Identification of hemoglobin Q India (α 1–64 Asp–His) through ARMS-PCR. First report from Pakistan

Various hemoglobinopathies have been reported from Pakistan excepting the rare ones like hemoglobin Q India. Our purpose of study was to identify the mutation (α 1 64 aspartate to histidine) through amplification restriction mutation system-polymerase chain reaction (ARMS-PCR) in patients where hemoglobin Q has been detected via high performance liquid chromatography (HPLC) and also to evaluate the cost effectiveness of the two technologies. All patients irrespective of age and gender who underwent HPLC for identification of their hemoglobin variant during January 1, 2006 to January 30, 2007 were studied. The blood samples with unknown peak at a retention time of 4.7 min were evaluated at the molecular level. Analysis of HPLC tracings of 11,008 subjects over a thirteen-month period identified ten individuals with hemoglobin Q. Male to female ratio was 1:1.5 and their age was variable ranging from 1 to 49 (mean 22.8) years. The mean hemoglobin level was 11.3 g/dl while MCV (fl) and MCH (pg) were 73.0 and 20.8 respectively. HPLC showed an unknown peak of 17.7% which was detected as Hb Q. ARMS based PCR showed Hb Q specific product of 370 bp and also an amplified product of 766 bp as the control fragment in these samples. This is the first ever report that documents the presence of Hb Q India (α 64 Asp to His) in Pakistani population. We recommend that HPLC be used as a useful screening tool especially in developing countries where PCR facilities may not be accessible.     

Effect of Acarbose on Vascular Disease in Patients with Abnormal Glucose Tolerance

INTRODUCTION: Excessive postprandial (pp) glucose excursion in people with IGT and type 2 diabetes is associated with a cascade of proatherogenic events. Acarbose, a potent competitive inhibitor of alpha-glucosidases of the small intestine specifically reduces pp hyperglycemia with an average reduction of HbA1c by 0.8% in Cochrane metaanalysis. This is associated with pleiotropic effects on a broad spectrum of cardiovascular (CV) risk factors: reduction of overweight, lowering of blood pressure, triglycerides, hsCRP, fibrinogen and other biomarkers of low grade inflammation. RESULTS AND DISCUSSION: Flow mediated vasodilation was improved and progression of intima media thickness was reduced by acarbose. In the STOP-NIDDM trial in people with IGT acarbose decreased the incidence of diabetes by 36%. The STOP-NIDDM trial with CV events as secondary objective is the only intervention trial in people with IGT so far with a significant benefit for CV disease inclusive hypertension. In a metaanalysis of controlled studies (MeRIA) in patients with type 2 diabetes, treatment with acarbose was associated with a 64% lower rate of myocardial infarction and 35% less CV events. CONCLUSION: Thus results so far available prove that acarbose is an effective and safe drug to treat abnormal glucose tolerance. They suggest that acarbose can help to control a broad spectrum of CV risk factors and may prevent CV disease.     

Multilocular cystic renal cell carcinoma: an experience of clinical management for 31 cases

In order to increase our knowledge and understanding about multilocular cystic renal cell carcinoma (MCRCC), including diagnosis, surgical management, pathologic and prognostic characteristics, clinical data of patients who suffered with MCRCC were reviewed retrospectively. From 1998 to 2005, among 770 patients diagnosed with renal cell carcinoma (RCC) at our institute, 31 cases (4.0%) were identified as MCRCC. The average age of patients suffered with RCC and MCRCC was 58.1 ± 3.6 and 45.9 ± 2.7, respectively (P < 0.01), whereas the gender ratio of male to female in RCC and MCRCC is 2.12:1 and 2.88:1(P < 0.01). Surprisingly, 28 of those 31 renal masses (90.3%) were first discovered on the radiographic image, and the size of tumors in maximum diameter ranged from 1.7 to 11.0 cm (mean 4.1 ± 2.2 cm). All those patients were treated with open nephrectomy, including 21 radical and 10 partial. The stages of tumor were classified as pT1N0M0, pT2N0M0, and pT3bN0M0 following the 1997 criteria of tumor-node-metastasis (TNM) classification in the number of 27(87.1%), 3(9.7%) and 1(3.2%), respectively. By contrast, according to the tumor nuclear grading system, those tumors were classified as Grades 1 and 2 in 13 (42%) and 18 patients (58%), respectively. Only 29 cases from those patients have been followedup for a period of 9 to 81 months so far (mean 32.6 ± 11), while no tumor recurrence occurred except for 1 case who died of causes other than MCRCC. In general, MCRCC is a frequent subtype of RCC in the clinic. A nephron-sparing procedure should be considered in the preoperative plan when a complex multicystic renal mass with enhanced density is observed.     

The Effect of Processing on Liver Biopsy Core Size

OBJECTIVES: Liver biopsy is a valuable clinical tool, but for the interpretation to be meaningful a certain core size should be obtained. This study examines the changes the liver biopsy core undergoes during processing steps. METHODS: A total of 61 consecutive percutaneous liver biopsies were obtained between November 2004 and April 2005. The needle type utilized was the 16-gauge automatic tru-cut. A measurement was made while each liver biopsy core specimen resided in the cartridge, then a measurement was made with the core placed on the tray, and a final measurement was made after the pathologist received the formalin-fixed specimen. RESULTS: The mean size of the biopsy core in the cartridge measured 15 +/- 2 mm, compared to a mean size on the tray of 19.6 +/- 3.5 mm, and a mean size after fixation of 18.3 mm. All mean sizes were statistically different from one another. The compressive effect of the cartridge was 23%. The shrinkage effect of formalin fixation was 7%. CONCLUSIONS: The liver biopsy core size changes significantly through the processing steps. It is imperative that the operator is aware of these changes so that appropriate decisions are made. As an example, if the operator underestimates the core size when measured in the cartridge, a second pass may be completed when in fact adequate tissue had been obtained on the first pass.     

Update on therapeutic options for <Emphasis Type="Italic">Helicobacter pylori</Emphasis>-related diseases

Triple therapy including clarithromycin, amoxicillin, and a proton pump inhibitor (PPI) has been recommended as the treatment of choice for Helicobacter pylori eradication. This regimen is now challenged by an increasing level of clarithromycin resistance that jeopardizes the treatment success. When clarithromycin resistance has been detected, or when its rate is known to be high in the geographic area, this drug cannot be used. It can be replaced by metronidazole, the resistance of which has a limited clinical relevance. Another option is to prescribe tetracycline and metronidazole with a PPI or ranitidine bismuth citrate. New antibiotics such as levofloxacin or rifabutin can also be used in combination with amoxicillin and a PPI. Probiotics can be added to all of these regimens to improve compliance by decreasing adverse events. But some authors advocate a quadruple therapy as a first-line treatment. Solutions to improve the limitations of this last regimen are now being proposed. Clarification of the controversial treatment indications such as gastroesophageal reflux disease or prevention of nonsteroidal anti-inflammatory drug gastroduodenal symptoms has been made. The question of prevention of gastric carcinoma by H. pylori eradication remains unanswered.     

Defining Optimal Self-Management in Osteoarthritis: Racial Differences in a Population-Based Sample

The aim of this study was to examine optimal self-management in osteoarthritis and its association with patient-reported outcomes. We recruited a population-based sample of Medicare beneficiaries (n = 551) residing in Allegheny County, PA, USA and elicited an expanded set of self-management behaviors using open-ended inquiry. We defined optimal self-management according to clinical recommendations, including use of hot compresses on affected joints, alteration of activity, and exercise. Only 20% practiced optimal self-management as defined by two or more of these criteria. Optimal and suboptimal self-managers did not differ in sociodemographic features. Both white and African–Americans who practiced optimal self-management reported significantly less pain, but the benefit was greatest in severe disease for whites and for mild-moderate disease among African–Americans. This backdrop of naturally occurring self-management behaviors may be important to recognize in planning programs that seek to bolster self-management skills.     

Managing Type 2 Diabetes Mellitus in Patients with Obesity

Obesity is the most important modifiable risk factor for type 2 diabetes mellitus and most patients with diabetes are overweight or obese. It is well known that excess bodyweight induces or aggravates insulin resistance, which is a characteristic feature of type 2 diabetes. Thus, bodyweight plays a central role in the prevention and treatment of diabetes. Recent data suggest that lifestyle intervention in patients with impaired glucose tolerance results in an impressive reduction in the conversion to overt diabetes, which is greater than the effect of early intervention with drugs such as metformin or acarbose. The prevention of diabetes has been shown to be associated with the extent of weight loss. In patients with type 2 diabetes, weight loss by any means is followed by an improvement of metabolic control and associated risk factors. The most appropriate recommendation for obese patients with type 2 diabetes is a nutritionally balanced, moderately hypocaloric diet with a reduced intake of saturated fat and an increase in physical activity. If this standard approach is only partly successful or not at all, additional strategies such as weight-lowering drugs, very low-calorie diets for limited periods of up to 12 weeks, and, for severely obese patients, bariatric surgery should be carefully considered. A large body of data suggests that such measures can be very effective in this patient group by improving metabolic disturbances and blood pressure. However, it is extremely important for the long-term outcome that the treatment is tailored to the needs and wishes of the individual patient. There is growing agreement that due to the low success rate of conventional therapies and the overwhelming benefit from weight loss, more determined and aggressive strategies may be appropriate to achieve the central goal of weight reduction in obese patients with type 2 diabetes.     

Glycyrrhizin enhances interleukin-10 production by liver dendritic cells in mice with hepatitis

Background Glycyrrhizin (GL), an aqueous extract of licorice root, is known to have various immune-modulating and biological response-modifier activities. GL is used in patients with hepatitis to reduce the activity of liver inflammation; however, the mechanism underlying the anti-inflammatory activity of GL is poorly understood. As antigen-presenting dendritic cells (DC) in the tissue play a major role in the regulation of the inflammatory mucosal milieu during tissue inflammation, we studied whether the function of liver DC was altered by GL therapy in a murine model of concanavalin-A (Con A)-induced hepatitis.Methods Liver DC were propagated from control mice or mice with Con-A-induced hepatitis, and the effect of GL on liver DC was evaluated in vivo and in vitro.Results The levels of interleukin (IL)-10 produced by liver DC were significantly lower in mice with Con-A-induced hepatitis compared with control mice. However, treatment with GL caused increased production of IL-10 in mice with Con A-induced hepatitis. The increased production of IL-10 by mice with Con A-induced hepatitis was also confirmed in vitro by culturing liver DC with GL.Conclusions This study indicates that increased production of IL-10 by liver DC due to GL administration may be involved in downregulation of the levels of liver inflammation in mice with Con A-induced hepatitis.     

Impact of the 2014–2015 influenza season on the activity of an academic emergency department

The morbidity and mortality of the 2014–2015 influenza season were more important than those in previous years. We assessed the impact of the 2014–2015 influenza season on the length of stay (LOS) and workload in an academic emergency department (ED). This is a monocentric retrospective study. The database of the microbiology laboratory was used to identify influenza nasal swabs performed during the influenza seasons from 2010 to 2015. Patients admitted to the ED during these periods were identified through the administrative database and cross-checked with patients who underwent an influenza nasal swab in the ED. Median LOS was used to estimate the impact of the isolation procedures on ED LOS. Bed occupancy rate and mean LOS in the ED were calculated as proxy of the ED workload. During the 2014–2015 influenza season, 55.9% of ED patients (n = 123) with confirmed influenza were hospitalised. In terms of workload, despite that influenza patients represented only 2.2% of all ED patients during the season, they occupied 28% of ED beds with respiratory isolation during the delay to realise and obtain the test results, as well as during the delay before being discharged home or transferred to a hospital ward. The median ED LOS for influenza-confirmed patients was significantly longer in comparison with all ED patients (21.6 h vs 4.0 for ambulatory patients and 24.7 h vs 12.3 for hospitalised patients). The 2014–2015 influenza season had significant consequences in terms of ED LOS and bed use. It dramatically increased the workload in the ED.