A rare case of duodenal inversum- A laparoscopically manageable entity

Duodenal inversum is a rare disease not frequently encountered in clinical practice. The diagnosis is usually made late due to its rarity. Many other causes of abdominal pain like ulcer disease, pancreatitis, malrotation are mostly thought of initially and the diagnosis is usually missed. Only a few cases of duodenal inversum present with outlet obstruction. Duodenojejunostomy is perhaps the ideal management for duodenal inversum if the patient presents with outlet obstruction. Our intention is to create awareness of such a rare disease with an available definitive treatment option in the form of minimally invasive surgery. One such case of a 31-year-old man is described that was successfully managed by laparoscopic duodenojejunostomy.

Public Engagement With and Recognition of the “Be Cancer Alert Campaign” - Colorectal Cancer Awareness

Background: Colorectal cancer is the most common cancers in males in Malaysia and the second most common cancer in females. Low awareness of cancer delays help-seeking and contributes to late presentation, poor detection and survival. We developed a culturally sensitive mass media campaign to increase awareness about the signs and symptoms of colorectal cancer among Malaysians, which was informed by previously successful campaigns in Northern Ireland. Aim: The aim of this study is to analyze the public engagement with the campaign on social media and to identify whether the public recognizes the campaign materials postintervention. Methods: Focus group discussions informed the cultural adaptation of the Be Cancer Alert Campaign - Colorectal Cancer (BCAC-CRC). Based on the focus discussions we developed a TV commercial and radio advertisement as well as a print advertisement campaign. In addition, we promoted the BCAC through a Web site and social media campaign. The BCAC-CRC will run from the 2nd of April for five weeks. The engagement with the Web site and the social media campaign will be analyzed on a daily basis to respond to public engagement immediately. A population-based survey postintervention including a randomly selected sample of approximately 700 participants will evaluate whether people recall the campaign key messages and have noticed the campaign materials. Results: Postintervention data collection will take place from May-July 2018. The results of the analysis will be presented at the conference. Conclusion: To our knowledge, the BCAC-CRC is the first colorectal cancer awareness campaign in Malaysia that will be evaluated for its public engagement on social media as well as public recognition of the TV, radio and print materials.

Halting the Comeback of “Kiddie Packs”: Defeating an Invisible Enemy

Background and context: “Kiddie packs”–packs of 10 or fewer cigarettes–have been banned in Malaysia in 2010. In August 2017, however, tobacco control civil society organizations (CSOs) were informed that the tobacco industry had approached the Malaysian government on this issue, claiming that a “return” would increase the government’s tobacco tax revenue. Unfortunately, this news was not formalised and CSOs were not allowed to reveal the source. We thus could not implement direction action organizing, and the media is much less likely to respond to “smoke without fires”. Aim: To stop the return of kiddie packs. Strategy/Tactics: Through discussions on a WhatsApp group, CSOs launched a “divide and conquer” battle. After a CSO took the risk and leaked the information to media (without revealing its source), many groups built on the voice, and “smoked out” the enemy. A few CSOs tackled a different front, including using social media to gather voices, rallying the support of policymakers, other ministers, and nonhealth civil societies, and coordinating a visit to the government. Program/Policy process: After a CSO disclosed the “kiddie pack” news to the largest selling daily newspaper, many groups followed up with interviews, media statements and letters. Meantime, another CSO reached out to its network of policymakers and nonhealth CSOs for support, and sent briefing points or draft “letters to the government” with key messages that tailored to the senders´ specialty (human rights, environment, etc.) When a protobacco retailer announced it had 3200 signatures from their members, one CSO launched an online petition on its Facebook page, shared the effects of kiddie packs on adolescents, and gathered 10 times the signature within a month. The final effort was a visit to the government - a tactic used by the e-cigarette industry previously - to submit the signatures and statement. Outcomes: The “leak” resulted in a front page coverage, allowing the Health Minister to state his views, and other CSOs to use it as a platform to voice their protest. It was also publicised in mainstream as well as online news in different languages. Within two weeks, the tobacco industry finally revealed its intention, and coordinated its media responses through its supporters. Each of these responses were met - point by point–by CSOs, resulting in at least 20 published “letters”. Nearly 40,400 (online and offline) signatures were gathered, representing 57 CSOs. To date, kiddie packs have not made a “return”. What was learned: Instant messaging applications and social media tools can replace meetings and on-the-ground efforts, especially when CSOs lack funds, time, and human resources. Also, great campaigns should consist of general (e.g., writing to the media) as well as specialized (social media, networking with policymakers) efforts. This allows different CSOs to focus their strengths, avoid redundant tasks or “working in silos”, and have every contribution count.

Colorectal Cancer Awareness and Beliefs in Malaysia: A Population-Based Survey

Background: Colorectal cancer (CRC) is the third most common cancer and the fourth major cause of cancer deaths globally; in Malaysia, CRC is the second most common cancer in both males and females. Low awareness of cancer delays help-seeking and contributes to late presentation, poor detection and survival. Aim: We aim to investigate the level of colorectal cancer awareness and beliefs among the Gombak district population of Malaysia as part of a larger study designed to evaluate a cancer awareness-raising campaign. Methods: A survey of colorectal cancer awareness was conducted in Rawang (Gombak district, Selangor) between January and March 2018. This district is representative of a mix of ethnicities, age groups, education levels and income groups. A total of 4000 households were selected randomly from a list of all households by the Government Department of Statistics Malaysia to attain a sample size of 730 adults as indicated by our power calculation and taking potential refusals into account. Trained enumerators randomly selected eligible adults aged over 40 years old from each household and conducted an interview that included sociodemographic information as well as the Bowel Cancer Awareness Measure (CAM), the Attitudes and Beliefs about Cancer questionnaire (ABC) and the Champion Health Belief Model Scale (CHBMS) which were validated in Malaysia. Results: Data collection for this part of the larger study was completed in March. Currently, we are cleaning and entering the survey data into a database in preparation for statistical analysis including χ2 tests of association and logistic regression. The results of the analysis will be presented at the conference. Conclusion: This analysis will provide the first profile of awareness and beliefs about colorectal cancer among the Gombak district population of Malaysia.

Navigating Muddy Waters: Clearing Waves While Keeping Ourselves Afloat

Background and context: As the oldest cancer-related nongovernmental organization in Malaysia, the National Cancer Society of Malaysia regularly receives proposals for collaborations. While many are mutually beneficial, some are “risky”. Examples include partnerships with fast food companies, health supplements which benefits are vastly exaggerated, or fundraisers being held at bars or pubs. While these campaigns are accepted norms within the region, they might not conform to the standards of more mature markets. As we are expected to promote these activities or products on our digital media accounts, we risk overcrowding our pages, or being perceived as endorsing a product or behavior. Aim: Keeping donors happy while maintaining credibility Strategy/Tactics: The current strategy for NCSM's digital outreach is to focus on education/awareness instead of marketing. Also, we match the campaign's values with that of NCSM when deciding whether to promote it. When promoting a campaign, we stay neutral or personalise the donation. Above all, we play “devil's advocate”, focus on the impact of the funds raised, and stay firm on our decision. Program/Policy process: Out of 12 social media posts each week, no more than 2 is on marketing campaigns. Donors, instead of the product, are featured in a personalised “Why I Give” post. At times, we also prioritize well-meaning campaigns over others. For fundraisers held in bars/pubs, we ask for compromises (e.g., to ban smoking in the area for a short time, or that we do not promote the alcohol manufacturer). We are also proactive in checking the promotional content and insist that the donor remove any unproven information. Outcomes: NCSM's Facebook page grew organically (without ad buys) from 4000 in 2016 to 15,000 in 2017. We have about 60 new followers each week, negligible “unfollows” even on marketing-heavy times, and a minimum reach of 15,000 people. Education content is more popular (2300 reach per post versus 400); the same trend is observed for personalised versus product-based posts (3700 vs 400). To date, we have good relationships with our donors, and have not received comments on any partnerships. What was learned: It's intention, and not visual or monetary value, that counts: our audiences are more appreciative of quality content, even if marketing/product posts might look better. Also, staff and survivors can sense sincere donors, which makes a difference in our promotional efforts (positive versus matter-of-fact tones). Well-meaning donors do adhere to our promotion guidelines, and do agree to not being promoted. In addition, featuring donors is a great way to publicise an activity without mentioning the product. Most importantly, being able to justify collaborations within the organization protects its integrity and credibility.

A Rare Association of Obesity, Diabetes Mellitus and Bilateral Cryptorchidism: Prader - Willi Syndrome

Prader-Willi syndrome is a genomic imprinting disorder, characterized by obesity, hyperphagia, mental retardation, short stature and hypogonadism. The presenting signs and symptoms depend upon the age at which the patient is seen. Here we report a case of Prader-Willi syndrome, who presented at 16 years of age with diabetes mellitus and cryptorchidism.

Intra-Individual Variation in Serum AZT Concentration is Not Related to Intestinal Absorption or Small Intestinal Inflammatory Changes in Human Immunodeficiency Virus-Infected Subjects

3′-Azido-3′-deoxythymidine (AZT; zidovudine) either alone or in combination with didanosine or another nucleoside analogue is the first-line treatment for patients with human immunodeficiency virus (HIV) infection, many of whom have concurrent gastrointestinal (GI) disease. This study assessed whether the absorption of AZT was affected by GI disease. The absorption and pharmacokinetics of AZT in 23 HIV-infected individuals was measured after a single dose of AZT and was related in 12 patients to small intestinal function. Levels of AZT and its metabolite 5′-glucopyranuronosylthymidine (G-AZT) were measured by radioimmunoassay. Intestinal permeability was assessed by differential urinary excretion of orally administered lactulose/1-rhamnose; absorptive capacity was measured simultaneously by the urinary excretion of 3-o-methyl-D-glucose, d-xylose and 1-rhamnose. Small intestinal inflammation was assessed by faecal excretion of indium-labelled neutrophils. Peak levels of AZT in serum varied between 170 and 1820 ng mL−1. The metabolite G-AZT was present in serum at peak concentrations varying from 1020 to 9930 ng mL−1. There was up to a sevenfold variation in the area under the curve (AUC). The time to maximum serum concentration for AZT was between 30 and 120 min, with an absorption half-life of between 2 and 38 min. The median elimination half-life was 57 min (range 46–72 min), close to the predicted half-life of 60 min. Intestinal permeability was increased in six of the 12 subjects studied and eight had evidence of reduced absorptive capacity. Ten of the 12 patients had evidence of small intestinal inflammation. We concluded that neither changes in permeability nor absorptive capacity influenced the absorption of AZT. There was no relationship between the presence of intestinal inflammation and AZT absorption. This study showed a significant intra-individual variation of serum AZT levels which cannot be explained on the basis of altered intestinal absorptive capacity or intestinal inflammatory changes.

Evaluating the reliability of component‐based software systems

Purpose

The purpose of this paper is to evaluate the reliability of individual software components in terms of the probability that each software component performs its intended functionality successfully. The overall software system reliability is evaluated.

Design/methodology/approach

This paper incorporates the reliability behavior of component‐based software system using Markov process.

Findings

It is found that the component‐based software system reliability increases as the component reliability increases.

Originality/value

This paper explores new directions in evaluating the reliability of component‐based software systems for software reliability and offers practical help to researchers and software industries in reliable software development. The proposed software simulation technique will act as a tool for the software quality assurance team for evaluating the reliability of component‐based software systems.

Successful free omental flap and skin graft reconstruction of scalp avulsion injury

For the management of a full-thickness scalp avulsion injury, thorough wound debridement and immediate primary revascularization or a split-thickness skin graft may be necessary. Graft failure may be common situation thereby predisposing the individuals to unnecessary multiple operations. In the recent times, the use of omental graft has gained much popularity. In the present study, we describe an interesting case of chronic non healing scalp ulcer in a young woman who eventually underwent a free omental flap reconstruction with split-thickness skin graft and had satisfactory outcome.

Meckel's Cave Tuberculoma with Unusual Infratemporal Extension

The authors describe a rare case of intracranial tuberculoma of the Meckel's cave and cavernous sinus with extension into the infratemporal fossa causing widening of the foramen ovale and adjacent bone destruction. The rarity of the lesion and the unusual extension of the lesion are presented with a brief review of literature.

Effect of vacuum annealing on the surface chemistry of electrodeposited copper(I) oxide layers as probed by positron annihilation induced auger electron spectroscopy

Vacuum anneal induced changes in the surface layers of electrodeposited copper(I) oxide (Cu2O) were probed by time-of-flight positron annihilation induced Auger electron spectroscopy (TOF-PAES) and by electron induced Auger electron spectroscopy (EAES). Large changes in the intensity of the Cu PAES intensity resulting from isochronal in situ vacuum anneals made at increasing temperatures indicated that, before thermal treatment, the surface was completely covered by a carbonaceous overlayer and that this layer was removed, starting at a temperature between 100 and 200 degrees C, to expose an increasing amount of Cu in the top layer as the anneal temperature was increased. The thickness of this overlayer was estimated to be approximately 4 A based on analysis of the EAES data, and its variation with the thermal anneal temperature was mapped. This study demonstrated the order-of-magnitude enhancement in the sensitivity of PAES to the topmost surface layer in Cu2O relative to the EAES counterpart; factors underlying this contrast are discussed. Finally, the implications of ultrathin carbon layers on semiconductor surfaces are discussed.

Cardiopulmonary bypass in surgery for complex-combined vascular malformation of the lower limb: case report

A 16-year-old boy was referred with features of Parkes Weber syndrome (PWS) involving the right lower limb. He had presented at birth with cutaneous vascular malformations (VM) in the right thigh and at the age of 7 years developed congestive cardiac failure, which was controlled with drugs. He received alpha interferon and steroids during this period without any benefit. He defaulted follow-up and at 12 years of age presented with further enlargement of the VM in the right thigh and leg with skin and soft tissue thickening. At this stage, embolization and subsequent excision of the VM were tried, but the surgery was abandoned because of massive hemorrhage. Over the next 4 years, the boy became totally bedridden because of massive increase in the size of the limb, repeated hemorrhages, and secondary infection of the VM. Right hip disarticulation was considered the best option to improve his quality of life. To prevent uncontrollable hemorrhage during surgery, the disarticulation was done under cardiopulmonary bypass with low circulatory flow. Postoperatively, the patient required intensive care nursing for a week. He is presently ambulatory with crutches. Cardiopulmonary bypass with low flow has been used for treating posttraumatic arteriovenous malformations. However, its use in surgery for PWS has not been reported earlier.

Lingual thyroid--a lesson to learn

We present a case of a middle-aged woman with a mass in the posterior third of the tongue which was diagnosed as a tongue haemangioma. The tumour was successfully excised via a midline mandibular osteotomy and tongue splitting approach. The histopathology examination, however, revealed the 5x4 cms mass to be a lingual thyroid. The salient features of this unusual presentation of a thyroid enlargement will be discussed.

Simultaneous infection with multiple strains of Mycobacterium tuberculosis identified by restriction fragment length polymorphism analysis

Simultaneous infection with multiple strains of Mycobacterium tuberculosis was confirmed in two isolates of a total of 543 culture-positive tuberculosis patients from the Model DOTS area of Thiruvallur, South India, using IS6110 and direct repeat restriction fragment length polymorphism (DR-RFLP). The two isolates showing different intensities of IS6110 band patterns were further analysed by repeating RFLP on their alternate cultures and individual colonies. The results showed respectively two and three distinct IS6110 RFLP patterns, indicating mixed infection. The possibility of cross contamination at laboratory or DNA level was ruled out. Additional DR-RFLP also confirmed infection with multiple strains. This study found evidence of co-infection with two or three different strains of M. tuberculosis, showing distinct RFLP patterns.

A review of burns patients admitted to the Burns Unit of Hospital Universiti Kebangsaan Malaysia

This is a retrospective review of 110 patients admitted to the Burns Units between October 1999 and November 2001. The aim was to determine the burns pattern of patients admitted to hospital UKM. There was an increasing trend for patients admitted. Female to male ratio was 1:2. Children consisted 34% of the total admission. Children had significant higher number of scald burns as compare to adult (p < 0.01). Domestic burns were consist of 75% overall admission. Mean percentage of TBSA (total body surface area) burns was 19%. Thirty percent of patients sustained more than 20% of TBSA. Sixty percent of patients had scald burns. Ninety percents of patients with second degree burns that were treated with biologic membrane dressing or split skin graft. Mean duration of hospital stay was 10 days. Over 70% of patients were discharged within 15 days. Overall mortality rate was 6.3%. The patients who died had significantly larger area of burns of more than 20% TBSA (p < 0.05) and a higher incidence of inhalation injury (p < 0.02). Hence, this study suggests a need for better preventive measures by the authority to prevent burns related accident and the expansion of the service provided by the Burns Unit.

2, 4-diamino-6- hydroxy pyrimidine inhibits NSAIDs induced nitrosyl-complex EPR signals and ulcer in rat jejunum

BACKGROUND

It has been suggested that one aspect of non-steroidal anti-inflammatory drugs induced intestinal damage is due to either uncoupling of mitochondrial oxidative phosphorylation or inhibition of electron transport. We investigated the latter possibility using electron paramagnetic resonance spectroscopy.

RESULTS

Electron paramagnetic studies of NSAIDS on sub-mitochondrial particles revealed that indomethacin, but not with nabumetone, bound to a site near to Complex I and ubiquinone to generate a radical species. Normal rats exhibited prominent [3Fe-4S]ox signals (g approximately 2.01) at 20 K. One hour after indomethacin there was a prominent, intense and broad absorption pattern at (g approximately 2.07) suggesting, appearance of radical species overlapping [3Fe-4S]ox and was unaffected by pretreatment with 2,4 diamino -6-hydroxy pyrimidine. At 24 hrs, when macroscopic ulcers were seen, there was a new signal due to a nitric oxide radical (NO*). In contrast, nabumetone and 2,4 diamino-6-hydroxy pyrimidine pre-treated animals receiving indomethacin exhibited electron paramagnetic resonance spectra identical to those of controls at 24 hrs and neither was associated with small intestinal ulcers. Indomethacin and 2,4 diamino hydroxy pyrimidine pre-treated rats, but not nabumetone, had increased intestinal permeability.

CONCLUSION

The results suggest that the in vivo effects of indomethacin modulate the mitochondrial respiratory chain directly at 1 h and 24 h through formation of nitric oxide. NO* appears to play an important role in the late pathogenic stages of NSAID enteropathy and may be the site for targeted treatment to reduce their toxicity.

Systemic effects of acute terminal ileitis on uninflamed gut aggravate bile acid malabsorption

BACKGROUND

Some patients with terminal ileitis suffer from significant bile acid malabsorption even if the inflammation is locally limited. We hypothesized that inflammation in the terminal ileum may lead to changes in mucosal absorption in more proximal intestinal segments and aggravate bile acid malabsorption.

METHODS

Five hamsters underwent laparotomy and localized instillation of 2,4,6-trinitrobenzenesulfonic acid (TNBS) in 10% ethanol into the last 4 cm of ileum to create terminal ileitis. A control group (n = 5) underwent instillation of saline. Animals were sacrificed after 24 h. Active and passive transport of radiolabeled bile acids was measured in the proximal and terminal ileum and glucose absorption in the jejunum using an everted sleeve technique. Myeloperoxidase (MPO) activity and histomorphology were examined by standard methods.

RESULTS

In animals with ileitis, active bile acid uptake decreased by 84% in the terminal ileum (t test, P <0.001) and by 58% in the proximal ileum (P < 0.05) compared with saline-treated controls. Jejunal glucose absorption decreased by 59% (P < 0.01). Passive bile acid and glucose absorption rates were not significantly changed in any segments of treated animals versus controls. Histological examination of the treated group revealed signs of acute terminal ileitis without changes in the proximal ileum and jejunum. All control tissues were uninflamed. MPO activity was 13-fold increased in the inflamed ileal samples compared with controls (P <0.001). No significant changes were seen in the proximal ileum and jejunum. There was no evidence of reflux of TNBS into proximal ileum. Nominal mucosal surface area values showed no significant changes between groups. Pretreatment of an additional group of hamsters (n = 5) with acetylsalicylic acid before TNBS instillation ameliorated the inflammatory response in the terminal ileum and largely abrogated the negative effects on ileal bile acid absorption.

CONCLUSION

These data suggest that limited acute ileitis impairs active bile acid uptake in the terminal ileum. It also diminishes active bile acid and glucose absorption in more proximal segments of the small intestine, likely by a systemic effect. This systemic effect may aggravate bile acid malabsorption in patients with limited ileitis.

A simple method for measuring of intestinal solute transport in mucosal biopsy specimens

Accurate in vitro measurements of intestinal mucosal solute uptake in humans are often difficult because only small amounts of tissue material are available. We describe a miniaturized everted sleeve method of measuring intestinal solute uptake in endoscopy biopsy samples that combines simplicity, good tissue viability and reproducibility. Biopsies were mounted on a dressmaker needle head stationed immediately over a stirring bar rotating at 1200 rpm. This approach was used to measure taurocholate uptake in sheep and human endoscopy biopsies. Comparison was made to conventional standardized everted sleeve preparations. Na+-dependent uptake rates correlated well among individual sheep (R2 = 0.88, P < 0.05). There was excellent correlation between conventional and biopsy preparations in humans (R2 = 0.98; P < 0.05). The biopsy method overestimated diffusional uptake rates in sheep and humans by two to three fold when compared to conventional everted sleeve preparations. We conclude that this method is valuable to measure Na+-dependent solute uptake rates in biopsy samples from human intestine.

Induction of porcine cytokine mRNA expression after DNA immunization and pseudorabies virus infection

Injection of plasmid DNA encoding pseudorabies virus (PRV) glycoprotein into pig muscle has been shown to result in protective immunity against lethal infection. Here, pigs were vaccinated by a single coinjection of three plasmids encoding PRV glycoproteins gB, gC, and gD, with plasmid expressing porcine granulocytemacrophage colony-stimulating factor (GM-CSF) or porcine interferon-alpha (IFN-alpha). DNA immunization induced a primary T cell-mediated response characterized by low rates of IFN-gamma, interleukin-2 (IL-2), and IL4 mRNA in peripheral blood mononuclear cells (PBMC). Very low rates of PRV-specific IgG1 and the absence of IgG2 were obtained. Codelivery of plasmid expressing GM-CSF or IFN-alpha had no effect on cytokine mRNA expression or on B cell response. After a high virulent challenge, high levels of cytokine mRNA, mainly IFN-gamma, and high secondary antibody (Ab) response were induced in all DNA-vaccinated pigs. Codelivery of GMCSF gene significantly increased both Th immune response (i.e., IFN-gamma and IL-4 mRNA expression) and clinical protection but had no effect on secondary B immune response. Codelivery of IFN-alpha gene had no beneficial effect on secondary T and B cell immune responses.

Uncoupling of intestinal mitochondrial oxidative phosphorylation and inhibition of cyclooxygenase are required for the development of NSAID-enteropathy in the rat

BACKGROUND

The pathogenesis of NSAID-induced gastrointestinal damage is believed to involve a nonprostaglandin dependent effect as well as prostaglandin dependent effects. One suggestion is that the nonprostaglandin mechanism involves uncoupling of mitochondrial oxidative phosphorylation.

AIMS

To assess the role of uncoupling of mitochondrial oxidative phosphorylation in the pathogenesis of small intestinal damage in the rat.

METHODS

We compared key pathophysiologic events in the small bowel following (i) dinitrophenol, an uncoupling agent (ii) parenteral aspirin, to inhibit cyclooxygenase without causing a 'topical' effect and (iii) the two together, using (iv) indomethacin as a positive control.

RESULTS

Dinitrophenol altered intestinal mitochondrial morphology, increased intestinal permeability and caused inflammation without affecting gastric permeability or intestinal prostanoid levels. Parenteral aspirin decreased mucosal prostanoids without affecting intestinal mitochondria in vivo, gastric or intestinal permeability. Aspirin caused no inflammation or ulcers. When dinitrophenol and aspirin were given together the changes in intestinal mitochondrial morphology, permeability, inflammation and prostanoid levels and the macro- and microscopic appearances of intestinal ulcers were similar to indomethacin.

CONCLUSIONS

These studies allow dissociation of the contribution and consequences of uncoupling of mitochondrial oxidative phosphorylation and cyclooxygenase inhibition in the pathophysiology of NSAID enteropathy. While uncoupling of enterocyte mitochondrial oxidative phosphorylation leads to increased intestinal permeability and low grade inflammation, concurrent decreases in mucosal prostanoids appear to be important in the development of ulcers.

Distribution of bile acid absorption and bile acid transporter gene message in the hamster ileum

The apical, Na-dependent, ileal bile acid transporter (IBAT) is critical for the reabsorption of bile acids in the ileum. Bile acid transport capacities as well as the distribution of bile acid transporter messenger ribonucleic acid (mRNA) and transporter protein were studied along the axis of the ileum. Na-dependent and Na-independent taurocholate uptake was measured in the hamster ileum using an everted-sleeve technique. The distribution of IBAT mRNA and protein were mapped by in-situ hybridization, immunohistochemistry, and Western blotting. Na-dependent and Na-independent bile acid uptake rates were highest 1-4 cm before the ileocecal valve (maxima 780 and 120 pmol/mm2 per min, respectively) and decreased proximally and distally. Na-independent absorption was increased in the last 6 cm of the ileum. IBAT mRNA and protein expression were linked closely to the distribution of uptake capacity. IBAT mRNA was more abundant near the crypt-villus junction whereas the protein was expressed evenly along the villus axis. We conclude that Na-dependent and Na-independent bile acid absorption capacities both have distinct distribution curves in the hamster ileum. All ileocytes on villi in the high-uptake area of the ileum express IBAT mRNA and protein.

Multiple foreign bodies (open safety pins) in the oesophagus

Intra luminal hypopharyngeal and oesophageal foreign bodies are common. Among these the incidence of open safety pin is relatively uncommon and the occurrence of multiple open safety pins in the same ' individual is a very rare phenomenon. Removal of one open safety pin itself is a surgical enigma, as inadvertant attempts at removal may cause the pointed end to get impacted submucosally or intramurally or may cause oesophageal tear and calls for the assistance of a thoracic surgeon. This article intends to highlight the occurrence of multiple open safety pins in the lumen of the oesophagus and its difficulty in successful retrieval.

Enantiomers of flurbiprofen can distinguish key pathophysiological steps of NSAID enteropathy in the rat

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal damage by a non-prostaglandin (PG) dependent "topical" action and by inhibiting cyclooxygenase.

AIMS

To discriminate between these two effects by studying some key pathophysiological steps in NSAID enteropathy following administration of (R)- and (S)-flurbiprofen, the racemic mixture, and an uncoupler, dinitrophenol.

METHODS

The effects of dinitrophenol, racemic, (R)-, and (S)-flurbiprofen on mitochondria were assessed in vitro and on key pathophysiological features of small intestinal damage in vivo (ultrastructure by electron microscopy, mucosal prostanoid concentrations, intestinal permeability, inflammation, and ulcer count) in rats.

RESULTS

All the drugs uncoupled mitochondrial oxidative phosphorylation in vitro, caused mitochondrial damage in vivo, and increased intestinal permeability. Dinitrophenol and (R)-flurbiprofen caused no significant decreases in mucosal prostanoid concentrations (apart from a decrease in thromboxane (TX) B2 concentrations following (R)-flurbiprofen) while racemic and (S)- flurbiprofen reduced mucosal prostanoids significantly (PGE, TXB2, and 6-keto-PGF1alpha concentrations by 73-95%). Intestinal inflammation was significantly greater following administration of (S)-flurbiprofen and racemate than with dinitrophenol and (R)-flurbiprofen. No small intestinal ulcers were found following dinitrophenol or (R)-flurbiprofen while both racemic and (S)-flurbiprofen caused numerous ulcers.

CONCLUSIONS

Dinitrophenol and (R)-flurbiprofen show similarities in their actions to uncouple mitochondrial oxidative phosphorylation in vitro, alter mitochondrial morphology in vivo, increase intestinal permeability, and cause mild inflammation without ulcers. Concurrent severe decreases in mucosal prostanoids seem to be the driving force for the development of severe inflammation and ulcers.

Comparison of indomethacin and nimesulide, a selective cyclooxygenase-2 inhibitor, on key pathophysiologic steps in the pathogenesis of nonsteroidal anti-inflammatory drug enteropathy in the rat

BACKGROUND

The predicted gastrointestinal tolerability of specific cyclooxygenase-2 inhibitors could be due to either a lack of 'topical' irritation and/or lack of effect on cyclooxygenase-1.

METHODS

Key pathophysiologic steps (in vitro and in vivo uncoupling, intestinal prostanoid levels (prostaglandin E, thromboxane B2, and 6-keto-prostaglandin F1alpha), intestinal permeability (51Cr-ethylenediaminetetraacetic acid), inflammation (faecal excretion of a granulocyte marker protein), and ulcer counts) in enteropathy induced by nonsteroidal anti-inflammatory drugs were assessed after administration of indomethacin, 10 mg/kg, and 15 (roughly equipotent), 30, and 60 mg/kg of the preferential cyclooxygenase-2 inhibitor nimesulide.

RESULTS

Indomethacin uncoupled oxidative phosphorylation at lower concentrations than nimesulide in vitro. Indomethacin was associated with electron microscopy changes suggestive of uncoupling in 60%-70% of enterocytes examined, whereas nimesulide affected 10%-30% of enterocytes, depending on the dose. Indomethacin increased intestinal permeability and caused inflammation and ulcers with 71%-96% reductions in prostanoid levels. Nimesulide at 15 mg/kg caused no damage, whereas 30 and 60 mg/kg nimesulide were associated with significant decreases in mucosal prostanoids (46%-75%), but only the 60-mg/kg dose caused a transient increase in intestinal permeability. However, at none of the doses did nimesulide cause intestinal inflammation or ulcers.

CONCLUSIONS

These results endorse the idea that selective cyclooxygenase-2 inhibitors may be associated with some gastrointestinal tolerance due to their selectivity for cyclooxygenase-2, inhibiting cyclooxygenase-1 at only very high doses, and reduced topical irritation.

Mitochondrial damage: a possible mechanism of the "topical" phase of NSAID induced injury to the rat intestine

BACKGROUND

The "topical" effect of non-steroidal anti-inflammatory drugs (NSAIDs) seems to be an important cause of NSAID induced gastrointestinal damage.

AIM

To examine the possible mechanism of the "topical" phase of damage in the small intestine.

METHODS

Electron microscopy and subcellular organelle marker enzyme studies were done in rat small intestine after oral administration of indomethacin (doses varied between 5 and 30 mg/kg). The effect of conventional and non-acidic NSAIDs on rat liver mitochondrial respiration was measured in vitro in a Clarke-type oxygen electrode.

RESULTS

The subcellular organelle marker enzymes showed mitochondrial and brush border involvement within an hour of indomethacin administration. Electron microscopy showed dose dependent mitochondrial changes following indomethacin administration consistent with uncoupling of oxidative phosphorylation (or inhibition of electron transport) which were indistinguishable from those seen with the uncoupler dinitrophenol. Parenteral indomethacin caused similar changes, but not in rats with ligated bile ducts. A range of NSAIDs, but not paracetamol or non-acidic NSAIDs which have a favourable gastrointestinal tolerability profile, uncoupled oxidative phosphorylation in vitro at micromolar concentrations and inhibited respiration at higher concentrations. In vivo studies with nabumetone and aspirin further suggested that uncoupling or inhibition of electron transport underlies the "topical" phase of NSAID induced damage.

CONCLUSION

Collectively, these studies suggest that NSAID induced changes in mitochondrial energy production may be an important component of the "topical" phase of damage induction.

Intestinal tolerability of nitroxybutyl-flurbiprofen in rats

BACKGROUND

Nitric oxide derivatives of non-steroidal anti-inflammatory drugs (NSAIDs) are thought to be much less ulcerogenic than their parent compounds.

AIM

To compare the effect and potency of flurbiprofen and nitroxybutyl-flurbiprofen to uncouple mitochondrial oxidative phosphorylation (an early pathogenic event in NSAID enteropathy), increase intestinal permeability (transitional stage), and cause macroscopic small intestinal damage.

METHODS

In vitro uncoupling potency was assessed using isolated coupled rat liver mitochondria and in vivo by electron microscopy of rat small intestinal mucosa (two hours after the drugs). A dose-response study with flurbiprofen (single doses of 5, 10, 20, and 40 mg/kg) and equimolar doses of nitroxybutyl-flurbiprofen was performed; assessing their effect on intestinal permeability (at 18-20 hours), with 51Cr EDTA, and the number of pointed (< 5 mm) and longitudinal (> 5 mm) small intestinal ulcers at 24 hours.

RESULTS

Flurbiprofen, but not nitroxybutyl-flurbiprofen, stimulated coupled respiration in vitro. Both drugs, however, uncoupled in vivo; in the case of nitroxybutyl-flurbiprofen possibly because hydrolysis of its ester bond released free flurbiprofen. Intestinal permeability was uniformly and equally increased with both drugs compared with controls. The number of small intestinal ulcers, pointed and longitudinal, was significantly reduced with nitroxybutyl-flurbiprofen apart from the number of longitudinal ulcers with the highest dose.

CONCLUSIONS

These studies show that nitroxybutyl-flurbiprofen is associated with significantly less macroscopic damage in the small intestine than flurbiprofen but was associated with mitochondrial damage in vivo and caused similar increases in permeability of the small intestine, suggesting that its beneficial effect is on the later pathogenic stages of the damage.

Assessing the site of increased intestinal permeability in coeliac and inflammatory bowel disease

BACKGROUND

The precise site of intestinal permeability changes in patients with coeliac and inflammatory bowel disease is unknown.

AIMS

To design a non-invasive technique for the localisation of altered gastrointestinal permeability to 51chromium labelled EDTA (51CrEDTA). The method depends on comparing and defining concentration/time profiles in serum of a series of simultaneously ingested indicators with a well defined absorption site (3-0-methyl-D-glucose (jejunal indicator), 57cobalt labelled vitamin B12 (ileal indicator), and sulphasalazine (caecal-colonic indicator)) in relation to simultaneously ingested 51CrEDTA.

SUBJECTS

Five normal controls, six patients with untreated coeliac disease, five with Crohn's ileitis, and five with pan-ulcerative colitis underwent study, which entailed the simultaneous ingestion of the above four test substances followed, during the next 24 hours, by timed serial collection of urine and serum for marker analysis.

RESULTS

Urinary excretion of 51CrEDTA was significantly increased in all patient groups. Analysis of serum appearances and profiles of the markers suggested that the increased intestinal permeation of 51CrEDTA took place in the diseased jejunum in patients with coeliac disease, predominantly in the ileum in Crohn's disease and in the colon in the patients with pan-ulcerative colitis.

CONCLUSION

A new non-invasive technique has been assessed that permits the localisation of the site of permeability changes with the gastrointestinal tract.

Intestinal absorptive capacity, intestinal permeability and jejunal histology in HIV and their relation to diarrhoea

Intestinal function is poorly defined in patients with HIV infection. Absorptive capacity and intestinal permeability were assessed using 3-O-methyl-D-glucose, D-xylose, L-rhamnose, and lactulose in 88 HIV infected patients and the findings were correlated with the degree of immunosuppression (CD4 counts), diarrhoea, wasting, intestinal pathogen status, and histomorphometric analysis of jejunal biopsy samples. Malabsorption of 3-O-methyl-D-glucose and D-xylose was prevalent in all groups of patients with AIDS but not in asymptomatic, well patients with HIV. Malabsorption correlated significantly (r = 0.34-0.56, p < 0.005) with the degree of immune suppression and with body mass index. Increased intestinal permeability was found in all subgroups of patients. The changes in absorption-permeability were of comparable severity to those found in patients with untreated coeliac disease. Jejunal histology, however, showed only mild changes in the villus height/crypt depth ratio as compared with subtotal villus atrophy in coeliac disease. Malabsorption and increased intestinal permeability are common in AIDS patients. Malabsorption, which has nutritional implications, relates more to immune suppression than jejunal morphological changes.

Comparison of enteral feeding and total parenteral nutrition after liver transplantation

Total parenteral nutrition is used for nutritional support in patients undergoing orthotopic liver transplantation but is associated with complications. We compared the efficacy and tolerability of early enteral feeding with total parenteral nutrition after liver transplantation. 24 patients were studied: 14 received enteral feeding and 10 total parenteral nutrition. A double-lumen enteral tube was used to deliver the feed directly into the jejunum with the second lumen of the tube being used for gastric aspiration. Enteral feeding was started post-operatively within 18 h, was well-tolerated, and of comparable efficacy to total parenteral nutrition. The median number of days for patients to start eating (4) and to achieve 70% of estimated requirements orally (5) did not differ significantly between the two groups. Mid-arm circumference, triceps skinfold thickness, and biceps skinfold thickness were, by comparison with pre-operative values, maintained on the tenth postoperative day in both groups. Early postoperative absorptive capacity, as assessed by a combined carbohydrate test, was reduced significantly in both groups but insufficiently to be of nutritional concern. Intestinal mucosal integrity, as assessed by an intestinal permeability test, was maintained throughout. We conclude that the practical aspects of enteral feeding after liver transplantation are surmountable and that enteral feeding is as effective at maintaining nutritional status as total parenteral nutrition, and has potential benefits in terms of reduced complications and costs.

The effect of intestinal hypoperfusion on intestinal absorption and permeability during cardiopulmonary bypass

BACKGROUND/AIMS

Mean arterial pressure is reduced during hypothermic cardiopulmonary bypass. The aim of this study was to assess whether this was associated with intestinal hypoperfusion and whether it affected intestinal absorption and permeability.

METHODS

Twenty-six patients undergoing coronary artery bypass grafting underwent an intestinal absorption-permeability test involving ingestion of 3-O-methyl-D-glucose, D-xylose, L-rhamnose, and lactulose. Ingestion took place 2 days before, within 3 hours, and 5 days after hypothermic cardiopulmonary bypass. Hemodynamic parameters and gastric mucosal laser Doppler blood flow were measured perioperatively in eight patients.

RESULTS

Hypothermic (28 degrees C), nonpulsatile cardiopulmonary bypass resulted in a 25% reduction in mean blood pressure, 10% reduction in cardiac index, and a 46% reduction in gastric mucosal laser Doppler blood flow. There was 85.4%, 85.5%, and 73.6% reduction (P < 0.01) in active (3-O-methyl-D-glucose) and passive (D-xylose) carrier-mediated transport and passive, nonmediated transcellular (L-rhamnose) transport in the immediate postoperative period, respectively. The differential urine excretion of lactulose/L-rhamnose increased sixfold. All parameters returned to control levels by the fifth postoperative day.

CONCLUSIONS

Cardiopulmonary bypass, while maintaining generally acceptable levels of hemodynamic performance, is associated with significant intestinal hypoperfusion and malabsorption of monosaccharides, which may have implications for enteral drug treatment in the immediate postoperative period.

Cardiopulmonary bypass impairs small intestinal transport and increases gut permeability

Gastrointestinal damage occurs in 0.6% to 2% of patients after cardiopulmonary bypass (CPB), and carries a mortality of 12% to 67%. The incidence of subclinical gastrointestinal damage may be much greater. We examined the effects of nonpulsatile, hypothermic CPB on intestinal absorption and permeability in 41 patients. Bowel mucosal saccharide transport and permeation were evaluated using 100 mL of an oral solution containing 3-O-methyl-D-glucose (0.2 g), D-xylose (0.5 g), L-rhamnose (1.0 g), and lactulose (5.0 g) to assess active carrier-mediated, passive carrier-mediated, transcellular, and paracellular transport, respectively, with a 5-hour urine analysis. Patients were studied before, immediately after, and 5 days after CPB. Immediately after CPB there was a decrease in urinary excretion of 3-O-methyl-D-glucose (from 34% +/- 2.2% to 5.2% +/- 0.7%; p < 0.0001), D-xylose (from 25.4% +/- 1.4% to 4.1% +/- 0.8%; p < 0.0001), and L-rhamnose (from 8.3% +/- 0.6% to 2.6% +/- 0.4%; p < 0.0001). The permeation of 3-O-methyl-D-glucose and D-xylose returned to normal levels 5 days after CPB, but that of L-rhamnose remained significantly below pre-CPB values at 6.6% +/- 0.5% (p = 0.004). However, the permeation of lactulose increased after CPB (from 0.35% +/- 0.04% to 0.59% +/- 0.1%; p = 0.018), and the lactulose/L-rhamnose gut permeability ratio increased markedly (from 0.045 +/- 0.04 to 0.36 +/- 0.08; normal = 0.06 to 0.08; p = 0.004). Patients who had a CPB time of 100 minutes or more had a greater increase in gut permeability (p = 0.049).(ABSTRACT TRUNCATED AT 250 WORDS)

The role of mitochondrial calcium transport during inflammation and the effect of anti-inflammatory drugs

The effects of inflammation induced by the inoculation of rats with Freund's adjuvant on calcium transport by isolated rat liver mitochondria and on mitochondrial in vivo protein synthesis were investigated. Mitochondria isolated from the liver of inflamed rats exhibited (i) a reduction in 45Ca2+ uptake and, (ii) a reduction in protein synthesis. Addition of ATP to the calcium uptake medium stimulate the uptake in inflamed rat liver mitochondria. After inflammation was controlled by treatment with a mixture of Clerodendron inerme flavonoidal glycosides and indomethacin, rat liver mitochondria showed (i) an increase in 45Ca2+ uptake and, (ii) an increase in mitochondrial in vivo protein synthesis. The mechanism of mitochondrial calcium transport and the mitochondrial protein metabolism during inflammation and after treatment with anti-inflammatory drugs were discussed.

Concentrations of four essential trace elements in breast milk of mothers from two socio-economic groups: preliminary observations

Concentrations are reported for Cu, Mn, Mo and Zn in human milk samples obtained from mothers belonging to low and middle per capita family income groups. The trace element levels in milk of both groups are compared for samples obtained at two stages, viz. 3-5 days and 4-6 weeks post partum. Although the Mn level during the first stage appears to be lower in samples from the low income group, the difference is not statistically significantly (p less than or equal to 0.01). However, at 4-6 weeks post partum, Zn is significantly lower (p less than or equal to 0.01) in milk of mothers belonging to this group.

Distribution of arsenic in human tissues and milk

Using neutron activation followed by radiochemical separations, the arsenic contents of various human tissues and milk were determined. The reliability of analysis was established by analysing a number of standard reference materials. The concentrations in different human tissues range from 1.6 ng As/g (fresh weight) in kidneys to 2140 ng As/g in hair. The mean arsenic levels are compared with those reported from other countries.