Does Adding a Cardia Biopsy Improve Gastric Intestinal Metaplasia Detection Rate by the Sydney System Protocol?

BACKGROUND

The Sydney system offers a standard biopsy protocol for detection and follow-up of gastric preneoplastic lesions such as intestinal metaplasia (IM). The highest frequency of cardia-type gastric adenocarcinoma (GA) in Iran has been documented in the north-western part of the country. This study aims to investigate the effect of the addition of mucosal biopsies of gastric cardia to the standard Sydney protocol on the rate of detection of IM in the asymptomatic residents of this high-risk region for proximal gastric cancer.

METHODS

A retrospective new analysis was performed on the previous data obtained in cross-sectional endoscopic screening in 2000 as well as a biopsy study of 508 asymptomatic volunteer residents in Meshkinshahr district, Ardabil province. The screening study was conducted in a group of residents aged 40 years and older who did not have any previous GI or hemodynamic problems.

RESULTS

Intestinal metaplasia at the Sydney protocol sampling sites was detected in 107 samples belonging to 76 of the 508 (14.99%) volunteers. Twenty-one patients had IM at the cardia. Of these, five patients had IM-cardia (IM only at the cardia). Therefore, adding a cardia biopsy to the set of biopsies diagnosed five more IM cases which were not diagnosed on the standard Sydney protocol (P=0.062).

CONCLUSION

The addition of a biopsy from the cardia to the Sydney protocol biopsy set does not seem to improve the frequency of detection of IM in the residents of this high-risk geographic area for proximal gastric carcinoma.

Psychomotor abilities in diagnostic upper gastrointestinal endoscopy derived from procedural task analysis techniques and expert review

BACKGROUND

Any prediction of a person's ability to succeed in a motor skill depends on the detection and accurate measurement of the basic abilities for the performance of that skill. Task analysis is needed to determine the psychomotor skills and abilities required to perform an action. This study aimed to determine the components of psychomotor abilities for diagnostic upper gastrointestinal (GI) endoscopy through procedural task analysis (PTA) and expert review.

MATERIAL AND METHODS

A multisource, multimethod task analysis was conducted in six metropolitan teaching hospitals affiliated with the adult gastroenterology and hepatology training centers in the Islamic Republic of Iran in 2019. Observation, video-recording, and think-aloud protocols were used while diagnostic upper GI endoscopy was performed. To confirm the accuracy of the PTA, the incorporated the views of the adult gastroenterology and hepatology subspecialty experts through the checklist of PTA assessment criteria. Finally, to determine the psychomotor abilities for each stage of the procedure, the study incorporated a panel of experts from occupational therapy, physical education, physical medicine, and adult gastroenterology and hepatology subspecialty.

RESULTS

Of the 15 psychomotor abilities examined, 11 were determined for upper GI endoscopy procedure, of which six cases (including visuospatial and perceptual abilities, hand-eye coordination, multilimb coordination, finger dexterity, arm-hand steadiness, and manual dexterity) were the most frequent.

CONCLUSIONS

PTA techniques and subsequent expert review were used to identify the components of psychomotor abilities for diagnostic upper GI endoscopy. It is suggested that PTA is performed for other procedures, and after psychomotor abilities are specified, proportional tests are developed.

INSULIN AUTOIMMUNE SYNDROME IN A YOUNG CAUCASIAN WOMAN

A young Caucasian woman presents several episodes of severe fasting hypoglycemia. Fasting lab tests revealed: glycemia 28 mg/dL, insulinemia 143.3 µU/mL, insulin antibodies above 100 U/mL, leading to the diagnosis of insulin autoimmune syndrome. Due to lack of clinical improvement after 2 months, prednisone was started at 0.5 mg/kg/day, and then tapered by 5 mg every 5 days. Three weeks after discontinuing corticotherapy, the patient had no more severe fasting hypoglycemia, but occasionally postprandial mild hypoglycemia. Fasting lab tests showed: glycemia 83 mg/dL, insulinemia 58.6 µU/mL. At 5 hours during oral glucose tolerance test glycemia was 33 mg/dL, insulinemia 152.9 µU/mL.

Comparison of Antifungal Efficacy of Zataria Multiflora and Nystatin for Treatment of Denture Stomatitis: A Randomized Clinical Trial

Statement of the Problem

Zataria multiflora (ZM) is a thyme-like plant that belongs to the Lamiaceae family. It is native to the center and south of Iran, Pakistan, and Afghanistan. Evidence shows that ZM contains thymol and carvacrol and is therefore, effective for the treatment of many conditions especially fungal infections. Oral candidiasis is the most common opportunistic infection of the oral mucosa that plays a role in the development of denture stomatitis.

Purpose

This study aimed to compare the antifungal efficacy of ZM and nystatin suspension for the treatment of denture stomatitis.

Materials and Method

This single-blind clinical trial evaluated 28 patients (> 18 years old) suffering from type II or III denture stomatitis. Patients were divided into two groups. The control group used nystatin suspension while the case group used ZM drop. The number of Candida albicans (C. albicans) colony-forming units (CFUs) and erythema of the palate were evaluated at baseline and at 14 days after treatment. Data were analyzed using SPSS version 11 via Student's t test and repeated measure ANOVA.

Results

The results showed similar efficacy of nystatin and ZM in the reduction of C.albicans CFUs compared to the baseline value (p= 0.593). Both medications significantly decreased the colony count (p< 0.001). Nystatin and ZM had similar efficacy for the reduction of erythema as well (p= 0.256) and both caused a significant reduction in erythema of the palate (p<0.001).

Conclusion

ZM drop was as effective as the nystatin drop in the resolution of erythema of the palate and reduction of C. albicans colony count.

SARS-CoV-2 antibody seroprevalence in the general population and high-risk occupational groups across 18 cities in Iran: a population-based cross-sectional study

Background

Rapid increases in cases of COVID-19 were observed in multiple cities in Iran towards the start of the pandemic. However, the true infection rate remains unknown. We aimed to assess the seroprevalence of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 18 cities of Iran as an indicator of the infection rate.

Methods

In this population-based cross-sectional study, we randomly selected and invited study participants from the general population (from lists of people registered with the Iranian electronic health record system or health-care centres) and a high-risk population of individuals likely to have close social contact with SARS-CoV-2-infected individuals through their occupation (from employee lists provided by relevant agencies or companies, such as supermarket chains) across 18 cities in 17 Iranian provinces. Participants were asked questions on their demographic characteristics, medical history, recent COVID-19-related symptoms, and COVID-19-related exposures. Iran Food and Drug Administration-approved Pishtaz Teb SARS-CoV-2 ELISA kits were used to detect SARS-CoV-2-specific IgG and IgM antibodies in blood samples from participants. Seroprevalence was estimated on the basis of ELISA test results and adjusted for population weighting (by age, sex, and city population size) and test performance (according to our independent validation of sensitivity and specificity).

Findings

From 9181 individuals who were initially contacted between April 17 and June 2, 2020, 243 individuals refused to provide blood samples and 36 did not provide demographic information and were excluded from the analysis. Among the 8902 individuals included in the analysis, 5372 had occupations with a high risk of exposure to SARS-CoV-2 and 3530 were recruited from the general population. The overall population weight-adjusted and test performance-adjusted prevalence of antibody seropositivity in the general population was 17·1% (95% CI 14·6–19·5), implying that 4 265 542 (95% CI 3 659 043–4 887 078) individuals from the 18 cities included were infected by the end of April, 2020. The adjusted seroprevalence of SARS-CoV-2-specific antibodies varied greatly by city, with the highest estimates found in Rasht (72·6% [53·9–92·8]) and Qom (58·5% [37·2–83·9]). The overall population weight-adjusted and test performance-adjusted seroprevalence in the high-risk population was 20·0% (18·5–21·7) and showed little variation between the occupations included.

Interpretations

Seroprevalence is likely to be much higher than the reported prevalence of COVID-19 based on confirmed COVID-19 cases in Iran. Despite high seroprevalence in a few cities, a large proportion of the population is still uninfected. The potential shortcomings of current public health policies should therefore be identified to prevent future epidemic waves in Iran.

Funding

Iranian Ministry of Health and Medical Education.

Translation

For the Farsi translation of the abstract see Supplementary Materials section.

Efficacy of Anti-TNF Therapy for the Treatment of Patients with Moderate-to-Severe Inflammatory Bowel Disease; a First Iranian Report

BACKGROUND The anti-TNF drugs are shown to be highly effective in treatment of patients with moderate-tosevere inflammatory bowel disease (IBD). Here, we aimed to assess the efficacy and safety of antiTNF therapy at the national level. METHODS IBD patients aged 15 > years who received Infliximab and/or CinnoRA® between 2013 to July 2018 were identified. The data extracted from medical dossier and telephonic interview. The efficacy of therapy was defined as time to drug discontinuation or need for IBD-related surgery. The safety was assessed based on patient's reported adverse events. RESULTS We included 315 patients. The mean age of patients was 37.2 years and 62.2% of them developed the disease before age 30 years. Involvement of masculoskeletal system was reported in 7.3% of patients. Partial and complete response to Anti-TNF therapy was seen in 67% of patients. About 16% of patients did not respond to induction therapy and 16.9% of patients lost their response to Anti-TNF during one year. No serious adverse events, serious opportunistic infection, tuberculosis and malignancies reported by patients. Two patients reported pneumonia. CONCLUSION This study for the first time in our country, provides the evidences for efficacy of anti-TNF therapy in moderate to severe IBD patients.

A randomized controlled trial investigating the effect of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols on the intestinal microbiome and inflammation in patients with ulcerative colitis: study protocol for a randomized controlled trial

Background

No conclusive treatment is available for irritable bowel disease (IBD). Adherence to a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) might alleviate clinical symptoms of IBD. However, no study has investigated the effect of low FODMAPs diet on the intestinal microbiota and inflammatory biomarkers in patients with IBD. The aim of current study is to examine the effect a low FODMAP diet on IBD symptoms, inflammation, and the intestinal microbiota in patients with ulcerative colitis.

Methods and analysis

This study is a randomized clinical trial. Thirty patients with mild to moderate ulcerative colitis will be randomly allocated to receive a low FODMAP diet (n = 15) or to continue their usual diet as control (n = 15), for 4 weeks. The quantity of intestinal microbiota including Clostridium cluster IV, Faecalibacterium prausnitzii, Rosburia spp., Lactobacillus spp., Bifidobacteria spp., Akkermansia muciniphila, Bacteroides fragilis, and Ruminococcus spp., and the Firmicutes to Bacteroidetes ratio and calprotectin and lactoferrin levels will be explored in fecal samples from patients. In addition, anthropometric measures and biochemical assessments including serum concentrations of highly sensitive-C reactive protein (hs-CRP), tumour necrosis factor-α (TNF-α) and IL-1β will be taken from patients at baseline and end of the study. The study has been registered in IRCT (IRCT20181126041763N1; registration date: 2019-01-18).

Discussion

Consumption of a low-FODMAP diet might decrease systemic and intestinal inflammation, change the bacterial population in the gut, and modulate clinical symptoms in patients with ulcerative colitis. Further studies investigating the effect of such a diet on other variables, including other bacterial species and inflammatory cytokines, are required to confirm future findings of this trial.

Pharmacological prophylaxis versus pancreatic duct stenting plus pharmacological prophylaxis for prevention of post-ERCP pancreatitis in high risk patients: a randomized trial

BACKGROUND

Acute pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this noninferiority study was to evaluate the effectiveness of pancreatic duct (PD) stenting plus pharmacological prophylaxis vs. pharmacological prophylaxis alone in the prevention of post-ERCP pancreatitis (PEP) in high risk patients.

METHODS

In this randomized, controlled, double-blind, noninferiority trial, patients at high risk of developing PEP were randomly allocated to pharmacological prophylaxis (rectal indomethacin, sublingual isosorbide dinitrate, and intravenous hydration with Ringer's lactate) plus PD stenting (group A) or pharmacological prophylaxis alone (group B). The rate and severity of PEP, serum amylase levels, and length of hospital stay after ERCP were assessed.

RESULTS

During 21 months, a total of 414 patients (mean age 55.5 ± 17.0 years; 60.2 % female) were enrolled (207 in each group). PEP occurred in 59 patients (14.3 %, 95 % confidence interval [CI] 11.1 % - 17.9 %: 26 patients [12.6 %, 95 %CI 8.6 % - 17.6 %] in group A and 33 [15.9 %, 95 %CI 11.4 % - 21.4 %] in group B). There was no significant difference between the two groups in PEP severity (P = 0.59), amylase levels after 2 hours (P = 0.31) or 24 hours (P = 0.08), and length of hospital stay (P = 0.07).

CONCLUSIONS

The study failed to demonstrate noninferiority or inferiority of pharmacological prophylaxis alone compared with PD stenting plus pharmacological prophylaxis in the prevention of PEP in high risk patients.

Iranian Registry of Crohn's and Colitis: study profile of first nation-wide inflammatory bowel disease registry in Middle East

Background/Aims

A recent study revealed increasing incidence and prevalence of inflammatory bowel disease (IBD) in Iran. The Iranian Registry of Crohn’s and Colitis (IRCC) was designed recently to answer the needs. We reported the design, methods of data collection, and aims of IRCC in this paper.

Methods

IRCC is a multicenter prospective registry, which is established with collaboration of more than 100 gastroenterologists from different provinces of Iran. Minimum data set for IRCC was defined according to an international consensus on standard set of outcomes for IBD. A pilot feasibility study was performed on 553 IBD patients with a web-based questionnaire. The reliability of questionnaire evaluated by Cronbach’s α.

Results

All sections of questionnaire had Cronbach’s α of more than 0.6. In pilot study, 312 of participants (56.4%) were male and mean age was 38 years (standard deviation=12.8) and 378 patients (68.35%) had ulcerative colitis, 303 subjects (54,7%) had college education and 358 patients (64.74%) were of Fars ethnicity. We found that 68 (12.3%), 44 (7.9%), and 13 (2.3%) of participants were smokers, hookah and opium users, respectively. History of appendectomy was reported in 58 of patients (10.48%). The most common medication was 5-aminosalicylate (94.39%).

Conclusions

To the best of our knowledge, IRCC is the first national IBD registry in the Middle East and could become a reliable infrastructure for national and international research on IBD. IRCC will improve the quality of care of IBD patients and provide national information for policy makers to better plan for controlling IBD in Iran.

NON-INVASIVE ASSESSMENT OF LIVER STEATOSIS AND FIBROSIS USING TRANSIENT ELASTOGRAPHY AND CONTROLLED ATTENUATION PARAMETER IN TYPE 2 DIABETES PATIENTS

CONTEXT

Nonalcoholic fatty liver disease is common in type 2 diabetes mellitus patients, being difficult to diagnose.

OBJECTIVE

To find a correlation between elastographic parameters and lab results, for facilitating the diagnosis of nonalcoholic fatty liver disease.

DESIGN

This is a cross sectional study, conducted at the Departments of Diabetes, Nutrition and Metabolic Diseases, and Gastroenterology and Hepatology, of the Clinical Emergency Hospital "Pius Brinzeu" Timisoara.

SUBJECTS AND METHODS

We included 190 type 2 diabetes mellitus patients, collected data regarding medical history, clinical and biological features and applied the Alcohol Use Disorders Identification Test. We excluded patients with other causes of liver disease. Liver steatosis and fibrosis were evaluated through transient elastography, yielding two parameters: liver stiffness as an indicator of liver fibrosis stage, expressed in kPa, and liver steatosis stage, assessed by controlled attenuation parameter, expressed in dB/m. Data were analyzed using SPSS 15.

RESULTS

The analyzed group comprised 113 patients. Elastographic measurements showed that 93.8% of the patients had steatosis (controlled attenuation parameter ≥232.5 dB/m) and 70.8% severe steatosis (controlled attenuation parameter ≥290 dB/m). Severe steatosis was more common in women (75.7%) than in men (68.1%) (p<0.0001). From the patients with steatosis, 47.2% had liver stiffness values suggestive for fibrosis and 19.8% for cirrhosis. Most patients with steatosis and severe fibrosis were obese (66.7%). Triglycerides/HDLc ratio >4 correlated with hepatic steatosis (p=0.04), being more common in patients with severe fibrosis/cirrhosis (58.3%) than in those with absent or mild fibrosis (36.2%).

CONCLUSIONS

Our study found a clear correlation between type 2 diabetes mellitus and the presence of liver steatosis. It correlates with body mass index, waist circumference (in men) and triglycerides/HDLc ratio. Controlled attenuation parameter is a useful noninvasive method for detection and quantification of liver steatosis.

VESICOVAGINALS FISTULAS: THE EXPERIENCE OF OUR CLINIC ON SURGICAL TREATMENT AND RESULTS

Vesicovaginals fistulas are the most common type of urogenital fistulas resulting after radical hysterectomy with or without radiotherapy. In most cases, surgery is necessary for healing. The present study was conducted over a period of 5 years. In all cases, the diagnosis was made on medical history, a complete clinical examination, intravenous pyelography and cystoscopy. Surgical closing technique of fistula tract could be applied in 28 cases (68.29%), out of which in 9 (22%) patients the exicision of the fistula tract and separate suture of the bladder and the vagina were performed while in 19 ( 46.3%) patients a flap was interposed too. All 25 patients who presented fistula after radical hysterectomy were feasible to surgical treatment of demolition of fistula and only 3 of 16 (18.75%) of the cases of hysterectomy and radiotherapy had indication for surgical closing technique of fistula tract. In 4 cases (9.7%) an external urinary diversion as the only therapeutic solution was performed. In 3 cases (7.3%) a percutaneous nephrostomy was inserted. Two patients (4.8%) presented vesicovaginal fistula and rectovaginal fistula as well. 24 (85.71%) of the 28 cases that have benefited from surgery remained continent, without loss of urine vaginally after the removal of urethro-bladder catheter. In 13 (31.7%) cases the success could not be obtained due to radiotherapy associated with hysterectomy. In the 25 cases where radiotherapy was not enforced, the success rate of surgery was 92%, while in patients who have benefited from radiotherapy too it goes down drastically (33%).The surgical closing technique of the vesicovaginal fistula has a very high success rate. The success of the operation can be obtained from the first surgery. The associated radiotherapy has a big influence in the approach of this pathology surgery.

The elimination of the onchocerciasis vector from the island of Bioko as a result of larviciding by the WHO African Programme for Onchocerciasis Control

The island of Bioko is part of the Republic of Equatorial Guinea and is the only island in the World to have endemic onchocerciasis. The disease is hyperendemic and shows a forest-type epidemiology with low levels of blindness and high levels of skin disease, and the whole population of 68,000 is estimated to be at risk. Control of onchocerciasis began in 1990 using ivermectin and this yielded significant clinical benefits but transmission was not interrupted. Feasibility and preparatory studies carried out between 1995 and 2002 confirmed the probable isolation of the vector on the island, the high vectorial efficiency of the Bioko form of Simulium yahense, the seasonality of river flow, blackfly breeding and biting densities, and the distribution of the vector breeding sites. It was proposed that larviciding should be carried out from January to April, when most of the island's rivers were dry or too low to support Simulium damnosum s.l., and that most rivers would not need to be treated above 500 m altitude because they were too small to support the breeding of S. damnosum s.l. Larviciding (with temephos) would need to be carried out by helicopter (because of problems of access by land), supplemented by ground-based delivery. Insecticide susceptibility trials showed that the Bioko form was highly susceptible to temephos, and insecticide carry was tested in the rivers by assessing the length of river in which S. damnosum s.l. larvae were killed below a temephos dosing point. Regular fly catching points were established in 1999 to provide pre-control biting densities, and to act as monitoring points for control efforts. An environmental impact assessment concluded that the proposed control programme could be expected to do little damage, and a large-scale larviciding trial using ground-based applications of temephos (Abate 20EC) throughout the northern (accessible) part of the island was carried out for five weeks from 12 February 2001. Following this, a first attempt to eliminate the vectors was conducted using helicopter and ground-based applications of temephos from February to May 2003, but this was not successful because some vector populations persisted and subsequently spread throughout the island. A second attempt from January to May 2005 aimed to treat all flowing watercourses and greatly increased the number of treatment points. This led to the successful elimination of the vector. The last biting S. damnosum s.l. was caught in March 2005 and none have been found since then for more than 3 years.

Reduction in the prevalence and intensity of infection in Onchocerca volvulus microfilariae according to ethnicity and community after 8 years of ivermectin treatment on the island of Bioko, Equatorial Guinea

Bioko is the only island known in the world with endemic onchocerciasis. The island's rural communities consist of villages and cocoa plantations inhabited by Bubi and Fang ethnic groups. The aim of this study was to evaluate the impact of 8 years of vertical ivermectin distribution on the prevalence and intensity of Onchocerca volvulus infection in the rural population by means of pre- (1989) and post-long term treatment (1998) epidemiological surveys. In both surveys, the entire population of 12 randomly selected communities (1723 and 1082 individuals) was examined. The mean ivermectin therapeutic coverage for the 8 years was 53.2%. Iliac crest skin snips were used for differential diagnosis between O. volvulus and Mansonella streptocerca. The crude O. volvulus infection prevalence before ivermectin intervention was 74.5% (1284/1723); after the intervention it was 38.4% (415/1082). The Community Microfilarial Load (CMFL) before and after ivermectin intervention was 28.29 microfilariae/snip vs. 2.32 microfilariae/snip. The reduction in prevalence and CMFL after eight annual rounds of ivermectin treatment corroborates the drug microfilaricidal activity and good tolerability. In the pre-treatment survey, the prevalence was higher in the Bubi group (77.1%, 1126/1461); post-treatment it was higher among the Fang (51.1%, 92/180). The reduction in prevalence and intensity of O. volvulus infection differed between ethnic groups and communities.

Cytotaxonomy, morphology and molecular systematics of the Bioko form of Simulium yahense (Diptera: Simuliidae)

Cytotaxonomic analysis of the polytene chromosomes from larvae of the Simulium damnosum Theobald complex from the island of Bioko in Equatorial Guinea is reported, and a new endemic cytoform is described. Chromosomally this cytoform is close to both S. squamosum (Enderlein) and S. yahense Vajime & Dunbar, but is not identical to either. However, it is morphologically and enzymatically identical to S. yahense. The Bioko form was also found to differ from other cytoforms of the S. damnosum complex in West Africa in the copy number or RFLP pattern of several different repetitive DNA sequences. It is clear that the Bioko form is genetically distinct from other populations of the S. damnosum complex, and whilst it is closest to S. yahense, it shows features that suggest a high degree of geographical and genetic isolation. Such isolation is an important consideration in the assessment of the potential for onchocerciasis vector eradication on Bioko.

The role of the carboxyl-terminal fragments of amyloid precursor protein in Alzheimer's disease

Two major pathological hallmarks of Alzheimer's disease (AD) are the senile plaques that are primarily composed of amyloid beta-peptide (Abeta) and neurofibrillary tangles consisting of tau aggregates. Abeta is generated proteolytically from a family of Abeta-containing precursor proteins (APP; 695-770 amino acid) by secretase enzymes to different specific carboxyl-terminal fragments (CTFs). Herein we examined APP and its products in autopsied brain sections from 10 AD and 10 non-AD control subjects immunochemically using an antibody that was raised against APP751-770 residue (O443). The O443 antibody was initially characterized by Western blot analysis and immunoprecipitation. In this study, we used this antibody for immunohistochemical analysis to determine the distribution of APP and its CTF species. In 10 brain regions showing different levels of plaques and tangles, antibody O443 stained the perinuclear region of the nucleus, plaques, and neurites. Tangle-bearing neurons also appeared to stain with the antibody, suggesting that these dysfunctional neurons continue to synthesize APP/CTF. Alternatively, the normally short-lived APP/CTF can be stabilized and persist in these neurons. Taken together, these results suggest that, in addition to the widely believed role of Abeta, CTFs may play a key role in the pathogenesis of AD. Studying their localization and biogenesis may reveal the biological activities of CTFs of APP. The present study may pave the way for possible antiamyloidogenic therapy in the treatment of AD.

Statins: mechanism of action and effects

The beneficial effects of statins are the result of their capacity to reduce cholesterol biosyntesis, mainly in the liver, where they are selectively distributed, as well as to the modulation of lipid metabolism, derived from their effect of inhibition upon HMG-CoA reductase. Statins have antiatherosclerotic effects, that positively correlate with the percent decrease in LDL cholesterol. In addition, they can exert antiatherosclerotic effects independently of their hypolipidemic action. Because the mevalonate metabolism generates a series of isoprenoids vital for different cellular functions, from cholesterol synthesis to the control of cell growth and differentiation, HMG-CoA reductase inhibition has beneficial pleiotropic effects. Consequently, statins reduce significantly the incidence of coronary events, both in primary and secondary prevention, being the most efficient hypolipidemic compounds that have reduced the rate of mortality in coronary patients. Independent of their hypolipidemic properties, statins interfere with events involved in bone formation and impede tumor cell growth.

The total peroxyl radical trapping potential in serum - an assay to define the stage of atherosclerosis

Lipid peroxides were identified among the factors that contribute to the atherosclerotic plaque formation in the arterial wall. We hypothesised that a correlation may exist between the content of antioxidant constituents in the serum and the gravity of atherosclerosis. To this purpose, we have determined the serum total peroxyl radical- trapping potential (TRAP), which is the combined capacity of all antioxidants to neutralize free radicals in serum and followed its variation in hyperlipemic animals in correlation with the stage of atherosclerosis. In addition, we compared TRAP values in the sera of coronary heart disease (CHD) patients, with or without type II diabetes mellitus. Results showed that after 18 weeks of hyperlipemic diet, the mean TRAP values measured in sera isolated from hyperlipemic hamsters exhibited an about 44% decrease, in good agreement with the increase of serum cholesterol and triglycerides. In the 3 groups of CHD patients, TRAP values decreased with about 10% in sera of stable angina patients, 20% in unstable patients, as compared with normal subjects. The lowest TRAP values were detected in the sera of patients with acute myocardial infarction. The results obtained for different experimental animals and for CHD patients sera indicate that the TRAP method, as adapted in our laboratory, is a reliable and reproducible assay, fit to be used in clinical studies as an ex vivo measurable parameter that correlates with the stage of the atherosclerosis.

The hyperlipemic hamster - a model for testing the anti-atherogenic effect of amlodipine

Male Golden Syrian hamsters were subjected to a hyperlipemic diet. At intervals ranging from 2 to 14 weeks, the animals were examined for changes in serum constituents and structural modifications of lesion-prone areas: the cardiac valves, coronary arteries and aortic arch. Serum was characterized by a gradual increase in cholesterol, triglycerides and a decrease in total peroxyl-radical trapping potential. The sequence of modifications of the endothelial cells, smooth muscle cells, and migrating plasma monocytes as well as of the extracellular matrix were established. Amlodipine treatment of hyperlipemic hamster was assessed. Amlodipine exhibited an athero-protective effect, acting as antioxidant, reducing the LDL uptake by the vessel wall and consequently, limiting the size and extent of lesioned areas. The hyperlipemic hamster is a reliable model to unravel the cellular alterations leading to atheroma formation, and for testing the effect of drugs in this process.

Neuropathological correlates of dysarthria in progressive supranuclear palsy

BACKGROUND

The dysarthria of progressive supranuclear palsy consists of prominent hypokinetic and spastic components with less prominent ataxic components.

OBJECTIVE

To correlate the types of dysarthria with neuropathological changes in patients with progressive supranuclear palsy.

DESIGN AND METHODS

In 14 patients with progressive supranuclear palsy, we correlated the perceptual speech findings with the neuropathological findings. A dysarthria assessment was performed a mean +/- SD of 31 +/- 15 months (range, 10-53 months) before death. The deviant speech dimensions were rated on a scale of 0 (normal) to 3 (severe). The neuropathological examination consisted of semiquantitative analysis of neuronal loss and gliosis by investigators (A.A.F.S., and L.A.B.) blinded to the clinical findings. Correlation and linear regression analysis were used to correlate the severity of the hypokinetic, spastic, and ataxic components with the degree of neuronal loss and gliosis in predetermined anatomical sites.

RESULTS

All patients had hypokinetic and spastic dysarthria, and 9 also had ataxic components. The severity of the hypokinetic components was significantly correlated with the degree of neuronal loss and gliosis in the substantia nigra pars compacta (r = 0.61, P =.02) and pars reticulata (r = 0.64, P =.01) but not in the subthalamic nucleus (r = 0.51, P =.07) or the striatum or globus pallidus (/r/<0.34, P>.20). The severity of the spastic and ataxic components was not significantly correlated with the neuropathological changes in the frontal cortex (r = 0.20, P =.50) and cerebellum (/r/<0.28, P>.33), respectively.

CONCLUSION

The hypokinetic dysarthria of progressive supranuclear palsy may result from degenerative changes in the substantia nigra pars compacta and pars reticulata and not from changes in the striatum or globus pallidus.

Widespread alterations of alpha-synuclein in multiple system atrophy

Glial cytoplasmic inclusions (GCI) are the hallmark of multiple system atrophy (MSA), a rare movement disorder frequently associated with autonomic dysfunction. In this study of 21 cases of MSA, GCI were consistently immunoreactive for alpha-synuclein and double-immunostained for ubiquitin and oligodendroglial markers, but not glial fibrillary acidic protein. No statistically significant difference was found in the density of GCI in various brain regions in the two forms of MSA, striatonigral degeneration (SND) and olivopontocerebellar atrophy (OPCA). Postmortem brain samples from 9 cases of MSA were fractionated according to solubility in buffer, Triton-X 100, sodium dodecyl sulfate (SDS), and formic acid, and alpha-synuclein immunoreactivity was measured in Western blots. Total alpha-synuclein immunoreactivity was increased in MSA compared to controls, with no statistically significant difference between SND and OPCA. Most of the increase was due to alpha-synuclein in SDS fractions. In controls this fraction had little or no immunoreactivity. In 7 cases and 4 controls correlations were investigated between quantitative neuropathology and biochemical properties of alpha-synuclein. Surprisingly, the amount of SDS-soluble alpha-synuclein correlated poorly with the number of GCI in adjacent sections. Furthermore, areas with few or no GCI unexpectedly had abundant SDS-soluble alpha-synuclein. These findings provide evidence that modifications of alpha-synuclein in MSA may be more widespread than obvious histopathology. Moreover, these alterations may constitute a biochemical signature for the synucleinopathies.

Peripheral neuropathy caused by proteolipid protein gene mutations

Pelizaeus-Merzbacher disease (PMD) is a dysmyelinating disorder of the central nervous system typically caused by duplications or missense mutations of the proteolipid protein (PLP) gene. Most investigators have found that peripheral nerve function and structure is normal in PMD patients. We have found that null mutations of the PLP gene cause demyelinating peripheral neuropathy, whereas duplications and a proline 14 to leucine mutation do not affect nerve function. A family with a nonsense mutation at position 144, which affects only PLP but not the alternatively spliced gene product DM20, has a very mild syndrome, including normal peripheral nerve function. Our findings suggest that DM20 alone is sufficient to maintain normal nerve function and that there may be domains of PLP/DM20 that have a relatively more active role in the peripheral nervous system compared with that in the central nervous system.

Enhanced platelet aggregation, high homocysteine level, and microvascular disease in diabetic muscle infarctions: implications for therapy

Muscle infarction is a rare complication in patients with diabetes mellitus, probably because of the rich vascular supply of this tissue. We describe a patient with type 1 diabetes who had infarction of the muscles in her right thigh. We report, for the first time, that the patient, in addition to an advanced microvascular disease in the muscle, had increased plasma total homocysteine levels and increased platelet aggregation. These pathologies might have a synergistic effect on the development of this rare complication and should be treated aggressively to prevent further episodes.

Diabetes-induced structural changes of venous and arterial endothelium and smooth muscle cells

The structural alterations of endothelium and smooth muscle cells of the hind limb and heart veins and arteries were investigated in Golden Syrian hamsters subjected to streptozotocin induced diabetes. Animals were examined at 5, 10, and 15 weeks after induction of diabetes. At each time point body weight and plasma glucose concentrations were recorded. Anesthetised animals were washed out of blood, fixed in situ, and the femoral vein and artery, saphenous vein and artery, and heart veins and coronaries were dissected out, and processed for electron microscopical examination. Anionic sites of the endothelial plasmalemma were visualized by in situ perfusion of cationized ferritin. The endothelial localization of von Willebrand factor was carried out by immunocytochemistry. The results showed that induction of experimental diabetes generated morphological changes of the endothelium and smooth muscle cells of both hind limb and heart vessels. The common alterations developed in endothelial cells of venous and arterial origin consisted in: 1) the development of a secretory phenotype, enriched in biosynthetic and degradative organelles; 2) the abundance of cytoskeletal elements, especially intermediary filaments; 3) the increase in number of fused plasmalemmal vesicles and transendothelial channels, and 4) the hyperplasia of the basal lamina. In contradistinction to the arterial endothelium, the peculiarities of the venous endothelium in the diabetic hamsters examined were: 1) the uniform distribution of the anionic sites exposed on the luminal plasma-lemma (as in normal animals), and 2) the increased number of copies of Weibel-Palade bodies (up to 13 copies per endothelial cell in the hind limb). Von Willebrand factor was immunodetected in Weibel-Palade bodies, Golgi cisternae and some vesicles of normal and diabetic hamsters. With time, and especially pronounced at 15 weeks of diabetes, the smooth muscle cells of veins and arteries examined exhibited a characteristic secretory phenotype, and were surrounded by a reticulated basal lamina and a hyperplasic extracellular matrix (especially pronounced in arteries). These data indicate that diabetes affects both heart and hind limb veins and arteries, producing structural changes of the endothelium and smooth muscle cells which may account, at least in part, for the specific vascular complications.

Distribution of the Simulium damnosum complex on Bioko island, Equatorial Guinea, and the potential for onchocerciasis elimination by vector eradication

Onchocerciasis is endemic on the island of Bioko, Equatorial Guinea, where it is transmitted by the 'Bioko form' of the Simulium damnosum complex, a cytospecies unique to the island. To determine the distribution of vector breeding, three dry season and two wet season expeditions were made in 1989, 1996 and 1997, and 226 of the island's 247 rivers (91.5%) were visited. Of these 226 rivers, 130 (58%) were flowing during the dry season, forty-five (20%) supported aquatic stages of Simuliidae of any species and twenty-five (11%) contained larvae or pupae of the S. damnosum complex. The twenty-one rivers not prospected were in the mountainous south of the island, where an additional seventeen rivers were reached but not satisfactorily prospected. Of these thirty-eight rivers, twenty-nine were considered highly likely to support vector breeding, bringing the total number of rivers which could harbour the vector during the dry season to fifty-four (21.9% of the island's total). Breeding was believed to be limited to river stretches below 1000 m altitude, and during the dry season the total length of those stretches which could support breeding on Bioko was estimated to be 1020 km. A combination of factors, including low river discharges during the dry season, the relatively low water temperature on Bioko, the suitability of limited stretches of most rivers as vector breeding sites and the close proximity of many rivers within a small geographical area, render the vector vulnerable to eradication by aerial treatment of rivers with insecticide. The isolation of the Bioko form of the S. damnosum complex suggests that reinvasion following treatment would be unlikely, and eradication of the vector might be achieved by a dry season larviciding programme in one or two years.

Pathobiology of the heart in experimental diabetes: immunolocalization of lipoproteins, immunoglobulin G, and advanced glycation endproducts proteins in diabetic and/or hyperlipidemic hamster

Diabetes is known to be accompanied by atherosclerotic disease and general cardiovascular complications. Hamsters were previously shown to develop hyperlipemia-induced atherosclerosis, similar in many respects to the human atherosclerotic process. To study the effect of hyperglycemia on heart vessels and valves, male Golden Syrian hamsters were rendered either diabetic or hyperlipemic and diabetic; controls were age-matched normal hamsters. At time intervals ranging from 2 to 24 weeks, animals were killed; plasma glucose, cholesterol, and lipid peroxides were measured; and the aortic arch and valves, coronary arteries, and heart microvessels were examined for ultrastructural modifications and for the presence of low-density lipoproteins (LDL), immunoglobulin G (IgG), and advanced glycation endproducts (AGE) proteins. Elevation of plasma glucose, peroxides, and cholesterol were observed in both diabetic as well as hyperlipemic and diabetic animals, along with characteristic diabetic changes: microangiopathy of the myocardium (ie, capillary narrowing, hyperplasia of basal lamina, and proliferation of extracellular matrix) and macroangiopathy of the aortic arch, valves, and coronary arteries (ie, intimal proliferation, fatty-streak formation, and calcification). LDL, IgG, and AGE-proteins were immunolocalized in focal deposits, ie, in the shoulder and cap of the plaques; these antigens were distributed diffusely in the extracellular space or within macrophage-derived foam cells and smooth muscle cells. Our findings indicate that hyperglycemia alone induces atherosclerotic lesions in the coronary arteries, aortic arch, and aortic valves as well as alterations of the extracellular matrix of heart microvessels and cardiomyocytes, changes which together may lead to cardiomyopathy, a common and severe complication of diabetes. In addition, the present study suggests that when hyperglycemia is accompanied by hyperlipemia, detectable amounts of modified LDL (possibly oxidized or glycated) and AGE are present in the intima of atherosclerotic arteries; and also that modified lipoproteins can act as immunoactive components of the atheroscerotic process generated by hyperglycemia.

[Tetanus in Libreville: hospital analysis of 30 cases]

We investigated 34 cases of tetanus in patients younger than 75 years old in Libreville. We found that the incidence of tetanus was 8 cases for every million people. The disease mostly affected people younger than 50 (85%). Only two neonatal tetanus cases were reported. The death rate was 74%, despite the availability of intensive care and respiratory assistance. We stress the benefits of tetanus immunization, which must be continued, and suggest the use of intrathecal serotherapy for the cure of tetanus in Libreville.

Immunodetection of modified lipoproteins in plasma and arterial walls of patients with coronary heart disease

Data from literature indicate that immune processes play an important role in atherogenesis. Modified lipoproteins might be immunogenic and generate autoantibodies in plasma. To determine whether the level of such circulating autoantibodies correlates with the extent of atherosclerosis expressed as cholesterol values in plasma (C), very low density (VLDL-C), low density (LDL-C), and high density lipoproteins (HDL-C), we compared the level of plasma autoantibodies of a group of coronary heart disease patients (CHD-P) with that of normal, age-matched donors, with no history of cardiac disease (N). All CHD-P (even normocholesterolemic) were characterized by an LDL-C/HDL-C ratio > 4, while all N (even hypercholesterolemic) had this ratio < 4. A double level of circulating autoantibodies against VLDL and LDL in CHD-P as compared to N group was detected. The anti-LDL antibodies level correlated well with LDL-C level and was negatively correlated with the age of patients. For tissue localization of native and modified LDL (as well as other possibly modified proteins) we used immunohistochemical techniques, employing antihuman LDL, antihydroxynonenal-lysine (HNE-Lys), and antiadvanced glycation end-products (AGE) proteins. Antibodies were applied on consecutive cryosections of the aortic arch, valves and coronary arteries of CHD-P. The immunodetected antigens were colocalized in focal deposits, in the cap and shoulders of the atheroma. Native LDL and modified proteins (AGE, HNE-Lys) were detected either diffuse-extracellularly or associated with macrophage-derived foam cells and smooth muscle cells of the intima. These data indicate the following: a) the existence of an elevated level of circulating autoantibodies against VLDL and LDL, which correlates negatively with the age of CHD patients; b) the presence of LDL (possibly glycated or oxidized) in detectable amounts in the intima of atherosclerosis-affected arteries; c) the modified lipoproteins are immunoactive components in the atherosclerotic process.

Pathobiochemistry of combined diabetes and atherosclerosis studied on a novel animal model. The hyperlipemic-hyperglycemic hamster

Because accelerated atherosclerosis is the main complication of diabetes, we devised a new animal model that combines these two diseases, and investigated their joint impact on the main plasma components and organs known to be most affected in each disorder. Male Golden Syrian hamsters were subjected to three experimental conditions: streptozotocin-induced diabetes (D), diet-induced hyperlipemia (H), and a combination of hyperlipemia and diabetes (HD). At time intervals ranging from 2 to 24 weeks, the animals were sacrificed, the appropriate plasma constituents were determined, and the ultrastructural modifications of relevant tissues such as the heart, cardiac valves, coronary arteries, aorta, retina, and kidney were examined. The HD hamsters were characterized by marked alternations of plasma components, ie, increase in circulating glucose, cholesterol and lipid peroxide levels, glycation of albumin, and the appearance of irreversibly glycated albumin (AGE-Alb). These humoral changes coexisted with micro- and macroangiopathic lesions characteristic to both diseases, ie, capillary narrowing, hyperplasia of endothelial basal lamina, proliferation of perivascular extracellular matrix (abnormalities reminiscent of type I diabetes), and concomitant intimal accumulation of modified lipoproteins and macrophage-derived foam cells in the aorta, coronaries, and cardiac valves, leading to accelerated formation of atherosclerotic plaques. These changes eventually appeared in the D hamsters also, but at a much slower rate, whereas the H group showed only modifications characteristic for atherosclerosis. Our findings indicate that, overall, 1) diabetes accelerated the early development and progression of atherosclerotic lesions leading to rapid calcification, and 2) hyperlipidemia associated with diabetes accelerated the rate of development of diabetes-induced microvascular disease. The hamster model may be useful to study the impact of various drugs on the diabetes-related vascular complications.

The pathomorphological alterations of endocardial endothelium in experimental diabetes and diabetes associated with hyperlipidemia

The structural alterations of endocardial endothelial cells of the heart right atrium and left ventricle were investigated in Golden Syrian hamsters subjected to streptozotocin-induced diabetes and to a combination of diabetes and diet-induced hyperlipidemia. Animals were examined at time intervals ranging from 2 weeks to 6 months. Anionic sites of the endothelial plasmalemma were visualized by in situ perfusion of cationized ferritin. The results indicated that: (a) both atrial and ventricular endocardial endothelium are affected in streptozotocin-induced diabetes: endothelium converts from continuous into a fenestrated type, (b) although the anionic charge of the plasmalemma decreased in advanced diabetes, the newly formed fenestrae highly bound cationized ferritin, (c) combined diabetes and hyperlipidemia induced more severe alterations of endocardial endothelium: new permeable endothelial structures were formed (transendothelial channels, open intercellular junctions, fused plasmalemmal vesicles), and the cells became particularly enriched in cytoskeleton (intermediate filaments and microtubules), (d) the thick subendocardial layer of connective tissue contained, in the combined experimental model, macrophage derived foam cells indicative for the occurrence of alterations of atherosclerotic type.

Correlated biochemical modifications of plasma lipoproteins in coronary heart disease: an accelerating pathologic factor

We investigated the presence of biochemically modified plasma lipoproteins as pathologic factor for coronary heart disease in 15 patients with angina pectoris (CHD-P) vs 20 normal subjects (N). Decreased HDL were the most significant pathological feature present in P over 66 years old, while, P under 66 had, in addition to low HDL-Cholesterol (HDL-C), high levels of plasma cholesterol (C), LDL-Cholesterol (LDL-C), and lipid peroxides (TBARS), together with the presence of desialylated LDL and VLDL. We demonstrated by statistic analysis that these risk factors are correlated: high plasma C with a more pronounced imbalance between LDL and HDL, which, in turn, is associated with high TBARS levels, and also with circulating desialylated VLDL; high plasma TBARS values with desialylated LDL. We detected an increased level of autoantibodies towards autologous LDL and VLDL, in P vs N. The level of autoantibodies anti-LDL correlated with LDL-C level and with LDL desialylation, thus modified circulating LDL being most probably atherogenic. Circulating anti-LDL autoantibodies together with the low level of HDL might contribute to acceleration and aggravation of the atherosclerotic process.

Pseudotumor cerebri: risk factors, clinical course, prognostic criteria

Eighty-five patients with the diagnosis of pseudotumor cerebri were retro- and prospectively studied. For clinical evaluation, the following criteria were used: neurological--headache, ophthalmological--visual acuity, visual field, ophthalmoscopy and psychic--memory. Each patient was assigned 2 categories of results expressed by: neuropsychic and ophthalmological scores which were statistically processed. The following conclusions related to the aim of our paper can be drawn: I.

RISK FACTORS

pregnancy (8% of cases), obesity (15%), generalized infections or located in the pelvic region+operated on (6%), hormonal treatment (cortisol (12%), estrogens (6%)); II. The clinical course was significantly favourable for: headache (51% of cases), defects of visual acuity (54%) and papilledema (63%). The long-lasting effects of the treatment applied showed: recovery (for the 2 parameters) in 27% of patients and improvement with sequelae for one and/or the other parameter in 73% of the cases; III. Among the more significant prognostic criteria were the ophthalmological symptoms and signs at onset of the disease. The ophthalmological sequelae (visual acuity, visual field defects, chronic papilledema and optic atrophy) are important factors in the prognosis of the disease and represent predictors for the surgical management.

Catamnestic study of cases with tardive decompensated hydrocephalus

One hundred patients with decompensated hydrocephalus (60 operated, 40 nonoperated) were studied both retrospectively and prospectively at 3 moments of the disease course. The indicators were clinical: neurologic, psychic and social, and paraclinical: results of pneumoencephalography, encephalography, radioisotope cisternography. The effects of surgical treatment (ventriculocardiac derivation) and of medical treatment were evaluated at short and long term. In surgical treatment, favourable short-term outcome (headache, gait and micturition disorders, improved consciousness, psychomotor activity, social behaviour) was found in 88% of the patients; long-term favourable outcome was present in 60% of the patients and implied only the psychic and social indicators. In medical treatment the favourable short-term outcome was nonsignificant and the long-term outcome was favourable in only 32% of the patients. In the remaining cases evaluated as unfavourable, the cognitive disorders increased progressively. The predictors for favourable therapeutic outcome were: early diagnosis, early surgical intervention, the clinical form of hydrocephalus, the sequelae and short-term effects of surgical treatment.

Experimental obstructive coronary atherosclerosis in the hyperlipidemic hamster

The evolution of coronary atherosclerotic lesions induced by a hyperlipidemic diet was examined in male hamsters subjected for up to 40 weeks to a standard chow supplemented with 3% cholesterol and 15% butter. Control animals were fed standard chow only. Five to seven hamsters were monthly sacrificed and investigated for serum lipids and coronary artery lesions. As compared with control animals, the hamsters fed the fat diet showed a progressive increase in serum cholesterol which reached maximum values up to 17 fold in the 10th month. The serum of the hyperlipidemic hamster examined by agarose electrophoresis, Laurell immunoelectrophoresis and cross-immunoelectrophoresis showed at most a 14 fold increase in low density lipoproteins after 10 months diet. The examination of coronary arteries revealed morphologic changes already detectable at 2 weeks of diet. The earliest modifications observed were characterized by proliferation of the subendothelial matrix or/and the appearance of liposome-like structures in the intima. After 2-3 weeks of diet, smooth muscle cells appeared occasionally in the intima and monocytes adhered and penetrated through the endothelium. Later on, smooth muscle cells and macrophage displayed lipid deposits. Focally, in areas of intimal proliferation and foam cells, endothelial cells were also lipid-loaded. Like in human atherosclerotic plaque, in the late stages of hamster coronary lesions, there was a progressive accumulation of extracellular unesterified cholesterol, calcium deposition and necrosis. Lesions evolved to a progressive narrowing of the coronary branches affected, with complete obstruction of some small arterial ramifications. Hamster appears to be a suitable model for studying the molecular and cellular events leading to obstructive coronary atherosclerosis.