A multicentric study with arteether in patients of uncomplicated falciparum malaria

Two hundred and sixty seven patients of uncomplicated P. falciparum malaria completed study in a multicentric phase III clinical trial of Arteether. Arteether was given intramuscularly in a dose of 150 mg daily for three consecutive days. Each patient was followed upto 28 days of alpha, beta arteether therapy. The cure rate was 97% with fever clearance time between 1-7 days (24-168 hours) and parasite clearance time between 1-3 days (24-72 hours). Parasite reappearance rate was found to be 3% and reported at only three of the centres. Following the treatment no adverse effect was observed on haematological, biochemical and vital clinical parameters.

In vitro evidence for auto-induction of artemisinin metabolism in the rat

Artemisinin disappearance rate was more rapid in incubations with liver microsomes from rats pre-treated with oral artemisinin (60 mg/kg/day for 5 days) compared with microsomes from control animals. A single pathway Michaelis-Menten saturable elimination model was fitted to the concentration-time data of artemisinin incubations by non-linear regression. Model parameters were obtained after fitting results for each animal separately and by pooling data for pre-treated and control animals. Parameter estimates (% coefficient of variation) from fitting the pooled data was maximum velocities (Vmax) = 1.8 (12) mmole/min/mg protein and Michaelis constants (Km) = 20(22) microM for artemisinin pre-treated and Vmax = 0.85 (35) mmole/min/mg protein and Km = 67(52) microM for control animals indicating a 2-fold increase in Vmax and a 3-fold decrease in Km with microsomes from artemisinin pre-treated animals. Estimates of intrinsic clearance in microsomes from the pre-treated animals were 8-fold higher compared with controls. Thus, artemisinin appears to be a potent auto-inducer of drug metabolism in rats as has also been observed in humans. The present findings suggest caution in the interpretation of repeat-dose rat toxicity studies with artemisinin unless its pharmacokinetics are simultaneously monitored, since during multiple administration, the exposure of the drug will not be constant over time.

Cisapride improves gallbladder emptying and bile lipid composition in patients with gallstones

BACKGROUND AND AIM

Biliary cholesterol supersaturation, gallbladder stasis and delayed intestinal transit are the key events in cholesterol gallstone formation. We studied the effect of cisapride, a prokinetic drug, on gallbladder emptying and bile composition in patients with gallstone disease undergoing cholecystectomy.

METHODS

Gallbladder emptying, cholesterol saturation index (CSI) and nucleation time were studied in 21 patients with gallstone disease. Eleven patients (cisapride group, age 41.9 +/- 2.9 years) received tablet cisapride 10 mg t.i.d. for 2 weeks, while 10 patients (placebo group, age 42.1 +/- 1.9 years) received placebo for the same duration. Gallbladder emptying was repeated in all patients after a 2-week treatment with cisapride or placebo. Gallbladder bile was obtained at the time of surgery for the measurement of CSI and nucleation time.

RESULTS

Residual volume of the gallbladder decreased (mean +/- SE, 18.6 +/- 2.5 mL vs 10.0 +/- 1.1 mL, P = 0.007), and the ejection fraction increased (43.5 +/- 5.3% vs 60.0 +/- 3.2%, P = 0.007) in patients in the cisapride group, while no change was observed in placebo group patients. Nucleation time was higher in the cisapride group than in the placebo group (14.9 +/- 1.3 days vs 8.0 +/- 0.9 days, P = 0.003). Patients in the cisapride group had a significantly lower cholesterol concentration (molar percentage, 5.1 +/- 0.3% vs 6.8 +/- 0.8%, P = 0.049) and CSI (1.0 +/- 0.1 vs 1.36 +/- 0.11, P = 0.034) than patients in the placebo group.

CONCLUSION

Cisapride improves gallbladder emptying and bile lithogenicity in patients with gallstone disease.

Complete diphallia associated with features of covered exstrophy

This report describes a 1-day-old boy with complete true diphallia associated with features of covered or pseudo-exstrophy and an anorectal malformation. The urinary bladder and rectum were single. A divided sigmoid colostomy was constructed at birth for the anorectal anomaly. Complete diphallia and its likely embryogenesis are discussed.

Massive amebic liver abscess--an unusual presentation

A 40-year-old woman presented with a huge lump in the right half of the abdomen and irregular menses. Ultrasonography showed a cystic lump with septations, extending from the upper abdomen to the pelvis; the right ovary was not seen. On exploration, there was a large cyst arising from the right lobe of the liver; the aspirate was bilious. Since the cyst wall was adherent to retroperitoneal structures, complete excision was not possible. A roux-en-Y loop of jejunum was anastomosed to the cyst wall. Biopsy of the wall showed inflammatory granulation tissue with trophozoites of Entamoeba histolytica. She was treated with metronidazole, and recovered uneventfully.

Adsorption-desorption behaviour of flufenacet in five different soils of India

Adsorption-desorption of the herbicide flufenacet (FOE 5043) has been studied in five soils from different locations in India (Delhi, Ranchi, Nagpur, Kerala and Assam) varying in their physicochemical properties. The organic matter (OM) content varied from 0.072 to 0.864%, clay content from 2.5 to 43.7% and pH from 4.45 to 8.35. The adsorption studies were carried out using a batch equilibration technique. Ten grams of soil were equilibrated with 20 ml of aqueous 0.01 M CaCl2 solution containing different concentrations (0-30 mg litre-1) of flufenacet. After equilibration, an aliquot of supernatant was taken out for analysis. During desorption, the amount withdrawn for analysis was replenished with fresh 0.01 M CaCl2 solution and further equilibrated. Desorption studies were carried out with the 30 mg litre-1 concentration of flufenacet only. The adsorption studies revealed that there was moderate to high adsorption of flufenacet considering the comparatively low organic carbon content in the five test soils. Average Kd values ranged from 0.77 to 4.52 and Freundlich KF values from 0.76 to 4.39. The highest adsorption was observed in Kerala soil (OM 0.786%; clay 25%; pH 4.45) followed by Ranchi, Nagpur and Delhi soils, and the lowest in Assam soil (OM 0.553%; clay 2.5%; pH 6.87). The trend in adsorption could be attributed to the chemical nature of flufenacet and the physicochemical properties of the soil such as pH, OM and clay contents. OM and clay contents were positively correlated whereas pH was negatively correlated. Soils having low pH, high OM and high clay contents showed higher adsorption. Desorption studies revealed that there was a hysteresis effect in all the soils. Hysteresis coefficient values (ratio of n(ad) and n(des)) varied from 0.09 to 0.45. The study implies that, because of its moderate to high adsorption, flufenacet is likely to persist in soil for some time. However, the possibility of its movement by leaching or surface run off is less.

Effects of gum resin of Boswellia serrata in patients with chronic colitis

Patients studied here suffered from chronic colitis characterized by vague lower abdominal pain, bleeding per rectum with diarrhoea and palpable tender descending and sigmoid colon. The inflammatory process in colitis is associated with increased formation of leukotrienes causing chemotaxis, chemokinesis, synthesis of superoxide radicals and release of lysosomal enzymes by phagocytes. The key enzyme for leukotriene biosynthesis is 5-lipoxygenase. Boswellic acids were found to be non-redox, non-competitive specific inhibitors of the enzyme 5-lipoxygenase. We studied the gum resin of Boswellia serrata for the treatment of this disease. Thirty patients, 17 males and 13 females in the age range of 18 to 48 years with chronic colitis were included in this study. Twenty patients were given a preparation of the gum resin of Boswellia serrata (900 mg daily divided in three doses for 6 weeks) and ten patients were given sulfasalazine (3 gm daily divided in three doses for 6 weeks) and served as controls. Out of 20 patients treated with Boswellia gum resin 18 patients showed an improvement in one or more of the parameters: including stool properties, histopathology as well as scanning electron microscopy, besides haemoglobin, serum iron, calcium, phosphorus, proteins, total leukocytes and eosinophils. In the control group 6 out of 10 patients showed similar results with the same parameters. Out of 20 patients treated with Boswellia gum resin 14 went into remission while in case of sulfasalazine remission rate was 4 out of 10. In conclusion, this study shows that a gum resin preparation from Boswellia serrata could be effective in the treatment of chronic colitis with minimal side effects.

Predicting anti-HIV activity: computational approach using a novel topological descriptor

The discriminating power of a novel topological descriptor termed as eccentric adjacency index in the estimation of anti-HIV activity, for a data set of 107 1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine (HEPT) derivatives was investigated in the present study. The value of eccentric adjacency index of each derivative was computed and active range was identified using moving average analysis. Subsequently, each derivative was assigned a biological activity which was then compared with the reported anti-HIV activity. The accuracy of prediction was found to be more than ninety percent in the active range using eccentric adjacency index. The proposed index offers a vast potential for structure-activity/property studies.

Covert fears and anxiety in asthma and congenital heart disease

AIM

To compare anxiety, fears and behavioural problems in children with asthma and children with congenital heart disease, and with the normative population. To also review the influence of maternal anxiety, time since diagnosis and severity of disease.

DESIGN

Children administered Fear Survey Scale (FSSC-R) and Child Manifest Anxiety Scale (R-CMAS). Mothers given Child Behaviour Checklist (CBCL) and State Trait Anxiety Scale (STAI-S and STAI-T). Normative means and SDs compared with means and SDs for both medical groups. The mother's scores on the STAI-S and STAI-T scales were correlated with the child's scores on the FSSC-R and the R-CMAS.

SETTING

Outpatient Asthma and Cardiology multidisciplinary Clinics at a tertiary care paediatric facility, Alberta Children's Hospital.

SUBJECTS

Forty children with asthma (aged 6--17 years) were compared with 39 children with congenital heart disease. Intake questionnaires and interviews determined these children to be without obvious psycho-social problems.

RESULTS

Children with asthma and children with congenital heart disease had more medical fears, and more physiological anxiety than normative samples. Increased maternal anxiety was correlated in both groups with increased child anxiety, medical fears and behavioural problems in the child. Similarly, increased severity of asthma or cardiac problems was associated with more physiological anxiety and more fears. Less time since diagnosis of the disease adversely affected social interactions in both groups of children.

CONCLUSION

Physiological anxiety, medical fears and maternal anxiety are important issues requiring attention in asthma and cardiac disease, even in the absence of obvious psychosocial problems. There may be specific problems with a recent diagnosis of a chronic illness.

Female pseudohermaphroditism associated with cloacal anomalies: faulty differentiation in the caudal developmental field

A 1(1/2)-year-old girl with a urogenital sinus defect associated with an enlarged phalluslike clitoris is described. The child had an anteriorly located anus, a single kidney with grade III vesicoureteric reflux, a 3.5-cm-long common urethrovaginal channel, a large vesical calculus, and a hamartoma in the pubic region. After a preliminary colostomy, definitive surgery consisted of urethral reconstruction, vaginal reconstruction using a colonic graft, and posterior relocation of the anus. The discussion centers on a review of the previously reported cases of female pseudohermaphroditism associated with cloacal or urogenital sinus defects (FPHCD). The likely embryogenesis of this condition is discussed, and the similarity of the features with those seen in some patients with complete penoscrotal transposition (CPST) is highlighted.

Superficial temporal artery biopsy diagnostic for lung carcinoma

PURPOSE

To report a unique finding of metastatic tumor cells in the lumen of a superficial temporal artery biopsy specimen in a patient with severe visual loss and optic neuropathy.

METHODS

Case report.

RESULTS

A 69-year-old man presented with anorexia, pancranial headaches, and acute unilateral visual loss. Ophthalmic examination showed a visual acuity of no light perception and an amaurotic pupil in the left eye. Fundus examination was normal. A superficial temporal artery biopsy, performed for presumed arteritic posterior ischemic optic neuropathy, demonstrated intraluminal cells with irregular nuclei and prominent nucleoli suggestive of metastatic malignancy. Further systemic evaluation uncovered a poorly differentiated adenocarcinoma of the lung with intravascular infiltration and multiple distant metastases.

CONCLUSION

Extensive systemic intravascular tumor embolization may be associated with optic neuropathy.

Molecular steps of tumor necrosis factor receptor-mediated apoptosis

Until recently it was believed that TNF-induced apoptosis is mediated exclusively by TNF-RI because TNF-RII lacks death domain. However, it has been demonstrated that TNF-RII enhances TNF-RI-mediated apoptosis. In this review, I have discussed the evidence and mechanisms by which TNF-RII regulates TNF-alpha-induced apoptosis. A role of RIP is emphasized and novel mechanisms of FLIP-mediated inhibition of apoptosis are discussed. In addition, various mechanisms of TNF-induced activation of mitochondrial pathway of apoptosis have been reviewed.

Infectious disease dynamics: What characterizes a successful invader?

Against the background of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and other potentially emerging (or re-emerging) infectious diseases, this review will focus on the properties which enable an infectious agent to establish and maintain itself within a specified host population. We shall emphasize that for a pathogen to cross a species barrier is one thing, but for it successfully to maintain itself in the new population is must have a 'basic reproductive number', R(0), which satisfies R(0) > 1. We shall further discuss how behavioural factors interweave with the basic biology of the production of transmission stages by the pathogen, all subject to possible secular changes, to determine the magnitude of R(0). Although primarily focusing on HIV and AIDS, we shall review wider aspects of these questions.

The epidemic behavior of the hepatitis C virus

Hepatitis C virus (HCV) is a leading worldwide cause of liver disease. Here, we use a new model of HCV spread to investigate the epidemic behavior of the virus and to estimate its basic reproductive number from gene sequence data. We find significant differences in epidemic behavior among HCV subtypes and suggest that these differences are largely the result of subtype-specific transmission patterns. Our model builds a bridge between the disciplines of population genetics and mathematical epidemiology by using pathogen gene sequences to infer the population dynamic history of an infectious disease.

Nitric oxide suppresses IL-8 transcription by inhibiting c-Jun N-terminal kinase-induced AP-1 activation

The role of activator protein-1 (AP-1) in tumor necrosis factor-alpha (TNF-alpha)-induced interleukin-8 (IL-8) gene expression was evaluated. We showed that TNF-alpha activates AP-1 in the transformed endothelial cell line ECV304 by transient transfections of IL-8 promoter construct pGL-3BF(2). Mutation of either the AP-1 site or the NF-IL-6 site on the IL-8 promoter suppressed the TNF-alpha-induced activation, suggesting cooperation between these transcription factors and transcription factor NF-kappaB. Overexpression of dominant negative mutants of c-Jun suppressed AP-1-driven transcription of the IL-8 promoter following stimulation by TNF-alpha, suggesting that cooperative interaction between AP-1 and NF-kappaB is essential for IL-8 transcription in the presence of TNF-alpha. We also showed that nitric oxide (NO), in the form of an exogenous NO donor, suppressed the level of activation of the AP-1 subunit, c-Jun, by down-regulation of c-Jun NH2 terminal kinase. This down-regulation could be the putative mechanism of action for NO-mediated inhibition of IL-8 secretion in activated endothelium. These observations suggest for the first time that NO has broad suppressive activities on various proinflammatory effectors in activated endothelium.

Mucocutaneous manifestations of secondary syphilis in north Indian patients: a changing scenario?

During the 1990s, no studies of various clinical presentations of syphilis have been published in the indexed literature. However, a change in the clinical profile of secondary syphilis was expected during the last decade with the rapid spread of the HIV epidemic. The objective was to study the mucocutaneous manifestations of secondary syphilis in patients attending the STD clinic at the Postgraduate Institute of Medical Education & Research Chandigarh, India, during the last decade and to compare them with other similar studies published during the 1980s. All patients who were diagnosed with secondary syphilis in our STD clinic from 1990 to 1999 were examined and investigated. Serological response was measured at 3, 6, 9, 12, and 24 months post-treatment or until serological negativity was reached. Fifty-three patients (males = 34, female = 19) during this period were found to have secondary syphilis. The most common symptoms were as follows-skin rash 38 (71.7%), lymphadenopathy 26 (49%), persistent chancre 4 (7.5%), nodular syphilides 2 (3.8%), lues maligna 2 (3.8%), patches in the oral mucosa 6 (11.3%), condylomata lata 14 (26.4%), split papules 2 (3.8%). Five patients had a thin and conspicuous genital scar of the healed primary chancre. Three patients were HIV seropositive (1 patient each with lues maligna, lichenoid, and nodular syphilides). With the spread of the HIV epidemic, atypical muco-cutaneous manifestations of secondary syphilis may be seen more frequently than before and may pose problems in diagnosis. In the present study, six patients had atypical manifestations, and three of them were HIV seropositive.

Cervical cerclage in the second trimester of pregnancy: a historical cohort study

OBJECTIVE

The purpose of this study was to compare second-trimester transvaginal cervical cerclage with conservative management on duration of pregnancy and perinatal outcome in patients with early or advanced cervical changes.

STUDY DESIGN

A historical cohort analysis was performed. Maternal and neonatal records between 1995 and 1999 were retrospectively reviewed for women presenting between 18 and 27 weeks of gestation with early cervical changes (length <3 cm, dilatation <2 cm, funneling of fetal membranes shown by transvaginal ultrasonography) (group 1, n = 31) and for women with advanced cervical effacement and dilatation (cervical dilatation > or =2 cm but < or =5 cm, fetal membranes visible) (group 2, n = 39). In each group, patients who underwent Shirodkar or McDonald cerclage were compared with patients treated conservatively with bed rest. Both groups also received multifactorial treatment with tocolytic agents, broad-spectrum antibiotics, and indomethacin. Outcome variables were analyzed for statistical significance by parametric and nonparametric methods.

RESULTS

Regardless of treatment method, patients with early cervical changes (group 1) were given a diagnosis earlier and delivered later in pregnancy compared with their counterparts who had advanced cervical changes (group 2) (P <.05). In both patients who underwent cerclage and those treated conservatively, the mean birth weight among surviving infants was higher and the mean neonatal intensive care unit stay was shorter in group 1 than in group 2 (P <.02). However, duration of maternal hospital stay and neonatal survival rates were not different. In both groups 1 and 2, the interval from treatment to delivery, the mean gestational age at delivery, and mean birth weight were increased, whereas neonatal intensive care unit stay was decreased by cerclage treatment (P <.05). In group 1, a higher percentage of patients treated with cerclage received antibiotics and indomethacin than did control subjects (P <.01), whereas in group 2, the use of multifactorial treatment was not different (P =.5). The duration of maternal hospital stay and neonatal survival did not differ significantly among patients treated conservatively or with cerclage.

CONCLUSIONS

Diagnosis of premature cervical changes by ultrasonography was correlated with treatment earlier in gestation and with a favorable impact on perinatal outcome in both patients treated with cerclage and those treated conservatively. Cervical cerclage was associated with an improved perinatal outcome (in comparison with conservative therapy) in women with early cervical changes detected by ultrasonography and in patients with advanced cervical dilatation and visible membranes. However, the apparent therapeutic effect of cerclage in patients with mild cervical incompetence may be due in part to an increased use of antibiotics and indomethacin in conjunction with cerclage.

A Semiparametric Deconvolution Model to Establish In Vivo–In Vitro Correlation Applied to OROS Oxybutynin

In vitro-in vivo correlation (IVIVC) models may be used to predict in vivo drug concentration-time profiles given in vitro release characteristics of a drug. This prediction is accomplished by incorporating in vitro release characteristics as an input function (A(vitro)) to a pharmacokinetics model. This simple approach often results in biased predictions of observed in vivo drug concentrations, and it can result in rejecting IVIVC. To solve this problem we propose a population IVIVC model that incorporates the in vitro information and allows one to quantify possibly changed in vivo release characteristic. The model assumes linear kinetics and describes the in vivo release as a sum of A(vitro) and a nonparametric function (A(d), a spline) representing the difference in release due to in vivo conditions. The function A(vitro) and its variability enter the model as a prior distribution. The function A(d) is estimated together with its intersubject variability. The number of parameters associated with A(d) defines the model: no parameters indicates perfect IVIVC, a large number of parameters indicates poor IVIVC. The number of parameters is determined using statistical model selection criteria. We demonstrate the approach to solve the IVIVC problem of an oral extended release oxybutynin form (OROS), administered in three pharmacokinetic studies. These studies present a particular challenging case; that is, the relative bioavailability for the OROS administration is >100% compared with that of the immediate-release form. The result of our modeling shows that the apparent lack of IVIVC can be overcome: in vivo concentration can be predicted (within or across data sets) based on in vitro release rate together with a simple form of systematic deviation from the in vitro release.

Efficacy and safety of sparfloxacin in combination with kanamycin and ethionamide in multidrug-resistant pulmonary tuberculosis patients: preliminary results

SETTING

Department of tuberculosis and chest diseases of a tertiary referral tuberculosis institute in New Delhi, India.

OBJECTIVE

To study the efficacy and safety of sparfloxacin, in combination with kanamycin (for the initial 3-4 months) and ethionamide, in multidrug-resistant (MDR) pulmonary tuberculosis patients.

DESIGN

Prospective, uncontrolled study of nine patients with pulmonary tuberculosis who had received adequate anti-tuberculosis treatment with first-line drugs, including supervised category II treatment regimen as per World Health Organization guidelines for 5 months, and were still sputum smear acid-fast bacilli positive. It was planned to give them kanamycin (initial 3-4 months), ethionamide and sparfloxacin for 2 years.

RESULTS

All nine patients achieved sputum conversion within 6 months. Seven patients converted within 3.5 months, two of these within 1 month. All patients reported improvement in clinical symptoms, and chest X-ray improved in seven patients. Four patients developed mild to moderate phototoxicity. Eight patients have completed treatment for an average of 19 months (range 15-24 months), and are still under follow-up. One patient defaulted after 7 months of treatment.

CONCLUSIONS

In MDR-TB patients, sparfloxacin, along with other anti-tuberculosis drugs, appears to be effective and safe. Mild to moderate phototoxicity is common. However, the long-term results, including relapses, are still awaited.

"Pot-lid" technique for aesthetic removal of small lipoma on the face

BACKGROUND

Patients presenting with an asymptomatic subcutaneous facial lipoma desire its removal in order to restore the contour of the face. The standard treatment for lipoma is excision, with the size of the incision being about one-half of that of the tumor itself. The long linear scar resulting from simple excision may fail to improve the appearance of the patient. The removal of the lipoma through a small incision or a punch hole decreases the size of the resulting scar, but does not eliminate it completely.

OBJECTIVE

To improve the aesthetic outcome of the commonly used technique for lipoma removal, known as the narrow hole extrusion technique (NHET), by modification.

METHODS

Four patients (three men and one woman) with small lipomas on the face (three on the forehead and one on the cheek) were selected for the procedure. A 5-mm punch was inserted deep into the center of the lesion to create a circular hole. The punched-out piece of skin was kept in normal saline. The lipoma was extruded with the help of a hemostat and by squeezing pressure. This resulted in the formation of a subcutaneous cavity. After achieving hemostasis, two absorbable buried subcutaneous sutures were placed to create support for the graft. The punched-out piece of skin was then positioned to cover the defect, like a "lid on a pot" and dressed.

RESULTS

The color and texture match of the graft with the surrounding skin were excellent in three of the four patients by the end of 6 months. The graft, which was depressed in the fourth patient, improved through spot dermabrasion.

CONCLUSION

The proposed modification of the NHET for lipoma removal improves the cosmetic outcome.