Nutritional status, hospitalization and mortality among patients with sickle cell anemia in Tanzania

BACKGROUND

Reduced growth is common in children with sickle cell anemia, but few data exist on associations with long-term clinical course. Our objective was to determine the prevalence of malnutrition at enrollment into a hospital-based cohort and whether poor nutritional status predicted morbidity and mortality within an urban cohort of Tanzanian sickle cell anemia patients.

DESIGN AND METHODS

Anthropometry was conducted at enrollment into the sickle cell anemia cohort (n=1,618; ages 0.5-48 years) and in controls who attended screening (siblings, walk-ins and referrals) but who were found not to have sickle cell anemia (n=717; ages 0.5-64 years). Prospective surveillance recorded hospitalization at Muhimbili National Hospital and mortality between March 2004 and September 2009.

RESULTS

Sickle cell anemia was associated with stunting (OR=1.92, P<0.001, 36.2%) and wasting (OR=1.66, P=0.002, 18.4%). The greatest growth deficits were observed in adolescents and in boys. Independent of age and sex, lower hemoglobin concentration was associated with increased odds of malnutrition in sickle cell patients. Of the 1,041 sickle cell anemia patients with a body mass index z-score at enrollment, 92% were followed up until September 2009 (n=908) or death (n=50). Body mass index and weight-for-age z-score predicted hospitalization (hazard ratio [HZR]=0.90, P=0.04 and HZR=0.88, P=0.02) but height-for-age z-score did not (HZR=0.93, NS). The mortality rate of 2.5 per 100 person-years was not associated with any of the anthropometric measures.

CONCLUSIONS

In this non-birth-cohort of sickle cell anemia with significant associated undernutrition, wasting predicted an increased risk of hospital admission. Targeted nutritional interventions should prioritize treatment and prevention of wasting.

Nocturnal haemoglobin oxygen saturation variability is associated with vitamin C deficiency in Tanzanian children with sickle cell anaemia

Aim

To compare pulse oximetry in children with sickle cell anaemia (SCA) and controls and test the hypothesis that vitamin C deficiency (VCD; <11.4 μmol/L) is associated with nocturnal haemoglobin oxygen desaturation in SCA.

Methods

We undertook nocturnal and daytime pulse oximetry in 23 children with SCA (median age 8 years) with known steady-state plasma vitamin C concentrations and 18 siblings (median 7 years).

Results

Median nocturnal delta 12 s index (delta12 s), a measure of haemoglobin oxygen saturation (SpO₂) variability, was 0.38 (interquartile range 0.28–0.51) in SCA and 0.35 (0.23–0.48) in controls, with 9/23 and 6/18, respectively, having a delta12 s >0.4, compatible with obstructive sleep apnoea (OSA). Eleven of twenty-three with SCA had VCD; logged vitamin C concentrations showed a 66% decrease per 0.1 unit increase in delta12 s ([95% CI −86%, −15%]; p = 0.023) and delta12 s >0.4 was associated with VCD (odds ratio 8.75 [1.24–61.7], p = 0.029). Daytime and mean nocturnal SpO₂ were lower in SCA but there was no association with vitamin C.

Conclusion

Obstructive sleep apnoea (OSA), detected from nocturnal haemoglobin oxygen saturation variability, is common in Tanzanian children and associated with vitamin C Deficiency in SCA. The direction of causality could be determined by comparing OSA treatment with vitamin C supplementation.

Haptoglobin and sickle cell polymorphisms and risk of active trachoma in Gambian children

Background

Susceptibility and resistance to trachoma, the leading infectious cause of blindness, have been associated with a range of host genetic factors. In vitro studies of the causative organism, Chlamydia trachomatis, demonstrate that iron availability regulates its growth, suggesting that host genes involved in regulating iron status and/or availability may modulate the risk of trachoma. The objective was to investigate whether haptoglobin (Hp) haplotypes constructed from the functional polymorphism (Hp1/Hp2) plus the functional promoter SNPs -61A-C (rs5471) and -101C-G (rs5470), or sickle cell trait (HbAS, rs334) were associated with risk of active trachoma when stratified by age and sex, in rural Gambian children.

Methodology and Principal Findings

In two cross sectional surveys of children aged 6–78 months (n = 836), the prevalence of the clinical signs of active trachoma was 21.4%. Within boys, haplotype E (-101G, -61A, Hp1), containing the variant allele of the -101C-G promoter SNP, was associated with a two-fold increased risk of active trachoma (OR = 2.0 [1.17–3.44]). Within girls, an opposite association was non-significant (OR = 0.58 [0.32–1.04]; P = 0.07) and the interaction by sex was statistically significant (P = 0.001). There was no association between trachoma and HbAS.

Conclusions

These data indicate that genetic variation in Hp may affect susceptibility to active trachoma differentially by sex in The Gambia.

Iron incorporation and post-malaria anaemia

Background

Iron supplementation is employed to treat post-malarial anaemia in environments where iron deficiency is common. Malaria induces an intense inflammatory reaction that stalls reticulo-endothelial macrophagal iron recycling from haemolysed red blood cells and inhibits oral iron absorption, but the magnitude and duration of these effects are unclear.

Methodology/Principal Findings

We examined the red blood cell incorporation of oral administered stable isotopes of iron and compared incorporation between age matched 18 to 36 months old children with either anaemia post-malaria (n = 37) or presumed iron deficiency anaemia alone (n = 36). All children were supplemented for 30 days with 2 mg/kg elemental iron as liquid iron sulphate and administered ⁵⁷Fe and ⁵⁸Fe on days 1 and 15 of supplementation respectively. ⁵⁷Fe and⁵⁸Fe incorporation were significantly reduced (8% vs. 28%: p<0.001 and 14% vs. 26%: p = 0.045) in the malaria vs. non-malaria groups. There was a significantly greater haemoglobin response in the malaria group at both day 15 (p = 0.001) and 30 (p<0.000) with a regression analysis estimated greater change in haemoglobin of 7.2 g/l (s.e. 2.0) and 10.1 g/l (s.e. 2.5) respectively.

Conclusion/Significance

Post-malaria anaemia is associated with a better haemoglobin recovery despite a significant depressant effect on oral iron incorporation which may indicate that early erythropoetic iron need is met by iron recycling rather than oral iron. Supplemental iron administration is of questionable utility within 2 weeks of clinical malaria in children with mild or moderate anaemia.

Iron metabolism and malaria

Recent evidence from a large, randomized, controlled trial has suggested that the universal administration of iron to children in malaria-endemic areas is associated with an increase in adverse health outcomes. The purpose of this paper is to summarize the available ecologic and intervention trials related to iron and malaria in children, and to set these against current knowledge of the biology of host-pathogen interactions involving iron metabolism. We conclude that, although not fully consistent, the balance of evidence confirms that administration of iron (usually in combination with folic acid) increases the incidence of malaria when given without prophylaxis and in the absence of universal access to treatment. The mechanisms by which additional iron can benefit the parasite are far from clear. There is evidence to suggest that the apparent detrimental effect of iron supplementation may vary according to levels of antecedent iron status, the presence of hemoglobinopathies and glucose-6-phosphate dehydrogenase (G6PD) deficiency, and other host genetic variants, such as variants in haptoglobin. The effects of malaria on host iron metabolism are also reviewed and reveal that the key cause of malaria-induced anemia is a maldistribution of iron and suppression of erythropoiesis rather than an exacerbation of gross iron deficiency. We tentatively conclude that, if it is to be recommended, universal iron supplementation in malarious areas should only be considered in conjunction with some form of prophylaxis (e.g., intermittent preventive therapy [IPT]) or in the context of good health services with ready access to facilities for malaria diagnosis and treatment. An alternative approach would be to screen for anemia and target supplementation only to anemic children. With regard to treatment, there is good evidence that iron supplementation should be withheld until the treatment schedule is complete, both because iron may inhibit treatment and because the absorption of oral iron is blocked by the inflammatory response.

Haptoglobin genotype, anaemia and malaria in Gambian children

OBJECTIVE

To retest our previous finding that the haptoglobin (Hp) 22 genotype is associated with seasonal anaemia, and to investigate the role of malaria in this effect.

METHODS

Haemoglobin (Hb) and peripheral parasitaemia were assessed at pre- and post-malarial season cross-sectional surveys in rural Gambian children aged 10-72 months. Between the surveys, active longitudinal surveillance was conducted to detect febrile episodes.

RESULTS

Unlike previously, no overall reduction in Hb was observed (Hb = 106.1 vs. 107.2 g/l, P = 0.13, n = 545). However, multi-variable linear regression revealed differences in Hb over the season by Hp and Hb-sickle (HbS) genotype (-2.20 g/l per copy of the Hp2 allele, P = 0.043; HbAS vs. HbAA + 3.13 g/l, P = 0.11, n = 536). There was no effect of malarial episodes during follow-up; this suggests that when effective treatment is given, Hb levels recover. The A61-C Hp promoter SNP, associated with the Hp2 allele, had no effect.

CONCLUSION

The effect of the Hp2 allele appears to be independent of effects on malaria incidence but may affect Hb levels through increased oxidant stress and red cell turnover. This may be supported by our previous observations that the effect of Hp22 was independent of markers of iron status and zinc protoporphyrin measured at the cross-sectional surveys and therefore also of iron availability for erythropoiesis.

Host-pathogen interactions: can micronutrients tip the balance?

Nutrients are essential to the human host and to its invading pathogens. The purpose of this International Nutrition Council symposium on Micronutrient Regulation of Host-Pathogen Interactions held at Experimental Biology 2006 was to examine new knowledge about the mechanisms by which certain limiting micronutrients can mediate the balance of power between the human host and its numerous potential pathogens. In this introductory article, we briefly review how competition for nutrients is critical to the survival of both host and pathogen and describe some of the evolved mechanisms by which each attempts to gain supremacy over the other. We provide examples of how the presence or absence of certain mechanisms for nutrient acquisition can govern the niche specificity of organisms. We then describe some of the extensive evidence suggesting that, of all the nutrients, iron plays an especially crucial role in host-pathogen interactions. To this end, we provide a reminder of early studies suggesting that universal iron administration under conditions of high pathogen exposure may lead to adverse consequences. Finally, we provide some cautionary tales in the form of intervention studies in which the administration of other micronutrients yielded unpredicted adverse effects. These lessons emphasize the need to step back from an unbalanced concentration of research funds on empirical trials (often built on an inadequate theoretical basis) and toward a greater concentration on integrated clinical research into nutrient effects on host defenses and pathogen virulence.

Haplotype association between haptoglobin (Hp2) and Hp promoter SNP (A-61C) may explain previous controversy of haptoglobin and malaria protection

Background

Malaria is one of the strongest recent selective pressures on the human genome, as evidenced by the high levels of varying haemoglobinopathies in human populations–despite the increased risk of mortality in the homozygous states. Previously, functional polymorphisms of Hp, coded by the co-dominant alleles Hp1 and Hp2, have been variously associated with several infectious diseases, including malaria susceptibility.

Methodology/Principal Findings

Risk of a clinical malarial episode over the course of a malarial transmission season was assessed using active surveillance in a cohort of Gambian children aged 10–72 months. We report for the first time that the major haplotype for the A-61C mutant allele in the promoter of haptoglobin (Hp)–an acute phase protein that clears haemoglobin released from haemolysis of red cells–is associated with protection from malarial infection in older children, (children aged ≥36 months, >500 parasites/ul and temperature >37.5°C; OR = 0.42; [95% CI 0.24–0.73] p = 0.002) (lr test for interaction, <36 vs ≥36 months, p = 0.014). Protection was also observed using two other definitions, including temperature >37.5°C, dipstick positive, plus clinical judgement of malaria blinded to dipstick result (all ages, OR = 0.48, [95% CI 0.30–0.78] p = 0.003; ≥36 months, OR = 0.31, [95% CI 0.15–0.62] p = 0.001). A similar level of protection was observed for the known protective genetic variant, sickle cell trait (HbAS).

Conclusions/Significance

We propose that previous conflicting results between Hp phenotypes/genotypes and malaria susceptibility may be explained by differing prevalence of the A-61C SNP in the populations studied, which we found to be highly associated with the Hp2 allele. We report the -61C allele to be associated with decreased Hp protein levels (independent of Hp phenotype), confirming in vitro studies. Decreased Hp expression may lead to increased oxidant stress and increased red cell turnover, and facilitate the development of acquired immunity, similar to a mechanism suggested for sickle cell trait.

Vitamin A supplementation increases ratios of proinflammatory to anti-inflammatory cytokine responses in pregnancy and lactation

Vitamin A supplementation reduces child mortality in populations at risk of vitamin A deficiency and may also reduce maternal mortality. One possible explanation for this is that vitamin A deficiency is associated with altered immune function and cytokine dysregulation. Vitamin A deficiency in pregnancy may thus compound the pregnancy-associated bias of cellular immune responses towards Th-2-like responses and exacerbate susceptibility to intracellular pathogens. We assessed mitogen and antigen-induced cytokine responses during pregnancy and lactation in Ghanaian primigravidae receiving either vitamin A supplementation or placebo. This was a double-blind, randomized, placebo-controlled trial of weekly vitamin A supplementation in pregnant and lactating women. Pregnancy compared to postpartum was associated with a suppression of cytokine responses, in particular of the proinflammatory cytokines interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha. Mitogen-induced TNF-alpha responses were associated with a decreased risk of peripheral parasitaemia during pregnancy. Furthermore, vitamin A supplementation was significantly associated with an increased ratio of mitogen-induced proinflammatory cytokine (IFN-gamma) to anti-inflammatory cytokine (IL-10) during pregnancy and in the postpartum period. The results of this study indicate that suppression of proinflammatory type 1 immune responses and hence immunity to intracellular infections, resulting from the combined effects of pregnancy and vitamin A deficiency, might be ameliorated by vitamin A supplementation.

Maternal vitamin A supplementation and immunity to malaria in pregnancy in Ghanaian primigravids

BACKGROUND

Vitamin A supplementation is believed to enhance immune responses to infection but few studies have assessed its effects on anti-malarial immunity, especially during pregnancy when women are at increased risk from both vitamin A deficiency and pregnancy-associated malaria. The pathological effects of malaria in pregnancy are believed to be due to the sequestration of parasites in the placenta mediated via binding of variant surface antigens (VSA) expressed on the surface of P. falciparum infected red blood cells to placental chondroitin sulphate A (CSA).

METHODS

We conducted a randomized double-blind controlled trial of vitamin A supplementation in 98 primigravid Ghanaian women to investigate the effects of vitamin A supplementation on levels of IgG antibodies binding to VSA of a clinical, P. falciparum placental isolate and to two isolates selected (or not) for adherence to CSA in vitro (anti-VSACSA IgG or anti-VSA IgG). Placental malarial infection was determined by placental blood smear and histology.

RESULTS

Vitamin A supplementation was non-significantly associated with a decreased risk of active or chronic-active placental malarial infection compared to past, resolved infection at delivery, as determined by histology (OR=0.42, P=0.13--adjusted for level of education). After adjustment for differences in baseline values, levels of anti-VSACSA IgG to a placental, CSA-adherent isolate (EJ-24) but not to two isolates selected for CSA-adhesion in vitro (FCR3CSA and BusuaCSA), were significantly lower in women receiving vitamin A supplementation than in women receiving placebo (P=0.002). There was no apparent effect of vitamin A supplementation to levels of Ab to non-CSA-adherent parasite isolates.

CONCLUSIONS

The data suggest that the reduction in the levels of anti-VSACSA antibodies to the known placental malaria isolate may reflect reduced intensity or duration of placental parasitaemia in women receiving vitamin A supplementation. These observations are of potential public health significance and deserve further investigation.

Rapid acquisition of isolate-specific antibodies to chondroitin sulfate A-adherent plasmodium falciparum isolates in Ghanaian primigravidae

Recent evidence suggests that pregnancy-associated malaria (PAM), associated with maternal anemia and low birth weight, results from preferential sequestration of parasitized red blood cells (pRBC) in the placenta via binding of variant surface antigens (VSA) expressed on the surface of pRBC to chondroitin sulfate A (CSA). The VSA mediating CSA binding (VSA(CSA)) and thus sequestration of pRBC in the placenta are antigenically distinct from those that mediate pRBC sequestration elsewhere in the body, and it has been suggested that VSA(CSA) are relatively conserved and may thus constitute an attractive target for vaccination against PAM. Using flow cytometry, levels of antibody to VSA and VSA(CSA) expressed on the surface of red blood cells infected with Plasmodium falciparum isolates were measured during pregnancy and lactation in Ghanaian primigravid women enrolled in a trial of maternal vitamin A supplementation. Antibody responses to VSA(CSA) were detected within the first trimester of pregnancy and increased with increasing duration of pregnancy, and they seemed to be isolate specific, indicating that different CSA-adherent parasite lines express antigenically distinct VSA and thus may not be as antigenically conserved as has been previously suggested. Levels of anti-VSA(CSA) were not significantly associated with placental malarial infection determined by histology, indicating that primary immune responses to VSA(CSA) may not be sufficient to eradicate placental parasitemia in primigravidae.

The efficacy of external ultrasound-assisted liposuction: a randomized controlled trial

BACKGROUND

Use of high-intensity, high-frequency external ultrasound before liposuction has been reported to enhance the ease of fat extraction, increase the amount of fat extracted, and decrease patient discomfort during liposuction.

OBJECTIVE

The purpose of this study was to compare the effect of application of high-intensity continuous wave ultrasound to extremely low-intensity ultrasound (placebo) prior to tumescent liposuction.

METHODS

A total of 19 patients (25 sites) completed the double-blind study. We used a split treatment area design so that each patient could serve as their own control. After tumesing the treatment area, a 3 W/cm2 continuous wave 1 MHz ultrasound was applied for 10 minutes. The placebo control was treated with 0.3 W/cm2 1 MHz for 10 minutes. Traditional tumescent liposuction followed ultrasound application. Doctors completed a visual analog scale rating the following: rate of extraction, degree of resistance to cannula movement, and color of fat. Patients also completed a questionnaire after the procedure and at 1 month postoperatively. Histologic samples of the fat treated with external ultrasound were taken from two patients.

RESULTS

In 14 of 19 patients the doctors graded either no difference between treatment and control sides or found a better response on the nontreated side in rate of fat removal and resistance to cannula advancement giving a P value of .0096. Only 5 of 19 aspirates were graded as differing in redness between treatment and control sides. Four of these were more red on the control side and one was more red on the treatment side. Therefore 15 of 19 had no better result with treatment, giving a P value of .0022. Seven patients graded the sensation during suctioning and/or postoperative course as better on the control side, four graded these variables as better on the treatment side, four showed no difference between the two sides, and four had mixed results. This gives only 4 of the 19 patients showing any advantage in treatment with a P value of .0022.

CONCLUSION

When the placebo effect is eliminated, there is no advantage to the application of external ultrasound prior to liposuction.

Characteristics of systemic antibody responses of nonhuman primates to cell envelope and cell wall antigens from periodontal pathogens

The immune response of the primate, Macaca fascicularis, to cell envelope (CEA) or cell wall (CWA) antigens of several periodontal pathogens was examined to develop a strategy to interfere with ligature-induced periodontitis. Animals were parenterally immunized with CEA of either Porphyromonas gingivalis, Prevotella intermedia or a combination of CEA/CWA of Campylobacter rectus, Fusobacterium nucleatum and Actinomyces viscosus. Serum samples were taken every 2-4 weeks over a 4-month period, which included a 13-week interval with molar teeth ligated. All of the nonhuman primates in the study exhibited baseline levels of IgG, IgM and IgA antibody to formalinized whole cells of the bacteria. These levels increased significantly following immunization and were elevated above baseline throughout the remainder of the experiment. The largest change in antibody responses was seen in IgA antibody levels of P. gingivalis and C. rectus (42-fold above baseline), IgM antibody to P. intermedia, (41-fold increase) and IgG antibody to F. nucleatum and A. viscosus (32 and 63-fold increases). Moreover, the nonhuman primates exhibited differences in isotype response levels to whole microorganisms compared with the cell envelope antigens. These findings demonstrate the capacity of these nonhuman primates to produce an active immune response to microorganisms chronically colonizing the subgingival microbiota. Additionally, it appears that the bacteria may exhibit some unique differences in their immunogenicity as detected by the nonhuman primate and may contribute to the ability of the immune responses to effectively interact with these pathogens.

Treatment of melasma with Jessner's solution versus glycolic acid: a comparison of clinical efficacy and evaluation of the predictive ability of Wood's light examination

BACKGROUND

Melasma can be resistant to topical therapy.

OBJECTIVE

Our purpose was to evaluate the efficacy of superficial peels in conjunction with topical tretinoin and hydroquinone in patients with melasma and to evaluate the ability of Wood's light examination to predict response to treatment.

METHODS

We measured increased light reflectance in melasma areas with a colorimeter. Clinical observations were scored through an index designed to weigh numerically homogeneity, intensity of color, and area of melasma.

RESULTS

Colorimetric analysis showed an average lightening of 3.14 +/- 3.1 on the glycolic acid-treated side and 2.96 +/- 4.84 on the Jessner's solution-treated side. There was no statistically significant difference between the right and left. There was an overall decrease in melasma area and severity of 63%.

CONCLUSION

Superficial peels hasten the effects of topical therapy in melasma. Wood's light examination did not help predict response to treatment.

Long-term efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses

BACKGROUND

Few studies have examined the long-term efficacy of fluorouracil (FU) or chemical peels for the treatment of actinic keratoses (AK). Our earlier work examined the efficacy and safety of a medium-depth chemical peel compared with the standard regimen of topical FU in the treatment of widespread facial AK through 12 months.

OBJECTIVES

To determine long-term efficacy of both treatments by extending our observations through 32 months.

METHODS

Fifteen patients with severe facial actinic damage were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% FU cream for 3 weeks. Parameters evaluated at 1, 6, 12, and 32 months included counts of visible AK, random skin biopsies from both treatment areas, development of intercurrent neoplasms, and surveys assessing sun exposure.

RESULTS

Eight patients were available for reevaluation at 32 months. Both treatment sides showed a reduction in mean number of AK at 12 months followed by an increase in mean AK number between 12 and 32 months. Improvements in biopsies of clinically actinically damaged skin were seen in keratinocytic atypia, hyperkeratosis, parakeratosis, and inflammation at all treatment times during the study with both treatments. Three squamous cell carcinomas developed in the patients after initial treatment; one developed on the side treated with the peel, and two developed on the side treated with fluorouracil. Surveys failed to demonstrate an association between sun exposure and clinical response.

CONCLUSION

Based on these findings, patient with widespread actinic keratoses treated with medium-depth chemical peel or with 5% FU should be reevaluated yearly or every 1.5 years for reappearance of AK and retreatment.

Preliminary characterization of the role of protein serine/threonine phosphatases in the regulation of human lung mast cell function

1. Okadaic acid, a cell permeant inhibitor of protein serine/threonine phosphatases (PPs), attenuated the IgE-dependent release of mediators from human lung mast cells (HLMC). The concentration of okadaic acid required to inhibit by 50% (IC50) the IgE-dependent release of histamine was 0.2 microM. Okadaic acid also inhibited the IgE-mediated generation of prostaglandin D2 (PGD2) and sulphopeptidoleukotrienes (sLT) with IC50 values of 0.2 microM and 0.6 microM respectively. 2. The IgE-mediated generation of histamine, PGD2 and sLT was inhibited by okadaic acid and two analogues of okadaic acid, okadaol and okadaone, with the following rank order of activity; okadaic acid > okadaol > okadaone. This order of activity for the inhibition of mediator release parallels the activity of these compounds as inhibitors of isolated PPs. 3. Extracts of HLMC liberated 32P from radiolabelled glycogen phosphorylase and this PP activity was inhibited by the PP inhibitors (all at 3 microM), okadaic acid (73 +/- 4% inhibition, P < 0.0005), okadaol (26 +/- 7% inhibition, P < 0.05) and okadaone (8 +/- 7% inhibition, P = 0.52). The rank order of activity of okadaic acid > okadaol > okadaone parallels the activity of these compounds as inhibitors of isolated PPs. 4. Dephosphorylation of radiolabelled glycogen phosphorylase by extracts of HLMC was inhibited by 15 +/- 3% (P < 0.001) by a low (2 nM) concentration of okadaic acid and by 88 +/- 4% (P < 0.0005) by a higher (5 microM) concentration of okadaic acid. Because 2 nM okadaic acid may act selectively to inhibit PP2A whereas 5 microM okadaic acid inhibits both PP1 and PP2A, these data suggest that both PP1 and PP2A are present in HLMC. 5. Inhibitor 2, a PP1-selective inhibitor, attenuated (71 +/- 3% inhibition, P < 0.05) PP activity in extracts of HLMC suggesting that HLMC contain PP1 and that it may constitute 71% of the phosphorylase PP activity in extracts of HLMC. 6. Radiolabelled casein, a PP2A-restricted substrate, was dephosphorylated by extracts of purified HLMC and this activity was inhibited (81 +/- 8% inhibition, P < 0.005) by 2 nM okadaic acid suggesting that PP2A is resident in HLMC. 7. Collectively, these data suggest that both PP1 and PP2A are resident in HLMC. However, although the data suggest that okadaic acid regulates responses in HLMC by interacting with PPs, it has not been possible to determine whether either PP1 or PP2A or both PPs are involved in the okadaic acid-induced inhibition of mediator release from HLMC.

A comparison of the efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses

BACKGROUND AND DESIGN

We compared the efficacy and safety of a medium-depth chemical peel with those of the standard regimen of topical fluorouracil in the treatment of widespread facial actinic keratoses (AK). Fifteen patients with severe facial actinic damage and similar numbers of AK on both sides of the face were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% fluorouracil cream for 3 weeks. Evaluations were conducted before treatment and at 1, 6, and 12 months after treatment. Visible AK were counted, random skin biopsies performed, adverse effects monitored, and patients questioned about preference and perception of efficacy.

RESULTS

Both treatments reduced the number of visible AK by 75% and produced equivalent reductions in keratinocyte atypia, hyperkeratosis, parakeratosis, and inflammation, with no significant alteration of preexisting solar elastosis and telangiectasia. Except for erythema that lasted 3 months in one patient, no untoward side effects were observed with the chemical peel. The majority of patients preferred the peel over fluorouracil because of the single application and less morbidity.

CONCLUSION

The medium-depth peel induced by Jessner's solution and 35% trichloroacetic acid is a useful alternative therapeutic option for widespread facial AK, particularly for poorly compliant patients, because it equals fluorouracil in efficacy while being superior in terms of the convenience of a single application with little associated morbidity.

Pemphigus erythematosus in a five-year-old child

A 5-year-old girl had pemphigus erythematosus based on clinical and immunohistologic criteria. The rare occurrence in childhood of the pemphigus group of disorders, and of pemphigus erythematosus in particular, is discussed. We also review current knowledge concerning the delineation of the different pemphigus subsets and the treatment of pemphigus erythematosus.

A spectrum of inflammatory metastasis to skin via lymphatics: three cases of carcinoma erysipeloides

We report a case in which carcinoma erysipeloides was the first sign of the primary malignancy in a patient with a rare form of prostate carcinoma (mixed adenosquamous type) and two cases in which carcinoma erysipeloides was a marker of tumor recurrence in two patients with breast carcinoma. The value of recognizing the distinctive inflammatory manifestation of carcinoma erysipeloides and the significance of dermal lymphatic involvement in this form of skin metastasis are discussed.

Salivary IgA responses to Porphyromonas gingivalis in the cynomolgus monkey. 1. Total IgA and IgA antibody levels to P. gingivalis

Porphyromonas gingivalis has been associated with the subgingival plaque of advancing disease lesions in various types of periodontitis. Additionally, this species of oral microorganism has been found to increase dramatically in ligature-induced periodontitis in nonhuman primates (Macaca fascicularis) and has recently been shown to induce progressing disease when implanted into the subgingival plaque in this animal model. Although systemic antibody responses have been demonstrated to P. gingivalis in both human and nonhuman primate with periodontitis, no information is available on the oral secretory IgA antibody response to this bacteria. This report describes the methods for reproducible collection of salivary secretions from cynomolgus monkeys and the development of methods for analyzing salivary IgA levels and specific IgA antibody in the saliva reactive with P. gingivalis. Purification of monkey salivary IgA allowed quantification of IgA using an enzyme-linked immunosorbent assay (ELISA). Estimation of total IgA levels in saliva showed approximately a 20% greater level of IgA in whole versus parotid saliva from a group of 13 monkeys, with a 2-3 fold variation in levels among this group of animals. Naturally occurring salivary IgA antibody to P. gingivalis, as measured by ELISA, were routinely detectable but low in whole saliva; however, many of the parotid saliva specimens collected exhibited negligible levels of antibody to this microorganism. The IgA antibody in whole saliva showed nearly an 18-fold variation among the samples from the monkeys. Correlational analyses indicated that, although there was a positive relationship between antibody levels in whole and parotid saliva, the majority of natural IgA antibody in whole saliva appears to be derived from other sources.(ABSTRACT TRUNCATED AT 250 WORDS)

Propagation of small bowel migrating motor complex activity fronts varies with anastomosis type

Fasting small intestine motility (migrating motor complex or MMC) occurs in humans and dogs in four phases. Activity fronts during phase III consist of high amplitude contractions propagating aborally and are interrupted by transection of the small intestine. To study the effect of anastomosis type on MMC propagation six dogs underwent resection of a 15-cm segment of bowel 45 cm distal to the ligament of Treitz and single layer hand sewn end-to-end (EE) anastomosis. Single layer end-to-side (ES) or side-to-side (SS) anastomoses were hand sewn 15 cm distal to the transection in six other dogs. Eight force transducer strain gauges were placed at 10-cm intervals about each anastomosis. At least 7 days after operation, small bowel contractions were recorded in fasted animals, and recordings were visually inspected. Only 1 of 36 activity fronts propagated across the end-to-end anastomosis within 45 days of surgery. However, after 60 days 25 of 39 phase III activity fronts propagated. There was no propagation of MMC activity across the ES anastomosis and only 10% of activity fronts propagated across the SS anastomosis. We conclude phase III MMC activity front propagation is interrupted by small bowel transection. Propagation regenerates after EE anastomosis, but not after ES or after SS anastomoses, even after prolonged healing.

Grouping of beta-haemolytic streptococci by agglutination

Streptococcal grouping sera, diluted and absorbed to remove cross-reactions, were bound to staphylococci and used to group trypsinised beta-haemolytic streptococci by coagglutination. The results compared well with those obtained using the Phadebact streptococcal grouping kit. The same sera bound to staphylococci without prior dilution and absorption could be used to group enzyme extracts of haemolytic streptococci by slide agglutination, the results again comparing favourably with those of the Phadebact kit.

Placental phosphatase of maternal serum: relationship to pregravid weight, prenatal weight gain, and infant birthweight in normal human pregnancies

Serum placental phosphatase (heat-stable alkaline phosphatase, HSAP) was measured in the following gravidae with normal weight gain: 71 normal weight normal subjects (NWN), 26 overweight normal subjects (OWN), and 28 underweight normal subjects (UWN); and in the following gravidae with excess gain (XsG), small gain (SmG), or weight loss (WtL): 11 NWN-XsG, seven NWN-SmG, seven OWN-SmG, two OWN-XsG, three OWN-WtL, and five UWN-XsG. The NWN regression equation between 31 and 40 weeks was: Y = 0.66X - 18.44. Overweight subjects' HSAP values were typically below and underweight subjects' values were above the regression line, providing that the weight gain was not less than normal in the overweight group or greater than normal in the underweight group. The average difference from the NWN regression line for each subject was designated "deltaHSAP." The differences between the mean delta HSAP values was statistically significant for: NWN versus OWN, NWN versus UWN, OWN versus UWN, NWN-XsG versus NWN-SmG, NWN-SmG, NWN versus NWN-XsG, and OWN versus OWN-WtL. The higher delta HSAP values were associated with relative caloric insufficiency, the lower values with relative caloric excess. A low degree of inverse correlation was found between infant birthweight and delta HSAP (r = -0.37; P less than 0.002).