A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department

OBJECTIVE

To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department.

METHODS

A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed.

RESULTS

A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge.

CONCLUSIONS

Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.

Acclimation of brackish water pearl spot (Etroplus suratensis) to various salinities: relative changes in abundance of branchial Na(+)/K (+)-ATPase and Na (+)/K (+)/2Cl (-) co-transporter in relation to osmoregulatory parameters

The present study was conducted to elucidate the osmoregulatory ability of the fish pearl spot (Etroplus suratensis) to know the scope of this species for aquaculture under various salinities. Juvenile pearl spot were divided into three groups and acclimated to freshwater (FW), brackish water (BW) or seawater (SW) for 15 days. The fish exhibited effective salinity tolerance under osmotic challenges. Although the plasma osmolality and Na(+), K(+) and Cl(-) levels increased with the increasing salinities, the parameters remained within the physiological range. The muscle water contents were constant among FW-, BW- and SW-acclimated fish. Two Na+/K+-ATPase α-isoforms (NKA α) were expressed in gills during acclimation in FW, BW and SW. Abundance of one isoform was up-regulated in response to seawater acclimation, suggesting its role in ion secretion similar to NKA α1b, while expression of another isoform was simultaneously up-regulated in response to both FW and SW acclimation, suggesting the presence of isoforms switching phenomenon during acclimation to different salinities. Nevertheless, NKA enzyme activities in the gills of the SW and FW individuals were higher (p < 0.05) than in BW counterparts. Immunohistochemistry revealed that Na(+)/K(+)-ATPase immunoreactive (NKA-IR) cells were mainly distributed in the interlamellar region of the gill filaments in FW groups and in the apical portion of the filaments in BW and SW groups. The number of NKA-IR cells in the gills of the FW-acclimated fish was almost similar to that of SW individuals, which exceeded that of the BW individuals. The NKA-IR cells of BW and SW were bigger in size than their FW counterparts. Besides, the relative abundance of branchial Na(+)/K(+)/2Cl(-) co-transporter showed stronger evidence in favor of involvement of this protein in hypo-osmoregulation, requiring ion secretion by the chloride cells. To the best of our knowledge, this is the first study reporting the wide salinity tolerance of E. suratensis involving differential activation of ion transporters and thereby suggesting its potential as candidate for fish farming under different external salinities.

Hashimoto's Thyroiditis and Medullary Carcinoma of Thyroid

Hashimoto's thyroiditis (HT) has been found to be associated with lymphoma, papillary carcinoma and Hürthle cell neoplasms of thyroid. In contrast, there are only a few reports of co-existence of HT with medullary carcinoma of thyroid. An overall prevalence of medullary carcinoma of only 0.35% has been reported in HT patients. Such a rare combination is being presented here. A 33 year old female presented with history of goiter for one year. Fine needle aspiration cytology (FNAC) of the swelling revealed cytological features suggestive of medullary carcinoma of thyroid. Histopathological examination of total thyroidectomy specimen revealed Hashimoto's thyroiditis along with medullary carcinoma of thyroid. Although Hashimoto's thyroiditis can uncommonly co-exist with thyroid neoplasm, its association with medullary carcinoma is extremely rare and hence being presented.

Pregnancy outcome in chronic myeloid leukemia patients on imatinib therapy

INTRODUCTION

Imatinib is a first-line therapy to treat chronic myeloid leukemia (CML) patients.

MATERIALS AND METHODS

We selected 22 CML cases of pregnancies and reported 9 accidental and 13 planned pregnancies that were on imatinib therapy. Willing female patients remaining in complete hematological, cytogenetic and major molecular responses for at least 2 years planned for pregnancy and were advised to stop imatinib for 1 month prior to conception and 3 months after conception (first trimester). Willing male patients stopped therapy 1 month prior to conception of their wives. In unplanned cases, all patients were in exposure to imatinib during conception. Twenty-two pregnancies resulted in seven male children and eight female children. There were three spontaneous abortions and four elective abortions along with one case of hypospadia and another one of mild hydrocephalus.

CONCLUSION

We may suggest that planned pregnancy during therapy may be encouraged but imatinib therapy in unplanned pregnancy can cause spontaneous abortion or congenital anomaly.

Chemoprevention gene therapy (CGT): novel combinatorial approach for preventing and treating pancreatic cancer

Pancreatic cancer remains one of the deadliest of all cancers despite aggressive surgical treatment combined with adjuvant radiotherapy and chemotherapy. Chemoresistance and radioresistance are the principal causes of failure of pancreatic cancer patients to respond to therapy. Conditionally replication competent adenovirus (CRCA)-based cancer gene therapy is an innovative strategy for treating cancers displaying inherent resistance to treatment. Limitations of current adenovirus (Ad)-based gene therapies for malignant tumors include lack of cancer-specificity, and effective and targeted delivery. To remedy this situation, CRCAs have been designed that express E1A, necessary for Ad replication, under the control of a cancer-specific progression elevated gene-3 promoter (PEG-Prom) with concomitant expression of an immunomodulatory cytokine, such as mda-7/IL-24 or interferon-γ (IFN-γ), under the control of a ubiquitous and strong cytomegalovirus promoter (CMV-Prom) from the E3 region. These bipartite CRCAs, when armed with a transgene, are called cancer terminator viruses (CTVs), i.e., Ad.PEG-E1A-CMV-mda-7 (CTV-M7) and Ad.PEG-E1A-CMV-IFN-γ (CTV-γ), because of their universal effectiveness in cancer treatment irrespective of p53/pRb/p16 or other genetic alterations in tumor cells. In addition to their selective oncolytic effects in tumor cells, the potent 'bystander antitumor' properties of MDA-7/IL-24 and IFN-γ embody the CTVs with expanded treatment properties for both primary and distant cancers. Pancreatic cancer cells display a "translational block" of mda-7/IL-24 mRNA, limiting production of MDA-7/IL-24 protein and cancer-specific apoptosis. Specific chemopreventive agents abrogate this "translational block" resulting in pancreatic cancer-specific killing. This novel chemoprevention gene therapy (CGT) strategy holds promise for both prevention and treatment of pancreatic cancers where all other strategies have proven ineffective.

Serum uric acid: an early indicator of oxidative stress in beta thalassemia population

Iron induced alteration in the redox balance is a major complication in the beta thalassemia major patients receiving regular blood transfusion. Variable degrees of association between uric acid level with the free iron and its storage form ferritin in thalassemic patients are suggested to play a significant role in this alteration by an unclear mechanism. In the present study, we made an effort to analyze the association of serum uric acid with oxidative stress and to evaluate the predictive value of serum iron, serum ferritin and serum uric acid level on oxidative stress induced lipid peroxidation in beta thalassemic patients. For this we assayed these parameters in 61 patients of β thalassemia major and 51 age and sex matched controls of a rural area of West Bengal. Serum TBARS, serum Uric acid, serum Ferritin and serum Iron levels were significantly higher in the patient group (p<0.001 for all of them). Significant correlations existed between serum levels of TBARS, Uric acid, Ferritin and Iron levels in the patient group whereas only serum TBARS levels showed significant correlation with serum iron level in the control group. Regression analysis revealed that uric acid levels have a better predictive value (β=0.3, p=0.001) than serum ferritin value (β=0.013, p=0.871) for indicating TBARS production.

Does follistatin gene have any direct role in the manifestation of polycystic ovary syndrome in Indian women?

BACKGROUND

Out of a panel of 37 candidate genes tested for linkage with polycystic ovary syndrome (PCOS), the strongest evidence of linkage was reported in the follistatin (FST) gene region. Subsequently, a couple of studies outside India investigated the FST gene for the presence of any mutations and its association with PCOS and the results were found to be largely inconsistent probably due to differences in the ethnic backgrounds and small sample sizes.

AIMS

To screen the FST gene for mutations and to establish their association pattern with PCOS among a large cohort of South Indian women.

SETTINGS AND DESIGN

Case-control study.

MATERIALS AND METHODS

PCOS cases were recruited according to the 2003 Rotterdam diagnostic criteria. All the exons of the FST gene were amplified and analyzed in all the cases and controls for the presence of mutations using polymerase chain reaction (PCR) and direct DNA sequencing.

RESULTS

A total of 549 women consisting of 250 PCOS cases and 299 controls were recruited for the study. No mutations were found in any of the exons of the FST gene in our Indian sample which is consistent with an earlier finding among the Asian women from Singapore. Although three of the four cohorts of Caucasian background studied earlier reported variants, none of them could establish a strong association with PCOS.

CONCLUSIONS

The occurrence of the exonic variants of FST gene seems to be dependent on the ethnic background of the subjects under study and its role in the PCOS pathophysiology cannot be established with hitherto available evidence.

Alterations in serum electrolytes, antioxidative enzymes and haematological parameters of Labeo rohita on short-term exposure to sublethal dose of nitrite

An experiment was conducted to study the effects of short-term exposure to sublethal levels of nitrite on electrolyte regulation, antioxidative enzymes and haematological parameters in Labeo rohita juveniles. The fishes were exposed to graded levels of nitrite (0-15 mg l(-1)) for different duration (0, 12, 24, 48 and 96 h). The 96-h LC(50) value for L. rohita (avg. wt, 66.5 ± 0.5 g) was found to be 11.28 mg l(-1). Activities of antioxidative enzymes (catalase and superoxide dismutase), acetylcholine esterase (AChE) and methaemoglobin reductase, serum electrolytes (sodium, potassium and chloride), haematological parameters and blood glucose level significantly varied (P < 0.05) in a dose-dependent manner. With increasing nitrite concentration and exposure period, a progressive reduction in the total erythrocyte count and haemoglobin were observed. With increase in nitrite concentration, a significant (P < 0.05) increase in activities was evidenced in catalase and superoxide dismutase in liver as well as gill, methaemoglobin reductase in blood, while progressive decline in AChE activity in brain was recorded. The serum sodium and chloride content showed a progressive decline, while potassium showed an increasing trend upon increase in nitrite concentration. The serum K(+) and Cl(-) after 96-h exposure demonstrated a linear relationship (Y = 0.221x + 2.542, R (2) = 0.938, P < 0.01 and Y = -5.760x + 129.5, R (2) = 0.952, P < 0.01, respectively) with nitrite concentrations. This study revealed that nitrite exposure causes alteration in all measured tissue enzymes, serum electrolytes and haematological parameters.

Heme binds to factor VIII and inhibits its interaction with activated factor IX

BACKGROUND

Heme is a redox active macrocyclic compound that is released upon tissue damage or hemorrhages. The extracellular release of large amounts of heme saturates scavenging heme-binding proteins. Free heme has been proposed to affect coagulation and has been co-purified with the factor VIII (FVIII)-von Willebrand factor (VWF) complex. The sites from which heme is released upon injury overlap with the sites to which FVIII is targeted for performing its hemostatic functions.

OBJECTIVES

To investigate the interaction of heme with FVIII and the consequence for the procoagulant activity of FVIII in vitro.

METHODS AND RESULTS

Heme bound to several sites on FVIII with high apparent affinity. Heme-binding inhibited FVIII procoagulant activity in a dose-dependent manner. FVIII inactivation in the presence of saturating amounts of heme implicated a reduced interaction of FVIII with activated FIX, as shown by ELISA, surface plasmon resonance and fluorescence quenching. Heme-mediated inactivation of FVIII was prevented by VWF, but not by human serum albumin, a heme-binding protein known for its protective activity in hemolytic conditions.

CONCLUSIONS

Our data identify FVIII as a novel heme-binding protein. Occupation of high affinity heme-binding sites on FVIII at low concentrations of free heme did not inactivate FVIII. Conversely, large molar excesses of heme over FVIII, which correspond to conditions of extensive heme release, inhibited FVIII activity in vitro. It remains to be demonstrated whether, under such conditions, heme-mediated modulation of the activity of FVIII plays some role in the regulation of coagulation.

Aβ(1-42) assembly in the presence of scyllo-inositol derivatives: identification of an oxime linkage as important for the development of assembly inhibitors

To identify a lead skeleton structure for optimization of scyllo-inositol-based inhibitors of amyloid-beta peptide (Aβ) aggregation, we have synthesized aldoxime, hydroxamate, carbamate, and amide linked scyllo-inositol derivatives. These structures represent backbones that can be readily expanded into a wide array of derivatives. They also provide conservative modifications of the scyllo-inositol backbone, as they maintain the display of the equatorial polar atoms, preserving the stereochemical requirement necessary for maximum inhibition of Aβ(1-42) fiber formation. In addition, a reliable work plan for screening derivatives was developed in order to preferentially identify a backbone(s) structure that prevents fibrillogenesis and stabilizes nontoxic small molecular weight oligomers, as we have previously reported for scyllo-inositol. In the present studies, we have adapted a high throughput ELISA-based oligomerization assay followed by atomic force microscopy to validate the results screen compounds. The lead compounds were then tested for toxicity and ability to rescue Aβ(1-42) induced toxicity in vitro and the affinity of the compounds for Aβ(1-42) compared by mass spectrometry. The data to suggest that compounds must maintain a planar conformation to exhibit activity similar to scyllo-inositol and that the oxime derivative represents the lead backbone for future development.