Increased tumor oxygenation and drug uptake during anti-angiogenic weekly low dose cyclophosphamide enhances the anti-tumor effect of weekly tirapazamine

Metronomic cyclophosphamide treatment is associated with anti-angiogenic activity and is anticipated to generate exploitable hypoxia using hypoxia-activated prodrugs. Weekly administration of tirapazamine (TPZ; 5 mg/kg body weight i.p.) failed to inhibit the growth of 9L gliosarcoma tumors grown s.c. in scid mice. However, the anti-tumor effect of weekly cyclophosphamide (CPA) treatment (140 mg/kg BW i.p.) was substantially enhanced by weekly TPZ administration. An extended tumor free period and increased frequency of tumor eradication without overt toxicity were observed when TPZ was given 3, 4 or 5 days after each weekly CPA treatment. Following the 2(nd) CPA injection, Electron Paramagnetic Resonance (EPR) Oximetry indicated significant increases in tumor pO(2), starting at 48 hr, which further increased after the 3(rd) CPA injection. pO(2) levels were, however, stable in growing untreated tumors. A strong negative correlation (-0.81) between tumor pO(2) and tumor volume during 21 days of weekly CPA chemotherapy was observed, indicating increasing tumor pO(2) with decreasing tumor volume. Furthermore, CPA treatment resulted in increased tumor uptake of activated CPA. CPA induced increases in VEGF RNA, which reached a maximum on day 1, and in PLGF RNA which was sustained throughout the treatment, while anti-angiogenic host thrombospondin-1 increased dramatically through day 7 post-CPA treatment. Weekly cyclophosphamide treatment was anticipated to generate exploitable hypoxia. However, our findings suggest that weekly CPA treatment induces a functional improvement of tumor vasculature, which is characterized by increased tumor oxygenation and drug uptake in tumors, thus counter-intuitively, benefiting intratumoral activation of TPZ and perhaps other bioreductive drugs.

Negative predictive value of mammography and sonography in mastalgia with negative physical findings

OBJECTIVE

To determine the negative predictive value of mammography and sonography in patients with focal/ diffuse breast pain with negative physical examination of the breasts.

METHODS

A descriptive study, conducted at Radiology Department ofAga Khan University Hospital from 2006-2007 for a period of 2 years. A total of 207 women were referred for mammography and sonography because of focal or diffuse breast pain. Complete follow-up was available only in 55 patients. The outcome or gold standard was mammograms or ultrasound after an average follow-up period of 18 months with negative/benign findings or histopathology of the suspicious lesion or imaging which was the gold standard to determine the negative predictive value.

RESULTS

Out of 55 patients, 17 (31%) had negative findings, benign findings were reported in 34 patients (62%), and 4 (7%) patients were subjected to mammographically guided breast biopsy. All the biopsies were done on the basis of abnormal findings on mammograms. All of the 4 patients had no evidence of cancer on subsequent histopathology. The negative predictive value of mammography and ultrasound in women with focal or diffuse breast pain was 100%.

CONCLUSION

Breast imaging using mammography and/or sonography in women who present with local or diffuse breast pain is of significant value, to reassure the patient as well as the clinician. However if imaging findings are suggestive of pathology a biopsy should not be delayed.

Vitamin D in pregnancy-time for action: a paediatric audit

Maternal vitamin D deficiency is a significant public health issue. This retrospective multicentre audit was undertaken to identify the scale of maternal vitamin D deficiency in London, using infant vitamin D deficiency as a surrogate marker. During January 2006 to June 2008, 74 infants presented with symptomatic vitamin D deficiency, a prevalence of 1.6 per 1000 deliveries in London. Of these, 49% were hypocalcaemic at presentation and 27% had hypocalcaemic seizures. A telephone survey in June 2008 showed that no London National Health Service antenatal units had departmental guidelines on vitamin D. This audit is presented to raise awareness of current recommendations and the sequelae of maternal vitamin D deficiency.

The Pakistan Risk of Myocardial Infarction Study: a resource for the study of genetic, lifestyle and other determinants of myocardial infarction in South Asia

The burden of coronary heart disease (CHD) is increasing at a greater rate in South Asia than in any other region globally, but there is little direct evidence about its determinants. The Pakistan Risk of Myocardial Infarction Study (PROMIS) is an epidemiological resource to enable reliable study of genetic, lifestyle and other determinants of CHD in South Asia. By March 2009, PROMIS had recruited over 5,000 cases of first-ever confirmed acute myocardial infarction (MI) and over 5,000 matched controls aged 30-80 years. For each participant, information has been recorded on demographic factors, lifestyle, medical and family history, anthropometry, and a 12-lead electrocardiogram. A range of biological samples has been collected and stored, including DNA, plasma, serum and whole blood. During its next stage, the study aims to expand recruitment to achieve a total of about 20,000 cases and about 20,000 controls, and, in subsets of participants, to enrich the resource by collection of monocytes, establishment of lymphoblastoid cell lines, and by resurveying participants. Measurements in progress include profiling of candidate biochemical factors, assay of 45,000 variants in 2,100 candidate genes, and a genomewide association scan of over 650,000 genetic markers. We have established a large epidemiological resource for CHD in South Asia. In parallel with its further expansion and enrichment, the PROMIS resource will be systematically harvested to help identify and evaluate genetic and other determinants of MI in South Asia. Findings from this study should advance scientific understanding and inform regionally appropriate disease prevention and control strategies.

Cytomegalovirus-seropositivity has a profound influence on the magnitude of major lymphoid subsets within healthy individuals

Cytomegalovirus (CMV) infects most individuals and elicits a strong CMV-specific immune response. We have studied the influence of CMV-seropositivity on the size of lymphoid subsets in healthy donors and demonstrate that the virus substantially modulates the peripheral lymphoid pool. CD8(+) T cell numbers are increased in all CMV-seropositive individuals because of a striking 60% increment in the CD8(+) T cell memory pool. The CD45RA(+) resting memory pool is doubled after CMV infection and increases further with age. The magnitude of the naïve CD8(+) T cell pool is dramatically reduced in CMV-seropositive individuals at all ages, and this accelerates the physiological decline by approximately 40 years. The number of CD4(+) effector memory T cells is increased in CMV-seropositive individuals and is differentially accommodated by a reduction in the number of naïve and central memory CD4(+) T cells in young and elderly donors respectively. CMV-seropositivity also increases the total number of B cells in older donors and suppresses the number of CD5(+) B cells. These data reveal that CMV has a profound influence on the immune system of all healthy individuals and add to growing concern regarding the clinical and immunomodulatory significance of CMV infection in healthy donors.

Transient isolated lesion of the splenium associated with clinically mild influenza encephalitis

Transient isolated lesions of the splenium with restricted diffusion are rare in the pediatric population. We report two such cases with influenza-associated encephalitis/encephalopathy (IAEE). These reversible isolated central splenial lesions are not specific for IAEE, but the notable feature associated with this specific presentation is a comparatively milder form of encephalitis that resolves clinically and radiologically within a short time.

Torsion of fallopian tube, fimbrial cyst

A case of fallopian tube fimbrial cyst torsion with haemorrhage is presented, occurring in a 37-year-old female who had tubal ligation 6 years back. She presented in emergency with acute abdomen. Initial assessment of ovarian cyst haemorrhage or torsion was made. Ultrasound showed cystic structures in left adnexa and complex cyst in right adnexa with suspicion of torsion. Laparoscopy was performed and bilateral fimbrial cysts in fallopian tubes were identified with torsion on right side, and a left ovarian haemorrhagic cyst, which was subsequently confirmed on histopathology. Although fallopian tube torsion of fimbrial cyst is rare, it should be considered in patients who had history of bilateral tubal ligation. Again it should also be considered in the differential diagnosis of acute abdomen in females.

Clinicopathological study of non-neoplastic lesions of nasal cavity and paranasal sinuses

An analysis of cases presenting as mass in nasal cavity (NC), paranasal sinuses (PNS), and nasopharynx (NP) was done over a period of 7 years in Jawaharlal Nehru Medical College, Aligarh. A provisional diagnosis was made after clinical assessment and radiological investigations, but final diagnosis was made after histopathological examination. The incidence of masses in NC, PNS, and NP was 34.3 cases per year, non-neoplastic lesions constituted 60% of these cases and their incidence was 20.7 cases per year. All the cases were carefully examined histopathologically and it was found that the region was affected by a variety of non-neoplastic lesions. Among 240 cases, 145 were non-neoplastic and 95 were neoplastic The lesions in the decreasing order of frequency were - nasal polyp, rhinoscleroma, tuberculosis, fungal infection, fibrous dysplasia, ossifying fibroma, cysts, nasal glioma, and cemento-ossifying fibroma. NP was involved by a range of neoplastic lesions; however, no non-neoplastic lesion was seen in this region.

Reporting on sex-based analysis in clinical trials of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker efficacy

BACKGROUND

Clinical practice recommendations for hypertension do not make recommendations specific to men or women. However, the sex hormones appear to modulate differently the renin-angiotensin system (RAS), which plays a central role in the regulation of blood pressure. Today, little is known about the effects of sex on the efficacy of therapies that antagonize the RAS, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

OBJECTIVE

To identify randomized controlled trials evaluating the efficacy of ACEIs and ARBs in preventing major cardiovascular outcomes, determine what proportion of the trial participants were female, and evaluate whether there was any evidence of a sex difference in the efficacy of these agents.

METHODS

A systematic review of the literature was conducted to identify randomized controlled trials that used either ACEIs or ARBs for the treatment of hypertension.

RESULTS

Thirteen ACEI trials and nine ARB trials were identified. Sex-specific outcome data were available in six of the ACEI trials and three of the ARB trials. These trials enrolled 74,105 patients; 39.1% were women. Seven of the nine trials indicated that ACEIs or ARBs may be slightly more beneficial in men. The magnitude of these differences, in most trials, was small.

CONCLUSIONS

Sex-specific data are reported in 43% of large hypertension clinical trials. Review of the trials reporting sex-specific effect sizes indicates that ACEIs and ARBs may be more effective in men.

Flavanol and flavonol contents of cocoa powder products: influence of the manufacturing process

Major brands of cocoa powder products present in the Spanish market were analyzed for monomeric flavanols [(+)-catechin and (-)-epicatechin] and flavonols [quercetin-3-glucuronide, quercetin-3-glucoside (isoquercitrin), quercetin-3-arabinoside, and quercetin]. In addition, the influence of the manufacturing process of cocoa powder products, in particular, the alkalinization treatment ( Dutching), on the original content of these flavonoids has been studied. (-)-Epicatechin was in the range of 116.02-730.26 microg/g, whereas (+)-catechin was in the range of 81.40-447.62 microg/g in the commercial cocoa products studied. Among flavonols, quercetin-3-arabinoside and isoquercitrin were the major flavonols in the cocoa powder products studied, ranging from 2.10 to 40.33 microg/g and from 3.97 to 42.74 microg/g, respectively, followed by quercetin-3-glucuronide (0.13-9.88 microg/g) and quercetin aglycone (0.28-3.25 microg/g). To our knowledge, these results are the first quantitative data in relation to the content of individualized flavonol derivatives in commercial cocoa powder products. The alkalinization treatment resulted in 60% loss of the mean total flavonoid content. Among flavanols, (-)-epicatechin presented a larger decline (67%, as a mean percentage difference) than (+)-catechin (38%), probably because of its epimerization into (-)-catechin, a less bioavailable form of catechin. A decline was also confirmed for di-, tri-, and tetrameric procyanidins. In the case of flavonols, quercetin presented the highest loss (86%), whereas quercetin-3-glucuronide, quercetin-3-arabinoside, and isoquercitrin showed a similar decrease (58, 62, and 61%, respectively). It is concluded that the large decrease found in the flavonoid content of natural cocoa powder, together with the observed change in the monomeric flavanol profile that results from the alkalinization treatment, could affect the antioxidant properties and the polyphenol biovailability of cocoa powder products.

Ultrasound - first imaging modality in the detection of parathyroid adenomas

Abstract We present a series of 12 patients in whom the typical ultrasound features of parathyroid adenomas were accurately demonstrated. High resolution ultrasound [in experienced hands] is a highly sensitive accurate, safe and non invasive method of localizing parathyroid adenomas especially in patients with typically located glands and an absence of thyroid pathology. Our aim was to compare ultrasound with nuclear medicine as an imaging gold standard in patients with thyroid adenomas.

Simultaneous lymphoma and squamous cell carcinoma presenting as a neck lump

We describe the unusual presentation of a patient with simultaneous follicular lymphoma and metastatic head and neck squamous cell carcinoma. He was initially treated for his lymphoma and then, following no regression in his cervical lymphadenopathy was referred for further assessment. This revealed squamous cell carcinoma arising from the left tongue base with metastatic disease in the left neck.

Hypothyroidism determines the clinical and immunological manifestations of Arabs with lupus

Abstract

Data on thyroid disease in Arabs with lupus is scarce. We conducted a cross-sectional and retrospective case–control study to report the prevalence of thyroid diseases in 110 Arabs with lupus who attended our Rheumatology Clinic between January 2002 and January 2007, and to delineate the clinical and immunological features of Arabs lupus patients with thyroid diseases. We found hypothyroidism in 15 (13.7%) patients. Overall, 25.6% had elevated thyroid peroxidase antibodies, 14.6% had elevated anti-thyroglobulin antibodies, and 13.7% were positive for both antibodies. Lupus patients with hypothyroidism had a significantly higher frequency of polyarthritis (OR = 9.3, CI: 2.0–41.7, P < 0.001), cutaneous manifestations (OR = 5.6, CI: 2.4–14.3, P < 0.0001), positive anti-thyroglobulin antibodies (OR = 19.9, CI: 8.38–47.4, P < 0.0001), and thyroid peroxidase antibodies (OR = 12.3, CI: 6.27–24.1, P < 0.0001) than lupus patients with normal thyroid function. Furthermore, neuropsychiatric (OR = 0.36, CI: 0.14–0.93, P < 0.05) and hematological (OR = 0.52, CI: 0.29–0.91, P < 0.05) manifestations were significantly lower in patients with hypothyroidism than in euthyroid patients. Surprisingly, the prevalence of anticardiolipin antibody immunoglobulin G (aCL IgG) (OR = 0.34, CI: 0.13–0.86, P < 0.05), lupus anticoagulant (OR = 0.02, CI: 0.001–0.35, P < 0.0001), and anticardiolipin syndrome (OR = 0.02, CI: 0.001–0.43, P < 0.0001) were significantly lower in lupus patients with hypothyroidism than in lupus patients with normal thyroid function. In conclusion, the prevalence of hypothyroidism in Arabs with lupus is comparable to that reported in the literature. Arab lupus patients with hypothyroidism have distinctive clinical and immunological features that differentiate them from euthyroid patients.

Quinoid radio-toxin (QRT) induced metabolic changes in mice: an ex vivo and in vivo EPR investigation

Radio-toxins are toxic metabolites produced by ionizing irradiation and have toxic effects similar to those caused by direct irradiation. We have investigated the effect of a quinoid radio-toxin (QRT) obtained from gamma-irradiated potato tuber on various organs in mice using ex vivo and in vivo EPR spectroscopy. Results indicate a decrease in the activity of ribonucleotide reductase enzyme in spleen of mice treated with 0.2mg QRT. A dose of 2mg QRT was fatal to mice within 45-60 min of treatment. Nitrosyl hemoglobin complexes alpha-(Fe(2+)-NO)alpha-(Fe(2+))beta-(Fe(2+))(2) were detected from spleen, blood, liver, kidney, heart, and lung tissue samples of mice treated with lethal doses of QRT. A significant decrease of pO(2) in liver and brain was observed after administration of QRT at the lethal dose. The time of the appearance of the nitrosyl hemoglobin complex and its intensity varied with the dose of QRT and the type of tissue. These results indicate that the effect of the QRT is more prominent in spleen and to a lesser extent in liver and blood. The QRT action at the lethal doses resulted in an increased hypoxia over time with disruption of compensatory adaptive response. The results indicate similar outcome of QRT as observed with gamma-irradiation.