Factors affecting delays in tuberculosis diagnosis in rural China: a case study in four counties in Shandong Province

Improving case detection is an urgent and serious challenge for tuberculosis (TB) control in China. We investigated the extent to which TB patients delayed seeking TB care and health services delayed reaching a diagnosis, and socio-economic factors associated with the delays. Standard questionnaires were administered to 190 new smear-positive TB patients who had completed treatment at TB dispensaries in four counties of Shandong Province in 2001. Multivariate analysis using Cox Regression showed that old age, lack of education and distance from home to a township health centre were significantly associated with delay in seeking care from service providers. In examining the delay between first contact with a service provider and diagnosis, we found that women experienced longer delays than men, and that the higher the level of facility patients first visited, the less time was needed to achieve a diagnosis. These two factors were statistically significant in multivariate Cox Regression analysis. We concluded that the elderly, the less educated, women, and those living far from health facilities face the longest delays in reaching TB services and achieving diagnosis.

Is INR between 2.0 and 3.0 the optimal level for Chinese patients on warfarin therapy for moderate-intensity anticoagulation?

AIM

To examine the optimal range of International Normalized Ratio (INR) for Chinese patients receiving warfarin for moderate-intensity anticoagulation.

METHODS

This was a retrospective cohort study conducted at the ambulatory setting of a 1400-bed public teaching hospital in Hong Kong. The INR measurements and occurrence of serious or life-threatening haemorrhagic and thromboembolic events among patients newly started on warfarin from 1 January 1999 to 30 June 2001 for indications with target INR 2-3 were analysed. The INR-specific incidence of bleeding and thromboembolism were calculated.

RESULTS

A total of 491 patients were included, contributing to 453 patient-years of observation period. Forty-seven of the 491 patients experienced 25 haemorrhagic events (5.5 per 100 patient-years) and 27 thromboembolic events (6.0 per 100 patient-years). The percentage of patient-time spent within therapeutic INR range (2-3), INR <2 and INR >3 were 50, 44 and 6%, respectively. The incidence of either haemorrhagic or thromboembolic events was lowest (< or =4 events per 100 patient-years) at INR values between 1.8 and 2.4.

CONCLUSIONS

An INR of 1.8-2.4 appeared to be associated with the lowest incidence rate of major bleeding or thromboembolic events in a cohort of Hong Kong Chinese patients receiving warfarin therapy for moderate-intensity anticoagulation.

Sonographic pitfalls in the diagnosis of enteric duplication cysts

OBJECTIVE

The sonographic double wall sign has been well described in the literature and is often the cornerstone in suggesting the diagnosis of an enteric duplication cyst. We report two cases with this sign that were erroneously diagnosed as enteric cysts and a third case without this sonographic feature that proved to be a duplication cyst. Histologic analysis of the specimens helps explain the cause of the sonographic pitfalls.

CONCLUSION

The potential sonographic visualization of the split hypoechoic muscularis propria layer or identification of all five layers will increase the specificity in making the sonographic diagnosis of duplication cyst.

Cl- channels are expressed in human normal monocytes: a functional role in migration, adhesion and volume change

Increased adhesion and diapedesis of monocytes appear to be primary initiating factors in the pathophysiology of occlusive vascular diseases, including atherosclerosis and restenosis. However, the underlying mechanisms of transendothelial migration and invasion of monocytes into the blood vessels are not known. Alterations in ion channels on the cell membrane are generally involved in induced changes in shape and volume. In the present study, we investigated the expression and functional role of chloride channels in freshly isolated human blood monocytes. The Cl- currents in whole-cells were measured by the patch-clamp technique. We observed whole cell Cl- currents, which were time-independent and outwardly rectifying. The chloride channel blockers 5-nitro-2-(3-phenylpropylamino) benzoic acid (NPPB) and R(+)-[(6,7-dichloro-2-cyclopentyl-2,3-dihydro-2-methyl-1-oxo-1H-inden-5yl)-oxy]acetic acid 94 (IAA94) attenuated the Cl- currents. NPPB and IAA94 also inhibited chemotaxis of monocytes, as measured in Boyden chemotactic chambers, with the same sensitivity. NPPB but not IAA94, increased the cell volume as measured by shape change, and decreased tumour necrosis factor (TNF)-alpha-induced monocyte adhesion to endothelial cells. These results suggest that monocytes contain Cl- channels which regulate transendothelial migration of monocytes, due presumably to an alteration in cell volume.

Use of convalescent plasma therapy in SARS patients in Hong Kong

In order to evaluate the efficacy of convalescent plasma therapy in the treatment of patients with severe acute respiratory syndrome (SARS), 80 SARS patients were given convalescent plasma at Prince of Wales Hospital, Hong Kong, between 20 March and 26 May 2003. Good outcome was defined as discharge by day 22 following the onset of SARS symptoms. Poor outcome was defined as death or hospitalization beyond 22 days. A higher day-22 discharge rate was observed among patients who were given convalescent plasma before day 14 of illness (58.3% vs 15.6%; P<0.001) and among those who were PCR positive and seronegative for coronavirus at the time of plasma infusion (66.7% vs 20%; P=0.001).

Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients

Treatment of severe acute respiratory syndrome (SARS) is experimental, and the effectiveness of ribavirin–steroid therapy is unclear. Forty SARS patients with progressive disease after ribavirin treatment and 1.5 g of pulsed methylprednisolone were given either convalescent plasma (n = 19) or further pulsed methylprednisolone (n = 21) in a retrospective non‐randomised study. Good clinical outcome was defined as discharge by day 22 following the onset of symptoms. Convalescent plasma was obtained from recovered patients after informed consent. Patients in the plasma group had a shorter hospital stay (p 0.001) and lower mortality (p 0.049) than the comparator group. No immediate adverse effects were observed following plasma infusion.

Use of fasting urinary methylmalonic acid to screen for metabolic vitamin B12 deficiency in older persons

OBJECTIVES

We sought to determine the cutoffs of fasting urinary methylmalonic acid (MMA) indicating elevated and mildly elevated serum MMA concentrations in older persons.

METHODS

We studied 113 female Chinese vegetarians older than 55 y with normal renal function. Fasting serum samples were obtained for measurement of vitamin B12, MMA, and folate and tests of renal function. A fasting urine sample was collected for MMA measurement by the stable-isotope dilution method. The correlation between serum and urinary MMA levels was examined. The optimal cutoffs of urinary MMA for predicting elevated and mildly elevated serum MMA were estimated by use of receiver operating characteristic curves.

RESULTS

Fasting urinary and serum MMA levels were linearly correlated. Pearson's correlation coefficient was 0.94. The cutoff of fasting urinary MMA of 2 microM/mM of creatinine had a sensitivity of 79%, a specificity of 85%, and a positive predictive value of 93% for elevated serum MMA (> 0.4 microM/L). A cutoff of 1.5 microM/mM of creatinine had a sensitivity of 86%, a specificity of 85%, and a positive predictive value of 95% for mildly elevated serum MMA (> 0.3 microM/L). Both cutoffs had high positive predictive values for subnormal vitamin B12 concentrations.

CONCLUSION

Overnight fasting urinary MMA concentrations have a strong linear relation to serum MMA in older vegetarians without renal impairment. Urinary MMA is potentially useful as a screening tool for metabolic vitamin B12 deficiency in older persons.

The expression of oestrogen receptor (ER)-beta and its variants, but not ERalpha, in adult human mammary fibroblasts

Whilst oestrogen receptor (ER)-alpha and ERbeta have been shown to be important in the development of the mammary gland, the cell-specific expression pattern of these two receptors within the human breast is not clear. Although it is well established that in the developing rodent mammary gland stromal ERalpha mediates the secretion of growth factors which stimulate the proliferation of the ductal epithelium, the expression of ERalpha in human adult breast stromal fibroblasts is controversial, and the expression of ERbeta has not been properly defined. In the present study, we have evaluated the expression of ERalpha and ERbeta by immunohistochemistry in normal tissue samples, and in purified human breast fibroblasts by Western blotting, RT-PCR analysis and ligand-binding sucrose gradient assay. Our data clearly demonstrated that ERbeta variants, including ERbeta1, ERbeta2, ERbeta5, ERbetadelta and ERbetains, but not ERalpha, are expressed in human adult mammary fibroblasts. These results are supported by the findings that an ERbeta-selective ligand, BAG, but not the ERalpha high-affinity ligand oestradiol, can induce fibroblast growth factor-7 release and activate transcription from an oestrogen-responsive element promoter in these adult human mammary fibroblasts. Together, these observations revealed that, in the adult breast and in breast cancer, the proliferative signals derived from the stroma of adult mammary glands in response to oestrogen are not mediated by ERalpha and provide new insights into the nature of stromal-epithelial interactions in the adult mammary gland. In addition, the expression of these ERbeta variants in cells where there is no ERalpha suggested that these ERbeta splice forms may have functions other than that of modulating ERalpha activity.

Antiproliferative activity of the extract of Gleditsia sinensis fruit on human solid tumour cell lines

BACKGROUND

The fruit extract of Gleditsia sinensis Lam. (GSE) is a traditional herbal medicine that is saponin-rich. However, its activity on solid tumour cell lines has never been demonstrated.

METHODS

The activity of GSE was demonstrated in four cancer cell lines (breast cancer MCF-7, MDA-MB231, hepatoblastoma HepG2 and oesophageal squamous carcinoma cell line SLMT-1) using MTT assay, anchorage-independent clonogenicity assay, DNA laddering and in situ cell death detection.

RESULTS

The mean MTT(50) (the mean concentration of GSE to reduce MTT activity by 50%) ranged from 16 to 20 microg/ml of GSE. An anchorage-independent clonogenicity assay showed that all of the four solid tumour cell lines gradually lost their regeneration potential after treatment with GSE, DNA fragmentation and TUNEL analysis demonstrated that the action of GSE is both dose- and time course-dependent.

CONCLUSIONS

Our results suggest that GSE has a cytotoxic activity and can induce apoptosis in human solid tumour cell lines.

Expression of EGFP/SDCT1 fusion protein, subcellular localization signal analysis, tissue distribution and electrophysiological function study

Full-length cDNA gene of sodium-dependent dicarboxylate co-transporter protein 1 (SDCT1) is cloned from normal human kidney tissue and inserted into EGFP (enhanced green fluorescent protein) expression vector along with N-terminal and C-terminal truncated SDCT1 genes, so to construct the eukaryotic expression vectors of EGFP/SDCT1 fusion proteins, which are transfected into human renal tubular epithelial cells (HKC). Subcellular localizations of these fusion proteins are observed by laser confocal microscope to determine the localization signal of the SDCT1 protein. Duplex PCR analysis validates that the fusion protein genes have been integrated into the genome of HKC. Western blot indicates that the fusion proteins have been expressed in HKC. Confocal microscopy analysis shows that human SDCT1 predominantly locates on the plasma membrane, which is consistent with the results predicted by bioinformatics approach; in HKC transfected with N-terminal truncated SDCT1 gene, the green fluorescence is mainly distributed on the plasma membrane; in HKC transfected with C-terminal truncated SDCT1 gene, the green fluorescence is mainly distributed in the cytoplasm. EGFP/SDCT1 mRNAs obtained by in vitro transcription are microinjected into Xenopus laevis oocytes for expression and the trans-membrane currents are measured by using two-microelectrode voltage-clamp technique. Na+ inward currents are present on cellular membrane of the injected oocytes. Immunohistochemical staining shows that human SDCT1 proteins are expressed on lumen membrane of the renal proximal tubule, but are negative in distal tubule, collecting duct, renal interstitium and glomerulus. The above-mentioned studies suggest that human SDCT1 protein is located on the lumen membrane of the renal proximal tubule, the C-terminal sequence of the SDCT1 is required for delivery and targeting localization, and the plasma membrane localization signal of the SDCT1 protein maybe locate in the C-terminal sequence.

The art of war: Innate and adaptive immune responses

Research over the last several years has greatly advanced our understanding of the mechanisms by which the immune system functions. There exist two main branches of immunity, termed innate and adaptive immunity. Innate immunity uses the genetic memory of germline-encoded receptors to recognize the molecular patterns of common pathogens. Adaptive immunity, akin to somatic memory, is a complex system by which the body learns to recognize a pathogen's unique antigens and builds an antigen specific response to destroy it. The effective development of the overall immune response depends on careful interplay and regulation between innate and adaptive immunity. Here we review our current understanding of how these integrated systems distinguish targets against which a response is appropriate and neutralize potentially pathogenic challenges.

Gene therapy to target dendritic cells from blood to lymph nodes

Peripheral lymph nodes (PLN) are strategic microenvironments where antigen-presenting dendritic cells (DC), loaded with environmental antigens, and naive lymphocytes meet to initiate immune responses. The unique capacity of DC to induce primary immune responses has led to their use in clinical medicine; however, delivering DC to lymph nodes is problematic. Intravenously injected DC cannot access to PLN, while DC injected into tissue migrate inefficiently through lymphatics to PLN. We achieved DC targeting to T-cell areas of PLN by endowing DC with a novel receptor for peripheral node addressin (PNAd), an adhesion molecule present on the lymph node venular endothelium. This novel receptor is a chimeric E/L-selectin (ELS) that, we have previously shown, binds to PNAd. DC were genetically modified by retroviral transduction to express ELS. ELS expression was targeted to tips of microvilli, and mediated rolling of DC on PNAd both in vivo and in vitro. Such genetically engineered DC could extravasate directly from blood through the lymph node endothelium as opposed to nontransduced DC. This study provides evidence that the trafficking of DC can be modified using gene transfer technologies. More efficient delivery of DC to PLN should assist the development of improved vaccination strategies.

Renormalization group theory for perturbed evolution equations

We show that proto-RG (renormaliation group) theory can be used to give a systematic description of the evolution of soltion of perturbed equations. The equations describing the deformation of its shape as the effect of perturbation are proto-RG equations. The RG approach may be simpler than inverse scattering theory (IST) and another approaches, because it dose not rely on any knowledge of IST. It is very concise and easy to understand.

[Clinical significance of Q-Tc dispersion after exercise in aged patients with old myocardial infarction]

OBJECTIVE

This study was aimed to evaluate clinical significance of Q-Tc dispersion after exercise in aged patients with old myocardial infarction.

METHOD

Sixty-four aged patients with old myocardial infarction(infarction group) were examined by treadmill exercise, dynamic electrocardiography, echocardiography, and were followed up for average of 24.12 +/- 7.7 months. 30 healthy aged persons were served as control group.

RESULTS

Compared with that (40.21 +/- 15.21 ms) before exercise, Q-Tc dispersion (59.37 +/- 20.17 ms) was increased significantly after exercise in infarction group(P < 0.01). But no significant difference was found in Q-Tc dispersion of control group before and after exercise(34.70 +/- 12.29 ms vs 38.91 +/- 13.62 ms P > 0.05). In infarction group, occurrence of abnormal contraction of left ventricular wall, aneurysms, NYHA III class and > III class of Lown's ventricular arrhythmia classification was significantly higher in Q-Tcd > 50 ms patients than that in Q-Tcd < 50 ms ones(P < 0.05). It was found that 5 patients died of cardiac sudden death in Q-Tcd > 50 ms patients and no one died of cardiac sudden death in Q-Tcd < 50 ms ones.

CONCLUSION

The Q-Tc dispersion after exercise is an important index to predict ventricular arrhythmia and cardiac death in the patients with old myocardial infarction.

Independent effect of vitamin B12 deficiency on hematological status in older Chinese vegetarian women

We have examined the independent effect of vitamin B(12) deficiency on hematological indices in older Chinese vegetarian women using a cross-sectional study design: 119 women older than 55 years who had been vegetarian for more than 3 years were studied. Fasting blood samples were taken for complete blood count, serum iron, total serum iron binding capacity, serum iron saturation, serum vitamin B(12), serum folate, serum methylmalonic acid levels (MMA), and renal function test. Subjects with iron deficiency (iron saturation <15%) and those with serum creatinine >150 mmol/L were excluded. The prevalence of definite vitamin B(12) deficiency (vitamin B(12) level < 150 pmol/L and MMA >or= 0.4 micromol/L) was 42%. Another 32.8% had possible vitamin B(12) deficiency (either criterion). The prevalence of iron deficiency was 10%. After exclusions, 96 subjects were further analyzed. Vitamin B(12) deficiency defined by serum vitamin B(12) and MMA was associated with a decrease in hemoglobin concentrations by up to 0.9 g/dL, but it was not associated with an increase in mean corpuscular volume (MCV). Serum MMA but not vitamin B(12) levels correlated inversely with hemoglobin and platelet counts and positively with MCV, after adjustment of confounding factors. However, the percentage of subjects with anemia did not increase significantly until serum MMA became >1.0 micromol/L. In conclusion, vitamin B(12) deficiency was associated with a significant decrease in hemoglobin concentration. However, anemia associated with vitamin B(12) deficiency was seldom macrocytic. We recommend that older vegetarians should be given vitamin B(12) supplements routinely.

Iterative renormalization group for anomalous dimension in a nonlinear diffusion process

We construct a classical successive method, the Picard method in integral equation theory, to make an iterative algorithm with the renormalization group (RG) approach to calculate the anomalous dimension in a nonlinear diffusion equation. We find our result improves than the original RG work because we begin with the var epsilonth RG solution, not the trivial fixed-point solution.

Estrogen receptors and proliferation markers in primary and recurrent breast cancer

To elucidate the clinical importance of estrogen receptor (ER) beta in breast cancer, 29 archival primary breast cancer specimens, six locally recurrent cancers, and five benign mammary tumors were examined histochemically for ERalpha, ERbeta and the proliferation markers Ki67 and cyclin A. In benign tumors, most epithelial cells contained ERbeta, but ERalpha was rare. In primary cancers, both ERalpha and ERbeta occurred in epithelial cells, the presence of ERbeta being associated with elevated expression of Ki67 and cyclin A, and ERalpha with decreased levels. Thus, the highest content of proliferation markers was seen in primary cancers that were ERalpha(-) ERbeta(+). Most Ki67-containing cells coexpressed ERbeta, but few showed ERalpha. In locally recurring cancers, ERalpha, ERbeta, and Ki67 were more highly expressed than in the corresponding primary tumors, and many cells containing ERbeta, but few with ERalpha, expressed Ki67. Surprisingly, ERbeta, but not ERalpha, was seen in the stromal cells of both primary and recurrent cancers. Because the response of breast cancers to tamoxifen therapy is correlated with the presence of ERalpha, cancer cells that lack ERalpha but contain ERbeta and proliferation markers represent a novel population of apparently proliferating cells that probably are not targeted by the current antiestrogens. Thus, appropriate ERbeta-specific ligands, perhaps in combination with tamoxifen, may be useful in improving the treatment of breast cancers.

Human T-cell leukemia virus type I tax protein induces the expression of anti-apoptotic gene Bcl-xL in human T-cells through nuclear factor-kappaB and c-AMP responsive element binding protein pathways

Human T-cell leukemia virus type I (HTLV-I) is the etiologic agent of adult T-cell leukemia (ATL), which is an aggressive form of human T-cell malignancy. The viral protein, Tax, immortalizes human T-cells and inhibits various types of apoptosis, and is thought to play crucial roles in the development of ATL. We have recently demonstrated that Tax induces the constitutive expression of the anti-apoptotic protein, Bcl-xL, in a mouse T-cell line. The mouse, however, is not a natural host of HTLV-I, and HTLV-I does not induce this malignancy in mice. We thus examined whether Tax also activates the expression of Bcl-xL in human T-cells. Expression of Tax in a human T-cell line, Jurkat, induced the expression of the Bcl-xL gene, but did not significantly affect the expression of the other apoptosis-related genes, Bcl-2 and Bax. Transient transfection assays showed that Tax stimulated human Bcl-xL promoter activity in Jurkat cells. Deletion of the two potential nuclear factor (NF)-kappaB binding sites in the human Bcl-xL promoter significantly decreased Tax-induced transactivation. In addition to NF-kappaB, Tax activates transcription through the c-AMP responsive element binding protein (CREB). Tax mutants segregating these two pathways showed that both the NF-kappaB and CREB pathways of Tax are required for maximum activation of a human Bcl-xL promoter, nevertheless, NF-kappaB alone was sufficient for that of a mouse Bcl-xL promoter. Northern blot analysis showed that all the human T-cell lines expressing Tax had higher levels of Bcl-xL mRNA than HTLV-I-uninfected ones. Furthermore, the sample from one patient with ATL expressed higher levels of Bcl-xL mRNA compared with levels from uninfected peripheral blood mononuclear cells. Our results suggest that Tax induces the expression of Bc-xL through the NF-kappaB and CREB pathways in HTLV-I-infected human T-cells, and then inhibits apoptosis, and such inhibition is necessary for the infected cells to advance to the leukemia in vivo.