were reported, an association with disease activity or therapeutic interventions could not be established. Apart from one publication which reported an increased risk of preeclampsia, there was no increase in adverse obstetric outcomes including preterm birth, fetal growth restriction or congenital malformations. Initial attacks and relapses were successfully managed with oral or intravenous corticosteroids and immunosuppressants, and refractory cases with immunoglobulin, plasma exchange and immunoadsorption. Conclusion: Increased NMOSD-related disability and relapses during pregnancy the postpartum period may respond to aggressive management with corticosteroids and immunosuppressants such as azathioprine, which are safely administered during pregnancy and lactation. Emerging safety data on monoclonal antibodies during pregnancy, make these attractive options, while intravenous immunoglobulin, plasma exchange and immunoadsorption can be safely used to treat severe relapses. The complex interplay between NMOSD and pregnancy outcomes would be best understood through prospective analysis of data collected through an international registry. Disclosure: Dalia Rotstein has served as a consultant or speaker for Alexion and Roche. She has received research support from Roche Canada. Rohan D'Souza has served as a consultant and speaker for Ferring Canada Inc and Ferring Global Inc, on topics unrelated to this manuscript. The other authors have no relevant relationships to disclose.

α-Solanine induces ROS-mediated autophagy through activation of endoplasmic reticulum stress and inhibition of Akt/mTOR pathway

α-Solanine is a glycoalkaloid found in species of the nightshade family including potato. It was primarily reported to have toxic effects in humans. However, there is a growing body of literature demonstrating in vitro and in vivo anticancer activity of α-solanine. Most of these studies have shown activation of apoptosis as the underlying mechanism in antitumor activity of α-solanine. In this study, we report α-solanine as a potential inducer of autophagy, which may act synergistically or in parallel with apoptosis to exert its cytotoxic effect. Induction of autophagy was demonstrated by several assays including electron microscopy, immunoblotting of autophagy markers and immunofluorescence for LC3 (microtubule-associated protein 1 (MAP1) light chain-3) puncta. α-Solanine-induced autophagic flux was demonstrated by additionally enhanced – turnover of LC3-II and – accumulation of LC3-specific puncta after co-incubation of cells with either of the autophagolysosome inhibitors – chloroquine and – bafilomycin A1. We also demonstrated α-solanine-induced oxidative damage in regulating autophagy where pre-incubation of cells with reactive oxygen species (ROS) scavenger resulted in suppression of CM-H₂DCFDA (5 (and 6)-chloromethyl-2′,7′-dichlorodihydrofluorescein diacetate acetyl ester) fluorescence as well as decrease in LC3-II turnover. α-Solanine treatment caused an increase in the expression of endoplasmic reticulum (ER) stress proteins (BiP, activating transcription factor 6 (ATF6), X-box-binding protein 1, PERK, inositol-requiring transmembrane kinase/endonuclease 1, ATF4 and CCAAT-enhancer-binding protein (C/EBP)-homologous protein) suggesting activation of unfolded protein response pathway. Moreover, we found downregulation of phosphorylated Akt (Thr³⁰⁸ and Ser⁴⁷³), mammalian target of rapamycin (mTOR; Ser²⁴⁴⁸ and Ser²⁴⁸¹) and 4E-BP1 (Thr^37/46) by α-solanine implying suppression of the Akt/mTOR pathway. Collectively, our results signify that α-solanine induces autophagy to exert anti-proliferative activity by triggering ER stress and inhibiting Akt/mTOR signaling pathway.

Displaced Intracapuslar Hip Fractures in the Working Age Alcohol-Abusing Patient

Management of alcohol-abusing patients presenting with intracapsular hip fractures is controversial. The aim of this study was to compare the management and outcome of working-age alcohol-abusing patients with similar-aged controls.

Patients were identified from a prospectively collected database of trauma admissions. Full case notes were available for 78 patients under 65 of age presenting with a displaced intacapsular fracture at a teaching hospital between 1998 and 2002. Thirty seven patients had evidence of alcohol abuse.

Alcohol-abusing patients presented to hospital later (p=0.05), underwent surgery a median of 18 hours later (p=0.011) and required a longer post operative stay (p=0.003) compared to non-abusers. Despite this, the results of internal fixation were comparable. There was no significant difference between alcohol-abusers and nonabusers in rates of avascular necrosis (6.9% vs 9.7%; odds ratio 0.69, 0.11–4.47) or revision surgery (0.21 vs 0.10 procedures/ patient; odds ratio 1.49, 0.30–7.33).

The high rates of alcohol abuse in this low-velocity trauma population suggest such patients are at increased risk of osteoporosis. Routine screening for osteoporosis should be considered in working-age alcohol abusers. After subcapital fracture, reduction and internal fixation is an acceptable treatment in this sub-group of patients.

To evaluate and compare the effects of first generation anti-histamine (chlorpheniramine maleate) and second generation anti-histamine (loratadine) on isolated trachea of rabbit

OBJECTIVE

The incidence of respiratory allergy has increased gradually over the past several years and current estimates suggest that allergic rhinitis affects approximately 20% of the population. Large scales population surveys indicate that up to 38% of patients with rhinitis have asthma. The allergic response in the airways is an important pathogensis to cause bronchoconstriction owing to increased responsiveness of tracheo bronchial tree to various stimuli and also causes the release of histamine and other chemical mediators from mast cells. Histamine has been shown to be an important mediator of an allergic reaction in both the upper and lower respiratory airways. Chlorpheniramine maleate is a stable, most potent, sedative first generation anti-histamine and is effective in the treatment of allergic disorders. Loratadine is a highly potent, non-sedating, long acting tricyclic, second generation anti-histamine. It is indicated in allergic rhinits, chronic idiopathic urticaria and allergic bronchial asthma. The purpose of study was to evaluate the antagonistic effects of chlorpheniramine maleate and loratadine on histamine induced contractions in isolated trachea of rabbit and also to compare the effects of first generation anti-histamine (chlorpheniramine maleate and second generation anti-histamine loratadine).

METHODS

In this study twenty-four experiments were performed on isolated trachea of rabbit, in the presence of selected standard concentration of histamine dihydrochloride, antagonistic effects of various concentrations of chlorpheniramine maleate (10-18 to 10(-3) gm/ml) and loratadine from concentrations 10(-18) to 10(-3) gm/ml were recorded by Polygraph Model 7B in terms of rate and amplitude.

RESULTS

Chlorpheniramine maleate showed non-significant antagonistic effect from concentrations 10(-18) to 10(-3) gm/ml in case of rate and 10(-18) to 10(-8) gm/ml in case of amplitude. Significant response showed from concentrations 10(-8) to 10(-3) gm/ml in case of rate (P<0.001) and 10(-7) to 10(-3) gm/ml in case of amplitude (P<0.001) while, loratadine showed non-significant response from concentrations 10(-18) to 10(-12) gm/ml in case of rate and from concentration 10(-18) to 10(-14) gm/ml in case of amplitude. Significant response observed from concentrations 10(-11) to 10(-3) gm/ml in case of rate and 10(-13) to 10(-3) gm/ml in case of amplitude.

CONCLUSION

It was concluded that chlorpheniramine maleate antagonized the histamine induced contractions 80.65% at concentration 10(-3) gm/ml in case of amplitude and 11.35% at concentration 10(-3) gm/ml in case of rate and loratadine 76.82% in case of amplitude and 10.59% in case of rate.

The mammary gland-infant intestine immunologic dyad

The human infant has a very small immune system and needs the support of the mother with the transplacentally arrived IgG antibodies to protect tissues with inflammatogenic and energy-consuming defense. The mucous membranes, where most infections occur, need support via the specialized secretory IgA antibodies and the many other mucosal defense mechanisms provided via the mother's milk. This defense is not inflammatogenic and energy-consuming. We learn about additional defense factors in the milk, like the anti-secretory factor, which seems to protect against diarrhoea. The milk contains numerous growth factors and cytokines, like leptin, which may promote the development of the intestine as well as the immune system. Results are appearing giving interesting evidence for enhanced protection against infection also after the termination of breastfeeding. This may occur via the priming of the infant's immune system after uptake of anti-idiotypic antibodies and lymphocytes from the milk. A breastfeeding motivation study in a large Pakistani village resulted in a 50% decrease of diarrhoea and infant mortality. Deep interviews with the mothers and the traditional birth attendants suggested that even better results may be obtained.

Radiation-induced bronchial stenosis: a new cause of platypnea-orthodeoxia

Platypnea-orthodeoxia is encountered in a variety of cardiac, pulmonary, and hepatic disorders. We report its occurrence in a 59-year-old man who had had combined external-beam and high dose-rate iridium brachytherapy for a stage I non-small-cell carcinoma of the right upper lobe 2 years earlier. The post-radiation course was complicated by a severe radiation bronchitis; the onset of platypnea-orthodeoxia signalled the development of severe bronchial stenosis that was transiently relieved, initially by dilatation, and later by stent placement, though the patient ultimately died of a pulmonary hemorrhage. The dosage of brachytherapy given, the combined external-beam therapy, and the long survival after completion of radiation therapy were likely factors in the development of bronchial stenosis. We discuss the tomographic and bronchoscopic features of radiation-induced bronchial stenosis.

Efficacy and safety of clonazepam in refractory neurally mediated syncope

Neurally mediated syncope is a complex syndrome that is often difficult to manage using currently available treatment strategies. The efficacy and safety of clonazepam was evaluated in 35 patients with refractory neurally mediated syncope. All patients had syncope (n = 33) or disabling presyncope (n = 2) and a positive head-up tilt table test (HUTT) despite treatment with one or more of the following therapies: beta-blocker, high-salt diet, fludrocortisone, elastic compression stockings, and disopyramide. Clonazepam was initiated at 0.5 mg/day and titrated in 0.25-0.5 mg/day increments for symptom control. Early (first 8 weeks) symptomatic response was achieved in 31 of 35 (89%) patients. Early HUTT reverted to negative in 29 of 35 (83%) patients. Two patients discontinued clonazepam during early follow-up due to side effects. Thirty-three patients received long-term clonazepam therapy. Twenty-five patients had late HUTT with 21 remaining negative. Of the eight patients who did not have late HUTT, one patient discontinued clonazepam prior to HUTT due to side effects. Seven patients refused late HUTT. All seven patients achieved symptomatic control on clonazepam with two requiring dose titration. Of the 21 patients with a negative late HUTT, 18 achieved symptomatic control with two of these patients requiring dose titration. Two patients who had only partial symptom control despite dose titration achieved total symptomatic control with the addition of disopyramide and beta-blockers. Two patients with a negative late HUTT discontinued clonazepam due to side effects. One patient had been symptomatically controlled while the other had recurrent symptoms with dose limiting side effects occurring after clonazepam dose titration. In the 4 patients with a positive late HUTT, 2 patients were symptomatically controlled, 1 patients required combination therapy with a beta-blocker to achieve symptomatic control, and 1 patient discontinued therapy due to side effects. Overall, 29 of 35 (83%) patients continue to receive clonazepam with symptom control. Based on intention-to-treat HUTT results, 21 of 35 (60%) patients were responders. Four patients required clonazepam dose titration and three required combination therapy with clonazepam plus disopyramide and/or a beta-blocker to achieve control. Clonazepam was discontinued in 6 patients, 5 for side effects and 1 following a transient ischemic attack. Clonazepam appears to be an effective therapeutic alternative in patients with refractory neurally mediated syncope. Based on our preliminary findings, a placebo controlled evaluation of clonazepam in neurally mediated syncope is warranted.

Implantation metastasis of primary malignant rhabdoid tumor of the brain in an adult (one case report)

Primary malignant rhabdoid tumor (PMRT) of the brain is a rare and recently described neoplasm of youth. We report magnetic resonance imaging (MRI), computed tomography (CT), and pathology of one case of PMRT in an adult which seeded along the needle track for stereotactic biopsy.

Differing scintigraphic patterns of lumboperitoneal shunt dysfunction in patients with normal pressure hydrocephalus and pseudotumor cerebri

The scintigraphic patterns of dysfunctioning lumboperitoneal shunts (LPS) may vary with the underlying disease. The authors reviewed 22 LPS studies performed on 15 patients during the past 2 years and correlated the findings with the patency status of the shunt as determined by brain CT/MRI and surgical revision. Most of the patients also had cerebrospinal fluid (CSF) pressure monitoring. Fifteen studies were performed in patients with LPS for the treatment of normal pressure hydrocephalus (NPH) and 7 were performed in patients with LPS for pseudotumor cerebri (PTC). After intrathecal administration of 0.5-1 mCi of In-111 DTPA, sequential 1 minute images of the abdomen were obtained for 20 minutes. Static images of the abdomen were then obtained at 30 minutes and 1, 2, 4, and 24 hours with imaging of the head at 4 and 24 hours. All NPH patients with partial obstruction had tracer activity in the peritoneal cavity with little or no shunt tubing visualization. However, all had marked penetration of the tracer into the lateral ventricles. Pseudotumor cerebri patients with partial obstruction also showed tracer entry into the peritoneal cavity. Shunt tubing and tracer extravasation into the needle tract, at the site of lumbar puncture was seen only in patients of PTC, probably because of high intracranial pressure. Although the tracer flowed quickly into the basal cistern in all patients with PTC, it entered the lateral ventricles. Complete shunt obstruction was characterized by nonvisualization of activity in the peritoneal cavity and flow of the tracer into the basal cistern within 1 hour after injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast feeding: overview and breast milk immunology

The transfer of host defence capacity to the human offspring provides a remarkable model of passive transfer of immunity. In fact it may also provide an example of active immunization. The transfer of mucosal protection via breast feeding offers many additional advantages for the mother and infant. Through its contraceptive effects it increases the spacing between births, thus diminshing the infant mortality and the burden on the mother. It also enhances bonding between mother and child, it seems to increase the IQ and school result of the infant and might decrease the risk of certain malignancies and perhaps of juvenile diabetes. A fully breast-fed infant receives as much as 0.5-1 g of secretory immunoglobulin A (SIgA) antibodies daily, the predominant antibody of human milk. This can be compared to the production of some 2.5 g of SIgA per day for a 60 kg adult. These SIgA antibodies have been shown to protect against Vibrio cholerae, ETEC, Campylobacter, Shigella and Giardia. Furthermore, milk is rich in receptor analogues for certain epithelial structures which microbes need for attachment to host tissues as an initial step in infections. Thus the adherence of Haemophilus influenzae and pneumococci for example to retropharyngeal cells is efficiently inhibited by human milk. This may be one explanation for the fact that breast-fed babies have less otitis media than the non-breast-fed. Other milk factors like lysozyme and lactoferin may contribute to the host defence, but this has not yet been well defined. However, human milk also supports the well-being of the infant by being anti-inflammatory.(ABSTRACT TRUNCATED AT 250 WORDS)

Radioaerosol mucociliary clearance of tracheobronchial tree in normal subjects and in patients with respiratory diseases

The rate of mucociliary clearance in the tracheobronchial tree was studied both in patients and controls using radioisotopic techniques. The radioisotope is deposited in the larger airways and its rate of movement is measured as it is being transported up the trachea due to mucociliary activity. The BARC aerosol generation system was modified and used for this purpose. One hour study was acquired on a computerised gamma camera in each case. The rate of movement of the bolus of radioactivity was calculated by measuring the distance travelled in a known period of time. The mean velocity of transport was 9.0mm/min in normal subjects. In patients variable speed of transportation was obtained ranging from absolutely no movement to near normal speeds. Different patterns of transport were observed including linear, spiral, static and regurgitative. It was concluded that this simple non-invasive technique can be used for in vivo monitoring of mucociliary tracheal activity.