Oxidant and antioxidant status among tobacco users: A cross-sectional study

Background

Smokeless and smoking tobacco use results in increased oxidative stress and lipid peroxidation, which play a major role in the causation of cancer in tobacco habituates. Malondialdehyde (MDA) is a product of lipid peroxidation, and glutathione peroxidase (GPx) and superoxide dismutase (SOD), the main enzymes in the antioxidant defense system, are assessed among tobacco users. This study gave insight into the relationship between tobacco use, oxidative stress, and antioxidant enzyme activity.

Aims and Objectives

This study aimed to estimate the levels of lipid peroxidation product MDA and antioxidant enzymes SOD and GPx among tobacco users and compare them with controls.

Method

A case-control study comprising 30 smokeless tobacco users, 30 smokers, and 30 controls was enrolled for the study. Serum MDA was assayed by the thiobarbituric acid method; serum SOD and GPx were assayed using Ransel antioxidant kits. The results were statistically analyzed using descriptive and inferential statistical analysis.

Results

Serum MDA levels, which indicate oxidative stress, were increased among all tobacco users and significantly increased among smokeless tobacco users as compared to smokers. Serum SOD and GPx levels were decreased among both forms of tobacco users compared with controls. With an increase in duration and frequency of tobacco use, there was a significant increase in serum MDA levels among both smokers and chewers and a decrease in serum SOD and GPx levels.

Conclusion

In the present day, the tobacco epidemic has attained enormous proportions with the tobacco habit starting as early as 13-14 years and leading to serious conditions with high morbidity and mortality. These biochemical parameters such as MDA, SOD, and GPx, which act as marker of oxidant and antioxidant system, can constitute important tools for evidence-based medicine for educating patients and motivating interventions in tobacco cessation therapy.

Effectiveness of pharmacological interventions for Sjogren syndrome - A systematic review

Background

Sjogren's Syndrome (SS) is characterized by xeropthalmia and/or xerostomia. Treating the associated salivary gland hypofunction has been challenging to the clinicians. A variety of topical and systemic therapies have been tried to restore/stimulate the gland function or replace saliva reducing the symptoms of xerostomia and to avoid the problems of diminished salivary flow.

Material and Methods

Four search engines (PUBMED/Medline, EMBASE, Google Scholar and The Cochrane) were used in conducting a systematic review using the terms "Sjogren's syndrome" with the combination of other terms. To define these study acceptability criteria, we used PICO model (Population, Intervention, Control and Outcome) and study design technique.

Results

Out of 47 articles initially screened, 28 studies met our selection criteria. Included studies showed positive results with interventions such as pilocarpine, rituximab, and interferon-alpha (IFN-α) for enhancing salivary flow and lacrimal secretion in SS condition. One study showed promising results for combination of prednisone and hydroxychloroquine in SS, however dose of prednisone is recommended to be tapered. Another study demonstrated comparable effects of dehydroepiandrosterone and the placebo in alleviation of dry mouth symptoms (p=0.006). Therapeutic effects have been reported with LASER therapy.

Conclusions

Pilocarpine was found to be highly beneficial whereas, rituximab and IFN-α were moderately effective in the reduction of hyposalivation in SS patient. Adverse events were common. Use of any alternative modalities for the management cannot be supported based on the current evidence; this demands more studies in future to be conducted staking into account adverse effects which might occur particularly with the pharmacological therapies. Key words:Sjogren's Syndrome, Xerostomia, Hyposalivation, Pilocarpine, Rituximab, Sialagogue.

Postural Disharmony Causing Myofacial Pain: A Case Report and Review of Literature of the Treatment

Myofacial pain, a chronic painful condition of muscle origin, has numerous precipitating factors, if undiagnosed or left untreated could lead to compromised function and poor quality of life. In this case report, a female patient giving a history of 10 years of pain in the head and neck region was eventually diagnosed with myofacial pain secondary to bowing posture. The patient was successfully treated with combination of treatment modalities (TENS therapy, exercises, occlusal splint, etc.), which resulted in relief from chronic pain and improvement in quality of life.

Comparative study of effectiveness of colposcopic examination versus visual examination for determining the biopsy site of potentially premalignant oral epithelial lesions

Diagnosis of oral malignant and potentially premalignant oral epithelial lesions (PPOELs) cannot be based solely on clinical findings. Tissue biopsy with histopathologic examination remains the gold standard in diagnosis. Selection of a representative biopsy site becomes essential to arrive at an early and precise diagnosis which substantially reduces the incidence of morbidity and mortality from oral cancer. The site for biopsy, however, is always a subjective choice that sometimes raises doubts about its representativeness. Among various techniques developed to complement clinical examination and facilitate early diagnosis, colposcopy can be a simple, reliable diagnostic method available for the selection of the most appropriate biopsy site based on the vascular patterns. Hence, this study has been planned to assess the role of colposcopic examination in the selection of the most representative specimen for histopathologic examination from the oral lesions.

Challenges in the Diagnosis and Treatment of Patients with Rare and Orphan Diseases

Orphan diseases are diverse group of disorders that have not gained much of public attention as they are rarely reported worldwide. The term orphan and rare diseases are often used interchangeably when describing diseases that fall into an orphan or rare category. Around 80% of orphan diseases are chronic, serious, or life threatening, are of genetic origin, and are more prevalent in children and in adults above 40 years of age. Due to rarity, lack of financial support and specific drug to treat these diseases, diagnosis, and treatment becomes challenging. Diagnosis is usually delayed, and patient continues to suffer by seeking multiple specialist opinion. Nonavailability of specific drug and lack of financial funding or waivers to conduct to conduct clinical trial for invention of new orphan drug are the obstacles for targeted treatment. Hence, there is need for comprehensive integrative approach to manage orphan disease patients and pharmaceutical companies should be encouraged for invention of drugs at a reasonable cost for orphan diseases. In addition, community education through genetic-based learning modules is essential to increase awareness of population about risk factors and early diagnosis of orphan diseases, and to take opinion of specific specialist for thorough clinical evaluation. This review discusses challenges faced by the specialists toward diagnosis and treatment of orphan disease for well-being of an individual living with the disorder.

Three-dimensional cone-beam computed tomographic sialography in the diagnosis and management of primary Sjögren syndrome: Report of 3 cases

Sjögren syndrome is a chronic autoimmune inflammatory disease characterized by lymphocytic infiltration of exocrine glands, predominantly the parotid and lacrimal glands, thereby resulting in oral and ocular dryness. It has been reported to occur most frequently in women between 40 and 50 years of age. Sjögren syndrome has an insidious onset, is slowly progressive, and presents a wide range of clinical manifestations, leading to delays or challenges in the diagnosis. Early diagnosis of this condition is essential to prevent the associated complications that affect patients' quality of life. This report presents 3 cases of Sjögren syndrome in female patients aged between 40 and 75 years who presented with complaints of persistent dry mouth and burning sensation. The cases highlight the diagnostic value of 3-dimensional cone-beam computed tomographic sialography in the detection of salivary gland pathologies at an early stage.

Clinical evaluation of photodynamic therapy for the treatment of refractory oral Lichen planus - A case series

Oral lichen planus (OLP) is a chronic inflammatory, immune mediated mucocutaneous disorder of uncertain etiology. Psychologic stress has been found to be a main contributing factor in onset and progression of lesions. Most erosive OLP patients are refractory to available therapies, even corticosteroids, and report remarkable side effects. As photodynamic therapy (PDT) has proved it to be an effective and safe alternative treatment of abnormal or neoplastic cells we employed PDT for this diagnosis. Due to limited literature on application of this method for treatment of refractory erosive OLP, we present a series of 10 cases of bilateral erosive LP treated by 5 -Aminolevulinic acid mediated PDT. Outcome of our clinical cases showed remarkable improvement in lesions with reduction in Reticulation, Erythema, Ulceration (REU) score (from 5 to 3) and burning sensation as recorded by Visual Analogue Scale (Pretreatment VAS ranged from 5 to 8, posttreatment VAS was 0-1). PDT could be used as a complementary treatment method for symptomatic resistant OLP lesions, although our findings necessitate further research to validate the efficacy of this method for control of resistant oral lichen planus.

Oral Spindle Cell Sarcoma: A Rare Case Report and Review of Literature

Spindle cell lesions of the head and neck region are diverse in nature by means of clinical and biological heterogeneity. Though few lesions are found to be malignant, several others are benign or merely reactive in nature. Although these lesions are fairly common occurring in other parts of the body, they are very rare in the oral cavity, accounting for less than 1% of all tumours in the oral region. Herein, a case of 48-year-old man who presented with a polypoid lesion of the maxilla has been reported. Histopathological examination and immunohistochemistry revealed spindle cell sarcoma of the left maxillary sinus. We present this rare tumour to contribute to the better understanding and awareness of this rare malignancy where diagnosis can be very challenging.

Expression of Epstein-Barr virus among oral potentially malignant disorders and oral squamous cell carcinomas in the South Indian tobacco-chewing population

BACKGROUND

Oral cancer is the sixth most common malignancy in the world. Viruses are the causative agents of approximately 10-15% of all cancers worldwide (Cancers, 6, 2014 and 2155). The tumorigenic roles of Epstein-Barr virus in oral cancer are unclear. Literature search results are conflicting and dependent on various factors such as geographical/regional variations, sociocultural lifestyles, dietary habits, chewing/smoking tobacco habit. This study is the first original observation about frequency of Epstein-Barr virus among South Indian tobacco-chewing patients to elucidate its involvement in oral carcinogenesis and to know whether this can be a valuable diagnostic and prognostic indicator.

MATERIALS AND METHODS

A total number of 75 tobacco chewer subjects aged between 23 and 76 years with histopathologically confirmed oral potentially malignant disorders (25), oral squamous cell carcinoma (25), and age-matched healthy controls (25) formed the study group. Immunohistochemical expression of Epstein-Barr virus latent membrane protein 1 was assessed among cases and healthy controls.

RESULTS

Out of the total 75 subjects, six subjects (8%) were positive for Epstein-Barr virus antigen and 69 subjects (92%) negative. The antigen positivity was observed among two cases of moderately differentiated oral squamous cell carcinoma, two cases of leukoplakia, and two healthy controls.

CONCLUSION

No significant association between Epstein-Barr virus positivity was observed among oral potentially malignant disorders and oral squamous cell carcinoma among South Indian tobacco-chewing patients. This can be partially explained by the methodology employed, by the patient population analyzed and different habits in various geographical regions.

Is dosimetry still a necessity in current dental practice?

Today, dentists have a wide range of imaging modalities to choose from, the film based techniques, digital techniques, and the recent introduction of 3D volumetric or cone beam computed tomography (CBCT). The inherent design features of the new generation dental x-ray equipment has significantly improved over the years with no evidence of substandard x-ray units in operation. In dental facilities radiological workload is comparatively low, newer radiation equipments and accessories follow safety guidelines and employ better radiation protection measures for the patient and the operator. Dentists' knowledge and expertise in radiation protection measures is good, enabling them to carry out riskfree radiation procedures in their practice. Therefore, the present study is aimed at assessing the need for dosimeters in current dental scenario. 'Is there currently a significant risk from dental radiography to merit the use of personal dosimetery in dental practice. 'Dental health professionals (Oral radiologists) and radiographic assistants of fourteen dental colleges in Karnataka state participated in this questionnaire study. The questionnaire consisted of the following questions--the make, type, year of manufacture of radiographic machines used in their setup, number of radiographs made per day in the institution, type of receptors used, number of personnel at risk for radiation exposure, radiation protection measures used, regular monitoring by personal dosimeters, equivalent dosage readings for the past 12 months and whether the reading of thermoluminescent dosimeters (TLD) for any personnel had exceeded the recommended exposure value in the last 3 years. Dosimetry records of the radiology staff in the last three years shows doses no more than 1.50 mSv per year. The various institutions' dose (person mSv) was in the range of 3.70 mSv-3.90 mSv. Personal monitoring for Dentists can be omitted in the dental colleges since the estimated dose of oral radiologists contributed less than 0.01 mSv to the total average annual effective dose equivalent. Hence personal monitoring services (TLD Badges) for dentists employed in dental colleges should not be made mandatory.

Rhinocerebral Mucormycosis Among Diabetic Patients: An Emerging Trend

Mucormycosis is an acute necrotic fungal infection with a fulminant course. Earlier considered a rare entity, mucormycosis is being reported with increasing frequency in recent years, possibly due to the increase in immunocompromised population especially diabetic patients. We report three cases of rhinocerebral mucormycosis among poorly controlled diabetic patients. This article emphasizes the need for further awareness of this disease, early diagnosis, and treatment to counter this opportunistic infection.

Tumour associated tissue eosinophilia as a predictor of locoregional recurrence in oral squamous cell carcinoma

Objectives: The increasing global burden of oral cancer has driven much of the focus of research to the determination of reliable prognostic markers which may have significant effects on survival and the control of post-treatment morbidity. This study was undertaken to evaluate tumour associated tissue eosinophilia (TATE) quantitatively in oral cancer specimens and observe for its possible association with tumour stage, patterns of locoregional recurrence and overall prognosis. Study Design: 14 patients undergoing surgical resection for primary oral squamous cell carcinoma (OSCC) were subjected to grey scale ultrasonography (USG) to assess tumour dimensions. The findings were compared with the cTNM stage initially documented. TATE was evaluated along the invasive tumour front (ITF) using H & E stained sections of histopathological specimens for 10 continuous high power fields (HPF) and graded as mild, moderate or intense. Patients were followed up over 5 years and observed for patterns of recurrence. Results: Loco regional recurrence was significantly associated with intense degree of TATE. (p<0.001) cTNM stage as well as USG stage did not correlate with the degree of TATE with p=0.419 and 0.772 respectively. None of the patients with mild/ moderate dysplasia developed locoregional recurrence within the period of follow up. Conclusions: Analysis of TATE in OSCC patients may provide an early indication of future locoregional recurrence. Identification of an appropriate biopsy site representing the ITF where TATE analysis can be performed may be a simple, inexpensive method of obtaining valuable prognostic information at the time of diagnosis.

Key words:Tumour associated tissue eosinophilia, oral cancer, prognosis.

Dental management in an encephalotrigeminal angiomatosis patient: a case report

Sturge-Weber Syndrome (SWS) is a rare, non-hereditary, congenital neuro cutaneous disorder characterized by vascular hamartomatous proliferations affecting classically, the leptomeninges and the skin of the face and may be associated with glaucoma, seizures and mental retardation. Intraoral findings are variable. A case of Roach type II Sturge Weber syndrome is reported here that did not show any neurological disorder but revealed a prominent angiomatous enlargement of the ipsilateral maxillary gingiva. SWS is a condition where dental management and surgical procedures of the patient can be risky, thus a sound knowledge of the disease and its management protocols better equips the clinician to avoid serious complications.

Relationship between femur bone mineral density, body mass index and dental panoramic mandibular cortical width in diagnosis of elderly postmenopausal women with osteoporosis

OBJECTIVES

To measure and determine mandibular cortical width (MCW) on the panoramic radiographs, to evaluate the usefulness of the method in identifying postmenopausal women with low femoral bone mineral densities (f- BMD) and to correlate the radiographic findings on panoramic radiographs with the f-BMD assessed by dual X-ray absorptiometry (DXA) to predict the efficacy of the radiographic method in diagnosing osteoporosis.

MATERIALS AND METHODS

One hundred and twenty postmenopausal women (60 normal and 60 osteoporotic) in the age group of 50-75 y with f-BMD assessed by DXA had undergone panoramic radiographic examination. The patients were classified as normal (T-score ≥ -1.0) and osteoporotic (T-score ≤ -2.5). MCW on panoramic radiographs was measured bilaterally at the mental foramen region with a caliper and their mean was used as the exposure measure in the analysis.

RESULTS

Student t-test showed that mean f-BMD, BMI and MCW was found be less in osteoporotic patients as compared to normal group with a statistically significant p-value < 0.001. Pearson correlation coefficient test revealed that MCW correlated positively with f-BMD and showed a significant decrease with age of the patient.

CONCLUSION

Postmenopausal women with low f-BMD had thinner mandibular cortex at the mental foramen region when compared to normal subjects and are more susceptible to femoral neck fractures. Mandibular inferior cortical width at the mental foramen region could be used to identify postmenopausal women with low f- BMD. Hence, dental panoramic radiographs serve as a useful screening tool for early diagnosis of osteoporotic fractures.

Echocardiography guided therapy for myocarditis after scorpion sting envenomation

OBJECTIVE

This study was to evaluate echocardiographic findings and its usefulness in clinical management of patients with scorpion sting envenomation.

MATERIAL AND METHODS

A total of 84 consecutive patients were prospectively studied. The data included demographics, at the time of presentation to the hospital, the clinical features, echocardiographic findings, admission to intensive care unit, use of inotropic medication, time to discharge, and mortality.

RESULTS

Out of 84 patients studied 60 patients (71.4%) had echocardiographic evidence of myocarditis (LVEF <50%). Majority of patients had LVEF <40% (50 patients, 83.3%). Severe LV dysfunction (LVEF <30%) was noted in 20 patients (33.3%). No patient had significant valvular regurgitation. RV dysfunction was noted in half of the patients who had LV dysfunction. RV dysfunction was not seen in isolation. Twenty four patients without evidence of myocarditis on echocardiography were observed in general wards and were discharged in 24 to 48 hours of admission. Ten patients with mild LV dysfunction (LVEF 50-40%) and 20 patients with moderate LV dysfunction were observed in high dependency units with regular monitoring for 24 to 48 hours. Only 3 patients were put on inotropics support and others could be discharged in 72 to 96 hours. All the patients with severe LV dysfunction and moderate LV dysfunction with significant RV dysfunction were admitted in intensive care unit irrespective of symptoms (Total 30 patients). These patients were put on inotropics support. Among severe LV dysfunction group, 4 patients required ventilator support and 2 (2.3%) patients died with refractory shock and multi-organ failure. Tachycardia, muffled and or gallop heart sounds and hypertension didn't predict presence of LV dysfunction. Persistent hypotension requiring inotropics support was a marker of severe LV dysfunction.

CONCLUSION

Echocardiography is a useful tool in emergency to assess LV function in patients with scorpion sting envenomation. It can guide therapy by identifying patients with severe LV dysfunction.

A Prospective Real World Experience of Moxonidine Use in Indian Hypertensive Patients-Prescription beyond Current Guidelines

OBJECTIVE

The primary objective of this study was to assess the use of moxonidine, a centrally acting anti-hypertensive agent in real world practice.

MATERIAL AND METHODS

Patients who attended out-patients clinic with diagnosis of hypertension were enrolled in the study. Demographics with co-morbid illnesses of all patients were recorded. Patient's prescriptions were recorded and anti-hypertensive medications were also analysed.

RESULTS

A total of 990 patients were eligible during the study period. Moxonidine was used in 4.54% of patients. Two groups could be identified in moxonidine users - one Group with resistant hypertension (30 patients, 3.03% of total, 66.66% of moxonidine users) on multiple drugs to control BP and another Group with intolerance to conventional, first line drugs (15 patients 1.51% of total, 33.33% of moxonidine users). Moxonidine was not used in newly diagnosed hypertension cases. Resistant hypertension and renal failure predicted the use of moxonidine. Majority of drug used was as per current guidelines.

CONCLUSIONS

Our study results reflected real world practice of current anti-hypertensive therapy. Patients generally receive medications in accordance with current recommendations and guidelines. Small but significant proportion of patients may require use of drugs like moxonidine to control high BP. Guidelines need to incorporate these real world practices.

Oral and salivary changes among renal patients undergoing hemodialysis: A cross-sectional study

We wanted to assess oral and salivary changes in end stage renal disease (ESRD) patients undergoing hemodialysis (HD) and to understand the correlation of such changes with renal insufficiency. The cross-sectional study was performed among 100 ESRD patients undergoing HD. Among these, 25 patients were randomly selected to assess the salivary changes and compared with 25 apparently healthy individuals who formed the control group. Total duration of the study was 15 months. Oral malodor, dry mouth, taste change, increased caries incidence, calculus formation, and gingival bleeding were the common oral manifestations. The flow rates of both unstimulated as well as stimulated whole saliva were decreased in the study group. The pH and buffer capacity of unstimulated whole saliva was increased in the study group, but stimulated whole saliva did not show any difference. ESRD patients undergoing HD require special considerations during dental treatment because of the various conditions inherent to the disease, their multiple oral manifestations and the treatment side-effects.

NT-proBNP in Myocarditis after a Scorpion Sting Envenomation

OBJECTIVE

This study was to evaluate the levels of NT-proBNP in patients with myocarditis which occurred after a scorpion sting envenomation.

MATERIAL AND METHODS

A total of 30 patients with scorpion sting envenomation and 21 patients with heart failure which was caused by cardiomyopathy, were prospectively studied. The data included the patient demographics, clinical features, echocardiography and the NT-proBNP levels.

RESULTS

An echocardiographic evidence of myocarditis with a left ventricular ejection fraction of less than 50%, was found in 22 patients. In all the 22 patients, NT-proBNP was significantly elevated. The NT-proBNP levels were very high in the patients with severe LV dysfunction. However, it was in the normal range in the patients without an evidence of myocarditis. The elevated NT-proBNP levels were correlated with the LV dysfunction and myocarditis. When they were compared with the patients with heart failure which was caused by cardiomyopathy, the NTproBNP levels were found to be significantly more elevated in scorpion sting myocarditis.

CONCLUSIONS

The NT-proBNP levels were significantly elevated in myocarditis which occurred after a scorpion sting envenomation.

Elevated Cardiac Troponin (cTnI) Levels Correlate with the Clinical and Echocardiographic Evidences of Severe Myocarditis in Scorpion Sting Envenomation

OBJECTIVE

This study was to evaluate the predictive value of the cardiac troponins in scorpion sting myocarditis at a tertiary care hospital in Raichur, (Karnataka state) India.

METHODS

A total of 84 consecutive patients were prospectively studied. The data included the demographics, the time of presentation to the hospital, the clinical features, the cardiac troponin levels and the echocardiographic findings.

RESULTS

12 patients with only local symptoms had troponin levels of less than 0.01μg/L. 12 patients with local and systemic symptoms without an echocardiac evidence of myocarditis had troponin values of 0.01 to 0.11 μg/L. 60 patients with an echocardiographic evidence of myocarditis had troponin levels of above 0.11 μg/L. 6 patients with severe myocarditis who required ventilator support or which led to death had troponin values which were higher than 10 μg/L.

CONCLUSIONS

High cardiac troponin levels predict myocarditis in scorpion sting envenomation and they can be a useful tool in guiding the therapy early.

Evaluation of the accuracy, precision and validity of hydrophilic vinyl polysiloxane impression material for bite mark analysis

The present study was undertaken to assess the accuracy, precision and validity of hydrophilic Vinyl Poly Siloxane [VPS] impression material for bite mark documentation and analysis. Medium body VPS impressions of maxillary and mandibular anterior teeth among thirty subjects were taken and dental stone casts prepared. Hollow volume overlays were made and metric analysis was done using advanced imaging software like Adobe Photoshop - 9 and Image J. These values were compared to the measurements taken from bite mark impressions of the same 30 individuals on wax wafers using light body VPS material. The mean differences in the parameters measured by the different techniques were compared using Intra Class Correlation Coefficients [ICCC]. Additionally validity parameters such as sensitivity, specificity, positive and negative predictive value were computed.

Comparison of the efficacy of conventional radiography, digital radiography, and ultrasound in diagnosing periapical lesions

OBJECTIVES

The aim of this study was to evaluate the efficacy of conventional radiography, digital radiography and ultrasound imaging in diagnosing periapical lesions.

STUDY DESIGN

Twenty-one patients aged between 15 and 45 years with well defined periapical radiolucency associated with anterior maxillary or mandibular teeth requiring endodontic surgery or extraction were selected and consented to the study. Preoperative intraoral periapical radiographs and digital images using charge-coupled device obtained by paralleling technique were assessed by 3 specialist observers who gave their diagnosis of the periapical lesions. Then ultrasound examination was performed and the images were assessed for size, contents, and vascular supply by 3 ultrasonographers. It was followed by curettage of periapical tissues to enable histopathologic investigation, which is the gold standard in diagnosis. The data were statistically analyzed using SPSS, analysis of variance, and kappa statistics.

RESULTS

The percentage accuracy of diagnosing periapical lesions using conventional radiography was 47.6%, digital radiography 55.6%, and ultrasound 95.2%. Ultrasound had the highest sensitivity and specificity: 0.95 and 1.00, respectively.

CONCLUSION

Conventional and digital radiography enable diagnosis of periapical diseases, but not their nature, whereas ultrasound provides accurate information on the pathologic nature of the lesions, which is of importance in predicting the treatment outcome. Therefore ultrasound can be used as an adjunct to conventional or digital radiography in diagnosing periapical lesions.

Wiscott Aldrich syndrome with oral involvement: a case report

Wiskott Aldrich syndrome is an X-linked recessive disorder characterized by thrombocytopenia with microplatelets, eczema, recurrent infections, and predisposition to autoimmune disease and malignancy. It is a rare syndrome, and the incidence rate is approximately 4 in every 1 million live male births with no clear ethnic or racial predilection. The purpose of this paper was to report a case of Wiskott Aldrich syndrome with oral involvement demonstrated by 2 male siblings.

Estimation of nicotine content in popular Indian brands of smoking and chewing tobacco products

OBJECTIVES

To estimate the nicotine content of some popular Indian brands of smoking tobacco (cigarettes and bidis) and pan masalas (chewable tobacco).

MATERIALS AND METHODS

Commercially available cigarettes, bidis, and pan masalas (chewable tobacco) were obtained from local retail outlets for the study. Nicotine was estimated using gas-liquid chromatography.

RESULTS

The analyses showed relatively higher levels of nicotine in tobacco from bidis (26.9 mg gm) as compared to cigarettes(15 mg/gm); the difference is statistically significant ( P P > 0.01). Nicotine concentration in chewing tobacco was 3.4 mg/gm.

CONCLUSION

The study concludes that the nicotine content of Indian brands of smoking tobacco was slightly high compared to other international brands. Higher concentration of nicotine was found in bidis compared to cigarettes. The nicotine content in commercially available chewing tobacco products was found to be much lower than in the smoking form of tobacco, but the average daily consumption made it comparable to the smoking form.

Carbon dioxide efflux from soil with poultry litter applications in conventional and conservation tillage systems in northern Alabama

Increased CO2 release from soils resulting from agricultural practices such as tillage has generated concerns about contributions to global warming. Maintaining current levels of soil C and/or sequestering additional C in soils are important mechanisms to reduce CO2 in the atmosphere through production agriculture. We conducted a study in northern Alabama from 2003 to 2006 to measure CO2 efflux and C storage in long-term tilled and non-tilled cotton (Gossypium hirsutum L.) plots receiving poultry litter or ammonium nitrate (AN). Treatments were established in 1996 on a Decatur silt loam (clayey, kaolinitic thermic, Typic Paleudults) and consisted of conventional-tillage (CT), mulch-tillage (MT), and no-tillage (NT) systems with winter rye [Secale cereale (L.)] cover cropping and AN and poultry litter (PL) as nitrogen sources. Cotton was planted in 2003, 2004, and 2006. Corn was planted in 2005 as a rotation crop using a no-till planter in all plots, and no fertilizer was applied. Poultry litter application resulted in higher CO2 emission from soil compared with AN application regardless of tillage system. In 2003 and 2006, CT (4.39 and 3.40 micromol m(-2) s(-1), respectively) and MT (4.17 and 3.39 micromol m(-2) s(-1), respectively) with PL at 100 kg N ha(-1) (100 PLN) recorded significantly higher CO2 efflux compared with NT with 100 PLN (2.84 and 2.47 micromol m(-2) s(-1), respectively). Total soil C at 0- to 15-cm depth was not affected by tillage but significantly increased with PL application and winter rye cover cropping. In general, cotton produced with NT conservation tillage in conjunction with PL and winter rye cover cropping reduced CO2 emissions and sequestered more soil C compared with control treatments.

Prevention of insulin resistance by ingesting aqueous extract of Ocimum sanctum to fructose-fed rats

The study was aimed to examine if oral administration of the aqueous extract of the whole plant OCIMUM SANCTUM (OS) protects against the development of insulin resistance in fructose fed rats. Male Wister rats were randomly divided into four groups of eight animals each: group-S (starch diet), group-F (fructose diet), group-F+OS (fructose diet along with OCIMUM SANCTUM extract at a dose of 200 mg/kg), group-S+OS (starch diet along with OCIMUM SANCTUM). During the experimental period of 60 days body weight, plasma glucose, insulin, and triglycerides were measured at an interval of 15 days. Insulin sensitivity was assessed at the end of experimental period by measuring glucose-insulin index, which is the product of the areas under the curve of glucose and insulin during oral glucose tolerance test. The nontoxic nature of OS was revealed by unaltered body weight, plasma glucose, insulin, and triglyceride levels in group-S+OS when compared with group-S. A significant gain in body weight, hyperglycemia, hyperinsulinemia, hypertriglyceridemia, and insulin resistance were observed in group-F when compared with group-S. OS treatment prevented the observed fructose induced alterations in group-F+OS. In conclusion, our results suggests that oral administration of OS aqueous extract could delay the development of insulin resistance in rats and may be used as an adjuvant therapy for treating diabetic patients with insulin resistance.

Health outcomes in type 2 diabetes

Outcome evaluation is of great interest throughout the healthcare field, but which outcomes are important depends on the viewpoint one holds. For the healthcare organisation costs and resource utilisation are paramount, whereas patients may be interested in being able to work and lead a productive life without long-term complications. Healthcare policy decisions are influenced by varying degrees of social forces, existing regulations and outcome research findings. Ideally, all three are in agreement but often they may be competitive or may not even be included in policy decision making. With respect to improving outcomes, much energy has been spent on developing diabetes care guidelines. However, these have had minimal impact on physician behaviour. Soon after onset or diagnosis of diabetes, we are most concerned with process measures such as micro-albumin levels, blood pressure monitoring, routine eye and foot examinations and lipid profiles. These process measures are related to the development of intermediate outcomes--proteinuria, retinopathy, foot ulcers and dyslipidaemia. Diabetes is an expensive disease but there is accumulating evidence that improved care can lead to better quality of life and reduction in health care resource utilisation. The UKPDS demonstrated that for one percentage point decrease in HbA1c there was a 35% reduction in the risk of complications. Preliminary data from various diabetes management programmes indicate that instituting standardised care may lead to cost savings and improved health. Rationing health care resources wisely requires consideration of multiple factors including quality of life years (QALYs) and healthy year equivalents (HYEs). Formal quantitative methods are used to measure overall desirability of a medical intervention. Questions to be answered include predictability of responsiveness or adverse events to drug therapy. Outcomes research will have a key role in future development of models of diabetes care.

A controlled evaluation of a national continuing medical education programme designed to improve family physicians' implementation of diabetes-specific clinical practice guidelines

AIMS

New approaches to continuing medical education will facilitate the implementation of clinical practice guidelines. This study assessed the short and long-term impact of a 7-h, small group workshop on family physicians' attitude, knowledge and self-reported practice patterns regarding diabetes mellitus.

METHODS

One hundred and seventy-seven of 1807 family physicians who participated in this nationwide workshop, and 113 non-participant controls completed two validated questionnaires. Participants completed one questionnaire before the workshop and a second equivalent questionnaire 1 month later. Non-participant controls also completed the two questionnaires 1 month apart. Between 8 and 24 months later, these individuals were mailed the same questionnaire they completed on the first occasion; 143 participants and 50 controls returned this third questionnaire.

RESULTS

Participants were more likely to be female (P = 0.03), not certified in family practice (P = 0.02), in a smaller centre (P = 0.0005), recent medical graduates (P = 0.001) and seeing fewer patients per month (P = 0.01) than controls. Compared to controls, participants had improved their attitude (P<0.0001), knowledge (P = 0.04) and self-reported practice patterns (P<0.002) regarding diabetes after 1 month but not after 1 year.

CONCLUSIONS

An interactive, small group, diabetes continuing education programme effectively disseminates practice guidelines to family physicians. The impact of such a programme declines after 1 year.

United Kingdom Prospective Diabetes Study (UKPDS). Effects of glucose and blood pressure control on complications of type 2 diabetes mellitus

The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive treatment (i.e., glucose-lowering drugs, with a goal fasting blood glucose level of 108 mg/dL) decreases the microvascular complications of type 2 diabetes mellitus. We summarize the key study results and their implications for clinical management of type 2 diabetes mellitus.

Nocardiosis in a recently transplanted renal patient

Opportunistic infections are common after renal transplantation because of the use of immunosuppression. Nocardiosis is a rare but important cause of morbidity and mortality among renal transplant recipients. Depending upon the transplant center, the estimated incidence of nocardiosis among renal transplant recipients varies widely from 0 to 20%. We report the first case of nocardiosis in a recently transplanted renal patient maintained on tacrolimus, prednisone, and mycophenolate mofetil. It is likely that the nocardial infection in our patient was related to the development of her diabetes mellitus, and to her early episode of rejection and treatment which included high-dose steroids, and the addition of mycophenolate mofetil. Our case illustrates the importance of maintaining a heightened awareness so that nocardiosis may be diagnosed early and treated successfully.

Pulmonary embolus in pregnant patients: survey of ventilation-perfusion imaging policies and practices

PURPOSE

To assess the policies and practices of nuclear medicine facilities as regards ventilation-perfusion (V-P) imaging in pregnant patients suspected of having pulmonary embolus.

MATERIALS AND METHODS

Surveys were mailed to physician-directors of 1,000 randomly selected facilities at which nuclear imaging studies are performed. Information gathered included use of V-P imaging in pregnant patients, written policies, informed consent procedures, and modifications of standard protocols.

RESULTS

Of the 1,000 surveys mailed, 327 (33%) completed surveys were returned. Of these 327 respondents, 220 (67%) reported that they perform V-P imaging in pregnant patients suspected of having pulmonary embolus. Of these 220 respondents, 115 (52%) routinely obtain informed consent, and 170 (77%) modify their standard V-P imaging protocol for pregnant patients. The most common modification (135 [79%] of 170 respondents) was reduction of the perfusion agent dose. Reported practice patterns for written policies, informed consent, and modifications did not show statistically significant trends among respondents in varying practice settings or geographic locations.

CONCLUSION

Most respondents perform V-P imaging in pregnant patients suspected of having pulmonary embolus, with considerable variability in their policies and practices.

Anorectic drugs and valvular heart disease: a biological and clinical perspective

The epidemiologic and pathologic evidence that fenfluramine and related drugs cause valvular heart disease is still speculative. However, at present, there is no alternative explanation for the cases of valvular disease found in patients taking these drugs, and there is evidence that similar substances can cause similar lesions. The manufacturer of fenfluramine and dexfenfluramine has prudently removed them from sale pending further studies.

Troglitazone: a new antihyperglycemic agent

Troglitazone is the first of a new family of antihyperglycemic drugs. We review its use in clinical practice.

Is there an association among low untreated serum lipid levels, anger, and hazardous driving?

Anger and hazardous driving were explored in two studies for their possible explanatory role in the low cholesterol-violent mortality association. In Study 1, we obtained fasting blood samples and indices of anger and driving habits from 102 healthy young adults. Among men (but not women), lower low-density lipoprotein (LDL) cholesterol levels were associated with significantly higher anger (r = 41, p < .01) and unsafe driving habits (r = -.30, p < .05), and although total cholesterol levels were correlated in the predicted direction, these were not significant. In Study 2, 78 healthy young men completed the same measures, and this time, both lower total and LDL-cholesterol were significantly related to increased anger and dangerous driving. Implications of these findings are discussed as are possible avenues for future research. Further scrutiny of the components of serum cholesterol and their relation to psychological factors may aid us in better understanding the reasons why men are at increased risk for hazardous behavior and violent death.

Reducing the incidence of coronary heart disease by managing hypertension: implications of syndrome X

Syndrome X is a constellation of abnormalities; it appears to be strongly linked to insulin resistance and the risk of atherosclerosis. It consists of hypertension, glucose intolerance, obesity, dyslipidemia and, observed more recently, coagulation abnormalities. It is possible that treating blood pressure levels alone while ignoring or worsening other strongly associated risk factors has resulted in minimal effects on the incidence of coronary heart disease (CHD). Syndrome X has raised the awareness of these associated risk factors and has further led to the consideration of hypertension as a metabolic disease. The epidemiologic evidence in support of the link between insulin resistance and hypertension is reviewed, and the public health implications of these data are outlined.

Augmented desensitization to epidermal growth factor (EGF) immediate actions: a novel mechanism for altered EGF growth response in mutant A431 cells

Epidermal growth factor (EGF) may either stimulate or inhibit cell growth. To elucidate the mechanism of these varied effects, we compared EGF action in parental A431 cells in which cell growth is inhibited, and clone 15, a mutant of these cells resistant to EGF growth inhibition. In both lines, EGF receptor was present in similar concentrations and underwent tyrosine phosphorylation to the same extent. Likewise, in both lines, acute exposure to EGF stimulated an increase in free cytoplasmic [Ca2+], as well as a similar increase in phosphorylation of lipocortin 1, a major substrate for the EGF receptor kinase whose phosphorylation is calcium-dependent. On the other hand, pretreatment of clone 15 cells with EGF for 72 h abolished EGF-induced phosphorylation of lipocortin 1 and led to a loss of the increase in cytoplasmic free [Ca2+], whereas no such desensitization was seen in the parental A431 cells. These data indicate a link between EGF-induced increase in cytoplasmic calcium, lipocortin phosphorylation, and cell growth and suggest that differences in mechanisms of desensitization to these immediate actions of EGF may lead to altered growth response to this hormone.

Epidermal growth factor receptor defects in leprechaunism. A multiple growth factor-resistant syndrome

Leprechaunism is a rare genetic disorder characterized by severe growth retardation and insulin resistance. Maximal epidermal growth factor (EGF) binding was reduced in fibroblasts from three unrelated patients with leprechaunism (Ark-1, Can-1, and Minn-1) compared with control (0.8-2.2%/mg protein vs. 5.5%/mg protein). This was due to a decrease in receptor affinity in Ark-1 and Can-1 and a decrease in receptor number in Minn-1. In all cell lines, EGF-stimulated receptor autophosphorylation was also decreased to 18-60% of control, whereas EGF internalization and degradation was normal. Sphingosine (40 microM), a protein kinase C inhibitor, increased EGF receptor affinity twofold in control cells and six- to nine-fold in cells of leprechaunism. However, sphingosine did not enhance EGF-stimulated receptor autophosphorylation in either the controls or the patients' cells. By contrast, only one of the three cell lines of patients with the type A syndrome demonstrated a decrease in EGF binding and all demonstrated normal or near normal EGF-stimulated receptor autophosphorylation. These data indicate that in patients with leprechaunism, there are functional abnormalities of the EGF receptor, as well as of the insulin receptor, that may contribute to the severity of the syndrome. These data also suggest a role for the insulin receptor in maintaining normal EGF receptor function in these cells.

Molecular defects in the insulin receptor in patients with leprechaunism and in their parents

Leprechaunism is a genetic form of insulin resistance characterized by severe growth retardation and early death. To clarify the molecular basis of the insulin resistance, we investigated the insulin binding and kinase properties of the insulin receptor and the receptor gene in cultured skin fibroblasts of two patients (Ark-1 and Ark-2) with leprechaunism and in those of three of their parents. Specific insulin binding to fibroblasts was markedly reduced (less than 25% of control) in both patients with leprechaunism but was essentially normal in the parents. In contrast, insulin receptor autophosphorylation in 1% Triton X-100 cell lysates was reduced in both patients and parents. In Ark-1, the 70% reduction in autophosphorylation correlated with the decrease in binding, whereas in Ark-2 and in the three parents included in the study, autophosphorylation of the insulin receptor was reduced below the level accounted for by a change in receptor content. Analysis of the insulin receptor gene by hybridization with the receptor cDNA probes revealed no gross defect in either Ark-1 or Ark-2. Both parents of Ark-2 were heterozygous for a restriction fragment length polymorphism in the beta-subunit detected with Bam HI digestion (observed in 15% of controls). Ark-2 was homozygous for the more common allele of this polymorphism (observed in 84% of controls). Thus, we have biochemically characterized a new family of leprechaunism (Ark-2) and have found insulin receptor phosphorylation defects in their phenotypically normal parents.

Altered expression and function of the insulin receptor in a family with lipoatrophic diabetes

To determine the role of genetic defects in the insulin receptor in the insulin resistance of lipoatrophic diabetes mellitus, we studied insulin binding, insulin receptor autophosphorylation, and insulin receptor mRNA levels and performed Southern blot analysis of genomic DNA in four siblings, all of whom have some degree of insulin resistance and three of whom have lipoatrophy. The insulin receptor concentration in Epstein-Barr virus-transformed lymphocytes was about 30% of normal in all three lipoatrophic siblings (LA1, LA2, and LA3) and was 55% of normal in the nonlipoatrophic sibling (LAS). Insulin receptor mRNA concentrations in the lymphocytes paralleled insulin binding and ranged from 15-67% of the mean normal level. Insulin binding to fibroblasts was also reduced about 50% in the lipoatrophic siblings. In addition, insulin binding to fibroblasts of LAS and LA2 exhibited a rightward shift of the competition curve, suggesting reduced receptor affinity [ED50, 35 and 50 ng/mL (5845 and 8350 pmol/L); normal, 1-3 ng/mL (167-501 pmol/L)]. Receptor autophosphorylation determined using Triton X-100 extracts of the fibroblasts was decreased in LA1 and LA3, but normal in LA2 and LAS. Using restriction enzyme digests of genomic DNA and probes spanning the entire cDNA of the insulin receptor, no gross alterations in receptor gene structure were detected in any members of this family. In 2 of the lipoatrophic siblings (LA1 and LA3) and in the sibling with insulin resistance but no lipoatrophy (LAS), a unique variant BamHI site was detected using a probe to the alpha-subunit region. This site was not found in 200 normal or diabetic insulin receptor alleles. By use of probes 5' and 3' to the alpha-subunit probe and by genomic cloning analysis, this variant BamHI site was localized to an intron in the insulin receptor gene downstream of exon 3 which encodes amino acids 191-296 of the alpha-subunit of the receptor. These data indicate the complex nature of familial lipoatrophic diabetes mellitus, with alterations in insulin receptor expression and/or function in both clinically affected and non-affected siblings. Both the reduced insulin binding and reduced levels of insulin receptor mRNA in the lipoatrophic siblings suggest that an insulin receptor gene defect contributes to this syndrome. Several members of this family also carry a unique variant insulin receptor gene, which, however, could not be linked to a specific alteration in receptor expression or the presence of lipoatrophy.(ABSTRACT TRUNCATED AT 250 WORDS)