Abstract WMP46: Rotational Ischemic Vertebral Artery Compression (RIVAC) Syndrome Due to Cervical Facet Hypertrophy and Uncinate Process Osteophyte: Review of Seven Consecutive Cases

Introduction: The authors propose a new terminology, Rotational Ischemic Vertebral Artery Compression (RIVAC) syndrome, to describe patients who present with TIA or stroke from compression of the cervical vertebral artery (VA) below C2 by facet hypertrophy or uncinate process osteophyte associated with rotation of the head. The authors review clinical presentation, radiological findings, and management of 7 consecutive cases.

Methods: Prospective analysis of 7 consecutive cases of RIVAC syndrome was performed between 2004 and 2012. We reviewed peri-operative imaging, method of treatment, and clinical and angiographic outcome.

Results: A total of 6 patients (mean 66+/- 4 years) presented with stroke (N=2) or TIA including reproducible dizziness, vertigo, or syncope (N=4) associated with rotation of the head. Pre-operative dynamic cerebral angiogram showed near complete occlusion of cervical VA (N=2) or severe stenosis (60 to 80%) (N=5) during rotation of the head. The location of cervical VA compression was as follows: right C3-4 (N=1), left C4-5 (N=3), left C5-6 (N=2) and left C6-7 (N=1). Treatment included endovascular stent placement of VA without open surgery (N=1), endovascular stent placement of VA followed by partial left C5-6 factectomy 2 years later (N=1), posterior surgical decompression of VA along with bilateral facet screw fixation (N=4), and anterior cervical discectomy and fusion (N=1). Follow up dynamic cerebral angiograms and CTA angiogram of neck (6 months to 3 years) showed resolution of VA compression on rotation of head in all patients except for one who had lost in follow up. Clinical evaluation (range of 1 to 48 months) showed no recurrent stroke or TIA in all patients (mRS score of 0, N=6 and mRS of 3, N=1).

Conclusion: RIVAC syndrome should be recognized as an important cause of posterior circulation TIA or stroke associated with rotation of head. Pre-operative dynamic cerebral angiogram and CT angiogram of neck are essential in localization and characterization of the level and cause of VA compression. Open surgical decompression and fixation appears to be safe and effective treatment of patients with RIVAC syndrome.

Deriving benefit of early detection from biomarker-based prognostic models

Many prognostic models for cancer use biomarkers that have utility in early detection. For example, in prostate cancer, models predicting disease-specific survival use serum prostate-specific antigen levels. These models typically show that higher marker levels are associated with poorer prognosis. Consequently, they are often interpreted as indicating that detecting disease at a lower threshold of the biomarker is likely to generate a survival benefit. However, lowering the threshold of the biomarker is tantamount to early detection. For survival benefit to not be simply an artifact of starting the survival clock earlier, we must account for the lead time of early detection. It is not known whether the existing prognostic models imply a survival benefit under early detection once lead time has been accounted for. In this article, we investigate survival benefit implied by prognostic models where the predictor(s) of disease-specific survival are age and/or biomarker level at disease detection. We show that the benefit depends on the rate of biomarker change, the lead time, and the biomarker level at the original date of diagnosis as well as on the parameters of the prognostic model. Even if the prognostic model indicates that lowering the threshold of the biomarker is associated with longer disease-specific survival, this does not necessarily imply that early detection will confer an extension of life expectancy.

Polymorphism (C677T) in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene: A preliminary study on north Indian men

An elevated level of plasma homocysteine, sulfur containing amino acid generated through demethylation of methionine has been widely accepted as a risk factor for cardiovascular disease (CVD). The increase can result from genetic and/or nutrient related disturbances in the remethylation or transsulfuration pathways for homocysteine metabolism. A common mutation (C677T) in the gene encoding for the enzyme 5, 10-methylenetetrahydrofolate reductase (MTHFR) or deficiency of the B vitamins namely folic acid, B(12), B(6) can lead to hyperhomocysteinemia.In the present study, we have investigated the incidence of the (C677T) MTHFR polymorphism in the North Indian males. 141 angiographically proven coronary artery disease (CAD) patients and 55 age and sex matched healthy volunteers were examined for the association between MTHFR gene polymorphism and CAD. The MTHFR genotyping was performed using polymerase chain reaction (PCR) followed by restriction-isotyping with Hinf 1 endonuclease. A trend for higher 'T' allele frequency (0.19) was observed in patients than in controls (0.16). However no significant association was found between C677T mutation and CAD severity. The lack of statistical significance could be due to the small sample size studied. Hence a larger study including various ethnic groups is warranted.

Peak expiratory flow rate of children working in lock factories

Peak expiratory flow rate (PEFR) of 106 children working in different units of lock factory was measured and compared with age and sex matched control group of same socio-economic status children. All the children worked for about ten hours per day. It was observed that there was a significant decrease in PEFR of children working in the different units of lock factories i.e. Hand press, Polishing, Lock fitting, Lock packing units as compared to control group (P>0.001). The reduction percentage of PEFR was maximum in children working in polishing unit (25.48%).

Raised serum TNF-alpha, blood sugar and uric acid in preeclampsia in third trimester of pregnancy

In preeclampsia, insulin resistance occurs but the exact cause is unknown. It is uncertain whether women destined to develop preeclampsia have preexisting insulin resistance or it is acquired with the development of the disease. Fasting blood samples were collected from 10 normal control pregnant women and from 30 cases of preeclampsia in the third trimester of pregnancy to measure circulating level of glucose, uric acid and tumor necrosis factor-alpha (TNF) concentrations. Preeclampsia was diagnosed as per standard guideline adapted from national high blood pressure education program working group. In control group (n=10) mean age was 25+/-3.71 years, mean sugar level was 86.73+/-13.06 mg/dl, uric acid level was 3.25+/-+/-.59 mg/dl and TNF-alpha level was 9.93+/-9.56 pg/dl. In preeclampsia group mean age was 25.56+/-3.96 years, mean sugar level was 93.46+/-18.6 mg/dl, uric acid was 6.00+/-1.64 mg/dl and TNF-alpha level was 67.66+/-61.83 pg/dl. Statistical analysis done using Kruskal Wallis's test showed significantly raised levels of TNF-alpha (p<0.001), uric acid (p<0.001) and blood sugar (p=0.201) in preeclampsia cases. In preeclampsia there was positive significant correlations of raised TNF-alpha with uric acid (p<0.005). Spearman's test for correlation showed positive correlation of TNF-alpha with blood sugar (p<0.043) in cases of preeclampsia. The findings suggest the involvement of cytokines (TNF-alpha) in preeclampsia and may have a role in gestational diabetes mellitus and insulin resistance. In the present study, there was positive association of raised level of TNF-alpha with blood sugar / and uric acid levels.

Lipoprotein(a) as a marker of coronary artery disease and its association with dietary fat

OBJECTIVE

The main objectives of the study were to evaluate the effect of dietary fat on plasma lipoprotein(a) [Lp(a)] levels and to study the potential of Lp(a) as a more reliable marker for CAD compared to other lipids and lipoproteins.

METHODS

Twenty CAD patients and 20 healthy controls were recruited for the study. Their fasting plasma Lp(a) levels and complete lipid profile were assayed. The fat intake was calculated using 24 hours dietary recall method. The patients and controls were each divided into two subgroups: Group A consuming dietary fat > 30% and Group B consuming dietary fat < or = 30% of the total kilo-calories/day.

RESULTS

Results indicated that plasma Lp(a), total serum cholesterol (TC), tryglyceride (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and LDL-C/HDL-C ratio of CAD patients were significantly higher than the controls. High fat intake was found to be associated with higher plasma Lp(a) levels (p<0.05) in patients only. No significant correlation was found between Lp(a) levels and other conventional lipoproteins.

CONCLUSION

The lack of correlation between Lp(a) and other lipoproteins indicates its potential as an independent risk factor for CAD. High fat intake led to higher plasma Lp(a) levels in patients; hence it would be worthwhile to evaluate the effect of quality and quantity of fat intake on plasma Lp(a) levels in a larger sample size.

Biocatalytic potential of Fusarium globulosum lipase in selective acetylation/deacetylation reactions and in ester synthesis

AIMS

The present study was carried out to assess the potential of Fusarium globulosum lipase (FGL) for chemoselective and regioselective biotransformations for the synthesis of industrially important organic compounds.

METHODS AND RESULTS

Different acetylation/deacetylation reactions and ester synthesis reactions were carried out in organic media. Fusarium globulosum lipase showed exclusive selectivity for the acetylation of the alcoholic hydroxyl group over the phenolic hydroxyl group of the hydroxymethylated phenols and aryl alkyl ketones. This also led to the enantiomeric resolution of the aryl alkyl ketone. In contrast, the lipase showed reversed selectivity in deacetylation where it preferred the phenolic acetoxy group over the alcoholic acetoxy moiety of the peracetates of hydroxymethylated compounds. The enzyme also exhibited strict regioselection for deacetylation at the para position of the peracetate of an aryl alkyl ketone. In addition, the lipase also synthesized a variety of industrially important fatty acid esters of sugars, sugar alcohols, alcohols and ascorbic acid with high preference for middle-chain fatty acids.

CONCLUSION

Fusarium globulosum lipase shows versatile catalytic potential in terms of chemo-, enantio- and regioselectivity and fatty acid specificity in carrying out a variety of industrially important biotransformations.

SIGNIFICANCE AND IMPACT OF THE STUDY

The biocatalytic potential of FGL can thus be utilized for the synthesis and modification of different types of polyphenolic compounds and esters. These compounds find widespread uses as surfactants, bioactive analogues, antioxidants and flavour components in the food, detergent, pharmaceutical and cosmetic industries.

Giant congenital nevomelanocytic nevus with satellite lesions, vitiligo and lipoma : a rare association

A case of giant congential nevomelanocytic nevus with satellite lesions, vitiligo and lipoma is described, owing to the rarity of the association. The constellation of finding can be explained on the basis of a defect in the neural crest, which is considered to be a common origin of melanoblasts, Schwann cells, sensory ganglia, bone, fat, muscle and blood vessels.

Early onset of endocrine abnormalities in beta-thalassemia major in a developing country

Endocrine complications in patients with thalassemia major in developing countries may be frequent due to suboptimal iron chelation. Data from developing countries are scant. We prospectively evaluated growth, growth hormone (GH), insulin-like growth factor I, thyroid hormone, cortisol and glucose tolerance in 84 patients over one year. Height standard deviation (SD) score of patients > 8 years (-2.2 +/- 1.5 against National Center for Health Statistics references) was significantly lower than that of normal controls (-1.0 +/- 0.7, p < 0.001). 51% of patients had GH deficiency, 13% hypocortisolism and 7.9% diabetes/impaired glucose tolerance. Ten of 11 adolescents/young adults had hypogonadism. Of 54 preadolescent children who underwent dynamic testing, 18 (33%) had at least one endocrine deficiency other than short stature. We conclude that hypogonadism and hypocortisolism form important causes for morbidity in our thalassemic children. Thalassemic patients in developing countries may be at risk for endocrine deficiencies at younger ages.

Comparative bioavailability of two formulations of azithromycin

AIM

To compare the bioequivalence of two brands of azithromycin capsules in healthy male volunteers for regulatory purpose.

METHOD

A single oral dose of 500 mg of either test (Panacea Biotec Ltd.) or reference (Pfizer India Ltd.) preparation of azithromycin was administered to 12 volunteers in double blind randomised cross over fashion. Serum levels of azithromycin were analysed using microbiological assay. The pharmacokinetic parameters studied were Cmax, Tmax, AUC, t1/2, Ke, CL and MRT. In vitro dissolution tests were conducted for both the preparations and compared with in vivo absorption.

RESULTS

The mean peak serum azithromycin concentration of 0.516 +/- 0.008 microgram/ml was observed at 2.33 +/- 0.22 h with test brand and was similar to that of reference brand with Cmax of 0.494 +/- 0.011 microgram/ml at 2.71 +/- 0.26 h. The statistical difference between all the other paharmacokinetic parameters were insignificant.

CONCLUSION

Both the brands of azithromycin can be considered to be bioequivalent on the basis of results obtained.

Get the right mix of bricks & clicks

The bright line that once distinguished the dot-com from the incumbent is rapidly fading. Success in the new economy will go to those who can execute clicks-and-mortar strategies that bridge the physical and virtual worlds. But how executives forge such strategies is under considerable debate. Despite the obvious benefits that integration offers--cross-promotion, shared information, purchasing leverage, distribution economies, and the like--many executives now assume that Internet businesses have to be separate to thrive. They believe that the very nature of traditional business--its protectiveness of current customers, its fear of cannibalization, its general myopia--will smother any Internet initiative. Authors Ranjay Gulati and Jason Garino contend that executives don't have to make an either- or choice when it comes to their clicks-and-mortar strategies. The question isn't, "Should we develop our Internet channel in-house or launch a spin-off?" but rather, "What degree of integration makes sense for our company?" To determine the best level of integration for their companies, executives should examine four business dimensions: brand, management, operations, and equity. Drawing on the experiences of three established retailers--Office Depot, KB Toys, and Rite Aid--the authors show the spectrum of strategies available and discuss the trade-offs involved in each choice. By thinking carefully about which aspects of a business to integrate and which to keep distinct, companies can tailor their clicks-and-mortar strategy to their own particular market and competitive situation, dramatically increasing their odds of e-business success.

Apolipoprotein(a) polymorphism and its association with plasma lipoprotein(a) levels: a north Indian study

Elevated levels of lipoprotein(a) has been regarded as an independent risk factor for coronary, peripheral and cerebral atherosclerosis. The enormous intra-personal variation in the plasma concentration of lipoprotein(a) is almost entirely controlled by the apolipoprotein(a) i.e. gene locus on the chromosome 6q 26-27. The apolipoprotein(a) molecule is highly polymorphic and is known to exist in multiple, genetically determined isoforms. These polymorphisms may be responsible for difference in promoter activity, variable size of apolipoprotein(a) and thereby variation in plasma lipoprotein(a) concentration. We studied the effect of two types of polymorphisms, (i) variation in length of the pentanucleotide repeat in the 5' flanking region starting -1373 bp upstream of AUG codon, and (ii) the Kringle-4 type 2 size polymorphism, on plasma lipoprotein(a) levels in North Indian population. The study group consisted of 88 angiographically assessed male coronary artery disease patients (age range 30-70 years) and 83 age- and sex-matched healthy controls. The pentanucleotide repeat polymorphism was analysed using polymerase chain reaction. In all, 8/11 pentanucleotide repeat isoforms were observed. Using SDS-agarose gel electrophoresis and immunoblotting isoforms having 12-50 Kringle-4 type 2 repeats were detected. Our study indicates a strong association of elevated plasma lipoprotein(a) concentration with coronary artery disease. An inverse correlation was seen between lipoprotein concentration and isoform size for both the pentanucleotide repeat polymorphism and the Kringle-4 type 2 polymorphisms; statistically significant difference (p = 0.001) was, however, observed only for the later.

Hepatocyte growth factor induces rat ovarian surface epithelial cell mitosis or apoptosis depending on the presence or absence of an extracellular matrix

The present studies showed that sequential treatment with equine CG (eCG) and hCG not only induced an increase in ovarian weight, but also caused an estimated 4.6-fold increase in the number of ovarian surface epithelial cells. In addition, eCG-hCG treatment increased ovarian hepatocyte growth factor (HGF) messenger RNA levels. These studies also demonstrated that rat primary ovarian surface epithelial cells as well as a cell line derived from rat ovarian surface epithelium (i.e. ROSE-179 cells) do not express the LH (hCG) receptor. Both of these cells express c-Met, the receptor for HGF. To assess the effects of hCG and HGF on ovarian surface epithelial cell mitosis, ROSE-179 cells were cultured for 24 h in serum-supplemented medium on either glass or the synthetic fibronectin-like extracellular matrix protein, pronectin (RGD). The cells were then cultured for 24 h in serum-free medium in the presence or absence of hCG or HGF. The numbers of cells at 2, 24, and 48 h of culture were determined. The percentage of apoptotic cells was assessed by in situ DNA staining at 48 h of culture. In the serum-supplemented medium in the presence or absence of RGD, the number of ROSE-179 cells doubled. In serum-free medium, cell proliferation was reduced, and the percentage of apoptotic nuclei ranged between 10-15% regardless of the substrate. Neither mitosis nor apoptosis was influenced by hCG in the presence or absence of RGD. For ROSE-179 cells cultured in serum-free medium on RGD, HGF induced mitosis, resulting in a 2.8 +/- 0.2-fold increase in cell number compared with the 24 h control values. On a glass substrate in serum-free medium, HGF did not induce mitosis, but increased the percentage of apoptotic nuclei. Time-lapse photographic analysis revealed that on RGD, cells undergoing HGF-induced mitosis showed a transient reduction in cell contact. On glass, HGF caused many cells to completely lose contact and separate from each other. Collectively, these data suggest that in vivo gonadotropins stimulate HGF expression and ovarian surface epithelial cell proliferation. Based on in vitro studies, it is likely that the mitogenic action of hCG is mediated by HGF. However, HGF only induces mitosis in the presence of an extracellular matrix.

Silicone gel sheet dressings for prevention of post-minigraft cobblestoning in vitiligo

Punch grafting was performed in 15 patients using punches varying in size from 2 to 3 mm in diameter. Silicone gel sheets were used as a post-operative dressing. Removal of the dressings after 7 days revealed no lifting of grafts in 13 patients. A minimally raised surface seen in two patients flattened after 6 to 8 weeks of continuous use of the dressing. At two months of follow-up, no cobblestoning or any other untoward effect was evident. Firm pressure provided by silicone gel sheets probably prevents cobblestoning by counteracting forces which tend to lift the grafts. Additionally, the sheets act as a brace preventing graft dislocation, provide a sterile atmosphere underneath the grafts, facilitate periodic observation due to their transparency, and are easily removed at the time of follow-up.

A role for hepatocyte growth factor/scatter factor in regulating normal and neoplastic cells of reproductive tissues

OBJECTIVE

To review data regarding the expression, function, and signal transduction pathways associated with hepatocyte growth factor/scatter factor (HGF/SF) as related to normal and neoplastic cells of reproductive tissues.

METHODS

Studies involving HGF/SF were reviewed and the data were summarized.

RESULTS

Hepatocyte growth factor/scatter factor is generally expressed within the stromal components of the testis, prostate, placenta, mammary gland, uterine endometrium, and ovary. The receptor for HGF/SF, c-met, is expressed in the epithelial cells of these tissues. Ligand activation of c-met results in its autotyrosine phosphorylation and the subsequent stimulation of numerous signal transduction pathways. Which pathways are activated determine in part the effect that HGF/SF has on a specific tissue. Hepatocyte growth factor/scatter factor can promote a variety of biologic responses including mitosis, motogenesis (i.e., cell movement), differentiation, and apoptosis. In addition, both HGF/SF and c-met continue to be expressed during the neoplastic transformation of cells from these reproductive tissues.

CONCLUSION

Hepatocyte growth factor/scatter factor plays an important role in regulating the physiologic function of several reproductive tissues and may also be involved in the oncogenesis of cells within these tissues.

Further delineation of a new (Van Den Ende-Gupta) syndrome of blepharophimosis contractural arachnodactyly, and characteristic face

We report on 2 unrelated Indian girls with blepharophimosis, arachnodactyly, digital contractures which improved spontaneously, elbow deformity, beaked nose, everted lips, and large ears, findings similar to those in 2 cases reported previously by Van Den Ende et al. [1992, Am J Med Genet 42:467-469] and Gupta et al. [1995, J Med Genet 32:809-812], thus delineating a new syndrome of contractural arachnodactyly with characteristic facial anomalies.