The cardiovascular and hemodynamic effects of erythropoietin in chronic renal failure

OBJECTIVE

Left ventricular hypertrophy (LVH) has been identified as an independent risk factor for mortality in patients with chronic renal failure (CRF) and anemia has been proposed to contribute to LVH. The cardiovascular and hemodynamic effects of correction of anemia with recombinant human erythropoietin (rHU EPO) was assessed in a 12 week prospective study in patients with CRF.

METHODS

Biochemical parameters and echocardiography were studied at the start and after three months therapy with EPO in 24 patients with CRF--11 predialysis (Group I) and 13 dialysis (Group II).

RESULTS

The mean haemoglobin (Hb)--g/dl increased significantly from 7.5 +/- 1.0 to 10.1 +/- 1.1 in group I and from 6.7 +/- 0.6 to 9.4 +/- 0.8 in group II (p < 0.05) on EPO therapy. The left ventricular mass index (LVMi)--g/m2 reduced significantly from 185.6 +/- 44.6 to 158.3 +/- 4.1 in group I and from 158.0 +/- 26.9 to 131.6 +/- 22.1 in group II (p < 0.05 in both). The interventricular septal thickness (IVST) also showed a significant decline in both groups, 1.17 +/- 0.06 to 1.14 +/- 0.05 (group I) and 1.09 +/- 0.25 to 1.01 +/- 0.21 (group II), p < 0.05 in both. The thickness of the left ventricular posterior wall remained unchanged. The left ventricular end diastolic and systolic diameters (LVEDD and LVESD) significantly reduced from their baseline values in both the groups (p < 0.05). The diastolic filling parameters across the mitral valve remained unchanged in both the groups. The cardiac index (CI)--L/min/m2 decreased from 3.53 +/- 0.3 to 3.03 +/- 0.27 in group I and from 3.31 +/- 0.64 to 2.80 +/- 0.60 in group II (p < 0.05) and the total peripheral resistance (TPR)--dynes/cm5/sec increased from 1567 +/- 164.8 to 1883 +/- 190.7 in group I and from 1618 +/- 375.7 to 2004 +/- 437.3 in group II. The differences in all the parameters at the start and after 3 months of EPO were comparable in groups I and II. The mean arterial pressure (MAP) changed insignificantly in both the groups.

CONCLUSIONS

To conclude, this study has shown that the decrease in LVMi with EPO reflects the role of anemia in the genesis of LVH and that the correction of anemia with EPO in CRF results in regression of LVMi and has a favourable effect on cardiovascular hemodynamics.

The use of chorionic villus biopsy catheters for saline infusion sonohysterography

BACKGROUND

Saline infusion sonohysterography is one of the recent refinements of ultrasonography that has the ability to enhance imaging of the uterine cavity in a safe, inexpensive and expedient manner. The technique can be difficult in women with a stenotic cervical os. This report describes a single-pass technique using chorionic villus sampling (CVS) catheters for saline infusion sonohysterography.

METHOD

Saline infusion sonohysterography requires the transcervical passage of a catheter, through which saline is infused. The subsequent distension of the uterine cavity enhances the ability to detect intrauterine pathology with ultrasonography. In women with cervical stenosis, a catheter can be used in place of the more conventional two-pass technique, which requires the use of a uterine sound or probe followed by a conventional catheter.

EXPERIENCE

We have used CVS catheters in women with cervical stenosis on 12 occasions. All have been successful and without significant discomfort to the patient.

CONCLUSION

The use of CVS catheters for saline infusion sonohysterography in women with cervical stenosis can alleviate the need to remove the cervical probe prior to introduction of the catheter.

Beta-adrenergic modulation of human type-1/type-2 cytokine balance

BACKGROUND

Neuroendocrine mediators are increasingly recognized as immunomodulatory agents. Lymphocytes and monocytes express receptors for a variety of neuroendocrine mediators, including catecholamines. It has been reported that beta-adrenergic agonists decrease IFN-gamma production, with varying effects on IL-4 and IL-5 production.

OBJECTIVE

Our purpose was to determine the effects of catecholamines (including beta-adrenergic agonists) on the type-1/type-2 cytokine balance in tetanus-stimulated human PBMCs.

METHOD

Human PBMCs were stimulated with tetanus in the presence of epinephrine (EPI), norepinephrine, or terbutaline. IFN-gamma, IL-4, IL-5, and IL-10 levels in the supernatants were determined by ELISA.

RESULTS

PBMCs stimulated in the presence of EPI produced decreased levels of IFN-gamma and increased levels of IL-10, IL-4, and IL-5. A small decrease in IFN-gamma production and an increase in IL-10, IL-4, and IL-5 production were also observed with norepinephrine. Terbutaline induced similar alterations in the type-1/type-2 cytokine balance compared with EPI, indicating that the beta(2)adrenergic receptor is involved in these cytokine alterations. Furthermore, these cytokine alterations were blocked by propranolol. Finally, IL-12p70 prevented the cytokine alterations, suggesting that the mechanism of beta-adrenergic-induced cytokine alterations involves a decrease in IL-12.

CONCLUSION

beta-Adrenergic agonists induce a shift in the human type-1/type-2 cytokine balance toward a type-2 response. These data provide a potential mechanism to explain the paradoxical increase in asthma morbidity and mortality associated with the chronic use of scheduled dosing of short-acting beta-adrenergic agonists.

Total dose iron infusion: safety and efficacy in predialysis patients

Iron deficiency anemia is not uncommon in predialysis patients. Oral iron often cannot maintain adequate iron stores. Hence we evaluated the safety and efficacy of total dose infusion (TDI) of iron in these patients. Anemic predialysis patients were screened and those with Hb < 7.0 g/dL and serum ferritin < 200 ng/mL were selected. Patients with active bleeding and acute liver disease were excluded. All patients were on oral iron 100 mg/day. None of the patients were on erythropoeitin. 11 patients (6 males and 5 females), aged 45.9 +/- 15 yrs, were suitable. Hb was 5.9 +/- 1.0 g/dL and serum ferritin was 89.5 + 50 ng/mL. The preparation used was iron dextran. A test dose of 25 mg in 100 mL normal saline was administered over 1 hr to all patients. One patient had fever and chills during the test dose and was not given TDI. 10 patients received TDI. None of these patients had any problem during the infusion. The dose of iron administered was 900 + 316.2 mg. One patient who received 1600 mg had arthralgia-myalgia and another patient had thrombophlebitis following TDI. One month after TDI, Hb was 8.0 + 1.0 g/dL and serum ferritin was 362 ng/mL. We feel that TDI is a safe and effective method of correcting iron deficiency in predialysis patients.

Hepatitis C virus infection during haemodialysis in India

BACKGROUND

Hepatitis C viral (HCV) infection is a major cause of hepatitis during haemodialysis after the control of hepatitis B following vaccination and isolation measures. Magnitude of this problem in India has not been studied and there are only few reports of HCV infection during haemodialysis from this country. This study was conducted to find out the incidence of HCV infection in patients of end stage renal disease (ESRD) and haemodialysis (HD), along with its source and to find out the clinical course of HCV positive patients.

METHODS

HCV infection was diagnosed by detecting anti-HCV antibodies using the IIIrd generation ELISA kits.

RESULTS

Of the 208 consecutive patients of ESRD accepted for the study, HCV prevalence was 4.3% at the time of start of study. Of the all risk factors studied, past history of jaundice and number of blood transfusion (BT) were significantly higher in HCV positive patients as compared to HCV negative patients. Of the 208 patients, 20 (9.6%) died, 119 (57.2%) lost follow-up and 69 (33.2%) got renal transplant (RT). Incidence of HCV in patients who died, lost follow-up and got RT was 10%, 3.4% and 36.2% while prevalence was 15%, 4.2% and 42% respectively. In these groups, duration of HD was 8.4, 5.2 and 22.7 weeks respectively while the mean blood transfusion (BT) was 1.2, 0.8 and 5.4 in number respectively. Mean age of patients in these groups was 37.85, 37.9 and 32.53 years and percentage of males were 65%, 75% and 89.9% respectively. At no stage of follow-up, patients with HCV infection had any symptoms or high serum bilirubin. Major abnormality was fluctuating ALT in these patients. HCV in 512 units of blood transfusions given to these patients and healthy volunteers was 1.17% and 0.66% respectively. Marked increase of HCV infection while patients were on HD is likely to be due to nosocomial spread. Blood transfusion was not found to be important source of HCV infection. Longer the patients remain on HD; more will be chance of HCV infection.

CONCLUSION

It is concluded that HCV is a major cause of concern in haemodialysis patients in India and the predominant source of spread of infection is nosocomial. In our set-up, blood transfusion is not an important source of infection. Majority of these patients remains asymptomatic at least for the short terms follow-up.

Multiple endocrine neoplasia type 1: clinical and genetic features of the hereditary endocrine neoplasias

MEN1 is a syndrome of parathyroid adenomas, gastrinomas, prolactinomas, and other endocrine tumors. Collagenomas and facial angiofibromas are newly recognized but common skin expressions. Many tumors in MEN1 are benign; however, many entero-pancreatic neuroendocrine tumors and foregut carcinoid tumors are malignant. MEN1 is thus the expression of a cancer gene but without available prevention or cure for malignancy. Hereditary (as compared to sporadic) endocrine tumors show early onset age and multiplicity, because each cell of the body has "one hit" by inheritance. Multiple neoplasia syndromes with endocrine tumor(s) all include nonendocrine components; their known defective genes seem mainly to disturb cell accumulation. Hereditary neoplasia/hyperplasia of one endocrine tissue reflects a defect that is tissue selective and directed at cell secretion. Though the hereditary endocrine neoplasias are rare, most of their identified genes also contribute to common sporadic endocrine neoplasms. Hereditary tumors may be caused by activation of an oncogene (e.g., RET) or, more often, by inactivation of a tumor suppressor gene (e.g., P53, MEN1). Recently, MEN1 was identified by positional cloning. This strategy included narrowing the gene candidate interval, identifying many or all genes in that interval, and testing the newly identified candidate genes for mutation in MEN1 cases. MEN1 was identified because it showed mutation in 14 of 15 MEN1 cases. NIH testing showed germline MEN1 mutations in 47 of 50 MEN1 index cases and in seven of eight cases with sporadic MEN1. Despite proven capacity to find germline MEN1 mutation, NIH testing found no MEN1 mutation among five families with isolated hyperparathyroidism, suggesting that this often arises from mutation of other gene(s). Analogous studies in Japan found that familial isolated pituitary tumors also did not show MEN1 germline mutation. MEN1 mutation testing can now be considered for cases of MEN1 and its phenocopies and for asymptomatic members of families with known MEN1 mutation. Germline MEN1 testing does not have the urgency of RET testing in MEN2a and 2b, as MEN1 testing does not commonly lead to an important intervention. Somatic MEN1 mutation was found in sporadic tumors: parathyroid adenoma (21%), gastrinoma (33%), insulinoma (17%), and bronchial carcinoid (36%). For each of these, MEN1 was the known gene most frequently mutated. MEN1 has a widely expressed mRNA that encodes a protein (menin) of 610 amino acids. The protein sequence is not informative about domains or functions. The protein was mainly nuclear. Menin binds to JunD, an AP-1 transcription factor, inhibiting JunD's activation of transcription. Most of the germline and somatic MEN1 mutations predict truncation of menin, a likely destructive change. Inactivating MEN1 mutations in germline and in sporadic neoplasms support prior predictions that MEN1 is a tumor suppressor gene. Germline MEN1 mutation underlies all or most cases of MEN1 (familial or sporadic). Somatic MEN1 mutation is the most common gene mutation in many sporadic endocrine tumor types.

Concomitant modified bladder neck closure and Mitrofanoff urinary diversion

PURPOSE

We describe a modification of bladder neck closure for managing urinary incontinence in children.

MATERIALS AND METHODS

In 11 patients with intractable urinary incontinence that persisted after multiple failed surgical procedures we performed modified bladder neck closure with construction of a catheterizable continent conduit.

RESULTS

Mean followup is 3 years. All patients were continent after the procedure and none had a fistula or urinary leakage. One patient required stomal and conduit revision, and bladder stones in 3 necessitated endoscopic removal.

CONCLUSIONS

We recommend this modified technique of bladder neck closure as an option for managing urinary incontinence in a complex group of children because it allows the achievement of continence with minimal morbidity.

Tumour necrosis factor-alpha and interleukin-2 in pus aspirate and blood in patients with amoebic liver abscess

OBJECTIVES

Cell mediated immunity (CMI), cytokines and humoral immunity have been implicated in the pathogenesis of invasive amoebiasis.

METHODS

The role of cytokines--tumour necrosis factor-alpha (TNF-alpha) and interleukin 2 (IL-2) in blood and pus aspirate was studied in 20 patients of amoebic liver abscess (ALA), before and after treatment and 10 controls.

RESULTS

The mean TNF-alpha levels (pg/ml) in the controls and before treatment in the patients in serum and pus were 24.3 +/- 11.6, 28 +/- 14.5 and 161.2 +/- 81.3 (p < 0.002) respectively. The mean IL-2 levels (pg/ml) in the controls, serum and pus aspirate in the patients prior to treatment were 10.3 +/- 8.5, 39.2 +/- 26.1 and 117.0 +/- 65.9 respectively. The levels in the patients after therapy, increased to 47 +/- 25.7 (p < 0.001) and 134 +/- 59.4 (p < 0.01).

CONCLUSIONS

The higher levels of TNF-alpha and IL-2 in the pus aspirate compared to blood pre treatment, supports the role of locally released cytokines in the target organ i.e. liver in amoebiasis. The rise in values observed after therapy are indicative of increased macrophage activity due to CMI occurring late in the course of the disease which may contribute to disease limitation and localisation in amoebiasis. The study suggests that locally released cytokines play an important role in the pathogenesis of ALA.

Perimenstrual alterations in type-1/type-2 cytokine balance of normal women

BACKGROUND

Perturbations of the type-1/type-2 cytokine balance play a role in the pathogenesis of many diseases. Several immune-based diseases, such as asthma, have significant clinical exacerbations during specific intervals of the menstrual cycle and are associated with oral contraceptive pills (OCRs). The mechanism for these changes is not known, but may involve alterations in the type-1/type-2 cytokine balance.

OBJECTIVE

To determine if the type-1/type-2 cytokine balance in healthy women changes during a regular menstrual cycle.

METHODS

Peripheral blood mononuclear cells from 14 healthy women (seven taking monophasic OCPs) obtained during the perimenstrual interval (3 days prior to 4 days after the onset of menses) and the mid-cycle interval (days 13 to 16) were stimulated with PHA. Supernatants were analyzed for type-1 (IFN-gamma) and type-2 (IL-10) cytokines.

RESULTS

During the perimenstrual interval PBMC produced less IFN-gamma and more IL-10, resulting in a decreased IFN-gamma: IL-10 ratio compared with the mid-cycle interval. The perimenstrual decrease in the IFN-gamma: IL-10 ratio was observed in women not taking OCP, but not in women taking OCP. Furthermore, the OCP group had a lower mid-cycle IFN-gamma: IL-10 ratio compared with the control group. Finally, subjects reported increased levels of distress during the perimenstrual interval compared with the mid-cycle interval.

CONCLUSIONS

These data suggest that healthy women have a perimenstrual shift in the type-1/type-2 cytokine balance toward a type-2 response that is blunted in women taking OCP.

The gene for multiple endocrine neoplasia type 1: recent findings

Multiple endocrine neoplasia type 1 (MENI) is a promising model to understand endocrine and other tumors. Its most common endocrine expressions are tumors of parathyroids, entero-pancreatic neuro-endocrine tissue, and anterior pituitary. Recently, collagenomas and multiple angiofibromas of the dermis also have been recognized as very common. MEN1 can be characterized from different perspectives: (a) as a hormone (parathyroid hormone, gastrin, prolactin, etc.) excess syndrome with excellent therapeutic options; (b) as a syndrome with sometimes lethal outcomes from malignancy of entero-pancreatic neuro-endocrine or foregut carcinoid tissues; or (c) as a disorder than can give insight about cell regulation in the endocrine, the dermal, and perhaps other tissue systems. The MEN1 gene was identified recently by positional cloning, a comprehensive strategy of narrowing the candidate interval and evaluating all or most genes in that interval. This discovery has opened new approaches to basic and clinical issues. Germline MEN1 mutations have been identified in most MEN1 families. Germline MENI mutations were generally not found in families with isolated hyperparathyroidism or with isolated pituitary tumor. Thus, studies with the MENI gene helped establish that mutation of other gene(s) is likely causative of these two MEN1 phenocopies. MEN1 proved to be the gene most frequent L4 mutated in common-variety, nonhereditary parathyroid tumor, gastrinoma, insulinoma, or bronchial carcinoid. For example, in common-variety parathyroid tumors, mutation of several other genes (such as cyclin D1 and P53) has been found, but much less frequently than MEN1 mutation. The majority of germline and somatic MEN1 mutations predicted truncation of the encoded protein (menin). Such inactivating mutations strongly supported prior predictions that MEN1 is a tumor suppressor gene insofar as stepwise mutational inactivation of both copies can release a cell from normal growth suppression. Menin is principally a nuclear protein; menin interacts with junD. Future studies, such as discovery of menin's metabolic pathway, could lead to new opportunities in cell biology and in tumor therapy.

Symmetric peripheral gangrene and falciparum malaria--an interesting association

Symmetric peripheral gangrene (SPG) is a rare syndrome in which disseminated intravascular coagulation (DIC) is the most common underlying condition. We report three cases of SPG in association with Plasmodium falciparum malaria and DIC, an association unreported so far.

Potent 1,3-disubstituted-9H-pyrido[3,4-b]indoles as new lead compounds in antifilarial chemotherapy

Substituted 9H-pyrido[3,4-b]indoles (beta-carbolines) identified in our laboratory as potential pharmacophore for designing macrofilaricidal agents, have been explored further for identifying the pharmacophore responsible for high order of adulticidal activity. This has led to syntheses and macrofilaricidal evaluations of a number of 1-aryl-9H-pyrido[3,4-b]indole-3-carboxylate derivatives (3-7). The macrofilarical activity was initially evaluated in vivo against Acanthoeilonema viteae. Amongst all the synthesized compounds, only twelve compounds namely 3a, 3c, 3d, 3f, 4c, 4d, 4f, 5a, 6f, 6h, 6i and 7h have exhibited either > 90% micro- or macrofilaricidal activity or sterilization of female worms. These compounds have also been screened against Litomosoides carinii and of these only 3f and 5a have also been found to be active. Finally these two compounds have been evaluated against Brugia malayi. The structure activity relationship (SAR) associated with position-1 and 3 substituents in beta-carbolines have been discussed. It has been observed that the presence of carbomethoxy at position-3 and an aryl substituent at position- in beta-carbolines effectively enhance antifilarial activity particularly against A. viteae. Amongst the various compounds screened, methyl 1-(4-methylphenyl)-9H-pyrido[3,4-b]indole-3-carboxylate (4c) has shown highest adulticidal activity and methyl 1-(4-chlorophenyl)-1,2,3,4-tetrahydro-9H-pyrido[3,4-b]indole-3-carboxyla te (3a) has shown highest microfilaricidal action against A. viteae at 50 mg/ kg x 5 days (i.p.). Another derivative of this compound namely 1-(4-chlorophenyl)-3-hydroxymethyl-9H-pyrido[3,4-b]indole (5a) exhibited highest activity against L. carinii at 30 mg/kg x 5 days (i.p.) and against B. malayi at 50 mg/kg x 5 days (i.p.) or at 200 mg/kg x 5 days (p.o.).

Delayed complications following Tenckhoff catheter removal

BACKGROUND

Tenckhoff catheter placement is well established to facilitate continuous ambulatory peritoneal dialysis (CAPD) in the treatment of end-stage renal failure. Complications of these catheters while in situ are well documented. However, little information is available concerning post-removal complications. Many centres, including our own remove these catheters by traction resulting in retained cuffs, rather than by formal dissection. We have evaluated the outcome of such removal over a 2-year period.

METHODS

Sixty-two patients underwent Tenckhoff catheter removal by traction over a 2-year period at our unit. Patients were evaluated retrospectively using case notes and operation records.

RESULTS

The catheters were sited for a mean of 23 months and were most commonly removed because of persistent peritonitis (48.4%). Sixty-one per cent of all patients had experienced at least one episode of CAPD peritonitis while the catheter was in situ, but this did not correlate with those who developed local sepsis. Fifteen patients (24.2%) subsequently developed local infective complications after a mean of 5.7 months (range 1-17 months). The subcutaneous cuff was involved in all cases and the peritoneal cuff was involved in six cases. Thirty patients were identified as being immunosuppressed, but this was not a risk factor in the development of retained cuff infections.

CONCLUSIONS

There is a significant risk of local sepsis with retained cuffs resulting from removal by traction and our data suggests that these catheters should be removed by dissection and excision of both cuffs.

Potent 1,3-disubstituted-9H-pyrido[3,4-b]indoles as new lead compounds in antifilarial chemotherapy

Substituted 9H-pyrido[3,4-b]indoles (beta-carbolines), identified in our laboratory as potential pharmacophores for designing macrofilaricidal agents, have been explored further for identifying the pharmacophore responsible for the high order of adulticidal activity. This has led to syntheses and macrofilaricidal evaluations of a number of 1-aryl-9H-pyrido[3,4-b]indole-3-carboxylate derivatives (3-7). The macrofilaricidal activity was initially evaluated in vivo against Acanthoeilonema viteae. Among all the synthesized compounds, only 12 compounds, namely 3a, 3c, 3d, 3f, 4c, 4d, 4f, 5a, 6f, 6h, 6i, and 7h, have exhibited either >90% micro- or macrofilaricidal activity or sterlization of female worms. These compounds have also been screened against Litomosoides carinii, and of these only 3f and 5a have also been found to be active. Finally these two compounds have been evaluated against Brugia malayi. The structure-activity relationship (SAR) associated with position 1 and 3 substituents in beta-carbolines has been discussed. It has been observed that the presence of a carbomethoxy at position 3 and an aryl substituent at position 1 in beta-carbolines effectively enhances antifilarial activity particularly against A. viteae. Among the various compounds screened, methyl 1-(4-methylphenyl)-9H-pyrido[3,4-b]indole-3-carboxylate (4c) has shown the highest adulticidal activity and methyl 1-(4-chlorophenyl)-1,2,3,4-tetrahydro-9H-pyrido[3, 4-b]indole-3-carboxylate (3a) has shown the highest microfilaricidal action against A. viteae at 50 mg/kg x 5 days (ip). Another derivative of this compound, namely 1-(4-chlorophenyl)-3-(hydroxymethyl)-9H-pyrido[3,4-b]indole (5a), exhibited the highest activity against L. carinii at 30 mg/kg x 5 days (ip) and against B. malayiat 50 mg/kg x 5 days (ip) or at 200 mg/kg x 5 days (po).

Bone histology in patients with nephrotic syndrome and normal renal function

BACKGROUND

The prevalence of metabolic bone disease in patients with nephrotic syndrome (NS) at normal level of renal function remains uncertain.

METHODS

To address this issue, we studied 30 patients (20 men and 10 women, mean age 27.3 +/- 11.7 years) with NS who had normal renal function (mean creatinine clearance 103 +/- 4 ml/min). We evaluated their serum calcium, phosphorus, alkaline phosphatase, immunoreactive parathyroid hormone (iPTH), vitamin D metabolites, urinary calcium, and skeletal survey. The extent of bone mineralization was analyzed by histomorphometric analysis of iliac crest bone biopsy specimens in all patients. The findings on bone histology were correlated with biochemical parameters.

RESULTS

The mean duration of NS was 35.5 +/- 26.9 months, with a protein excretion of 7.3 +/- 3.2 g/24 hr and a serum albumin of 2.2 +/- 0.8 g/dl. Total serum calcium was 7.8 +/- 0.8 mg/dl, whereas ionized calcium was 5.7 +/- 0.7 mg/dl, phosphorus 3.2 +/- 1.2 mg/dl, and alkaline phosphatase 149 +/- 48.6 U/liter. Serum iPTH levels were normal in all except two patients. The mean serum 25-hydroxyvitamin D [25(OH)D] level was 3.9 +/- 1.2 ng/ml (normal 15 to 30 ng/ml), whereas 1,25-dihydroxyvitamin D was 24 +/- 4.7 pg/ml (normal 16 to 65). There was an inverse correlation between serum levels of 25(OH)D and the magnitude of proteinuria (r = -0.42, P < 0.05). The mean 24-hour urinary calcium excretion was 82 +/- 21 mg/day. The skeletal survey was normal in all patients. Bone histology was normal in 33.3% of the patients, whereas 56.7% had isolated osteomalacia (OSM), and 10% had an increased bone resorption in association with defective mineralization. The severity of OSM measured by mineralization lag time correlated linearly with the duration (r = 0.94, P < 0.0001) and the amount (r = 0.97, P < 0.0001) of proteinuria. All patients with NS for more than three years had histological changes. Patients with OSM had lower 25(OH)D and serum albumin as compared with those with normal histology (P < 0.005). Bone mineralization had no significant correlation with serum iPTH, divalent ions, or vitamin D levels.

CONCLUSIONS

OSM is a frequent finding in adult patients with NS, even at a normal level of renal function. Its severity correlates with the amount and duration of proteinuria.

Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux

OBJECTIVES

DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR).

METHODS

During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars.

RESULTS

One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor.

CONCLUSIONS

Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.

Clinical and laboratory profile of diabetes in elderly

India is amidst a demographic transition showing an ageing trend. This will increase non-communicable diseases including diabetes which is already showing an increasing trend. With scanty literature existing on elderly diabetics (> 60 years of age), it was decided to study the clinico-laboratory and complication profile of this group of patients. Fifty consecutive elderly diabetics were studied and evaluated for ECG, chest x-ray, blood sugar, urea, creatinine, lipid profile, proteinuria, motor nerve conduction velocity and autonomic neuropathy. Duration of diabetes varied from one month to 28 years. Fifty-six per cent of the patients presented with classical symptoms of polyuria, polyphagia and polydipsia. Hypertension was present in 40% and cataract in 54% of the patients. Eighteen per cent were obese, 52% had evidence of peripheral neuropathy while 56% had autonomic neuropathy. Background diabetic retinopathy was present in 56%, pre-proliferative retinopathy and maculopathy in 4% each; hypertensive retinopathy in 10% of patients; 44% had microproteinuria and 8% had chronic renal failure. Hypercholesterolaemia was present in 64% and hypertriglyceridaemia in 42% of the patients with 26% having coronary artery disease. Sixty per cent were harbouring infections--20% had foot infections, 14% had tuberculosis and 10% had urinary tract infections. Ninety-two per cent of the patients were aware of their disease but 62% were not aware of the complications and of the need for strict dietary and drug compliance. There was a high prevalence of associated diseases viz, osteoarthritis, cataract, hypertension, hepatitis and parkinsonism. Therefore, this study brings out the need to have a holistic and multidisciplinary approach for management of elderly diabetics who constitute a heterogeneous group with distinct health care problems.

Cloning and expression of a novel chicken sulfotransferase cDNA regulated by GH

We have used mRNA differential display to compare gene expression in normal and GH receptor-deficient dwarf chickens, and report here the characterization of one differentially expressed gene, which shows significant sequence identity to the sulfotransferase gene family. Partial cDNA clones were isolated from a chicken liver cDNA library and an additional sequence was obtained using 5' rapid amplification of cDNA ends. A complete cDNA probe hybridizes to three transcripts (2.4, 2.0 and 1.45 kb) on Northern blots of chicken liver RNA, which differ in the length of the 3' untranslated region. All three transcripts are expressed at higher levels in normal vs dwarf chickens, as expected for a GH-regulated gene. The expression of this sulfotransferase mRNA was also detected in skeletal muscle, but not other tissues. The administration of GH to chickens increased the hepatic expression within 1 h, suggesting this sulfotransferase could be directly regulated by GH. Sulfotransferase activity, using estradiol or corticosterone as substrate, is detected in cells transfected with an expression vector containing the full-length cDNA. The sequence of this sulfotransferase does not show significant similarity with any subfamily of the sulfotransferases and its endogenous substrate is presently unknown. However, we speculate that GH activation of sulfotransferase activity could play a role in reducing concentrations of growth-antagonistic steroid hormones in GH target tissues. These results demonstrate the usefulness of differential display in this model system to identify genes that play a role in mediating GH action.