vol 02, issue 04, january-march, 2007

Smoking harms nearly every organ of the body,causing many diseases and reducing the health ofsmokers in general. The adverse health effects from

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cigarette smoking account for an estimated 438,000deaths, or nearly of every 5 deaths each year in theUnited States. More deaths are caused each year by

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tobacco use than by all deaths from humanimmunodeficiency virus (HIV), illegal drug use,alcohol use, motor vehicle injuries, suicides, andmurders combined. In this issue of the Journal, the

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article by Dr. M. Suleman Khan et al highlights thesome of the major health problems caused bysmoking as follows:

Cancer1. Cancer is the second leading cause of death and

was among the first diseases causally linked tosmoking.

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2. Smoking causes about 90% of lung cancer deathsin men and almost 80% of lung cancer deaths inwomen. The risk of dying from lung cancer ismore than 23 times higher among men whosmoke cigarettes, and about 13 times higheramong women who smoke cigarettes comparedwith never smokers.

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3. Smoking causes cancers of the bladder, oralcavity, pharynx, larynx (voice box), esophagus,cervix, kidney, lung, pancreas and stomach, andcauses acute myeloid leukemia.

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4. Rates of cancers related to cigarette smoking varywidely among members of racial/ethnic groups,but are generally highest in African-Americanmen.

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Cardiovascular Disease1. Smoking causes coronary heart disease, the

leading cause of death in the United States.1

Cigarette smokers are 2–4 times more likely todevelop coronary hear t disease thannonsmokers.

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2. Cigarette smoking approximately doubles aperson's risk for stroke.

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3. Cigarette smoking causes reduced circulation bynarrowing the blood vessels (arteries). Smokersare more than 10 times as likely as nonsmokers todevelop peripheral vascular disease.

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4. Smoking causes abdominal aortic aneurysm.

Respiratory Disease and Other Effects1. Cigarette smoking is associated with a tenfold

increase in the risk of dying from chronicobstructive lung disease. About 90% of all

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deaths from chronic obstructive lung disease areattributable to cigarette smoking.

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2. Cigarette smoking has many adverse repro-ductive and early childhood effects, including anincreased risk for infertility, preterm delivery,stillbirth, low birth weight and sudden infantdeath syndrome (SIDS).

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3. Postmenopausal women who smoke have lowerbone density than women who never smoked.Women who smoke have an increased risk for hipfracture than never smokers.

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It is very heartening to know that the risk of variouscomplications decrease substantially after successfuldiscontinuation of smoking. The most importantprerequisite is a strong will; however medical helpmay be required in some cases. If a serious attempt ofquitting has failed, one of the several medicines maybe tried. The choices include nicotine chewing gum,bupropion, buspirone or varincillin. Nicotine gumsprovides only one of the approximately 4000substances in the tobacco, however it can suppresswithdrawal symptoms. These nicotine substitutes canthemselves be addictive at least theoretically.Bupropion, an antidepressant, can reduce thepsychological component of the withdrawalsymptoms and has been successfully used in somepatients. The latest addition to our armamentariumagainst smoking is varinicillin, which has an agonistand antagonist activity against nicotinergicacetylcholine receptors on the hippocampus. Theagonist activity prevents withdrawal symptoms whensmoking is stopped, and antagonist activity blocks the“kick” effect if one does smoke while taking this drug.This dual activity can really be very helpful in theeffort of quitting. The drug appears promising, but itis too early to say that it is the drug of choice.It can not be overemphasized that, for any medicineto be effective, a strong will power is essential. Thisalso go a long way in preventing relapses that are socommon. There is an extremely important role ofhealth professionals to educate and motivate patientsto give up smoking before they developedcomplications.

Prof. Dr. Aziz-ur-Rehman

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Health Effects of Cigarette Smoking

E D I T O R I A L

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1. U.S. Department of Health andHuman Services. The HealthConsequences of Smoking: AReport of the Surgeon General.U.S. Department of Health andHuman Services, Centers forD i s e a s e C o n t r o l a n dPrevention, National Center forChronic Disease Preventionand Health Promotion, Officeon Smoking and Health 2004[cited 2006 Dec 5].

2. Centers for Disease Control andPrevention. Annual Smoking-Attributable Mortality, Years ofPo t e n t i a l L i f e L o s t &Productivity Losses—UnitedStates, 1997– 2001. Morbidityand Mortality Weekly Report[serial online]. 2002; 51(14):300–303 [cited 2006 Dec 5].

3. Centers for Disease Control andPrevention. Health UnitedStates, 2003, With Chart book

on Trends in the Health ofAmericans. (PDF–225KB)Hya t t s v i l l e , MD: CDC,National Center for HealthStatistics; 2003 [cited 2006 Dec5].

4. McGinnis J, Foege WH. ActualCauses of Death in the UnitedStates. Journal of the AmericanMedical Association 1993; 270:2207–2212.

5. Novotny TE, Giovino GA.Tobacco Use. In: Brownson RC,Remington PL, Davis JR (eds).Chronic Disease Epidemiologyand Control. Washington, DC:

American Public Health Assoc-iation; 1998;117–148 [cited 2006Dec 5].

6. U. S. Department of Health andHuman Services. Reducing theHealth Consequences of Smok-ing — 25 Years of Progress: AReport of the Surgeon General.Atlanta, GA: U. S. Departmentof Health and Human Services,CDC; 1989. DHHS Pub. No.(CDC) 89–8411 [cited 2006 Dec5].

7. U. S. Department of Health andHuman Services. Tobacco UseAmong U.S. Racial/EthnicMinority Groups—AfricanAmericans, American Indiansand Alaska Natives, AsianAmericans and Pacific Islanders,

and Hispanics: A Report of theSurgeon General. Atlanta, GA:U. S. Department of Health andHuman Services, CDC; 1998[cited 2006 Dec 5].

8. Ockene IS, Miller NH. CigaretteSmok ing , Ca rd iovascu l a rDisease and Stroke: A Statementfor Healthcare ProfessionalsFrom the American HeartA s s o c i a t i o n . Jo u r n a l o fAmerican Health Association.1997; 96 (9): 3243–3247 [cited2006 Dec].

9. Fielding JE, Husten CG, EriksenMP. Tobacco: Health Effects andControl. In: Maxcy KF, RosenauMJ, Last JM, Wallace RB,Doebbling BN (eds.). PublicHealth and Preventive Medicine.New York: McGraw-Hill; 1998;817–845 [cited 2006 Dec 5].

10. U. S. Department of Health andHuman Services. Women andSmoking: A Report of theSurgeon General. Rockville, MD:U.S. Department of Health andHuman Services, CDC; 2001[cited 2006 Dec 5].

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References

Esculapio VOLUME 02 , ISSUE 04, Jan - Mar, 2007

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Portosystemic Encephalopathy: Pathogenesis and Treatment

Najam-un-Nasir, Aftab Rubbani, M. Arif Nadeem, Farah Shafi and Aftab Mohsin

Review Article

Portosystemic encephalopathy (PSE) or Hepaticencephalopathy (HE), represents a potentiallyreversible decline in neurologic function associatedwith impaired hepatic function.Despite the frequency of the condition, we still lacka clear understanding of pathogenesis.Ammonia is clearly implicated; in addition, theremay be a role for inhibitory neurotransmissionthrough gamma amino butyric acid (GABA)receptors in the central nervous system (CNS) andchanges in central neurotransmitters and circulatingamino acids.This syndrome, however, is not a single clinicalentity. It may reflect either a reversible metabolicencephalopathy, brain atrophy, brain edema, or anycombination of these conditions.The mechanisms causing brain dysfunction in liverfailure are still unknown.In advanced coma, the effects of brain swelling,impaired cerebral perfusion, and reversibleimpairment of neurotransmitter systems cannot bedistinguished.These factors are directly related to liver failure (eg,decreased metabolism of ammonia). In addition,concurrent disorders can contribute to thedevelopment of HE.These include:Decreased oxygen delivery, which can result from avariety of factors including gastrointestinal bleeding,sepsis, the effects of cytokines or compoundsreleased from necrotic liver tissue.The effects of hypotension on cerebral perfusionmay be magnified in liver failure because of anassociated impairment in the autoregulation ofcerebral blood flow functional and structuralchanges in cerebral function independent of theliver failure as in alcoholics, intravenous drug users,and patients with Wilson's disease.Creation of a portosystemic shunt to treat portalhypertension, as with a transjugular intrahepaticportosystemic shunt, precipitates HE in approxi-mately 30 percent of patients. Other events whichcan precipitate HE are administration of sedatives,hypokalemia and hyponatremia.The effect of hypokalemia is thought to be mediatedby potassium movement out of the cells to replenishextracellular stores. Electroneutrality is maintained

in part by the movement of extracellular hydrogeninto the cells; the ensuing intracellular acidosis in renaltubular cells increases the production of ammonia.The often concurrent metabolic alkalosis maycontribute by promoting the conversion ofammonium (NH4+), a charged particle which cannotcross the blood-brain barrier, into ammonia (NH3)which can enter the brain.

NeurotoxinsAmmonia — Ammonia is the best characterizedneurotoxin that precipitates HE. The gastrointestinaltract is the primary source of ammonia, which entersthe circulation via the portal vein. Ammonia isproduced by enterocytes from glutamine and bycolonic bacterial catabolism of nitrogenous sources,such as ingested protein and secreted urea. The intactliver clears almost all of the portal vein ammonia,converting it into glutamine and preventing entry intothe systemic circulation.The increase in blood ammonia in advanced liverdisease is a consequence of impaired liver functionand of shunting of blood around the liver.Muscle wasting, a common occurrence in thesepatients, also may contribute since muscle is animportant site for extrahepatic ammonia removal.The arterial concentration of ammonia is increased inabout 90 percent of patients with HE.Ammonia interferes with brain function at severalsites, each of which can contribute to thedevelopment of encephalopathy.In addition, other toxins, such as mercaptans or short-chain fatty acids (C4 to C8), may potentiate ammoniatoxicity.Impaired blood to brain transport of amino acids —Hyperammonemia may increase the cerebral uptakeof neutral amino acids by enhancing the activity ofthe L-amino acid transporter at the blood-brainbarrier. This effect may be the consequence of thebrain to blood transport of glutamine, which isformed in excess for ammonia removal.The ensuing elevation in the cerebral concentrationof neutral amino acids tyrosine, phenylalanine, andtryptophan may affect the synthesis of theneurotransmitters dopamine, norepinephrine, andserotonin.

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Brain edema has been observed in patients withcirrhosis and HE. One possible explanation forbrain edema is an increase in intracellular osmolalityresulting from the metabolism of ammonia inastrocytes to form glutamine.In addition to cell swelling, vasodilatation maycontribute to the increase in intracranial pressure inacute liver failure. Ammonia induced glutamaterelease and impaired glutamate clearance mayelevate extracellular glutamate levels and causeoverstimulation of NMDA (N-methyl-D-aspartate)receptors. NMDA receptor activation triggers nitricoxide synthetase (n-NOS) via a calmodulin mediatedmechanism. NOS catalyzed synthesis of nitric oxide(NO) produces vasodilatation.Swelling of astrocytes may be a key event in thedevelopment of HE. It has been assumed that onemajor pathogenetic effect in the development ofHE in chronic liver disease is an increase in astrocytehydration without clinically overt increase inintracranial pressure, but sufficient to triggermultiple alterations of astrocyte function. Suchchanges in cell size interfere with various basic cellfunctions and may also lead to brain edema.Altered neuronal electric activity — Ammoniadirectly affects neuronal electric activity by inhibitingthe generation of both excitatory and inhibitorypostsynaptic potentials.Oxindole — Oxindole is a tryptophan metaboliteformed by gut bacteria (via indol) that can causesedation, muscle weakness, hypotension, and coma.Cerebral concentrations of oxindole are increased200 folds in rats with acute liver failure, an effect thatwas partially reversed by oral neomycin. Theapplicability of this observation to humans isuncertain but more than a 50 fold increase in theplasma concentration of oxindole has been found inpatients with HE. The mechanism by whichoxindole causes neurodepression is currently underinvestigation.

Impairment of NeurotransmissionGABA-benzodiazepine neurotransmitter system —A role has been proposed for increased tone of theinhibitory GABAA-benzodiazepine neuro-transmitter system in the development of HE.An increasing body of evidence supports the notionthat activation of astrocytic (peripheral-type)benzodiazepine receptors (PTBR) contributes to thepathogenesis of the central nervous systemsymptoms of HE. Binding site densities for thePTBR ligand [3H-PK11195] are increased inautopsied brain tissue from PSE patients as well as in

the brains of animals with experimental chronic liverfailure. In the case of the animal studies, increasedPTBR sites resulted from increased PTBR geneexpression. This increase may be due to exposure toammonia or manganese.Activation of PTBR results in increased cholesteroluptake and increased synthesis in brain ofneurosteroids, some of which have potent positiveallosteric modulator properties on the GABA-Areceptor system. Accumulation of such substances inthe brain in chronic liver failure could contribute tothe development of HE.Neurobehavioral studies — Rats with liver failure aremore sensitive to the sedative effects ofbenzodiazepines than normal rats. Furthermore,administration of antagonists of the GABAA-benzodiazepine receptor complex to animals withfulminant hepatic failure and HE has led to a transientclinical improvement which was associated with anormalization of abnormal visual evoked potentials.Antagonists with partial inverse agonistic propertiesappear to be most effective for the amelioration ofHE. However, the beneficial effects of these agonistsdo not necessarily imply overactivity of the GABAA-benzodiazepine neurotransmitter system. Analternative explanation is an imbalance of excitatoryand inhibitory neurotransmission.Electrophysiological studies — Single cell recordingsfrom Purkinje neurons have revealed increasedsensitivity in HE to the inhibitory effects ofbenzodiazepine agonists, a finding consistent withactivation of the GABAA-benzodiazepineneurotransmitter system in HE.Endogenous benzodiazepines — Endogenousbenzodiazepines involved in the activation of theGABAA-ergic neurotransmission have been isolated,characterized, and positively identified by gaschromatography-mass spectroscopy as benzo-diazepines in brain, sera, and CSF of experimentalanimals and humans with acute liver failure due toacetaminophen toxicity. The brain concentration ofthese substances correlated closely with the degree ofneurologic impairment in an animal model of HE. Inthese drug-free animals, the presence ofbenzodiazepines (including diazepam and desmethyl-diazepam) cannot be explained by exogenousbenzodiazepine administration, which could occur inhumans. However, the use of benzodiazepines priorto HE was carefully excluded in human studies.Glutamatergic neurotransmission - There isincreasing evidence that alterations of glutamatergicfunction are implicated in the pathogenesis of centralnervous system consequences of acute liver failure.

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isolated, characterized, and positively identified bygas chromatography-mass spectroscopy asbenzodiazepines in brain, sera, and CSF ofexperimental animals and humans with acute liverfailure due to acetaminophen toxicity. The brainconcentration of these substances correlated closelywith the degree of neurologic impairment in ananimal model of HE. In these drug-free animals, thepresence of benzodiazepines (including diazepamand desmethyl-diazepam) cannot be explained byexogenous benzodiazepine administration, whichcould occur in humans. However, the use ofbenzodiazepines prior to HE was carefully excludedin human studies.Glutamatergic neurotransmission — There isincreasing evidence that alterations of glutamatergicfunction are implicated in the pathogenesis ofcentral nervous system consequences of acute liverfailure.

Neurochemical studies — Total brain glutamatelevels are decreased in various models of HEand in patients dying from chronic liver failure.This decrease in glutamate is presumably due toglutamine formation during the process ofammonia detoxification. It is not knownwhether a similar change occurs in neuronalglutamate.In contrast, extracellular glutamate concent-rations are elevated in HE .This effect may bedue to excessive release of glutamate fromneurons depolarized by ammonia or to impairedreuptake by neurons or glial cells. Astrocytesmay be involved in these derangements sinceammonia can impair the ability of these cells totake up glutamate. Reduced capacity ofastrocytes to reuptake neuronally-releasedglutamate and the ensuing compromise inneuron-astrocytic trafficking of glutamatecould contribute to the pathogenesis of HE.This effect may result from diminishedexpression of GLT (glutamate transporter)-1mRNA.Receptor binding studies in some experimentalanimals with acute liver failure suggested thatglutamatergic neurotransmission may be alteredin HE. However, this finding has not beenfound in other models.Glutamate receptors — There are three majorsubtypes of glutamate receptors, definedaccording to their coupling to ion channels and

their affinity to certain ligands: NMDA (N-methyl-D-aspartate) Non NMDA — AMPA(amino-3-hydroxy-5-methyl-4-isoxazol propio-nic acid) and kainate Metabotropic glutamatereceptor.In one study of liver failure induced by ischemia,a selective loss of up to 60 percent of bindingsites for the kainate and AMPA receptor ligandswas observed at coma stages of HE in thecerebral cortex, the hippocampus, thehypothalamus, and cerebellum. NMDA-receptors were within normal limits. In contrast,other models of acute liver failure have notedincreased NMDA-displaceable glutamatebinding in the cerebral cortex and hippocampus.The selective loss of AMPA sites is consistentwith the inhibition of AMPA-mediated neuronaldepolarization resulting from exposure ofhippocampal neurons to millimolar concent-rations of ammonia. NMDA sites are uniquelyneuronal, whereas kainate and AMPA sites arelocalized on both neurons and astrocytes. Thus,the selective loss of non-NMDA sites in acuteliver failure may reflect astrocytic changes.Because astrocytic glutamate receptors areimplicated in potassium and neurotransmitterreuptake, alterations in their density could resultin altered neuronal excitability and couldcontribute to the neurologic dysfunctioncharacteristic of HE in acute liver failure.Neurobehavioral studies — Memantine is anoncompetitive NMDA-receptor antagonist. Inportacaval shunted rats infused with ammoniaand rats with acute hepatic failure due to liverischemia, memantine improved clinical grading,EEG activity, and the increases in CSF glutamateconcentrations, intracranial pressure, and brainwater content. Memantine had no effect onammonia concentrations in either model. Inanother study, different NMDA receptorantagonists, acting on different sites of NMDAreceptors, prevented death in mice induced byinjection of ammonium acetate. These resultssuggest that NMDA-receptor activation mightbe involved in the encephalopathy in thesesettings.Catecholamines — Altered concentrations ofcatecholamines in HE have been linked to alteredamino acid metabolism. In chronic liver failure, the

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valine, leucine, and isoleucine are reduced. Sincethese amino acids share a common carrier at theb lood -b r a in ba r r i e r , d e c r e a s ed BCAAconcentrations in the blood may result in increasedtransport of AAA into the brain. A low molar ratioof plasma BCAA to AAA is a consistent finding inpatients with cirrhosis and HE, but also occurs inpatients without HE. This ratio closely correlateswith indices of liver function, with a decreased ratioimplying poor hepatocellular function. Thus, itappears unlikely that changes in the plasmaconcentrations of neutral amino acids contribute tothe development of HE.Another fairly consistent finding in animal modelsof acute or chronic liver failure is a reducednorepinephrine (noradrenaline) concentration in thebrain. The decreased brain norepinephrine contentis due to overactivity of noradrenergicneurotransmission, possibly induced byhyperammonemia.In contrast to these changes in brainnorepinephrine, cerebral dopamine concent- rationsin HE are usually within the normal range in bothexperimental animals and in humans with HE.Furthermore, depletion of brain dopamine in ratsdoes not result in the induction of coma. Thus, thereis no firm evidence that impaired dopaminergicneurotransmission contributes to an appreciableextent to HE. However, some of the extrapyramidalsymptoms in patients with cirrhosis may be due toaltered dopaminergic function, which is closelyrelated to accumulation of manganese in basalganglia. Manganese appears to normalize low striatallevels of dopamine. Thus, manganese accumulationin basal ganglia may represent an attempt of thebrain to correct dopamine deficiency in liver disease.Serotonin — A two to fourfold increase in cerebralconcentration of the serotonin metabolite 5-hydroxyindoleacetic acid is the most consistentneurochemical finding in HE. In addition, HE isassociated with alterations in the number of 5HT1Aand 5HT2 receptors and increased activity of bothMAOA and MAOB (enzymes catabolizing 5-HT).These findings suggest an increased serotoninturnover rate in HE, but do not necessarily imply anoveractivity of this neurotransmitter system.Histamine — The binding properties and theregional densities of histamine H1 receptors in thebrains of rats with portacaval anastomosis suggestedthat this neurotransmitter system is also affected inliver failure. Autopsied brain tissue from cirrhoticpatients with HE displayed a higher density and alower affinity of histamine H1 receptors compared

with control human frontal cortex. Binding washighest in the parietal and temporal cortices andlowest in caudate-putamen. A selective increase in H1receptor density was also observed in parietal andinsular cortices of patients with HE. The centralhistaminergic system is implicated in the control ofarousal and circadian rhythmicity. A selective up-regulation of brain H1 could contribute to theneuropsychiatric symptoms characteristic of humanHE, and may be amenable to treatment with selectivehistamine H1 receptor antagonists.Melatonin — Sleep disturbances are common inpatients with sub clinical HE and may be due to acentrally mediated alteration of circadian rhythm.The 24-hour rhythm of melatonin, which isconsidered to be the output signal of the biological"clock", is considerably altered in patients withcirrhosis. The onset of the rise in plasma levels ofmelatonin and the melatonin peak during the nightare displaced to later hours. Furthermore, plasmamelatonin levels are significantly higher duringdaylight hours, at a time when melatonin is normallyvery low or absent.

Alteration of the Blood-Brain BarrierThe brain uptake of various tracer substances isincreased in several animal models of acute liverfailure. The reason for this nonspecific increase inblood-brain barrier permeability is unknown.Regardless of the mechanism, this change can lead toexposure of the brain to a variety of neurotoxicsubstances circulating in the blood and may result inbrain edema.There are more specific changes in blood-brainbarrier transport in HE. Of specific interest arechanges of amino acid transport into the brain.Amino acids such as tyrosine, phenylalanine, andtryptophan are precursors of the neurotransmittersdopamine, norepinephrine, and serotonin, whileother amino acids, such as glutamate, aspartate,taurine, and glycine, are neurotransmittersthemselves. Alterations in specific transport systemsseem to be important in chronic HE.

Altered Brain Energy MetabolismUndisturbed energy supply and energy metabolism isa prerequisite for normal brain function. Glucose isthe most important cerebral energy fuel andhypoglycemia can occur in the terminal stages of liverfailure due to impaired hepatic gluconeogenesis.However, the administration of glucose is notsufficient to normalize brain function in HE.The depression in cerebral glucose metabolism is due

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in part to hyperammonemia. This effect seems tobegin with increased synthesis of glutamine.Ammonia itself is without effect at concentrationsless than 1 µmol/mL if it is not converted intoglutamine. Hyperammonemia may also reduce brainATP levels, indicating a marked impairment of brainenergy metabolism. However, this abnormality wasfound only in agonal stages and may therefore beunrelated to the evolution of HE.

ConclusionThe various hypotheses of the pathogenesis of HEare not mutually exclusive. It seems likely that manyof the described abnormalities may be present at thesame time and may ultimately be responsible for thedevelopment of HE. The synergistic action ofammonia with other toxins may account for many ofthe abnormalities occurring in liver failure, such asthe changes in blood-to-brain transport ofneurotransmitter precursors, the metabolism ofamino acid neurotransmitters, and cerebral glucoseoxidation. These changes may lead to activation ofinhibitory (GABA, serotonin) and impairment ofexc i t a to r y (g lu t ama te , c a t echo l amines )neurotransmitter systems, resulting in enhancedneural inhibition.

TreatmentCurrently available therapies for hepaticencephalopathy are based upon these hypotheses.Some treatments are based upon clinicalobservations, some upon extrapolation ofexperimental data obtained in animal models ofhepatic encephalopathy, and a smaller number uponcontrolled, randomized clinical trials.Treatment of Precipitating Causes — It is importantto recognize that hepatic encephalopathy, acute andchronic, is potentially reversible and that aprecipitating cause rather than worsening ofhepatocellular function can be identified in themajority of patients.In one classic study, over 80 percent of 100 caseswere attributable to such factors as gastrointestinalbleeding, increased protein intake, hypokalemicalkalosis, infection, and constipation (all of whichincrease arterial ammonia levels), or to hypoxia andthe use of sedatives and tranquilizers.Treatment of precipitating events is typicallyassociated with a prompt and permanentimprovement of hepatic encephalopathy. As aresult, every attempt should be made to identify suchprecipitating events while instituting therapy with

the specific agents described below.

Treatments Based Upon The AmmoniaHypothesisThe gastrointestinal tract is the primary source ofammonia, which enters the circulation via the portalvein. Ammonia is produced by enterocytes fromglutamine and by colonic bacterial catabolism ofnitrogenous sources such as ingested protein andsecreted urea. The intact liver clears almost all of theportal vein ammonia, converting it into glutamine andpreventing entry into the systemic circulation.Elevations of ammonia are detected in 60 to 80percent of patients with hepatic encephalopathy andtherapy aimed at reduction of the circulatingammonia level usually results in resolution of theencephalopathy. Treatment is aimed at eitherreducing or inhibiting intestinal ammonia productionor increasing the removal of ammonia.Correction of hypokalemia — Correction ofhypokalemia, if present, is an essential component oftherapy since hypokalemia increases renal ammoniaproduction. The often concurrent metabolic alkalosismay contribute by promoting ammonia entry into thebrain by promoting the conversion of ammonium(NH4+), a charged particle which cannot cross theblood-brain barrier, into ammonia (NH3), which can.Reduction in ammoniagenic substrates — Removingthe source of the ammonia from the gastrointestinaltract can be an important step in certain patients. Themodalities used vary with the clinical setting.Nasogastric lavage should be performed in patientswith upper gastrointestinal bleeding, while limitingprotein intake and treating constipation may beeffective in patients with chronic encephalopathy.Both cleansing enemas and dietary protein restrictionare effective in patients with acute hepaticencephalopathy.Lactulose and lactitol — Synthetic disaccharides(lactulose and lactitol) are currently the mainstay oftherapy of hepatic encephalopathy, albeit there islimited evidence from well-designed randomizedcontrolled trials to demonstrate their efficacy. Asystematic review found that lactulose or lactitol weremore effective than placebo in improving hepaticencephalopathy (RR of no improvement 0.62, 95percent CI 0.46 to 0.84) but had no significant benefiton mortality.The rationale for treatment is due to the absence of aspecific disaccharidase on the microvillus membraneof enterocytes in the human small bowel, therebypermitting entry into the colon. In the colon,lactulose (beta-galactosidofructose) and lactitol

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(beta-galactosidosorbitol) are catabolized by thebacterial flora to short chain fatty acids (eg, lacticacid and acetic acid) which lower the colonic pHabout 5.0. The reduction in pH favors the formationof the nonabsorbable NH4+ from NH3, trappingNH3 in the colon and effectively reducing plasmaammonia concentrations.Other effects that may contribute to the clinicaleffectiveness of lactulose and lactitol include:Increased incorporation of ammonia by bacteria forsynthesis of nitrogenous compounds Modificationof colonic flora, resulting in displacement of urease-containing bacteria with Lactobacillus. Catharticeffects of a hyper- osmolar load in the colon whichimproves the slow gastrointestinal transit in patientswith subclinical hepatic encephalopathy Increasedfecal nitrogen excretion of up to fourfold due to theincrease in stool volume. Reduced formation ofpotentially toxic short-chain fatty acids (eg,propionate, butyrate, valerate).The dose of lactulose (45 to 90 g/day) should betitrated to achieve two to three soft stools per daywith a pH below 6. Approximately 70 to 80 percentof patients with hepatic encephalopathy improve onlactulose treatment. Treatment is usually welltolerated, and the principal toxicity is abdominalcramping, diarrhea, and flatulence.A number of clinical trials and at least two meta-analyses suggest that lactitol is at least as effective aslactulose, is more palatable, and may have fewer sideeffects.In patients with lactase deficiency, the nonmetabolized lactose has most of the same effects asthe synthetic disaccharides in the colon and is muchcheaper.Enemas — Cleansing of the colon is a rapid andeffective method to remove ammoniagenicsubstrates. It can be achieved either by cathartics orby enemas. A randomized trial involving 20 patientssuggested that 1 to 3 L of 20 percent lactulose orlactitol solution enemas were more effective than tapwater enema. A possible explanation is that colonicacidification rather than bowel cleansing was theeffective therapeutic mechanism.As part of the study, the investigators alsorandomized a total of 33 patients to lactulose orlactitol solutions and noted "a favorable response" in78 and 86 percent of patients respectively. Theefficacy of oral versus enema administration oflactulose or lactitol is unclear. Its conveniencesuggests oral administration is the preferred route ofadministration.Dietary protein reduction — There is no good

clinical evidence supporting protein restriction inpatients with acute hepatic encephalopathy. The onlyrandomized trial, reported only in abstract form,found no difference between moderate (0.8 g/kg perday) and more aggressive protein restriction.Patients with grade III to IV hepatic encephalopathyusually do not receive oral nutrition. As soon as theyimprove, individual protein tolerance can be titratedby gradually increasing oral protein intake every threeto five days from a baseline of 40 g/day. Oral proteinintake should not exceed 70 g/day in a patient with ahistory of hepatic encephalopathy; a level below 70g/day is rarely necessary and minimum intake shouldnot be lower than 40 g/day to avoid negative nitrogenbalance.The titration of individual protein tolerance after anepisode of acute hepatic encephalopathy shouldpermit the design of an individual diet for eachpatient. A randomized cross-over trial in eightpatients suggests that vegetable proteins weresuperior to proteins derived from fish, milk, or meatwith regard to nitrogen balance.Inhibition of intestinal ammonia production andabsorption — Lowering of blood ammonia levels canbe effectively achieved by reducing ammoniaproduction and absorption with antibiotics, syntheticdisaccharides (such as lactulose), or theadministration of a non-urease-producing bacterium.Oral antibiotics — Although neomycin has been usedfor many years to treat hepatic encephalopathy, nocontrolled studies have found it to be effectivecompared with standard treatment alone. A 1977study found neomycin to be as effective as lactulose in33 patients, but a more recent randomized trial of 39patients comparing neomycin at a dose of 6 g per dayto placebo reported no difference in outcomesbetween the two treatment groups. In addition,neomycin is associated with ototoxicity andnephrotoxicity, limiting long-term use.Other antibiotics, such as metronidazole,vancomycin, and rifaximin, have been found effectivein limited clinical trials and are better tolerated thanneomycin. Nevertheless, strong evidence ofeffectiveness is lacking, and all antibiotics can causealterations in gut flora that may contribute to bacterialovergrowth syndromes. Thus, their use is typicallylimited to patients who cannot tolerate or are resistantto disaccharides.Modification of colonic flora (probiotics andprebiotics) — Alteration of gut flora (either withprobiotics or with prebiotics such as fermentablefiber) has been associated with improvement inhepatic encephalopathy in pilot studies. Such therapy

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appears to lower blood ammonia concentrationspossibly by favoring colonization with acid-resistant,non-urease producing bacteria.Acarbose — Acarbose (an inhibitor of alphaglycosidase that is approved for treatment ofdiabetes mellitus) inhibits the upper gastrointestinalenzymes (alpha-glucosidases) that convertcarbohydrates into mono- saccharides. It alsopromotes the proliferation of intestinalsaccharolytic bacterial flora that producemercaptans, benzodiazepine-like substances, andammonia. Their reduction could improve hepaticencephalopathy. This hypothesis appeared to beconfirmed by a randomized controlled crossovertrial involving 107 cirrhotic patients with diabetesmellitus and grade 1 to 2 hepatic encephalopathy.Treatment was associated with a significantreduction in blood ammonia alevels andimprovement in encephalopathy.Stimulation of metabolic ammonia metabolism —Ammonia is removed by formation of urea inperiportal hepatocytes and/or by synthesis ofglutamine from glutamate in perivenoushepatocytes. In cirrhosis, the activities ofcarbamylphosphate synthetase and of glutaminesynthetase (the key enzymes for urea and glutaminesynthesis) are impaired and the glutaminase flux isincreased in a compensatory fashion, resulting inhyper- ammonemia. As a result, ornithine-aspartateand benzoate have been used to lower plasmaammonia concentrations by enhancing themetabolism of ammonia to glutamine andhippurate, respectively.Ornithine-aspartate — Ornithine serves both as anactivator of carbamylphosphate synthetase andornithine-carbamyltransferase in periportalhepatocytes, and as a substrate for ureagenesis.Ornithine (via alpha-ketoglutarate) and aspartateincrease ammonia removal by these cells viastimulation of glutamine synthesis.The benefit of ornithine-aspartate in patients withmild hepatic encephalopathy has been demonstratedin randomized, controlled trials. As an example, onestudy of 126 patients with cirrhosis, hyper-ammonemia, and chronic hepatic encephalopathywere randomly assigned to treatment with ornithine-aspartate (20 g infusion over four hours for sevendays) or placebo. Patients with mildly symptomatichepatic encephalopathy in the active treatmentgroup had significant improvements in fasting andpostprandial blood ammonia concentrationscompared with placebo, as well as improvement inclinical measures. There was no effect in patients

with sub clinical hepatic encephalopathy. A smallerplacebo-controlled study also found benefits of oralornithine-aspartate (18 g/day) with no adverseeffects.Thus, the available data suggest that ornithine-aspartate is somewhat more effective than placebo,but further study is necessary. It has not been directlycompared with lactulose or lactitol, and experiencewith ornithine-aspartate in patients with more severehepatic encephalopathy is limited.Sodium benzoate — An entirely different approachto eliminate ammonia is the use of benzoate.Benzoate reacts with glycine to form hippurate. Foreach mole of benzoate used, one mole of wastenitrogen is excreted into the urine.A prospective, randomized, double-blind study of 74patients with acute hepatic encephalopathy foundthat treatment with sodium benzoate (5 gm twicedaily) resulted in similar improvements inencephalopathy as lactulose. There was no placebogroup. The cost of lactulose was 30 times that ofsodium benzoate.While this study is encouraging, we are reluctant torecommend sodium benzoate as first line therapyprior to a trial of lactulose until the results areconfirmed in a placebo-controlled study, given themuch broader experience with lactulose.

Treatments Based Upon The FalseNeurotransmitter HypothesisIt has been suggested that increases in the ratio ofplasma aromatic amino acids (AAA) to branched-chain amino acids BCAA) as a consequence ofhepatic insufficiency could contribute toencephalopathy. The altered ratio could then increasebrain levels of aromatic amino acid precursors formonoamine neurotransmitters and contribute toaltered neuronal excitability. As a result, a number ofstudies have evaluated the effects of the provision ofBCAA, given either intravenously or orally.BCAA infusions — Several randomized, controlledstudies have evaluated the use of parenteral nutritionwith modified amino acid solutions with a highcontent of BCAA and a low content of AAA. Ameta-analysis suggested that mental recovery wasconsistently more rapid in treated patients. Threestudies suggested lower mortality in treated patientswhile two others suggested that treatment increasedmortality. The studies included in this meta-analysisdiffered with respect to the amino acid solutions used,the study protocols, patient selection, and theduration of treatment, and therefore cannot becompared directly with each other. In addition, allstudies were of relatively short duration. We do not

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with hepatic encephalopathy.Oral BCAA supplements — The benefit of oralbranched chain amino acid supplements (BCAA) isunclear. A systematic review of 11 randomized trials(with a total of 556 patients) found no convincingevidence of a benefit. However, significantimprovement in chronic hepatic encephalopathy hasbeen described in some of the trials suggesting apotential benefit in some patients. As an example, adouble-blind trial of 64 patients found that long-term supplementation of oral BCAA to a lowprotein diet was more likely to improve mentalperformance at three months than supplementationwith casein (80 versus 35 percent). In addition, somepatients who did not improve on casein rapidlyimproved when switched to BCAA. Another reportevaluated 37 hospitalized protein-intolerant patientswith cirrhosis. Addition of BCAA to the dietenabled the daily protein intake to be increased to upto 80 g without worsening of cerebral function; incomparison, many control patients (receiving acasein as protein source) deteriorated afterincreasing dietary protein intake. No benefit ofBCAA supplementation was observed in protein-tolerant patients. Based upon these results, we feelthat dietary BCAA supplementation is indicatedonly in severely protein-intolerant patients.

Treatments Based Upon The GABAHypothesisThe GABA-receptor complex appears to be acontributor to neuronal inhibition in hepaticencephalopathy. This complex, in the postsynapticmembrane, is the principal inhibitory network in thecentral nervous system. It consists of a GABA-binding site, a chloride channel, and barbiturate andbenzodiazepine receptor sites. Increases intransmission could be caused by increases in ligandsfor any of the three receptors. Since there is evidencefor an increase in benzodiazepine receptor ligands inpatients with hepatic encephalopathy, the effects ofbenzodiazepine receptor antagonists have beenstudied. GABA-ergic transmission may interact withammonia in the pathogenesis of hepaticencephalopathy.The benzodiazepine receptor antagonist flumazenilhas been used for treatment of hepaticencephalopathy in a number of uncontrolled studiesand in several controlled trials with limited success.Response to treatment, when it occurred, was seenwithin a few minutes after intravenousadministration in most patients; however, two-thirdsof the patients who responded deteriorated two to

four hours later. The controlled trials varied in designand exclusion criteria, and are therefore not directlycomparable.The available data were summarized in a systematicreview of 12 controlled trials that included a total of765 patients. The authors concluded that treatmentwith flumazenil was associated with a significantimprovement in hepatic encephalopathy comparedwith placebo at the end of treatment (30 versus 7percent, absolute improvement of 23 percent [95percent CI 18 to 28 percent]). The benefit was short-term, and appeared to be confined to patients whootherwise had a favorable prognosis. No significantbenefit on recovery or survival was demonstrated. Asecond meta-analysis that included six of thecontrolled trials reached similar estimates of efficacy.These findings suggest that while some patients withhepatic encephalopathy may benefit from flumazenil,it cannot be recommended as routine therapy.Flumazenil may be helpful, however, in patients whohave received benzodiazepines.

Miscellaneous TreatmentsZinc and melatonin have been suggested as havingpotential value in some patients with chronic orrecurring hepatic encephalopathy, although littleevidence exists to document their effectiveness.Zinc — Zinc deficiency is common in patients withcirrhosis and in those with hepatic encephalopathy.Zinc is contained in vesicles in presynaptic terminalsof a class of neurons, many of which are a subclass ofthe glutamatergic neurons. Stimulated release maymodulate ion channel function and neuro-transmission. Zinc may also enhance the hepaticconversion of amino acids into urea.Little information is available on the clinical effects ofzinc supplementation in overt hepatic encephalo-pathy. A patient has been described who exhibited arelationship between zinc deficiency and severerecurrent hepatic encephalopathy.The study included a period in which zinc deficiencywas artificially induced by oral histidine. An episodeof overt encephalopathy occurred that was identicalto earlier episodes and responded to oral zinc. Long-term zinc supplementation significantly improvedsevere recurrent hepatic encephalopathy which hadbeen refractory to protein restriction, lactulose, andneomycin.However, this anecdotal report has not beenconfirmed in larger studies. As an example, short-term zinc supplementation had no clinicallysignificant effect in 15 patients with chronic hepaticencephalopathy studied in a blinded crossover trial.

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supplementation for treatment of hepaticencephalopathy.Melatonin — one of the most frequently described,sometimes disabling, symptoms of sub clinicalforms of hepatic encephalopathy are sleepdisturbances or, more generally, alterations in thesleep/wake cycle. Unsatisfactory sleep is alsocharacteristic of cirrhotic patients withoutencephalopathy, as found in 48 percent of patients inone study.The abnormalities in sleep may be due in part toalterations in the 24-hour rhythm of the hormonemelatonin, which is considered to be the outputsignal of the biological "clock" (see "Physiology andclinical use of melatonin"). In one series of patientswith cirrhosis, the onset of the rise in plasmaconcentrations of melatonin and the melatonin peakduring the night was displaced to later hours.Furthermore, plasma melatonin levels in cirrhoticswere significantly higher during daylight hours, at atime when melatonin is normally very low or absent.These findings support the hypothesis that analteration of circadian rhythmicity is responsible forthe disruption in the sleep/wake cycle frequentlyseen in cirrhosis. Melatonin can influence its ownrhythm when administered at defined time points ofthe day, shifting the curve forward or backward.Orally administered melatonin therefore could be atreatment option in cirrhotic patients with alteredsleep/wake cycles. The hypnotic effect of melatonincould also improve sleep quality, thereby decreasingthe need for sedatives.

Experimental TreatmentsA number of experimental approaches are beingevaluated in animal models for the treatment ofhepatic encephalopathy. Few have received anytesting in clinical trials.L-Carnitine — Carnitine is a metabolite in thedegradation pathway of the essential amino acidlysine and is synthesized by oxidation of E-amino-trimethyl-lysine. It serves as a carrier for short chainfatty acids across the mitochondrial membrane (see"Carnitine metabolism in renal disease and dialysis",section on Role of carnitine in intermediarymetabolism). Data in portacaval-shunted ratssuggest that L-carnitine is protective againstammonia neurotoxicity.The available clinical data are insufficient to assessthe role of L-carnitine in human disease. In cirrhoticpatients subjected to a rectal ammonium overloadtes t , in t ravenous L-carn i t ine improvedpsychometric tests significantly after 30 minutes,

whereas circulating ammonia levels were notinfluenced. However, the increase in plasmaammonia after rectal ammonia overload wassignificantly lower in treated patients with evidenceof portal hypertension than in patients without thesesigns.Glutamatergic antagonists — There is good evidencethat the glutamatergic neurotransmitter system isinvolved in the pathogenesis of hepaticencephalopathy. The N-methyl-D-aspartate(NMDA) receptor is one of three known centralglutamate receptors. NMDA overactivity has beenobserved in two different experimental rat models ofencephalopathy. The administration of the NMDAreceptor antagonist memantine resulted in asignificant improvement in clinical grading and lessslowing of EEG activity, smaller increases in CSFglutamate concentrations, and lower intracranialpressure and brain water content than in untreatedcontrol rats.S e ro ton in an t ag on i s t s — Accumu l a t edneurochemical data in different animal models offulminant hepatic failure and in humans with hepaticencephalopathy suggest that serotonin- ergic tone isincreased in the brain in hepatic encephalopathy. Thenonselective serotonin receptor antagonistmethysergide had no effect in control rats, butincreased motor activity in rats with stage II to IIIhepatic encephalopathy stage in a dose-dependentmanner; in contrast, the 5-HT2 receptor antagonistseganserin had no effect.

Opioid antagonists — Plasma levels of Met-enkephalin and beta-endorphin are elevated inpatients and in experimental animals sufferingfrom liver failure. Administration of (+/-)-naltrexone, but not (+)-naloxone, significantlyincreased the motor activity of rats with stage IIIhepatic encephalopathy.

RecommendationsAcute therapy — The initial management ofacute hepatic encephalopathy involves two steps:1. Correction of precipitating causes.2. Measures to lower the blood ammonia

concentration.1. Correction of precipitating causes — The

first step is the identification and correctionof pre cipitating causes. Careful evaluationshould be performed to determine thepresence of Hypovolemia, gastrointestinalbleeding, hypokalemia and/or metabolic

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Rarely, hepatoma and/or vascular occlusion(hepatic vein or portal vein thrombosis) mayhave to be considered.

2. Lower blood ammonia — The second step isinitiation of measures to lower the bloodammonia concentrations (whether or not thevalues are frankly elevated). Nasogastriclavage should be performed in patients withupper gastrointestinal bleeding. Correction ofhypokalemia is also an essential component oftherapy since hypokalemia increases renalammonia production.Drug therapy is the mainstay of treatment tolower the blood ammonia concentration.Drug therapy consists of the following: Werecommend initiating drug therapy for acutehepatic encephalopathy with lactulose orlactitol. While a well-performed, placebo-controlled study of lactulose therapy has notbeen performed, the efficacy of thedisaccharidases is considered beyond doubtgiven our broad clinical experience. The doseof lactulose (45 to 90 g/day) should be titratedto achieve two to three soft stools per day witha pH below 6. Lactulose enemas can be givenif the patient cannot take lactulose orally.Approximately 70 to 80 percent of patientswith hepatic encephalopathy improve onlactulose or lactitol treatment. For those whohave not improved within 48 hours, second-line therapy includes either ornithine-aspartate infusion (20 g infusion per day overfour hours) or oral sodium benzoate (5 g twicedaily). While experience with both drugs islimited, a relatively large placebo-controlledstudy or ornithine-aspar tate and acomparative study of sodium benzoate andlactulose suggest that both drugs are effective

in patients with acute hepatic encephalopathy.There are no data to suggest which drug is thebest alternative to the disaccharidases.Antibiotics, particularly oral neomycin, havegenerally been considered second-line therapyin patients who have not responded todisaccharidases, but we are concerned about itslack of efficacy in a placebo-controlled trial andits toxicity. Thus, we do not recommend use ofneomycin. Other antibiotics may be safer, butclinical experience is limited. Flumazenil isrecommended only if the patient has beengiven benzodiazepines.

Chronic therapy — We recommend continuousadministration of lactulose in patients withrecurrent encephalopathy or sub clinicalencephalopathy. Limitation of protein intake(to 70 g/day) is also recommended, but proteinrestriction should be avoided as it will lead tonegative nitrogen balance. The titration ofindividual protein tolerance after an episode ofacute hepatic encephalopathy should permitthe design of an individual diet for each patient.In protein-intolerant patients, vegetableproteins are superior to proteins derived fromfish, milk, or meat, and they improve nitrogenbalance.Another alternative for patients intolerant toprotein is the addition of branched-chainamino acids to a low protein diet. BCAAsupplementation is indicated only in severelyprotein-intolerant patients.

Department of MedicineSIMS/Services Hospital, Lahore

[email protected].

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References

1. Ferenci, P, Müller, CH. Hepaticencephalopathy: Treatment. In:Burroughs, A, Feagan, B,M c D o n a l d , J W B ( e d s ) .E v i d e n c e B a s e dG a s t r o e n t e r o l o g y. B M J.London 1999:443.

2. Weissenborn, K, Ennen, JC,Schomerus, H, Ruckert N,Hecker H. Neuropsychologicalcharacterization of hepaticencephalopathy. J Hepatol

2001; 34(5):768-73.3. Fessel, JN, Conn, HO. An

analysis of the causes andprevention of hepatic coma.Gastroenterology 1972; 62:191.

4. Gabduzda GJ, Hall PW 3rd.Relation of potassium depletionto renal ammonium metabolismand hepatic coma. Medicine(Baltimore) 1966; 45(6):481-90.

5. Uribe M, Campollo O, Vargas F,Ravelli GP, Mundo F, Zapata L et

al. Acidifying enemas (lactitol andlactulose) vs. non acidifyingenemas (tap water) to treat acuteportal-systemic encephalopathy:A double-blind randomizedclinical trial. Hepatology 1987;7(4):639-43.

6. Plauth M, Merli M, Kondrup J,Weimann A, Ferenci P, Muller MJet al. ESPEN guidelines fornutrition in liver disease andtransplantation. Clin Nutr 1997;


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7. Basile AS, Harrison AM, HughesRD, Gu ZQ, Pannell L,McKinney A et al. Relationshipb e t w e e n p l a s m abenzodiazepine receptor ligandconcentrations and severity ofhe pa t i c ence pha lopa thy.Hepatology 1994; 19(1):112-21.

8. Basile AS, Hughes RD, HarrisonPM, Murata Y, Pannell L, JonesEA et al. Elevated brainconcentrations of 1-4 benzo-diazepines in fulminant hepaticfailure. N Engl J Med 1991;325(7):473-8.

9. Basile, AS, Jones, EA. Ammoniaand GABA-erg ic neuro-transmission: Interrelatedfactors in the pathogenesis ofhe pa t i c ence pha lopa thy.Hepatology 1997; 25(6):1303-5.

10. Haussinger D, Kircheis G,Fischer R, Schliess F, vom DahlS. Hepatic encephalopathy inchronic liver disease: A clinicalmanifestation of astrocyteswelling and low-grade cerebraledema? J Hepatol 2000;32(6):1035-8.

11. Häussinger D, Roth E, Lang F,Gerok W. Cellular hydrationstate: an important determinantof protein catabolism in healthand disease. Lancet 1993;341(8856):1330-2.

12. Raabe W. Effects of hyper-ammonemia on neuronalfunction: NH4+, IPSP and Cl-extrusion. Adv Exp Med Biol1993; 341:71-82.

13. Allert N, Koller H, Siebler M.Ammonia induced depolariz-ation of cultured rat corticalastrocytes. Brain Res 1998;782:261-70.

14. Lockwood, AH, Ginsberg, MD,Rhoades, HM, Gutierrez, MT.Cerebral glucose metabolismafter portocaval shunting in therat. Pattern of metabolism andimplications for the patho-genesis of hepatic encephalo-pathy. J Clin Invest 1986;78(1):86-95.

15. Carpenedo, R, Mannaioni, G,

Moroni, F. Oxindole, a neuro-depressant tryptophan meta-bolite, accumulates in the bloodor brain of rats with hepaticfailure. J Neurochem 1998;70:1998.

16. Moroni F, Carpenedo R,Venturini I, Baraldi M, ZeneroliM L . O x i n d o l e i n t h epa thog enes i s o f he pa t i cencephalopathy. Lancet 1998;351:1861.

17. Schafer DF, Pappas SC, BrodyLE, Jacobs R, Jones EA. Visualevoked potentials in a rabbitm o d e l o f h e p a t i cencephalopathy. I. Sequentialchanges and comparisons withd r u g - i n d u c e d c o m a s .Gastroenterology 1984; 86:540-5.

18. Schafer DF, Jones EA. Hepaticencephalopathy and the gamma-aminobutyr ic -ac id neuro-transmitter system. Lancet 1982;1:18-20.

19. Ferenci P, Püspök A, Steindl P.Cur rent concepts in thepathophysiology of hepaticencephalopathy. Eur J Clin Invest1992; 22:573-81.

20. Butterworth RF. The astrocytic("peripheral-type") benzo-diazepine receptor: Role in thepathogenesis of portal-systemicencephalopathy. Neurochem Int2000; 36:411-6.

21. Basile AS, Gammal SH, MullenKD, Jones EA, Skolnick P.Differential responsiveness ofcerebellar Purkinje neurons toGABA and benzodiazepinereceptor ligands in an animalm o d e l o f h e p a t i cencephalopathy. J Neurosci 1988;8:2414-21.

22. Basile AS, Pannell L, Jaouni T,Gammal SH, Fales HM, JonesEA et al. Brain concentrations ofbenzodiazepines are elevated inan animal model of hepaticencephalopathy. Proc Natl AcadSci USA 1990; 87(14):5263-7.

23. Basile AS, Hughes RD, HarrisonPM, Murata Y, Pannell L, Jones

EA et al. Elevated brainconcentrations of 1,4-benzo-diazepines in fulminant hepaticfailure. N Engl J Med 1991;325(7):473-8.

24. Yurdaydin C, Gu ZQ, Nowak G,Fromm C, Holt AG, Basile AS.Benzodiazepine receptor ligandsare elevated in an animal modelof hepatic encephalopathy:Relationship between brainconcentration and severity ofencephalopathy. J PharmacolExp Ther 1993; 265(2):565-71.

25. Norenberg MD. Astrocytic-ammonia interactions in hepaticencephalopathy. Semin Liver Dis1996; 16(3):245-53.

26. Bosman DK, Deutz NE, DeGraaf AA, vd Hulst RW, van EijkHM, Bovee WM et al. Changes inbra in metabol i sm dur inghyperammonemia and acute liverfailure: results of a comparative1H-NMR spectroscopy andbiochemical invest igat ion.Hepatology 1990; 12(2):281-90.

27. Moroni, F, Lombardi, G, Moneti,G, Cortesini, C. The release andneosynthesis of glutamic acid areincreased in experimental modelsof hepatic encephalopathy. JNeurochem 1983; 40(3):850-4.

28. de Knegt RJ, Schalm SW, van derRijt CC, Fekkes D, Dalm E,Hekking-Weyma I. Extracellularbrain glutamate during acute liverfa i lure and dur ing acutehyperammonemia simulatingacute liver failure: An experi-mental study based on in vivobrain dialysis. J Hepatol 1994;20(1):19-26.

29. Hermenegildo C, Marcaida G,Montoliu C, Grisolia S, MinanaMD, Felipo V. NMDA receptorantagonists prevent acuteammonia toxicity in mice.Neurochem Res 1996; 21(10):1237-44.

30. Fischer JE, Baldessarini RJ. Falseneurotransmitters and hepaticfailure. Lancet 1971; 2:75-80.

References

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IntroductionSuicide is a Latin word, 'sui' means to kill oneself. Itis an act of taking one's own life voluntarily andintentionally. Suicide has been committed by people

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from all walks of life since the beginning of knownhistory. Suicide is often interpreted as a cry for helpand attention or to express despair and the wish toescape rather than a genuine intent to die.

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Poisoning is a harmful effect that occurs when atoxic substance is swallowed, inhaled, or comes incontact with the skin, eyes or mucous membranes.The damage caused by poisoning depends on thepoison, the amount utilized, the age, and theunderlying health of the person who takes it. Wechose to conduct this study in order to evaluatemorbidity, mortality and outcome associated withthe intake of wheat pills during the hospital stay.

Wheat PillChemical composition:Aluminium Phosphide = 56 %

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Inert ingredients = 44 %Paraffin

Use:Aluminium phosphide is an inorganic phosphideused to control insects and rodents in a variety of

settings. It is mainly used as an indoor fumigant atcrop transport, storage or processing facilities. It may

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be used as an out door fumigant for burrowingrodents and mole control.

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Availability:It is available in the form of pellets, tablets, porousblister packs, sachets or powder.

Mechanism of Action:Metal phosphides liberate Phosphine gas aftercoming in contact with moisture of grains or water orHCL of the stomach after ingestion. Other gasesliberated are Ammonia (NH3) and Carbon dioxide(CO2).

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Pathophysiology:1. It causes non-competitive inhibition of

cytochrome e-oxidase leading to inhibition ofmitochondrial oxidative phosphorylation whichin turn leads to multiorgan dysfunction.

2. Once absorbed into the body phosphine candamage cell membranes and enzymes importantfor respiration and metabolism like decrease incatalases and increase in harmful enzymes likesuperoxide dismutases etc.

Rabia Rathore and Muhammad Zafar Ullah Khan

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Morbidity, Mortality and Management of Wheat Pill Poisoning

Original Article

Background: Suicide is one of the leading causes of death worldwide. People adopt differentways to commit suicide.

Methods: We enrolled 50 patients presenting to emergency department, Mayo Hospital, Lahorewith intake of wheat pills with suicidal intention. The end point was death, discharge or leavinghospital against medical advice. The study was designed to know the effects of wheat pill onvarious systems of the body and its outcome.

Results: Of the total 50 patients studied, 28 (56%) were males and 22 (44%) were females. 35(70%) patients died, 8 (16%) were discharged and 7 (14%) left against medical advice.

Conclusion: It can be concluded that wheat pill poisoning is becoming very common as a modeof committing suicide. Since wheat pill is highly toxic, mortality is significantly higher and painful.Wheat pill is freely available and very cheap so awareness should be created among rural areasand urban peripheries regarding its toxicity and high mortality. A legal ban should be imposed onits over the counter sales. Its possession should be authorized to personnel trained in properstorage and dispensing.

Keywords: Suicide, Wheat pill, poisoning, arrhythmias,Aluminium Phosphide

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15

dosis. There is hypomagnesaemia.

System Symptoms

G.I.T. 100% Thirst, nausea, vomiting, burning

epigastrium, abdominal cramps.

CVS 100% Hypotension, shock, brady/tachy-

congestive cardiac failure and ulti-

-cardia, arrhythmias, myocarditis,

Respiratory Dyspnoea, crackles/ rales, pulmo-50-60% -nary edema (ARDS), chest tight-

-ness, cough.

20-30% raised transaminases, increased

bilirubin.

Renal 5-10% Oliguria, proteinuria, hematuria or

acute renal failure.

CNS Anxiety, apprehension, restless-ness, convulsions, coma, headache

vision.

Electrolytes Blood gas analysis reveals combi-

ned respiratory and metabolic aci-

-mately cardiac arrest.

Hepatobiliary Jaundice, tender hepatomegaly

dizziness, impaired gait, double

3. It has been seen that phosphine causes decreasein Magnesium intracel lular ly and itsconcentration increases extracellularly.

4. When phosphine is inhaled it can react withmoisture in the lungs to form phosphoric acidwhich can cause blistering and edema leading toARDS.

5. It also causes the denaturing of oxyhaemoglobinleading to decreased Oxygen delivery to bodytissues.

6. Local trauma to the gastric tissues leading togastritis.

Characteristics of Phosphine Gas:Description Colorless gas, odor of garlic or

decaying fish.Molecular weight 34.0 Daltons.Melting point - 209 F (-134 C)

o o

Boiling point -126 F (-87.7 C) (at 760 mmHg)o o

Vapour pressure > 760 mmHg at 68 F (20 C)o o

Gas density 1.17 (air = 1)Water solubility Slightly water soluble (0.3 % at

68° F (2°c)Flammability Extremely flammable and

explosive, may ignite spontan-eously on contact with air.

Acute Exposure:Phosphine interferes with enzymes and proteinsynthesis primarily in mitochondria of heart andlungs. Metabolic changes in heart muscles causes

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cation disturbances that alter transmembranepotentials. Ultimately cardiac arrest, peripheralvascular collapse and pulmonary edema may occur.Pulmonary edema and pneumonitis are believed toresult from direct cytotoxicity to pulmonary cells.In fatal cases, centrilobular necrosis of heart hasbeen reported. Most deaths occur within first 12-24

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hours after exposure and are cardiovascular inorigin. After 24 hours usual cause of death is liverfailure.

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Chronic Exposure:Chronic exposure to very low concentrations mayresult in anemia, bronchitis, gastrointestinaldisturbances and usually speech and motordisturbances.

Carcinogenicity:The EPA has determined that phosphine is notclassifiable as to its human carcinogenicity.

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Reproductive and Developmental Effects:Phosphine is not included amongst reproductive

and developmental toxicants, No teratogenic effectsfrom acute exposure are known.

Table-1: System wise symptomatology pertaining towheat pill poisoning.

Management Guidelines for Wheat PillPoisoning:There is no specific antidote for wheat pill(Aluminium phosphide). Supportive measures aredone till phosphine is excreted.§ Brush all visible particles from clothes, skin and

hair. Thoroughly flush exposed skin and hair.Thoroughly flush exposed skin and hair withwater for 3-5 minutes; then wash with mild soap.

§ If Phosphides have been ingested, do not induceemesis.

§ Thoroughly flush exposed skin and hair withwater for 3-5 minutes; then wash with mild soap.

§ If Phosphides have been ingested, do not induceemesis.

§ Confirm the presence of wheat pill poisoning byuse of AgNO (Silver Nitrate) paper. This can be3

done by placing Silver Nitrate paper in front ofpatient's mouth and asking him or her to exhalerepeatedly; the colour of the paper will turn blackin case the patient is phosphine gas positive.

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§ Gastric lavage with 1:1000 potassiumpermanganate – till patient is confirmedphosphine gas negative by silver nitrate paper.

§ Slurry of activated charcoal at 1 mg/kg (adults60-90 gm) orally or through a nasogastric tube.Mineral oil or coconut oil may be used for gastric


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Maintain two intravenous lines with wide bore§

canula.

Treatment of Sequel or Other RelatedProblems

Shock:Ø Intravenous fluids (3-4 liters of fluid out of

which 50% should be normal saline under CVPguidance.

Ø Dopamine (4-6 ug/kg/min) with Dobutamine tokeep the systolic blood pressure above100mmHg.

Ø Intravenous hydrocortisone 200-400 mg afterevery 4-6 hours to be administered.a. To reduce the dose of dopamineb. To check capillary leakage in lungs.c. To potentiate responsiveness of shock to

endogenous catecholamines.d. To compensate for low levels of cortisol

found in cases with severe poisoning.

Hypoxia:Ø Patent airway & Oxygen inhalation through

mask.Ø Assisted ventilation if needed.Ø Monitor blood gas analysis 4 hourly.

Arrhythmias:Ø Amiodarone has been claimed to be of some

success in a study.Ø Magnesium sulphate has been tried with success

in reversion of supraventricular and ventriculararrhythmias. It has anti peroxidant effect andremains stable in hypoxic cell environment.

Ø Atropine is not effective to combat bradycardiaor bradyarrhythmias of this poisoning.

Adult Respiratory Distress Syndrome- Oxygen is delivered through face mask at

moderate flow rates of 5-10 litres/min. 100percent of oxygen to achieve PaO of 60-702

mmHg with lowest FiO2

- Mechanical support is needed if above measuresfail.

Steps to Reduce Systemic ToxicityNo agent of proven efficacy as it rapidly binds toenzyme systems and produces cellular dysfunction.However, Mg is thought to have anti peroxidant,

++

anti arrhythmic and membrane stabilizing effects,

hence, has been tried with some success.

Dosage ScheduleØ One gm of Magnesium Sulphate IV stat, thenØ One gm after every hour for next 3 hours and

thenØ One gm after every 4-6 hours up to a maximum

of 5 days.With this dose, serum Magnesium levels remainbetween 3.0 to 4.6 mEq/L which is safe.Lower and higher doses have been employed withoutany success. Another regime for giving MgSO is 3 gm4

of MgSO in 500 ml of Dextrose water in first three4

hours, followed by 6 gm of MgSO4 in 500 ml ofDextrose water over 24 hours starting next day andcontinued for 3-5 days. Intravenous SodiumBicarbonate 50-100 meq in 1000 ml normal salineevery 8 hours to keep bicarbonate level around 18-20meq and pH above 7.1 (300 meq/day) is alsoadvocated.

Steps to Increase Ph Excretion3

Ø Phosphine is stable and is excreted throughbreath and partially in the urine.

Ø Steps to enhance its excretion through urine:a. Adequate hydration.b. Renal perfusion by IV fluid andc. Low dose dopamine (4-6 ug/kg/min).

Ø Diuretics and dialysis are not employed due tohaemodynamic instability, however may be usedif patient develops acute renal failure andbecomes haemodynamically stable.

Post Hospital ManagementAdmission and Follow-up:

· Monitoring of delayed effectsPulmonary edema and liver damage may be delayedfor 72 hours or more so patients with significantexposure should be admitted and observedcarefully (survival for 4 days usually predicts fullrecovery).

· Patient releaseAsymptomatic patients with normal initialexamination, minimal exposure, and no signs oftoxicity after observation for 4 to 6 hours may bedischarged with instructions to return to theemergency department if symptoms of toxicitydevelop.

Mortality (50-90 %)Factors:- Freshness of pills.

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- Dose consumed.- Onset of symptoms.- Emptiness of stomach i.e. vomiting etc.- Delay in arrival in hospital- Delay in institution of therapy.

Mortality with:- Supportive therapy alone 70-100 %.- Supportive therapy & Magnesium Sulphate

25-45 %.

Patients and MethodsFifty patients were enrolled who presented to theemergency of West Medical Ward, Mayo Hospital,Lahore with history of ingesting wheat pills withsuicidal intention during the period between August2006 and April 2007. End point was leaving thehospital either dead, discharged or leaving againstmedical advice.

ResultsOf the total 50 patients studied, 28 (56%) were malesand 22 (44%) were females. 35 (70%) patients died, 8(16%) were discharged and 7(14 %) patients leftagainst medical advice. Age distribution showed 10patients were in second decade (11-20 years), 22patients in third decade (21-30 years), 8 patients infourth decade (31-40 years), 7 in fifth decade (41-50)and 3 in sixth decade (50-60 years). 35 (70 %) out of50 patients had cardiac involvement i.e. 12 patientshad atrial fibrillation, 4 had ventricular fibrillation, 4had ventricular tachycardia, 5 had complete heartblock, 2 developed sinus bradycardia and 8 patientshad non specific T wave and ST segment changes. 19(38%) patients had CNS involvement i.e. becamevery irritable. 6 (12%) patients had hepaticinvolvement with raised aminotransferases, 30(60%) patients had GIT involvement with intensethirst, 5(10%) patients developed pulmonary edemaand none of the patient had renal involvement.

DiscussionSuicide is a leading cause of death world wide.

12

There are four major groups of people who commitsuicide. By far the greatest number falls into

situational problems i.e. patients commit suicide inyounger age groups usually due to unsuccessful loveaffairs and social inhibitions, economic situations dueto joblessness and failure in examination. In fourth

13

decade it is usually a fight with spouse or financialproblems, whereas in old age usually due to familyinattention or chronic illness, otherwise suicidalattempt is clearly a stratagem for controlling orhurting others. Suicide can be attempted due to severedepression or psychiatric illness. The gender ratio inour study is similar to accepted view of maledominance that has been reported in many countriesas well as in other local studies.

14

Suicide is the second common cause of mortality in15-34 year olds. The rate increases with age peakingfor women in their sixties and men in their seventies.

15

In our study 40 patients were in the age group of 10-30 years, 7 patients were in the age group from 30-60years whereas only 3 patients over the age of 60 yearscommitted suicide. The finding goes against theincreasing incidence of suicide with age. Patientspresenting to emergency with intake of wheat pillsusually belong to rural areas who indulge in out dooractivities of harvesting, processing and storage ofcrops. The higher mortality is associated with intakeof freshly bought wheat pills from the market(probably freshly prepared), intake of more than onepills and time lapse of more than 4 hours beforecoming to emergency. It can be concluded that wheatpill poisoning is becoming very common as a modeof committing suicide. Since wheat pill is highlytoxic, mortality is significantly higher and painful.Wheat pill is freely available and very cheap soawareness should be created among rural areas andurban peripheries regarding its toxicity and highmortality. A legal ban should be imposed on its overthe counter sales. Its possession should beauthorized to personnel trained in proper storage anddispensing.

Department of Medicine,King Edward Medical College, Lahore .

[email protected]/esculapio.html.

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1. Awan NR. Principles andpractice of Forensic Medicine,Lahore. Sublime Arts: 2002:25.

2. Bluglass R, Bawden P (eds).Principles and practice ofF o r e n s i c P s y c h i a t r y .Edinburgh: Churchill LivingStone; 1990: 213-606.

3. Royal Society of Chemistry.1991 (as updated). The Agro-chemicals Handbook, RoyalSociety of Chemistry Inform-ation Services, Cambridge, UK.

4. Garry VF, Griffith J, Danzl TJ,Nelson RJ, Whorton EB,Krueger LA et al. Humangenotoxicity: pesticide appli-cators and Phosphine. Science1989;246(35): 251-254.

5. Newton PE, Shroeder RE,Sullivan JB, Busey WM, BanasDA. Inhalation toxicity ofPhosphine in the rat: acute, sub-chronic and developmental.

Inhal Toxicol 1993; 5 (2): 223-239.

6. Klimmer OR. Contribution tothe s tudy of ac t ion ofphosph ine . Arch iv fu rToxikologie, 1969; 24 (23): 164-187.

7. Leuschner F. Evaluation of theacute toxicity of Phostoxin(Active ingredient: aluminumphosphide) to rainbow trout.Laboratory for Pharmacologyand Toxicology. Hamburg,German Federal Republic 1984.

8. Waseem T, Bhatti NB, Khan AH,Nasir N. Acute poisoning due towheat preservative aluminumphosphide. Pak J. Cardiol 1997;8(3-4): 43-48.

9. U.S. Environmental ProtectionAgency. 1994. File: AluminumPhosphide Integrated RiskI n f o r m a t i o n S y s t e m(IRIS) U S E P A ,

Washington, DC.10. Chugh SN. Metal Phosphide

poisoning. J Ind Acad Clin Med1999; 4(2):83-9.

11. Gautam CS, Pandhi P, SharmaPL. Beneficial effect of xanthinolnicotinate in experi- mentalaluminium phosphide poisoning.Indian Journal of Pharmacology1992, 24: 134-137.

12. Maris RW. Suicide. Lancet 2002;360:319-326.

13. Kim WJ, Singh T. Trends anddynamics of youth suicides indeveloping countries. Lancet2004; 363: 1090-1091.

14. Sultana K. Proportion of suicidaldeaths among autopsy. AnnAbbasi Shaheed Hosp Khi MedDent Coll 2002; 7:317-8.

15. Snowdon J. Suicide rates andmethods in different age groups:Australian data and perceptions.Int J Geriatr Psychiatry 1997; 12

References

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VOLUME 02 , ISSUE 04, Jan - Mar, 2007Esculapio

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IntroductionTobacco smoke is an air pollutant. Of all the airpollutants tobacco smoke is the one associated withthe highest prevalence of disease. The cigarettesmoke contains toxins, carcinogens and largeamount of free radicals, which cause injury to cellsand tissues. The various lesions in oral cavity,esophagus, lungs and heart are related to cigarettesmoking. The risk for development of these lesionsis related to the dose of exposure, frequentlyexpressed in terms of “pack years” e.g., (one pack

1

of 20 cigarettes smoked daily for 10 years equals 10pack years).Nucleolar Organiser Regions (NORs) are loops ofribosomal DNA located within nucleolus. The twoargyrophilic proteins which are associated withRNA transcription and processing are nucleolin andnucleophosmin . These proteins are argyrophilic

2

and are easily stainable by silver stains. The silverstained NORs can be identified as black dots presentthroughout the nucleolar area. AgNOR countref lects ce l l act iv i ty, prol i ferat ion andtransformation. Smoking enhances proliferativeactivity (higher AgNOR count) in buccal mucosal

3

cells of smokers which suggests a correlation4

between smoking and AgNOR count. The presentstudy was planned to find out such correlation in

buccal cytosmears of smokers.

Material and MethodsA total of 150 cases (75 smokers and 75 non-smokers) with normal buccal mucosa were selectedfor the study. Smokers were selected according topack years of smoking. One pack year is equal to 20cigarettes smoked per day per year. Subjects withhistory of greater than 15 pack years of smoking wereincluded in the study. Cases with history of cigar orhooka smoking, naswar intake and tobacco chewingwere excluded. Cytological smears were made in allcases from buccal mucosa. These were stained withthe silver stain technique used by Khalid et al. Silver

5

stained NORs are called AgNORs. AgNORs appearas discrete black dots in the nucleus against paleyellow background. The count was established in 100nuclei of cells and mean count was noted. Acorrelation was sought out between AgNOR countand pack years of smoking. Data analysis wasperformed by using student's t-test (Mean AgNORcount) and correlation between AgNOR count andpack years was assessed using SPSS analysis.

ResultsThe overall mean of the AgNORs count in 100 nucleiof the cells in smokers (3.28 ± 0.41) was significantlyhigher (p<0.01) than that of non-smokers (1.82 ±

M. Suleman Khan, Abdul Hakeem, M. Abdullah, M. Abdur-Rehman and M. Ikram Hashmi.

19

Association of Smoking (Pack Years) with AgNOR Count in Buccal

Mucosal Cytology

Original Article

Background: Tobacco smoking is a self-inflicted major health hazard worldwide. Cigarettesmoking influences proliferative activity in normal oral mucosa. This proliferative activity can bedetected by AgNOR count. This study was conducted in an attempt to find any associationbetween smoking (Pack Years) andAgNOR count.

Methods: Silver stained cytologic smears of buccal mucosa in 75 smokers and 75nonsmokers were viewed for AgNOR count and a comparison between pack years ofsmoking & increasedAgNOR number was assessed using SPSS analysis.Results: A positive correlation (r = .604) significant at the 0.01 level was found, between packyears and AgNOR count. This explains significant replicative activity under the influence ofcigarette smoking.

Conclusion: The effect of cigarette smoking in buccal mucosa is related to dose exposure(Pack Years of smoking) and a positive correlation exists between proliferative activity (AgNORCount) and smoking (Pack Years). An association between pack years of smoking and increasedAgNOR count explains cigarette smoke's effect on buccal mucosa.

Keywords: Buccal Mucosa, Cytology, Argyrophilic Nucleolar Organiser Region (AgNOR) countand pack years.

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was 2.4–4.16 in contrast to non-smokers 1.42–2.20(Table-1).Table-2 shows descriptive statistics; pack yearsmean is 21.2267 and standard deviation is 4.57837.Mean AgNOR count mean is 3.2632 and standarddeviation is 0.64863.Table-3 shows correlation between pack years andmean AgNOR count. This correlation is significantat the level 0.01.

Table-1: Mean AgNOR count in buccal mucosa ofsmokers and non-smokers.

Table-2: Descriptive Statistics.

Table-3: Correlation between pack years & meanAgNOR count.

** Correlation is significant at the 0.01 level (1-tailed).

Graph-1: Correlation of Pack years with MeanAgNOR count.

There is a positive correlation between AgNORcount and pack years of smoking (Table-2,3 andGraph-1)

DiscussionCancer is a serious worldwide problem in whichtreatment modalities are limited and become morelimited in advanced cancers of different organs .

6

Under these circumstances prevention and earlydetection of cancer carries prime importance.Prevention of cancer is thought to be a possibility ifawareness is emphasized through cost effectiveprogrammes, which are very important in third worldcountries like Pakistan. Prompt detection of cancersnot only influences prognosis through early treatmentplanning but also can be prevented altogether ifpreventive measures are taken. Such plans existregarding carcinoma of cervix. It is also possible toapply such measures in sites like oral cavity and upperrespiratory tract. There are many techniques forcancer diagnosis like Ki-67, PCNA, flow cytometry,molecular analysis etc. AgNOR technique has beenfound to be simple, reliable and cost effective.AgNOR technique has potential in distinguishingbetween dysplastic and non-dysplastic oral lesions

7

and for early diagnosis, prognosis and treatmentplanning in these cases. Its successful application hasbeen reported in cell cytology and tumour pathology

8 9

with convincing results.In our study, we applied this technique in buccalcytosmears obtained from smokers & nonsmokers. Asignificantly raised AgNOR count (p < 0.01) wasfound in smokers. This explains increased cellularproliferation under influence of cigarette smoking(pack years). On this basis, we concluded a strongpositive correlation (r=0.604 significant at 0.01 level)between AgNOR count and pack years of smoking.Such relationship was found by Wu et al who

10

observed similar findings. We did not find dysplasia inany case. This may be due to reason that other factorslike HPV (Human Papilloma Virus) may act inconcert with tobacco smoking to bring about

11

dysplastic changes. This idea needs to be exploredfurther.

Department of PathologySheikh Zayed Hospital Rahim Yar Khan

[email protected]/esculapio.html

Groups Range Mean ± SD p Value

Smokers 2.4-4.16 3.28 ± 0.41 <0.01

Nonsmokers 1.42-2.20 1.82 ± 0.28 <0.01

Mean Std. Deviation n

Pack Years 21.2267 4.57837 75

Mean AgNOR count 03.2632 0.64863 75

N 1 0.604**

Mean AgNOR count P. Correlation 0.604** 1

Sig. (1-tailed) 0.000 -

N 0.604** 1

Pack Years Pearson Correlation 1 0.604**

Sig. (1-tailed) - 0.000

Pack Years AgNOR

1. Kumar V, Cotran RS, Robbins SL.Tobacco Smoke. Robbins BasicIn:Pathology 7 ed. Elsevier New

th

Delhi, India. 2005; 275.2. Derenzi M. The AgNORs.

Micron. 2000;31 (2):117-203 Sampaio Hde C, Loyola AM,.

Gomez RS, Mesquita RA.AgNOR count in exfoliativecytology of normal buccal

mucosa: effect of smoking. ActaCytol 1999; 43: 117-20.

4. Cancado RP, Yurgel LS, Filho MS.Evaluation of the nucleolarorganizer region associated

References

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proteins in exfoliative cytologyof normal buccal mucosa.Effect of smoking. Oral Oncol2001; 37 (5): 446-54.

5. Khalid AW, Khan SA, ChaudhryNA, Tayyib M, Tehseen S. Silverstaining nucleolar organizerregion (AgNOR) count inbenign and malignant effusions.Pak Postgrad Med J 1996; 7(3-4): 54-56.

6 . Lus is E, Gutmann DH.Meningioma: an update. CurrOpin Neurol 2004; 17(6): 687-

92.7. Pandit S, Aithal D. A qualitative

and quantitative estimation ofAgNORs in dysplastic and nondysplastic leukoplakias. Indian JDent Res 2002; 13 (1): 27-30.

8. Akhtar GN, Chaudhry NA,Tayyab M, Khan SA. AgNORstaining in malignant and benigneffusions. Pak J Med Sci 2004; 20(1):29-2.

9. Ahsan S, Khan SA, Chaudrhy NA.Arg yro- ph i l i c nuc leo l a rorganizer regions (AgNORs) in

nodu l a r hyper p l a s i a andcarcinoma of the prostate. Pak JPathol 1992; 3(2):81-83.

10. Wu PA, Loh CH, Hsieh LL, LiuTY, Chen CJ, L iou SH.Clastogenic effect of cigarettesmoking but not areca quidchewing as measured bymicronuclei in exfoliated buccalmucosal cells. Mutat Res 2004;562 (1-2):27-38.

11. Kumar V, Cotran RS, Robbins SL.Leukoplakia. In: Robbins BasicPathology 7 Ed. Elsevier New

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Picture Quiz

Answer of picture quiz on page 24

21

This lady presented with acute shortness of breath for the last five days; her neck swelling had been there fortwenty five years and previously labeled euthyroid. What is the likely cause of dyspnea?


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IntroductionSigmoid colon has been utilized by the urologists forurinary diversion since ages. Ureterosigmoidostomywas first carried out by Smith in 1878 . Although the

1

procedure is simple to perform yet it is almost2

obsolete in the developed world due to associatedcomplications. Since the nature has not designedbowel for the storage of urine, therefore the misuseof this organ for urine storage is associated withvarious complications due to permeability of theendothelium in contrast to urothelium. Different

3

methods of urinary diversion have their ownadvantages and disadvantages. Although most ofthe modern surgical procedures are associated withlesser complications, they are time consuming andcarry significant morbidity. Moreover incidence ofcomplications involving stoma is quite high.Ureterosigmoidostomy is a well accepted alternativeto continent urinary diversion and providessatisfactory quality of life with less morbidity .

7

Common complications seen after uretero-sigmoidostomy are renal failure , metabolic

8

disorders , colon cancer, benign polyps , urinary9 10

tract infections, nephrolithiasis and anastomotic2

strictures. Conventional mucosa to mucosaanastomosis is time consuming and is associatedwith high incidence of stricture formation andreflux . We have used a new single stitch technique

12

for anastomosis which is conventionally used forureteric reimplantation in the bladder.

Material and MethodsRecord of patients having ureterosigmoidostomybetween Jan 1997 and Dec 2006 was reviewed.Parameters of study were age, disease entity,postoperative complications (chest infection, woundinfection, metabolic complications, fever, urinarytract infections, hydronephrosis and renalimpairment), duration of the procedure, duration ofmaintenance of drains and rectal tube, and hospitalstay was recorded. Patients with history of intestinalresection, irradiation, renal failure, diverticulitis,regional enteritis, ulcerative colitis and incompetentanal sphincter were excluded. During thepreoperative workup, the patients had BUN, serumcreatinine, electrolytes, abdominal ultrasound andintravenous pyelography.

Figure -I: Incision over taenia coli.

22

Ureterocolic Anastomosis By Modified Lich Method

Abdul Mannan, Muhammad Safdar Khan, Shehzad Anwar, Muhammad Farooq and

Riaz A. Tasneem

Original Article

Objective: This was a retrospective study to evaluate the results of a modified techniquefor ureterocolic anastomosis.Patients and Methods: Record of patients having ureterosigmoidostomy between Jan1997 and Dec 2006 were reviewed. Parameters studied were age, disease entity,postoperative complications, duration of the procedure, and hospital stay.Results: There were 23 patients with mean age of 42.3 years. Out of these, carcinomaurinary bladder, ectopia vesicae and vesico vaginal fistula were seen in 14, 8 and 1patients respectively. Mean duration of the procedure was 20.8 minutes, while meanhospital stay was 8.4 days and mean duration of maintenance of rectal tube was 7.13days. The complications noted were pneumonia (4.35%), wound infection (8.7%),hypokalemia (43.48%), recurrent fever (17.4%) and bilateral hydronephrosis (8.7%).Conclusion: We have concluded that the procedure is simple, quick and associated withminimal morbidity.Key words: Ureterocolic, ureterosigmoidostomy, ureteric reimplantation.

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Patients were operated through midline abdominalincision. Cystectomy if required was performedfirst. Retroperitoneal space was opened and uretersidentified at or below common iliac arteries. Theoverlying peritoneum was incised, ureters mobilizedup to vesicoureteric junction and transected. Bothureters were spatulated and implanted in the sigmoidcolon just above the rectosigmoid junction overtaenia coli by single stitch modified Lich method.Muscles of taenia were closed making a tunnel toprevent reflux. These operative steps are shown infigure 1 to 3. If needed the anastomoses weresecured by stents. Peri anastomosis drain was placed.Rectum was drained with 28 Fr catheter. Rectalcatheter and stents were removed after 7 days ifthere was no contraindication. Patients werefollowed for one year at 1, 3, 6 and 12 monthsinterval.

Figure -2: Spatulated ends of both ureters.

Figure-3: Closure of taenia coli muscles overimplanted ureters.

ResultsThere were 23 patients who under wentureterosigmoidostomy. Mean age of the patientswas 42.3 years. Different pathologies for whichureterosigmoi- dostomy was done are summarized

in table 1.

Table-1: Clinical conditions requiring uretero-sigmoidostomy.

The complications noted in these patients were;pneumonia in one (4.35%), wound infection in two(8.7%), hypokalemia in ten (43.48%), recurrent feverin four (17.4%) and bilateral hydronephrosis in two(8.7%) cases.Mean duration of different parameters is summarizedin table II.

Table-2: Duration of different parameters.

DiscussionUreterosigmoidostomy is almost obsolete in modernworld, but it is still a preferred option in many patientsin the developing countries like Pakistan. Economicconstraints are a major factor in our country. Patientsare unable to afford the stoma appliances.Secondly, most of the patients are uneducated andfind it difficult to take care of stoma and itscomplications. In such patients uretero-sigmoidostomy is a suitable alternative. Moreover,many patients opt for this type of urinary diversion asthey feel that it is more natural and it does not hampertheir prayers.Long term follow up of patients undergoingureterosigmoidostomy has revealed that somepatients may develop carcinoma of colon. Incidence

of neoplasia has been reported as high as 40% .10,13

Out of these, 50% are adenocarcinomas andremaining are benign polyps. Mean duration of

14

development of neoplasia is 20 years14,15.

We have not seen this complication as the follow up inour patients was of short duration. Patients withcarcinoma of urinary bladder undergoing urinarydiversion are elderly and many of them will not livelong enough to develop this complication.Anastomotic stenosis may lead to hydronephrosisdue to back pressure. The reported incidence

Clinical Condition Number of Cases

Carcinoma urinary bladder 14

Ectopia vesicae 08

Vesico vaginal fistula 01

Total 23

Parameter Mean Duration

Procedure 20.8 minutes

Drainage tube 2.5 days

Rectal tube 7.13 days

Hospital stay 8.4 days

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of anastomotic stenosis is 8-14%. In our11

patients 8% developed bilateral hydronephrosis.Hypokalemia is an important metaboliccomplication seen in ureterosigmoidostomy. It

12

can be easily managed with potassiumsupplements. We have seen hypokalemia in43.5% of cases. Recurrent fever associated withUTI was seen in four (17.4%) patients whoresponded to long term antibiotics. Death dueto renal failure has been reported in 10% ofcases. We have not seen this complication in our

8

patients.We have concluded that the procedure is simple,quick and associated with minimal morbidity.The complications seen in this series weremanaged easily. Mean duration of developingneoplasia is long, therefore it can be performedsafely in elderly with carcinoma bladder.

Department of UrologySIMS/Services Hospital, Lahore.

[email protected]

1. Winter CC, Goodwin WE.Results of sigmoidocystoplasty. JUrol 1958; 80: 467-74.

2. Yossepowitch O, Baniel J.Uretero sigmoidostomy andobstructive uropathy. NatureClinical Practice Urology 2005; 2:511-15

3. Gerharz EW, Turner WH, KableT, Woodhouse CRJ. Metabolicand functional consequences ofurinary reconstruction withbowel. BJU 2003; 91: 143-9.

4. Spirnak JP, Caldamone AA.Ureterosigmoidostomy. UrolClin North Am 1986;2: 285–294.

5. Wear JB Jr, Barquin OP.Ureterosigmoidostomy. Long-term results. Urology 1973;3:192–200.

6. Zabbo A, Kay R. Uretero-sigmoidostomy and bladderexstrophy: a long-term followup.

J Urol 1986;2: 396–398.7. Bastian PJ, Alberz P, Hanitzsch

H, Fabrizi G, Casadei R,Haferkamp A et al. Healthrelated quality-of-life followingm o d i f i e d u r e t e r o -sigmoidostomy (Mainz Pouch II)as continent urinary diversion.Eur Urol 2004;5: 591–97

8. Mesrobian HG, Kelalis PP,Kramer SA. Long-term followup of 103 patients with bladdere x s t r o p h y . J U r o l1988;4:719–722.

9. Stampfer DS, Mcdougal WS,McGovern FJ. The use of inbowel urology. Metabolic andnutritional complications. UrolC l i n N o r t h A m1997;24:715–722.

10. Malone MJ, Izes JK, Hurley LJ.Carcinogenesis. The fate of

intestinal segments used inurinary reconstruction. Urol ClinNorth Am 1997;4:723–728.

11. McDougal WS. Use of intestinalsegments and urinary diversion.Campbell's Urology. 8 ed. WB

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Saunders, Philadelphia. 2002:3763

12. Spirnak JP Caldamone AA;Ureterosigmoidostomy.UrolClin North Am 1986;13:285.

13. Strachan JR, Woodhouse CRJ.Malignancy following uretero-sigmoidostomy in patients withexstrophy. Br J Surg 1991; 10:1216–1218.

14. Stewart M. Neoplasia andureterosigmoidostomy: a colonoscopy survey. Br J Surg 1982; 7:414–416.

15. Husmann DA, Spence HM.Current status of tumor of the

References

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Answer

Picture Quiz

This old lady was admitted to Mayo Hospital, Lahore with the diagnosis of acute pulmonary edema. Her goiterwas visible for the last 25 years and had previously been worked up and labeled euthyroid. During her stay in thehospital she had atrial fibrillation. She was subjected to thyroid function tests and thyroid scan and was found tohave thyrotoxicosis and toxic nodular goiter.The case highlights the need for repeat workup, especially the thyroid scan which is occasionally ignored in thepresence of previous reports.


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IntroductionHyperprolactinemia is known to cause infertility inapproximately 11% of oligospermic males. The

1, 2

pulsatile secretion of the gonadotropin releasingh o r m o n e ( G n R H ) i s i n h i b i t e d b yhyperprolactinemia. This produces secondaryhypogonadism by decreasing the pulsatility offollicle stimulating hormone (FSH), luteinizinghormone (LH) and testosterone. It then leads tospermatogenic arrest, impaired sperm motility andsperm quality.

1

Prolactin also plays a direct role in spermatogenesisand steroidogenesis as prolactin receptors have beendetected in Sertoli cells and Leydig cells in testes.

2,3

This produces primary hypogonadism (lowtestosterone and high FSH levels). It is seen thatoligospermic patients with normal serum levels ofgonadotropins show relatively higher serum levelsof prolactin proving a role of prolactin ing ametogenes i s tha t i s independent ofgonadotropins.

3,4

The semen analysis in such patients may even showazoospermia. The aim of our study was to

5,6

determine the frequency of hypogonadism in ourmale azoospermic/oligospermic patients who weresuffering from hyperprolactinemia.

Material and MethodsThis study was carried out in the Department ofPhysiology, Federal Post Graduate Medical Institute,

Sheikh Zayed Hospital Lahore, in collaboration withinfertility clinics in Multan. A total number of 120subjects were included in this study (twentyapparently healthy males and hundred infertile maleshaving either oligospermia or azoospermia). Amonginfertile males we ruled out any history of mumps,testicular trauma, excessive genital irradiation, intakeof cytotoxic drugs and bilateral cryptorchidism.

7

After taking a formal consent of the subject, generalphysical examination was carried out. Semen analysiswas done for sperm count according to WHOcriteria. Serum prolactin, FSH and testosterone

8

levels were estimated by radioimmunoassay (RIA).Arithmetic means and standard deviation (SD) ofeach variable in the control and test group wascalculated. Student's “t” test was applied to comparethe results of the control and test group. Differenceof results was considered as significant for P<0.05and highly significant when P value was <0.01. It wasdeclared non-significant for P>0.05. Linearregression analysis and correlation coefficients wereused to determine correlation between sperm countand serum prolactin levels and also between spermcount and serum FSH level among thehyperprolactinemic group having primary hypo-gonadism.

ResultsWe found twenty five cases of hyperprolactinemiawith significantly (more than twice normal) high

Shahroona Masud, Fatima Mehboob, Muhammad Usman Bappi

25

Severe Hyperprolactinemia Directly Depresses theGonadal Activity Causing Infertility

Original Article

Background: To quantify the degree of correlation between serum hormones (prolactin, FSHand testosterone) and sperm count in primary hypogonadism due to hyperprolactinemia inoligo/azoospermic infertile patients.

Methods: Serum prolactin, FSH and testosterone levels of 100 male infertile oligospermic/azoospermic patients were assayed by radioimmunoassay (RIA) and their data was analyzed forsignificant correlation with the same parameters of 20 control cases.

Results: 25 out of 100 infertile patients had hyperprolactinemia out of which 13 hadhypogonadism. Out of the 13 hyperprolactinemic hypogonadism cases, 9 had azoospermia. Thevalues of serum prolactin and FSH were significantly raised (p<0.001). The sperm count in thegroup was strongly correlated to serum FSH (r = 0.67 p<0.05).

Conclusion: Severe degree of hyperprolactinemia can cause infertility by inducingazoospermia directly. The levels of serum FSH rise in an attempt to reverse these changes.

Keywords: Hyperprolactinemia, primary hypogonadism, oligo/azoospermia.

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gonadotropins and testosterone levels were normal.The rest of the patients (13/25) had hyper-gonadotropic hypogonadism (primary hypo-gonadism). The mean SD sperm count in these 13+patients was 4.4 8.04 millions/ml (9 cases of+azoospermia and 4 of oligospermia). This wassignificantly low in comparison to the control groupwhose mean SD sperm count was 120.05 42.41+ +millions/ml (p<0.001).The mean serum prolactin level of these patientswas 383.232 146.28 µIU/ml compared to 115.65++ 24.02 µIU/ml of the control group. This value ismore than twice the normal prolactin value and isstatistically significant (p<0.001).The serum FSH level was 26.40 11.43 mIU/ml+(mean SD) in the test group whereas the levels in+the control group were 3.71 1.25 mIU/ml+(p<0.001). Serum testosterone levels weresignificantly lower (4.10 2.23 ng/dl) in test group+as compared to the control group where it was14.02+2.48 ng/dl (mean SD) and p<0.001.+(Table 1 & Fig.1)There was a strong correlation (r=0.67, p<0.05)between serum FSH level and the sperm count. Thesperm count was not significantly correlated toeither serum prolactin levels or serum testosteronelevels. (Table 2 & Fig.2)

DiscussionHyperprolactinemia is usually caused by hyper-secretion from lactotrophes in anterior pituitary.

9

Mild to moderate hyperprolactinemia may also be aresult of stress, drug intake or renal disease. The

10

usual clinical presentation of hyperprolactinemia in

infertility is a picture of secondary hypogonadism. It1

may sometimes present as primary hypogonadism. Insuch instances the high levels of FSH are a result offeed back stimulation of anterior pituitary bydefective and deficient spermatogenesis. The levels

11

of serum FSH elevate to attempt betterspermatogenesis in hyperprolactinemia. This hasbeen shown by Yazawa T et al who have

12

experimentally demonstrated that prolactin inducesapoptosis in penultimate spermatogonial stage of thetestes in Japanese newt and then addition of FSH tothese tissue cultures reverses these changes. Theinverse relationship of levels of FSH and prolactin isalso evident by the work of Sawhney et al who

13

discovered that serum prolactin levels were highest inNovember whereas FSH levels were highest in Marchamong the scientists residing in Antarctica. Thesefindings were correlated to better sperm count inMarch as compared to the count in November. Thesefacts are consolidated by the research of Yazawa T etal who conclude that low temperature causes

14

elevation of prolactin concentration in the newtblood, that induces cell death of spermatogonia justbefore meiosis. FSH is the main regulator ofspermatogenesis. As long as the hypersecretion of

15

FSH can induce spermatogenesis, azoospermia isreversible.

12

From above discussion we can suggest the role ofFSH therapy in hyperprolactinemia. This might provebeneficial as an adjuvant of bromocriptine orcabergoline treatment. In the case of primaryhypogonadism the structure of testes is normal andfunction is deranged by hyperprolactinemia.

Control group n=20 Test group n=13

Sperm count millions/ml 120.05 ± 42.41 4.40 ± 8.05

Serum FSH mIU /ml 3.71 ± 1.25 26.40 ± 11.40

Serum Testosterone ng/dl 14.02 ± 2.48 4.10 ± 2.23

Variable

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Table-1: Comparison of sperm count, serum FSH, serum testosterone and serum prolactin levels in the control andthe test groups.

p Value

Serum Prolactin µIU/ml 115.65 ± 24.02 4.10 ± 2.23

<0.001*

<0.001*

<0.001*

<0.001*

* Non Significant ==0.05 Significant = <0.05 Highly Significant <0.001

Table-2: Correlation of sperm count with serum FSH, serum testosterone and serum prolactin levels.

Control group n=20 Hyperprolactinemia with primary hypogonadism n=13

Sperm count vs serum FSH 0.132 0.67

Sperm count vs serum testosterone 0.291 0.224

Sperm count vs serum PRL 0.021 0.05

Variable

<0.05 *

>0.05

>0.05

R value P valueP value R value

>0.05

>0.05

>0.05

* Significant <0.05 Non Significant >0.05


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1= Control group 2=Test group

ConclusionHyperprolactinemia may cause azoospermia/oligospermia and infertility by inducing primaryhypogonadism in males. There is a potential role ofFSH therapy in such cases.

Sheikh Zayed Medical College,Rahim Yar Khan.

[email protected]/esculapio.html

Fig-1: Comparison of sperm count, serum FSH, serum testosterone andserum prolactin levels in the control and the test group.

Fig-2: Correlation between Sperm Count and Serum FSH in hyperprolactinemiaassociated with primary hypogonadism.

1 De Rosa M, Zarrilli S, Di SarnoA. Hyperprolactinemia in men:Clinical and Biochemicalfeatures and response totreatment. Endocrine 2003,Feb-Mar; 20(1-2): 75-82.

2. Vandekerckhove P, Lilford R,V a i l A , H u g h e s E .Bromocriptine for idiopathico l i g o / a s t h e n o s p e r m i a .Chochrane Database Syst Rev2000;(2): CD 000152.

3. Arowojolu AO, Akinloye O,Shittu OB. Serum and seminalplasma prolactin levels in maleattenders of an infertility clinicin Ibadan. J Obstet andGynaecol 2004 April; 24(3):306-9.

4. Colao A, Vitale G, CappabiancaP, Briganti F, Cocarelli A, DeRosa M et al. Outcome ofcabergoline treatment in menwith prolactinoma: effects of 24months treatment on prolactinlevels, tumor mass, recovery ofpituitary function and semenanalysis. J Clin Endocrinol

Metab 2004 April; 89(4):1704-11.5. Yazawa T, Fu j imo to K ,

YamamotoT, Abe SI. Caspaseactivity in newt spermatogonialapoptosis induced by prolactinand cycloheximide. Mol ReprodDev 2001 June; 54 (2):209-14.

6. Yan W, Huang JX, Lax AS,Pelliniemi L, Salminen E,Poutanen M et al . Overexpression of BCL-W in thetestis disrupts spermatogenesis.Revelation of a role of BCL-W inmale germ cell cycle control. MolEndocrinol 2003;17:1868-1879.

7. Lipshultz LI, Howard SS (eds).Scheme of evaluation of theinfertile male. New York,Churchill Livingstone. 1983; 535-08.

8. World Health Organization(WHO) Laboratory Manual forthe examination of humansemen and cervical mucusi n t e r a c t i o n . C a m b r i d g eUniversity Press: 1992: 1-20.

9. Schuppe HC, Neuman NJ,Schock SG, Hoppner W,

Feldkamp J. Secondary infertilityas early symptom in a m a nwi th mu l t i p l e endoc r ineneoplasia type I. Human Reprod1999 Jan; 14(1):25-40.

10. Leonard MP, Nickel CJ, MoralesA. Hyper prolactin- emia andimpotence. Why, when and howto investigate. The Journal ofUrology 1998; 142:992-4.

11. Abalovich M, Levalle O, HermesR, Scaglia H, Aronda C.Hypothalamo pituitary testicularaxis and seminal parameters inhyperthyroid males. Thyroid1999 Sep; 9(9):857-63.

12. Yazawa T, Yamanoto T, Abe S.Prolactin induces apoptosis inthe penultimate spermatogonialstage of the testes in Japanese redb e l l i e d n e w t ( C y n o p sPyrrhogaster). Endocrinology2000 June; 141(6):2027-32.

13. Sawhney RC, Malhotra AS, PalK, Kumar R, Bajay AC. Pituitarygonadal hormones duringp r o l o n g e d r e s i d e n c y i nAntarctica. Int J Biometeorol

References

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1 2

0

100

200

300

400

Sperm count million/ml

Serum FSH mIU /ml

Serum Testosterone ng/dl

Serum PRL µIU/ml


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1998 Aug; 42 (1):51-4.14. Yazawa T, Yamamoto T,

Kikuyama S, Abe SI. Elevationo f p l a s m a p r o l a c t i nc o n c e n t r a t i o n s b y l o wtemperature is the cause of

spermatogonial cell death in thenewt, Cynops Pyrrhogaster. GenComp Endocrinol 1990 Feb;113(2): 302-11.

15. Merino G, Martinez Chequer JC,Chan RG, Cuevas ML, Carranza

Lira S. Relationship betweenhormone levels and testicularbiopsies of azoospermic men.Arch Androl 1999 May-Jun;42(3): 145-9.

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If you're constantly reaching for antacids tocontrol your heartburn, you may have a moreserious problem called reflux disease. Some 25million Americans have it and now they have anew option to treat it. Using a newly-approveddevice for the first time in the U.S., doctors haveperformed surgery to fix reflux problemswithout making a single incision. Developingthe technology took decades, but the operationonly took an hour. When it was over, doctors atOhio State University Medical Center may haveushered in a new era of surgery when it comes tofixing reflux problems. Experts at OSUMC saythey're the first in the U.S. to use recentlyapproved remote control instruments to repairthe valve between the esophagus and stomachwithout using a scalpel. "This device eliminatesthe need for any incisions whatsoever. Theentire reconstruction, or rebuilding of the valve,can be done from the inside all with aninstrument through the mouth," says ScottMelvin, MD, at Ohio State University MedicalCenter. By going entirely through a patient'smouth, doctors don't have to cut into the body.That can dramatically cut down on recovery

time and the risk of complications. GertrudeGreen was one of the first patients in the countryto try the procedure, after 20 years of tryingnearly everything else to control her reflux."Over the last 20 years I've taken over the countermedications, prescriptions and seen more thanone doctor," says Green. Gertrude has knownfor years that surgery was an option, but in thepast, it was more invasive and would require moretime to recover. Now this new technique canchange that and possibly more. "Reflux can givepeople heartburn, but it also has been associatedwith an increased risk of esophageal cancer.Right now in North America, esophageal cancerhas increased dramatically over the last decade -doubling even tripling the number of cases," saysMelvin. It's too early to tell if this surgery willimpact the number of cancer cases, but it's clearto patients like Gertrude that it's alreadyaddressed the burning issue of reflux. Doctorssay getting heartburn once in a while is normal. Ifyou get it 3 or 4 times a week, you should get itchecked. Right now, through-the-mouth surgeryis only available at certain hospitals. It is expectedto become more common in the coming years.

Endoscopic Management of GERD

Medical News


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BackgroundMalignant Melanoma is the leading cause of deathdue to skin diseases. Acral Lentiginous Melanomamay be difficult to diagnose because pigmentedlesions of hands, feet and nails occur in darkcoloured persons. Here we describe a patient whopresented with features of subcutaneous nodules,shortness of breath and was finally diagnosed as acase of malignant melanoma on excisional biopsy.

Case PresentationA 67 years old female presented in emergencydepartment with 6 years history of smallsubcutaneous nodules all over the body and twomonths history of shortness of breath, anorexia andweight loss. At presentation she had orthopnoea andparoxysmal nocturnal dyspnoea. Around one and ahalf month before the present illness, she haddyspnoea, anorexia and pedal edema. She wasinvestigated at that time. Her echocardiographyshowed pericardial effusion. Pericardiocentesis wasdone, diagnosis of tuberculosis was made and antituberculosis therapy was started.On her present visit, on examination, she was an oldwoman of average built with multiple swellings incervical region, hands, arms and feet and was welloriented in time, place and person. Her pulse was82/min regular; blood pressure supine was110/60mmHg. Her respiratory rate was 25/min.There was bilateral pitting edema; pallor was also

there.On examination of the cardiovascular system, therewas tachycardia, raised JVP and diffuse apicalimpulse. Auscultation of the chest revealed bibasilarinspiratory crackles. She had tender hepatomegalyand spleen was also enlarged. There was moderateascites. Her oxygen saturation was 89%. She wasstarted on supplemental oxygen, diuretics and antituberculous therapy. X-ray chest showed right upperlobe consolidation. Electrocardiogram showed sinustachycardia. Echocardiography showed globalhypokinesia, mild mitral regurgitation with disturbedsystolic and diastolic function.Complete blood picture showed a Hb of 8.5g/dl andESR 125. Her liver function tests were mildlyderanged. A provisional diagnosis of Lymphoma wasmade. Excision biopsy of subcutaneous swelling ofthe cervical area (lymph node) was done. The reportwas strongly suggestive of the diagnosis of malignantmelanoma.

ConclusionAs the diagnosis of Malignant Melanoma was notsuspected in our case, first diagnosis was Tuberculosisand ATT was started then suspicion of Lymphomawas made but at the end Malignant Melanoma was aproven diagnosis.Acral Lentiginous Melanoma is more in darklypigmented persons and in races other than whites.Dermoscopy to evaluate the pigmented lesion and

Syed Mohsin Ali Gilani and Aziz-ur-Rehman

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A Rare Presentation of Malignant Melanoma

Case Report

Background: Malignant Melanoma is slightly commoner in females than males butstill is not a common disease. A proportion of Melanomas (around 30%) appear todevelop in pre-existing moles while the remainder develops on previously normal skin.

Case Presentation: Patient presented with history of multiple swellings all over thebody, generalized body itching and symptoms of heart failure. We describe the clinicalpresentation, investigations and outcome of this case and review the literature on theinvolvement of different organs and sites of body by melanoma.

Conclusion: Malignant Melanoma is rare in Pakistan, however it can be suspected asa cause of multiple nodes (swellings) with color changes in the body along withinvolvement of skin, mouth, anogenital region, esophagus and the meninges. Increasingrecognition of the entity and the use of excisional biopsy may help us detect more cases ofthe disease.Keywords: malignant melanoma, skin cancers, moles

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full thickness excision biopsy of the effected or thesuspected area are helpful in early diagnosis andtreatment. Treatment of Melanoma consists ofexcision after histological diagnosis. The area isusually excised with margins dictated by thickness oftumor. Alpha interferon and vaccine therapy mayreduce reoccurrence in patient with high risk.

Facts1. The greatest problem of detecting melanoma at

an early (surgically curable) stage appears to bein patients over the age of 50 who have nodularmelanoma, particularly in the head and neck.

2. Acral Lentiginous Melanoma occurs on thepalms, soles and subungual sites, and has a poorprognosis.

3. Micrometastatic disease can be present in anysentinel node regardless of its location, and for

the SLNB technique to be accurate, all truesentinel nodes must be biopsied in every patient.

4. Despite the difficulty in clinical diagnosis ofcardiac melanoma, early detection has importanttherapeutic and prognostic implications.

5. Abnormal electrocardiographic and echocardiographic findings are recorded at the timeof diagnosis of the disease in a significantpercentage of patients with malignantmelanoma.

Department of MedicineSIMS/Services Hospital, Lahore

[email protected]/esculapio.html.

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AbstractWe are presenting few ethical situations extractedfrom the American Medical Association guidelines.These are for the benefit of the students and thetrainees. Most of the doctors are unaware of thesefacts. The AMA has a code of ethics. The attitudes,ethics and other orders are for good clinical practicesand ultimately for the benefit of doctors and thepatients.

1- Ethical ScenarioShould physicians use surgical "placebo" controls(subjects undergo surgical procedures that have theappearance of therapeutic intervention but duringwhich the essential therapeutic maneuver is omitted)when assessing the efficacy of a surgicalintervention?

Surgical "Placebo" Controls:The use of placebo control is not justified whentesting a surgical technique that represents a minorimprovement of an existing surgical procedure.When a new surgical procedure is developed withthe prospect of treating a condition for which noknown surgical therapy exists, using surgical"placebo" controls may be justified but must beevaluated in light of whether the current standard ofcare includes a non-surgical treatment arid thebenefits, risks, and side effects of that treatment.During the informed consent process, carefulexplanation of the risks of the operation must bedisclosed. Additional safeguards may include using aneutral third party to provide information andobtain consent.

2- Ethical ScenarioWhat are a physician's reporting responsibilities if apatient's medical problems impair his or her abilityto drive safely?

Impaired Drivers and Their Physicians:Physicians should use their best judgment whendetermining when to report impairments that couldlimit a patient's ability to drive. In situations wherethere is a strong threat to patient and public safety,and where the physician's advice to discontinuedriving is ignored, it is desirable and ethical to notify

the State's Department of Motor Vehicles.

3- Ethical ScenarioResults of an experiment that does not meetcontemporary standards of human subjectsprotection is submitted for publication in a medicaljournal. What should the editors do?

Information from Unethical Experiments:If data from unethical experiments can be replaced byother sources of sound data, then the results shouldnot be published. If data from unethical experimentsare scientifically valid and are the only data availableand necessary in order to save lives, then publicationof such information may be appropriate.If the results are published, the editors should includea disclaimer that clearly describes the unethical natureof the experiment; clearly states that the publicationof the data is needed to save lives; pays respect to thevictims; if the results are published, the editors shouldinclude a disclaimer that: avoids trivializing traumasuffered by the participants; acknowledges theunacceptable nature of the experiments; andendorses adoption of higher ethical standards forhuman subjects' protection.

4- Ethical ScenarioA student is uncomfortable about medical studentsperforming procedures on each other for educationalpurposes. How should the physician-educatorrespond to the student's concerns?

Medical Students Performing Procedures onFellow Students:Instructors should explain to students how theprocedures will be performed, making certain thatstudents are not placed in situations that violate theirprivacy or sense of propriety. Students should begiven the choice of whether to participate prior toentering the classroom.There should be no requirement that the studentsprovide a reason for their unwillingness to participate.Students should not be penalized for refusal toparticipate.

5- Ethical ScenarioWhen residents or medical students are part of a

Muhammad Nasar Sayeed Khan

31

Shaping Professionalism: Medical Ethics

Guidelines

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taken into account by the attending physician whenbilling for services?

Billing for House staff and Student Services:When a physician assumes responsibility for theservices rendered to a patient by a resident orstudent, the physician can bill for services whichwere performed under the supervisory physician'sdirect personal observation, direction, andsupervision.

6- Ethical ScenarioShould consent be obtained before filming patientsfor commercial programs that will be publiclybroadcast?

Filming Patients in Health Care Settings:Filming patients without consent for commercialpurposes is a violation of the patient's privacy.Consent is therefore ethically required for bothinitial filming and subsequent broadcast.

7- Ethical ScenarioA contract research organization is recruitingphysicians to participate in clinical trials that involvepatients to whom they provide care. What ethicalissues do physicians have to consider?

Managing Conflicts of Interest in the Conductof Clinical Trials:Physicians should only conduct trials that arescientifically sound and that have been approved byan appropriate IRB.The informed consent process must differentiatethe physician's roles as clinician and investigator, andthis is best achieved when someone other than thetreating physician obtains consent.

8- Ethical ScenarioIs it ethically permissible to accept gifts frompharmaceutical representatives?

Gifts to Physicians from Industry:Any gift accepted by a physician should primarilyentail a benefit to patients and should not be ofsubstantial value.Individual gifts of minimal value are permissible aslong as they relate to the physician's work. .

9- Ethical ScenarioIs it ethically permissible for physicians to sell non-health-related goods from their offices?

Sale of Non-Health-Related Goods fromPhysicians' Offices:Physicians may sell non-health-related goods fromtheir offices for the benefit of communityorganizations if: the goods are low cost; the physicianearns no profit; such sales are not a regular part of thephysician's business. Patients are not pressured intomaking purchases.

10- Ethical ScenarioIs it appropriate to use terms such as “student doctor"to identify medical students who are caring forpatients?

Medical Student Involvement in Patient Care:Patients should be informed of the training status ofindividuals involved in their care. Terms that may beconfusing when describing the training status ofstudents should not be used. Physicians should relatethe benefits of student participation to patients andshould ensure that they are willing to permit suchparticipation.

11- Ethical ScenarioA medical error has occurred in the course of caringfor a patient. Should the treating physician disclosethis information to the patient?

Patient Information:When a patient suffers significant medicalcomplications that may have resulted from aphysician's error, the physician is ethically required toinform the patient of all the facts necessary to ensureunderstanding of what has occurred.

12- Ethical ScenarioIn the context of managed care, should physiciansdisclose financial incentives that raise potentialconflicts of interest to their patients?

Referral of Patients: Disclosure of Limitations:Physicians must assure disclosure of any financialinducements that may tend to limit the diagnostic andtherapeutic alternatives that are offered to patients.Physicians may satisfy this obligation by assuring thatthe managed care plan makes adequate disclosure topatients enrolled in the plan.

13- Ethical ScenarioShould medical trainees perform procedures such asendotracheal intubation on the newly deceased

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Performing Procedures on the NewlyDeceased Patient:In the absence of previously expressed preferences,physicians should request permission from thefamily before performing procedures. Without suchpermission, physicians should not performprocedures for training purposes on the newlydeceased patient.

14- Ethical ScenarioShould physicians treat themselves or members oftheir own families?

Self-Treatment or Treatment of ImmediateFamily Members:Professional objectivity may be compromised whenan immediate family member of the physician is thepatient. In emergency or isolated settings, physicianscan treat themselves or family members untilanother physician becomes available.

15- Ethical ScenarioShould physicians use strikes as a tactic in collectivebargaining?

Collective Action and Patient Advocacy:Collective action should not be conducted in amanner that jeopardizes the health and interests ofpatients. Physicians should refrain from the use ofthe strike as a bargaining tactic. Alternative tacticsavailable include informational campaigns and non-disruptive public demonstrations.

16- Ethical ScenarioA resident has concerns that an attending physician'sorder is reflective of poor clinical judgment. Howshould this situation be handled?

Disputes between Medical Supervisors andTrainees:Trainee should refuse to participate in patient careordered by their supervisors in those rare cases inwhich they believe the orders reflect serious errors inclinical or ethical judgment, or physician impairmentthat could result in a threat of imminent harm to thepatient or to others. Trainees may withdraw from thecare ordered by the supervisor, provided withdrawaldoes not itself threaten the patient's immediatewelfare. The trainee should communicate his or herconcerns to the physician issuing the orders and, ifnecessary, to the appropriate persons for mediatingsuch disputes.Third-party mediators of such disputes may includethe chief of staff of the involved service, the chiefresident, a designated member of the institutionalgrievance committee, or, in large institutions, aninstitutional ombudsperson largely outside of thehospital staff hierarchy. . Retaliatory or punitiveactions against trainees who raise complaints areunethical and are a legitimate cause for filing agrievance with the appropriate institutionalcommittee.

Strengthening ProfessionalismReaffirm core values and principles in medicinethrough oath taking.Increase awareness and understanding of medicalcodes.Promote mechanisms to encourage compliancewith ethical guidelines.Foster lifelong mentoring and the importance ofrole models.

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When submitting a paper, the author should always makea full statement to the editor about all submissions andprevious reports that might be regarded as redundant orduplicate publication of the same or very similar work. Ifredundant or duplicate publication is attempted oroccurs without such notification, authors may face aprompt rejection of the submitted manuscript.Acceptable Secondary Publication: The authorsshould receive approval from the editors of both journals;the editor concerned with secondary publication musthave a photocopy, reprint or manuscript of the primaryversion. A suitable footnote on the title page might read:"This article is based on a study first reported in the (titleof journal, with full reference)".Preparation of Manuscript: The text of observationaland experimental articles is usually (but not necessarily)divided into sections with the headings Introduction,Methods, Results, and Discussion. Type or print out themanuscript on white bond paper, 216 x 279 mm (8.5 x 11inches), or ISO A4 (212 x 297 mm), with margins of atleast 25 mm (1 inch). Type or print on only one side of thepaper. Use double spacing throughout, including for thetitle page, abstract, text, acknowledgments, references,individual tables, and legends. Number pagesconsecutively, beginning with the title page. Put the pagenumber in the upper or lower right-hand corner for eachpage. authors should: beWhen submitting disks,certain to include a print-out of the version of the articlethat is on the disk; put only the latest version of themanuscript on the disk; name the file clearly; label the diskwith the format of the title and the file name; provideinformation on the hardware and software used.Title Page: The title page shall carry (1) the of thetitlearticle, which should be concise but informative; (2) thename by which each author is known, with his or herhighest academic degree(s) and institutional affiliation; (3)the name of the department(s) and institution(s) to whichthe work should be attributed; (4) disclaimers, if any; (5)the name and address of the author responsible forcorrespondence about the manuscript; (6) the name andaddress of the author to whom requests for reprintsshould be addressed or a statement that reprints will notbe available from the authors; (7) source(s) of support inthe form of grants, equipment, drugs, or all of these; and(8) a short running head or foot line of no more than 40characters (count letters and spaces) at the foot of the titlepage.Authorship: Each author should have participatedsufficiently in the work to take responsibility forappropriate portions of the content.Authorship credit should be based only on (1) substantialcontributions to conception and design, or acquisition of

data, or analysis and interpretation of data; (2) drafting thearticle or revising it critically for important intellectualcontent; and (3) final approval of the version to bepublished. These conditions must be met. Increasingly,authorship of multi center trials is attributed to a group. Allmembers of the group who are named as authors shouldfully meet the above criteria for authorship.Abstract and Key Words: The second page should carryan abstract (of no more than 150 words for unstructuredabstracts or 250 words for structured abstracts). Theabstract should state the purposes of the study orinvestigation, basic procedures (selection of study subjectsor laboratory animals; observational and analyticalmethods), main findings (giving specific data and theirstatistical significance, if possible), and the principalconclusions. It should emphasize at new and importantaspects of the study or observations. Below the abstract,authors should provide, and identify as such, 3 to 10 keywords. Terms from the Medical Subject Headings (MeSH)list of Index Medicus should be used.Introduction: State the purpose of the article andsummaries the rationale for the study or observation.Recommendation when appropriate may be included.Methods: Describe your selection of the observational orexperimental subjects (patients or laboratory animals,including controls) clearly. Identify the age, sex, and otherimportant characteristics of the subjects. Because therelevance of such variables as age, sex, and ethnicity to theobject of research is not always clear, authors shouldexplicitly justify them when they are included in a studyreport. The guiding principle should be clarified about howand why a study was done in a particular way. For example,authors should explain why only subjects of certain ageswere included or why women were excluded. Authorsshould avoid terms such as "race," which lacks precisebiological meaning, and use alternative descriptors such as"ethnicity" or "ethnic group" instead.Authors should specify carefully what the descriptorsmean, and tell exactly how the data were collected. Identifythe methods, apparatus (give the manufacturer's name andaddress in parentheses), and procedures in sufficient detailto allow other workers to reproduce the results. Givereferences to established methods, including statisticalmethods; provide references and brief descriptions formethods that have been published but are not well known;describe new or substantially modified methods, givereasons for using them, and evaluate their limitations.Identify precisely all drugs and chemicals used, includinggeneric name (s), dose (s), and route (s) of administration.Reports of randomized clinical trials should presentinformation on all major study elements, including theprotocol, assignment of interventions and the method of

34

Instructions to Authors

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masking (binding). Authors submitting reviewmanuscripts should include a section describing themethods used for locating, selecting, extracting, andsynthesizing data. These methods should also besummarized in the abstract. en reporting experiments onanimals, indicate whether the institution's or a nationalresearch council's guide for, or any national law on, thecare and use of laboratory animals was followed. Describestatistical methods with enough detail to enable aknowledgeable reader with access to the original data toverify the reported results.Avoid relying solely on statistical hypothesis testing, suchas the use of values, which fails to convey importantPquantitative information. Restrict tables and figures tothose needed to explain the argument of the paper and toassess its support. Use graphs as an alternative to tableswith many entries; do not duplicate data in graphs andtables.Results: Present your results in logical sequence in thetext, tables, and illustrations. Do not repeat in the tax allthe data in the tables or illustrations; emphasize onlyimportant observations.Discussion: Emphasize the new and important aspectsof the study and the conclusions that follow from them.Do not repeat in detail data or other material given in theintroduction or the results' section. Include in thediscussion section the implications of the findings andtheir limitations, including implications for futureresearch. Relate the observations to other relevant studies.Link the with the goals of the study but avoidconclusionunqualified statements and conclusions not completelysupported by the data. In particular, authors should avoidmaking statements on economic benefits and analyses.Acknowledgments: List all contributors who do notmeet the criteria for authorship, such as a person whoprovided only general support. Financial and materialsupport should also be acknowledged. Groups of personswho have contributed materially to the paper but whosecontributions do not justify authorship may be listedunder a heading such as "clinical investigation "or"participating investigators," and their function orcontribution should be described e.g," "critically reviewedthe study proposal,"collected data," or "provided andcared for study patients."References should be numbered consecutively in theorder in which they are first mentioned in the text.Identify references in text, tables, and legends by Arabicnumerals in parentheses. References cited only in tables orfigure legends should be numbered in accordance withthe sequence established by the first identification in thetext of the particular table or figure.Use the style of the examples below, which are based onthe formats used by the NLM in The titlesIndex Medicus.of journals should be abbreviated according to the styleused in Consult theIndex Medicus. List of Journals Indexed inIndex Medicus, published annually as a separate publicationby the library and as a list in the January issue of IndexMedicus. The list can also be obtained through the library's

web site (http://www.nlm.nih.gov).Avoid using abstracts as references. References to papersaccepted but not yet published should be designated as "inpress" or "forthcoming"; authors should obtain writtenpermission to cite such papers as well as verification thatthey have been accepted for publication. Information frommanuscripts submitted but not accepted should be cited inthe text as "unpublished observations" with writtenpermission from the source. Avoid citing a "personalcommunication" unless it provides essential informationnot available from a public source, in which case the nameof the person and date of communication should be citedin parentheses in the text. The references must be verifiedby the author(s) against the original documents. Standardjournal article. List the first six a1,1thors followed by et al.(Note: NLM now lists up through 25 authors; if there aremore than 25 authors, NLM lists the first 24, then the lastauthor, then et al). Vega K. J., Pina 1, Krevsky B. Hearttransplantation is associated with an increased risk forpancreatobiliary disease. Ann. Intern. Med., 1996June 1;124 (11):980-3.More than six authors: Parkin D. M., Clayton D., Black R. J.,Masuyer E., Friedl H. P., Ivanov E. et al. Childhoodleukaemia in Europe after Chernobyl: 5 year follow-up. Br.J. Cancer, 1996; 73:1006-12.Organization as author: The Cardiac Society of Australia andNew Zealand. Clinical exercise stress testing. Safety andperformance guidelines. Med.J. Aust., 1996; 164: 282-4. Noauthor given: Cancer in South Africa Editorial). S. Afr. Med.J., 1994; 84: 15. Shen H. M., ZhangVolume with supplement:Q. F. Risk assessment of nickel carcinogenicity andoccupational lung cancer. Environ. Health Perspect, 1994;102 Suppl. 1: 275-82. Ozben T.,Volume with part:Nacitarhan S., Tuncer N. Plasma and urine sialic acid innon-insulin dependent diabetes mellitus. Ann. Clin.Biochem., 1995; 32 (pt. 3):303-6. Personal author(s):Ringsven M. K., Bond D. Gerontology and leadership skillsfor nurses. 2nd Ed. Albany (NY): Delmar Publishers; 1996.Editor(s), compiler(s) as author(s): Norman 1. J., Redfern S. J.,Editors. Mental health care for elderly people. New York:Churchill Livingstone; 1996. Organization as author andpublisher: Institute of Medicine (US). Looking at the futureof the Medicaid program. Washington: The Institute; 1992.Conference proceedings: Kimura J., Shibasaki H., Editors.Recent advances in clinical neurophysiology. Proceedingsof the 10 International Congress of EMG and Clinical

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Neurophysiology; 1995 Oct. 15-19; Kyoto,Japan.Amsterdam: Elsevier; 1996. Bengtsson S.,Conferencepaper:Solheim B. G. Enforcement of data protection, privacy andsecurity in medical informatics. In: Lun K. c., Degoulet P.,Piemme T. E., Rienhoff 0, Editors. MEDINFO 92.Proceedings of the 7th World Congress on MedicalInformatics; 1992 Sept. 6-10; Geneva, Switzerland.Amsterdam: North-Holland; 1992: P. 1561-5. Dissertation:Kaplan S. J. Post-hospital home health care: the elderly'saccess and utilization (dissertation). St. Louis (MO):Washington Univ.; 1995. (Note: NLM prefersIn press:

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forthcoming" because not all items will be printed).Leshner A. I. Molecular mechanisms of cocaineaddiction. N. Engl. J. Med. In Press, 996. Journal article inelectronic format: Morse S. S. Factors in the emergence ofinfectious diseases. Emerg. Infect. Dis. (Serial online)1995 Jan. Mar. (cited 1996 Jun. 5); 1 (1): (24 screens).Available from: URL: http://www.cdc.gov/ncidod/EID/ eid .htmlTables: Type or print out each table with double spacingon a separate sheet of paper. Do not submit tables asphotographs. Number tables consecutively in the orderof their first citation in the text and supply a brief title foreach. Give each column a short or abbreviated heading.Place explanatory matter in footnotes, not in the heading.Explain in footnotes all nonstandard abbreviations thatare used in each table. For footnotes use the followingsymbols, in this sequence: Do not use internal horizontaland vertical rules; be sure that each table is cited in thetext. The use of too many tables in relation to the lengthof the text may produce difficulties in the layout of pages.Illustrations (Figures): Submit the required number ofcomplete sets of figures. Figures should be professionallydrawn and photographed; freehand or typewrittenlettering is unacceptable. Instead of original drawings, x-ray films, and other material, send sharp, glossy, black-and-white photographic prints, usually 127 x 173 mm (5 x7 inches) but no larger than 203 x 254 mm (8 x 10inches).Letters, numbers, and symbols should be clear andeven throughout and of sufficient size that when reducedfor publication each item will still be legible. Titles anddetailed explanations belong in the legends forillustrations not on the illustrations themselves. Eachfigure should have a label pasted on its back indicating the

number of the figure, author's name, and top of the figure.Do not write on the back of figures or scratch or mar themby using paper clips. Do not bend figures or mount themon cardboard. Photomicrographs should have internalscale markers. Symbols, arrows, or letters used inphotomicrographs should contrast with the background.Figures should be numbered consecutively according tothe order in which they have been first cited in the text. Forillustrations in color, ascertain whether the journal requirescolor negatives, positive transparencies, or color prints.Type or print out legends for illustrations using doublespacing, starting on a separate page, with Arabic numeralscorresponding to the illustrations. Avoid abbreviations inthe title and abstract.Sending the Manuscript to the Journal: Send therequired number of copies of the manuscript in a heavy-paper envelope, enclosing the copies and figures incardboard, if necessary, to prevent the photographs frombeing bent. Place photographs and transparencies in aseparate heavy-paper envelope. Manuscripts must beaccompanied by a covering letter signed by all coauthors.This must include (1) information on prior or duplicatepublication or submission elsewhere of any part of thework as defined earlier in this document; (2) a statement offinancial or other relation ships that might lead to a conflictof interest; (3) a statement that the manuscript has beenread and approved by all the authors, that the requirementsfor authorship as stated earlier in this document have beenmet, and that each author believes that the manuscriptrepresents honest work; and (4) the name, address, andtelephone number of the corresponding author, who isresponsible for communicating with the other authorsabout revisions and final approval of the proofs.

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