Long COVID in Pakistan: a cross-sectional analysis of health and psychosocial outcomes

According to the World Health Organization-led Delphi consensus, long COVID corresponds to the occurrence of symptoms beyond twelve weeks after the onset of acute COVID-19 illness that cannot be explained by alternate diagnosis. This cross-sectional study aimed to analyse the impacts of long COVID on general health and psychosocial well-being. For this study, the participants were interviewed either face to face or via telephone, and their responses were recorded on a questionnaire capturing information on demographics, COVID-19 status, duration of symptoms and long COVID symptoms. The psychosocial impacts of the pandemic were assessed using scales like Short Mood and feeling questionnaire (sMFQ), Warwick-Edinburgh Mental Well-being Scale (WEMWBS), Generalized Anxiety Disorder Assessment (GAD-7) and Perceived Stress Scale (PSS). Regression analysis was conducted to analyse the predictors of long COVID. A total of 300 participants were interviewed, of which 155 (52%) had COVID-19 illness. Of these 54 (35%) had persistent symptoms for a period of more than 12 weeks classified as long COVID. Muscle problems and fatigue were the most frequent (14.7%) symptoms encountered, followed by breathing problems (12.6%) and cognitive issues (12.6%). The symptoms of decrease in appetite and confusion or disorientation during the initial phase of the infection were associated with long COVID. The majority of the participants (83.3%) had moderate level of perceived stress, while moderate to severe levels of stress were observed in 17.3% of the individuals. Moreover, a high level of positive mental well-being was also observed. This study highlights the need for further research into the clinical aspects and implications of long COVID in Pakistan and emphasizes the importance of ongoing support for affected individuals.

Mutation screening of multiple Pakistani MCPH families revealed novel and recurrent protein-truncating mutations of ASPM

Autosomal primary microcephaly (MCPH) is a heterogenetic disorder that affects brain's cerebral cortex size and leads to a reduction in the cranial vault. Along with the hallmark feature of reduced head circumference, microcephalic patients also exhibit a variable degree of intellectual disability as well. Genetic studies have reported 28 MCPH genes, most of which produce microtubule-associated proteins and are involved in cell division. Herein this study, 14 patients from seven Pashtun origin Pakistani families of primary microcephaly were analyzed. Mutation analysis was performed through targeted Sanger DNA sequencing on the basis of phenotype-linked genetic makeup. Genetic analysis in one family found a novel pathogenic DNA change in the abnormal spindle microtubule assembly (ASPM) gene (NM_018136.4:c.3871dupGA), while the rest of the families revealed recurrent nonsense mutation c.3978G>A (p.Trp1326*) in the same gene. The novel reported frameshift insertion presumably truncates the protein p.(Lys1291Glyfs*14) and deletes the N-terminus domains. Identification of novel ASPM-truncating mutation expands the mutational spectrum of the ASPM gene, while mapping of recurrent mutation c.3978G>A (p.Trp1326*) will aid in establishing its founder effect in the Khyber Pakhtunkhwa (KPK) inhabitant population of Pakistan and should be suggestively screened for premarital counseling of MCPH susceptible families. Most of the recruited families are related to first-degree consanguinity. Hence, all the family elders were counseled to avoid intrafamilial marriages.

Indirect calculation of LDL using thirteen equations in Pakistani population

BACKGROUND

Owing to the atherogenic properties, low density lipoprotein cholesterol (LDL-C) is the primary target for treatment and diagnosis of cardiovascular diseases (CVDs), hence accurate measurement of LDL-C is critical. Despite the availability of direct measurement assays for LDL-C, it is routinely calculated by Friedewald equation in clinical settings in Pakistan mostly due to financial constraints. However, the validity of this equation is impacted by several factors, therefore several other equations have been developed for the calculation of LDL-C.

MATERIALS AND METHODS

LDL-C of 39,385 individuals measured directly by homogenous assays (dLDL) was compared with LDL-C calculated by thirteen equations (cLDL-C). Stratifications based on different lipids i.e., triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL) were made to check the validity of these equations across all ranges of lipid profile. The correlation and median difference between dLDL and cLDL-C was statistically analyzed.

RESULTS

Overall Teerakanchana equation displayed a strong positive correlation (ρ = 0.967) and least median difference (-8.81) with dLDL, followed by Martin equation (ρ = 0.967). For higher TG ranges (>500 mg/dL), Teerakanchana equation had the least median difference (1.31) and a strong correlation (ρ = 0.800).

CONCLUSION

Our data suggest that Teerakanchana equation may be employed as an alternative to Friedewald equation for Pakistani population.

Anti-bacterial activity of essential oils against multidrug-resistant foodborne pathogens isolated from raw milk

The presence of pathogenic bacteria in food is considered as a primary cause of food-borne illness and food quality deterioration worldwide. The present study aimed to determine the effectiveness of five essential oils (EOs) against multidrug-resistant foodborne pathogens. In the current study Gram-negative bacteria (Escherichia, Enterobacter, Citrobacter, Proteus, Pseudomonas, and Klebsiella) and the Gram-positive bacteria Staphylococcus were isolated from raw milk and biochemically characterized. The anti-bacterial effect of different antibiotics and EOs (thyme, oregano, lemongrass, mint, and rosemary) was determined using the standard disc diffusion method. The antibiogram study revealed that Gram-negative bacteria were highly resistant to penicillin while Staphylococcus was resistant to streptomycin, amoxicillin, and lincomycin. Moderate resistance was observed to doxycycline, amikacin, enrofloxacin, kanamycin and cefixime. Isolates were found less resistant to gentamycin, chloramphenicol, and ciprofloxacin. EOs showed a broad range of antimicrobial activity against all bacteria except P. aeruginosa. Of these, thyme was more effective against most of the multi-drug resistant bacterial strains and formed the largest zone of inhibition (26 mm) against Escherichia followed by oregano oil (18 mm) against Staphylococcus (p<0.05). Klebsiella spp and Citrobacter spp showed resistance to mint and lemongrass oil respectively. The EOs such as lemongrass, mint and rosemary were less active against all the bacteria. The findings of the recent study suggest the use of EOs as natural antibacterial agents for food preservation.

Immune-related therapeutics: an update on antiviral drugs and vaccines to tackle the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic rapidly spread globally. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, is a positive-sense single-stranded RNA virus with a reported fatality rate ranging from 1% to 7%, and people with immune-compromised conditions, children, and older adults are particularly vulnerable. Respiratory failure and cytokine storm-induced multiple organ failure are the major causes of death. This article highlights the innate and adaptive immune mechanisms of host cells activated in response to SARS-CoV-2 infection and possible therapeutic approaches against COVID-19. Some potential drugs proven to be effective for other viral diseases are under clinical trials now for use against COVID-19. Examples include inhibitors of RNA-dependent RNA polymerase (remdesivir, favipiravir, ribavirin), viral protein synthesis (ivermectin, lopinavir/ritonavir), and fusion of the viral membrane with host cells (chloroquine, hydroxychloroquine, nitazoxanide, and umifenovir). This article also presents the intellectual groundwork for the ongoing development of vaccines in preclinical and clinical trials, explaining potential candidates (live attenuated-whole virus vaccines, inactivated vaccines, subunit vaccines, DNA-based vaccines, protein-based vaccines, nanoparticle-based vaccines, virus-like particles and mRNA-based vaccines). Designing and developing an effective vaccine (both prophylactic and therapeutic) would be a long-term solution and the most effective way to eliminate the COVID-19 pandemic.

Maternal cardiovascular function and risk of intrapartum fetal compromise in women undergoing induction of labor: pilot study

OBJECTIVE

Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion predisposing to intrapartum fetal distress. The aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labor (IOL).

METHODS

In this prospective cohort study, patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A®) was used for cardiovascular assessment. The study outcome was operative delivery due to presumed fetal compromise, which included Cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardiovascular markers, as well as the maternal characteristics, and the risk of operative delivery due to presumed fetal compromise. Receiver-operating-characteristics-curve analysis was used to assess the predictive accuracy of the cardiovascular markers for the risk of operative delivery for presumed fetal compromise.

RESULTS

A total of 99 women were recruited, however four women were later excluded from the analysis due to semi-elective Cesarean section (n = 2) and failed IOL (n = 2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise (controls) were more likely to be parous, compared to those who had operative delivery due to fetal compromise (52.9% vs 18.5%; P = 0.002). Women who underwent operative delivery due to presumed fetal compromise had a significantly lower cardiac index (median, 2.50 vs 2.60 L/min/m² ; P = 0.039) and a higher systemic vascular resistance (SVR) (median, 1480 vs 1325 dynes × s/cm⁵ , P = 0.044) compared to controls. The baseline model (being parous only) showed poor predictive accuracy, with an area under the curve of 0.67 (95% CI, 0.58-0.77). The addition of stroke volume index (SVI) < 36 mL/m² , SVR > 7.2 logs or SVR index (SVRI) > 7.7 logs improved significantly the predictive accuracy of the baseline model (P = 0.012, P = 0.026 and P = 0.012, respectively).

CONCLUSION

In this pilot study, we demonstrated that prelabor maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SVI, SVR or SVRI improved significantly the predictive accuracy of the baseline antenatal model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

P1930Pharmacodynamic effects of vorapaxar as an add-on antiplatelet therapy in patients with and without diabetes mellitus: the optimizing anti-platelet therapy in diabetes mellitus (OPTIMUS)-5 study

Background

Vorapaxar (Vora) is a protease-activated receptor (PAR)-1 inhibitor which when added to dual antiplatelet therapy (DAPT) in patients with a history of myocardial infarction (MI) or with peripheral arterial (PAD) reduces thrombotic cardiovascular events at the expense of increased bleeding. The efficacy of Vora is enhanced in patients with diabetes mellitus (DM) compared to non-DM. However, the differential pharmacodynamic (PD) effects of Vora in DM vs non-DM patients are unknown. Moreover, although withdrawal of aspirin has emerged as a strategy to reduce bleeding when adjunctive antithrombotic therapies are used, the PD effects of Vora after stopping aspirin in DAPT treated patients is unknown.

Purpose

To assess the PD effects of Vora in addition to standard DAPT as well as in combination with clopidogrel following aspirin withdrawal in patients with and without DM.

Methods

This was a prospective parallel-design PD study conducted in post-MI or PAD patients with and without DM. Patients on DAPT with aspirin (81mg/qd) and clopidogrel (75mg/qd) were divided in two groups according to DM status. Each cohort was treated with Vora (2.5mg/qd) in addition to DAPT (i.e., triple therapy) for 30 days and afterwards stopped aspirin and maintained treatment with Vora plus clopidogrel (i.e., dual therapy) for other 30 days. PD testing using 5 different assays was conducted at 3 time-points: baseline (while on DAPT); after 30 days of triple therapy; after 30 days of dual therapy. The primary endpoint was the non-inferiority of CAT (Collagen-ADP-TRAP)-induced aggregation, a marker of global platelet reactivity, of Vora plus clopidogrel (dual therapy) vs Vora plus DAPT (triple therapy).

Results

The PD population was composed of a total of 64 patients (DM, n=30; non-DM, n=34). Although adding Vora to DAPT significantly reduced CAT-induced aggregation, stopping aspirin was associated with an increase in CAT-induced aggregation in both DM (mean difference=12; 95% CI: 3 to 21; p=0.010) and non-DM (mean difference=10; 95% CI: 4 to 16; p=0.003), thus not meeting the primary endpoint of non-inferiority (Figure). The magnitude of such increase was higher in DM compared with non-DM (p=0.036). Although Vora abolished TRAP-induced aggregation in both DM and non-DM patients, it did not affect markers of clot kinetics including speed of thrombin generation. Aspirin withdrawal was associated with a marked increase in makers sensitive to cyclooxygenase-1 (COX-1) blockade; markers of P2Y12 signaling were higher in DM compared to not DM after aspirin withdrawal.

CAT-induced aggregation

Conclusion

Adjunctive treatment with Vora reduces platelet-mediated thrombogenicity without affecting clot kinetics in both DM and non-DM patients while on DAPT. However, platelet-mediated thrombogenicity is increased after aspirin withdrawal, a phenomenon which is enhanced in DM patients underscoring the pivotal contribution of the COX-1 signaling pathway in these high risk patients.

Acknowledgement/Funding

The study was supported in part by an investigator initiated study grant from Merck

P1934Platelet inhibitory profiles of prasugrel versus ticagrelor in patients with CYP2C19 loss-of-function genotypes undergoing percutaneous coronary intervention: results of a randomized feasibility study

Background

Although clopidogrel is the most widely used P2Y12 inhibitor, loss-of-function (LOF) allelic variants located within the hepatic cytochrome P450 (CYP) 2C19 gene lead to attenuated bioactivation, increased rates of high platelet reactivity (HPR), and worse outcomes in patients undergoing percutaneous coronary intervention (PCI). Drug regulating authorities have suggested using alternative P2Y12 inhibitors (i.e., prasugrel or ticagrelor) in these patients. However, tailoring antiplatelet therapy in clinical practice according to results of genetic testing has been limited due to lack of access to promptly available results. Moreover, there are no head-to-head pharmacodynamic (PD) comparisons of prasugrel vs ticagrelor among patients with CYP2C19 LOF alleles.

Purpose

The aim of this study was to evaluate the feasibility of using rapid genetic testing in clinical practice and to compare the PD effects of prasugrel vs ticagrelor in patients undergoing PCI with CYP2C19 LOF alleles.

Methods

This was a prospective, randomized study conducted in patients with stable coronary artery disease and non-ST elevation acute coronary syndrome scheduled for left heart catheterization (LHC) with the intent to undergo PCI. Patients underwent rapid genetic testing using the Spartan RX assay, which defines CYP2C19 genetic status within 1 hour, allowing patients to be genotyped the same day of their LHC. Patients who were carriers of at least one LOF (*2 or *3) allele were randomized to receive either prasugrel [60mg loading dose (LD) - 10mg/day maintenance dose (MD)] or ticagrelor (180mg LD - 90mg b.i.d MD). Blood samples for PD analysis by VerifyNow were collected at 5 time points: baseline (prior to PCI), 30 minutes, 2 hours, 24 hours (or at hospital discharge whichever came first), and 1–4 weeks post-LD. All patients were treated with aspirin. The primary endpoint of our study was the non-inferiority in platelet reactivity, measured as PRU, at 24 hours of prasugrel vs ticagrelor in LOF allele carriers.

Results

A total of 781 consecutive patients scheduled for LHC were genotyped, of whom 223 (28.5%) were carriers of at least one LOF. Of these, 65 patients underwent PCI and randomized to prasugrel (n=32) vs ticagrelor (n=33). PRU levels at 24 hours were 33 vs 36 (prasugrel vs ticagrelor; mean difference = −3; 95% CI: −28 to 22; p=0.814) meeting the primary endpoint of non-inferiority. Both prasugrel and ticagrelor significantly reduced PRU to a similar extent with no differences between groups at all other time points (Figure). Accordingly, HPR rates were low and similar between groups.

PRU by VerifyNow

Conclusion

Rapid genetic testing using the Spartan assay is feasible providing results in a timely fashion in a real-world clinical practice of patients undergoing PCI. Among patients with CYP2C19 LOF carrier status, prasugrel and ticagrelor are associated with similar levels of platelet inhibition.

Acknowledgement/Funding

Genetic testing was provided by Spartan RX

Effect of single-dose intravenous tranexamic acid on postoperative nasal bleed in septoplasty

OBJECTIVE

Postoperative nasal bleeding is a common complication of septoplasty and may lead to painful procedure of nasal packing to stop bleeding. Since Tranexamic acid (TXA) has been reported to reduce bleeding, the purpose of this study is to investigate the effect of single dose of intravenous TXA on postoperative nasal bleed associated with septoplasty.

MATERIALS AND METHODS

This prospective randomized, double-blinded clinical trial consisted of 176 patients aged 18-55 years who underwent septoplasty for symptomatic deviated nasal septum. These participants were randomly divided into 2 groups; 88 patients were given normal saline (Control group) and 88 patients were administered a single shot of intravenous TXA 10mg/kg (TXA group). Operative technique applied was same in all cases. At the end of surgery nasal packs, nasal splints or trans-septal suturing were not done. Nasal bleeding was monitored after surgery and up to 2 weeks postoperatively.

RESULTS

Patients receiving TXA showed significantly less postoperative nasal bleeding compared with controls. Extensive bleeding in terms of number of gauze pads used and duration was also higher in placebo with a statistically significant difference (all P=<0.05). Seven patients required nasal packing in control group to stop bleeding as compared to one patient in TXA group. Adverse reactions to TXA were minimal, and these were easily managed conservatively.

CONCLUSION

Single intravenous dose of TXA is shown to be effective and safe agent in preventing postoperative nasal bleeding after septoplasty therefore avoiding additional techniques of nasal packing, intranasal splint or trans-septal suturing during surgery.

Implementing an electronic clinical handover system in a university teaching hospital

INTRODUCTION

Clinical handover is defined as inter-clinician communication occurring at care interfaces. In this study, we analyse the clinical outcomes and physician attitudes associated with the implementation of a electronic clinical handover system in our medical department.

AIM

The aim of this project was to introduce a reliable, standardised, reproducible method of communicating information regarding inpatients within our medical department. We also sought to assess the attitudes of physicians within our department to medical handover.

METHODS

We designed and implemented an electronic handover template with a protocol to guide staff as to its use. Handover was audited weekly. In addition, we surveyed attitudes of doctors to handover before and after our handover pilot.

RESULTS

An average of 32 patients were handed over each week. Compliance with mandatory handover of ICU/CCU patients averaged at 59%. Extrapolating our pilot results for the year would result in approximately 1655 handover events per annum in our department. One hundred percent of physicians surveyed felt that documentation of handover was beneficial, and staff satisfaction with handover improved after initiation of the pilot (81 vs 24%, p = 0.000914). While 64% of staff were concerned that typed electronic handover would increase their workload, only 6% of the post pilot survey group felt that it did increase workload significantly.

CONCLUSION

Electronic clinical handover is feasible and practical within the Irish healthcare system. In addition, it was found in our study to be attractive and effective to physicians without increasing their workload.

Quantitative characterization of chitosan in the skin by Fourier-transform infrared spectroscopic imaging and ninhydrin assay: application in transdermal sciences

The chitosan has been used as the primary excipient in transdermal particulate dosage form design. Its distribution pattern across the epidermis and dermis is not easily accessible through chemical assay and limited to radiolabelled molecules via quantitative autoradiography. This study explored Fourier-transform infrared spectroscopy imaging technique with built-in microscope as the means to examine chitosan molecular distribution over epidermis and dermis with the aid of histology operation. Fourier-transform infrared spectroscopy skin imaging was conducted using chitosan of varying molecular weights, deacetylation degrees, particle sizes and zeta potentials, obtained via microwave ligation of polymer chains at solution state. Both skin permeation and retention characteristics of chitosan increased with the use of smaller chitosan molecules with reduced acetyl content and size, and increased positive charge density. The ratio of epidermal to dermal chitosan content decreased with the use of these chitosan molecules as their accumulation in dermis (3.90% to 18.22%) was raised to a greater extent than epidermis (0.62% to 1.92%). A larger dermal chitosan accumulation nonetheless did not promote the transdermal polymer passage more than the epidermal chitosan. A small increase in epidermal chitosan content apparently could fluidize the stratum corneum and was more essential to dictate molecular permeation into dermis and systemic circulation. The histology technique aided Fourier-transform infrared spectroscopy imaging approach introduces a new dimension to the mechanistic aspect of chitosan in transdermal delivery.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Formulation, and physical, in vitro and ex vivo evaluation of transdermal ibuprofen hydrogels containing turpentine oil as penetration enhancer

The aim of the present study was to investigate the transdermal permeation enhancing capability of turpentine oil for ibuprofen from hydrogels. Ibuprofen 1% w/v hydrogels were developed with carboxypolymethylene with and without turpentine oil. Turpentine oil was incorporated in increasing concentrations, i.e. 0.5, 1, 1.5, 2, 2.5 and 3% of the total gel formulation, and its permeation enhancing effect was examined. Gels were examined physically for pH, viscosity, spreadability, extrudability, smoothness and appearance. To study the in vitro and ex vivo permeation potential of formulated gels, permeation studies were performed with a Franz diffusion cell using cellulose membrane and excised rabbit abdominal skin. Ibuprofen hydrogel with 3% turpentine oil showed a maximum flux of 10.87 mg/cm2/h across artificial skin and 17.26 mg/cm2/h across rabbit abdominal skin.

Wnt and SHH in prostate cancer: trouble mongers occupy the TRAIL towards apoptosis

Prostate cancer is a serious molecular disorder that arises because of reduction in tumour suppressors and overexpression of oncogenes. The malignant cells survive within the context of a three-dimensional microenvironment in which they are exposed to mechanical and physical cues. These signals are, nonetheless, deregulated through perturbations to mechanotransduction, from the nanoscale level to the tissue level. Increasingly sophisticated interpretations have uncovered significant contributions of signal transduction cascades in governing prostate cancer progression. To dismantle the major determinants that lie beneath disruption of spatiotemporal patterns of activity, crosstalk between various signalling cascades and their opposing and promoting effects on TRAIL-mediated activities cannot be ruled out. It is important to focus on that molecular multiplicity of cancer cells, various phenotypes reflecting expression of a variety of target oncogenes, reversible to irreversible, exclusive, overlapping or linked, coexist and compete with each other. Comprehensive investigations into TRAIL-mediated mitochondrial dynamics will remain a worthwhile area for underlining causes of tumourigenesis and for unravelling interference options.

Palmitate induced insulin resistance by PKCtheta-dependent activation of mTOR/S6K pathway in C2C12 myotubes

The underlying mechanism of palmitate-induced insulin resistance in skeletal muscle cells is obscure. In this study, we showed that palmitate inhibited the insulin signaling in C2C12 myotubes, accompanied with the enhanced phosphorylation of protein kinase C-theta (PKCΘ). The inhibitory effects of palmitate on the insulin signaling were diminished in PKCΘ- and mTOR (mammalian target of rapamycin)-deficient C2C12 myotubes, and C2C12 myotubes pre-treated with rapamycin. In addition, the phosphorylation of mTOR and p70 ribosomal S6 kinase (S6K) enhanced by palmitate was attenuated in PKCΘ-deficient C2C12 myotubes and in C2C12 myotubes treated with PKCΘ pseudosubstrate. Taken together, our results suggested that palmitate-induced insulin resistance in C2C12 myotubes is mediated by PKCΘ/mTOR/S6K pathway.

Efficacy of Dongsulin (rDNA human insulin) in a normal clinical practice setting

The aim of this study was to evaluate the effectiveness ofDongsulin (rDNA, insulin) in maintaining HbA1c level in a normal clinical practice setting and secondly to assess weight gain, episodes of hypoglycaemia, insulin dose change and its safety. Fifty two diabetic patients already on human insulin (rDNA) were enrolled to a 12 week of treatment. Patients with HbA1c level between 6-8% were switched to Dongsulin on same dosage. The compliance of the patient regarding dietary pattern, physical activity and insulin dosages were assessed. HbA1c was checked after 12 weeks. Patient known to have either of the noncompliance factors during the study period were grouped as group B (non compliant) while, patients who were compliant were grouped as group A (compliant). Thirty nine patients completed the study. No significant difference was found between the HbA1c of two visits in group A (p = 0.32) while, HbA1c in group B was significantly raised as compared to first visit (p = 0.000). In group B patients missed the doses, changes in their diets and decreased their physical activity significantly. The mean insulin dose and weight of the patient remained the same in both groups. No major episode of hypoglycemia was observed. This study has shown that patients who remained compliant during the study period, switched over to Dongsulin had no significant change in the glycaemic control as measured by HbA1c.

A case of Turcot's Syndrome in a child with malignant transformation

Turcot's syndrome or the glioma polyposis syndrome is a rare variant of the polyposis syndrome and it is characterized by colonic polyposis and central nervous system neoplasm typically a glioblastoma or a medulloblastoma. We present a case of Turcot's syndrome in a child with malignant transformation.

Intrauterine torsion of a wandering spleen presenting as an abdominal cystic swelling

Wandering spleen is a rare clinical condition that presents commonly with splenic infarction secondary to torsion. Intrauterine torsion of a wandering spleen, however, is extremely rare. An unusual case of intrauterine torsion of a wandering spleen presenting as an abdominal mass is reported.

Pseudomyxoma peritonei manifesting as intestinal obstruction

Pseudomyxoma peritonei is an appendiceal tumor with distinct clinical and pathologic features. It frequently presents a problem in diagnosis and management. We report a case of pseudomyxoma peritonei, which initially appeared with intestinal obstruction. This is a rare initial manifestation in patients who have not had multiple surgical procedures. We review the literature and discuss the unique clinical features and misconceptions surrounding pseudomyxoma peritonei.

Congenital Morgagni's hernia in infants and children

Morgagni's hernia is an uncommon type of diaphragmatic hernia in the pediatric age group. Out of 52 children with different types of congenital diaphragmatic hernia that we have treated, 5 (9.6%) had Morgagni's hernia. There were 2 infants and 3 children including one with Down's syndrome. All suffered from repeated attacks of chest infection, and only after a chest X-ray was the diagnosis of Morgagni's hernia suspected. In 2 cases this appeared as an opacity in the anterior mediastinum adjacent to the pericardium; diagnosis was confirmed by barium enema in one and a CT-scan in the other. The remaining 3 cases showed anterior herniation of bowel loops on chest X-ray which was bilateral in one. This bilaterality was confirmed pre-operatively by CT scan. Associated anomalies were present in all cases, including 2 with malrotation. All patients were treated surgically via a transabdominal approach. Our study shows a relative high frequency of Morgagni's hernia in our patients and, although late-presenting Morgagni hernias are relatively benign, it can cause significant morbidity. This calls for early diagnosis and early referral for surgery. Chest X-ray is to be strongly advocated in children with repeated attacks of chest infection.

Congenital pyloric atresia and junctional epidermolysis bullosa: a report of two cases

The association between epidermolysis bullosa (EB) and congenital pyloric atresia (CPA) is rare, but is known distinct clinical entity with autosomal recessive inheritance. The outcome of such an association was universally fatal. This is a report of two newborns with EB and CPA, associated with additional aplasia cutis congenita in one case. One patient was treated postoperatively with phenytoin and survived. Aspects of the diagnosis, pathogenesis, and management are also discussed.

Neonatal intestinal atresia

Full text is available as a scanned copy of the original print version.

Synchronous bilateral Wilms' tumor

Synchronous bilateral Wilms' tumor (WT) accounts for 5% of all WTs. Of 34 cases of WT we treated, 7 (20.6%) were bilateral, 5 of them males. This high frequency of bilaterality as well as the male preponderance in our series is different from that reported in other parts of the world; this may reflect regional variations of WT. The details of diagnosis, therapy, including the role of preoperative chemotherapy, and outcome are presented.

A method to overcome the inability to draw blood from central venous lines in children

The insertion of central venous catheters has become an established practice in the management of children with different types of malignancies for the administration of chemotherapeutic agents, antibiotics, blood and blood products, as well as drawing blood for various investigations. A commonly encountered problem is that despite the catheter being patent it may be impossible to draw blood from it. We believe this is related to the cut of the catheter tip. To overcome this problem, a technique for cutting the tip of the catheter is described.

Esophageal atresia and tracheoesophageal fistula: success and failure rates in the United Arab Emirates

The management of esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved markedly over the years, with a current overall survival of 80%-90%. This however, is not the case in developing countries, where mortality continues to be high. The results of treatment of 41 consecutive cases EA and/or TEF have been analyzed to determine factors pertinent to the outcome. The distribution of anomalies and a postoperative survival of 86.8% were comparable to those from developed countries. Aspiration pneumonia was unusually frequent in our patients (78%), but did not adversely influence outcome. Associated congenital anomalies as well as low birth weight continue to be important predictors of outcome in our setting. Our post-operative complications were similar to those from developed countries apart from a high incidence of stricture formation. This was attributed to gastroesophageal reflux, non-ventilation post-operatively, and the use of silk sutures to construct the anastomosis.

An unusual case of esophageal atresia and double distal tracheoesophageal fistula

This report describes a neonate with a very rare and an unusual variety of esophageal atresia and tracheoesophageal fistula. The anomaly consisted of esophageal atresia and double distal tracheoesophageal fistula. The two fistulae as well as part of the distal esophagus were made up of tracheobronchial tissues. The embryology of the anomaly is also discussed.

Clostridium difficile colitis associated with treatment of Helicobacter pylori infection

Helicobacter pylori infection of the stomach is being detected and treated more often now than ever before. This is likely to result in an increase in complications such as antibiotic-associated diarrhea. However, there is no literature on the incidence of such diarrhea, particularly Clostridium difficile colitis, in patients treated for Helicobacter pylori infection. We report the case of a patient who developed Clostridium difficile colitis after treatment for Helicobacter pylori infection with metronidazole, amoxicillin, H2 blockers, and bismuth subsalicylate. This patient presented with severe diarrhea that responded to a course of metronidazole with rapid disappearance of symptoms. The incidence of Clostridium difficile colitis in patients treated for Helicobacter pylori infection has not been studied. This unique association, although not unexpected, has not yet been reported in the literature. The increasing number of patients being diagnosed and treated for this infection requires a heightened awareness on the part of physicians, to assure early diagnosis and treatment of this treatable, yet potentially dangerous, complication.