MANEC TUMOR OF RECTUM. A RARE CASE SERIES OF 3 PATIENTS AND A LITERATURE REVIEW

The term Mixed Adeno-Neuro-Endocrine Carcinoma (MANEC) was introduced in 2010 by the WHO Classification of Tumors of the Digestive System. It refers to a neoplasm with dual epithelial and neuroendocrine differentiation, each component representing at least 30% of the tumor. It is an uncommon tumor accounting for < 3% of all colon and rectum malignancies. We report three cases of this extremely rare MANEC of the rectum. All three cases presented with hematochezia, variable constipation, and abdominal pain. They were diagnosed and staged appropriately with colonoscopy, biopsy with immunohistochemistry, and imaging. They underwent an anterior resection with circular stapled anastomoses. Because of the low incidence of this histotype, we reviewed the clinical presentation, diagnostic characteristics, and treatment of MANEC of the colon and rectum.

Fusions of Consciousness

What are conscious experiences? Can they combine to form new experiences? What are conscious subjects? Can they combine to form new subjects? Most attempts to answer these questions assume that spacetime, and some of its particles, are fundamental. However, physicists tell us that spacetime cannot be fundamental. Spacetime, they say, is doomed. We heed the physicists, and drop the assumption that spacetime is fundamental. We assume instead that subjects and experiences are entities beyond spacetime, not within spacetime. We make this precise in a mathematical theory of conscious agents, whose dynamics are described by Markov chains. We show how (1) agents combine into more complex agents, (2) agents fuse into simpler agents, and (3) qualia fuse to create new qualia. The possible dynamics of n agents form an n(n-1)-dimensional polytope with nn vertices-the Markov polytopeMn. The total fusions of n agents and qualia form an (n-1)-dimensional simplex-the fusion simplexFn. To project the Markovian dynamics of conscious agents onto scattering processes in spacetime, we define a new map from Markov chains to decorated permutations. Such permutations-along with helicities, or masses and spins-invariantly encode all physical information used to compute scattering amplitudes. We propose that spacetime and scattering processes are a data structure that codes for interactions of conscious agents: a particle in spacetime is a projection of the Markovian dynamics of a communicating class of conscious agents.

Characterization of microfibers emission from textile washing from a domestic environment

Microfibers and microplastics are widely recognized emerging pollutants, which have the potential to cause an Eco-toxicological effect. Cellulosic and synthetic fibers are being released almost equally to the environment. Synthetic fibers released were non-biodegradable resulting in a significant negative impact on the environment. In the present study, four different households using fully automated washing machines (2 top-load, 2 front-load) were studied in a domestic laundry environment under real conditions. Laundry effluents were collected and contaminants analysis was carried out. The results estimated that the average emission rate of the four households was 7,453,635 MF/7Kg (FL, H1), 7,375,500 MFs/6Kg (FL, H2), 10,692,255 MFs/7Kg (TL, H3) and 7,589,017 MFs/6.2Kg (TL, H4). Synthetic fiber's emission rate was only about 19 %, and the average length range of microfibers released was found to be in the range of ≤5 μm (48.64 %), and the least amount of emission was found in the >500 μm range (11.49 %).

Fitness Beats Truth in the Evolution of Perception

Does natural selection favor veridical percepts-those that accurately (if not exhaustively) depict objective reality? Perceptual and cognitive scientists standardly claim that it does. Here we formalize this claim using the tools of evolutionary game theory and Bayesian decision theory. We state and prove the "Fitness-Beats-Truth (FBT) Theorem" which shows that the claim is false: If one starts with the assumption that perception involves inference to states of the objective world, then the FBT Theorem shows that a strategy that simply seeks to maximize expected-fitness payoff, with no attempt to estimate the "true" world state, does consistently better. More precisely, the FBT Theorem provides a quantitative measure of the extent to which the fitness-only strategy dominates the truth strategy, and of how this dominance increases with the size of the perceptual space. The FBT Theorem supports the Interface Theory of Perception (e.g. Hoffman et al. in Psychon Bull Rev https://doi.org/10.3758/s13423-015-0890-8 , 2015), which proposes that our perceptual systems have evolved to provide a species-specific interface to guide adaptive behavior, and not to provide a veridical representation of objective reality.

Methods and variables in Electrical discharge machining of titanium alloy - A review

Titanium alloys are difficult to machine using conventional methods, therefore, nonconventional processes are often chosen in many applications. Electrical discharge machining (EDM) is one of those nonconventional processes that is used frequently for shaping titanium alloys with their respective pros and cons. However, a good understanding of this process is very difficult to achieve as research results are not properly connected and presented. Therefore, this study investigates different types of EDM processes such as, wire EDM, die-sink EDM, EDM drill and hybrid EDM used to machine titanium alloys. Machining mechanism, tool electrode, dielectric, materials removal rate (MRR), and surface integrity of all these processes are critically analysed and correlated based on the evidence accessible in literature. Machining process suffer from lower material removal rate and high tool wear while applied on titanium alloys. Formation of recast layer, heat affected zone and tool wear is common in all types of EDM processes. Additional challenge in wire EDM of titanium alloys is wire breakage under severe machining conditions. The formation of TiC and TiO₂ are noticed in recast layer depending on the type of dielectrics. Removal of debris from small holes during EDM drilling is a challenge. All these restricts the applications EDMed titanium alloys in high-tech applications such as, aerospace and biomedical areas. Most of these challenges come up due to extraordinary properties such as, low thermal conductivity, high melting point and high hardness, of titanium alloys. Though hybrid EDM has been introduced and there is some work on simulation of EDM process, further developments in EDM of this alloy is required for widening the application of this methods.

Extra-ribosomal functions of Mtb RpsB in imparting stress resilience and drug tolerance to mycobacteria

Emerging observations suggest that ribosomal proteins (RPs) play important extra-ribosomal roles in maintenance of cellular homeostasis. However, the mechanistic insights into these processes have not been extensively explored, especially in pathogenic bacteria. Here, we present our findings on potential extra-ribosomal functions of Mycobacterium tuberculosis (Mtb) RPs. We observed that Mtb RpsB and RpsQ are differentially localized to cell wall fraction in M. tuberculosis (H37Rv), while their M. smegmatis (Msm) homologs are primarily cytosolic. Cellular fractionation of ectopically expressed Mtb RPs in surrogate host (M. smegmatis) also shows their association with cell membrane/cell wall without any gross changes in cell morphology. M. smegmatis expressing Mtb RpsB exhibited altered redox homeostasis, decreased drug-induced ROS, reduced cell wall permeability and increased tolerance to various proteotoxic stress (oxidative stress, SDS and starvation). Mtb RpsB expression was also associated with increased resistance specifically towards Isoniazid, Ethionamide and Streptomycin. The enhanced drug tolerance was specific to Mtb RpsB and not observed upon ectopic expression of M. smegmatis homolog (Msm RpsB). Interestingly, C-terminus deletion in Mtb RpsB affected its localization and reversed the stress-resilient phenotypes. We also observed that M. tuberculosis (H37Rv) with upregulated RpsB levels had higher intracellular survival in macrophage. All these observations hint towards existence of moonlighting roles of Mtb RpsB in imparting stress resilience to mycobacteria. This work open avenues for further exploration of alternative pathways associated with fitness and drug tolerance in mycobacteria.

Fact, Fiction, and Fitness

A theory of consciousness, whatever else it may do, must address the structure of experience. Our perceptual experiences are richly structured. Simply seeing a red apple, swaying between green leaves on a stout tree, involves symmetries, geometries, orders, topologies, and algebras of events. Are these structures also present in the world, fully independent of their observation? Perceptual theorists of many persuasions—from computational to radical embodied—say yes: perception veridically presents to observers structures that exist in an observer-independent world; and it does so because natural selection shapes perceptual systems to be increasingly veridical. Here we study four structures: total orders, permutation groups, cyclic groups, and measurable spaces. We ask whether the payoff functions that drive evolution by natural selection are homomorphisms of these structures. We prove, in each case, that generically the answer is no: as the number of world states and payoff values go to infinity, the probability that a payoff function is a homomorphism goes to zero. We conclude that natural selection almost surely shapes perceptions of these structures to be non-veridical. This is consistent with the interface theory of perception, which claims that natural selection shapes perceptual systems not to provide veridical perceptions, but to serve as species-specific interfaces that guide adaptive behavior. Our results present a constraint for any theory of consciousness which assumes that structure in perceptual experience is shaped by natural selection.

Immunization with Salmonella Abortusequi phage lysate protects guinea pig against the virulent challenge of SAE-742

Salmonella Abortusequi causes important clinical diseases in horses possibly leading to abortion. In the present investigation, the protective efficacy of both plain and aluminum hydroxide gel adjuvanted phage lysate was evaluated in guinea pig model. Broad host range bacteriophage P_IZ-SAE-2, was characterized and used for generation of lysates. Three different lysate batches, produced through separate cycles and characterized, were pooled together for immunization study. Plain and adjuvanted phage lysate preparations elicited both humoral and cellmediated immunity. The adjuvanted lysate at a dose of 50 μl elicited the highest protective efficacy against direct challenge at 28th DPI. Thus, the present study describes a new method of bacterial inactivation for producing a new class of better & safe immunprophylactic agents. This is the first report of producing an inactivated vaccine candidate using a new approach against equine salmonellosis.

Rapid visual isothermal nucleic acid-based detection assay of Brucella species by polymerase spiral reaction

AIM

The aim of this study was to develop polymerase spiral reaction (PSR) for rapid, sensitive and specific detection of Brucella sp.

METHODS AND RESULTS

Polymerase spiral reaction assay was developed using specifically designed primers targeting the conserved multicopy IS711 gene of Brucella sp. The assay could be performed within 60 min at an isothermal temperature of 64°C. The lower limit of detection of PSR was 11·8 fg and conventional PCR was 1·18 pg of Brucella abortus genomic DNA. Thus, PSR was found to be 100-fold more sensitive than conventional PCR and was comparable to real-time PCR. The specificity of PSR was tested with other non-Brucella bacteria and also with some bacterial and viral pathogens causing abortions. The assay was found to be specific as it did not detect any putative pathogens other than Brucella sp. Fifty-six clinical samples suspected for brucellosis (aborted fetal stomach content) were screened with PSR to validate the applicability of the test to detect Brucella DNA. The same samples were also screened with conventional PCR and real-time PCR. Of 56 samples, 25 samples were found to be positive with both PSR as well as real-time PCR, whereas only 20 samples were found positive with conventional PCR.

CONCLUSIONS

The results of this study indicated that the PSR assay is a simple, rapid, sensitive and specific method for the detection of Brucella sp. that may improve diagnostic potential in clinical laboratories or can be used at diagnostic laboratories with minimal infrastructure.

SIGNIFICANCE AND IMPACT OF THE STUDY

The PSR assay, because of its simplicity and low cost, can be preferred to other molecular methods in the diagnosis of infectious diseases.

Evaluation of multiplex polymerase chain reaction as an alternative to conventional antibiotic sensitivity test

Aim

This study was designed to evaluate the potential of the use of multiplex polymerase chain reaction (PCR) as an alternative to conventional antibiotic sensitivity test.

Materials and Methods

Isolates of Staphylococcus aureus (total = 36) from clinical cases presented to Teaching Veterinary Clinical Complex of College of Veterinary and Animal Sciences (CVAS), Navania, Udaipur, were characterized by morphological, cultural, and biochemical methods. Then, the isolates were further subjected to molecular characterization by PCR targeting S. aureus-specific sequence (107 bp). Phenotypic antibiotic sensitivity pattern was analyzed by Kirby-Bauer disc diffusion method against 11 commonly used antibiotics in veterinary medicine in and around Udaipur region. The genotypic antibiotic sensitivity pattern was studied against methicillin, aminoglycosides, and tetracycline targeting the gene mecA, aacA-aphD, and tetK by multiplex PCR.

Results

There was 100% correlation between the phenotype and genotype of aminoglycoside resistance, more than 90% correlation for methicillin resistance, and 58.3% in the case tetracycline resistance.

Conclusion

As there is a good correlation between phenotype and genotype of antibiotic resistance, multiplex PCR can be used as an alternative to the conventional antibiotic susceptibility testing, as it can give a rapid and true prediction of antibiotic sensitivity pattern.

Abstract P3-08-10: Development and validation of a broad-based second generation multi marker “Morphometric IHC” test for optimal treatment planning of stage 1 and 2 breast cancer patients in low resource settings

Aims:

Assessment of 'risk of recurrence' in ER+ breast cancer patients based on clinical parameters and existing hormone receptor signaling pathway and/or proliferation based biomarkers is insufficient, leading to treatment of majority of patients with chemotherapy. First generation risk identification tests like OncotypeDx and Mammaprint are not impactful in India and SE Asia as are largely prognostic with limited chemotherapy-predictivity and are prohibitively expensive. A cost-effective 'predictive' test which will accurately estimate the 'risk of recurrence' for a 'broader' (node - & +) set of breast cancer patients in low resource settings is urgently required.

Materials and Methods:

Using a retrospective training cohort of 300 node– and node+ patients, we developed 'CanAssist-Breast'- a Morphometric Immunohistochemistry based test comprising 5 biomarkers plus three clinical parameters (Tumor size, grade and node status) to arrive at 'CanAssist-Breast Score'. The risk stratification model was developed using cutting edge support vector based machine learning technology. CanAssist-Breast Score stratifies patients into an all actionable 'low or high' risk for recurrence, with no intermediate zone. CanAssist-Breast biomarkers include cancer stem cell markers, Cadherins, and ATP transporter proteins - all critical players in the various steps of chemotherapy resistance leading to metastasis.

Results:

We validated CanAssist-Breast in accordance with EGAPP recommendations which require that prognostic tests be validated both analytically and clinically prior to being utilized in patients. Analytical validation experiments were performed to assess 'variation' in the outcome prediction due to critical IHC variables. We tested inter-pathologists, sample, operator and laboratory site variation and found high concordance in the outcome predictions across all variables, confirming the robustness and reproducibility of the test.

Extended clinical validation on 1000+ pre and post-menopausal cases shows NPV of 95%. The majority of patients in 'low risk' had Stage 2, Grade 2/3 disease over Stage 1, Grade 1 disease, demonstrating that CanAssist-Breast reclassifies patients who would be considered high risk clinically.

In a head-to-head pilot study of 100 patients with Oncotype Dx, CanAssist-Breast test had about 80% concordance with Oncotype in the 'low risk' category. Importantly, CanAssist-Breast correctly stratified few recurred cases as 'high risk' which were called 'low risk' by Oncotype Dx and thus were not treated with chemotherapy.

Conclusion:

In conclusion, we have developed a robust, accurate and low-cost prognostic test to predict risk of recurrence and enable optimal treatment planning in patients with early stage Breast Cancer.

Citation Format: SP S, Bakre MM, Ramkumar C, Basavaraj C, Attuluri A, Madhav L, Prakash C, Naidu N, Malpani S. Development and validation of a broad-based second generation multi marker “Morphometric IHC” test for optimal treatment planning of stage 1 and 2 breast cancer patients in low resource settings [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-10.

A prototype of novel agro-waste based column bed device for removal of textile dye Optilan Red

The aim of the study was to assess the potentiality of an agro-waste (sugarcane bagasse) for removal of the textile dye (Optilan Red) using novel column based filtration unit with a packed column of chemically treated sugarcane bagasse. The treated and untreated sugarcane bagasse (biosorbent) were characterized by Fourier transform infrared (FT-IR) spectroscopy. Effect of initial dye concentration on percentage removal of dye, equilibrium adsorption of sugarcane bagasse, kinetic studies, breakthrough point equilibrium and desorption of dye from the column material were studied. An inverse dependence of initial dye concentration on percent removal of dye was observed, whereas the equilibrium adsorption (q_e) showed a direct relationship with dye concentration. The time required for reaching breakthrough point was 120 min. Desorption of dye through alkali wash resulted in complete desorption after 1 h washing of the column for its reuse for next cycle. FT-IR analysis shows vibration in valence bands of the hydrogen bond of OH group, and the bands of intra-molecular and intermolecular hydrogen bonds, which results in interaction of treated bagasse with Optilan Red textile dye. The present study showed that more than 93% removal of the dye can be achieved in the concentration range 10-50 ppm (aqueous solution). The removal efficiency of the column remained almost unchanged for the treatment of dye-house wastewater spiked with the dye. The agro-waste based treatment process shows a considerable potential for a low-cost treatment of dye contaminated water.

The effect of antidepressants and antipsychotics on weight gain in children and adolescents

Psychiatric illness in the paediatric population is increasing and the weight effect of medications for these problems is often unclear. A comprehensive literature search was undertaken to identify studies reporting weight in relation to antipsychotic and antidepressant use in children and adolescents. From 636 articles, 42 were selected for review. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) do not cause weight gain and may lead to improvements in weight status over the short, but not, long term. Antipsychotics were generally associated with weight gain. In drug comparison studies, risperidone had a larger weight gain effect than lithium, divalproex sodium and pimozide. Studies assessing the weight-protective effects of augmentation therapy with metformin or topiramate show less weight gain with addition of these agents. In conclusion, prescribing of SSRIs and SNRIs may be associated with improvements in weight status in children and adolescents but trials assessing their use in obesity, outside of established psychiatric illness, are limited and still experimental. Youth prescribed antipsychotic medication should be monitored for exaggerated weight gain and in those where obesity is a pre-existing concern agents other than olanzapine, clozapine and risperidone may be advantageous.

Objects of consciousness

Current models of visual perception typically assume that human vision estimates true properties of physical objects, properties that exist even if unperceived. However, recent studies of perceptual evolution, using evolutionary games and genetic algorithms, reveal that natural selection often drives true perceptions to extinction when they compete with perceptions tuned to fitness rather than truth: Perception guides adaptive behavior; it does not estimate a preexisting physical truth. Moreover, shifting from evolutionary biology to quantum physics, there is reason to disbelieve in preexisting physical truths: Certain interpretations of quantum theory deny that dynamical properties of physical objects have definite values when unobserved. In some of these interpretations the observer is fundamental, and wave functions are compendia of subjective probabilities, not preexisting elements of physical reality. These two considerations, from evolutionary biology and quantum physics, suggest that current models of object perception require fundamental reformulation. Here we begin such a reformulation, starting with a formal model of consciousness that we call a "conscious agent." We develop the dynamics of interacting conscious agents, and study how the perception of objects and space-time can emerge from such dynamics. We show that one particular object, the quantum free particle, has a wave function that is identical in form to the harmonic functions that characterize the asymptotic dynamics of conscious agents; particles are vibrations not of strings but of interacting conscious agents. This allows us to reinterpret physical properties such as position, momentum, and energy as properties of interacting conscious agents, rather than as preexisting physical truths. We sketch how this approach might extend to the perception of relativistic quantum objects, and to classical objects of macroscopic scale.

Metabolism, pharmacokinetics and excretion of a potent tachykinin NK1 receptor antagonist (CP-122,721) in rat: Characterization of a novel oxidative pathway

The metabolism, pharmacokinetics and excretion of a potent and selective substance P receptor antagonist, (+)-(2S,3S)-3-(2-methoxy-5-trifluoromethoxybenzlamino)-2-phenylpiperidine, CP-122,721, have been studied in rat following oral administration of a single dose of [14C]CP-122,721. Total recovery of the administered dose was 84.1+/-1.1% for male rat and 80.9+/-2.7% for female rat. Approximately 81% of the administered radioactivity recovered in urine and faeces were excreted in the first 72 h. Absorption of CP-122,721 was rapid in both male and female rat, as indicated by the rapid appearance of radioactivity in plasma. The plasma concentrations of total radioactivity were always much greater than unchanged drug, indicating early formation of metabolites. CP-122,721 t1/2 was 3.1 and 2.2 h for male and female rat, respectively. The plasma concentrations of CP-122,721 reached a peak of 941 and 476 ng ml-1 for male and female rat, respectively, at 0.5 h post-dose. Based on AUC0-tlast, only 1.5% of the circulating radioactivity was attributable to unchanged drug (average of male and female rats) and the balance, approximately 98.5% of the plasma radioactivity was due to metabolites. The major metabolic pathways of CP-122,721 were due to O-demethylation, aromatic hydroxylation and indirect glucuronidation. The minor metabolic pathways included aliphatic oxidation at the piperidine moiety and aliphatic oxidation at the benzylic position of the trifluoromethoxy anisole moiety. In addition, a novel oxidative metabolite resulting from ipso substitution by the oxygen atom and trifluoromethoxy elimination followed by glucuronide conjugation was also identified.

Metabolism and excretion of CP-122,721, a non-peptide antagonist of the neurokinin NK1 receptor, in dogs: identification of the novel cleaved product 5-trifluoromethoxy salicylic acid in plasma

The metabolism and excretion of a potent and selective substance P receptor antagonist, CP-122,721, have been studied in beagle dogs following oral administration of a single 5 mg kg(-1) dose of [(14)C]CP-122,721. Total recovery of the administered dose was on average 89% for male dogs and 95% for female dogs. Approximately 94% of the radioactivity recovered in urine and feces was excreted in the first 72 h. Male bile duct-cannulated dogs excreted a mean of approximately 56% of the dose in bile, approximately 11% in feces, and approximately 25% in urine. The sum of radioactivity in bile and urine indicates >80% of the [(14)C]CP-122,721-derived radioactivity was absorbed by the gastrointestinal tract. CP-122,721 was extensively metabolized in dogs, and only a small amount of parent CP-122,721 was excreted as unchanged drug. There were no significant gender-related quantitative/qualitative differences in the excretion of metabolites in urine or feces. The major metabolic pathways of CP-122,721 were O-demethylation, aromatic hydroxylation, and indirect glucuronidation. The minor metabolic pathways included: Aliphatic oxidation at the piperidine moiety, O-dealkylation of the trifluoromethoxy group, and N-dealkylation with subsequent sulfation and/or oxidative deamination. In addition, the novel cleaved product 5-trifluoromethoxy salicylic acid (TFMSA) was identified in plasma. These results suggest that dog is the most relevant animal species in which the metabolism of CP-122,721 can be studied for extrapolating the results to humans.

Identification of the human cytochrome P450s responsible for the in vitro metabolism of a leukotriene B4 receptor antagonist, CP-195,543

1. The major human cytochrome P450 (CYP) form(s) responsible for the metabolism of CP-195,543, a potent leukotriene B4 antagonist, were investigated. 2. Incubation of CP-195,543 with human liver microsomes resulted in the formation of three major metabolites, M1-3. M1 and M2 were diastereoisomers and formed by oxidation on the benzylic position. M3 was formed by aromatic oxidation of the benzyl group attached to the 3-position of the benzopyran ring. 3. The results from experiments with recombinant CYPs, correlation studies and inhibition studies with form-selective inhibitors and a CYP3A antibody strongly suggest that the CYP3A4 plays a major role in the metabolism of CP-195,543. Recombinant CYP3A5 did not metabolize CP-195,543. 4. The apparent K(m) and V(max) for the formation of M1-3 in human liver microsomes were determined as 36 microM and 4.1 pmol min(-1) pmol(-1) P450, 44 microM and 10 pmol min(-1) pmol(-1) P450, and 34 microM and 2.0 pmol min(-1) pmol(-1) P450, respectively. The average in vitro intrinsic clearance for M2 was the highest both in human liver microsomes and recombinant CYP3A4 compared with M1 and M3. Intrinsic clearance for M2 in human liver microsomes and recombinant CYP3A4 was 0.231 and 0.736 ml min(-1) pmol(-1) P450, respectively. The intrinsic clearances for M1 and M3 in human liver microsomes and CYP3A4 were 0.114 and 0.060 and 0.197 and 0.088 ml min(-1) pmol(-1) P450, respectively. This suggests that benzylic oxidation is the predominant phase I metabolic pathway of CP-195,543 in man.

Esophageal motor disorders

Esophageal motor function remains of investigative and clinical interest because of its relevance to symptoms and its relation to the occurrence and management of gastroesophageal reflux disease. Refinement in diagnostic methods continues to occur, and improved tests for identifying the nature or severity of motor disturbances in both the proximal and distal esophageal regions are now well described. Controversy concerning the management of achalasia, the best-understood distal motor disorder, is resolving as the benefits and disadvantages of available treatment options are becoming recognized. The relation of esophageal motor dysfunction to outcomes from antireflux surgery remains incompletely understood.

Angio-proliferative lesions in a homosexual boar with features resembling Kaposi's sarcoma

Clinical, biopsy and necropsy studies of a homosexual boar revealed angio-proliferative lesions in the skin of the thigh, scrotum and the inguinal lymph node. Angiofibromas were identified in the dermis and subcutis of the thorax and mandible. The avidin-biotin-peroxidase complex technique demonstrated Factor VIII-related antigen as a marker for the neoplastic endothelial cells of the tumors. This boar also showed weight loss and lymphopenia. Explants of tumors were maintained in cultures for 22 passages and cultured cells produced tumors when injected subcutaneously into nude mice. No viral antigen was detected in the cultured tumor cells. Similarities and differences between the lesions in the boar and human Kaposi's sarcoma are discussed.

Similarities in cyclic vomiting syndrome across age groups

OBJECTIVE

Cyclic vomiting syndrome is well recognized in children yet has poorly defined pathogenesis and treatment. Cyclic vomiting syndrome is occasionally diagnosed in older subjects, but little attempt has been made to determine if such cases represent a unique disorder.

METHODS

We reviewed clinical data from 39 patients aged 1.8-75 yr with cyclic vomiting syndrome meeting published criteria for diagnosis. Clinical characteristics were compared between subjects with symptom onset in childhood (<12 yr, n = 18) and subjects with onset at an older age (> or =12 yr, n = 21; mean age at onset 34.8+/-3.8 yr).

RESULTS

All patients had stereotypical episodes of vomiting separated by varying symptom-free intervals. The prevalence rates of prodromal symptoms, triggering events, alleviants, associated symptoms including abdominal pain and diarrhea, and past or family history of migraine were similar in the children and older subjects with the syndrome (p > 0.3 for each). Delay in diagnosis was greater in the older subset (3.1+/-0.8 yr vs 7.9+/-3.1 yr, p < 0.05). Interepisode intervals and total number of hospitalizations did not differ significantly between younger and older patients, but duration of episodes was significantly longer in the older group (2.0+/-0.5 days vs 3.8+/-0.4 days, p < 0.01). When subjects were further substratified by age of illness onset, duration of episodes progressively increased from infant/toddlers (1.8+/-0.4 days) through childhood (2.3+/-0.5 days) and adolescence (2.9+/-1.0 days) and into adulthood (3.9+/-0.5; p < 0.05 across groups). Episode duration did not lengthen further in subgroups >20 yr of age.

CONCLUSIONS

Many characteristics of cyclic vomiting syndrome are similar irrespective of age at disorder onset, suggesting a uniform pathogenesis. Duration of episodes increases with age to age 20 yr. Increased awareness of the condition and a high index of suspicion may help decrease delay in diagnosis after symptom onset.

Effects of dietary proteins and trypsin inhibitor on growth and lipid metabolism in hamsters

The purpose of this study was to determine trypsin inhibitor (TI) activity in sweetpotato and soy flour diets and their effects on the growth and lipid metabolism of hamsters. Male Golden Syrian hamsters were fed different types of dietary protein containing casein, soyprotein, transgenic sweetpotato plus soy flour (TSPF+SF), nontransgenic sweetpotato (NTSPF) plus soy flour (NTSPF+SF), transgenic sweetpotato (TSPF) and nontransgenic sweetpotato flour for 28 days. The TI activity was highest in TSPF+SF (19.30 TIU/mg) and NTSPF+SF (17.20 TIU/mg) diets that induced growth retardation in animals, lowest in TSPF (5.80 TIU/mg) and NTSPF (5.50 TIU/mg) diets, which did not affect the growth of the animals, and negligible in casein (<1.00 TIU/mg) and soyprotein (2.00 TIU/mg) diets. Plasma total cholesterol (TC), high density lipoprotein-cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C) and triglyceride (TG) concentrations were significantly higher in hamsters fed the casein diet compared to those fed the soy protein, TSPF+SF, NTSPF+SF, TSPF and NTSPF diets. A positive correlation was observed between plasma TC concentrations of hamsters and dietary methionine, lysine, leucine content and methionine/glycine ratios. Liver TC and TG concentrations of hamsters fed casein were significantly higher than those of all other diet groups. The supplementation of sweetpotato flour with soy flour increased both protein and TI activity in the diets and the lipid metabolism of hamsters were unaffected by TI activity.

Topographic esophageal manometry: an emerging clinical and investigative approach

Topographic esophageal manometry utilizes an increased number of pressure sensors and three-dimensional displays to fully reveal the pressure continuum representing peristalsis. The techniques demonstrate that peristalsis is comprised of a chain of pressure segments, beginning at the upper esophageal sphincter and continuing through lower sphincter aftercontraction. Topographic methods have already proven useful in both research and clinical settings. Description of the techniques, the topographic representation of normal and abnormal esophageal motility, and advantages of topography over conventional manometric methods are discussed in this review.

Narrow-bore high-performance liquid chromatography in combination with ionspray tandem mass spectrometry for the determination of the substance P receptor antagonist ezlopitant and its two active metabolites in plasma

A simple, but highly sensitive and specific, assay was developed for the quantitative determination of ezlopitant and its two active metabolites in human plasma using narrow-bore reversed-phase high-performance liquid chromatography (HPLC) coupled with electrospray tandem mass spectrometry (ES-MS-MS). Ezlopitant, its two pharmacologically active metabolites, an alkene analogue (CJ-12 458) and a benzyl alcohol analogue (CJ-12 764), and their corresponding trideuterated internal standards (I.S.), were extracted from plasma with methyl tert.-butyl ether (MTBE). The dried MTBE extracts were reconstituted and analyzed using a narrow-bore (2.1 mm I.D.) YMC basic HPLC column and a mobile phase of acetonitrile-20 mM ammonium acetate, pH 5 (60:40, v/v). Column effluent was monitored by pneumatically assisted electrospray tandem mass spectrometry. Multiple reaction monitoring (MRM) using the parent to product ions was used to quantify ezlopitant and its two active metabolites. The assay exhibited a linear dynamic range of 0.1-100 ng/ml. Average absolute recoveries from plasma were approximately 71, 80 and 99% for ezlopitant and its two active metabolites CJ-12 485 and CJ-12 764, respectively. The precision (RSD %) and accuracy (Deviation %) values for the method were within +/- 12% and +/- 15%, respectively, for all analytes. Sample analysis times were less than 5 min from one injection to the next. The assay proved to be suitable for pharmacokinetics studies.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is a significant worldwide medical problem. Despite modern measures for diagnosis and treatment, morbidity and mortality rates associated with gastrointestinal bleeding remain largely unchanged. Aggressive medical resuscitation while initiating an evaluation to localize the site of blood loss remains the key to successful management of acute gastrointestinal bleeding. A multidisciplinary approach with early involvement of a gastroenterologist, surgeon, and radiologist can be extremely helpful in the management of these patients. With the logical and direct approach to the evaluation of patients with gastrointestinal bleeding described in this article, most episodes can be managed successfully.

Sphincter of oddi manometry: is it necessary to measure both biliary and pancreatic sphincter pressures?

BACKGROUND

Data are scant on the miss rate of sphincter of Oddi dysfunction if basal pressure in both biliary and pancreatic sphincter segments is not measured during manometry.

METHODS

Motility tracings with basal pressure measurements of both sphincter segments were retrospectively analyzed. Basal sphincter pressure greater than 40 mm Hg was considered abnormal in either sphincter segment.

RESULTS

The study population consisted of 73 subjects (64 women, 9 men; age 45.3 +/- 1.6 yr). The basal pressures in the 2 sphincter segments were highly discordant (correlation coefficient = 0.2, p = 0.04). Basal pressures were normal in both segments in 19%, abnormal in both segments in 40%, and abnormal in 1 segment but normal in the other in 41%. The negative predictive value of normal biliary sphincter pressure in excluding sphincter dysfunction was 0. 42; when the pancreatic sphincter pressure was normal, the negative predictive value was 0.58. The incidence of pancreatitis with dual duct manometry was comparable to the institutional experience with all sphincter studies.

CONCLUSIONS

Although the clinical relevance of individually elevated sphincter pressures remains uncertain, there is significant discordance of basal pressures between the biliary and pancreatic sphincter segments. If only the biliary sphincter pressure were to be measured, one fourth of abnormal sphincter pressures would be missed. Therefore, if the first sphincter segment has a normal basal pressure, the other segment should also be evaluated.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.

Response to hepatitis B vaccination in high risk population

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

AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics committee. The paper was approved by the committee on May 16, 1999, and by the AGA governing board on July 18, 1999.

Identification of the major human liver cytochrome P450 isoform(s) responsible for the formation of the primary metabolites of ziprasidone and prediction of possible drug interactions

AIMS

To identify the cytochrome P450 (CYP) isoform(s) responsible for the formation of the primary metabolite of ziprasidone (ziprasidone sulphoxide), to determine the kinetics of its formation and to predict possible drug interactions by investigating CYP isoform inhibition in an in vitro study.

METHODS

In vitro metabolism of [14C]-ziprasidone was studied using human liver microsomes. The metabolites were identified using mass spectrometry. The kinetics of metabolite formation were determined using [14C]-ziprasidone (10-200 microM) over 5 min, and Km and Vmax were estimated from Lineweaver-Burk plots. IC50 values for the inhibition of specific probe substrates for CYP1A2, CYP2C9, CYP2C19, CYP2D6 and CYP3A4, by ziprasidone, risperidone and 9-hydroxyrisperidone were also determined using human liver microsomes from three subjects. Mean Ki values were calculated.

RESULTS

Three CYP-mediated metabolites - ziprasidone sulphoxide, ziprasidone sulphone and oxindole acetic acid - were identified. The apparent Km and Vmax values for the formation of the major metabolite, ziprasidone sulphoxide (measured as the sum of sulphoxide and sulphone) were 235 microM and 1.14 nmol mg(-1) protein min(-1), respectively. Isoform-selective inhibitors and recombinant enzymes indicated that CYP3A4 is responsible for the formation of ziprasidone metabolites. Ziprasidone was not a substrate for the other isoforms studied. Similar in vitro inhibition of CYP2D6 (Ki 6.9-16 microM) and CYP3A4 (Ki 64-80 microM) was obtained with ziprasidone, risperidone and 9-hydroxyrisperidone. The in vivo free drug concentrations associated with clinically effective doses of ziprasidone are at least 1500-fold lower than the mean Ki for either CYP2D6 inhibition or CYP3A4 inhibition.

CONCLUSIONS

Ziprasidone is predominantly metabolized by CYP3A4 in human liver microsomes and is not expected to mediate drug interactions with coadministered CYP substrates, at clinically effective doses.

Long-term outcome from tricyclic antidepressant treatment of functional chest pain

Antidepressants are of demonstrated value in short-term treatment of functional chest pain, but long-term outcome data are unavailable. Follow-up information over a median of 2.7 years (0.8-8.6 years) was systematically obtained from 21 outpatients treated with tricyclic antidepressants after incomplete response to antireflux therapy. Initial treatment produced at least moderate symptom reduction or remission in 17 subjects (81.0%). Of these, 7 (41.2%) were successfully treated continuously or for symptom relapses over an average of 2.6 years; 5 (29.4%) discontinued successful treatment after >0.5 years with sustained benefits; and 5 (29.4%) eventually discontinued treatment because of side effects or for uncertain reasons (1 having a sustained remission). Low-dose tricyclic antidepressants were considered the most effective long-term chest pain treatment significantly more often than were antireflux medications or calcium-channel blockers in this selected patient group (P<0.05 for each). We conclude from this retrospective review that fully three fourths of subjects with functional chest pain who initially respond to open-label treatment with low-dose tricyclic antidepressants will use them continuously or for symptom relapses over at least the next two to three years and consider them the most effective treatment for their symptoms.

Cyclic vomiting syndrome in adults: clinical features and response to tricyclic antidepressants

OBJECTIVE

Cyclic vomiting syndrome (CVS) has been described infrequently in adults, and treatment in both children and adults remains unsatisfactory. We report clinical features of a group of adults with CVS and anecdotal outcome from open-label treatment with tricyclic antidepressants, medications that have some efficacy in other unexplained gastrointestinal disorders.

METHODS

Clinical data were examined from 17 adult patients with CVS seen over a 10-yr period, each having been treated with a tricyclic antidepressant. Outpatient records were reviewed, clinical outcome was extracted using a priori criteria, and findings were compared with 37 patients having usual functional nausea and vomiting who also received tricyclic antidepressant therapy.

RESULTS

Symptoms in CVS began at age 35 yr (range 14-73 yr); the average episode length was 6 days (range 1-21 days) and the symptom-free interval averaged 3.1 months (range 0.5-6 months). Vomiting cycles typically began without warning, and fewer than one-third of the subjects reported a prodrome or potential trigger event, such as menstrual periods, pregnancy, or large meals. Sleep was seemingly beneficial in 23.5%. Tricyclic antidepressant therapy was associated with complete remission in 17.6% and partial response in 58.8%, but was less effective than for functional nausea and vomiting (p = 0.02).

CONCLUSIONS

CVS is a rare diagnosis with distinctive features in adults. Duration of episodes and cycles varies considerably across subjects. In open-label, uncontrolled use, tricyclic antidepressants appear beneficial for some subjects but are less effective in CVS than in chronic, persistent functional nausea and vomiting.

Endoscopic hemostasis in acute diverticular bleeding

BACKGROUND AND STUDY AIMS

Early reports of urgent colonoscopy in acute lower intestinal bleeding suggest a role for endoscopic therapy for bleeding colonic lesions, but scant data exist on bleeding diverticula. We report our experience with endoscopic hemostasis in acute diverticular bleeding.

PATIENTS AND METHODS

Bleeding diverticula were identified on urgent diagnostic endoscopy in five patients with acute gastrointestinal bleeding, two in the duodenum, and three in the colon. All patients had co-morbid conditions preventing more conventional therapeutic approaches. The five cases are described, including the technique of endoscopic hemostasis and outcome.

RESULTS

Endoscopic therapy using epinephrine injection, thermal cautery and/or laser therapy successfully induced hemostasis in all patients. One patient died of co-morbid illness during the hospital stay, while the remaining four patients had no recurrent bleeding over a mean follow-up period of 20.6 months.

CONCLUSION

Endoscopic therapy of bleeding diverticula is technically possible when the culprit diverticulum can be identified. This therapeutic modality may have a place in debilitated patients in whom other more invasive procedures are contraindicated, but further experience is needed to establish its safety.

Esophageal motor disorders

A consolidation of ideas regarding the pathogenesis and management of esophageal motor disorders occurred over the past year. The development and application of diagnostic techniques has stimulated new thinking about the events responsible for peristalsis and has provided novel avenues for studying mechanisms of symptom production. Achalasia remains the most investigated and understood motor disorder, and the year's research focused heavily on management approaches for this important condition. Other topics addressed in this review include proximal esophageal symptoms and disorders, spastic disorders, and esophageal hypomotility.

Diagnosis and management of small intestinal diseases

Advances in the diagnosis and management of small bowel diseases are the subject of this review. Topics covered include improving the specificity of breath tests for bacterial overgrowth; small bowel enteroscopy; early diagnosis of mesenteric ischemia; the use of polymerase chain reaction for diagnosing central nervous system involvement in Whipple's disease; progress in defining the cause and pathogenesis of chronic idiopathic intestinal pseudoobstruction and the Peutz-Jeghers syndrome; defining the role of gut barrier function in health and disease; the therapeutic role for bile acid-binding resins in diarrhea after refeeding in critically ill patients; use of genetic techniques and topical steroid therapy in treating graft-versus-host disease; and the beneficial effects of combination hormonal therapy in occult gastrointestinal blood loss resulting from angiodysplasia.