Genetic analysis of inherited bone marrow failure syndromes from one prospective, comprehensive and population-based cohort and identification of novel mutations

INTRODUCTION

Inherited bone marrow failure syndromes (IBMFSs) often have substantial phenotypic overlap, thus genotyping is often critical for establishing a diagnosis.

OBJECTIVES AND METHODS

To determine the genetic characteristics and mutation profiles of IBMFSs, a comprehensive population-based study that prospectively enrols all typical and atypical cases without bias is required. The Canadian Inherited Marrow Failure Study is such a study, and was used to extract clinical and genetic information for patients enrolled up to May 2010.

RESULTS

Among the 259 primary patients with IBMFS enrolled in the study, the most prevalent categories were Diamond-Blackfan anaemia (44 patients), Fanconi anaemia (39) and Shwachman-Diamond syndrome (35). The estimated incidence of the primary IBMFSs was 64.5 per 10(6) births, with Fanconi anaemia having the highest incidence (11.4 cases per 10(6) births). A large number of patients (70) had haematological and non-haematological features that did not fulfil the diagnostic criteria of any specific IBMFS category. Disease-causing mutations were identified in 53.5% of the 142 patients tested, and in 16 different genes. Ten novel mutations in SBDS, RPL5, FANCA, FANCG, MPL and G6PT were identified. The most common mutations were nonsense (31 alleles) and splice site (28). Genetic heterogeneity of most IBMFSs was evident; however, the most commonly mutated gene was SBDS, followed by FANCA and RPS19.

CONCLUSION

From this the largest published comprehensive cohort of IBMFSs, it can be concluded that recent advances have led to successful genotyping of about half of the patients. Establishing a genetic diagnosis is still challenging and there is a critical need to develop novel diagnostic tools.

Adipose differentiation-related protein regulates lipids and insulin in pancreatic islets

The excess accumulation of lipids in islets is thought to contribute to the development of diabetes in obesity by impairing beta-cell function. However, lipids also serve a nutrient function in islets, and fatty acids acutely increase insulin secretion. A better understanding of lipid metabolism in islets will shed light on complex effects of lipids on beta-cells. Adipose differentiation-related protein (ADFP) is localized on the surface of lipid droplets in a wide range of cells and plays an important role in intracellular lipid metabolism. We found that ADFP was highly expressed in murine beta-cells. Moreover, islet ADFP was increased in mice on a high-fat diet (3.5-fold of control) and after fasting (2.5-fold of control), revealing dynamic changes in ADFP in response to metabolic cues. ADFP expression was also increased by addition of fatty acids in human islets. The downregulation of ADFP in MIN6 cells by antisense oligonucleotide (ASO) suppressed the accumulation of triglycerides upon fatty acid loading (56% of control) along with a reduction in the mRNA levels of lipogenic genes such as diacylglycerol O-acyltransferase-2 and fatty acid synthase. Fatty acid uptake, oxidation, and lipolysis were also reduced by downregulation of ADFP. Moreover, the reduction of ADFP impaired the ability of palmitate to increase insulin secretion. These findings demonstrate that ADFP is important in regulation of lipid metabolism and insulin secretion in beta-cells.

Association of oral candidal carriage with dental caries in children

INTRODUCTION

Oral candidiasis is one of the most common opportunistic oral fungal infections. Oral candidal carriage in schoolchildren is a subject of increasing interest worldwide and has recently been associated with increased caries incidence in children.

AIMS

This study was carried out to identify association between oral candidal carriage in children and dental caries.

SUBJECTS AND METHODS

One hundred subjects with an age range between 6 and 12 years were included in this study. The subjects were distributed equally into two groups, i.e., study (caries-positive) and control (caries-free) groups. Oral hygiene index and DMFT/dmft scores were recorded for each subject. Sampling for Candida was carried out using intraoral swabs and concentrated oral rinse. Sabouraud dextrose agar containing 0.1 mg/ml of chloramphenicol was used as the primary culture medium. Candida was identified by employing API-20C AUX and germ tube formation tests.

RESULTS

The subjects in the caries-positive group showed a high frequency of oral candidal carriage compared to the caries-free subjects and the results were statistically very significant (p < 0.01). The odds ratio was 67.37, implying a high caries risk with positive oral candidal carriage (95% CI 14-323).

DISCUSSION

The findings of this study underscore the possible association of Candida with dental caries.

CONCLUSIONS

The occurrence of dental caries in children with mixed dentition is positively correlated with the frequency of oral candidal carriage.

Facial tuberculoid leprosy: case report

Leprosy is a chronic, infectious, systemic disease caused by Mycobacterium leprae and is classified as paucibacillary and multibacillary types. It is contagious and has an insidious onset. Clinical presentation is characterised by hypopigmented skin lesions with reduced sensation. Presence of acid-fast bacilli in tissue specimens is regarded as a gold standard for diagnosis. Treatment is based on multi-drug regimens. We report a case of borderline tuberculoid leprosy in a 31-year-old woman.

Antenatal screening for Down's syndrome using the Integrated test at two London hospitals

We carried out an audit of antenatal screening for Down's syndrome using the Integrated test (which provides a single screening result from information collected in the late first and early second trimesters of pregnancy) which was introduced into routine antenatal care at two London hospitals, University College Hospital (UCH) and St Mary's Hospital, in 2003–4. The audit was based on 15,888 women who accepted screening and booked in the first trimester. The Down's syndrome detection rate was 87% (95% confidence interval [CI], 74–95) consistent with an expected detection rate of 89% based on applying the estimates of screening performance of the Serum, Urine and Ultrasound Screening Study (SURUSS) to the maternal age distribution of women who were screened at UCH and St Mary's. The observed false-positive rate was 2.1% (95% CI, 1.9–2.3), compared with an expected of 2.5% for women of the same age. An audit trail (conducted at UCH) indicated that 98% (10,746/10,961) of women accepted integrated screening (2% having a first trimester test) and of these, 94% (10, 116) completed both stages of the test. The audit demonstrated that it is feasible to conduct integrated screening within the NHS with a high acceptance rate and a screening performance consistent with that determined from previous research studies.

Influenza and respiratory syncytial virus infections in British Hajj pilgrims

Viral respiratory infections including influenza and respiratory syncytial virus (RSV) have been reported during the Hajj among international pilgrims. To help establish the burden of these infections at the Hajj, we set up a study to confirm these diagnoses in symptomatic British pilgrims who attended the 2005 Hajj. UK pilgrims with symptoms of upper respiratory tract infection (URTI) were invited to participate; after taking medical history, nasal swabs were collected for point-of-care testing (PoCT) of influenza and for subsequent PCR analysis for influenza and RSV. Of the 205 patients recruited, 37 (18%) were positive for either influenza or RSV. Influenza A (H3) accounted for 54% (20/37) of the virus-positive samples, followed by RSV 24% (9/37), influenza B 19% (7/37), and influenza A (H1) 3% (1/37). Of the influenza-positive cases, 29% (8/28) had recently had a flu immunisation. Influenza was more common in those who gave a history of contact with a pilgrim with a respiratory illness than those who did not (17 versus 9%). The overall rate of RSV was 4% (9/202). This study confirms that influenza and RSV cause acute respiratory infections in British Hajj pilgrims. Continuing surveillance and a programme of interventions to contain the spread of infection are needed at the Hajj, particularly when the world is preparing for an influenza pandemic.

MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis

AIMS

To identify the relationship between depth and size of soft-tissue mass lesions relative to histological diagnosis in a range of malignant neoplastic, benign neoplastic, and non-neoplastic conditions on magnetic resonance imaging (MRI).

METHOD

The MRI findings of 571 consecutive patients referred to a supra-regional orthopaedic oncology unit with a suspected soft-tissue neoplasm were reviewed and included in the study. The patient age, histological diagnosis, lesion size, anatomical location, and lesion depth (superficial or deep to fascia) were recorded.

RESULTS

There were 288 males and 283 females (mean age 48 years, age range 2-92 years). The mean age was 54.1 years for malignant neoplastic lesions compared with 40.1 years for benign neoplastic and 45.4 years for non-neoplastic conditions. There was a significant age difference when malignant lesions were compared with benign neoplastic and non-neoplastic lesions (p<0.001). No significant relationship was present between lesion depth (480 deep, 91 superficial) and diagnosis (288 malignant neoplastic, 197 benign neoplastic and 86 non-neoplastic lesions). However, a significant relationship was identified between lesion size and diagnosis (p<0.001). Furthermore, a significant relationship was identified when lesion size greater than 5 cm, lesion depth, and diagnosis were analysed.

CONCLUSION

Current guidelines suggest the most important variables for assessing risk of malignancy in a soft-tissue lesion include size, depth in relation to the fascia, increasing size, and pain. The current study suggests that relationship to fascia is less important as a predictor of malignant potential in a patient cohort treated at a supra-regional centre. Significant risk factors include increasing patient age and lesion size greater than or equal to 5 cm.

Disease progression in recently diagnosed patients with inherited marrow failure syndromes: a Canadian Inherited Marrow Failure Registry (CIMFR) report

BACKGROUND

Inherited bone marrow failure syndromes (IMFSs) are genetic disorders characterized by defective single-lineage or multi-lineage hematopoiesis. IMFS patients are at risk for severe cytopenias, development of marrow cytogenetic abnormalities (MCA), myelodysplasia (MDS), and malignancy. The rate of disease progression and proportion of patients at risk for these complications is currently unclear. We examined recently diagnosed IMFS patients to determine distribution of diagnoses, disease progression and development of significant outcomes.

METHODS

The CIMFR is a prospective multi-center study established in 2001 to register all IMFS patients in Canada. Analysis was restricted to patients diagnosed after November 30, 1997. Summary statistics were used to depict the study population while survival was described using the Kaplan-Meier method.

RESULTS

74 CIMFR patients were considered recently diagnosed. Median age at diagnosis was 2.7 years (range, birth to 40.6). Annual follow-up data were available for 53 (72%) patients. The five most prevalent diagnoses were Fanconi anemia (FA), Shwachman-Diamond syndrome (SDS), Diamond-Blackfan anemia (DBA), dyskeratosis congenita (DKC), and Kostmann's neutropenia (KS). Eighteen (24%) patients were unclassifiable. Twenty-eight (53%) follow-up patients had disease progression as indicated by new or worsening cytopenias, new marrow changes, or initiation of transfusion support and/or medical therapy. Fourteen (19%) fulfilled minimal diagnostic criteria for myelodysplasia. Eleven patients had hematopoietic stem cell transplantation (HSCT) by first follow-up. Five patients have died. Survival at 36 months is 89.8 +/- 5.7%.

CONCLUSIONS

IMFS patients are often diagnosed at a young age. The relative distribution of diagnoses is similar to previous reviews of published cases; however, 25% of patients are currently unclassifiable. Disease progression has occurred in approximately 50% of follow-up patients. Early mortality is noted. Continued prospective observation of these patients is warranted.

Patients' perceived health status following primary surgery for oral and oropharyngeal cancer

How oral and oropharyngeal cancer patients view their 'quality of life' is of fundamental importance. Any differences seen in their health state compared with normative data and with other disease conditions allows a wider perspective on their outcome after surgery. A cross-sectional postal survey was undertaken of patients treated for oral/oropharyngeal squamous cell carcinoma by primary surgery using the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL v4) and the EuroQol EQ-5D. Of 348 patients surveyed, 224 returned analysable forms, (response rate 64%). In the EQ-5D items, 40% of the group reported a problem in walking, 23% with self-care, 44% in performing usual activities, 50% with pain or discomfort and 33% with anxiety or depression. The mean overall health visual analogue scale (VAS) score was 74 (SE 1) minimum 30 and maximum 100. The mean utility (health index) score was 0.75 (SE 0.02) minimum -0.18 and maximum 1.0. Compared to national reference data, patients in our cohort of under 60 years of age fared significantly worse than expected for their age but this was not so for older patients. There were strong correlations between appropriate domains of the EQ-5D and UW-QOLv4 and between UW-QOL global measures and EQ-5D VAS.

A survey of factor prophylaxis in the Canadian haemophilia A population

High-dose factor prophylaxis, defined as the infusion of 25-40 factor (F) VIII International Units (IU) kg bodyweight (bw)(-1)> or = x 3 per week, started at age 1-2 years of life in boys with severe haemophilia A prevents the development of significant bleed-related arthropathy. However, programmes of prophylaxis are very expensive and venous access is a challenge. To ascertain patterns of prophylaxis in Canada during the period of a global shortage of recombinant FVIII concentrate a survey was conducted in 2001. The response rate was 83% and the survey identified 247 inhibitor-negative haemophilia A cases receiving prophylaxis, defined as the regular administration of FVIII at least once weekly, from 14 Canadian haemophilia treatment centres. The median age of the group identified was 13 years (range: 1-65) and 95% of cases had severe haemophilia A defined by a circulating factor level of <1%. The median FVIII infusion dose was 26 (range: 16-33) IU kg(-1); infusions were administered > or = x 3 per week in 67% of cases. High-dose factor prophylaxis was used most frequently in boys <5 years of age (23 of 28 cases, 82%) as compared with 56% (56 of 100), 66% (40 of 61) and 62% (36 of 58) of males ages 5-12, 13-18 and >18 years. Prophylaxis accounted for 50% of the annual Canadian FVIII consumption and was a major driving force in the 10% increase (=19.3 million FVIII IU) in the FVIII consumption in Canada in the 4-year period 1999-2003. Given the economic implications of increased use of prophylaxis prospective studies are warranted to better define optimal prophylaxis regimens in the haemophilia A population.

Quality of Life Evaluations of Caregivers of Ovarian Cancer Patients During Chemotherapy Treatment

OBJECTIVES

(1) To examine the quality of life (QOL) of caregivers of women undergoing chemotherapy for advanced ovarian cancers, and (2) to correlate the QOL measures of caregivers to those of the women undergoing chemotherapy.

METHODS

Over a 9-month period, all women undergoing chemotherapy for ovarian cancer at the Saskatoon Cancer Centre, and their caregivers, were offered participation. Two well-validated instruments were used to measure the "quality of life" concept. Women with ovarian cancer completed the Functional Assessment of Cancer Therapy--Ovarian (FACT-O) questionnaire in the clinic prior to each course of chemotherapy. Each caregiver completed a Caregiver Quality of Life Index--Cancer (CQOL-C) questionnaire at home at the start and conclusion of each chemotherapy regimen (cycle 1 and after the last chemotherapy treatment). The demographics of the caregivers were described. A paired t test was used to detect changes to caregivers' QOL scores before and after chemotherapy treatment. Correlation analysis was carried out to examine the relationship between the caregivers' total QOL scores and the various subscale and total scores of the FACT-O questionnaires completed by the women with ovarian cancer. Multivariate regression models were constructed to examine the relative importance of each of the QOL domain measures of the woman with cancer in predicting the effect on her caregiver's QOL.

RESULTS

Thirty different patient-caregiver pairs participated in the study, providing 50 separate assessments since not all pairs had completed the post-chemotherapy assessments. There was improvement (P <.05) in the caregiver's QOL scores at the conclusion of the chemotherapy treatment compared to the baseline assessments. The improvement was unrelated to the performance status or response to chemotherapy of the woman undergoing treatment. There was also a correlation (P <.05) between an increase in a caregiver's distress and worsening scores in the "emotional," "functional," and "concerns" QOL domain assessments of the woman undergoing treatment. Stepwise regression analysis showed the "concerns" score, measuring specific ovarian cancer-related symptoms, to be the only predictor of a caregiver's distress (P <.05).

CONCLUSIONS

Standard chemotherapy for ovarian cancer does not worsen a caregiver's QOL. There is a direct relationship between the QOL of women with cancer and that of their caregivers. Future research is required to identify how best to integrate the results of QOL assessments in cancer treatment protocols and to examine the long-term effects of ovarian cancer and its treatment on both caregivers and the women for whom they care.

Quality-of-life issues in patients with ovarian cancer and their caregivers: a review

Significant progress has been made towards the treatment of ovarian cancer resulting in longer median survival despite a persistent low cure rate. Relatively few studies have examined the impact of the cancer and its treatment on the patients and their caregivers due to the difficulty in the definition and measurement of the Quality of Life (QOL) concept. A review of the literature revealed significant alterations in the quality of life of ovarian cancer patients during treatment and long term follow ups. For the caregivers, it is important for health care providers to realize that: 1) caregivers are being asked to assume an increasing number of complex care giving tasks at home, 2) there exists a high proportion of unmet caregiver needs, 3) the care giving experience includes both positive and negative elements and, 4) perception of caregivers' burden is positively linked to negative reactions to care giving. Supportive programs for patients and caregivers should be designed with these needs in mind. Future research should study the best way to incorporate results of quality of life assessments into routine treatment decision-making.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to outline the current data on QOL issues in patients with ovarian cancer, and to describe potential working definitions of QOL.

Quality of life evaluations in patients with ovarian cancer during chemotherapy treatment

OBJECTIVES

To examine the impact of treatment- and disease-related factors on the quality of life of patients with ovarian cancers undergoing chemotherapy.

PATIENTS AND METHODS

Over 18 months period, all patients with ovarian cancer receiving chemotherapy at the Saskatoon Cancer Center were recruited. The Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaire was used to assess patients' quality of life before each chemotherapy cycle. Platinum-based chemotherapy was used initially or in patients with a platinum-free interval of more than 6 months in a recurrence setting. After progression on the platinum-based regimens, liposomal doxorubicin, topotecan, and cisplatinum/etoposide were used as salvage chemotherapy pending on drug availability and convenience of administration to patients. Regression analysis was used to identify significant disease and treatment-related factors that can significantly affect patients' quality of life measures.

RESULTS

Seventy-two patients participated in the study providing 270 separate observations. The mean age was 57.81 years with a standard deviation of 13.40. The median duration of chemotherapy-free interval for patients with recurrent disease was 7 months. All patients had stage 3 or 4 disease. About half (52.2%) of the patients had optimal surgical resection with small (<1 cm) residual cancer masses before primary adjuvant chemotherapy. Seventy percent of the patients had either a first diagnosis or a first recurrence of cancer with the other 30% previously treated with two or more chemotherapy regimens. Sixty-two percent had an initial complete response to platinum-based chemotherapy. Multivariate regression analysis showed the use of topotecan or cisplatinum/etoposide, patients' poor responses to chemotherapy, experience with two or more previous line of chemotherapy treatment, and younger ages were significant predictors of poor quality of life during chemotherapy.

CONCLUSION

There were significant differences in side effects of commonly used chemotherapy regimens on patients' quality of life. Quality of life assessments should be routinely incorporated in selecting specific chemotherapy to be used. Future research should be carried out to identify the best strategies to further integrate the results of quality of life assessments in cancer treatment protocols and to examine the long-term effects of cancer and its treatment on patients and their families.

Antioxidant vitamins improves hemoglobin level in children with group a beta hemolytic streptococcal infection

A study was done on school children infected with group A beta hemolytic streptococci to examine whether antioxidant vitamins play a role in improving the hemoglobin level. A total of 606 primary school children aged 5 to 15 years were randomly divided into two intervention groups. Group 1 (n=299) was treated with pehnoxymethyl penicillin V and group 2 (n=307) was treated with phenoxymethyl penicillin V plus antioxidant vitamins for eight weeks. From each group two blood samples were drawn in acute and convalescent (after eight weeks) states. Before treatment, mean hemoglobin values were 11.0 and 10.8 mg/dL in groups 1 and 2 respectively. After treatment hemoglobin values were 10.5 and 11.6 mg/dL respectively. Values were significantly decreased in group 1 (P=0.0001), whereas increased in group 2 (P=0.001). Adjustment for age and sex by ANCOVA confirmed the difference in hemoglobin levels between group (LS means-0.5 vs 0.8 in groups 1 and 2 respectively (P=0.0001). Hemoglobin level increases after antioxidant vitamin supplementation in children suffering from group A beta hemolytic streptococcal infection.

Neonatal estrogen exposure of male rats alters reproductive functions at adulthood

The effects of neonatal exposure to different doses of diethylstilbestrol (DES) on the reproductive functions of male rats at adulthood were evaluated. Sprague-Dawley rats (5-8/group) received sc injections of 25 microl olive oil containing DES (Sigma Chemical Co., St. Louis, MO) at a dose of 10 microg, 1 microg, 100 ng, 10 ng, or 1 ng per rat on alternate days from Postnatal Days 2-12. Control animals received olive oil only. All animals were allowed to develop until 83-91 days of age; however, when they were 70 to 80 days old, four male rats each from the 10 microg, 1 microg, 100 ng, and control groups were cohabited with untreated 60- to 70-day-old females (1:1) for 12 days. At the end of cohabitation, both mated and unmated male rats were weighed, and blood and tissue samples were collected and processed. Results revealed that although sperm motility patterns and sperm morphology were adversely affected in the 10- microg group, other reproductive parameters, including 1). daily sperm production (DSP)/testis; 2). absolute and relative weights of the testis, epididymis, and seminal vesicle; and 3). sperm numbers in both regions of the epididymis declined significantly in a dose-dependent manner in the 10- and 1- microg groups. Conversely, in the <1- microg groups, none of these parameters (except DSP/testis and weight of the epididymis in the 100-ng group, and sperm numbers in the epididymis of the 100- and 10-ng groups) was different from controls. Generally, plasma testosterone levels decreased in the 10- and 1- microg groups, FSH level increased in the 10-microg group, and prolactin and LH levels were unaltered. In the fertility study, although each male in the 1-microg, 100-ng, and control groups produced a copulatory plug and impregnated a female, none could do so in the 10-microg group. The mean number of pups per litter was reduced to eight in the 1-microg group, in contrast to 15 each in the 100-ng and control groups. In conclusion, exposure of neonatal male rats to DES altered sperm motility patterns, sperm fertility (as evident from the reduced number of pups in the 1-microg group), and sexual behavior (as evident from the absence of copulatory plugs in the 10-microg group) and reduced weights of reproductive organs, DSP/testis, and sperm numbers in the epididymis. Whether these alterations/reductions persist in older rats (6-8 mo of age) is under investigation.

Ancient adaptation of the active site of tryptophanyl-tRNA synthetase for tryptophan binding

The amino acid binding domains of the tryptophanyl (TrpRS)- and tyrosyl-tRNA synthetases (TyrRS) of Bacillus stearothermophilus are highly homologous. These similarities suggest that conserved residues in TrpRS may be responsible for both determining tryptophan recognition and discrimination against tyrosine. This was investigated by the systematic mutation of TrpRS residues based upon the identity of homologous positions in TyrRS. Of the four residues which interact directly with the aromatic side chain of tryptophan (Phe5, Met129, Asp132, and Val141) replacements of Asp132 led to significant changes in the catalytic efficiency of Trp aminoacylation (200-1250-fold reduction in k(cat)/K(M)) and substitution of Val141 by the larger Glu side chain reduced k(cat)/K(M) by 300-fold. Mutation of Pro127, which determines the position of active-site residues, did not significantly effect Trp binding. Of the mutants tested, D132N TrpRS also showed a significant reduction in discrimination against Tyr, with Tyr acting as a competitive inhibitor but not a substrate. The analogous residue in B. stearothermophilusTyrRS (Asp176) has also been implicated as a determinant of amino acid specificity in earlier studies [de Prat Gay, G., Duckworth, H. W., and Fersht, A. R. (1993) FEBS Lett. 318, 167-171]. This striking similarity in the function of a highly conserved residue found in both TrpRS and TyrRS provides mechanistic support for a common origin of the two enzymes.

Study of water quality of Hudiara drain, India-Pakistan

This paper examines the extent of pollution in Hudiara drain water due to untreated industrial and sewage waste of India and Pakistan. Ninety-nine surface water samples from the Pakistani side of the Hudiara drain were collected during September 1997, and April and June 1998. The analytical results of the Hudiara drain samples point out the industrial and sewage inputs from India and Pakistan. Higher values of biochemical oxygen demand (BOD), chemical oxygen demand(COD), total organic carbon(TOC), and trace metals in drain samples from the Indo-Pak border clearly indicate the Indian industrial and sewage pollution. Large variations in the levels of various measured parameters (COD, BOD, TOC, pH, total soluble substances, and trace metals) were observed along the Hudiara drain in the Pakistani vicinity. These variations were due to different types of industrial effluents and small village drains. The study showed that suspended solids(SS), COD, and fecal coliform (FC) were the major pollutants. Accordingly, the most feasible alternative is to convert the drainage network to a sedimentation and temporary storage reservoir. If disinfected, the runoff water can be used for restricted irrigation. Groundwater samples taken from the drain's surrounding area have also been analyzed. Thirty percent of the samples are not fit for drinking purposes due to NO3-N, Se and FC counts as prescribed by World Health Organization (WHO) guidelines. A trilinear diagram clearly indicates the influence of surface water of the Hudiara drain on ground water; moreover, higher values of nitrate and FC clearly indicate the seepage from the Hudiara drain.

Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry

The outcome for children with deep vein thrombosis (DVT) and pulmonary embolism (PE) is unknown. An understanding of morbidity and mortality of DVT/PE is crucial to the development of rational treatment protocols. The Canadian Childhood Thrombophilia Registry has followed 405 children aged 1 mo to 18 y with DVT/PE for a mean of 2.86 y (range, 2 wk to 6 y) to assess outcome. The all-cause mortality was 65 of 405 children (16%). Mortality directly attributable to DVT/PE occurred in nine children (2.2%), all of whom had central venous line-associated thrombosis. Morbidity was substantial, with 33 children (8.1%) having recurrent thrombosis, and 50 children (12.4%) having postphlebitic syndrome. Recurrent thrombosis and postphlebitic syndrome were more common in older children, although deaths occurred equally in all age groups. The incidence of recurrent thrombosis and postphlebitic syndrome are likely underestimated because of difficulties in diagnosis, especially in younger children. The significant mortality and morbidity found in our study supports the need for international multicenter randomized clinical trials to determine optimal prophylactic and therapeutic treatment for children with DVT/PE.

First Report of Soybean Dwarf Virus Infecting Lentil and Beet Western Yellows Virus Infecting Lentil and Chickpea Crops in Ethiopia

A survey conducted during November 14-23, 1998, to identify viruses infecting chickpea (Cicer arietinum) and lentil (Lens culinaris) crops in the Shewa province of Ethiopia covered 33 chickpea and 32 lentil fields randomly selected. Identity of the viruses present and virus incidence were determined on the basis of laboratory testing of 100 to 200 randomly collected samples in addition to 15 to 20 symptomatic samples from each field. A total of 5,427 lentil and 3,836 chickpea samples were collected and tested for the presence of 12 different viruses by tissue blot immunoassay (1) at the Plant Pathology Laboratory in Debre Zeit Agriculture Research Center, Ethiopia. All antisera were virus specific, including those for beet western yellows virus (BWYV; ATCC PVAS-647) and soybean dwarf virus (SbDV; ATCC PVAS-650). More than 21% of the samples from 5 chickpea fields were infected; the most common virus was BWYV. Also, at least 21% of the samples from 11 lentil fields were virus positive; the most widespread virus was PSbMV. Highest rates of infection: of lentil in a single field, PSbMV in 58.5% of the samples; in a chickpea field, 41.3% of the samples positive for BWYV. Other viruses such as faba bean necrotic yellows nanovirus (FBNYV) and broad bean wilt fabavirus in chickpea and FBNYV, broad bean stain comovirus, bean yellow mosaic potyvirus, and cucumber mosaic cucumovirus in lentil were detected at very low incidence. Reference: (1) K. M. Makkouk and A. Comeau. Eur. J. Plant Pathol. 100:71, 1994.

Retroperitoneal actinomycosis masquerading as inflammatory pseudotumor

Inflammatory pseudotumors present clinically as mass lesions and microscopically show a spectrum of nonspecific inflammatory and regenerative changes. When the mesentery or retroperitoneum are involved, differentiation from inflammatory fibrosarcoma poses a diagnostic problem. The authors report on a 7-year-old boy who presented with fever, anemia, weight loss, and a retroperitoneal mass. Needle biopsy results of the mass showed features consistent with inflammatory pseudotumor. Examination of the resected mass showed actinomycosis.

Overnight metabolic fuel deficiency in patients treated conventionally for hypopituitarism

BACKGROUND

Hormone replacement in hypopituitary adults attempts to reproduce normal physiology. Conventional regimens fail to mimic normal hormone profiles over 24 hours.

OBJECTIVE

To investigate the metabolic consequences of conventional hormone replacement in hypopituitary adults by measuring circulating levels of the major fuels, glucose, non-esterified fatty acids (NEFA), glycerol and 3-hydroxybutyrate (3-OHB) over 24 hours in hypopituitary subjects and controls.

SUBJECTS

Ten GH and adrenocorticotrophin deficient hypopituitary adults on conventional replacement and 13 controls matched for age, sex and body mass index were studied. The patients received replacement with hydrocortisone twice daily (at 0730 and 1730 h; mean (range) daily dose 22 (10-30) mg/24 h) but not with GH. Other hormones were replaced as clinically necessary.

MEASUREMENTS

Circulating glucose, NEFA, glycerol and 3-OHB levels were measured over 24 hours together with concentrations of cortisol (total and free), GH and insulin, and urinary free cortisol.

RESULTS

Levels of glucose, NEFA and 3-OHB were lower in patients than controls (mean +/- SEM) (4.3 +/- 0.1 vs 5.3 +/- 0.1 mmol/l, P = 0.0001; 291 +/- 46 vs 448 +/- 48 mumol/l, P = 0.015; 78 +/- 8 vs 136 +/- 24 mumol/l, P = 0.035, respectively) before breakfast. This decrease in glucose, NEFA and 3-OHB was observed in the patient group throughout the night, from midnight to breakfast. For NEFA, the decrease persisted throughout the 24 hours. Glycerol did not differ significantly in patients and controls. Integrated levels of total and free plasma cortisol, and 24-hour urine cortisol excretion, were normal in patients but total and free plasma cortisol concentrations overnight were markedly decreased (overnight area under the curve (AUC) of total cortisol: 440 +/- 154 vs 1593 +/- 267 nmol/l h, P = 0.0024; overnight AUC of free cortisol: 24 +/- 8 vs 161 +/- 26 nmol/l h, P = 0.0001). GH levels were low throughout the whole 24 hours in the patient group (24-hour AUC: 10.6 +/- 5.1 vs 74.6 +/- 19.6 mU/l h, P = 0.008).

CONCLUSIONS

Hypopituitary adults on conventional hormone replacement regimens have low concentrations of metabolic fuels, glucose, non-esterified fatty acids and 3-hydroxybutyrate throughout the night, possibly related to GH deficiency or to decreased overnight circulating cortisol levels. This overnight fuel deficiency may underlie the mechanism for the non-specific symptoms, such as fatigue and headache in the early morning, which are frequent in this group of patients.

[Feasibility of obtaining a highly active mutant of Streptomyces hygroscopicus SU-A5 using induced mutagenesis]

Mutagenic and lethal effects of gamma-radiation, N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) and 4-nitroquanidine-1-oxide were investigated on spore suspensions of Streptomyces hygroscopicus SU-A5. It was shown that all the agents induced high percentage of plus mutants. The most stable and active ones were induced by gamma-radiation. The frequency of the plus mutants and the variation coefficient were used as the criteria of the mutagen efficiency. The successive exposure to gamma-radiation, MNNG and gamma-radiation resulted in the formation of a mutant with the activity 3 times higher than that of the parent strain.

Correcting for ethnicity when defining large for gestational age infants in diabetic pregnancies

The large-for-gestational-age (LGA) infant, defined as > 90th birthweight percentile, is associated with mild disturbances of maternal glucose tolerance. In the UK the same birthweight percentile charts are used for all ethnic groups when assessing LGA infants. The influence of maternal hyperglycaemia on LGA infants of Asian (Indian Subcontinent) mothers in the UK is likely to be under-reported, as Asian birthweights tend to be lower than White/Europid birthweights. We assessed the number of LGA infants born consecutively to 21 Asian and 26 White/Europid mothers with gestational diabetes mellitus (GDM), delivered between 37 and 42 weeks gestation, and also in 34 Asian and 121 White/Europid mothers with a positive screening test for GDM but a normal 75 g oral glucose tolerance test (OGTT). Large-for-gestational-age infants were identified using both the standard UK percentile charts of the Medical Research Council and percentile charts constructed from 30,418 Asian and 162,477 White/Europid singleton births, delivered between 37 and 42 weeks gestation to non-diabetic mothers delivered in the North West Thames Region of England. The standard Medical Research Council percentile charts, compared with the ethnically derived charts, identified fewer LGA Asian (7/56 vs 15/56) but more White/Europid infants (33/147 vs 21/147). When correcting for ethnicity more Asian than White/Europid GDM mothers delivered LGA infants (9/21 vs 3/26, chi 2 = 4.76, p < 0.05). The maternal 2 h OGTT plasma glucose was a significant independent contributor to birthweight in the Asian (r2 = 0.319, p < 0.0005) but not the White/Europid infants, in whom gestational age and maternal height were significant independent contributors to birthweight (r2 = 0.158, p < 0.0001). We conclude that ethnic influences are important when defining LGA infants and that mild disturbances of maternal glycaemia have a greater influence on the birthweight of Asian than White/Europid infants.

Human immunodeficiency virus (HIV) antigen testing to detect HIV infection in female sex workers in Singapore

Human immunodeficiency virus (HIV) infection is characterised by seroconversion after a ¿window¿ period of 2 to 3 months. After this period antibodies are usually detectable by screening tests (enzyme immunoassay or particle agglutination) confirmed by Western blot analysis. We studied 1000 newly enrolled female sex workers who had not been previously tested for HIV to assess the usefulness of HIV antigen testing to improve the efficacy of HIV infection detection. Blood was taken at enrollment for HIV antigen and HIV antibody testing. The Abbott HIVAG-1 test was used to detect antigen; antibody detection was by the Abbott recombinant HIV-1/HIV-2 3rd generation enzyme immunoassay (EIA) test, the Fujirebio Serodia-HIV particle agglutination (PA) test for screening, and the Diagnostic Biotechnology HIV Blot 2.2 Western blot (WB) test for antibody confirmation. Of the 1000 samples, 26 were positive for HIV antibody testing (26/26 for EIA, 25/25 for PA, 26/26 for WB), giving a prevalence rate of 2.6%, Of these 26 seropositive samples 1 was positive on HIV antigen testing. There were no samples which were antigen-positive and antibody-negative. HIV antigen testing does not add to increased efficacy of HIV detection among female sex workers in Singapore.

The Canadian Hemophilia Registry as the basis for a national system for monitoring the use of factor concentrates

BACKGROUND

Canada's publicly funded blood system has recently introduced high-purity concentrates as the standard treatment for individuals with hemophilia. The added cost and the need to document patient outcomes have prompted the consideration of a national blood product monitoring system.

STUDY DESIGN AND METHODS

This study investigates the suitability of the Canadian Hemophilia Registry (CHR) as the basis of such a monitoring system by assessing the degree to which it represents users of factor concentrates.

RESULTS

Currently, there are 1978 individuals registered with the CHR, of whom 1594 (81%) have hemophilia A and 384 (19%) have hemophilia B. The total prevalence is 7.2 per 10(5) population, with the prevalence of severe cases being 2.3 per 10(5). This overall prevalence is similar to that seen in other countries with national registries. The CHR national prevalence also compares favorably with that in the province of Quebec, where registration of users of blood products is compulsory. The CHR figures indicate that the number of persons currently infected with human immunodeficiency virus, both alive and dead, is 652, which is similar to the number of applicants (658) to the federal government's assistance program. The registry is stable, and the number of persons with severe cases, other than young children, newly registered or lost to follow-up during the last 2 years is very small.

CONCLUSION

The CHR includes the vast majority of factor concentrate users and is therefore ideal as the basis for a national monitoring system.

Evaluation of enzyme immunoassay for the detection of anogenital infections caused by Chlamydia trachomatis

BACKGROUND--Infection caused by Chlamydia trachomatis is now recognised as the most prevalent sexually transmitted disease in many parts of the world. Anorectal infections caused by C. trachomatis is not uncommon. Enzyme-linked immunoassay (EIA) detects an antigen lipopolysaccharide (LPS) of C. trachomatis directly in clinical specimens. OBJECTIVE--Our aim was to compare an enzyme immunoassay, Wellcozyme Chlamydia (WZ04) with cell culture for the diagnosis of chlamydial infection of the anogenital tract. METHOD--Rectal swabs were taken from 100 prostitutes (80 females and 20 males) for chlamydia culture, WZ04 and direct immunofluorescence (DIF). In addition, endocervical specimens were obtained from the females for the above three tests. MAIN FINDINGS--All the positive rectal specimens were from females. Nine patients had a positive chlamydia culture from the rectum but negative WZ04 and DIF. Two patients had false positive results by WZ04 but negative culture and DIF. For cervical specimens, WZ04 identified 43% (3/7) of the culture positive cases. Specificity was 98.6%. WZ04 identified an additional specimen as positive which was also confirmed as positive by DIF. CONCLUSION--Our study shows that in our hands enzyme-linked immunoassays such as Wellcozyme Chlamydia are neither sensitive nor specific in detecting C. trachomatis infection of the rectum. For cervical infections, the sensitivity of WZ04 was 43% and the specificity 98.6% as compared to culture, with a positive predictive value of 75% and a negative predictive value of 94.7%.

Insulin secretion and sensitivity in women fulfilling WHO criteria for gestational diabetes

Abnormalities of insulin secretion rather than insulin sensitivity are described in women fulfilling the American criteria for gestational diabetes. We examined insulin secretion and insulin sensitivity in 38 women at risk of gestational diabetes categorized according to the less stringent WHO criteria, based on the 75 g oral glucose tolerance test, performed at 24 weeks gestation. Insulin sensitivity was assessed at 28 and 36 weeks using the short insulin tolerance test. Applying WHO criteria, 18 women had GDM. Age and body mass index of the GDM and glucose tolerant women were similar (32.4 +/- 1.1 (SE) vs 32.3 +/- 1.9 yr; 28.7 +/- 1.5 vs 28.8 +/- 1.7 kg m-2, respectively). Fasting glucose was higher in the GDM women than controls (5.1 +/- 0.2 vs 4.5 +/- 0.1 mmol l-1, p < 0.025) while fasting insulin was similar (75 +/- 18 vs 90 +/- 16 pmol l-1). The 30-min insulin concentration during the OGTT was lower in the GDM women than controls (436 +/- 61 vs 788 +/- 152 pmol l-1, p < 0.05), while the insulin sensitivity at 28 (87 +/- 5 vs 76 +/- 5 mumol l-1 min) and 36 weeks (73 +/- 8 vs 76 +/- 8 mumol l-1 min) was similar. A negative correlation existed between the 30-min insulin and 120-min glucose concentration during the OGTT (Rho -0.328, p < 0.05). The WHO criteria for GDM identify women with similar abnormalities of insulin secretion as the more stringent American criteria.

Randomised trial of intravenous immunoglobulin G, intravenous anti-D, and oral prednisone in childhood acute immune thrombocytopenic purpura

The most serious complication of childhood acute immune thrombocytopenic purpura (ITP), intracranial haemorrhage, occurs in about 1% of children with platelet counts below 20 x 10(9)/L. We conducted a randomised study to explore three treatment options in this high-risk group. 146 children (> 6 months and < 18 years old) with typical acute ITP and platelet counts of 20 x 10(9)/L or lower were randomised to receive high-dose intravenous immunoglobulin G (IVIgG) 1 g/kg on 2 consecutive days (n = 34), 0.8 g/kg once (n = 35), intravenous anti-D 25 micrograms/kg on 2 consecutive days (n = 38), or oral prednisone 4 mg/kg per day with tapering and discontinuation of prednisone by day 21 (n = 39). The rate of response as reflected by the number of days with platelet counts at 20 x 10(9)/L or lower and the time taken to achieve a platelet count 50 x 10(9)/L or more was significantly faster for both IVIgG groups than for the anti-D group (p < 0.05); the difference between prednisone and IVIgG was significant (p < 0.05) only for the IVIgG 0.8 g/kg group, and responses to the two IgG groups were similar. These differences in response rates were reflected in the percentages of children with platelet counts of 20 x 10(9)/L or lower at 72 hours following the start of treatment: 3% (IVIgG 0.8 g/kg x 1), 6% (IVIgG 1 g/kg x 2), 18% (anti-D), and 21% (oral prednisone 4 mg/kg/day). Treatment-associated toxicities included a fall in haemoglobin with anti-D (to less than 100 g/L in 24% of cases); weight gain with oral prednisone; and fever, nausea, vomiting, and headache with IVIgG. On the basis of these results, intravenous anti-D cannot be recommended as initial therapy for children with acute ITP and platelet counts of 20 x 10(9)/L or lower. A single dose of 0.8 g/kg IVIgG offers the fastest recovery for the least treatment; additional IgG or oral prednisone can be reserved for the one-third of children who continue to have platelet counts of 20 x 10(9)/L or less at 48-72 hours after the start of treatment.

Fetal proinsulin and birth weight

In both diabetic and non-diabetic pregnancies fetal insulin is an important anabolic hormone. Fetal hyperinsulinaemia is associated with accelerated fetal growth and increased birth weight. Insulin and C-peptide concentrations in both umbilical cord and amniotic fluid reflect fetal beta-cell secretion and are correlated with birth weight. In the present study umbilical venous proinsulin and insulin concentrations were measured in 54 term infants born to women with and without mild disturbances of glucose tolerance. Umbilical venous cord proinsulin, assayed using a highly specific immunoradiometric assay, was independently correlated with infant birth weight (Rho = 0.53, p < 0.0001) and birth percentile (Rho = 0.65, p < 0.0001). The correlation between birth weight and birth percentile weight with umbilical venous insulin, measured using a non-specific insulin assay, was lost following correction for the influence of proinsulin. Umbilical venous cord proinsulin appears to be a good indicator of fetal beta-cell activity, and in this study, a superior marker to insulin assayed using a non-specific insulin radioimmunoassay. The longer half-life of proinsulin compared with insulin may contribute to proinsulin being a more robust marker of overall fetal beta-cell activity than insulin.

Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE

Deep vein thrombosis (DVT) and pulmonary embolism (PE) occur in pediatric patients; however, the incidence, associated morbidity, and mortality are unknown. A Canadian registry of DVT and PE in children (ages 1 month to 18 years) was established July 1, 1990 in 15 tertiary-care pediatric centers. One-hundred thirty-seven patients were identified prospectively and are the subject of this report. The incidence of DVT/PE was 5.3/10,000 hospital admissions or 0.07/10,000 children in Canada. Infants under 1 year old and teenagers predominated with equal numbers of both sexes. DVT were located in the upper (n = 50) and lower (n = 79) venous system, or as PE alone (n = 8). Central venous lines (CVLs) were present in approximately 33% of children with DVT (n = 45). Associated conditions were present in 96% of children and 90% of children had two or more associated conditions for DVT. DVT was diagnosed by venography (n = 83), duplex ultrasound (n = 37), and other combinations (n = 17). Twenty-two of the 31 ventilation/perfusion scans performed were interpreted as high-probability scans for PE. Therapy consisted of heparin (n = 115), thrombolysis (n = 15), surgical removal of a CVL or thrombus (n = 22), and oral anticoagulant therapy (n = 103). Significant bleeding complications did not occur. However, three (2.2%) children died as a direct consequence of their thromboembolic disease; DVT reoccurred in 23 children and postphlebitic syndrome (PPS) occurred in 26. In conclusion, DVTs occur in a significant number of hospitalized children with a mortality of 2.2%. Complications are not hemorrhagic, but thrombotic, and characterized by PE, recurrent disease, and PPS. In contrast to adults, the upper venous system is frequently affected because of the use of CVLs. The frequency of DVT/PE justifies controlled trials of primary prophylaxis in high-risk groups, and therapeutic trials to determine optimal treatment.

Increased maternal fasting proinsulin as a predictor of insulin requirement in women with gestational diabetes

Circulating proinsulin was assessed during a 75g OGTT in 55 pregnant women who fulfilled WHO criteria for impaired glucose tolerance before the 32nd gestational week. Proinsulin was assayed retrospectively using a two-site immunoradiometric assay and immunoreactive insulin by radioimmunoassay. Of the 55 women, 19 required insulin treatment in addition to diet later in pregnancy. Fasting proinsulin concentrations were significantly higher in the 19 women who later required insulin treatment compared with the 36 women treated with diet alone (3.4 +/- 0.7 vs 1.8 +/- 0.2 pmol l-1, p < 0.005). There was no difference between the treatment groups of 60 and 120 min proinsulin values during the OGTT. Fasting plasma glucose and immunoreactive insulin were similar in the insulin-treated and diet-treated women and remained similar during the OGTT. No women within the insulin-treated group had a fasting plasma proinsulin value < 1.1 pmol l-1 in contrast with 12 women in the diet-treated group (p = 0.0123). Ten of the 19 insulin-treated women had a fasting plasma proinsulin > 2.5 pmol l-1 compared with 8 of the 36 diet-treated women (p = 0.0346). Fasting proinsulin values early in pregnancy have prognostic implications in women with gestational diabetes.