The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy.

Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as "adjuncts" to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method - a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.

Measurement of energy cost of selected household and farm activities performed by rural women.

A nutritional study was carried out on 30 rural, low-income women, aged 25 to 35 years, in the village of Dhandra, Ludhiana District, Punjab, India, to measure the energy cost of selected household and farm activities. The mean weight, mid-upper-arm circumference, and triceps skinfold thickness were below the reference standards. A negative energy balance among the subjects indicated their poor energy status. The energy costs of selected household and farm activities were assessed by the Caltrac personal activity computer. The energy costs of household activities--making dough, making chapatis, grinding masala, hand pumping, washing utensils, sweeping, mopping, washing the floor, mud pasting, and washing clothes--were 0.0306, 0.0281, 0.0595, 0.0337, 0.0266, 0.0424, 0.0530, 0.0331, 0.0634, and 0.0453 kcal/kg/min, respectively. The energy costs of farm activities--collecting fodder, chaffing fodder, milking, making dung cakes, picking sag, harvesting wheat, bundling wheat, picking paddy, brooming paddy, and separating paddy--were 0.0472, 0.0372, 0.0530, 0.0270, 0.0337, 0.0623, 0.0374, 0.0411, 0.0370, and 0.0744 kcal/kg/min, respectively. All selected activities were categorized as light, except for grinding masala, mopping, mud pasting, harvesting wheat, separating paddy, and milking, which were categorized as moderate on the basis of Food and Agriculture Organization (FAO) physical activity ratios. The Caltrac gave lower values for the energy costs of most of the activities. Although it is simpler and less costly, the Caltrec must be calibrated against methods of measuring oxygen consumption for similar activities.

Iron and energy supplementation improves the physical work capacity of female college students.

A nutritionally controlled study was conducted on two groups of 15 female college students aged 16 to 20 years, selected from Punjab Agricultural University, Ludhiana, Punjab, India. The girls were either anemic (hemoglobin 7.7 g/dl) but energy adequate (AEA), or anemic (hemoglobin 7.4 g/dl) and energy deficient (AED). The AEA group was given iron supplementation (60 mg iron/day) for 6 to 9 months along with 100 mg of ascorbic acid, and the AED group was given iron as well as energy supplementation for 3 months. There was a significant (p < .01) increase in weight, body mass index, mid-upper-arm circumference, and body fat in the AED group after iron-energy supplementation. Hemoglobin, serum iron, transferrin saturation, total iron-binding capacity, and unsaturated iron-binding capacity were below normal in both groups; however, after iron and iron-energy supplementation, there was a significant (p < .01) increase, and these indices were in the normal range. There was a significant (p < .01) increase in exercise time and maximum work load tolerance after iron and iron-energy supplementation. Combined energy and iron deficiency had a greater adverse effect on physical work capacity than energy or iron deficiency alone.

Heterotopic gastric tissue in the duodenal bulb.

Heterotopic gastric tissue in the duodenal bulb is a rare congenital lesion. Its prevalence has been reported to be 0.5-2%. It must be differentiated from gastric metaplasia of the duodenal bulb because the two entities have different clinical implications. During one year, we found three cases of gastric heterotopia of the duodenal bulb. In one of the cases, active acid-secreting gastric mucosa was documented by performing the pentagastrin Congo red dye test. The differences between gastric heterotopia of the duodenal bulb and gastric metaplasia of the duodenal bulb have been discussed.

Serum ferritin as a measure of iron stores in the college girls.

The average daily iron consumption of the college girls was 48 per cent of the recommended dietary allowances of ICMR (1990). The Hb level was below the normal value. The values of serum iron, transferrin saturation (TS) and unsaturated iron bearing capacity (UIBC) were in the normal range but near the lower margin. The TIBC was above the normal range. The serum ferritin values showed very poor iron stores. A highly significant (p < 0.01) correlation was observed between Hb, serum iron and TS with serum ferritin. There is a superiority of ferritin over other blood parameters as it indicates the liver iron stores, hence, a better predictor of iron deficiency status.

In cirrhotic patients variceal bleeding is more frequent in the evening and correlates with severity of liver disease.

BACKGROUND/AIMS: It has been observed that the portal pressure in cirrhotic patients shows circadian variation and is at a maximum at night. Our aims in this study were a) to evaluate the frequency of upper gastrointestinal (UGI) bleeding from esophageal/gastric varices or portal congestive gastropathy during the day, evening or night shift, and b) to correlate the frequency of bleeding during various shifts with severity of liver disease. METHODOLOGY: At our institution, during the period from January 1997 to June 1995, 15,000 gastrointestinal (GI) endoscopic reports and consultations were evaluated. Episodes of bleeding due to portal hypertension (PH), i.e., esophageal varices, gastric varices or congestive gastropathy, were noted. The time of occurrence of bleeding from PH in various shifts, e.g., day shift (DS), evening shift (ES) or night shift (NS) was determined. The severity of liver disease was classified as A, B or C according to Child's classification. RESULTS: There were 221 episodes of UGI bleeding due to PH in 144 patients. 75.5% of patients presented with hematemesis, whereas 24.5% presented with melena (p < 0.025). Bleeding started during the DS in 39/221 (17.6%), during the ES in 122/221 (55.2%), and during the NS in 60/221 (27.1%). There were 29 (13.1%) patients in Child's A, 75 (33.9%) in Child's B, and 117 (52.9%) in Child's C. Among the 122 bleeders during ES, 85 (69.6%) were in category C. It seems that in these patients UGI bleeding is more frequent during the ES compared to DS and NS (p < 0.0001; chi square; 95% CI: 0.52-0.58). Child's C patients are more likely to bleed during ES compared to Child's A or B patients (p < 0.0001; Odds Ratio: 4.8%; 95% CI: 2.7-8.5). CONCLUSIONS: 1) The majority of the cirrhotic patients with PH who develop UGI bleeding present with hematemesis rather than melena. 2) The bleeding in these patients is more likely to occur during the ES. 3) Child's C patients are more likely to bleed during the ES.

The safety of hot biopsy forceps in the removal of small colonic polyps.

Nine hundred and seven polyps (mean size 3.7 mm; range 2-8) from 460 patients (mean age 67 years; range 34-94) were removed with monopolar electrocoagulation forceps ('hot biopsy forceps'). Sixty-three percent of the polyps were adenomatous and 36% were hyperplastic. In this series there were 3 cancers and 1 neurofibroma. About 42% of the polyps were in the sigmoid-rectum region; the rest were evenly distributed in the remaining part of the colon. There were no complications. Specifically there were no cases of perforation or massive bleeding after removal of these polyps. Within the guidelines mentioned, hot biopsy removal of small colonic polyps is safe.

A comparative study of energy balance among housewives of Ludhiana city.

PIP: Energy gap is the main nutritional factor which affects work efficiency in all age groups. The low intake of food results in impaired working efficiency and a low level of vitality. Energy balance was evaluated among 30 healthy, nonpregnant, nonlactating housewives aged 29-40 years drawn from the campus of Punjab Agricultural University and its surrounding areas. The women's mean overall energy intake was 1777 +or- 31 kcal/day, 87% of the ICMR (1990) recommended allowances. Total energy expenditure was measured using a computer-based Nutriguide program of Song et al., Caltrac, FAO/WHO/UNU (1985) equations based upon body weight, and an ICMR (1990) prediction equation also based upon body weight. Statistical analysis identified a significant difference in the energy expenditure measured by all 4 methods except between the FAO/WHO/UNU and ICMR prediction equations. The overall energy balance was maximum and positive according to Caltrac at 4.5 kcal/day. The energy expenditure measured by the Nutriguide, FAO/WHO/UNU, and ICMR methods was significantly correlated to weight. Energy intake was significantly and highly correlated to energy balance in all of the 4 methods. While the subjects were overweight when compared with Life Insurance Corporation of India (1965) Standards, the women's body mass index of 23.11 kg/sq.m was within the normal range.^ieng

Role of cAMP-dependent protein kinase in controlling aggregation and postaggregative development in Dictyostelium.

We have examined the role of cAMP-dependent protein kinase (PKA) in controlling aggregation and postaggregative development in Dictyostelium. We previously showed that cells in which the gene encoding the PKA catalytic subunit has been disrupted (pkacat- cells) are unable to aggregate [S. K. O. Mann and R. A. Firtel (1991). A developmentally regulated, putative serine/threonine protein kinase is essential for development in Dictyostelium. Mech. Dev. 35, 89-102]. We show that pkacat- cells are unable to activate adenylyl cyclase in response to cAMP stimulation due to the inability to express the aggregation-stage, G-protein-stimulated adenylyl cyclase (ACA). Constitutive expression of ACA from an actin promoter results in a high level of Mn(2+)-stimulated adenylyl cyclase activity and restores chemoattractant- and GTP gamma S-stimulated adenylyl cyclase activity but not the ability to aggregate. Similarly, expression of the constitutively active, non-G protein-coupled adenylyl cyclase ACG in pkacat- cells also does not restore the ability to aggregate, although ACG can complement cells in which the ACA gene has been disrupted. These results indicate that pkacat- cells lack multiple, essential aggregation-stage functions. As the mound forms, high, continuous levels of extracellular cAMP functioning through the cAMP serpentine receptors activate a transcriptional cascade that leads to cell-type differentiation and morphogenesis. The first step is the induction and activation of the transcription factor GBF and downstream postaggregative genes, followed by the induction of prestalk- and prespore-specific genes. We show that pkacat- cells induce postaggregative gene expression in response to exogenous cAMP, but the level of induction of some of these genes, including GBF, is reduced. SP60 (a prespore-specific gene) is not induced and ecmA (a prestalk-specific gene) is induced to very low levels. Expressing GBF constitutively in pkacat- cells restores ecmA expression to a moderate level, but SP60 is not detectably induced. Overexpression of PKAcat from the Actin 15 (Act15), ecmA prestalk, and the PKAcat promoters in pkacat- cells result in significant aberrant spatial patterning of prestalk and prespore cells, as determined by lacZ reporter studies. Our studies identify new, essential regulatory roles for PKA in mediating multicellular development.

Expression of cAMP-dependent protein kinase in prespore cells is sufficient to induce spore cell differentiation in Dictyostelium.

The activity of cAMP-dependent protein kinase (PKA) is required for proper development at several stages during the Dictyostelium life cycle. We present evidence that activation of PKA is rate-limiting for the differentiation of prespore cells to spores and that PKA activation may be the developmental trigger for sporulation. Strains that overexpress the gene encoding the catalytic subunit of PKA (PKAcat) or lack a functional regulatory subunit (rdeC strains) undergo rapid, heterochronic development. We show that overexpression of PKAcat in prespore cell is sufficient to directly induce expression of the spore maturation marker spiA and differentiation to spores, in a cell-autonomous manner. Moreover, overexpression of PKAcat in prespore cells can bypass a mutation that blocks an earlier developmental step to induce spiA expression. Our results suggest that the regulatory pathway in prespore cells between the activation of PKA and spiA induction/spore maturation is quite short and that PKAcat expression in prespore cells may mediate spore differentiation at the level of transcription. This induction of sporulation requires the prior activation of the prespore cell pathway. In addition, we show that beta-galactosidase activity expressed from a PKAcat promoter/lacZ reporter construct is highly enriched in the anterior prestalk A region during the tipped aggregate, slug, and early culminant stages and that this pattern switches abruptly to a prespore pattern at the time of spore maturation, supporting the proposed role of PKA in this process.

Impact of nutrition counselling and supplements on the mineral nutriture of rural pregnant women and their neonates.

Sixty six young women from low and lower middle income groups selected from 8 villages of Ludhiana district in the first trimester of pregnancy were divided equally into Experimental (E) and Control (C) Groups, out of which only 60 subjects reached to the term. Folifer and calcium tablets were supplied to E group from second trimester till delivery along with regular medical supervision and nutrition education about additional nutrient needs. Intake of all the nutrients were less than the Recommended Dietary Allowances in the E and C groups during the third trimester. However, the requirement of iron, calcium, folic acid, vitamin B12, Vitamin D and ascorbic acid were met in group E due to supplementation. The Fe, Ca and Cu levels improved significantly during the third trimester in group E. The cord serum levels of Fe, Ca and Cu were also significantly higher in Group E. The relationships between maternal and cord blood levels of Fe, Ca and Cu were also significantly higher in Group E. The relationships between maternal and cord blood levels of Fe, Ca, Cu and Zn were significant, the co-efficients of correlation being 0.67, 0.92, 0.97 and 0.43, respectively. Serum Mn had an insignificant correlation with other minerals. The results indicated that 86.7, 94.7 and 44.8% variation (r2) in cord serum Ca, Cu and Fe levels was determined by the corresponding maternal serum levels. It is concluded that regular medical supervision, supplementation and nutrition education significantly improved the nutriture of the pregnant women and their neonates.

Enterokinase.

Enterokinase is a glycoprotein and is now designated enteropeptidase (E.C.3.4.4.8.). It is present in the duodenal and jejunal mucosa. Pancreatic proteolytic enzymes are secreted as proenzymes. Enterokinase converts trypsinogen to trypsin in the duodenal lumen. Duodenopancreatic reflux of duodenal enterokinase may be important in the pathogenesis of experimental and clinical acute pancreatitis. Congenital enterokinase deficiency is a distinct clinical entity characterized by diarrhea, failure to thrive, hypoproteinemia, and edema. Acquired enterokinase deficiency may occur in some diffuse small bowel diseases. Steatorrhea of celiac spruce may be due partly to the fact that deficiency of secretin and cholecystokinin may interfere with the action of enterokinase. The interrelationship between secretin, cholecystokinin, enterokinase, and bile salts is not completely understood.

Impact of nutrition education and medical supervision on pregnancy outcome.

Sixty Punjabi women from low and lower middle income groups were selected from eight villages of Ludhiana district. The supplements of iron, folic acid and calcium in the form of Folifer and Calcium Sandoz tablets were regularly supplied to experimental (E) group from second trimester onwards. A pamphlet about the diet during pregnancy was distributed to the E group along with four individual and three group contacts during the second half of pregnancy. The control (C) group was provided iron and folate supplements as per Government practice. Body height, weight, mid-upper arm circumference (MUA) and skinfold thickness of the subjects were recorded. Weight gained during pregnancy and post partum weight were also recorded and body mass index was calculated. In addition, crown heel length (CHL), birth weight (BW), skinfold thickness, MUA, head circumference (HC), Chest circumference (CC) and ponderal index (PI) of the neonates were recorded within eight hours of their birth. The gain in weight during pregnancy was 6.30 and 5.7 kg in E and C groups respectively. The study revealed that BW, CHL, skinfold thickness and PI of the newborns were significantly (p < 0.01) higher in E group. The mean BW of newborns in E and C groups was 2700 g and 2300 g, respectively. Weight gained during pregnancy had significant (p < 0.05) correlation to MUA, BW and skinfold thickness of the newborn.

PIP: The growth pattern and physical state of pregnant women are profoundly influenced by nutrition. With the intention of augmenting the nutritional status of pregnant women and neonates, the government of India provides medical supervision and Folifer tablets to pregnant women through subsidiary health centers during their last one hundred days of pregnancy. This approach, however, has failed to significantly influence program target indicators. The authors therefore investigated the effect of combined nutrition education, medical supervision, and nutrient supplementation on the anthropometry of rural pregnant women and their neonates. Sixty Punjabi women from low and lower-middle income groups were selected for the study from eight villages in Ludhiana district. There were thirty women in the experimental group and thirty controls. The average weights of women in the experimental and control groups during the first trimester were 48.4 kg and 46.5 kg, respectively. Women in the control group received iron and folate supplements as per government practice, while subjects in the experimental group received regular supplements of iron, folic acid, and calcium in the form of Folifer and Calcium Sandoz tablets from the second trimester onwards. Women in the experimental group also received a pamphlet on diet during pregnancy along with four individual and three group contacts during the second half of pregnancy. Researchers recorded subjects' body height, weight, mid-upper arm circumference, skinfold thickness, weight gained during pregnancy and post partum weight. Subjects' body mass index was also calculated. Among the neonates, the crown heel length, birth weight, skinfold thickness, mid-upper arm circumference, head circumference, chest circumference, and ponderal index were recorded within eight hours of their birth. Weight gain during pregnancy was found to be 6.30 and 5.7 kilograms in the experimental and control groups, respectively. Birth weight, crown heel length, skinfold thickness, and ponderal index of the newborns were significantly higher among infants of mothers in the experimental group. Mean birth weight of newborns in the experimental and control groups was 2700 g and 2300 g, respectively, with weight gained during pregnancy significantly correlated with mid-upper arm circumference, birth weight, and skinfold thickness of the newborn.

cAMP-dependent protein kinase differentially regulates prestalk and prespore differentiation during Dictyostelium development.

We and others have previously shown that cAMP-dependent protein kinase (PKA) activity is essential for aggregation, induction of prespore gene expression and multicellular development in Dictyostelium. In this manuscript, we further examine this regulatory role. We have overexpressed the Dictyostelium PKA catalytic subunit (PKAcat) in specific cell types during the multicellular stages, using prestalk and prespore cell-type-specific promoters to make PKA activity constitutive in these cells (independent of cAMP concentration). To examine the effects on cell-type differentiation, we cotransformed the PKAcat-expressing vectors with reporter constructs expressing lacZ from four cell-type-specific promoters: ecmA (specific for prestalk A cells); ecmB (specific for prestalk B and anterior-like cells in the slug); ecmB delta 89 (specific for stalk cells); and SP60 (prespore-cell-specific). By staining for beta-galactosidase expression histologically at various stages of development in individual strains, we were able to dissect the morphological changes in these strains, examine the spatial localization of the individual cell types, and understand the possible roles of PKA during multicellular development. Expression of PKAcat from either the ecmA or ecmB prestalk promoters resulted in abnormal development that arrested shortly after the mound stage, producing a mound with a round apical protrusion at the time of tip formation. Prestalk A and prestalk B cells were localized in the central region and the apical mound in the terminal differentiated aggregate, while prespore cells showed an aberrant spatial localization. Consistent with a developmental arrest, these mounds did not form either mature spores or stalk cells and very few cells expressed a stalk-cell-specific marker. Expression of PKAcat from the prespore promoter resulted in abnormal morphogenesis and accelerated spore cell differentiation. When cells were plated on agar, a fruiting body was formed with a very large basal region, containing predominantly spores, and a small, abnormal sorocarp. Mature spore cells were first detected by 14 hours, with maximal levels reached by 18-20 hours, in contrast to 24-26 hours in wild-type strains. When cells were plated on filters, they produced an elongated tip from a large basal region, which continued to elongate as a tubular structure and produce a 'slug-like' structure at the end. The slug was composed predominantly of prestalk cells with a few prespore cells restricted to the junction between the 'slug' and tube. As the slug migrated, these prespore cells were found in the tube, while new prespore cells appeared at the slug/tube junction, suggesting a continual differentiation of new prespore cells at the slug's posterior.(ABSTRACT TRUNCATED AT 400 WORDS)

Celiac sprue and diabetes mellitus.

The frequent association of celiac sprue (CS) and insulin-dependent diabetes mellitus (DM) which may be the result of interplay between genetic, hormonal, and immunologic factors has obvious therapeutic implications. A gluten-free diet may improve the diarrhea in some patients with DM where the reason for diarrhea is underlying celiac sprue; the diet may also improve control of DM by normalizing the serum hormonal profile.

Molecular cloning of casein kinase II alpha subunit from Dictyostelium discoideum and its expression in the life cycle.

A Dictyostelium discoideum cDNA encoding an alpha-type subunit of casein kinase II was isolated, and its cDNA was used to study developmental expression of casein kinase II during the Dictyostelium life cycle. The 1.3-kb cDNA insert contained an open reading frame of 337 amino acids (M(r) 39,900). The deduced amino acid sequence has high homology with those of casein kinase II alpha subunits from other species. Genomic Southern blot analysis suggested that there is a single gene encoding casein kinase II alpha subunit in D. discoideum. Northern (RNA) blot analysis showed that the casein kinase II alpha-subunit gene is expressed constitutively as a 1.9-kb mRNA throughout vegetative growth and multicellular development. Casein kinase purified from normal vegetative cells contained a major protein band of approximately 36 kDa, which was recognized by antisera raised against rat testis casein kinase II. Comparison of the in vitro transcription/translation product of the alpha-subunit cDNA clone and the purified 36-kDa protein by partial proteolysis indicated that the isolated cDNA clone encodes the Dictyostelium casein kinase II alpha subunit. No protein corresponding to a beta subunit was detected in purified casein kinase. Immunoblot analysis using anti-rat casein kinase II sera showed that the alpha subunit of casein kinase II is expressed constitutively like its mRNA during the life cycle of D. discoideum. Casein kinase II activity measured by using a specific peptide substrate paralleled the level of alpha subunit detected by immunoblotting during the life cycle, with a maximum variation of approximately 2-fold. We were unable to obtain disruptants of the casein kinase II alpha gene, suggesting that there is a single casein kinase II alpha gene, which is essential for vegetative growth of D. discoideum.

DdPK3, which plays essential roles during Dictyostelium development, encodes the catalytic subunit of cAMP-dependent protein kinase.

We have previously reported the analysis of DdPK3, a developmentally regulated putative serine/threonine kinase that shares approximately 50% amino acid sequence identity with metazoan cAMP-dependent protein kinase A (PKA) and protein kinase C, within their catalytic domains. Cells in which the DdPK3 gene has been disrupted do not aggregate but they are able to induce aggregation-stage genes in response to cAMP pulses and the prestalk-specific ras gene DdrasD in response to high continuous levels of cAMP but will not induce prespore gene expression. In this report, we present conclusive evidence that DdPK3 encodes the catalytic subunit of the Dictyostelium PKA. DdPK3 null cells lack kinase activity that phosphorylates a PKA-specific substrate and is specifically inhibitable by recombinant cAMP-dependent protein kinase inhibitor. DdPK3 expressed in Escherichia coli has PKA activity that is inhibitable by protein kinase inhibitor. When Ddpk3 null cells are complemented with DdPK3 expressed from an actin promoter on an extrachromosomal vector (low copy number), PKA activity is restored and the cells proceed to the slug stage but will not culminate, suggesting that properly regulated PKA activity is essential for culmination. Moreover, overexpressing DdPK3 in wild-type cells on integrating vectors (high copy number) from either an actin or prespore-specific promoter results in accelerated development and the ability to form mature spores in monolayer culture in the presence of high cAMP, a developmental potential lacking in wild-type cells.

Effect of zinc sulfate and acetylcysteine on experimental gastric ulcer: in vitro study.

A small ulcer produced in vitro by monopolar electrocoagulation on endoscopically obtained human antral biopsies and incubated in Trowel T-8 medium at 37 degrees C for 8 h has many histologic features of chronic gastric ulcer in man. Zinc sulfate and acetylcysteine in low concentrations had a significant healing effect in this ulcer model. Since the beneficial effect of zinc sulfate and acetylcysteine was counteracted by N-ethylmaleimide, a known blocker of sulfhydryl compounds, the beneficial effect of these two compounds probably was mediated through sulfhydryl compounds. Using special stain, N-(4-aminophenyl)maleimide, the sulfhydryl groups were localized in the epithelial cells of the surface layer and gastric glands.