Issues and Challenges in Pharmacovigilance of Herbal Formulations

Pharmacovigilance is important for generating accurate safety of herbal medications information. The present methods were designed for synthetic medications and will need to be modified to account for the unique characteristics of medicinal plants. The objective of pharmacovigilance is to identify, measure, and explain adverse effects or other potential drug-related issues associated with herbal, traditional, and complementary therapies, as well as to avoid them. Required data for pharmcovigilance of herbal drugs and formulation were obtained from electronic sources (google scholar, PubMed, Scopus, Web of Science), several textbooks. The keywords used to search for various journal publishers such as Willey Online Library, Springer, Wolters Kluwer and Elsevier were closely monitored. This review article covers all the relevant information on issues and challenges in pharmacovigilance of formulation covering Herbal drugs.

The British Transplantation Society guidelines on cardiothoracic organ transplantation from deceased donors after circulatory death

Maximising organ utilisation from donation after circulatory death (DCD) donors could help meet some of the shortfall in organ supply, but it represents a major challenge, particularly as organ donors and transplant recipients become older and more medically complex over time. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to transplantation of cardiothoracic organs.

Development and Determination of Alcohol Content of Nutritional Noni Wine using Woodfordia fruticosa Flowers as a Traditional Fermentation Catalyst

Background:

Morinda citrifolia L. is a well-known fruit commonly known as noni, a perennial plant widespread in Southeast Asia. Due to its versatility of adaptation and manifold uses, noni has attracted the attention of the food and pharmaceutical industries. The nutritional and therapeutic value of noni fruit has revealed the presence of more than 100 phytochemicals. Noni has many therapeutic applications and is used in diabetes, rheumatoid arthritis, muscle pain, cardiac diseases, and also in cancer prevention. Moreover, it possesses free radical scavenging properties. Noni fruits are not edible due to their unpleasant odour and taste; however, they are used commercially in the preparation of many herbal formulations and beverages.

Objective:

The aim of the present work is to develop a fruit wine using a traditional fermentation catalyst and its evaluation.

Methods:

Fresh ripe fruits, jaggery, and Woodfordia fruticosa flowers were used in the formulation. Phytochemical screening was performed to determine the chemical composition. Furthermore, the wine was evaluated for total alcohol content, alcohol-soluble extractive value, and the presence of methanol.

Results:

The developed noni wine has shown an alcohol content of 7.23%. Alcohol soluble extractive value was found to be 310.6 g/L with a pH of 3.9±0.5. Phytochemical screening of the wine revealed mainly the presence of alkaloids, steroids, terpenoids, and polyphenolics as secondary metabolites with carbohydrates and proteins. However, it showed the absence of methanol content.

Conclusion:

The developed method can be employed in small and large-scale production of noni wine.

Novel hybrids of thiazolidinedione-1,3,4-oxadiazole derivatives: synthesis, molecular docking, MD simulations, ADMET study, in vitro, and in vivo anti-diabetic assessment

As compared to standard medicinal compounds, hybrid molecules that contain multiple biologically active functional groups have greater affinity and efficiency. Hence based on this concept, we predicted that a combination of thiazolidinediones and 1,3,4-oxadiazoles may enhance α-amylase and α-glucosidase inhibition activity. A series of novel 3-((5-phenyl-1,3,4-oxadiazol-2-yl)methyl)thiazolidine-2,5-dione derivatives (5a-5j) were synthesized and characterized using different spectroscopic techniques i.e., FTIR, ¹H-NMR, ¹³C-NMR and MS. To evaluate in silico, molecular docking, MMGBSA, and MD simulations were carried out which were further evaluated via in vitro inhibition of α-amylase and α-glycosidase enzyme inhibition assays. In addition, the in vivo study was performed on a genetic model of Drosophila melanogaster to assess the antihyperglycemic effects. The compounds (5a-5j) demonstrated α-amylase and α-glucosidase inhibitory activity in the range of IC₅₀ values 18.42 ± 0.21-55.43 ± 0.66 μM and 17.21 ± 0.22-51.28 ± 0.88 μM respectively when compared to standard acarbose. Based on the in vitro studies, compounds 5a, 5b, and 5j were found to be potent against both enzymes. In vivo studies have shown that compounds 5a, 5b, and 5j lower glucose levels in Drosophila. These compounds could be further developed in the future to produce a new class of antidiabetic agents.

Current Drug Targets in Alzheimer's Associated Memory Impairment: A Comprehensive Review

Alzheimer's disease (AD) is the most prevalent form of dementia among geriatrics. It is a progressive, degenerative neurologic disorder that causes memory and cognition loss. The accumulation of amyloid fibrils and neurofibrillary tangles in the brain of AD patients is a distinguishing feature of the disease. Therefore, most of the current therapeutic goals are targeting inhibition of beta-amyloid synthesis and aggregation as well as tau phosphorylation and aggregation. There is also a loss of the cholinergic neurons in the basal forebrain, and first-generation therapeutic agents were primarily focused on compensating for this loss of neurons. However, cholinesterase inhibitors can only alleviate cognitive symptoms of AD and cannot reduce the progression of the disease. Understanding the molecular and cellular changes associated with AD pathology has advanced significantly in recent decades. The etiology of AD is complex, with a substantial portion of sporadic AD emerging from unknown reasons and a lesser proportion of early-onset familial AD (FAD) caused by a mutation in several genes, such as the amyloid precursor protein (APP), presenilin 1 (PS1), and presenilin 2 (PS2) genes. Hence, efforts are being made to discover novel strategies for these targets for AD therapy. A new generation of AChE and BChE inhibitors is currently being explored and evaluated in human clinical trials for AD symptomatic treatment. Other approaches for slowing the progression of AD include serotonergic modulation, H3 receptor antagonism, phosphodiesterase, COX-2, and MAO-B inhibition. The present review provides an insight into the possible therapeutic strategies and their molecular mechanisms, enlightening the perception of classical and future treatment approaches.

Pharmacovigilance in Herbal Drugs: A Challenge

There is a growing awareness of a disease at many levels, its treatment, and treatment outcomes including side effects. Alternative therapy techniques, herbal medicines and formulations are extensively acknowledged and practiced in India and around the world. Herbal medicine is usually considered being safe regardless of the absence of scientific evidence to support its claims. Several issues concerning the methods in which herbal medications are labelled, evaluated, sourced, and used are connected to herbal medicine. Herbal therapeutics in the management and treatment of diabetes, rheumatism, hepatic disorders and other mild to chronic diseases and disorders are widely accepted. However, the adversities are difficult to recognize. The idea that the nature is safe and may be taken without the prescription of a physician has resulted in widespread self-medication across the world, sometimes with disappointing results, side effects, or unpleasant after-effects. The existing pharmacovigilance paradigm and its accompanying tools were created in connection with synthetic medicines. Nevertheless, adopting these approaches to keep records of herbal medications' safety poses a distinct challenge. This might be due to the variations in the usage of non-traditional medicines, which can offer unique toxicological issues whether taken alone or in conjunction with other medications. The goal of pharmacovigilance is to identify, analyse, explain, and minimize the adverse reactions and other drug-related complications associated with herbal, traditional, and complementary medications. Systematic pharmacovigilance is required to collect accurate data on the safety of herbal medications to create adequate guidelines for effective and safe usage.

Phytopharmacological Review of a Food Supplement Zingiber officinale Roscoe (Zingiberaceae)

Abstract:

Zingiber officinale, a medicinal herb commonly used in Ayurveda, which belongs to family Zingiberaceae and is reported to have various therapeutic properties. Roots as well as rhizomes of this plant are commonly used in the treatment of Digestive disorder. It has also been used as expectorant, spasmolytic, anti-tussive, anti-allergic, antihistaminic activity and inhibits coughing. The roots and rhizomes are rich sources of essential oil, which may be one of the reasons for the medicinal properties. Required data on this plant were obtained from electronic sources (google scholar, PubMed, Scopus, Web of Science), several classical textbooks on Ayurveda, and ethnopharmacology. This review article covers all the relevant information on its pharmacological and phytochemical aspects. In this study, we have critically reviewed recent advancements of Zingiber officinale in an attempt to authenticate its use as a multipurpose therapeutic ingredient.

ABO phenotype and SARS-CoV-2 infection: Is there any correlation?

COVID-19 is the currently evolving viral disease worldwide. It mainly targets the respiratory organs, tissues and causes illness. A plethora of studies has been performing to bring proper treatment and prevent people from the infection. Likewise, susceptibility to some infectious diseases has been associated with blood group phenotypes. The co-relationship of blood group with the occurrence of SARS-CoV-2 infection and death has been examined in numerous studies. This review explained the described studies regarding the correlation of blood group and the other essential factors with COVID-19.

POS0679 A NEW QUESTIONNAIRE AND SCORE (MISA) FOR ASSESSING METHOTREXATE INTOLERANCE IN RHEUMATOID ARTHRITIS

Background:

Methotrexate (MTX) intolerance refers to unpleasant symptoms that accompany use of MTX and may lead to its discontinuation. However, it lacks a validated score in RA patients; with the only option being to use the MISS score which was validated for use in children and not adults.

Objectives:

To develop and validate a questionnaire and score (s) for measuring MTX intolerance and its severity in rheumatoid arthritis.

Methods:

A 10-item questionnaire called ‘Methotrexate Intolerance and Severity assessment in Adults’ (MISA) was validated in 105 RA patients. A score was calculated by adding the scores of first 7 questions (0 to 3 based on severity on symptoms), to last 3 questions (0 or 1); it ranged from 0 to 24 (MISA score) and was assessed for correctly classifying MTX intolerance (compared to an interview) by ROC analysis. Its area-under-curve (AUC) was compared with ‘Methotrexate Intolerance Severity Score’ (MISS), developed for children. Subsequently, it was administered to 414 RA patients to assess the prevalence and associations of MTX intolerance. In addition, the MISA cross-products score, that was calculated by adding the cross-products (severity (1 to 3) x duration per week (0.5 to 7 days)) of symptoms, was compared to MISA and MISS for assessing severity of intolerance.

Results:

In the initial phase, 105 RA patients on MTX≥6 months were included, a majority were female (87%), mean age was 51 (13.4) years and methotrexate dose was 18.8±6 mg/week. Thirty-five (33%) were found to be intolerant to MTX based on interview. MISA score had a good predictive ability (AUC of 0.904), to correctly classify MTX intolerance, and was better than MISS score (AUC of 0.823) (Figure 1A). The optimal cut-off for MISA was ≥1, with a sensitivity and specificity of 91.4% and 84.3%. Using the MISA score (≥1), 38.4% of 414 RA patients were found to have MTX intolerance: with nausea, lethargy and irritability being common symptoms. (Figure 1B, C) On multivariable analysis, age (OR 0.972) and BMI (OR 1.061) were significant predictors of MTX intolerance. (Table 1) On assessing for severity of intolerance, MISA cross product score performed the best, with an area-under-curve of 0.899 (95% CI 0.831-0.966), being higher than AUC for MISS and MISA score which were 0.847 (95% CI 0.768-0.927) and 0.837 (95% CI 0.754-0.920).

Conclusion:

MISA is the first validated questionnaire for assessing methotrexate intolerance in rheumatoid arthritis, with the MISA score having a good accuracy (at cut-off ≥1), to detect MTX intolerance. Methotrexate intolerance was present in more than one-third of RA patients, with nausea, lethargy and irritability being most common.

Table 1.

Baseline characteristics of 414 RA patients.

VariableAll(n=414)Tolerant(n=255)Intolerant(n=159)p-valuetol. vs ntol.P-valuemultivariablemodelFemales, n (%)370 (89)231 (91)139 (87)0.31Age, yrs, mean (SD)50 (12.5)51.2 (12.6)48.2 (12.2)0.016*0.008**Duration of RA, yrs, mean (SD)10.0 (7.0)10.8 (7.4)9.6 (6.3)0.168BMI, Kg/m2a, mean (SD)24.0 (4.9)23.6 (4.9)24.6 (4.7)0.1070.03*RF positiveb, n (%)300 (73)191 (82)109 (78)0.29CDAI, mean (±SD)14.0 (11.8)14 (12.1)14.1 (11.4)0.69Dose of MTX, mg/wk, mean (SD)18.6 (5.6)18.6 (5.5)18.7 (5.8)0.83Injectable MTX, n (%)47 (11)25 (10)22 (14)0.21Use of FA, n (%)395 (95)241 (95)154 (97)0.27Use of other DMARD, n (%)272 (66)160 (62)112 (70)0.11HCQ n (%)209 (51)123 (48)86 (54)0.25Prednisolone n (%)156 (38)87 (34)69 (43)0.0580.21Using antiemetics, n (%)12 (3)1 (0.5)11 (7)<0.001

a Available for 262 patients bAvailable for 372 patients

Figure 1.

Figure showing the ROC curve for MISA and MISS questionnaires for MTX intolerance (A), Bar diagram showing the prevalence of various symptoms of intolerance in 414 RA patients (B), and Box-and-whiskers plot showing the duration of unpleasant symptoms (C).

Disclosure of Interests:

None declared

Functional assessment of outcome of surgery to correct patellofemoral instability in human patients

A case-control study with 6 months of patient follow up. This study sought to determine if surgery followed by rehabilitation for patellar instability could restore normal gait function. A previous study has established abnormalities in gait pattern and joint congruence in patients with a history of patellar instability. We hypothesised that surgery for patellofemoral instability would improve knee function. Eight human patients (mean age 29, range 17-42) who were awaiting patella stabilisation surgery (5 tibial tuberosity osteotomy, 2 medial patellofemoral ligament reconstruction, 1 trochleoplasty) were compared against eight normal Controls (mean age 28, range 19-31). Patients were assessed pre-operatively and six months after surgery by biomechanical gait analysis. Gait trials involved simultaneous collection of kinematic and force data. Patients were grouped into two subgroups pre-operatively based on knee joint net moment during stance, and their joint moments during stance pre- and post-operatively were compared against the Control subjects. In pre-operative gait analysis, four patients (P1) produced some extensor moment in early stance and four (P2) demonstrated a severe gait deficiency with failure to generate a knee extensor moment during stance. Normalisation in gait pattern was observed in all patients post-operatively. Those who had the most severe gait abnormality (P2) demonstrated the most improvement in their knee joint moments. Improvements were observed in the milder (P1) cases, but these were less dramatic. Patella stabilisation by surgery can restore normal gait function. Normalising the anatomy of the knee extensor mechanism is the objective of surgery. Normal anatomy facilitates the rehabilitation objectives of optimising extensor function during the weight-bearing phase of gait.

Application of two-dimensional binary fingerprinting methods for the design of selective Tankyrase I inhibitors

In the present study, five important binary fingerprinting techniques were used to model novel flavones for the selective inhibition of Tankyrase I. From the fingerprints used: the fingerprint atom pairs resulted in a statistically significant 2D QSAR model using a kernel-based partial least square regression method. This model indicates that the presence of electron-donating groups positively contributes to activity, whereas the presence of electron withdrawing groups negatively contributes to activity. This model could be used to develop more potent as well as selective analogues for the inhibition of Tankyrase I. Schematic representation of 2D QSAR work flow.

Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint.

METHODS

A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API).

RESULTS

We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2  = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported.

CONCLUSION

Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.

Practice-based, clinical trial of a silorane-based composite resin system in posterior teeth

INTRODUCTION

Newer monomer systems have been introduced in an attempt to improve the success rate of direct composite restorations by minimising shrinkage.

AIMS AND OBJECTIVES

To evaluate the in vivo performance of a silorane-based resin composite system (Filtek Silorane, also known as P90), used together with a two-step self-etch bonding system (P90 System Adhesive, Self-Etch Primer and Bond), for the restoration of Class I and Class II cavities in human permanent posterior teeth.

MATERIALS AND METHODS

A total of 53 restorations were completed and patients were recalled one year later. The restorations were assessed by two ndependent clinicians, using the Modified U.S. Public Health Service evaluation criteria for the following parameters: retention, colour match, marginal discolouration, secondary caries, anatomic form, marginal adaptation, surface texture, occlusal and interproximal contacts.

RESULTS

Of the 41 restorations assessed at the one year follow-up, 92.7% showed clinically acceptable scores for all the parameters evaluated. Cronbach's alpha values ranged from 0.72-1.00 showing a good inter-examiner agreement and reliability.

CONCLUSION

Silorane-based composite, Filtek Silorane, when used in conjunction with the recommended adhesive system showed a clinically acceptable performance in posterior teeth restorations over a one year clinical service.

Use of gentamicin-collagen sponges in closure of sternal wounds in cardiothoracic surgery to reduce wound infections

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Are antibiotic implants like gentamicin-collagen implants useful in preventing sternal wound infections (SWIs)? Altogether, more than 484 papers were found using the reported search; of these, 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that most randomized controlled trials (RCTs) have been performed with gentamicin-collagen sponges for sternal closure. Two out of four RCTs showed a significant benefit of the implant in a reduction in superficial and deep SWIs in routine and emergency cardiac surgery. One RCT showed a significant reduction in superficial infections in 2005, a follow-up trial by the same group in 2009 showed a reduction in deep infections as well. Another group has shown a reduction in deep and superficial SWI with gentamicin implant, in an RCT on 800 patients, however have not published details of the complete trial. The third trial on 542 patients showed no benefit of the implant, but was not adequately powered. However, the most recent multicentre RCT conducted on 1052 patients showed no benefit of gentamicin-collagen sponges in elective surgery (coronary artery bypass grafting and/or valve surgery) in high-risk patients with diabetes, obesity or both. Concerns were raised that gentamicin sponges dipped in saline 1-2 s prior to application may have lost the gentamicin into the saline, thereby reducing their efficacy and that some surgeons may have been unfamiliar with wound closure with sponges. However, these were robustly refuted by the authors. One RCT showed that gentamicin sponges may cause increased sternal rebleeding if used in double layers. Coagulase-negative staphylococci were predominantly isolated from infected wounds in all the trials except the one from USA, where infections were polymicrobial. Gentamicin resistance among common pathogens causing SWIs can vary from 15 to 80%. Gentamicin-collagen is unlikely to reduce SWIs in high-risk patients and polymicrobial infections.

Periarticular calcification causing acute carpal tunnel syndrome: a case report

We report a case of acute carpal tunnel syndrome caused by periarticular calcification (hydroxyapatite deposition disease) around the wrist joint in a 64-year-old woman. She had acute severe pain, exacerbated by wrist movements and extension of the fingers. Her full blood count, urea, electrolytes, uric acid, calcium, phosphate, alkaline phosphatase, and thyroid function levels were all within normal ranges, and her serum was negative for rheumatoid factor. Computed tomography revealed lobulated calcification close to the volar capsule. She underwent an emergency surgical decompression of the carpal tunnel under general anaesthesia within 3 hours of presentation. The flexor tendon sheaths were excised, and 'toothpaste-like' chalky material (hydroxyapatite crystals) in the capsule was removed. The pain was relieved dramatically and her median nerve function recovered. She was symptom-free at the one-year follow-up.

Use of suture anchors for coronoid fractures in the terrible triad of the elbow

PURPOSE

To report outcomes in 6 patients with the terrible triad of the elbow treated with our modified protocol.

METHODS

6 men aged 26 to 54 years underwent surgery for the terrible triad of the elbow by a single surgeon. All the patients had a displaced comminuted fracture of the radius, posterior dislocation of the elbow, and Morrey type-I fracture of the coronoid. They all underwent replacement of the radial head and repair of the lateral collateral ligament to the isometric part of the lateral condyle using suture anchors. Five had an additional capsular fixation to the anterior coronoid using suture anchors; in patient 6 the coronoid was not repaired because it was stable. Functional outcomes were evaluated using the Hospital for Special Surgery (HSS) elbow assessment score. Bone union, implant loosening, heterotopic ossification, and degenerative changes were assessed using anteroposterior and lateral radiographs.

RESULTS

After a mean follow-up of 2.2 (range, 1-3) years, the mean arc of flexion-extension was 116 degrees and the mean flexion contracture was 15 degrees. All patients maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation, with isometric fixation of the lateral collateral ligament. No patient had dislocation of the radial-head prosthesis. All had good-to-excellent HSS elbow scores, and none required re-operation. Patient 2 had neuropraxia of the radial nerve, which recovered within 3 months. Patient 4 had a range of movement of only 20 to 100 degrees, but was satisfied with the outcome.

CONCLUSION

Repair of the articular capsule using suture anchors in addition to replacement of the radial head and repair of the lateral collateral ligament achieves favourable outcome in patients with the terrible triad of the elbow.

Osteoid osteoma of the talus: a case report

Diagnosing osteoid osteomas in the small bones of the hands and feet is difficult because of their atypical presentations. We report an 8-year-old boy who presented with pain in the left ankle and a limp. Plain radiographs of the ankle and foot were normal; the diagnosis was eventually made using magnetic resonance imaging.

Crown augmentation using modified bilayered restoration for anchorage: a case report

An ankylosed tooth can be suitable for obtaining orthodontic anchorage. However, if such a tooth lacks adequate clinical crown height, the anchorage will not be effective. In those situations surgical luxation or restorative crown augmentation is suggested. This case report is about the restorative treatment of an ankylosed, infraoccluded tooth to enhance the anchorage for forced orthodontic eruption of impacted maxillary canines. A crown augmentation in the form of a modified bilayered (sandwich) restoration using GIC, Composite resin and Silver amalgam on left maxillary first molar (26) was successful in sustaining the anchorage for forced eruption and alignment of impacted canines.

How best to manage the space after pneumonectomy? Theory and experience but no evidence

OBJECTIVE

We set out to find a policy for the management of the pneumonectomy space which would minimise risk and be acceptable to all the surgeons. We believe this will reduce opportunities for error, be welcomed by nursing staff, and improve adherence to protocols.

METHODS

We sought evidence in the scientific and educational literature. Finding no sure guidance, we audited our own experience of two policies, with the emphasis on minimising risk.

RESULTS

There was no evidence from randomised trials. There was no cohesive advice in the text books. Our data indicated that it was improbable that randomised controlled trial (RCT) would have the power to find the evidence. Unable to establish the best strategy, we chose what appeared to be the lowest risk management policy.

CONCLUSIONS

It is instructive that such a fundamental question should be unanswered. We have adopted a low risk and well established strategy--an unclamped underwater seal drain--but have no evidence base other than clinical experience. This is illustrative of much of what we do in clinical surgical practice. Avoiding major risk is often more important than proving small differences in benefit.

Long uvula: an unusual cause of chronic cough

Chronic cough is a distressing symptom for patients and parents in paediatric practice. Investigations of the child with persistent cough can be simple or complex depending on the underlying cause. There are some unusual reasons for chronic cough, which need to be kept in mind when investigating the cause. A case of a long, floppy uvula causing chronic cough through mechanical irritation of upper airway is reported.

Primary Non-Hodgkin's Lymphoma of the Bone: A Single Institution Experience

Primary non-Hodgkin's lymphoma of the bone is an unusual entity. Twenty-five patients with diffuse large cell lymphoma of the bone were registered at the Tata Memorial Hospital (TMH) from August, 1991, to May, 2002. Pain at the local site and soft tissue swelling were the commonest symptoms. Involvement of the bones in the lower half of the body was more frequent than the bones in the upper half. Osteolytic lesions and an associated soft tissue mass were the common radiological findings. Nineteen patients received CHOP chemotherapy and five received COP chemotherapy. Twenty-three patients received involved field radiotherapy. The overall response to therapy was 96%. On follow-up, two patients had a nodal relapse. One patient died of progressive disease, and one patient died of cryptococcal meningitis. There were no deaths due to treatment-related toxicity. The mean progression free survival was 9.39 yr and the overall survival was 11.66 yr. The median overall survival has not been reached. At last follow-up, 21 patients were being following up at TMH and are free of disease.

CONCLUSION

Primary bone lymphoma is a malignancy that is highly curable with a combination of chemotherapy and radiotherapy.

Comparative evaluation of effect of auxiliary retentive features on retention of complete cast crowns in teeth with adequate and inadequate crown height. An invitro study

This study was done to evaluate the retention of complete cast crowns in teeth with adequate and inadequate crown height and to evaluate the effects of auxiliary retentive features on retention from of complete cast crowns. Thirty-six extracted human maxillary first premolars were obtained. In one group teeth were prepared to a constant height of 3.5 mm and in the second group teeth were prepared to a constant height of 2.5 mm. Each group was further subgrouped into three. In the first subgroup teeth were prepared conventionally, second subgroup proximal grooves were incorporated and in the third subgroup proximal boxes were incorporated. Tensional forces required to dislodge each cemented casting from its preparation was used for comparison of retention quality. These results were then subjected to an analysis of variance (ANOVA). The retention of crown in tooth with adequate crown height were statistically highly significant (P < 0001), compared to inadequate crown height and in boxes compared to grooves and conventional preparation.

Effect of carotid endarterectomy on the ocular circulation and on ocular symptoms unrelated to emboli

OBJECTIVE

To evaluate haemodynamic changes in the ophthalmic artery and the retina following carotid endarterectomy and their effect on the pathophysiology of the eye.

DESIGN

Prospective study.

METHOD

Twenty-two consecutive patients with severe carotid stenosis underwent 23 carotid endarterectomies and one subclavian-carotid bypass. The following measurements were made preoperatively and 3 months after operation; Ophthalmic artery (OA) and retinal arteriole (RA) peak systolic velocity (PSV) and peak diastolic velocity (PDV), macular photostress recovery time, visual acuity, intraocular pressures, colour vision and visual fields testing.

RESULT

The RA PSV increased by 50% (p = 0.005) and PDV increased by 22% (p = 0.03). The OA PSV increased by 51% (p = 0.001). Macular photostress testing decreased from 58 s to 42 s (p = 0.001). Visual acuity improved in four and was unchanged in 13 eyes ipsilateral to the endarterectomy which had abnormal preoperative measurements. One patient experienced a dramatic increase in the ipsilateral intraocular pressure associated with visual deterioration. In two patients there was resolution of periorbital pain.

CONCLUSION

Our results demonstrate an increase in the PSV of the RA and OA following carotid surgery. There are pathophysiological changes in the eye, which accompany tight stenotic extracranial carotid artery disease and these may be influenced by carotid endarterectomy.

Tracheal suction in meconium stained infants: a randomized controlled study

We performed a randomized controlled study of the mortality and morbidity of 49 babies born with thick meconium staining of amniotic fluid. These unasphyxiated babies were consecutively born and were admitted to the intensive care unit for observation as routine. The groups were comparable in regard to sex, birth weight, gestational age, maternal factors like anaemia, toxaemia, antepartum haemorrhage, prolonged rupture of membranes, presentation, and interventions including caesarian section. The control group, comprising 26 babies received only oropharyngeal suction, while the intervention group, comprising 23 babies, underwent oropharyngeal suction followed by tracheal suction. There was no significant difference in the mortality or morbidity in form of evidence of air leak or hypoxic ischaemic encephalopathy.

Adult acute lymphoblastic leukemia: results of an aggressive regimen in India

A total of 42 adults with acute lymphoblastic leukemia were treated with an aggressive induction/consolidation chemotherapy (MCP-841) between June 1986 and December 1991. 32 patients (76.19%) achieved complete remission at the end of induction. There were 9 induction deaths, 6 of them due to infection. All patients received cranial irradiation in the dose of 20 Gy and intrathecal methotrexate for CNS prophylaxis. Twelve patients relapsed, 10 in the bone marrow, one case had isolated CNS relapse and the other relapsed in the bone marrow and CNS. The actuarial overall survival of all patients at the end of 5 years was 41.94%. Patient characteristics including age, sex, FAB morphology, phenotype, WBC count, platelet count and LDH did not influence survival significantly.

Heparin-modified lenses for eyes at risk for breakdown of the blood-aqueous barrier during cataract surgery

To determine the appropriateness of heparin-surface-modified (HSM) lenses in eyes at risk for breakdown of the blood-aqueous barrier, 36 consecutive patients with cataracts associated with chronic recurrent or past uveitis had extracapsular cataract extraction and insertion of an HSM posterior chamber one-piece intraocular lens (IOL). Examinations for implant precipitates (IPs), fibrin membranes, IOL synechias, and visual outcome were done postoperatively. Results show that despite a recurrence of overt uveitis with keratic precipitates in 13 eyes (36.1%), IPs were seen in only six eyes (16.6%) and were generally small and few in number. An acute postoperative fibrin reaction, which is related to blood-aqueous barrier breakdown, occurred in nine eyes. Implant synechias were found in three eyes. We found that HSM provided a cell-free IOL surface in the majority of eyes at high risk for blood-aqueous barrier breakdown and uveitis. Heparin surface modification does not prevent complications but tends to protect the IOL from inflammation changes that might otherwise occur.

Urinary desmosine, elastolysis, and lung disease

Desmosine is an amino acid specific to elastin. Animal studies suggest that urinary desmosine (UD) represents endogenous elastin degradation. Therefore, UD has previously been used to investigate endogenous elastolysis, but was not elevated in subjects with chronic obstructive airways disease (COAD), although accelerated pulmonary elastolysis is thought to contribute to COAD. We have investigated whether this reflects large day-to-day and between-subject variation in UD and whether, in man, dietary desmosine contributes significantly to that in urine. Mean 24-hour UD output (over 5 consecutive days) from 10 asymptomatic subjects (5 males) was higher in males than females (77.4 +/- 9.6 and 40.2 +/- 5.0 nmol/24 hours, respectively; mean +/- SD, P less than .001), but not significantly different when expressed in terms of creatinine (micrograms desmosine/100 mg creatinine: males, 2.5 +/- 0.4; females, 3.1 +/- 0.8; mean +/- SD). The lowest between-subject variation was observed when the mean of 5 days' 24-hour UD values was analyzed on the basis of gender (coefficient of variation [CV], 12.5%); when gender was not considered, the least between-subject variation was found for the mean of 5 days' desmosine/creatinine analysis (CV, 24.5%). Approximately 1% of dietary desmosine (ingested as [3H]elastin and [3H] desmosine) was excreted in the urine within 24 hours, contributing approximately 15% of UD while on a normal diet. Although ingestion of a low elastin diet (less than 1/10 desmosine/24 hours than a normal diet) resulted in lower within-subject variation in 24-hour UD excretion (mean CV decreased from 31.5% to 20.2%), the between-subject CV and UD levels did not alter.(ABSTRACT TRUNCATED AT 250 WORDS)

Mutagenicity of N-hydroxylamines and N-hydroxycarbamates towards strains of Escherichia coli and Salmonella typhimurium

The mutagenic activity of several arylamines, alkyl- and arylcarbamates and their corresponding N-hydroxylated derivatives towards Escherichia coli WP2uvrA was investigated using the fluctuation test without a metabolic activation system. None of the parent amines or carbamates were mutagenic while several arylhydroxylamines and N-hydroxycarbamates were direct-acting base-pair substitution mutagens. With the exception of n-hexyl-N-hydroxycarbamate, the mutagenic activity of the N-hydroxycarbamates increased with increase in the length of alkyl substituent. Some arylamines and arylhydroxylamines were further examined, again without a metabolic activation system, using a plate test in conjunction with bacterial strains which detect either base-pair or frameshift mutagens. The arylhydroxylamines were found to cause both base-pair and frameshift mutations but were more active as frameshift mutagens. Possible reasons for the observed mutagenic activity are considered.