A double-blind crossover study in moderately hypercholesterolemic men that compared the effect of aged garlic extract and placebo administration on blood lipids

A double-blind crossover study comparing the effect of aged garlic extract with a placebo on blood lipids was performed in a group of 41 moderately hypercholesterolemic men [cholesterol concentrations 5.7-7.5 mmol/L (220-290 mg/dL)]. After a 4-wk baseline period, during which the subjects were advised to adhere to a National Cholesterol Education Program Step I diet, they were started on 7.2 g aged garlic extract per day or an equivalent amount of placebo as a dietary supplement for a period of 6 mo, then switched to the other supplement for an additional 4 mo. Blood lipids, blood counts, thyroid and liver function measures, body weight, and blood pressure were followed over the entire study period. The major findings were a maximal reduction in total serum cholesterol of 6.1% or 7.0% in comparison with the average concentration during the placebo administration or baseline evaluation period, respectively. Low-density-lipoprotein cholesterol was also decreased by aged garlic extract, 4% when compared with average baseline values and 4.6% in comparison with placebo period concentrations. In addition, there was a 5.5% decrease in systolic blood pressure and a modest reduction of diastolic blood pressure in response to aged garlic extract. We conclude that dietary supplementation with aged garlic extract has beneficial effects on the lipid profile and blood pressure of moderately hypercholesterolemic subjects.

Efficacy of octreotide in diarrhoea due to Vibrio cholerae: a randomized, controlled trial

Although octreotide, a long-acting analogue of somatostatin, is currently used in the treatment of chronic secretory diarrhoea due to various causes, its role in the management of acute secretory diarrhoea is not well established. In the present study, therefore, the therapeutic value of octreotide in the management of cholera, a classical example of acute secretory diarrhoea, was investigated. During an outbreak of cholera, patients admitted with acute secretory diarrhoea of < or = 24 h duration and a purging rate > 100 ml/h were enrolled on the study and randomly assigned to octreotide (N = 17) and control (N = 16) groups. All 33 patients received intravenous fluid replacement and antibiotic treatment (200 mg ofloxacin twice daily for 3 days, by mouth). Each patient in the octreotide group was also given a subcutaneous injection containing 100 micrograms octreotide every 8 h for a maximum of six doses. The stool output of each patient was recorded every hour until there had been none for an hour, which was taken as the endpoint. Mean (S.D.) total stool output was lower [6.56 (3.7) v. 9.7 (6.5) litres] and the mean (S.D.) duration of diarrhoea after admission was shorter [32.9 (15.6) v. 47.8 (22.3); P < 0.05] in the octreotide group than in the control group. However, as both groups generally had similar purging rates, the higher volume of stools from the control group was simply the result of the longer period of diarrhoea in this group. Octreotide therefore only decreased the duration of diarrhoea in the cholera patients.

Trace element nutrition in developing countries

Trace element status in humans is often poorly established in developed, let alone developing, countries. There have been assumptions about inevitable adequacy, especially for ultra-trace elements, like chromium, with varied diets. However, new pressures on trace element adequacy are emerging, like developments in food technology with the new formulated foods and element pollutants (toxic metals) with potential interactions with essential elements. Improved, more sensitive methods for trace element measurements in foods and biological specimens, functional indices of trace element status, with application to nutritional epidemiology, and the pursuit of clinical trials, should allow appropriate revision of current views. This process is likely to more consequential in developing countries.

Clinicopathological features and management of immunoproliferative small intestinal disease and primary small intestinal lymphoma in Pakistan

This study was performed to confirm the existence of immunoproliferative small intestinal disease (IPSID) in Pakistan. Clinicopathological features of 12 patients with histologically confirmed disease were analysed. Patients were mostly young males with median age of 24.6 years. Two thirds belonged to poor socioeconomic class. Main presenting features were chronic diarrhoea and weight loss. Eleven patients had radiologic evidence of malabsorption syndrome. Endoscopic findings of mucosal thickening, edema, and flattened villi were present in the majority. Patients had both secretory and non-secretory types of disease. Six patients presented with stage A disease. Four responded to antibiotics or steroids, although mucosal abnormalities persisted in three. Two stage A patients evolved into stage C disease, one was lost to follow-up, the other is alive with disease. Three patients presented with stage B disease. Two responded completely to chemotherapy, the third refused treatment and expired after 16 months. Three patients had stage C disease at diagnosis. They received aggressive combination chemotherapy and remain in complete remission with a median follow-up of 2.2 years. This is the first series of patients with IPSID reported from Pakistan. Clinicopathological features and therapeutic results are consistent with the experience elsewhere. Increased awareness may result in early diagnosis and better management.

Comparison of liver histology in chronic active hepatitis C and chronic active hepatitis B

OBJECTIVE

To study the histological features of chronic active hepatitis C (CAH-C) and to compare these with those of chronic active hepatitis B (CAH-B).

METHODS

Thirty-two liver biopsy specimens from patients with chronic active hepatitis and presence of antibodies to hepatitis C on second generation enzyme immunoassay were studied and compared with those in 34 patients with CAH-B. Seventeen of the 32 CAH-C patients had fully developed or developing cirrhosis of liver whereas the remainder had only chronic active hepatitis.

RESULTS

Among 32 patients with CAH-C, fatty change (20), Kupffer cell hyperplasia (30), sinusoidal lymphocytosis (27) lymphoid follicles aggregates in portal tracts (26) and bridging necrosis (16) were regular features. Focal necrosis, bile duct necrosis, cholestasis and ground glass cells were however seen much less often. On the other hand, in patients with CAH-B, fatty change (no patient), sinusoidal lymphocytosis (one patient) and lymphoid follicles/aggregates in portal tracts (one patient) were rare. Also, Kupffer cell hyperplasia (22 patients) was seen less commonly in patients with CAH-B as compared to CAH-C. Focal necrosis (34 patients), bile ductular proliferation (9 patients), cholestasis (17 patients) and ground glass cells (15 patients) were more prominent in CAH-B.

CONCLUSION

Presence of certain histological features can help in distinguishing between CAH-C and CAH-B.

Barrett's oesophagus and Helicobacter pylori

In order to demonstrate the presence of Helicobacter pylori in the metaplastic epithelium of Barrett's oesophagus and to evaluate its possible association with this entity, we examined 29 cases of Barrett's oesophagus where concomitant antral biopsies were also available. These cases were compared with an equal number of age and sex matched controls of uncomplicated reflux oesophagitis. H. pylori was present in 11 of 29 cases of Barrett's oesophagus (38%). No increase in the frequency of H. pylori antral gastritis was found in patients of Barrett's oesophagus compared to the control group of uncomplicated reflux oesophagitis. The positivity of Barrett's oesophagus for H. pylori correlated with the presence of H. pylori antral gastritis (P < 0.05), although in two cases of H. pylori-positive Barrett's oesophagus antral biopsies were negative for H. pylori. No difference was found in the severity of inflammatory and dysplastic changes of H. pylori-positive and H. pylori-negative Barrett's oesophagus. Presence of H. pylori does not seem to alter the natural history of Barrett's oesophagus.

The value of fine needle aspiration biopsy in the management of breast disease

Fine needle aspiration biopsy is a technique used all over the world in the diagnosis and management of breast lumps. It is safe, quick, accurate, cost effective and acceptable to the patients. We reviewed 234 fine needle aspiration biopsies performed over a period extending from 1991-1993 for diagnosis of breast lesions. Majority of the patients presented with breast lumps (89.7%). On FNAB 144 (61.4%) cases were reported as benign and 60 (25.6%) as malignant. Histological diagnosis was available in 116 cases. On comparison with open biopsy diagnosis, FNAB was found to have a sensitivity of 96.4%, a specificity of 95.5% and efficiency rate of 96.2%. The results of the study endorse the use of FNAB as an accurate and effective technique in the management of breast ailments in our set-up.

Malignant tumours of the male breast--a review of 50 cases

Carcinoma of breast is one of the less frequent malignancies in males. In this study 50 cases of malignant tumours of male breast diagnosed during a 10 years period (1980-1989) are analysed retrospectively. The malignant breast tumours in males were about 3% of all breast malignancies in both sexes and 0.34% of all types of malignant tumours diagnosed during the study period. One male breast was involved for every 33 female cases. The peak incidence was between 5th to 7th decade with mean age of 58.54 years. The mean duration of symptoms was 13.69 months and 46.15% cases reported to the hospital after one year of their symptoms. Clinically, a painless lump in the breast was most frequently seen, followed by ulceration of the skin. Histologically, the infiltrating duct carcinoma (grade III) was the predominant lesion and one case of Paget's disease of the breast was also seen.

Pattern of malignant bone tumour in northern areas of Pakistan

A review of 280 primary malignant bone tumours diagnosed during 1984-1988 is presented. These constituted 3.14% of all malignant tumours. Male to female ratio was 2.3:1. Majority of these patients presented with rapidly growing mass, pain and deformity. Histologically, osteosarcoma was the most frequent (36.4%) primary malignant tumour. Male to female ratio was 3.31:1. More than 49% of these cases were in their second decade of life. In females the greatest frequency was in 10-15 years and in males 16-20 years age groups. Femur was the most frequent site. Other common malignant bone tumours included chondrosarcoma (22.1%), plasma cell myeloma (15.0%) and Ewings's sarcoma (8.6%). Miscellaneous cases of fibrosarcoma, chrodoma, adamentinoma and ameloblastoma were also seen. This study outlines the frequency, symptomatology and histological pattern of various malignant bone tumours in northern areas of Pakistan.

Peculiar histopathological features of giardiasis in distal duodenal biopsies

Histological changes in 20 Giardia positive duodenal biopsies (Group A) were compared with 50, Giardia negative duodenal biopsies (Group B), taken during the same period. Stool examinations in Group B were negative for Giardia. Surface epithelium, villous and crypt architecture and cellular infiltrates were examined and compared between the groups. Atrophic changes in the villi were more common in Group A as compared to B(P < 0.0001). Intraepithelial neutrophil infiltration (P < 0.001), infiltration of the lamina propria with plasma cells (P < 0.5), and presence of eosinophils in the lamina propria (P < 0.001) were significant findings in group A. Some of the changes were related to the density of Giardia colonization e.g., the goblet cell depletion (P < 0.05) and the density of plasma cell infiltration in lamina propria (P < 0.01). Erosions and ulcerations were less commonly seen in group A. Thus we conclude that giardiasis manifests its peculiar features in the distal duodenal mucosa and a biopsy of this region is an important diagnostic tool for detection of this disease.

Ki-1 large cell anaplastic lymphoma--a clinicopathological study

Ki-1 large cell anaplastic lymphoma is a recently described variant of malignant lymphoma. A retrospective study of 10 cases of Ki-1 lymphoma was carried out at the Armed Forces Institute of Pathology (AFIP) Rawalpindi to document its clinical and morphological features. The morphological features were evaluated by a study of paraffin embedded sections stained with haematoxylin and eosin stains. Immunohistochemical stains for BER-H2 and leucocyte common antigen (LCA) were performed in all cases. The age of the patients ranged from 2 to 60 years and male to female ratio was 2.3:1. Cervical lymphadenopathy was the most common presentation. Histologically, there was a complete effacement of the lymph node architecture in 8 cases. The Reed-Sternberg like cells were seen in 2 and histiocyte like cells in 7 cases. Immunohistochemically all cases were positive for BER-H2. It is suggested that the possibility of Ki-1 lymphoma should be considered in all cases of lymphoma with pleomorphic morphology.

Management of chronic ventricular arrhythmias

Premature ventricular contractions occurring in asymptomatic patients without heart disease are benign and need not be treated. Beta blockers may be used for symptomatic patients. Antiarrhythmic therapy for patients after myocardial infarction is controversial; authors of recent studies have tended to discourage this therapy. Patients with malignant arrhythmias--who have been resuscitated from cardiac arrest caused by ventricular ectopy or who have ventricular tachycardia-associated syncope--should be referred for electrophysiologic testing and individualized therapy.

Non-Hodgkin's lymphomas with primary manifestation in gonads--a clinicopathological study

Analysis of 19 cases of Non-Hodgkin's lymphoma (NHL) with primary manifestation in gonads, diagnosed during 1984-1990 at AFIP Rawalpindi is presented. It constituted 10.4% of all extranodal lymphomas during the same period in this institute. Testis were more commonly involved. Mean age at diagnosis was 60.4 years and only 11.4% cases were below 50 years of age. Majority of the patients reported early (mean duration was 4.2 months). The mean tumour size was 3.2 cm. In a significant number of cases (43.5%). NHL was associated with hydrocoele. Diffuse large cell lymphoma was the predominant (73.70%) subtype in testicular lymphoma. One case of Burkitt's lymphoma presenting as ovarian mass was also noted. Most of these cases (56.4%) were in le stage according to Ann Arbor staging. More clinical work-up is required to delineate the course of this entity in Pakistan.

A water-soluble fragment of Micrococcus lysodeikticus cell wall

A fragment of Micrococcus lysodeikticus cell wall was obtained by extraction of walls with water, dimethylformamide or dimethyl sulfoxide. The water-soluble polymer was obtained from the cell walls prepared either with or without trypsin treatment of the cell. This fragment was studied by the Smith periodate oxidation, methylation, mild acid treatment and enzymic procedures. The polymer consists of polysaccharide chains composed of (1-->4)-O-(2-acetamido-2-deoxy-beta-D-mannopyranosyluronic acid)-(1-->6)-O-alpha-D-glucopyranosyl residues. The polysaccharide chain is linked to C-6 of a 2-acetamido-3-O-(D-1-carboxyethyl)-2-deoxy-beta-D-gluco-pyranosyl residue of a peptidoglycan chain composed of repeating (1-->4)-O-(2-acetamido-2-deoxy-beta-D-glucopyranosyl)-(1-->4)-[2-acet ami do-3-O-(D-1-carboxyethyl)-2-deoxy-beta-D-glucopyranosyl] residues. The water-soluble cell-wall fragment was also observed in the-culture medium of Micrococcus lysodeikticus and was also extractable from the cells in minor quantity.

Melancholy: an elusive dimension of depression?

This paper presents a view of melancholy based on Kierkegaard's insight of the self, showing that this dimension of depression is anticipatory of threat to well-being. The view of self, contrasted with a view presuming a connection between two factors only--body and mind--has a third factor or ethico-spiritual element. Taken as an explanatory category, this factor allows for making a distinction between melancholy as crisis and melancholy as ailment, and has implication for detecting and treating the latter. That is, in the initial patient-physician dialogue, the physician might be expected to indicate whether she/he is open to consider the possibility of a third factor as an explanatory category in the formation of self-hood. Such indication would provide for patients with an inkling of their own condition, a basis for making a choice about whom they will accept as caregiver.

Burkitt's lymphoma--a study of 50 consecutive cases

A retrospective study of Burkitt's lymphoma done over a period of 7 years is presented. The relative frequency of Burkitt's lymphoma as compared to other non-Hodgkin's lymphomas was 6.35%. Although Pakistan is non-endemic for Burkitt's lymphoma, but the frequency of the disease is higher than other non-endemic countries. There was male predominance (M:F 2.3:1). Majority of the cases were in pediatric age group and 12% were older than 35 years. The main clinical presentation was abdominal (42%), either in the intestinal tract (22%) or retroperitoneal (18%) region (American mode of presentation). Jaw tumour (4%) (African mode) was rare. Sporadic cases at almost all sites were also encountered. Burkitt's lymphoma presenting as primary nodal disease was seen in 36% cases. Fifty-four percent showed bone marrow infiltration. The stage of the disease at diagnosis was advance in 54% cases. Follow-up of ten cases revealed poor survival inspite of treatment.

Efficacy, safety, and tolerability of isradipine in hypertension as used in general practice in a developing country (Pakistan)

This open-label trial of isradipine was carried out in 3422 outpatients by 893 general practitioners to assess the efficacy, safety, and tolerability of isradipine as monotherapy in mild-to-moderate hypertension. Patients received 2.5 mg isradipine twice daily as monotherapy for 6 weeks following a placebo wash-out period of 1 week. After 6 weeks of active treatment, diastolic blood pressure was significantly reduced from 106 +/- 7.7 to 89.4 +/- 8.0 mm Hg (P < .001). Systolic blood pressure also decreased significantly, from 166.8 +/- 19.6 to 141.8 +/- 15.7 mm Hg (P < .001). Blood pressure was normalized in 75.68% of the patients. A total of 629 patients (19%) reported adverse events, 79 (2.3%) of whom withdrew from the study for this reason. The most common side-effects were headache (8.7%), palpitations/tachycardia (3.8%), vertigo (2.89%) and flushing (1.00%). In conclusion, 2.5 mg isradipine twice daily is a safe, effective, and well tolerated form of monotherapy in the treatment of hypertension in general practice in a developing country (Pakistan).

Pilomatricoma: a retrospective study

A study of 53 Pakistani patients with pilomatricoma diagnosed at AFIP during 1985-1989 is presented. It constituted 37.2% of all benign adnexal tumors, during the same period. 56.2% of patients were more than 30 years of age. Differences in site, sex, and age distribution from Western reports were observed. Unusual clinical presentations were also noted. This study outlines the clinicopathologic features of pilomatricoma in Pakistan.

Non-Hodgkin's lymphoma--clinicopathological pattern

A study of histopathological and clinical features of non-Hodgkin's lymphoma in 495 consecutive cases, diagnosed at AFIP during 1984-1989 is presented. Children below the age of 15 years were not included in this study. The relative frequency of non-Hodgkin's lymphoma was 4.29% in our material. Non-Hodgkin's lymphoma was more frequent than Hodgkin's disease, ratio being 2.44:1. Lymphadenopathy (78.78%), fever (33.08%), weight loss (31.62%) and anemia (30.14%) were the main presenting features. New working formulation was used for morphological characterisation. Follicular lymphoma constituted 8.08% of all cases. Follicular lymphoma was seen only in older age whereas diffuse lymphoma occurred in all age groups. Intermediate and high grade lymphoma represented 73.54% of all NHL. Small lymphocytic lymphoma was common in low grade tumours (13.13%). Extra nodal lymphoma was encountered in a significant proportion (21.22%), gastrointestinal tract being the most frequent site. This study outlines certain interesting features of NHL in Pakistan.