Case report: durable response of gliomatosis cerebri with concurrent tumor-treating fields (TTFields) and chemoradiotherapy treatment

BACKGROUND

Gliomatosis cerebri (GC) is a rare and aggressive form of widely disseminated glioma infiltrating at least 3 lobes of the brain. It is a diffuse pattern of growth seen in glioma rather than a distinct pathological diagnosis based on new Word Health Organization (WHO) classification. Despite this, it is associated with worse prognosis than equally graded gliomas. Tumor treating fields (TTFields) treatment is a more recent advancement in glioma treatment delivered through low energy, intermediate frequency (200 kHz) electromagnetic fields, with multi-modal mechanisms of action. It is Food and Drug Administration (FDA) approved for newly diagnosed and recurrent glioblastoma (GBM). The aim of this case report is to present a durable response of GBM associated GC to concurrent TTFields with chemoradiation.

CASE DESCRIPTION

We report a 64-year-old male with left parietal GBM, IDH wild type, WHO grade 4 with extensive GC change. After resection of the enhancing lesion, the patient received concurrent tumor-treating fields (TTFields) with radiation and temozolomide, enrolled in SPARE trial (NCT03477110). The patient had a rapid response in the areas of gliomatosis change demonstrated on the magnetic resonance imaging 1 month post-radiation treatment. The response of GC was durable. His glioma recurred 11 months after surgery with new enhancing lesions, treated with radiosurgery. He had further extensive progression of enhancing lesions 13 months after surgery, and received bevacizumab treatment. The patient ultimately passed away 17 months after surgery. Despite progression of enhancing lesions, the GC changes remained controlled. He also had favorable progression-free survival of 11 months and overall survival of 17 months.

CONCLUSIONS

This case serves as an example of how combination TTFields with chemoradiation may elicit a durable response of GC in patients with GBM.

Biodegradation of low density polyethylene (LDPE) by mesophilic fungus 'Penicillium citrinum' isolated from soils of plastic waste dump yard, Bhopal, India

Low density Polyethylene (LDPE) in various forms has become a part of life. Its accretion due to non degradable nature is concern, endangering life on earth. Amongst various methods of LDPE disposal bioremediation is regarded as ecofriendly & widely accepted. Current investigation was an attempt to isolate potent PE degrading fungus from municipal landfill soils of Bhopal, India loaded with plastic waste.16 fungal isolates were recorded from the site; PE deteriorating fungus was screened using mineral salt agar medium amended with 3% LDPE powder as sole carbon source. The isolate Penicillium citrinum showed fast fungal colony growth in screening medium was selected for biodegradation study. P.citrinum showed 38.82 ± 1.08% weight loss of untreated LDPE pieces; to improve the degradation capacity nitric acid pretreatment was performed; biodegradation was significantly stimulated by 47.22 ± 2.04% after it's pretreatment. Laccase, lipase, esterase & manganese peroxidase activities were assayed by spectrophotometer. LDPE biodegradation was analyzed by weight loss %, change in pH during fungal growth, field emission scanning electron microscopy (FE-SEM), fourier transform infrared spectroscopy (FTIR) & thermogravimetric analysis (TGA). FTIR spectra showed appearance of new functional groups assigned to hydrocarbon biodegradation, confirming enzymatic role in process. Changes in FTIR spectra of LDPE samples (untreated & pretreated) before & after biodegradation & surface changes in the biodegraded LDPE (indicated from FE-SEM) confirmed depolymerization of LDPE. Further changes in thermal decomposition rates of biodegraded samples in comparison to control, validate biodegradation. This is the first report signifying high competence of P.citrinum in LDPE degradation without prior pretreatment.

Pharmacological basis of the putative therapeutic effect of Topical Vitamin D3 on the experimental model of atopic dermatitis in mice

OBJECTIVE

The aim of the study was to explore the effect of topical vitamin D3 in atopic dermatitis (AD) induced by ovalbumin (OVA) in contrast with topical betamethasone in mice.

MATERIALS AND METHODS

35 BALB/c adult male mice, weighing between 25-30 gm were used to induce AD by topically sensitizing the dorsal surface of the skin with the OVA patch. Subsequently, treatments were performed in each group by application of vitamin D3 cream (0.0003%), betamethasone cream (0.1%), or vehicles (QV cream) on the skin.

RESULTS

Remarkably, vitamin D3 had a marked improvement in the skin of OVA-induced AD mice. Additionally, vitamin D3 revealed a considerable diminution in the levels of IgE, IL-5, filaggrin, and epidermal thickness, whereas a significant augmentation in the levels of IL-4 and IL-13 was observed when compared with the control group, and histopathological studies had further confirmed these findings.

CONCLUSIONS

This study essentially highlighted the anti-inflammatory effect of vitamin D3 by effective alteration in the immunological components responsible for AD. Moreover, this pioneer experimental work represents a new paradigm and sheds a light on the importance of vitamin D3 in the implications of AD. A comprehensive creative approach is crucial to concretely establish and further corroborate vitamin D3 for this therapeutic role.

Pre-hospital administration of tranexamic acid in trauma patients: A systematic review and meta-analysis

Background

The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) trial proved that tranexamic acid (TXA) is a time-dependent drug, having a better outcome if given within 1-hour of injury. In order to test this theory, studies have been conducted to examine the effect of TXA in the pre-hospital setting. We conducted a systematic search and meta-analysis to evaluate the role of TXA administration in the civilian pre-hospital setting on patient outcomes.

Methods

Embase, Medline, CINAHL and Cochrane were searched for randomized control trials (RCTs), retrospective, and prospective studies that examined the effect of TXA on patients in the pre-hospital setting versus a control group. Outcome measures were overall mortality rate and thromboembolic events. Two authors extracted the data independently. To appraise the included studies, we used the NIH quality assessment tool for cohort and cross-sectional studies. Results are presented as Risk Ratio (RR), a random-effect model was implemented, and the I2 test was used to assess heterogeneity.

Results

The search identified 1886 papers, but only five retrospective studies met the inclusion/exclusion criteria and were selected for further analysis. A meta-analysis confirmed that TXA reduced the overall mortality rate (pooled risk ratio of 0.74 (95% CI 0.45, 1.25)) and thromboembolic events (risk ratio of 0.71 (95% CI 0.35, 1.44)).

Conclusion

The pooled effects for both outcome measures favour the administration of TXA in the pre-hospital setting, although none of the findings reported a significant effect. Our study highlights the need for additional high-quality evidence to validate the significance of these findings.

Level of evidence

Level III, therapeutic study.

CTNI-19. CONCURRENT CHEMORADIATION AND TUMOR TREATING FIELDS (TTFields, 200 kHz) FOR PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA MAY INCREASE THE RATE OF DISTANT RECURRENCE

INTRODUCTION: Current standard of care for glioblastoma (GBM) includes concurrent chemoradiation and maintenance temozolomide (TMZ) along with Tumor Treating Fields (TTFields). Preclinical studies suggest TTFields and radiation treatment have synergistic effects. Secondary analysis of EF14 trial demonstrated TTFields treatment may increase the rate of distant recurrence. We report our experience evaluating areas of progression in our pilot clinical trial of concurrent chemoradiation with TTFields. METHODS: This is a single arm pilot study (clinicaltrials.gov Identifier: NCT03477110). Adult patients (age ≥ 18 years) with KPS ≥ 60 with newly diagnosed GBM were eligible. All patients received concurrent scalp-sparing radiation (60 Gy in 30 fractions), standard concurrent TMZ (75 mg/m2 daily), and TTFields. Maintenance therapy included standard TMZ and continuation of TTFields. Radiation treatment was delivered through TTFields arrays. Incidence and location of progression was documented. Distant recurrence was defined as recurrence more than 2 cm from primary enhancing lesion. RESULTS: A total of 30 patients were enrolled on the trial. Twenty were male, and ten were female, with median age 58 years (19-77 years). Median KPS was 90 (70-100). Median follow-up was 11.6 months (1.7-22.1 months). Twenty (66.7%) patients had an unmethylated MGMT promotor status and ten (33.3%) patients had a methylated promoter status. Twenty patients (66.7%) had progression, with median PFS of 9.1 months (range 1.6 to 12.9 months). Five patients (26%) of patient presented with distant recurrence, with median distance from primary lesion of 5.1 cm (2.26-9.12 cm). One infratentorial progression was noted. Another patient transferred care and location of progression is unknown. CONCLUSIONS: Concurrent chemoradiation with TTFields for patients with newly diagnosed glioblastoma may have increased incidence of distant recurrence. This finding is suggestive of improved local control of primary site. Further data are needed to validate this finding.

RADT-22. CONCURRENT TTFIELDS (200 KHZ) WITH CHEMORADIATION FOR PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA MAY INCREASE THE RATE OF PSEUDOPROGRESSION: ANALYSIS OF A PILOT CLINICAL TRIAL

OBJECTIVE

The standard of care for the adjuvant treatment of glioblastoma is concurrent chemoradiation, maintenance temozolomide, and Tumor Treating Fields (TTFields). TTFields may reversibly impact the blood-brain barrier, most significantly at 100 kHz. We hypothesized that this may increase the rate of pseudoprogression (PsP) in patients who receive concurrent chemoradiation with TTFields (200 kHz).

METHODS

This is a single arm pilot study (clinicaltrials.gov Identifier: NCT03477110). Patients with newly diagnosed glioblastoma, age ≥ 18 years, and KPS ≥ 60 were eligible. They received concurrent temozolomide (75 mg/m2), scalp-sparing radiation (60 Gy in 30 fractions), and TTFields (200 kHz). Radiation was delivered through the TTFields arrays. PsP was defined as radiographic progression of enhancing lesions without clinical decline that improved or remained stable upon subsequent imaging. The rate of PsP was determined by an evaluation of the 2nd MRI at our multidisciplinary tumor board after the completion of trimodality treatment. These findings were confirmed with official radiology reports.

RESULTS

30 patients were enrolled. Of these, 29 had imaging available for evaluation. Male-to-female ratio was 20:10. Median follow-up was 11.6 months (1.6-22.4 months), median age was 58 years (19-77 years), and median KPS was 90 (70-100). 20 (66.7%) patients had unmethylated and 10 (33.3%) had methylated MGMT promotor. Median time from surgery to initiation of radiation was 34 days (26-49 days). Median time from completion of trimodality treatment to 2nd follow-up MRI was 90 days (29-109 days). 15/29 (51.7%) patients had PsP. Patients with methylated and unmethylated MGMT promotor had 50.0% (5/10) and 52.6% (10/19) rates of progression respectively.

CONCLUSIONS

51.7% of the patients who received concurrent chemoradiation with TTFields demonstrated PsP. The incidence is greater than historical reports. However, these findings should be explored in larger cohorts as this study was limited by a small sample size.

NIMG-39. RADIOMIC ANALYSIS FOR NON-INVASIVE IN VIVO PROGNOSTIC STRATIFICATION OF DE NOVO GLIOBLASTOMA PATIENTS: A MULTI-INSTITUTIONAL EVALUATION FOR GENERALIZABILITY IN THE RESPOND CONSORTIUM

PURPOSE

Multi-parametric MRI based radiomic signatures have highlighted the promise of artificial intelligence (AI) in neuro-oncology. However, inter-institution heterogeneity hinders generalization to data from unseen clinical institutions. To this end, we formulated the ReSPOND (Radiomics Signatures for PrecisiON Diagnostics) consortium for glioblastoma. Here, we seek non-invasive generalizable radiomic signatures from routine clinically-acquired MRI for prognostic stratification of glioblastoma patients.

METHODS

We identified a retrospective cohort of 606 patients with near/gross total tumor resection ( >90%), from 13 geographically-diverse institutions. All pre-operative structural MRI scans (T1,T1-Gd,T2,T2-FLAIR) were aligned to a common anatomical atlas. An automatic algorithm segmented the whole tumors (WTs) into 3 sub-compartments, i.e., enhancing (ET), necrotic core (NC), and peritumoral T2-FLAIR signal abnormality (ED). The combination of ET+NC defines the tumor core (TC). Quantitative radiomic features were extracted to generate our AI model to stratify patients into short- (< 14mts) and long-survivors ( >14mts). The model trained on 276 patients from a single institution was independently validated on 330 unseen patients from 12 left-out institutions, using the area-under-the-receiver-operating-characteristic-curve (AUC).

RESULTS

Each feature individually offered certain (limited but reproducible) value for identifying short-survivors: 1) TC closer to lateral ventricles (AUC=0.62); 2) larger ET/brain (AUC=0.61); 3) larger TC/brain (AUC=0.59); 4) larger WT/brain (AUC=0.55); 5) larger ET/WT (AUC=0.59); 6) smaller ED/WT (AUC=0.57); 7) larger ventricle deformations (AUC=0.6). Integrating all features and age, through a multivariate AI model, resulted in higher accuracy (AUC=0.7; 95% C.I.,0.64-0.77).

CONCLUSION

Prognostic stratification using basic radiomic features is highly reproducible across diverse institutions and patient populations. Multivariate integration yields relatively more accurate and generalizable radiomic signatures, across institutions. Our results offer promise for generalizable non-invasive in vivo signatures of survival prediction in patients with glioblastoma. Extracted features from clinically-acquired imaging, renders these signatures easier for clinical translation. Large-scale evaluation could contribute to improving patient management and treatment planning.

*Indicates equal authorship.

NIMG-22. PREDICTION OF GLIOBLASTOMA CELLULAR INFILTRATION AND RECURRENCE USING MACHINE LEARNING AND MULTI-PARAMETRIC MRI ANALYSIS: RESULTS FROM THE MULTI-INSTITUTIONAL RESPOND CONSORTIUM

PURPOSE

Multi-parametric MRI and artificial intelligence (AI) methods were previously used to predict peritumoral neoplastic cell infiltration and risk of future recurrence in glioblastoma, in single-institution studies. We hypothesize that important characteristics of peritumoral tissue heterogeneity captured, engineered/selected, and quantified by these methods relate to predictions generalizable in the multi-institutional ReSPOND (Radiomics Signatures for PrecisiON Diagnostics) consortium.

METHODS

To support further development, generalization, and clinical translation of our proposed method, we trained the AI model on a retrospective cohort of 29 de novo glioblastoma patients from the Hospital of the University of Pennsylvania (UPenn) (Male/Female:20/9, age:22-78 years) followed by evaluation on a prospective multi-institutional cohort of 84 glioblastoma patients (Male/Female:51/33, age:34-89 years) from Case Western Reserve University/University Hospitals (CWRU/UH, 25), New York University (NYU, 13), Ohio State University (OSU, 13), University Hospital Río Hortega (RH, 2), and UPenn (31). Features extracted from pre-resection MRI (T1, T1-Gd, T2, T2-FLAIR, ADC) were used to build our model predicting the spatial pattern of subsequent tumor recurrence. These predictions were evaluated against regions of pathology-confirmed post-resection recurrence.

RESULTS

Our model predicted the locations that later harbored tumor recurrence with sensitivity 83%, AUC 0.83 (99% CI, 0.73-0.93), and odds ratio 7.23 (99% CI, 7.09-7.37) in the prospective cohort. Odds ratio (99% CI)/AUC(99% CI) per institute were: CWRU/UH, 7.8(7.6-8.1)/0.82(0.75-0.89); NYU, 3.5(3.3-3.6)/0.84(074-0.93); OSU, 7.9(7.6-8.3)/0.8(0.67-0.94); RH, 22.7(20-25.1)/0.94(0.27-1); UPenn, 7.1(6.8-7.3)/0.83(0.76-0.91).

CONCLUSION

This is the first study that provides relatively extensive multi-institutional validated evidence that AI can provide good predictions of peritumoral neoplastic cell infiltration and future recurrence, by dissecting the MRI signal heterogeneity in peritumoral tissue. Our analyses leveraged the unique dataset of the ReSPOND consortium, which aims to develop and evaluate AI-based biomarkers for individualized prediction and prognostication, by moving from single-institution studies to generalizable, well-validated multi-institutional predictive biomarkers.

RADT-13. SPARE TRIAL: SCALP-SPARING RADIATION WITH CONCURRENT TEMOZOLOMIDE AND TUMOR TREATING FIELDS FOR PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA

INTRODUCTION

Current adjuvant treatment for patients with newly diagnosed glioblastoma includes concurrent chemoradiation and maintenance temozolomide with Tumor Treating Fields (TTFields). We report our clinical trial evaluating feasibility and tolerability of scalp-sparing radiation with concurrent temozolomide and TTFields.

METHODS

Adult patients (age ≥ 18 years) with newly diagnosed glioblastoma with a KPS of ≥ 60 were eligible. All patients received concurrent scalp-sparing radiation (60 Gy in 30 fractions) with temozolomide (75 mg/m2 daily) and TTFields (200 kHz). Maintenance therapy included temozolomide and continuation of TTFields. Radiation treatment was delivered through TTFields arrays. The primary endpoint was safety and toxicity of tri-modality treatment within 30 days of completion of chemoradiation treatment.

RESULTS

Thirty patients were enrolled. Twenty were male and ten were female, with a median age of 58 years (range 19 to 77 years). Median follow-up was 10.8 months (range 1.6 to 21.3 months). Twenty (66.7%) patients had unmethylated MGMT promotor and ten (33.3%) patients had methylated promoter. Scalp dose constraints were achieved for all patients. Skin adverse events (erythema, dermatitis, irritation, folliculitis) were noted in 83.3% of patients, however, these were limited to Grade 1 or 2 events, which resolved spontaneously or with topical medications. No patient had radiation treatment interruption due to skin AEs. Other Grade 1 events included pruritus (33.3%), fatigue (30%), nausea (13.3%), headache (10%), dizziness (6.7%), and cognitive impairment (3.3%). Other Grade 2 events included headache (3.3%). The median PFS for the entire cohort was 9.1 months (at least 8.5 months, 95% confidence). The median PFS for patients with MGMT promoter methylation status was 11.4 months (at least 9.5 months, 95% confidence). Overall survival was not reached.

CONCLUSIONS

Concurrent TTFields with scalp-sparing chemoradiation is feasible treatment option with limited toxicity. Future randomized prospective trials are warranted to define therapeutic advantages of concurrent TTFields with chemoradiation.

A Pilot Trial Using Telemedicine in Radiation Oncology: The Future of Health Care Is Virtual

Background: Social determinants of health directly affect cancer survival. Driven by advances in technology and recent demands due to COVID-19, telemedicine has the ability to improve patient access to care, lower health care costs, and increase workflow efficiency. The role of telemedicine in radiation oncology is not established. Materials and Methods: We conducted an IRB-approved pilot trial using a telehealth platform for the first post-radiation visit in patients with any cancer diagnosis. The primary endpoint was feasibility of using telehealth defined by completion of five telehealth visits per month in a single department. Secondary endpoints included the ability to assess patients appropriately, patient and physician satisfaction. Physicians were surveyed again during the pandemic to determine whether viewpoints changed. Results: Between May 27, 2016 and August 1, 2018, 37 patients were enrolled in the Telehealth in Post-operative Radiation Therapy (TelePORT) trial, with 24 evaluable patients who completed their scheduled telehealth visit. On average, 1.4 patients were accrued per month. All patients were satisfied with their care, had enough time with their physician and 85.7% believed the telehealth communication was excellent. All physicians were able to accurately assess the patient's symptoms via telehealth, whereas 82.3% felt they could accurately assess treatment-related toxicity. Physicians assessing skin toxicity from breast radiation were those who did not feel they were able to assess toxicity. Discussion and Conclusions: Both health care providers and patients have identified telemedicine as a suitable platform for radiation oncology visits. Although there are limitations, telemedicine has significant potential for increasing access of cancer care delivery in radiation oncology.

Target treatment with stereotactic radiation for recurrent gliomas

High grade gliomas (HGG) have a propensity to recur locally and have poor outcomes. As such, safe and effective treatment is paramount. Target treatment with stereotactic radiation allows safe re-irradiation through minimizing normal brain tissue radiation due to its high precision. In this review, we evaluated the clinical experiences using SRS and FSRT for re-irradiation in HGG. We report the radiobiological advantages and disadvantages of both modalities as well as the safety and efficacy published in current literature.

A phase II study to assess the safety and efficacy of the dual mTORC1/2 inhibitor vistusertib in relapsed, refractory DLBCL

Patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) who are unfit for or relapsed postautologous stem-cell transplantation have poor outcomes. Historically, mTORC1 inhibitors have produced responses in approximately 30% of patients in this setting. mTORC1 inhibitor efficacy may be limited by resistance mechanisms including AKT activation by mTORC2. To date, dual mTORC1/2 inhibitors targeting both the TORC1 and TORC2 complexes have not been investigated in DLBCL. This phase II trial investigated the oral dual mTORC1/2 inhibitor vistusertib in an intermittent dosing schedule of 125 mg b.d. for 2 days per week. Thirty patients received vistusertib and six received vistusertib-rituximab for up to six cycles (28-day cycles). Two partial responses were achieved on monotherapy. Durations of response were 57 and 62 days, respectively, for these patients. 19% had stable disease within six cycles. In the monotherapy arm, the median progression-free survival was1.69 (95% confidence interval [CI] 1.61-2.14) months and median overall survival was 6.58 (95% CI 3.81-not reached) months, respectively. The median duration of response or stable disease across the trial duration was 153 days (95% CI 112-not reached). Tumour responses according to positron emission tomography/computed tomography versus computed tomography were concordant. There were no differences noted in tumour volume response according to cell of origin by either gene expression profiling or immunohistochemistry. Vistusertib ± rituximab was well tolerated; across 36 patients 86% of adverse events were grade (G) 1-2. Common vistusertib-related adverse events were similar to those described with mTORC1 inhibitors: nausea (47% G1-2), diarrhoea (27% G1-2, 6% G3), fatigue (30% G1-2, 3% G3), mucositis (25% G1-2, 6% G3), vomiting (17% G1-2), and dyspepsia (14% G1-2). Dual mTORC1/2 inhibitors do not clearly confer an advantage over mTORC1 inhibitors in relapsed or refractory DLBCL. Potential resistance mechanisms are discussed within.

From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination

BACKGROUND

Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003.

METHODS

We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys.

RESULTS

The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis.

CONCLUSIONS

Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

Links between the Prophet Muhammad (PBUH) recommended foods and disease management: A review in the light of modern superfoods

Nutrition and other bioactive natural products present in specific foods within a balanced diet play an indispensable role in maintaining and promoting human health. Plants are rich sources of a balanced nutrition because of high content of bioactive products; hence, most of them recently have acquired the status of superfoods. It has been used since ancient times for the treatment of various ailments, and these traditional medicines still remain as one of the most affordable and easily accessible sources of treatment in the primary health-care system. The scientifically based use of these superfoods date back to the era of Prophet Muhammad along with other historical uses of plant products. Prescription of a large number of herbal foods such as dates, pomegranate, olives, figs, grapes, and black seeds was successfully proposed by him. These recently have become superfoods with their powerful healing properties and act as favorable dietary interventions for disease prevention as well as for the good maintenance of health. The use of these foods as ingredients of natural origin with fewer side effects seems to be more favorable than the chemical treatment, which is often complicated. The present review is an attempt to provide a brief survey of the literature on scientifically based significance of these superfoods carried out by various researchers and exploration of a wide spectrum of their pharmacological actions which include antidiabetic, anticancer, immune modulator, analgesic, anti-inflammatory, and hepatoprotective properties.

Purified Mushroom Tyrosinase Induced Melanogenic Protein Expression in B16F10 Melanocytes: A Quantitative Densitometric Analysis

Background:

Human skin exists in a wide range of different colors and gradations, ranging from white to brown to black. This is due to the presence of a chemically inert and stable pigment known as melanin, which is produced deep inside the skin but is displayed as a mosaic at the surface of the body.

Methods & Materials:

In mammalian melanocytes, melanosome is a highly specialized organelle where melanin is synthesized. Melanin synthesis is controlled by tyrosinase, the vital enzyme in melanogenic pathway. The present investigation is based on the effect of purified tyrosinase of Agaricus bisporus on B16F10 melanocytes for melanogenic protein expression.

Results:

After the treatment of purified tyrosinase B16F10 melanocytes did not show any cytotoxic effect. Melanin content in B16F10 melanocytes was increased by purified tyrosinase in a dose-dependent manner. Quantitative western blot analysis revealed that cellular tyrosinase intensity was enhanced after treatment with purified tyrosinase for 48 hours, where the band intensity had a steady increase in the absorption of purified tyrosinase in B16F10 cells. The density analysis described increased absorption for 2 to 5 bands as 2.7, 3.7, 6.7 and 8.6% respectively. The bands in the comparative analysis of western blot were between the Rf value range (0.40-0.57) with maximum absorption of 3000 intensity curve at 32μg/mL, rather than higher concentration 64μg/mL, showing a decrease in the absorption.

Conclusion:

It is presumed that purified tyrosinase can be used as contestants for the treatment of vitiligous skin conditions.

Risk of inferior alveolar nerve injury with coronectomy vs surgical extraction of mandibular third molars-A comparison of two techniques and review of the literature

The removal of mandibular third molar teeth is one of the most common oral surgical procedures. In a significant number of patients, it carries a degree of associated morbidity, including damage to the inferior alveolar nerve (IAN). For this reason, practitioners desire the most up-to-date guidance on the most appropriate technique, informed by the best available evidence that will produce the lowest incidence of iatrogenic complications. The aim of this study was to perform a systematic review comparing the effect of coronectomy vs complete surgical extraction of mandibular third molar teeth on the risk of IAN injury and other complications in adults. Studies were identified through Embase (1980-2016) and Ovid MEDLINE (1946-2016) database searches. Search terms included coronectomy, partial root removal, deliberate vital root retention, odontectomy, surgical removal, surgical extraction, complete tooth extraction and extract. Limits of the study included humans, English language and randomised controlled trials (RCTs). Only RCTs comparing IAN damage associated with surgical extraction of mandibular third molars vs coronectomy were included. From our database searches, we identified two unique RCTs matching the inclusion criteria. Both evaluated patients who had specific radiographic signs of intimate relationships with the IAN. Upon detailed analysis, the studies were noted to exhibit a high risk of bias in many categories, thereby rendering their results inconclusive. Although evidence from two RCTs suggests that coronectomy can reduce the risk of IAN injury compared to surgical removal of high-risk mandibular third molars, the quality of evidence is insufficient to provide definitive conclusions regarding the preferred technique.

Melanogenic effect of purified mushroom tyrosinase on B16F10 Melanocytes: A Phase Contrast and Immunofluorescence Microscopic Study

Cutaneous melanin pigment plays a critical role in camouflage, mimicry, social communication, and protection against harmful effects of solar radiation. It has been proven that tyrosinase plays a pivotal role in melanocytes dendrite formation; however, the molecular mechanism underlying this process has not been fully elucidated. The morphological changes were observed under a phase contrast microscope. These changes were evident, with globular cell bodies and increased numbers of tree branch-like dendrites. The present work aimed to study the morphoanatomic effects of purified tyrosinase to determine its skin-darkening potential using B16F10 melanocyte, which has not been done to date. Phase contrast and immunofluorescence microscopic analysis of B16F10 melanocytes has been done after treatment with various concentrations of purified tyrosinase along with standard tyrosinase (Sigma) in order to explore the mechanism of action of purified tyrosinase induced skin darkening. The phase contrast microscopic results showed that the number of melanocytes with melanin-loaded dendrites has increased significantly in purified tyrosinase treated cells in a dose dependent manner leading to skin darkening. In addition, immunofluorescence microscopic analysis revealed purified tyrosinase increase cellular tyrosinase expression in doze dependent manner due to tyrosinase absorption in B16F10 melanocyte. Present findings proved that purified tyrosinase possesses a skin darkening potential and could be used as a safe melanogenic agent for the treatment of hypopigmentation disorders or vitiligo.

Pharmacists' self-perceptions in relation to the 'Advanced Pharmacy Practice Framework'

BACKGROUND

The Australian Pharmacy Practice Framework was developed by the Advanced Pharmacy Practice Steering Committee and endorsed by the Pharmacy Board of Australia in October 2012. The Steering Committee conducted a study that found practice portfolios to be the preferred method to assess and credential Advanced Pharmacy Practitioner, which is currently being piloted by the Australian Pharmacy Council. Credentialing is predicted to open to all pharmacists practising in Australia by November 2015.

OBJECTIVE

To explore how Australian pharmacists self-perceived being advanced in practice and how they related their level of practice to the Australian Advanced Pharmacy Practice Framework.

METHOD

This was an explorative, cross-sectional study with mixed methods analysis. Advanced Pharmacy Practice Framework, a review of the recent explorative study on Advanced Practice conducted by the Advanced Pharmacy Practice Framework Steering Committee and semi-structured interviews (n = 10) were utilized to create, refine and pilot the questionnaire. The questionnaire was advertised across pharmacy-organizational websites via a purposive sampling method. The target population were pharmacists currently registered in Australia.

RESULTS

Seventy-two participants responded to the questionnaire. The participants were mostly female (56.9%) and in the 30-40 age group (26.4%). The pharmacists self-perceived their levels of practice as either entry, transition, consolidation or advanced, with the majority selecting the consolidation level (38.9%). Although nearly half (43.1%) of the participants had not seen the Framework beforehand, they defined Advanced Pharmacy Practice similarly to the definition outlined in the Framework, but also added specialization as a requirement. Pharmacists explained why they were practising at their level of practice, stating that not having more years of practice, lacking experience, or postgraduate/post-registration qualifications, and more involvement and recognition in practice were the main reasons for not considering themselves as an Advanced Pharmacy Practitioner. To be considered advanced by the Framework, pharmacists would need to fulfill at least 70% of the Advanced Practice competency standards at an advanced level. More than half of the pharmacists (64.7%) that self-perceived as being advanced managed to fulfill 70% or more of these Advanced Practice competency standards at the advanced level. However, none of the self-perceived entry level pharmacists managed to match at least 70% of the competencies at the entry level.

CONCLUSION

Participants' self-perception of the term Advanced Practice was similar to the definition in the Advanced Pharmacy Practice Framework. Pharmacists working at an advanced level were largely able to demonstrate and justify their reasons for being advanced practitioners. However, pharmacists practising at the other levels of practice (entry, transition, consolidation) require further guidance regarding their advancement in practice.

On the role of histamine receptors in regulating pigmentary responses in Oreochromis mossambicus melanophores

PURPOSE

The present work was carried out to reveal the involvement of histamine receptors at the neuro-melanophore junction of teleost, Oreochromis mossambicus.

METHODS

The isolated scale melanophores were assayed using the mean melanophore size index and their responses were recorded in presence of various concentrations of histamine along with H(1) and H(2) receptor specific agonists and antagonist and potentiator compound 48/80.

RESULTS

Melanophores showed high sensitivity to histamine and its specific agonists. Histamine caused a dose-dependent pigment aggregation, whereas 2-(2-Pyridyl) ethylamine (PEA), a specific H(1)R agonist also caused aggregation in a similar manner. Conversely, amthamine, a specific H(2)R agonist resulted in pigment dispersion. The effects were antagonized by mepyramine; specific H(1)R antagonist and ranitidine a specific H(2)R antagonist.

CONCLUSION

It is concluded that O. mossambicus melanophores have both H(1) and H(2) receptors which mediate melanophore aggregation and dispersion respectively. Compound 48/80 augmented the melanin-aggregating and dispersing effects of PEA and amthamine. It is suggested that the effect of histamine is directly mediated through H1 and H2 receptors, whereas H1Rs may be predominantly involved in the aggregatory responses.

Expression of microRNAs: potential molecular link between obesity, diabetes and cancer

Clinicians are routinely challenged in their management of cancer patients because of the complexities of obesity and diabetes that are often found as comorbid conditions. Although attention has been given to optimizing treatment planning for these patients, less attention has been given to manage their obesity and diabetes. This suggests that newer, comprehensive approaches must be developed for the treatment of cancer patients as a 'whole' rather than as a single disease. While the specific pathologies of each are unique, years of research have indicated intimate molecular links between these chronic diseases. The contribution of sedentary lifestyles and poor dietary habits is recognized; however, the precise molecular links are still not well-explored. In addition, emerging evidence suggests the important role of microRNAs (miRNAs) in the development and progression of several diseases, yet their roles in linking obesity, diabetes and cancer are only now beginning to be recognized. It is hoped that miRNAs will serve as novel biomarkers and molecular targets for cancer therapy in patients with comorbid conditions. In this review, we discuss the current understanding of the pathobiology of obesity, diabetes and cancer, and document molecular roles of miRNAs linking cancer with obesity and diabetes.

5-HT receptors as novel targets for optimizing pigmentary responses in dorsal skin melanophores of frog, Hoplobatrachus tigerinus

BACKGROUND AND PURPOSE

Biochemical identification of 5-HT has revealed similar projection patterns across vertebrates. In CNS, 5-HT regulates major physiological functions but its peripheral functions are still emerging. The pharmacology of 5-HT is mediated by a diverse range of receptors that trigger different responses. Interestingly, 5-HT receptors have been detected in pigment cells indicating their role in skin pigmentation. Hence, we investigated the role of this monoaminergic system in amphibian pigment cells, melanophores, to further our understanding of its role in pigmentation biology together with its evolutionary significance.

EXPERIMENTAL APPROACH

Pharmacological profiling of 5-HT receptors was achieved using potent/selective agonists and antagonists. In vitro responses of melanophores were examined by Mean Melanophores Size Index assay. The melanophores of lower vertebrates are highly sensitive to external stimuli. The immediate cellular responses to drugs were defined in terms of pigment translocation within the cells.

KEY RESULTS

5-HT exerted strong concentration-dependent pigment dispersion at threshold dose of 1 × 10(-6) g·mL(-1). Specific 5-HT(1) and 5-HT(2) receptor agonists, sumatriptan and myristicin. also induced dose-dependent dispersion. Yohimbine and metergoline synergistically antagonized sumatriptan-mediated dispersion, whereas trazodone partially blocked myristicin-induced dispersion. Conversely, 5-HT(3) and 5-HT(4) receptor agonists, 1 (3 chlorophenyl) biguanide (1,3 CPB) and 5-methoxytryptamine (5-MT), caused a dose-dependent pigment aggregation. The aggregatory effect of 1,3 CPB was completely blocked by ondansetron, whereas L-lysine partially blocked the effect of 5-MT.

CONCLUSIONS AND IMPLICATIONS

The results suggest that 5-HT-induced physiological effects are mediated via distinct classes of receptors, which possibly participate in the modulation of pigmentary responses in amphibian.

In vitro responses of fish melanophores to lyophilized extracts of Psoralea corylifolia seeds and pure psoralen

CONTEXT

Psoralens are naturally occurring furanocumarins used in photochemotherapy of several skin diseases. They are obtained from dried ripe fruits of Psoralea corylifolia Linn. (Fabaceae). However, little research has been done to study the melanogenic activity of P. corylifolia seeds and their active ingredients on the pigment cells, the melanophores taking account of their cholinergic activity.

OBJECTIVE

The present work was carried out to determine the effects of lyophilized seed extracts of P. corylifolia, along with pure psoralen on the isolated scale melanophores of Channa punctatus Bloch. (Channidae), which are a disguised type of smooth muscle cells and offer excellent in vitro opportunities for studying the effects of drugs.

MATERIALS AND METHODS

Effects of lyophilized extracts of P. corylifolia and pure psoralen were studied on the isolated scale melanophores of C. punctatus as per the modified method of Bhattacharya et al. (1976) .

RESULTS

The lyophilized extract of P. corylifolia and its active ingredient psoralen caused significant melanin dispersal responses leading to darkening of the fish scale melanophores, which were completely antagonized by atropine and hyoscine. These melanin dispersal effects were also found to be markedly potentiated by neostigmine, an anticholinesterase agent.

DISCUSSION

In the present study, the lyophilized extract of P. corylifolia seeds and standard psoralen in different dose ranges induced powerful melanin dispersal effects of the previously adrenaline-aggregated isolated scale melanophores of C. punctatus. Comparatively, psoralen caused a more sustained and powerful melanin dispersal within the isolated fish melanophores and interestingly the concentrations required to achieve maximal dispersion of melanophore were 10 times less than that of lyophilized seed extract of P. corylifolia. The physiologically significant dose-related melanin dispersion effects of lyophilized P. corylifolia seeds and synthetic psoralen per se were found to be completely abolished by atropine and hyoscine, which are specific cholino-muscarinic receptor blockers. These data strongly indicate that in the fish C. punctatus, the dispersion of melanin granules within the scale melanophores is mediated by choline receptors of muscarinic nature.

CONCLUSION

It appears that the melanin dispersal effects of the extracts of P. corylifolia and pure psoralen leading to skin darkening are mediated by cholino-muscarinic- or cholino-psoralen-like receptors having similar properties.

Precipitation pattern formation in the copper(II) oxalate system with gravity flow and axial symmetry

Chemical systems that are far from thermodynamic equilibrium may form complex temporal and spatiotemporal structures. In our paper, we present unusual precipitation patterns that have been observed in the system of Cu(II)-oxalate. Starting with a pellet of copper sulfate immersed in or by pumping copper sulfate solution into a horizontal layer of sodium oxalate solution, we have observed the formation of a precipitate ring and an array of radially oriented thin fingers. The development of these patterns is related to the internal structure of the different crystals, the gravity flow, and the circular symmetry of the experimental arrangement.

The clinical implications (or lack thereof) of vegetations detected by echocardiography in patients not thought to have endocarditis

BACKGROUND

The clinical impact of echocardiographic demonstration of a vegetation (Veg) in patients in whom infective endocarditis (IE) is not suspected has not previously been analyzed.

HYPOTHESIS

In this study, an echocardiographic database was interrogated to test whether discovery of a vegetation by echocardiography should result in treatment for endocarditis if IE is not suspected.

METHODS

In all, 2,750 serial transthoracic echocardiograms (TTE) were reviewed to generate a list of reports containing the word Veg or thickening (Thk). A chart review of cases identified the impact the report had on patient management. To analyze reader bias due to echocardiographic requests, stating "rule out Veg or IE" as the reason for the study, an additional 1,000 serial TTE requests were segregated into two groups with and without this term. The incidence of the terms Veg or Thk in TTE reports of these groups was tabulated.

RESULTS

Of 2,750 reports, 20 contained the word Veg. Blood cultures were drawn in 16 of 20, with 7 of 16 being positive. Therapy for IE was initiated in 5 of 7 patients with positive cultures. Of 1,000 requests reviewed in the second phase, 24% of those with rule out Veg as the indication for TTE (n = 29) had Veg and 7% had Thk, while in 971 cases with other indications for TTE 0.2% had Veg and 9.3% had Thk.

CONCLUSIONS

Clinicians disregard TTE demonstration of Veg if clinical suspicion for IE is low. It is not clear whether the initial echo request biases the interpretation.

Racial differences in patients with heart failure

BACKGROUND AND HYPOTHESIS

Limited data exist regarding racial differences in heart failure. The objective of this prospective study was to document racial differences in the baseline demographics and patterns of health care utilization and outcomes in patients with heart failure.

METHODS

The data on 163 consecutive patients (113 black, 50 white) admitted with a diagnosis of heart failure confirmed by pulmonary congestion on chest x-ray were prospectively evaluated. Patient demographics, physical examination findings at admission, comorbid conditions, and medications at admission and discharge were analyzed. Follow-up was performed to document visits to the physician's office after discharge and readmission rate during a 6-month time period.

RESULTS

Compared with whites, blacks were younger in age (mean age 63.8 +/- 13.7 years vs. 70.8 +/- 13.1, p = 0.003), and had a higher prevalence of hypertension (86 vs. 66%, p = 0.004), left ventricular hypertrophy (24 vs. 8%, p = 0.02), ejection fraction < 40% (64 vs. 43%, p = 0.03), and readmission rate (33 vs. 18%, p = 0.05). Whites had a higher prevalence of atrial fibrillation (42 vs. 21%, p = 0.006) and more frequently followed up with their cardiologists as outpatients (58 vs. 39%, p = 0.04).

CONCLUSION

Significant racial differences exist in patients with heart failure with regard to age, incidence, etiologic factors, left ventricular hypertrophy, left ventricular function, and clinical follow-up. It is important to consider these racial differences in the evaluation and management of patients with heart failure.

Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India

An etiological and epidemiological study of oral submucous fibrosis (OSMF) has been done in Patna, Bihar. Total 157 cases of OSMF and 135 control subjects were selected for study in the period of 2002-2004. It was observed that Male:Female ratio was 2.7:1. The youngest case of OSMF was 11 year old and the oldest one was 54 years of age. Maximum number of cases were belonging to 21-40 years of age and they were belonging to low or middle socioeconomic class. Most of the OSMF cases used heavy spices and chillies, where as control mild spices and chillies. Gutkha was the most commonly used by the OSMF cases only 3 per cent did not use any gutkha or other areca nut product where as 80 per cent control did not have any chewing habit. The OSMF cases used gutkha and other products 2-10 pouches per day and kept in the mouth for 2-10 minutes and they were using since 2-4 years. Most of the OSMF cases kept gutkha in the buccal vestibule or they chewed and swallowed it, only a small number of patients chewed and spitted it out. It was also observed that OSMF developed on one side of the buccal vestibule where they kept the chew and other side was normal.

The relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality

BACKGROUND

Prediction of in-hospital mortality may direct hospital resources towards those patients most at risk. A number of single domain risk instruments have been developed, indicating that functional status, nutritional assessment, and severity of illness individually predict in-hospital mortality. The interaction among these predictors is less well described.

OBJECTIVE

To determine the relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality.

DESIGN, SETTING, SUBJECTS

Cohort study of 1712 consecutive admissions over a one year period to an Internal Medical Service at a tertiary university teaching hospital.

MAIN OUTCOME MEASURES

Death during hospital admission.

RESULTS

Dependency in activities of daily living (OR = 3.37, 95% CI 1.78 to 6.37, p = 0.0002) and body mass index less than 20 (OR = 2.38, 95% CI 1.20 to 4.74, p = 0.01) predicted in-hospital mortality after adjusting for nutritional risk assessment, and severity of illness score.

CONCLUSIONS

Impairment in functional status and low body mass index produce the best predictors of inhospital mortality, after adjusting for nutritional risk and severity of illness score. Among these factors, functional impairment may be amenable to correction.

Genomic variations among wildtype and mutant strains of pseudorabies virus

Both wild-type virulent and mutant strains of pseudorabies virus (PrV) were used in this study. Mutants used were derived from the plaque purified strain PrVmAIP. A total of six drug resistant mutants, three bromodeoxyuridine (BUdR) resistant and three iododeoxyuridine (IUdR) resistant, respectively, were isolated and passaged in chicken embryo fibroblast (CEF) cells. The DNA of these PrVs were compared with the wild-type isolates by means of the restriction fragment pattern (RFP) findings produced with Bam HI, Kpn I, Hind III and Bgl II restriction enzymes (RE). Compared to the wild-type PrVs (PrV-VBA1-parental strain of PrVmAIP; PrV-VBA2; PrV-VBA3), the RFP of PrVmAIP showed the presence of mutations within the RE sites studied. Both PrV-VBA1 and PrV-VBA2 appeared to be closely related but their RFPs differed from PrV-VBA3. Significant differences either in the number, size or migrations of the DNA fragments could also be detected in the BUdR resistant strains. Even though different features of cytopathic effect (GPE) were observed in the IUdR resistant PrVs, the RFP findings remained identical. The PrVs studied showed considerable differences from the reference PrV (PrV-CD).

An evaluation of theophylline dosing. Suggested by the Saudi national protocol for children with severe asthma

OBJECTIVE

To evaluate the impact of Saudi national protocol on the diagnosis and management of asthma for optimizing theophylline use in children with severe asthma. To also review theophylline clearance and provide guidelines for individualization of doses.

METHODS

Theophylline level was estimated in blood samples of 66 children with severe asthma who were admitted to King Abdulaziz University Hospital during the period 1998-1999. The theophylline doses given to these patients was reviewed and patients were categorized into 2 groups: Group one had received doses recommended by Saudi national protocol +/- 10%, group 2 had received doses <90% of that recommended by Saudi national protocol. The distribution of theophylline levels in blood samples of each group was estimated. Theophylline steady state level was used to estimate theophylline clearance using a standard pharmacokinetic equation.

RESULTS

Out of the total samples from group one, 70% of theophylline levels were within therapeutic range, while only 10% of the total samples of group 2 were within therapeutic range. The mean theophylline clearance in children (1-8 years) was estimated as 0.092 +/- 0.023 and was found significantly higher than the mean theophylline clearance (0.069 +/- 0.014) which is observed in older children (9-13 years).

CONCLUSION

Saudi national protocol theophylline dose guidelines had a favorable impact on the optimization of theophylline use in children with severe asthma. Guidelines that ensure accurate adjustment of doses on individual basis in view of drug level were suggested.

Detection of hTERT protein by flow cytometry

Telomerase is a telomere-specific DNA polymerase consisting of protein and RNA components, which is activated in germline cells and the majority of cancers and serves to counter the consequences of telomere shortening. The protein component, hTERT, is believed to be the catalytic subunit of human telomerase and its expression at the mRNA level correlates well with telomerase activity in vitro. Current techniques for assaying telomerase activity detect only the mean activity in a sample and are unable to isolate specific cell sub-populations. This report describes the development and validation of a cellular, immunofluorescence-based flow cytometry assay that allows detection of intranuclear hTERT while maintaining identifiable cell population characteristics. The assay was shown to be both sensitive to changes in telomerase expression and was semi-quantitative. In both cell line differentiation experiments and in primary cells, a good correlation existed between hTERT expression measured by flow cytometry and telomerase activity detected by the telomeric repeat amplification protocol (TRAP). The method developed offers a quick, simple and reproducible cellular-based assay for hTERT expression. This assay will provide a useful, new tool for future investigations, facilitating the analysis of hTERT expression in mixed cell populations.

Clinical predictors of heart failure in patients with first acute myocardial infarction

BACKGROUND

The occurrence of heart failure associated with an acute myocardial infarction has a strong adverse effect on long-term morbidity and mortality. The prediction and prevention of heart failure could influence these adverse events.

METHODS AND RESULTS

We studied 483 consecutive patients who had their first acute myocardial infarction and who were admitted within 24 hours of the onset of symptoms. Heart failure was defined as the presence of pulmonary rales or an S3 gallop, or the presence of alveolar or interstitial edema by radiograph. Baseline demographic data, determination of peak creatine phosphokinase level, echocardiographic left ventricular ejection fraction, blood pressure, and pulse were obtained. Heart failure occurred in 41.6% (201 of 483) of the patients. We observed a bimodal occurrence of heart failure with an early occurrence at admission in 4% (20 of 483) followed by a second increase beginning after the fourth day of admission in 39% of the remaining patients (181 of 463). Predictors of early heart failure were older age, diabetes mellitus, or previous cardiac symptoms, whereas the predictors of heart failure after the fourth day included the same demographic predictors in addition to a history of hypertension, male sex, increased peak creatine phosphokinase level and heart rate, and decrease in left ventricular ejection fraction. In-hospital death occurred in 5.3% compared with 1.4% (P =.012) in patients who did and did not have heart failure, respectively. The occurrence of heart failure during hospital admission also adversely affected the 18-month follow-up, with 14.9% deaths in the patients with heart failure and 6.4% in those without heart failure (P =.002).

CONCLUSION

Heart failure is frequently associated with acute myocardial infarction and occurs with a bimodal distribution and is associated with increased risk of death during hospitalization and during 18 months of follow-up. Predictors of early heart failure include previous medical conditions and age. The second peak occurrence can be predicted by similar characteristics in addition to increased peak creatine phosphokinase level, decreased left ventricular ejection fraction, and increased heart rate.

Cimetidine-associated optic neuropathy

Two cases of optic neuropathy associated with cimetidine therapy are reported. Recovery occurred in both after drug withdrawal. Rechallenge with the same agent totally reproduced the condition in the first case. Cimetidine exerts an unequivocal toxicity on the central and peripheral nervous systems. Since its introduction in 1976, it has been used in over 100 million patients, but only 3 cases of optic neuropathy have been reported as far as we know. Although the mechanism of toxicity is still unclear, cimetidine is a well-recognized zinc chelator, and zinc deficiency has been implicated in causing optic neuropathy. Hence, it can be concluded that cimetidine produced this toxicity through its mechanism of zinc chelation. However, close ophthalmic follow-up of such patients is unnecessary, but an unexplained visual deterioration should prompt immediate drug withdrawal.

Ventricular remodeling. Mechanisms and prevention

The changes that take place in the structure and form of the left ventricle have become closely related to increase in clinical events in patients with heart failure. These changes are included in the term remodeling and occur as a response to the initial loss of left ventricular muscle mass. The mechanisms that initiate and maintain this remodeling process have become of great importance since a variety of effective pharmacologic agents have become available. A more complete understanding of remodeling has the potential of preventing the progression of heart failure. This article considers the various aspects of left ventricular remodeling including the cardiomyocytes, the myocardial interstitium, the importance that apoptosis plays the remodeling process.

Histamine receptors in the skin melanophores of Indian bullfrog Rana tigerina

Histamine and 2-methyl histamine caused dose-dependent aggregation of the integumental melanophores of Rana tigerina both in vitro and in vivo. The aggregating effects were antagonised by mepyramine and metiamide, specific H1 and H2 receptor blockers, respectively. Compound 48/80 and EDTA augmented the melanin-aggregating effects of exogenously applied histamine and 2-methyl histamine in in vivo experiments. 4-Methyl histamine, a specific H2 receptor agonist, dispersed the frog melanophores in in vitro studies, the dispersing effects were blocked by metiamide.

Usefulness of exercise echocardiography in predicting cardiac events in an outpatient population

The prognostic value of exercise echocardiography in an outpatient population is not well defined. A total of 1,020 consecutive patients referred for exercise echocardiography in an ambulatory care setting were studied by reviewing their medical records and exercise echocardiographic data. Of these, 71 (7%) were excluded due to technically inadequate tests, leaving 949 patients who were included in the analysis. A positive exercise echocardiogram (EE) was defined as an appearance of a new wall motion abnormality or worsening of a baseline abnormality. Cardiac events, defined as myocardial infarction, coronary angioplasty, coronary bypass surgery, and death, were documented during a 12-month follow-up period. Cardiac events occurred in 17% of patients (26 of 152) with a positive exercise echocardiogram (EE) and in 2.5% (20 of 797) with a negative EE (p <0.001). The incidence of myocardial infarction (2.6% vs 0.4%, p <0.02), coronary angioplasty (7% vs 1%, p <0.001), and coronary bypass surgery (9% vs 1%, p <0.001) were higher in patients with a positive versus a negative EE. There was 1 death in the positive study group and none in the negative group. Significant independent variables (p <0.05) that predicted cardiac events included a positive exercise electrocardiogram, history of coronary angioplasty, nonspecific ST-T changes on the baseline electrocardiogram, double product <25,000, men, chest pain on exercise test, and a positive exercise electrocardiogram. On a stepwise logistic regression model, exercise echocardiography emerged as an independent predictor of future cardiac events in an outpatient population. This predictive value was enhanced in the presence of a positive exercise electrocardiogram compared with a negative exercise electrocardiogram (24.2% vs 7.9%, p <0.03). Our study suggests that exercise echocardiography is an independent predictor of future cardiac events in an outpatient population.

Abnormalities of cardiocytes in regions bordering fibrous scars of dogs with heart failure

Progressive deterioration of left ventricular function is a characteristic feature of the heart failure state and is often speculated to result from ongoing loss of viable myocytes. We previously showed that in dogs with chronic heart failure, cardiocyte death through apoptosis occurs in the border region of fibrous scars (old infarcts). In the present study we examined the structural integrity of cardiocytes in regions bordering fibrous scars using transmission electron microscopy. Morphometric studies were performed using left ventricular tissue obtained from ten dogs with chronic heart failure produced by intracoronary microembolizations. Mitochondrial number increased significantly with proximity to the scar, while mitochondrial size decreased leading to a gradual decrease in mitochondrial volume fraction. Severe injury to mitochondria was present in only 5% of organelles in myocytes far from the scar but increased markedly to 28-41% in myocytes adjacent to or incorporated within the scar. Similarly, severe myofibrillar abnormalities were present in only 3% of myocytes that were far from the scar but increased significantly to 12-73% in myocytes adjacent to or incorporated within the scar. These results indicate that in dogs with chronic heart failure, constituent myocytes of left ventricular regions bordering fibrous scars manifest heterogeneity in the extent of degeneration. The extent of degeneration is greatest in myocytes closest to the scar and least in myocytes far from the scar. We postulate that this wavefront of myocyte degeneration is a dynamic process that may lead to progressive expansion of the scar through loss of viable myocytes and ultimately may contribute, in part, to the progressive left ventricular dysfunction that characterizes the heart failure state.

Effect of histaminergic drugs on integumental melanophores of adult Bufo melanostictus

Histamine and 2-methyl histamine caused dose-dependent aggregation of melanophores in toad B. melanostictus. The effects were effectively antagonised by mepyramine, a specific H1 histamine receptor antagonist, and metiamide a specific H2 receptor antagonist. On the other, hand 4-methyl histamine, a specific H2 receptor agonist dispersed the melanophores. The results suggest that adult Bufo melanophores have H1 histamine receptors which mediate melanophore aggregation, however, dispersion of melanophores may be controlled by undifferentiated histamine receptors of H2 type.

Synthesis of Some Hydrazone Derivatives Structurally Related to the Insecticide Pymetrozine

Reaction of pyridine-3-carbaldehyde methylhydrazone with 1,1'-carbonylbis-1H-imidazole afforded (E)-1'-methyl-2'-(3"-pyridyl) methylidene ]-1H-imidazole-1-carbohydrazide (2). Reaction of (2) with ethylamine, ethanol, ethanethiol, hydrazine monohydrate and methoxyamine afforded the corresponding semicarbazide, carbazate, thiocarbazate, carbonohydrazide and 4-methoxysemicarbazide derivatives (3a-d,g). Reaction of (2) with methylhydrazine gave the carbonohydrazide derivative (3f) together with 2,4-dimethyl-6-(3'-pyridyl)-1,4,5,6-tetrahydro-1,2,4,5-tetrazin-3(2H)-one (4a). The preparation of (E)-3-[(3'-pyridyl) methylideneamino ]oxazolidin-2-one (5a) and (E)-3-[(3'-pyridyl) methylideneamino ]tetrahydro-2H-1,3-oxazin-2-one (5b) is described.

Abnormalities of contractile structures in viable myocytes of the failing heart

We examined the incidence and severity of abnormalities of contractile structures of residual viable cardiomyocytes in the left ventricular free wall, septum and right ventricular free wall of 10 dogs with chronic heart failure produced by multiple intracoronary microembolizations and in septal biopsies of 13 patients with chronic heart failure. The abnormalities were evaluated by transmission electron microscopy and classified as either (i) type-1, defined as complete interruption of myofibrils; (ii) type-2, defined as disconnection of end-sarcomeres from the intercalated disc; or (iii) type-3, sarcomere abnormalities defined as Z-bands irregularities and/or focal myofilament disarray. In the left ventricular free wall of dogs, type-1 abnormalities were present in 33 +/- 8% of myocytes, type-2 in 26 +/- 8%, and type-3 in 63 +/- 9%. The incidence of a type-3 abnormality but not type-1 or type-2 was greater in the left ventricular wall compared with the septum and right ventricular wall (P < 0.05). Among abnormal myocytes, 29 +/- 3% of myofibrils were interrupted, 18 +/- 4% of end-sarcomeres were disconnected from the intercalated disc and 12 +/- 2% of sarcomeres were abnormal. The severity of a type-1 but not type-2 or type-3 abnormalities was greater in the left ventricular wall compared with the septum and right ventricular wall. A similarly high incidence of abnormalities was observed in septal myocytes of patients. The results indicate that abnormalities of contractile structures are common among viable myocytes of the failing heart. The incidence of these abnormalities is sufficiently high to warrant serious consideration of their potential role in the progression of left ventricular dysfunction that characterizes the heart failure state.