Total pulmonary arterial reconstruction in a patient with arterial tortuosity syndrome affecting the pulmonary artery: a case report and review of the literature.

BACKGROUND: Arterial tortuosity syndrome is a rare Autosomal recessive disease that leads to a loss of function of the connective tissues of the body, this happens due to a mutation in the solute carrier family 2 member 10 (SLC2A10) gene. ATS is more likely to occur in Large and medium-sized arteries including the aorta and pulmonary arteries. This syndrome causes the arteries to be elongated and tortuous, This tortuosity disturbs the blood circulation resulting in stenosis and lack of blood flow to organs and this chronic turbulent flow increases the risk of aneurysm development, dissection and ischemic events. CASE PRESENTATION: A 2 years old Arabian female child was diagnosed with ATS affecting the pulmonary arteries as a newborn, underwent a pulmonary arterial surgical reconstruction at the age of 2 years old due to the development of pulmonary artery stenosis with left pulmonary artery having a peak gradient of 73 mmHg with a peak velocity of 4.3 m/s and the right pulmonary artery having a peak gradient of 46 mmHg with a peak velocity of 3.4 m/s causing right ventricular hypertension. After surgical repair the left pulmonary artery has a peak pressure gradient of 20 mmHg, with the right pulmonary artery having a peak pressure gradient of 20 mmHg. CONCLUSION: ATS is a rare genetic condition that affects the great arteries especially the pulmonary arteries causing stenotic and tortuous vessels that may be central branches or distal peripheral branches that leads to severe right ventricular dysfunction and hypertension. We believe that surgical treatment provides the optimum outcomes when compared to transcather approaches especially when the peripheral arteries are involved. Some challenges and hiccups might occur, especially lung reperfusion injury that needs to be diagnosed and treated accordingly.

Induction of Systemic Resistance in Hibiscus sabdariffa Linn. to Control Root Rot and Wilt Diseases Using Biotic and Abiotic Inducers.

The possibility of inducing systemic resistance in roselle against root rot and wilt diseases was investigated using biotic and abiotic inducers. The biotic inducers included three biocontrol agents (i.e., Bacillus subtilis, Gliocladium catenulatum, and Trichoderma asperellum) and two biofertilizers (i.e., microbein and mycorrhizeen), while the abiotic inducers included three chemical materials (i.e., ascorbic acid, potassium silicate, and salicylic acid). In addition, preliminary in vitro studies were conducted to evaluate the inhibitory activity of the tested inducers on the growth of pathogenic fungi. The results show that G. catenulatum was the most efficient biocontrol agent. It reduced the linear growth of Fusarium solani, F. oxysporum, and Macrophomina phaseolina by 76.1, 73.4, and 73.2%, respectively, followed by B. subtilis by 71.4, 69, and 68.3%, respectively. Similarly, potassium silicate was the most effective chemical inducer followed by salicylic acid, each at 2000 ppm. They reduced the linear growth of F. solani by 62.3 and 55.7%; M. phaseolina by 60.7 and 53.1%; and F. oxysporum by 60.3 and 53%, respectively. In the greenhouse, all inducers applied as a seed treatment and/or foliar spray strongly limited the development of root rot and wilt diseases. In this regard, G. catenulatum, at 1 × 109 CFU mL-1, achieved the highest values of disease control, followed by B. subtilis; while T. asperellum, at 1 × 105 CFU mL-1, recorded the lowest values. In addition, the plants treated with potassium silicate followed by salicylic acid, each at 4 g/L, recorded the highest disease control compared to ascorbic acid at 1 g/L, which had the lowest values. The mixture of mycorrhizeen + microbein (at 10 g/kg seeds) was the most effective compared to either of them alone. All treatments, applied alone or in combination in the field, significantly reduced the incidence of diseases. The most effective treatments were a mixture of G. catenulatum (Gc) + Bacillus subtilis (Bs) + Trichoderma asperellum (Ta); a mixture of ascorbic acid (AA) + potassium silicate (PS) + and salicylic (SA); G. catenulatum; potassium silicate; and a mixture of mycorrhizeen + microbein. Rhizolix T had the highest disease-reducing efficacy. In response to the treatments, significant improvements in growth and yield, changes in biochemicals, and increased activities of defense enzymes were achieved. This research points to the activity of some biotic and abiotic inducers that can play a vital role in managing the root rot and wilt of roselle through the induction of systemic plant resistance.

Impact of Folic Acid in Modulating Antioxidant Activity, Osmoprotectants, Anatomical Responses, and Photosynthetic Efficiency of Plectranthus amboinicus Under Salinity Conditions.

Salinity is a major threat to the sustainability of agricultural production systems. Salt stress has unfavorable implications on various plant physio-morphological and biochemical reactions, causing osmotic and ionic stress. Exogenously applied folic acid (FA) may at least provide one mechanism to evade the injurious stress effects of saline irrigation water on Plectranthus amboinicus. In this regard, two pot trials were performed during the 2018-2019 and 2019-2020 seasons in an open greenhouse of an experimental farm (29°17'N; 30°53'E) in Fayoum, Egypt. We tested four levels of saline irrigation water (SW): 34, 68, and 102 mM NaCl, plus tap water as the control = 0), combined with FA at three concentrations (25 and 50 µM, plus spray with distilled water as the control = 0). The growth parameters, biochemistry, physiology, elemental leaf status, essential oil content, and anatomical responses were assessed. Salt markedly reduced photosynthetic productivity [Fv/Fm and performance index (PI)], total chlorophyll [soil plant analysis development (SPAD)], and leaf osmoprotectant compounds, i.e., total soluble sugars (TSS), free amino acids, proline, and total phenolics, thus hampering P. amboinicus growth and essential oil yield. However, the addition of FA as a foliar spray to P. amboinicus irrigated with saline water induced increases in Fv/Fm, SPAD, and PI. These were linked with enriched stem anatomical structures, leaf osmoprotectant compounds, and enhanced leaf enzymatic activity, e.g., superoxide dismutase, catalase, ascorbate peroxidase, glutathione reductase, glutathione, ascorbic acid, and antioxidant content. Under salt stress, supplementation of 25 and 50 µM FA increased the growth and production of essential oil by 27.8 and 55.6%, respectively, compared with no applied FA. The highest growth characteristics and elemental leaf contents were obtained when P. amboinicus was irrigated with 0 mM saline water and treated foliarly with 50 µM of FA compared with non-treated plants. Overall, these data showed that foliar spraying with FA reduces the impact of salt stress on P. amboinicus irrigated with saline water.

Biological Control of Celery Powdery Mildew Disease Caused by Erysiphe heraclei DC In Vitro and In Vivo Conditions.

The present study aimed to investigate the potentiality of certain biocontrol agents, namely Bacillus subtilis, B. pumilus, B. megaterium, Pseudomonas fluorescens, Serratia marcescens, Trichoderma album, T. harzianum and T. viride, as well as the synthetic fungicide difenoconazole to control celery powdery mildew caused by Erysiphe heraclei DC, in vitro (against conidia germination and germ tube length of E. heraclei) and in vivo (against disease severity and AUDPC). In vitro, it was found that the antifungal activity of the tested biocontrol agents significantly reduced the germination percentage of the conidia and germ tube length of the pathogen. The reduction in conidia germination ranged between 88.2% and 59.6% as a result of the treatment with B. subtilis and T. album, respectively compared with 97.1% by the synthetic fungicide difenoconazole. Moreover, the fungicide achieved the highest reduction in germ tube length (92.5%) followed by B. megaterium (82.0%), while T. album was the least effective (62.8%). Spraying celery plants with the tested biocontrol agents in the greenhouse significantly reduced powdery mildew severity, as well as the area under the disease progress curve (AUDPC), after 7, 14, 21 and 28 days of application. In this regard, B. subtilis was the most efficient followed by B. pumilus, S. marcescens and B. megaterium, with 80.1, 74.4, 73.2 and 70.5% reductions in disease severity, respectively. In AUDPC, reductions of those microorganisms were 285.3, 380.9, 396.7 and 431.8, respectively, compared to 1539.1 in the control treatment. On the other hand, the fungicide difenoconazole achieved maximum efficacy in reducing disease severity (84.7%) and lowest AUDPC (219.3) compared to the other treatments. In the field, all the applied biocontrol agents showed high efficiency in suppressing powdery mildew on celery plants, with a significant improvement in growth and yield characteristics. In addition, they caused an increase in the concentration of leaf pigments, and the activities of defense-related enzymes such as peroxidase (PO) and polyphenol oxidase (PPO) and total phenol content (TPC). In conclusion, the results showed the possibility of using tested biocontrol agents as eco-friendly alternatives to protect celery plants against powdery mildew.

Integrated Application of Selenium and Silicon Enhances Growth and Anatomical Structure, Antioxidant Defense System and Yield of Wheat Grown in Salt-Stressed Soil.

Selenium (Se) and silicon (Si) are considered advantageous elements to induce plants' tolerance to various environmental stresses. Wheat yield is negatively affected by salinity stress, especially in dry and semi-dry areas. Therefore, the objective of the current study was to investigate the effects of Se, Si and their combinations (0 as control, Se15, Se30, Si15, Si30, Se15 + Si15, and Se30 + Si30 mM) in alleviating the deleterious effects of salinity stress (7.61 dS m-1, real field conditions) on anatomical characteristics as well as the physio-biochemical and productivity parameters of wheat plants. The selenium and silicon treatments and their combinations caused significant amelioration in growth, anatomical and physiological attributes, and grain yields of salinity-stressed wheat in comparison with the untreated plants (control treatment). The integrated application of Se30 + Si30 significantly increased plant growth (i.e., plant height 28.24%, number of tillers m-2 76.81%, fresh weight plant-1 80.66%, and dry weight plant-1 79.65%), Fv/Fm (44.78%), performance index (PI; 60.45%), membrane stability index (MSI; 36.39%), relative water content (RWC; 29.39%), total soluble sugars (TSS; 53.38%), proline (33.74%), enzymatic antioxidants (i.e., CAT activity by 14.45%, GR activity by 67.5%, SOD activity by 35.37% and APX activity by 39.25%) and non-enzymatic antioxidants (i.e., GSH content by 117.5%, AsA content by 52.32%), yield and its components (i.e., number of spikelets spike-1 29.55%, 1000-grain weight 48.73% and grain yield ha-1 26.44%). The anatomical traits of stem and leaves were improved in wheat plants treated with Se30 + Si30. These changes resulting from the exogenous applications of Se, Si or their combinations, in turn, make these elements prospective in helping wheat plants to acclimate successfully to saline soil.

Comparative study on dynamic and immunopathology of four intermediate-plus infectious bursal disease (IBD) vaccines in commercial broiler chickens.

INTRODUCTION: The selection of the right IBD control strategy is primarily based on the choice of the appropriate vaccine strain. High maternal IBD-specific antibodies (Abs) compete with the efficacy IBD vaccine, which necessitates the application of intermediate-plus vaccine strain. METHODS: A comparative experimental study was designed for evaluation of four different commercially available intermediate-plus IBD vaccines in commercial broilers before complete weaning of IBD-specific maternal Abs. RESULTS: As determined by IBD- specific quantitative real-time polymerase chain reaction, three tested vaccine strains (228E, Winterfield H2512, and Winterfield 2512) were able to establish in the bursal tissues as early as six hours (hrs) post-vaccination (PV). Both the 228E and the Winterfield H2512 strains vaccinated groups had the highest viral load and replication rate in the bursal tissues at 24, 36, 48 and 72 hrs PV. Earlier seroconversion, 7-14 days PV, was observed in the case of Winterfield H2512, 228E, and Winterfield 2512 vaccinated birds compared to the Lukert vaccinated birds. The 228E strain was more virulent and induces the highest lesion score with severe degrees of lymphocyte depletion and necrosis which persisted up to 28 days PV. CONCLUSION: Overall, the different intermediate-plus IBD strains possess variable early kinetics in the bursal tissues and eliciting antibody (Ab) responses differently withdifferent degrees of bursal lesions. The assessment of the intrabursal vaccine load together with humoral immunity and bursal damage lesion score are fundamental parameters in the evaluation of the intermediate-plus IBD vaccines.

Implication of CDKAL1 single-nucleotide polymorphism rs 9465871 in obese and non-obese Egyptian children.

INTRODUCTION: CDKAL1 single-nucleotide polymorphism rs 9465871variant is a risk locus for Type 2 Diabetes (T2DM).The study evaluated the associations of CDKAL1- rs9465871 with glycosylated hemoglobin A1C Level (HbA1c), fasting insulin level, insulin resistance and metabolic syndrome among obese and non- obese Egyptian children. MATERIALS AND METHODS: The study included 43 obese children and 40 normal weight children. Anthropometric body measurements, bio-specimen and biochemistry assays were done. Genotyping of rs9465871 (CDKAL1) was conducted. RESULTS: The percentages of the CC, CT, and TT genotypes of rs9465871in the lean children were 15%, 42.5%, and 42.5%, respectively. Regarding obese children, the frequencies were 18.6%, 58.1% and 23.3% respectively with no significant statistical difference. Comparison between the CDKAL1 rs 9465871 polymorphism showed that the highest value of fasting insulin was recorded in CC genotype (22.80± 15.18 [uIU/mL] P<.014). Levels of HOMA-IR, FBS and HBA1C were highest in CC group with no statistical significant differences. However, fasting insulin level was higher in the CC group than in the TT+ CT group (P<.01). A higher level of HbA1c was found among CC group at CDKAL1-rs9465871 (5.9%) than TT+CT genotype group (5.6%), with no statistical significant difference. There was increase in the risk of type 2 diabetes the percentages were 78.6% and 46.4% respectively when comparing CC with TT+CT genotype groups ( P<.039). CC group was not associated with significant increase in metabolic syndrome. CONCLUSION: There is a significant risk association between CDKAL1-rs9465871polymorphism and development of T2DM in a subset of the Egyptian children.

Possible Protective Effects of Quercetin and Sodium Gluconate Against Colon Cancer Induction by Dimethylhydrazine in Mice.

Micronutrients in food have been found to have chemopreventive effects, supporting the conclusions from epidemiologie studies that consumption of fresh fruits and vegetables reduces cancer risk. The present study was carried out to evaluate the role of querctin (Q) and sodium gluconate (GNA) supplementation separately or in combination in ameliorating promotion of colon tumor development by dimethyl-hydrazine (DMH) in mice. Histopathological observation of colons in mice treated with DMH showed goblet cell dysplasia with inflammatory cell infiltration. This pathological finding was associated with significant alteration in oxidative stress markers in colon tissues and carcinoembryonic antigen (CEA) levels in plasma. Mice co-treated with GNA and Q showed mild changes of absorptive and goblet cells and inflammatory cell infiltration in lamina properia, with improvement in oxidative stress markers. In conclusion, findings of the present study indicate significant roles for reactive oxygen species (ROS) in pathogenesis of DMH-induced colon toxicity and initiation of colon cancer. Also, they suggest that Q, GNA or the combination of both have a positive beneficial effect against DMH induced colonic cancer induction in mice.

Endoscopic approaches to benign sphenoid sinus lesions: development of an algorithm based on 13 years of experience.

OBJECTIVE: To develop an algorithm for selecting the optimal endoscopic approach for benign sphenoid lesions. METHODS: Charts of 392 patients were reviewed and categorised according to disease nature and extent as follows: group 1 comprised isolated sphenoid sinus lesion cases, group 2 consisted of pansinus lesion cases and group 3 comprised lateral sphenoid recess lesion cases. Surgical approaches, difficulties and complications were noted. RESULTS: A transnasal approach was employed in 40.8 per cent of cases (23.2 per cent were group 1 patients, 16.1 per cent were group 2 patients and 1.5 per cent were group 3 patients), a transethmoidal approach was utilised in 54.3 per cent of cases (group 2 patients) and a transpterygopalatine fossa approach was selected in 4.9 per cent of cases (group 3 patients). Surgical difficulties were encountered in 11.9, 10.8 and 0 per cent of patients in whom transnasal, transethmoidal or transpterygopalatine approaches were utilised, respectively. CONCLUSION: Radio-pathological categorisation provided a means of developing an algorithm for selecting the most appropriate endoscopic approach. Transnasal sphenoidotomy should be the first choice of approach whenever applicable. Lateral sphenoid recess non-inflammatory diseases should be managed through a transpterygopalatine fossa approach. Revision surgery does not play a key role in the algorithm.

Serum complement C4a and its relation to liver fibrosis in children with chronic hepatitis C.

AIM: To evaluate serum complement C4a and its relation to liver fibrosis in children with chronic hepatitis C virus (HCV) infection. METHODS: The study included 30 children with chronic HCV infection before receiving antiviral therapy. Chronic HCV infection was defined by positive anti-HCV, a positive polymerase chain reaction for HCV-RNA for more than 6 mo with absence of any associated liver disease. A second group of 30 age- and sex-matched healthy children served as controls. Serum C4a levels were measured by enzyme-linked immunosorbent assay. Liver fibrosis stage and inflammatory grade were assessed using Ishak scoring system. Serum C4a levels were compared according to different clinical, laboratory and histopathological parameters. Statistical significance for quantitative data was tested by Mann-Whitney U non-parametric tests. For qualitative data, significance between groups was tested by χ(2) test. Correlation was tested by Spearman's test. Results were considered significant if P value ≤ 0.05. RESULTS: The age of the patients ranged from 3.5 to 18 years and that of controls ranged from 4 to 17 years. C4a mean levels were merely lower in patients (153.67 ± 18.69 mg/L) than that in the controls (157.25 ± 11.40 mg/L) with no statistical significance (P = 0.378). It did not differ significantly in patients with elevated vs those with normal transaminases (152.25 ± 16.62 vs 155.36 ± 21.33; P = 0.868) or with different HCV viremia (P = 0.561). Furthermore, there was no statistical significant difference in serum levels between those with no/mild fibrosis and those with moderate fibrosis (154.65 ± 20.59 vs 152.97 ± 17.72; P = 0.786) or minimal and mild activity (155.1 ± 21.93 vs 152.99 ± 17.43; P = 0.809). Though statistically not significant, C4a was highest in fibrosis score 0 (F0), decreasing in F1 and F2 to be the lowest in F3. When comparing significant fibrosis (Ishak score ≥ 3) vs other stages, C4a was significantly lower in F3 compared to other fibrosis scores (143.55 ± 2.33 mg/L vs 155.26 ± 19.64 mg/L; P = 0.047) and at a cutoff value of less than 144.01 mg/L, C4a could discriminate F3 with 76.9% sensitivity and 75% specificity from other stages of fibrosis. CONCLUSION: Serum complement C4a did not correlate with any of transaminases, HCV viremia or with the histopathological scores. Although C4a decreased with higher stages of fibrosis, this change was not significant enough to predict individual stages of fibrosis. Yet, it could predict significant fibrosis with acceptable clinical performance.

Six years of evidence-based adult dissection tonsillectomy with ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection.

OBJECTIVE: To conduct an adequately powered, prospective, randomised, controlled trial comparing adult dissection tonsillectomy using either ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection. METHODS: Three hundred patients were randomised into four tonsillectomy technique groups. The operative time, intra-operative bleeding, post-operative pain, tonsillar fossa healing, return to full diet, return to work and post-operative complications were recorded. RESULTS: The bipolar radiofrequency group had a shorter mean operative time. The mean intra-operative blood loss during bipolar radiofrequency tonsillectomy was significantly less compared with cold dissection and ultrasonic scalpel tonsillectomy. Pain scores were significantly higher after bipolar electrocautery tonsillectomy. Patients undergoing bipolar electrocautery tonsillectomy required significantly more days to return to full diet and work. The bipolar electrocautery group showed significantly reduced tonsillar fossa healing during the first and second post-operative weeks. CONCLUSION: In this adult series, bipolar radiofrequency tonsillectomy was superior to ultrasonic, bipolar electrocautery and cold dissection tonsillectomies. This method combines the advantages of 'hot' and 'cold' tonsillectomy.

Frequency of VKORC1 (C1173T) and CYP2C9 genetic polymorphisms in Egyptians and their influence on warfarin maintenance dose: proposal for a new dosing regimen.

INTRODUCTION: Warfarin is one of the most widely used anticoagulants, yet interindividual differences in drug response, a narrow therapeutic range and a high risk of bleeding or stroke complicate its use. We aimed to determine the allele and genotype frequency of VKORC1 1173 C>T, CYP2C9*2 and CYP2C9*3 variant polymorphisms in the Egyptian population and to evaluate their influence on the interindividual differences in warfarin dosage. METHODS: A total of 154 unrelated healthy adult patients and 46 warfarin-treated patients were included. SYBR Green-based real-time polymerase chain reaction (PCR) assay was used for studying VKORC1 (C1173T) and CYP2C9*3 polymorphisms. Mutagenically separated PCR assay was used to detect the CYP2C9*2 allele. RESULTS: VKORC1 genotype frequencies were 11%, 24% and 65% for CC, CT and TT, respectively. The prevalence of CYP2C9 haplotypes was 81% (*1\*1), 3.3% (*1\*2), 9.7% (*1\*3), 4.5% (*2\*2) and 0.65% (2\*3 and *3\*3). VKORC1 TT and CYP2C9*2\*2 were associated with a significantly lower warfarin dose. VKORC1 and CYP2C9 accounted for 31.7% and 15.6% of warfarin dose variability, respectively, and together with clinical factors explained 61.3% of total variability. CONCLUSION: VKORC1-TT and CYP2C9 *1/*1 are the most prevalent genotypes among Egyptians. Patients with VKORC1-TT genotype required a lower warfarin dose.

Detection of local failures after management of nasopharyngeal carcinoma: a prospective, controlled trial.

OBJECTIVES: To conduct a prospective study (1) to evaluate and compare the efficacies of nasopharyngeal endoscopy and computed tomography in the diagnosis of local failure of external beam radiotherapy for nasopharyngeal carcinoma, and (2) to assess whether multiple endoscopic nasopharyngeal biopsies are superior to a single, targeted biopsy, for the same purpose. METHODS: Forty-six patients who had been treated with external beam radiotherapy for primary nasopharyngeal carcinoma were enrolled in the study. For every patient recruited, computed tomography, rigid nasopharyngeal endoscopy and nasopharyngeal biopsies were performed 12 weeks after radiotherapy. RESULTS: Twelve weeks after treatment, six patients (13 per cent) had evident disease on histological examination of biopsies. Nasopharyngeal endoscopy showed a sensitivity, specificity, positive predictive value and negative predictive value of 66.6, 95, 66.6 and 95 per cent, respectively. There was statistically significant agreement between the endoscopic findings and the histological findings (Kappa reliability coefficient = 0.617, p < 0.01). Computed tomography showed a sensitivity, specificity, positive predictive value and negative predictive value of 50, 45, 12 and 85.7 per cent, respectively. There was no statistically significant agreement between the computed tomography findings and the histological findings (Kappa reliability coefficient = 0.021, p > 0.05). A targeted, single biopsy performed under endoscopic control demonstrated excellent sensitivity, specificity, positive predictive value and negative predictive value, being 83.3, 100, 100 and 97.5 per cent, respectively. The Kappa test showed a very statistically significant agreement between the histological findings for the single and the multiple endoscopic biopsies (Kappa reliability coefficient = 0.897, p < 0.001). CONCLUSIONS: Rigid nasopharyngeal endoscopy should be considered the primary follow-up tool after radiotherapy treatment of nasopharyngeal carcinoma, with computed tomography being reserved for patients with histological or symptomatic indications. Routine postnasal biopsies are not necessary, given the excellent specificity and negative predictive value of rigid nasopharyngeal endoscopy. Single, targeted endoscopic biopsy provides an excellent alternative to the usual multiple biopsies. In addition, it reduces cost, time, morbidity and patient discomfort.

Nasal nitric oxide in objective evaluation of chronic rhinosinusitis therapy.

BACKGROUND: The assessment of the response of chronic rhinosinusitis (CRS) to therapy is difficult. Computerized tomographic (CT) scans cannot be repeatedly used so measures such as symptom scores, endoscopic findings, and parallel measures such as saccharin clearance time are employed instead. OBJECTIVE: To study the effect of CRS therapy on nasal nitric oxide and to see whether nasal nitric oxide level changes correlate with other assessments. METHODS: The study was a prospective randomized trial of patients with CRS, with or without polyps, who had failed initial medical therapy with douching and nasal corticosteroids and who then had abnormal CT scans. They were treated either medically or surgically, with follow up at 6 and 12 months whilst still taking nasal corticosteroids. Nasal nitric oxide was measured initially and at 6 and 12 months as well as symptom scores, endoscopy, polyp grading, and saccharin clearance time. RESULTS: Initial absolute nasal nitric oxide levels correlated inversely with CT scan changes, (P<0.001). The percentage rise in nasal nitric oxide seen on both medical and surgical treatment correlated with changes in symptom scores (P<0.001), saccharin clearance time (P<0.001), endoscopic changes (P<0.001), polyp grades (P<0.05 at 6 months, P<0.01 at 12 months) and surgical scores (P<0.01). There was no significant correlation with age, sex, smoking or allergy. CONCLUSION: Nasal nitric oxide, which is easily measured, provides a valuable non-invasive objective measure of the response of CRS to therapy. Topical nasal corticosteroids may be needed to reduce the contribution of nasal epithelial nitric oxide and allow that emanating from the sinuses to be measured.

Treatment of chronic rhinosinusitis and its effects on asthma.

The effects of rhinosinusitis treatment upon asthma are disputed. The first randomised prospective study of surgical compared with medical therapy of chronic rhinosinusitis in 90 patients with and without nasal polyps was previously reported. Asthma symptoms, control, forced expiratory volume in one second (FEV1), peak flow, exhaled nitric oxide, medication use and hospitalisation at 6 and 12 months from the start of the study were also monitored. This paper reports these results in 43 of those patients with concomitant asthma. Both medical and surgical treatment of chronic rhinosinusitis were associated with subjective and objective improvements in asthma. Overall asthma control improved significantly following both treatment modalities, but was better maintained after medical therapy, where improvement could also be demonstrated in the subgroup with nasal polyps. Medicine was superior to surgery with respect to a decrease in exhaled nitric oxide and increase in FEV1 in the polyp patients. Two patients noted worsening of asthma post-operatively. Improvement in upper airway symptoms, as assessed using a visual analogue scale, correlated with improvement in asthma symptoms and control. Treatment of chronic rhinosinusitis, medical or surgical, benefits concomitant asthma; that associated with nasal polyposis benefits more from medical therapy.

Comparison of caffeine-induced changes in cerebral blood flow and middle cerebral artery blood velocity shows that caffeine reduces middle cerebral artery diameter.

Changes in cerebral blood flow (CBF) can be assessed directly with xenon clearance (XeC) or indirectly by measuring changes in middle cerebral artery blood velocity (Vmca) with transcranial Doppler (TCD). The aim of this study was to compare the changes in CBF and Vmca following caffeine ingestion. Nineteen patients (age 48-86, recovering from an acute stroke) and ten controls (age 52-85) were each studied twice. Bilateral measurements of CBF and Vmca were made before and after ingestion of 250 mg caffeine or matched placebo. The percentage change in CBF and Vmca after caffeine was calculated. Full results (CBF and Vmca) were obtained from 14 patients and 9 controls. There was no significant difference between patients and controls, so results were combined. Caffeine reduced CBF by 22% (95% confidence interval (CI) = 17% to 28%) and reduced Vmca by 13% (95% CI = 10% to 17%). The fall in Vmca was significantly less than that in CBF (p = 0.0016), showing that caffeine reduces mca diameter. Analysis based on Poiseuille flow in the arterioles suggests that caffeine reduced arteriole diameter by 5.9% (95% CI = 4.6% to 7.3%) and mca diameter by 4.3% (95% CI = 2.0% to 6.6%). TCD is being used as an alternative to XeC for assessing the effect of vasoconstrictors and vasodilators on CBF. This study has demonstrated that in mca diameter can be changed by the vasoactive agents, and that changes in Vmca do not necessarily reflect changes in CBF.

Ability to learn inhaler technique in relation to cognitive scores and tests of praxis in old age.

Clinical observations have shown that some older patients are unable to learn to use a metered dose inhaler (MDI) despite having a normal abbreviated mental test (AMT) score, possibly because of dyspraxia or unrecognised cognitive impairment. Thirty inhaler-naive inpatients (age 76-94) with an AMT score of 8-10 (normal) were studied. Standard MDI training was given and the level of competence reached was scored (inhalation score). A separate observer performed the minimental test (MMT), Barthel index, geriatric depression score (GDS), ideational dyspraxia test (IDT), and ideomotor dyspraxia test (IMD). No correlative or threshold relationship was found between inhalation score and Barthel index, GDS, or IDT. However, a significant correlation was found between inhalation score and IMD (r = 0.45, p = 0.039) and MMT (r = 0.48, p = 0.032) and threshold effects emerged in that no subject with a MMT score of less than 23/30 had an inhalation score of 5/10 or more (adequate technique requires 6/10 or more), and all 17/18 with an inhalation score of 6/10 or more had an IMD of 14/20 or more. The three patients with a MMT >22 and inhalation score <6 had abnormal IMD scores. Inability to learn an adequate inhaler technique in subjects with a normal AMT score appears to be due to unrecognised cognitive impairment or dyspraxia. The MMT is probably a more useful screening test than the AMT score in this context.

An open audit of montelukast, a leukotriene receptor antagonist, in nasal polyposis associated with asthma.

BACKGROUND: Nasal polyposis occurs frequently in patients with intrinsic asthma, especially in those who are aspirin sensitive. It can be difficult to treat effectively, even with surgery and regular topical intranasal corticosteroids many patients are still symptomatic. OBJECTIVE: To investigate the response to montelukast, a leukotriene D4 receptor antagonist, as an add-on therapy to topical and inhaled corticosteroids in patients, both aspirin sensitive (AS) and aspirin tolerant (AT), with nasal polyposis and asthma. METHODS: Nasal polyposis symptoms were assessed by visual analogue scales; nasal polyps were assessed by nasendoscopy and via the measurement of nasal volumes by acoustic rhinometry. The nasal airway was assessed by nasal inspiratory peakflow (NIPF). Asthma was monitored using symptom scores and peak expiratory flow measurements. Aspirin sensitivity was assessed by history together with intranasal lysine aspirin challenge. Upper and lower airway nitric oxide measurements were made before and during treatment. RESULTS: Clinical subjective improvement in nasal polyposis occurred in 64% AT (P < 0.01), patients and 50% AS patients (P > 0.05); asthma improvement in 87% AT and 61% AS patients (P < 0.05 for both). Objective changes in peak flow occurred only in AT patients (P < 0.05). Acoustic rhinometry, nasal inspiratory peak flow and nitric oxide levels did not change significantly in any group, however, correlations were seen between nitric oxide levels and polyp scores and between nitric oxide levels and acoustic rhinometry changes. Improvement on montelukast therapy was not associated with any of the following variables: age, sex, skin prick test positivity, disease duration or aspirin sensitivity. (P > 0.05 for all). CONCLUSION: The findings are consistent with a subgroup of nasal polyps/asthma patients in whom leukotriene receptor antagonists are effective. This is not related to aspirin sensitivity. Further placebo-controlled studies need to be undertaken.

Role of IgE in primary murine Schistosomiasis mansoni.

Schistosoma mansoni infection proceeds in normal mice in the absence of detectable levels of polyclonal or specific immunoglobulin (Ig)E until worms mature and deposit eggs. Hence, the course of a primary S. mansoni infection is not expected to vary appreciably in mice with defects in the IgE production. Experimental increase of IgE production early after infection may, however, influence worm development. In the first approach towards this goal, BALB/c mice were injected with interleukin(IL)4 to raise the level of endogenously synthesized IgE. A significant increase in serum polyclonal IgE and antischistosome IgG1 during the prepatent period was not associated with significant changes in worm and egg burden or liver pathology. During the second approach, mice were injected with IgE which was affinity purified from serum of BALB/c mice infected for 16 weeks with S. mansoni. The purified IgE bound to carbohydrate-independent epitopes of soluble antigens from 3 h larvae, adult worms and eggs and recognized the schistosomular surface membrane. No differences in worm and egg load or granuloma number and size were noted between untreated and exogenous IgE-injected mice. Together, the data demonstrate that by itself IgE does not influence the outcome of infection in primary murine S. mansoni.