QT prolongation associated with azithromycin/amiodarone combination

Administration of oral azithromycin, in addition to previously well-tolerated long-term amiodarone therapy, was associated with a marked prolongation of QT interval and increased QT dispersion, both substrates for life-threatening ventricular tachyarrhythmia and torsades de pointes. This is a report of QT prolongation and increased QT dispersion associated with the use of azithromycin. The report assumes an added significance, in view of widespread empirical use of this antibiotic for the treatment of lower respiratory infections and belief of its safety in patients with cardiac diseases. Based on the authors' experience, they would like to emphasize that the combination of azithromycin with other drugs known to prolong QT or causing torsades de pointes be used with caution until the question of the proarrhythmic effect of azithromycin is resolved by further studies.

Natural products of plant origin as anticancer agents

Natural products have been used as effective remedies for the treatment of various ailments. Numerous plant products in the form of decoction, tincture, tablets and capsules have been clinically used for the treatment of different kinds of cancer. This review covers some of the important plants with clinically proven anticancer activity, including Catharanthus roseus, Podophyllum peltatum, Taxus brevifolia, Camptothecin acuminata, Cephalotaxus harringtonia, Viscum album, Onchrosia elliptica, Annona bullata, Asmina triloba and Rhizoma zedoariae. Synthetic analogues in some cases have also been prepared to improve the efficacy and decrease the side effects of parent compounds. The modes of action of clinically used drugs are also delineated.

Chikungunya infection--an emerging disease in Malaysia

Many countries neighboring Malaysia have reported human infections by chikungunya virus, a mosquito-borne togavirus belonging to the genus Alphavirus. However, although there is serological evidence of its presence in Malaysia, chikungunya virus has not been known to be associated with clinical illness in the country. An outbreak of chikungunya virus occurred in Klang, Malaysia, between December 1998 and February 1999. The majority of the cases were in adults and the clinical presentation was similar to classical chikungunya infections. Malaysia is heavily dependent on migrant workers from countries where chikungunya is endemic. It is speculated that the virus has been re-introduced into the country through the movement of these workers.

Enalapril acts through release of nitric oxide in patients with essential hypertension

BACKGROUND

Endothelial dysfunction has been proposed as an etiological agent in the pathogenesis of essential hypertension. Amongst the various antihypertensive drugs, angiotensin converting enzyme inhibitors (ACEI) have been implicated in modifying the vascular endothelium by the release of mediators that include bradykinin, nitric oxide, prostaglandins and thromboxane A2.

MATERIALS AND METHODS

To study the mechanism of action of enalapril, an ACEI, serum reactive nitrite intermediates (RNI) and citrulline, by products of nitric oxide metabolism were measured before and after treatment with enalapril in 25 consecutive patients of essential hypertension.

RESULTS

Following treatment serum RNI intermediate increased from a pretreatment value of 164.5 +/- 20.2 nmol/mL to a post treatment value of 266.9 +/- 47.3 nmol/mL (p < 0.05), however there was no significant change in the levels of citrulline (p > 0.1). There was no significant correlation between the severity of hypertension and serum RNI. Serum RNI levels were lower in the postmenopausal women but did not reach statistical significance.

CONCLUSIONS

It is postulated that enalapril exhibits its antihypertensive property through release of nitric oxide.

Anomalous circumflex coronary artery: benign or predisposed to selective atherosclerosis

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly and is usually considered benign. Although several researchers in the past believed that aberrancy predisposes this vessel to accelerated atherosclerosis, this could not get wide acceptance owing to lack of convincing data. To examine the suggestion that atherosclerosis affects the anomalous circumflex artery more severely, the authors reviewed the clinical and angiographic features of patients with this anomaly identified from 2,684 coronary angiography procedures performed between January 1998 and March 2000 at their institution. The degree of atherosclerotic narrowing in the anomalous artery was compared with that in other coronary arteries in the same patient as well as in the nonanomalous circumflex arteries in controls. For comparison 3 control subjects were selected for each patient with anomalous circumflex artery, matched by age, sex, and clinical presentations. The results showed earlier and greater degree of atherosclerotic narrowing of the anomalous artery as compared to the other coronary arteries in the same patients as well as to nonanomalous circumflex arteries of age- and gender-matched control subjects with similar clinical characteristics. However, this predilection for atherosclerosis was evident only in anomalous vessels arising from the right side and pursuing a retroaortic course. The anomalous artery was responsible for myocardial infarction in 3 patients, all of whom were 60 years or older. Two of the patients with this anomaly and myocardial infarction underwent successful angioplasty with stent placement for symptomatic relief.

Safety and efficacy of moxonidine in mild to moderate hypertension

AIMS

Moxonidine, a new imidazoline II receptor agonist was evaluated in patients with essential hypertension.

METHODOLOGY

After an informed consent, 16 patients with essential hypertension were recruited. After a wash out period, the patients received increasing doses of Moxonidine (maximum dose 0.6 mg) for four weeks to control the blood pressure.

RESULTS

The mean reduction in blood pressure (systolic/diastolic) was 17.6/14.5 mm Hg in supine position and 18.2/12.6 mm Hg in standing position. The significant side effect was observed only in one patient.

CONCLUSIONS

Moxonidine thus appears to be safe and effective antihypertensive drug in patients with essential hypertension.

Pemphigus vulgaris: the role of IL-1 and IL-1 receptor antagonist in pathogenesis and effects of intravenous immunoglobulin on their production

Intravenous immunoglobulin (IVIG) is increasingly being used for the treatment of autoimmune diseases. In the present report, the role of IVIG on in vivo and in vitro production of IL-1 and IL-1 receptor antagonist (Ra) was studied in patients with pemphigus vulgaris (PV). Serum samples from 20 untreated patients with active PV prior to initiation of systemic therapy, 20 patients receiving IVIG treatment, 20 patients in clinical remission after conventional therapy, and 20 normal human controls were studied to determine the serum levels of IL-1alpha, IL-1beta, and IL-1Ra. The in vitro production of these cytokines was measured in the culture supernatant of peripheral blood mononuclear cells (PBMC) from 10 PV patients immediately before and after IVIG therapy and from age and sex-matched 10 healthy donors simultaneously. Elevated levels of IL-1alpha and IL-1beta were detected (i) in the serum of untreated PV patients with active disease prior to systemic therapy and (ii) before IVIG infusions in patients receiving IVIG therapy. These increased levels are statistically significant when compared to the levels in healthy controls (P < 0.01). A marked reduction of IL-1alpha and IL-1beta was detected (i) in the serum of patients in prolonged clinical remission and (ii) immediately after IVIG infusion in those patients on IVIG therapy. Increased level of IL-1Ra was detected in PV patients in prolonged clinical remission and after IVIG infusion in those receiving IVIG therapy. These differences were statistically significant when compared to the levels in normal controls and to the levels in the sera of patients with active disease (P < 0.01) or just before the beginning of IVIG infusion (P < 0.01). Similar differences in the levels of IL-1alpha, IL-1beta, and IL-1Ra were found in the culture supernatant of PBMC isolated from the PV patients pre and post IVIG therapy. These observations suggests that, compared to normal controls, patients with active PV have reversed levels of IL-1alpha, IL-1beta, and IL-1Ra. IVIG therapy may down-regulate production of IL-1alpha and IL-1beta and enhance production of IL-1Ra, in vivo and in vitro. This might be one of the important mechanisms by which IVIG produces its early therapeutic effects in pemphigus vulgaris.

Autoantibodies to human alpha6 integrin in patients with oral pemphigoid

Mucous membrane pemphigoid or cicatricial pemphigoid is a mucocutaneous blistering disease characterized by autoantibodies to different molecules in the basement membrane zone. Our objectives were to identify the target antigen recognized by sera from 20 untreated patients with pemphigoid disease limited to the oral cavity, and to determine the pathogenicity of autoantibodies in oral pemphigoid, with an organ culture model. We conducted indirect immunofluorescence, immunoblot, and immunoprecipitation assays, with accompanying absorption experiments, using normal human skin, conjunctiva and gingiva, bovine gingiva and a tumor cell line, which were reacted with sera from patients with oral pemphigoid, anti-alpha6 antibody, and control sera. Sera of oral pemphigoid patients selectively and specifically bound to human alpha6 integrin, a 120-kDa protein present in gingiva and the tumor cell line. Oral pemphigoid sera and anti-alpha6 antibody produced separation of epithelium from basement membrane (blister formation) of normal human buccal mucosa, after 48 hours, in organ culture.

Pheochromocytoma: a 10-year experience in a tertiary care North Indian hospital

BACKGROUND

The study was carried out to highlight the clinical and biochemical profile of patients with pheochromocytoma in a tertiary care center of North India.

METHODS AND RESULTS

Thirty consecutive cases of pheochromocytoma admitted over a period of 10 years to our Institute were analyzed. The chief clinical complaints of these 30 patients (17 males and 13 females, mean age 24+/-7 years) were palpitation (80%), headache (77%), sweating (60%), breathlessness (67%) and flushing (56%). The clinical triad of headache, flushing and sweating occurred in 26.7% of cases. On clinical examination, 97% of the patients were hypertensive and 16.6% presented with malignant hypertension. Laboratory measurements showed that the levels of 24-hour urinary vanillylmandelic acid were elevated in 80% of cases. Levels of plasma adrenaline and noradrenaline were raised in 78% and 79% of cases, respectively. Anatomical localization of the tumor on computerized tomographic scan showed the presence of an adrenal tumor in 80% and extra-adrenal tumor in 20%. Surgical removal of the tumor could be carried out in 28 cases following control of the blood pressure with antihypertensive drugs including alpha and beta adrenoreceptor blockers.

CONCLUSIONS

Pheochromocytoma should be suspected in all young hypertensive persons. The appropriate therapy for this tumor is surgical removal preceded by adequate blood pressure control including the use of alpha and beta adrenoreceptor antagonists.

Interleukin 1 components in cicatricial pemphigoid. Role in intravenous immunoglobulin therapy

Interleukin (IL-)1 is an important mediator of inflammatory responses and plays an important role in the pathogenesis of various autoimmune diseases. Cicatricial pemphigoid (CP) is a multisystem autoimmune inflammatory disease. We have studied the role of IL-1 in its pathogenesis. We have investigated the serum levels of IL-1 components (IL-1alpha, IL-1beta, and IL-1Ra), and determined the role of intravenous immunoglobulin (IVIg) therapy in patients with CP. Serum levels of IL-1alpha and beta were significantly higher in untreated patients with active disease compared to levels in patients in prolonged clinical remission and normal human controls (P<0.0001). The serum levels of IL-1Ra were higher in patients in prolonged clinical remission compared to patients with active disease (P=0.002). Hence elevated levels of IL-1alpha and beta and low levels of IL-1Ra correlate with disease activity. The levels of IL-1alpha and beta were statistically significantly higher in sera of CP patients with active disease pre-IVIg therapy compared to post-IVIg therapy (P<0.0001). Statistically significantly higher levels of IL-1Ra were present in post-IVIg treatment serum samples when compared to levels in pre-IVIg treatment (P<0.0001). In the in vitro experiments, the levels of IL-1alpha and beta produced by the peripheral blood mononuclear cells (PBMC) isolated from patients before IVIg therapy were significantly higher when compared to the PBMC isolated from post-IVIg patients (P<0.0001). Significantly higher levels of IL-1Ra were observed in the supernatants of PBMC collected from pre-IVIg patients and cultured with exogenously added IVIg, when compared to the levels of PBMC to which IVIg was not added (P<0.0001). IL-1 may be an important cytokine involved in the pathogenesis of CP. The regulation of IL-1 could be one of the mechanisms, amongst others, by which IVIg may exert its beneficial effect in the treatment of CP.

Identification of ocular cicatricial pemphigoid antibody binding site(s) in human beta4 integrin

PURPOSE

To identify specific site(s) on human ss4 molecule to which sera from ocular cicatricial pemphigoid (OCP) patients bind and to determine its role in the process of blister formation.

METHODS

Clone the fragments representing the extracellular and intracellular domain of ss4 molecule from normal human conjunctival mRNA into an expression vector; map the region to which sera from OCP patients bind by Western blot analysis. Determine the role of the immunodominant region in pathogenesis by demonstrating the ability of the rabbit antibody to the immunodominant region to produce separation of basement membrane zone (BMZ) from the basal epithelial layer when incubated with normal human conjunctiva in an in vitro organ culture model.

RESULTS

Majority of the OCP sera tested bound to the C-terminal end of the intracellular domain (IC3.0) of the human ss4 integrin. Further subcloning of IC3.0 demonstrated that a smaller fragment extending from 1489 aa to 1572 aa (IC3.4) was responsible for this binding. This region may have multiple antibody binding sites. Antibody to human IC3.0 and IC3.4 produced in rabbit, resulted in BMZ separation, histologically identical with that observed when normal human conjunctiva was cultured with OCP sera in an human conjunctival organ culture model.

CONCLUSIONS

These observations identify IC3.4 as the antibody binding site for sera of OCP patients and suggest a possible role for it in blister formation. Indirectly it highlights certain important aspects of the structural and functional dynamics of the biology of the hemidesmosomes and basement membranes.

Bullous pemphigoid: interaction of interleukin 5, anti-basement membrane zone antibodies and eosinophils. A preliminary observation

Bullous pemphigoid (BP) is an autoimmune blistering skin disease characterized by the presence of autoantibodies to normal components of the hemidesmosome (BPAg1 and BPAg2). Histology of skin lesions demonstrate a subepidermal vesicle and a predominantly eosinophilic dermal cellular infiltrate. Interleukin 5 (IL-5) plays a major role in eosinophil recruitment and function. Using an ELISA, we investigated the levels of IL-5 in the sera and blister fluid of BP patients with active disease and those in prolonged clinical remission treated with intravenous immunoglobulin, and compared it to that in normal controls. Significantly increased levels of IL-5 were detected in the serum and particularly the blister fluid of patients with active disease (P=0.0043) when compared to levels in normal controls. There was no significant difference in IL-5 levels in patients in prolonged clinical remission compared to normal control serum. In an immunoblot assay, using bovine gingival lysate as substrate, we determined the presence of IgG and IgE autoantibodies specific to basement membrane zone proteins in blister fluid and serum of BP patients. IgG autoantibodies to BPAg1 and BPAg2 were detected in both blister fluid and serum of patients, whereas IgE autoantibodies, in much lower titers, were detected to only BPAg1. Elevated levels of blood and tissue eosinophilia were observed in these patients. Based on these data, we present a preliminary hypothesis for the initiation, progression and localization of blister formation in BP.

Effect of calcium antagonists on stress-induced rise in blood pressure and heart rate: a double-blind, placebo-controlled study

OBJECTIVE

The current study was designed to evaluate the effect of treatment with calcium antagonists on stress-induced increases in blood pressure and heart rate. SUBIECTS, MATERIAL AND METHODS: Two models of stress were chosen, cold stress and isometric handgrip exercise. Six healthy volunteers were randomized to receive amlodipine (5 mg), lacidipine (4 mg) for a two-day period in a double-blind, crossover design. Thirty hypertensive patients received the same treatment for a period of one week in a double-blind, parallel design. The effects of stress on blood pressure and heart rate were taken at baseline and after drug treatment.

RESULTS

Cold stress and handgrip exercise significantly increased the systolic and diastolic blood pressure as well as the heart rate. In normotensive volunteers, the resting heart rate and blood pressure were not altered by the drugs. The increase in systolic and diastolic blood pressure produced by cold stress and isometric exercise were unchanged by amlodipine and lacidipine. In hypertensive patients, both drugs reduced the resting blood pressure (p < 0.05). As in normotensive individuals, the pressor response to stress was not altered by the drugs.

CONCLUSION

Cold stress and handgrip exercise produced a significant rise in blood pressure and heart rate in normotensive volunteers and patients with hypertension. Cardiovascular reactivity to cold stress and handgrip exercise is not altered by the administration ofamlodipine and lacidipine.

Tropical pyomyositis: experience of a tertiary care hospital in north-west India

OBJECTIVE

Tropical pyomyositis (TP), a disease of varied aetiology, has been reported frequently from Africa and Latin America. However there are only a few reports from India.

MATERIAL AND METHODS

Between January 1992 to June 1999, 26 patients with TP were admitted to Post Graduate Institute of Medical Education and Research Chandigarh, a tertiary care centre in north-west India and formed the study material.

RESULTS

The disease was more common in young adults with male to female ratio being 5:2. In majority, presenting features were muscle pains (100%) and fever (81%). The diagnosis was confirmed by aspirating pus from the involved muscle. The pus grew organisms in 41.7% patients and methicillin sensitive Staphylococcus aureus was the commonest causative organism. Blood cultures were positive in 14.3% of cases. The common complications were bronchopneumonia (23.1%), empyema (19.2%) and venous thrombosis (15.4%). In three patients, the disease occurred in association with tuberculosis of dorsal-lumbar spine. The overall mortality was low (7.7%).

CONCLUSIONS

TP is not an uncommon disease in India. Though the presenting features were similar to earlier studies, complications varied and mortality was low. An early recognition and aggressive treatment helps in decreasing morbidity and mortality.

Intellectual psycho-educational and functional status of low birth weight survivors beyond 5 years of age

To determine the intellectual, psycho-educational and functional status of low birth weight (LBW) survivors (birth weight < or = 2000 gms) beyond 5 years of age and to compare their status with normal birth weight counterparts. This was cross-sectional study. On hospital based cohort on longitudinal follow-up at the High Risk and Well Baby Clinics of a teaching hospital. The demographic data of these children was recorded. A detailed physical examination was performed. The tests of cognition included the Stanford Binet and the Raven's Progressive Matrices. Academic achievement was evaluated by the Wide range achievement test-Revised (WRAT-R). Assessment of visuo motor integration was done by the Bender Gestalt Test. The proportion of children having soft neurological signs was determined. Vineland Social Maturity Scale was performed on all children. Fifty-nine LBW children and fifty-seven matched control children participated in the study. 27 of LBW children were examined at a mean age of 7.0 +/- 1.1 years (group I) and 32 were examined at a mean age of 10.6 +/- 1.2 years (group II). The LBW children as a group performed in the normal range on the tests of cognition and academic achievement, but were significantly disadvantaged (p < 0.005) as compared to controls. A higher percentage of LBW children had low scores on the Bender Gestalt. Test as compared to controls but the difference was not significant. A significantly higher proportion of LBW children of both the groups showed the presence of soft neurological signs as compared to controls. The social quotient as assessed by the vineland Social Maturity Scale was significantly lower in the LBW children as compared to controls. Thus, though the LBW children were performing in the normal range on various measures, comparison with the control group showed that they were clearly disadvantaged on nearly every measure tested, emphasizing the need for early detection and referral for special education.

Paterson-Kelly syndrome and celiac disease--a rare combination

Paterson-Kelly syndrome is characterized by an association of iron deficiency with dysphagia. We describe a patient with this syndrome who was later diagnosed to have celiac disease.

Cryptococcal prostatitis in a patient with chronic lymphocytic leukemia

Cryptococcosis is a systemic mycosis usually affecting patients of immunodeficiency i.e. transplants recipients, patients on chemotherapy for neoplastic diseases and in those suffering from human immunodeficiency virus infection. We report a 52-year old male suffering from chronic lymphocytic leukemia (CLL) on chemotherapy who presented with fever and features of prostatism. Cryptococcus neoformans infection (CN) was diagnosed on aspiration of a prostatic nodule. Subsequent investigations revealed a disseminated involvement by cryptococcus. The case represents an unusual presentation of disseminated cryptococcosis.

Primary nodal neuroendocrine (Merkel cell) tumor in a patient with HIV infection

Lymphadenopathy in the human immunodeficiency virus (HIV) can be of diverse etiology, ranging from infection to cancer. A neoplasm of epithelial origin manifested as inguinal lymphadenopathy without a primary lesion is rare. We report a case of Merkel cell tumor confined only to a lymph node in a patient with the acquired immunodeficiency syndrome (AIDS). We believe this is the first report of primary nodal Merkel cell tumor in a patient with HIV. Because Merkel cell tumor is a rare skin neoplasm with features suggestive of high malignant potential, it is important to distinguish a primary nodal Merkel cell tumor from malignant metastatic processes on the one hand and relatively benign causes of adenopathy on the other.

A follow-up study of balloon angioplasty and de-novo stenting in Takayasu arteritis

Percutaneous balloon angioplasty (PTBA) is a universally accepted mode of therapy for stenotic coronary and peripheral arterial lesions. To establish the role of PTBA and stent placement in patients with Takayasu's arteritis (TA), these procedures were performed in 20 patients with TA. All patients received steroids, aspirin and ticlodipine (for stent placement) prior to procedure. Angioplasty was carried in patients with symptomatic stenotic vessel of more than 70% of normal diameter or a peak systolic gradient of more than 50 mm across stenotic aortic lesion. Stenting was performed for ostial lesion, long segment lesion or incomplete relief of stenosis and dissection following angioplasty. Carotid angioplasty and stenting was performed in five patients, aortic angioplasty in nine patients, aortic angioplasty and stenting in four patients, renal angioplasty in three patients, renal angioplasty and stenting in two patients and subclavian angioplasty in two patients, subclavian, angioplasty and stenting in three patients and coronary angioplasty and stent placement in one patient. The procedure was successful in all but one patient. On following up, two patients with carotid stent placement had restenosis. A saccular aneurysm developed at the lower end of stent in one patient with aortic stent placement. The PTBA with or without stent placement is a safe and effective method for relief of stenotic lesion in patients with TA.

Regulation of acetyl coenzyme A synthetase in Escherichia coli

Cells of Escherichia coli growing on sugars that result in catabolite repression or amino acids that feed into glycolysis undergo a metabolic switch associated with the production and utilization of acetate. As they divide exponentially, these cells excrete acetate via the phosphotransacetylase-acetate kinase pathway. As they begin the transition to stationary phase, they instead resorb acetate, activate it to acetyl coenzyme A (acetyl-CoA) by means of the enzyme acetyl-CoA synthetase (Acs) and utilize it to generate energy and biosynthetic components via the tricarboxylic acid cycle and the glyoxylate shunt, respectively. Here, we present evidence that this switch occurs primarily through the induction of acs and that the timing and magnitude of this induction depend, in part, on the direct action of the carbon regulator cyclic AMP receptor protein (CRP) and the oxygen regulator FNR. It also depends, probably indirectly, upon the glyoxylate shunt repressor IclR, its activator FadR, and many enzymes involved in acetate metabolism. On the basis of these results, we propose that cells induce acs, and thus their ability to assimilate acetate, in response to rising cyclic AMP levels, falling oxygen partial pressure, and the flux of carbon through acetate-associated pathways.

Self-reported uterine prolapse in a resettlement colony of north India

The aims of this study are to estimate the prevalence of self-reported uterine prolapse and to determine the treatment-seeking behavior of the respondents. Participants of this study are married women of Dadu Majra colony, Chandigarh, India, January-February, 1996. A house-to-house screening of the women was done by a nursing student utilizing a checklist of indicator symptoms of uterine prolapse. All women reporting such symptoms were interviewed further. Among the 2,990 women surveyed, 227 (7.6%) reported symptoms of uterine prolapse. Of the 227 women with self-reported uterine prolapse, 128 (57%) had not taken any treatment, 28 went to a traditional birth attendant (TBA), and 47 (21%) consulted a doctor. Thirty-eight women were advised to have an operation, but only eight complied. Other treatments used by small numbers of women included the use of a ring pessary or alcohol-soaked swab and heel pressure technique. Reasons for non-consultation included shyness (80; 63%), lack of cooperation by the husband, lack of time (80; 63%) and lack of money (74; 58%). The prevalence of prolapse was significantly higher in women with higher parity. More than 7% of the women reported symptoms of uterine prolapse.

Response to hepatitis B vaccination in high risk population

Hepatitis B vaccine is well established as very efficacious, but immune response to the vaccine is highly individual specific. A study involving fifty vaccinees was undertaken at the Hepatitis Laboratory, National Institute of Communicable Disease, Delhi. One ml (20 microgram) of Engerix B vaccine (recombinant yeast derived vaccine) was administered in the standard three dose schedule (0, 1 and 6 months). The sero-conversion of the vaccinees was 24%, 66%, 76% and 78% at 1 month, 6 months, 7 months, and 12 months respectively. There was no seroconversion in 22% of the vaccinees. Sero-conversion was assessed using Macro ELISA test (Ausab, Abbott Labs) for Anti HBs reactivity.