Prevalence of obstructive sleep apnea syndrome in a cohort of 1,207 children of southern Italy

STUDY OBJECTIVE

To determine the prevalence of sleep-related breathing disturbances in a large cohort of school-aged and preschool-aged children of Southern Italy.

DESIGN AND SETTING

This cross-sectional prevalence study was designed in two phases: a screening phase aimed to identify symptomatic children from a cohort of 1,207 by a self-administered questionnaire, and an instrumental phase for the definition of sleep-related disorders.

PATIENTS AND METHODS

One thousand two hundred seven children were screened by a self-administered questionnaire. There were 612 female children (51%) and 595 male children (mean age, 7.3 years; range, 3 to 11 years). According to answers, children were classified in three groups: nonsnorers, occasional snorers, and habitual snorers. All habitual snoring children underwent a polysomnographic home evaluation, and those with an oxygen desaturation index > 2 were considered for nocturnal polygraphic monitoring (NPM). Children with an apnea/hypopnea index > 3 received a diagnosis of obstructive sleep apnea syndrome (OSAS).

RESULTS

A total of 895 questionnaires (74.2%) were returned and scored; 710 children (79.3%) were identified as nonsnorers, 141 children (15.8%) were identified as occasional snorers, and 44 children (4.9%) were identified as habitual snorers. The percentage of male children who were habitual snorers was higher than the percentage of female children who were habitual snorers (6.1% vs 3.7%, respectively; p < 0.09). OSAS was diagnosed in nine children by NPM.

CONCLUSION

The lower limit of prevalence of OSAS in childhood is 1% (95% confidence interval [CI], 0.8 to 1.2). If we add the five children who underwent adenoidectomy and/or tonsillectomy because of worsening clinical condition and the two children who were shown to have evidence of OSAS on domiciliary oximetry, then the prevalence is 1.8% (higher limit of prevalence; 95% CI, 1.6 to 2.0).

Retroperitoneal endometriosis causing unilateral hip pain

BACKGROUND

The usual symptoms of endometriosis are secondary dysmenorrhea, dyspareunia, and infertility, but when located in the retroperitoneal space, it might have atypical symptoms that delay diagnosis and postpone therapy.

CASE

A young nulligravida presented with secondary dysmenorrhea and concurrent cyclic hip pain. Recent laparoscopy was reportedly normal. Computed tomography (CT)-directed percutaneous needle biopsy of a retroperitoneal mass showed endometriosis. Laparotomy with retroperitoneal dissection removed the endometriosis, and operative arthroscopy released strictured hip tendons improving her hip pain and limp.

CONCLUSION

Retroperitoneal endometriosis presenting as hip pain was diagnosed by CT-guided percutaneous needle biopsy permitting removal by a multidisciplinary surgical approach.

Influence of soybean trypsin inhibitor on small bowel enzyme activities during rotavirus infection in malnourished infant mice

Rotavirus (RV) is considered to be one of the major causes of acute episodic diarrhoea throughout the world. This study was undertaken to investigate the effect of soybean trypsin inhibitor (TI) on brush-border enzymes during rotavirus infection in protein energy malnourished (PEM) infant mice. Animals were divided into 4 groups, namely controls, PEM, PEM+RV and PEM+RV+TI (n = 36 each). Group 1 and 2 animals were orally inoculated with 50 microl of normal saline each. Group 3 animals were orally inoculated with 50 microl of 100 ID50 dose of RV stock each. Group 4 animals were similarly inoculated with 0.6 mg TI/g body weight along with 50 microl of RV stock each. Animals were examined daily for diarrhoea and their body weight was recorded on alternate days postinoculation (dpi). Animals were killed by cervical dislocation after being given light chloroform anesthesia on 0, 1, 3, 5, 7 and 10 dpi. Small intestines were excised and homogenized in normal saline. Proteins, gammaglutamyl transpeptidase, alkaline phosphatase and disaccharidases were estimated in jejunum and ileum. Body weight was significantly reduced in PEM animals and with RV infection. Histologically, focal areas of vacuolar degeneration of lining epithelium were seen in RV-infected animals. Disaccharidases and other enzyme activities were decreased significantly in the PEM group compared to healthy controls and further depressed with RV infection in malnourished animals as compared to non-infected PEM. The enzyme activities were restored in animals receiving TI along with RV compared to the group receiving RV without TI. With the administration of soybean TI, the activities of disaccharidases, alkaline phosphatase, gammaglutamyl transpeptidase and intestinal architecture were restored showing a protective effect in PEM during RV infection.

Protection against rotavirus diarrhoea in mice by trypsin inhibitor

To investigate the role of soyabean trypsin inhibitor (TI) during rotavirus (RV) diarrhoea, changes in enzyme activities of six relevant mucosal enzymes (lactase, sucrase, maltase, trehalase, glucoamylase and alkaline phosphatase) were assayed following inoculation of suckling mice with EB rotavirus (serotype 3) along with the TI and compared with the age-matched healthy control mice. The animals were divided into three groups i.e. group 1 (controls), group 2 (RV inoculated) and group 3 (RV + TI inoculated and sacrificed under light anaesthesia on 0, 1, 3, 5, 7 and 10 day post inoculation (dpi). Then intestines were excised and divided into two parts (jejunum and ileum). They were separately homogenized in 0.9% cold normal saline and activities of mucosal enzyme were measured. Alkaline phosphatase and disaccharidases were found to be decreased significantly in RV inoculated animals in both the anatomical portions of small intestine of mice. These enzyme levels were restored with the administration of TI i.e. in group 3 and became comparable to the controls in both intestinal portions. These studies suggest that activity of intestinal enzymes which are important in digestive absorptive functions of small intestine were restored with the addition of TI whengiven to infant mice showing its protective efficacy during rotavirus infection.

Effect of rotavirus infection on lipid composition and glucose uptake in infant mouse intestine

OBJECTIVE

To study the effect of rotavirus infection on lipid composition and glucose uptake in small intestine of infant mice.

METHODS

Thirty six 7-day old balb/c mice were given 50 mL (100 ID50) rotavirus suspension orally; 36 control animals received only normal saline. Body weight of animals was recorded. Six animals in each group were sacrificed on days 0, 1, 3, 5, 7 and 10 post-inoculation (pi). Intestines were removed, everted and homogenized in ice-cold saline. Cholesterol and phospholipid content, glucose uptake and alkaline phosphatase in the jejunum and ileum were determined.

RESULTS

Rotavirus infection led to a significant decrease in body weight with on days 3 and 5 pi as compared to controls, and to an increase in cholesterol and phospholipid content of the intestine. Uptake of glucose also increased significantly. Alkaline phosphatase activity was significantly reduced on days 3 and 5 pi as compared to controls.

CONCLUSION

This study provides characterization of the lipid composition and uptake of glucose in infant mice small intestinal segments during rotavirus infection.

Influence of resin cross-linking on solid-phase chemistry

A range of PS-DVB resins were prepared by suspension polymerization with styrene, p-chloromethyl styrene, and DVB. Yields of polymerization increased (from 40% to almost 80%) with increasing cross-linking. The beads exhibited the expected swelling characteristics, with the 0.3% resin swelling to almost 9 times its dry volume in CHCl3. Kinetics of cleavage of the dye Methyl Red from the range of Rink linked resins showed rate enhancements of up to 500% between the 6.0 and the 0.3% cross-linked resins. Total synthesis of Kawaguchipeptin B was carried out on the resins, and their performance during the syntheses was investigated. Contrary to expectations, the purities of the cyclic peptide product increased with increasing resin cross-linking doubling from the 0.3-6.0% resin. A Suzuki reaction showed the half-lives of reaction increased with increasing resin cross-linking with an 11-fold increase in half-life between the 0.3-2.7% resin. Surprisingly, we observed very little reaction in the case of the 3.0 and 6.0% cross-linked resins.

Synergistic interaction of adrenaline and histamine in human platelet aggregation is mediated through activation of phospholipase, map kinase and cyclo-oxygenase pathways

This study was conducted to examine the mechanism(s) of synergistic interaction of histamine- and adrenaline-mediated human platelet aggregation. We found that platelet aggregation mediated by subthreshold concentrations of histamine (1-4 microm) plus adrenaline (0.5-2 microm) is inhibited by both an alpha(2)-adrenoceptor blocker (yohimbine) and a histamine (H1) receptor antagonist (diphenhydramine). In examining the role of the downstream signalling pathway, we found that such an interaction is inhibited by the calcium channel blockers verapamil and diltiazem. However, platelet aggregation by adrenaline plus histamine was inhibited by very low concentrations of the phospholipase C (PLC) inhibitor, U73122 (IC(50)= 1.2 microm), the MEK inhibitor, PD98059 (IC(50)= 1.1 microm) and the cyclo-oxygenase (COX) inhibitor, indomethacin (IC(50)= 7 microm). However the inhibition of receptor tyrosine kinase, protein kinase C and phosphatidylinositol 3-kinase by genistien, chelerythrine and wortmannin, respectively, had no significant effect on aggregation. Similarly the nitric oxide donor (SNAP) had no effect on this synergism. These data suggest that the synergistic effect of histamine and adrenaline during human platelet aggregation is receptor mediated and involves activation of PLC, COX and MAP kinase signalling pathways.

Combination nucleoside analog reverse transcriptase inhibitor(s) plus nevirapine, nelfinavir, or ritonavir in stable antiretroviral therapy-experienced HIV-infected children: week 24 results of a randomized controlled trial--PACTG 377. Pediatric AIDS Clinical Trials Group 377 Study Team

One hundred eighty-one antiretroviral-experienced, protease inhibitor-naive, clinically stable HIV-infected children between 4 months and 17 years of age were randomly assigned to receive one of four combination regimens to evaluate the change in plasma HIV RNA, safety, and tolerance when changing antiretroviral therapy to a protease inhibitor-containing combination regimen. All four regimens contained stavudine; in addition children received nevirapine plus ritonavir, lamivudine plus nelfinavir, nevirapine plus nelfinavir, or lamivudine plus nevirapine plus nelfinavir. Twelve additional children chose to receive stavudine plus lamivudine plus nelfinavir, with nelfinavir given bid, rather than tid as for the main regimens. Overall, 51% (89/176; 95% CI 43-58%) of the children on the randomized portion of the study had an HIV RNA response (< or =400 copies/ml) on at least two of the three HIV RNA determinations taken at Weeks 8, 12, and 16. At Week 24 the proportion of children with an HIV RNA response still on initial therapy was 47% (83/176; 95% CI 40-55%) and ranged from 41 to 61% for the four randomized treatment arms. Rash was frequently seen (27%) on the treatment arms containing nevirapine. At Week 24 64% (7/11, 95% CI 31-89%) of the children on the bid nelfinavir combination regimen were still on initial therapy with an HIV RNA response as compared with 46% (23/50; 95% CI 32-61%) on the corresponding tid nelfinavir combination regimen. A change in antiretroviral therapy to a protease inhibitor-containing regimen was associated with a virological response rate of approximately 50% for this patient population.

Intestinal pseudo-obstruction due to neurofibromatosis responding to cisapride

Gastrointestinal involvement in neurofibromatosis presenting with mechanical obstruction, hemorrhage or intussusception is known. Small bowel dysmotility and intestinal pseudo-obstruction due to neurofibromatosis is rare. A 23-year-old man with classical neurofibromatosis presented with intermittent episodes of intestinal pseudo-obstruction, small bowel bacterial overgrowth and steatorrhea. The patient had good symptomatic improvement with cisapride.

Synergistic activation of yeast-expressed rat androgen receptor by modulators of protein kinase-A

We have employed a yeast (Saccharomyces cerevisiae) based rat androgen receptor expression system to examine the cross-talk between different signalling pathways. We report here the synergistic modulation of androgen regulated transcriptional activation of beta-galactosidase reporter activity by the activators of protein kinase-A, like forskolin and 8-bromo-cyclic AMP. A similar ligand-dependent enhancement of reporter activity compared to a DHT treated control has been noticed with okadaic acid, which is a potent inhibitor of protein phosphatase. The activation could be blocked by protein kinase-A/C inhibitor, H7. Forskolin treatment neither altered levels of receptor mRNA nor [3H]R1881 binding to the receptor. Although it promotes binding of receptor to an androgen response element, forskolin was unable to activate subsequent interaction with the transcription machinery in the absence of androgen. Additionally, the synergistic actions of these activators were independent of the degree of androgen response element occupancy. Anti-androgens, cyproterone acetate and flutamide, which failed to exhibit antagonistic behaviour with yeast expressed receptor, were able to antagonize only the forskolin mediated augmentation of reporter activity. Finally, analyses of mutants established the role of DNA and steroid binding domains of receptor for this synergism.

Influence of the CCR2-V64I polymorphism on human immunodeficiency virus type 1 coreceptor activity and on chemokine receptor function of CCR2b, CCR3, CCR5, and CXCR4

The chemokine receptors CCR5 and CXCR4 are used by human immunodeficiency virus type 1 (HIV-1) in conjunction with CD4 to infect cells. In addition, some virus strains can use alternative chemokine receptors, including CCR2b and CCR3, for infection. A polymorphism in CCR2 (CCR2-V64I) is associated with a 2- to 4-year delay in the progression to AIDS. To investigate the mechanism of this protective effect, we studied the expression of CCR2b and CCR2b-V64I, their chemokine and HIV-1 coreceptor activities, and their effects on the expression and receptor activities of the major HIV-1 coreceptors. CCR2b and CCR2b-V64I were expressed at similar levels, and neither molecule affected the expression or coreceptor activity of CCR3, CCR5, or CXCR4 in cotransfected cell lines. Peripheral blood mononuclear cells (PBMCs) from CCR2-V64I heterozygotes had normal levels of CCR2b and CCR5 but slightly reduced levels of CXCR4. CCR2b and CCR2b-V64I functioned equally well as HIV-1 coreceptors, and CCR2-V64I PBMCs were permissive for HIV-1 infection regardless of viral tropism. The MCP-1-induced calcium mobilization mediated by CCR2b signaling was unaffected by the polymorphism, but MCP-1 signaling mediated by either CCR2b- or CCR2-V64I-encoded receptors resulted in heterologous desensitization (i.e., limiting the signal response of other receptors) of both CCR5 and CXCR4. The heterologous desensitization of CCR5 and CXCR4 signaling by both CCR2 allele receptor types provides a mechanistic link that might help explain the in vivo effects of CCR2 gene variants on progression to AIDS as well as the reported antiviral activity of natural CCR2 ligands.

HIV prevention among injecting drug users: responses in developing and transitional countries

OBJECTIVE

Human immunodeficiency virus (HIV) infection associated with injecting drug use has been reported in at least 98 countries and territories worldwide. There is evidence that new epidemics are emerging in different regions, including Eastern Europe, Latin American, and the eastern Mediterranean. The authors provide a global overview of the situation of HIV infection associated with injecting drug use and responses that have been implemented in various developing and transitional countries.

METHODS

Although there has been extensive documentation of the extent and nature of of HIV infection associated with injecting drug use in many developed countries and the various interventions implemented in those countries, there is very limited information on the situation in developing and transitional countries. This chapter brings together information from a broad range of sources, including published literature; "gray" or "fugitive" literature; data collected by the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations International Drug Control Programme (UNDCP); personal communications; and direct observation by the authors. The authors have traveled extensively to a wide range of developing and transitional countries and have accessed information not readily available to the international research community.

RESULTS

A wide range of HIV prevention strategies targeting injecting drug users (IDUs) has been implemented in developing countries and countries in transition. Interventions include opioid substitution pharmacotherapy, needle syringe exchange and distribution, condom and bleach distribution, outreach to IDUs, peer education programs, and social network interventions. In some communities, completely new models of intervention and service delivery have developed in response to specific local needs and limitations.

CONCLUSIONS

Although empirical data may currently be lacking to demonstrate the effectiveness of may HIV prevention programs targeting IDUs in developing and transitional countries, there is evidence that innovative HIV prevention initiatives are being implemented and sustained in a wide range of sociocultural settings.

Activation of rat androgen receptor by androgenic ligands is unaffected by antiandrogens in Saccharomyces cerevisiae

The E. coli lacZ has been utilized as a reporter to evaluate ligand-mediated activation of the rat androgen receptor (AR) in Saccharomyces cerevisiae strain YCR1. beta-galactosidase activity was androgen-specific and was found to be inducible approximately 260-fold by dihydrotestosterone (DHT), testosterone and R1881. None of the antiandrogens tested was able to antagonize the DHT-dependent induction of beta-galactosidase activity. In the gel retardation assay, exposure of the receptor to DHT in vitro led to the formation of a protein-DNA complex that was not detected in yeast extracts unexposed to hormone. However, activation of AR by a steroidal (cyproterone acetate) and a non-steroidal antiandrogen (flutamide) either alone or in combination with DHT also results in a similar migration pattern. Additionally, LEM1, the ABC transporter that selectively modulates the biological potency of steroids in yeast, although operative in YCR1, was not responsible for antiandrogen resistance. These results thus indicate the involvement of other non-receptor factor(s) in mediating the effect of antiandrogens in yeast.

CXCR-4 is expressed by primary macrophages and supports CCR5-independent infection by dual-tropic but not T-tropic isolates of human immunodeficiency virus type 1

Primary macrophages are infected by macrophage (M)-tropic but not T-cell line (T)-tropic human immunodeficiency virus type 1 (HIV-1) strains, and CCR5 and CXCR-4 are the principal cofactors utilized for CD4-mediated entry by M-tropic and T-tropic isolates, respectively. Macrophages from individuals homozygous for an inactivating mutation of CCR5 are resistant to prototype M-tropic strains that depend on CCR5 but are permissive for a dual-tropic isolate, 89.6, that can use both CCR5 and CXCR-4, as well as CCR2b, CCR3, and CCR8. Here we show that 89.6 entry into CCR5-deficient macrophages is blocked by an anti-CXCR-4 antibody and by the CXCR-4-specific chemokine SDF but not by the ligands to CCR2b or CCR3. Reverse transcription-PCR demonstrated expression of CXCR-4 but not CCR3 or CCR8 in macrophages, while CCR2b was variable. Macrophage surface expression of CXCR-4 was confirmed by immunofluorescence staining and flow cytometry. Thus, CXCR-4 is expressed by primary macrophages and functions as a cofactor for entry by dual-tropic but not T-tropic HIV-1 isolates, and macrophage resistance to T-tropic strains does not result from a lack of the T-tropic entry cofactor CXCR-4. Since CXCR-4 on macrophages can be used by some but not other isolates, these results indicate that HIV-1 strains differ in how they utilize chemokine receptors as cofactors for entry and that the ability of a chemokine receptor to mediate HIV-1 entry differs, depending on the cell type in which it is expressed.

Classical light scattering quantitation of protein aggregates: off-line spectroscopy versus HPLC detection

This paper describes the development and validation of a new off-line approach to quantitate both covalent and noncovalent, in-solution aggregates present in protein formulations and compares the new assay to established HPLC methods. This off-line analysis is well suited for use in QC release testing, formulation development and stability indicating applications. An inexpensive, continuous source HPLC fluorometer has been adapted with the addition of second order filters for use as a sensitive right-angle scatterometer which can determine the molecular weight of protein aggregates in solution. When used as an HPLC detector, right-angle light scattering is a sensitive method which can determine the molecular weight of peaks separable by HPLC, thus discriminating between monomers of different conformations and aggregates. The weight-averaged molecular weight of aggregate peaks can be calculated with system calibration, yielding the average number of monomers per aggregate. If the protein concentration is high enough for an adequate signal, the off-line technique of right-angle light scattering of protein formulations has advantages of convenience and speed over the HPLC approach. Samples are placed in standard fluorometer cuvettes and toluene is used as a calibrator. Data are presented which show the off-line (static) method to be extremely rapid, rugged and precise. The accuracy of this approach is demonstrated through cross-validation to traditional GPC analysis of protein aggregate distributions. This non-invasive light scattering approach is particularly useful when non-covalent protein aggregation is reversible and readily altered by chromatographic separations typically used for characterizing aggregates.

Discontinuation of long-term transfusion therapy in patients with sickle cell disease and stroke

Long-term transfusion therapy in patients with sickle cell disease and stroke markedly decreases the risk of stroke recurrence. However, it is not known how long the transfusions should be continued. Published reports have documented a high risk of stroke recurrence after stopping transfusion. We report on nine consecutive patients with sickle cell disease and stroke whose long-term transfusion therapy was discontinued and in whom no ischemic strokes developed during 80.75 patient years of follow-up.

Homocysteine in sickle cell disease: relationship to stroke

PURPOSE

The risk factors and pathophysiology of stroke and other serious complications of sickle cell disease (SCD) are poorly defined. Hyperhomocysteinemia has recently been identified as a risk factor for stroke and other vascular diseases in the general population, however its role in SCD has not been investigated.

PATIENTS AND METHODS

We measured serum homocysteine and red cell folate levels in 100 patients with SCD, including 16 patients with stroke. A disease severity score was determined for all patients and those without stroke were classified into mild (44 patients) or severe (40 patients) disease groups.

RESULTS

Homocysteine levels for the stroke group (median 13.3 mumol/L, mean 13.1 +/- 4.3 mumol/L) were significantly higher than those in patients without stroke (median 9.7 mumol/L, mean 10.7 mumol/L) (P < 0.02), and on multiple regression analysis homocysteine level was independently correlated with stroke (P < 0.026). Homocysteine and folate levels were inversely correlated (r = -0.41, P < 0.00005). Using logistic regression, the odds ratio for stroke in patients with homocysteine levels above the median (10.1 mumol/L) was 3.5 in this group of patients (95% confidence interval 1.1 to 11.9).

CONCLUSION

High homocysteine levels may be a risk factor for development of stroke in SCD patients. The role of homocysteine in the pathogenesis of stroke in SCD needs to be examined in a longitudinal, prospective study.

Study of oxidative-stress in rifampicin-induced hepatic injury in growing rats with and without protein-energy malnutrition

1. Rifampicin (RMP) induced hepatic injury was investigated in growing rats. The interaction of moderate and severe protein-energy malnutrition (PEM) was also investigated. 2. Status of oxidative/antioxidative profile was studied by the mechanistic approach, to enumerate the nature of injury. 3. Successful hepatic injury in rats was produced by giving intraperitoneal injection of RMP (50 mg/kg/day). 4. Hepatic lipid peroxidation was significantly increased in all the RMP treated rats. 5. Superoxide dismutase, catalase and glutathione peroxidase activities in the hepatic tissue decreased with RMP treatment. 6. Hepatic thiols represented as total and protein-bound thiols, showed significant elevation, whereas the non protein thiols remain unchanged with RMP treatment. 7. Glutathione-S-transferases also showed significant elevation against 1,2-dichloro-4 nitrobenzene (DCNB) and ethacrynic acid (EA) as substrates. 8. The oxidative/antioxidative profile was observed to be more severely affected with coexistence of malnutrition. 9. Histopathological correlation showed an additional fatty infiltration of hepatocytes with coexistence of malnutrition. 10. Thus, in conclusion, it can be speculated that an altered oxidative/antioxidative profile is the closely associated with production of RMP induced hepatic injury.

Role of CCR5 in infection of primary macrophages and lymphocytes by macrophage-tropic strains of human immunodeficiency virus: resistance to patient-derived and prototype isolates resulting from the delta ccr5 mutation

The alpha-chemokine receptor fusin (CXCR-4) and beta-chemokine receptor CCR5 serve as entry cofactors for T-cell (T)-tropic and macrophage (M)-tropic human immunodeficiency virus type 1 (HIV-1) strains, respectively, when expressed with CD4 in otherwise nonpermissive cells. Some M-tropic and dual-tropic strains can also utilize other beta-chemokine receptors, such as CCR2b and CCR3. A mutation of CCR5 (delta ccr5) was recently found to be common in certain populations and appears to confer protection against HIV-1 in vivo. Here, we show that this mutation results in a protein that is expressed intracellularly but not on the cell surface. Primary CD4 T cells from delta ccr5 homozygous individuals were highly resistant to infection with prototype M-tropic HIV-1 strains, including an isolate (YU-2) that uses CCR5 and CCR3, but were permissive for both a T-tropic strain (3B) and a dual-tropic variant (89.6) that uses CXCR-4, CCR5, CCR3, or CCR2b. These cells were also resistant to M-tropic patient isolates but were readily infected by T-tropic patient isolates. Primary macrophages from delta ccr5 homozygous individuals were also resistant to infection with M-tropic strains, including YU-2, but the dual-tropic strain 89.6 was able to replicate in them even though macrophages are highly resistant to CXCR-4-dependent T-tropic isolates. These data show that CCR5 is the essential cofactor for infection of both primary macrophages and T lymphocytes by most M-tropic strains of HIV-1. They also suggest that CCR3 does not function for HIV-1 entry in primary lymphocytes or macrophages, but that a molecule(s) other than CCR5 can support entry into macrophages by certain virus isolates. These studies further define the cellular basis for the resistance to HIV-1 infection of individuals lacking functional CCR5.

Thyroid dysfunction in HIV-infected children: is L-thyroxine therapy beneficial?

PURPOSE

To assess thyroid function in symptomatic HIV-infected infants and children with failure to thrive and to evaluate clinical response in patients with hyperthyrotropinemia to levothyroxine.

METHODS

We evaluated 11 children (mean age: 1.5 years; males = 5, females = 6) with HIV infection and failure to thrive (weight and height > 2 SD below the mean) for presence of hypothyroidism. Thyroid-stimulating hormone (TSH) and thyroxine (T4) were measured. Four children with high basal TSH and one child with a normal basal TSH underwent the Thyrotropin-releasing hormone (TRH) stimulation test as well. Four children received treatment with L-thyroxine.

RESULTS

Eight of the 11 children had high basal TSH levels. All patients had normal or increased T4 values. The TRH stimulation test showed an exaggerated response in all four patients with high basal TSH values and a normal response in one patient with normal basal THS values. All four patients who received treatment with L-thyroxine showed normalization of the TSH. Increased growth velocity was noted in 3 of 4 patients. The fourth patient died within two weeks following initiation of therapy for overwhelming candida sepsis. The autopsy of this patient showed atrophy of the thyroid gland. Two of the four patients with high TSH levels, who did not receive L-thyroxine, died; the other two did not show any improvement in their height z scores. Two patients with a high TSH also had high thyroid-binding hormone (TBG) levels. Both patients with the high TBG died within 2 to 3 months of the study.

CONCLUSIONS

Hypothyroidism as indicated by elevated basal TSH and abnormal TRH response was common in the HIV-infected children in this study and may have contributed to failure of growth in these children. Replacement therapy resulted in correction of abnormal TSH and improvement of height z scores during the period of observation. The significance of these findings needs to be confirmed in a larger prospective study.

Protein-energy malnutrition and oxidative injury in growing rats

1. Weaning rats were fed ad libitum isocaloric diets containing 5% and 20% casein based proteins. 5% protein diet was protein deficient diet. Pair fed rats with the 5% protein group were maintained simultaneously on 20% protein diet but the amount restricted to the amount taken up by PEM group. 2. Glutathione, antioxidative enzymes, lipid peroxidation and histopathological studies in liver and only glutathione and antioxidative enzymes in blood were carried out. 3. Rats fed the 5% protein diet developed a severe protein energy malnutrition (PEM) whereas those on pair-fed diet developed mild to moderate PEM. 4. Glutathione related thiols superoxide dismutase, glutathione peroxidase, catalase and glutathione-Stransferase with (1 Chloro 2,4-dinitro benzene (CDNB) substrate) were decreased in liver with concomitant increase of lipid peroxidation in severe PEM. In blood glutathione, glutathione peroxidase and catalase were decreased while superoxide dismutase was increased in severe PEM group. 5. Mild to moderate PEM (pair-fed group) also resulted in similar changes in liver except glutathione peroxidase, lipid peroxidation in liver and superoxide dismutase in blood. 6. Hepatic injury was detectable only in the severe PEM group. 7. Oxidative-stress and hepatic injury occurred in severe PEM and to a lesser degree in mild to moderate PEM.

Involvement of an efflux system in mediating high level of fluoroquinolone resistance in Mycobacterium smegmatis

A wild type strain of Mycobacterium smegmatis mc2 155 was serially adapted to 64 fold of minimal inhibitory concentration of an antimycobacterial agent, ciprofloxacin. This clone (CIPr) exhibited cross resistance to ofloxacin and ethidium bromide. The rate of drug efflux was accelerated in CIPr compared to the wild type strain. Verapamil, a calcium channel blocker, enhanced the drug accumulation in CIPr by diminishing the efflux and thus reversed the resistant phenotype. Additionally, a missense mutation was detected in the quinolone resistance determining region of the DNA-gyrase A subunit of CIPr. Taken together, these results suggest that drug efflux plays a major role in conferring such a high level of resistance in CIPr, in addition to the mutation in the DNA-gyrase locus.

Resistance to HIV-1 infection in caucasian individuals bearing mutant alleles of the CCR-5 chemokine receptor gene

HIV-1 and related viruses require co-receptors, in addition to CD4, to infect target cells. The chemokine receptor CCR-5 (ref.1) was recently demonstrated to be a co-receptor for macrophage-tropic (M-tropic) HIV-1 strains, and the orphan receptor LESTR (also called fusin) allows infection by strains adapted for growth in transformed T-cell lines (T-tropic strains). Here we show that a mutant allele of CCR-5 is present at a high frequency in caucasian populations (allele frequency, 0.092), but is absent in black populations from Western and Central Africa and Japanese populations. A 32-base-pair deletion within the coding region results in a frame shift, and generates a non-functional receptor that does not support membrane fusion or infection by macrophage- and dual-tropic HIV-1 strains. In a cohort of HIV-1 infected caucasian subjects, no individual homozygous for the mutation was found, and the frequency of heterozygotes was 35% lower than in the general population. White blood cells from an individual homozygous for the null allele were found to be highly resistant to infection by M-tropic HIV-1 viruses, confirming that CCR-5 is the major co-receptor for primary HIV-1 strains. The lower frequency of heterozygotes in seropositive patients may indicate partial resistance.

Declining risk for HIV among injecting drug users in Kathmandu, Nepal: the impact of a harm-reduction programme

OBJECTIVE

To measure changes in self-reported risk behaviour for HIV infections and HIV seroprevalence among injecting drug user (IDU) clients of an outreach harm-reduction programme in Kathmandu, Nepal.

METHODS

The Lifesaving and Lifegiving Society (LALS) of Kathmandu began providing sterile injecting equipment and education to Nepalese IDU in 1991. A sample of these IDU were interviewed and tested for HIV each year from 1991 through 1994.

RESULTS

Indicators of unsafe injecting fell, as knowledge of HIV rose more in 1994 for those who had been in touch with LALS for longer. Indicators of unsafe sex did not change. HIV seroprevalence remained low, 1.6% in 1991 and 0% in 1994.

CONCLUSION

We conclude that programmes for the prevention of HIV spread among IDU are possible and effective in Asia, and are urgently needed.

Mild-to-moderate malnutrition and small intestine of young rhesus monkeys

The effect of severe malnutrition and protein deficiency on small intestine has been documented, but the literature on the effect of mild-to-moderate protein-energy malnutrition (PEM) on small intestine is scant. Mild-to-moderate PEM is most prevalent in India. Twenty-four young rhesus monkeys weighing 1.5-2.0 kg were divided into two groups, control and experimental. Mild-to-moderate PEM was induced in the experimental group by giving half of the required normal diet providing 2.42 g protein.kg-1.day-1 and 55 kcal.kg-1.day-1. Body weight, serum protein, and D-xylose were measured before starting the experiment, at PEM stage, and after rehabilitation. Experimental monkeys representing group I were killed after a 25-30% reduction in body weight along with control group 1 animals at 12 wk. The rest of the experimental animals were rehabilitated for another 10-12 wk and killed along with their respective controls (control group 2). Brush-border membrane vesicles were prepared from three parts of the small intestine. Viable vesicles were used for the uptake of [U-14C]L-proline. Alkaline phosphatase and enterokinase were also measured. Uptake of L-proline amino acid and the activity of both enzymes were found to be decreased significantly in the PEM group; a D-xylose test was abnormal. All animals recovered after rehabilitation. These results indicate that even mild-to-moderate malnutrition affects the absorptive and digestive capacity of the brush border of the small intestine, which reversed back on rehabilitation.

Assessment of optimal dose of lactose for lactose hydrogen breath test in Indian adults

To evaluate the possibility of using a 12.5 g or 25 g oral dose of lactose for hydrogen breath test for diagnosis of lactose intolerance instead of the usual 50 g dose. 35 patients with non-ulcer dyspepsia and an abnormal 50 g lactose breath hydrogen of more than 20 ppm over the base line were retested using 12.5 g and 25 g lactose. 32 (91.4%) and 15 (42.8%) of these 35 patients had an abnormal hydrogen breath test using 25 g (p = ns compared to 50 g dose) and 12.5 g (p < 0.001) lactose doses respectively. This study reveals that it may be possible to use a 25 g lactose dose instead of a 50 g dose for the lactose hydrogen breath test.

Aetiology and dynamics of dyspepsia in Shimla: a study of 500 patients

Dyspepsia is a frequent presenting symptom amongst patients attending medical clinics worldwide. However their aetiologies differ geographically. The present study was conducted to identify the aetiologies of dyspepsia of our centre and to determine their clinical characteristics. Five hundred consecutive patients presenting with dyspepsia were studied at our Institute. All patients underwent detailed structured questionnaire, stool examination, upper gastrointestinal endoscopy, ultrasound scan of upper abdomen and sigmoidoscopy when necessary. Among 500 patients, 34% suffered from essential dyspepsia, 28% had peptic ulcer, 19.2% had cholelithiasis, 10.8% had irritable bowel syndrome and 6% had gastro-oesophageal reflux. Significantly more patients with peptic ulcer experienced night paints, pain relief with food, milk, antacids or H2 receptor antagonists and periodic pain. In patients with essential dyspepsia, pain was continuous, mild to moderate in intensity, aggravated by food or alcohol, without relief with milk, antacids or H2 receptor antagonists and night pains were absent in them.

Enhancement of pain control with ketorolac tromethamine in patients with sickle cell vaso-occlusive crisis

Twenty one patients with sickle cell disease admitted to the hospital with the pain of vaso-occlusive crisis (VOC) were treated by continuous IV infusion of ketorolac or normal saline for up to 5 days. All patients received supplemental IM injections of meperidine, 100 mg, as necessary, but not more frequently than every 3 hr. Over the 5 days the ketorolac treated patients (KT) required 33% less meperidine than did the placebo treated patients (PL), P = 0.04, and had significantly better pain relief as assessed by categorical, visual analog, and pain relief scales. By the end of 5 days infusions had been discontinued in six KT and one PL. The time to discontinuation of the infusion was significantly shorter in KT, (P = 0.009). The median duration of hospital stay from the start of treatment was 3.3 days for KT and 7.2 days for PL, P = 0.027. Adverse events were mainly related to the digestive system. This study showed that continuous infusion of ketorolac significantly reduced total meperidine requirement and that the analgesia produced by this combination was superior to that produced by meperidine alone. Further evaluation of this drug in the management of sickle cell VOC is warranted.

Electrocardiographic changes during upper gastrointestinal endoscopy in ambient hypoxia

Electrocardiographic (ECG) changes were studied in 120 consecutive subjects during and after upper GI endoscopy done in ambient hypoxia (PO2-120 mmHg) at Shimla (2200 m). No premedication was given to any of the subjects. There were 75 men and 44 women. Fifty three subjects were aged 40 years or below (Group I) and 67 subjects were above 40 (Group II). There were 29 subjects with and 91 subjects without cardiac diseases. Increase in heart rate was seen in 96.6% of subjects. Maximum rise in heart rate was found in cardiac patients. ST depression was seen in 14.2%, T wave inversion in 13.3%, supraventricular tachycardia in 5.8% and ventricular ectopics in 1.6%. ST depression was more frequent in cardiac than in non cardiac patients (P less than 0.001) and T wave inversion was more frequent in women than in men (P less than 0.001). All the changes reverted to normal within 10 minutes. ECG changes notwithstanding, upper GI endoscopy without premedication in the presence of ambient hypoxia is a safe procedure.

Acute granulomatous iritis following 5 fluorouracil therapy for failed trabeculectomy

We are reporting a case which developed idiosyncratic anterior granulomatous uveitis following a single dose of subconjunctival 5 Fluorouracil. This has not been previously reported anywhere in the world.

Heterotopic gastric and pancreatic tissue in large bowel

Heterotopic gastric and pancreatic tissues rarely involves large bowel. We report the case of a 30-yr-old man who presented with lower gastrointestinal bleeding. The barium enema showed an ulcerated mass lesion at the splenic flexure. Colonoscopy revealed a polypoid ulcerated lesion at the splenic flexure. The resected specimen, on histological examination, showed a polypoid lesion lined by gastric mucosa. The base of the polyp also showed ectopic pancreatic tissue. The patient recovered completely after surgery.

Nutritional support in hospitals in the United Kingdom: national survey 1988

The increasing sophistication of enteral and total parenteral nutritional support techniques has resulted in improvements in the clinical practice of such support in recent years. This survey was designed to establish current clinical practice in the management of nutritionally-compromised hospital patients in 206 districts in the United Kingdom. However, despite recent developments in these techniques, the response revealed a wide variation in the practice of clinical nutritional support. The results also indicate that in each district there should be a group of people, with an interest in clinical nutrition, to monitor and advise on nutritional support. It is suggested that, a national multidisciplinary group should be formed, similar to the American and European Societies of Parenteral and Enteral Nutrition. The group would promote the appropriate use of, and research into, nutritional support specifically for the nutritionally compromised patient in the United Kingdom.

Bedside ultrasonography. A low-cost definitive diagnostic procedure in obstructive jaundice

We evaluated real-time ultrasonography carried out by gastroenterologists for its diagnostic accuracy in 89 patients with obstructive jaundice. The positive predictive values for the site and nature of the obstruction were 94.3 and 89.9%, respectively. The advanced stage of disease in our patients and the clinical background of the investigators may have contributed to the high diagnostic accuracy of ultrasonography in this study. Nevertheless, we recommend that gastroenterologists themselves perform bedside ultrasonography for a definitive diagnosis in patients with obstructive jaundice. The high degree of precision achieved by ultrasound in our setting makes more expensive investigations unnecessary as routine procedures.

Iron status and liver function in healthy adults: a multiracial pilot study

We tested 157 apparently healthy, urban adults (78 black, 40 nonblack, 39 race not designated), and found that 7.7% of the entire group had high plasma ferritin levels (6.4%) or transferrin saturation levels (1.3%). Overall, men had significantly higher mean plasma ferritin, serum glutamic pyruvic transaminase, and total serum bilirubin values than women. In this study 17.6% of black men had high plasma ferritin levels and another 11.8% had high transferrin saturation levels. Their mean serum iron and transferrin saturation levels were significantly higher than those of nonblack men. Black men had significantly higher mean serum iron, transferrin saturation, plasma ferritin, serum glutamic pyruvic transaminase, and total serum bilirubin levels than black women. The same tests were not significantly different when black and nonblack women were compared. Likely causes of the laboratory abnormalities are occult inflammation and occult liver disease, but a primary disorder of iron metabolism is also possible.