Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion: deductions from studying immune status after knee arthroplasty

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post-traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti-coagulated salvaged blood transfusion, in the knowledge that others have shown that non-anti-coagulated (fibrinolysed) salvaged blood was immunosuppressive. A prospective non-randomized cohort study of patients undergoing primary total knee arthroplasty included 25 who received salvaged blood transfusions collected post-operatively into acid-citrate-dextrose anti-coagulant (ASBT cohort), and 18 non-transfused patients (NSBT cohort). Biomarkers of sterile trauma included haematological values, damage-associated molecular patterns (DAMPs), cytokines and chemokines. Salvaged blood was analysed within 1 and 6 h after commencing collection. Biomarkers were expressed as fold-changes over preoperative values. Certain biomarkers of sterile trauma were common to all 43 patients, including supranormal levels of: interleukin (IL)-6, IL-1-receptor-antagonist, IL-8, heat shock protein-70 and calgranulin-S100-A8/9. Other proinflammatory biomarkers which were subnormal in NSBT became supranormal in ASBT patients, including IL-1β, IL-2, IL-17A, interferon (IFN)-γ, tumour necrosis factor (TNF)-α and annexin-A2. Furthermore, ASBT exhibited subnormal levels of anti-inflammatory biomarkers: IL-4, IL-5, IL-10 and IL-13. Salvaged blood analyses revealed sustained high levels of IL-9, IL-10 and certain DAMPs, including calgranulin-S100-A8/9, alpha-defensin and heat shock proteins 27, 60 and 70. Active synthesis during salvaged blood collection yielded increasingly elevated levels of annexin-A2, IL-1β, Il-1-receptor-antagonist, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IFN-γ, TNF-α, transforming growth factor (TGF)-β1, monocyte chemotactic protein-1 and macrophage inflammatory protein-1α. Elevated levels of high-mobility group-box protein-1 decreased. In conclusion, we demonstrated that anti-coagulated salvaged blood reversed PTI, and was attributed to immune stimulants generated during salvaged blood collection.

Clinical and haemato-pathological characteristics of adult acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is a heterogeneous group of disorders. It varies with respect to the morphologic, cytogenetic, molecular and immunologic features of the neoplastic cells reflecting the variable clinical-pathologic presentations and outcome of the patients. The aim of the study was to observe the clinical and haemato-pathological characteristics in newly diagnosed adult ALL patients. A total number of 61 patients morphologically diagnosed as acute lymphoblastic leukaemia aged 15 and above assigned for this observational study. The study was carried out in the Department of Haematology, BSMMU from January 2007 to December 2008. Among 61 patients, aged 15 to 80 years with median age 25 years, 79% were male and 21% were female. Most of the patients presented with anaemia (67%), fever (66%), lymphadenopathy (64%) and splenomegaly (57%). Other common clinical findings were hepatomegaly (39%), bone tenderness (44%) and bleeding manifestations (34%). Among haemato-pathological findings 67% patients had Hb level ≤10gm/dl, 46% patients had WBC count ≥30×10⁹/L, 67% patients had platelet count ≤100×10⁹/L, 93% patients had blast in peripheral blood and 61% patients had ≥90 % blasts in the bone marrow at the time of diagnosis. In this study adult ALL patients were analyzed only for their clinical and haemato-pathological characteristics. But their biologic characteristics were not analyzed due to lack of availability of facility. A progressive understanding of the biologic and genetic characteristics of ALL will allow us to identify different prognostic subgroups with specific molecular and cellular features. All the necessary measures have to be developed in our country in order to identify prognostically distinct subgroups of patients.

A multicenter phase II study incorporating high-dose rituximab and liposomal doxorubicin into the CODOX-M/IVAC regimen for untreated Burkitt's lymphoma

BACKGROUND

Despite improvement with intensive multi-agent chemotherapy, 2-year progression-free survival (PFS) rates for adults with high-risk Burkitt's lymphoma (BL) remains <55%.

PATIENTS AND METHODS

We conducted a phase II trial for newly diagnosed classic BL utilizing liposomal doxorubicin (Adriamycin) in lieu of doxorubicin and incorporating intravenous rituximab (at 500 mg/m(2) twice/cycle) into the CODOX-M/IVAC regimen. Correlative analyses included paired serum and cerebrospinal fluid (CSF) rituximab levels and close examination of cardiac function.

RESULTS

Among 25 BL patients, the median age was 44 years (23-70) and 4 patients were HIV positive. There were 20 high-risk and 5 low-risk patients. At baseline, 40% of high-risk patients had bone marrow involvement, 35% had bulky disease and 15% had central nervous system involvement. The overall response rate was 100% (complete remission 92%). At 34-month median follow-up, the 2-year PFS and overall survival (OS) rates for all patients were 80% and 84%, respectively (low-risk: both 100%; high-risk: 76% and 81%, respectively). Furthermore, the 2-year PFS, OS, and disease-specific survival (DSS) rates for high-risk, HIV-negative patients were 84%, 89% and 100%, respectively. Adverse events (AEs) appeared to be consistent with prior CODOX-M/IVAC data, although there were several grade 3 cardiac events noted (all declined ejection fraction without clinical symptoms). The mean serum rituximab levels at 24 h after cycles 1 and 3 for patients without relapse were 258 and 306 μg/ml, respectively, versus 131 and 193 μg/ml, respectively, for patients with early progression (P = 0.002 and 0.002, respectively). The mean CSF rituximab levels for all patients were 0.11 and 0.24 μg/ml, respectively, at cycle 1 (24/72 h), which equated to serum:CSF ratios of 0.05% and 0.20%, respectively.

CONCLUSIONS

The integration of rituximab into CODOX-M/IVAC for adult BL was feasible and tolerable, while changes in cardiac function warrant continued examination. This regimen was associated with excellent survival rates for HIV-negative BL. Further investigation of the predictive value of serum rituximab is needed. Clinicaltrials.gov NCT00392990.

Inflammation and Oxidative Stress via Persistent Hyperglycemia in Progression of Diabetic Nephropathy in Type 2 Diabetes Mellitus

Diabetic nephropathy is a major microvascular complication of diabetes, representing the leading cause of end stage renal disease in the world, and a major cause of morbidity and mortality in type 2 diabetic subjects. In the kidney, a number of pathways that generate reactive oxygen species (ROS) such as glycolysis, specific defects in the polyol pathway, uncoupling of nitric oxide synthase, xanthine oxidase, NAD (P) H oxidase, and advanced glycation have been identified as potentially major contributors to the pathogenesis of diabetic kidney disease. Changes in oxidative stress biomarkers, including super­oxide dismutase, catalase, glutathione reductase, glutathione peroxidase, glutathione levels, vitamins, lipid peroxidation, nitrite concentration, nonenzymatic glycosylated proteins have been associated with diabetic nephropathy due to oxidative stress induced hyperglycemia. Oxidative stress in diabetes is responsible for endothelial dysfunction releasing inflammatory markers cytokines from the damaged renal tissue. Hyperglycemia induces intracellular reactive oxygen species in mesan­gial and tubular epithelial cells which induces cytokines, IL-6 and TNF-α production in glomerular mesangial and tubular epithelial cells in diabetic kidney. Antioxidants inhibit high glucose induced transforming growth factors and extra cellular matrix expression in glomerular mesangial and tubular epithelial cells, which ameliorate features of diabetic nephropathy, suggesting that oxidative stress plays an important role in diabetic renal injury causing diabetic nephropathy. Journal of Chitwan Medical College 2013; 3(1): 1-4 DOI: http://dx.doi.org/10.3126/jcmc.v3i1.8456

The Metabolic Syndrome: Comparison of Newly Proposed IDF, Modified ATP III and WHO Criteria and their Agreements

Background: Metabolic syndrome (MS) results from clustering of cardiovascular risk factors occurring in association with insulin resistance and obesity. With the increasing prevalence of obesity worldwide, MS is of keen interest in research. The disorder is defined in various ways, but one consolidated definition is needed to make studies comparable worldwide. The study was to determine the risk factors of metabolic syndrome in Bangladesh and comparison of newly proposed definition of International Diabetes Federation (IDF), modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and the World Health Organization (WHO) criteria and their agreements. Materials and Methods: This was a cross sectional hospital based study. We randomly selected 229 participants. After obtaining informed written consent data collectors collected data by interview, clinical examination, anthropometric measurement and investigations. We calculated independent sample t-test means between to distinguish which risk factors were present in participants with and without MS, using SPSS v17. Results: The percentage of risk factors of MS among subjects according to different criteria was 72% of Modified ATP-III, 69% of IDF and 39% of WHO definition .In Modified NCEP ATP III when did independent sample t-test mean of BMI, waist circumference, systolic blood pressure, diastolic blood pressure, fasting blood glucose, high density lipoprotein and triglyceride were present statistically significant difference between without MS and with MS (p<0.05). According to WHO criteria BMI, waist circumference, fasting blood glucose were statistically significant (p<0.05) and similarly fasting blood glucose & triglyceride were statistically significant difference between without MS and with MS (p<0.05) according to IDF criteria.ATP III and WHO criteria showed good agreement (k 0.56) compared to ATP III with IDF (k 0.31) and WHO with IDF (k 0.11) criteria. Conclusion: Metabolic syndrome is highly prevalent in Bangladesh. We detected the highest proportion of participants with MS using the ATP III definition, which emphasizes the predominant focus on the modified waist circumference for Asian participants. However, MS prevalence following WHO criteria in those with impaired glucose regulation is comparable with ATP III definition. Follow up study needed to examine the significance of MS following all definitions for the assessment of risk for diabetes and or cardiovascular disease. Cardiovascular Journal Volume 6, No. 1, 2013, Page 17-22 DOI: http://dx.doi.org/10.3329/cardio.v6i1.16110

Cough in systemic lupus erythematosus

This observational study was conducted in the lupus clinic of Department of Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2007 to July 2007. Thirty-six consecutive SLE patients fulfilled American College of Rheumatology (ACR) diagnostic criteria and having cough for any duration was enrolled. Equal number of age and sex matched controls (The patient attending in the out patient department in the Medicine having cough without SLE) was taken after having informed consent. Severely disabled cases and cases unwilling to participate with a cough were excluded. Mean age of study population was 29.1±8.7 years and 29.8±9.9 years in controls. Duration of cough was less than 3 weeks in 17% of SLE patients and 8% of control group and was more than three weeks in 83% and 92% respectively. In SLE patient commonest causes of cough was bronchial asthma 47% and was 33% in controls. Post nasal drip syndrome was the next common causes and frequently due to sinusitis and allergic rhinitis. Its frequency was 14% and 16% in SLE and control groups respectively. Other causes were pneumonia (11%, 14%), Diffuse Parenchymal Disease lung (DPLD) (5.6% & 2.8%), and tuberculosis (5.6% & 8%) in SLE & control groups respectively. Gastro esophageal reflux disease (GERD) was 2.6% in SLE group but was not found in control group. Cough is common in SLE patients. Frequency distribution though similar to that of causes of cough in community but warns the possibility of serious underlying diseases in SLE cases and attentive evaluation.

Interdependence of Genotype and Growing Site on Seed Mineral Compositions in Common Bean

Essential minerals are considered as key determinants of optimum health and nutritive quality of common bean seed. This study aimed to identify genetically stable essential minerals in common bean. Eleven diverse common bean genotypes were grown in three distinct growing environments and 17 essential minerals were analyzed by Inductively Coupled Plasma-Optical Emission Spectroscopy. Genetic control of mineral composition in common bean seed was demonstrated by large (p<0.01) genotypic differences in Ca and Sr contents and moderate genotypic difference was observed in Fe content. Significant influence of genotype and environments (G×E) interaction was observed in the content of all minerals. The ratios between genetic and environmental variances and between genetic and G×E variances indicated the greater influence and stability of genetic factor on the concentration of Ca and Sr in common bean seed. Significant positive correlations among important minerals such as Zn with S, P, Fe and Na and Cu with K, Mg, Ni, P were identified. The stability of genetic effects on Ca and Sr concentration in common bean has been identified in this study. Calcium is one of the most important minerals which regulates many cellular processes and has important structural roles in living organisms. Further studies to characterize Ca physiology in common bean may identify genetic or biochemical markers to expedite breeding common bean with enhanced Ca concentration.

Outcome of adult acute lymphoblastic leukaemia following induction chemotherapy with modified MRC UKALL XII/ECOG E2993 protocol

Cure rates for adult acute lymphoblastic leukaemia (ALL) in developing countries are significantly lower because of problems unique to these countries. Recent studies have reported complete response rates for any induction regimen of more than 90% in adult ALL patients. This study was conducted to evaluate the response rate of induction chemotherapy in adult ALL patients in the Department of Haematology, Bangabandhu Sheikh Mujib Medical University, from January 2007 to December 2008. In this observational study, 35 newly diagnosed ALL patients classified either as L1/L2 according to French-American-British (FAB) classification, aged between 15 to 60 years were assigned for induction therapy with modified MRC UKALL XII/ECOG E2993 protocol. But ultimately 30 patients completed therapy and available for statistical analysis. Among the studied 30 cases 12(40%) patients after phase 1 and overall 24 (80%) patients after phase 2 induction therapy, achieved morphologic complete remission (CR). After phase 2 therapy 6 (20%) patients fell in the group of non responders (NR) as the blast percentage was > or = 5% at the time of bone marrow evaluation. This study shows the response rates in adult ALL with induction therapy slightly below the anticipated response rates of developed countries which may be due to little modification of the original protocol.

The role of noninvasive methods in assessing airway inflammation and structural changes in asthma and COPD

AIM

The aim of our study was to assess the role of non-invasive methods in assessing airway inflammation and structural changes in asthma and COPD.

METHODS

The study was conducted on patients attending outpatient and inpatient department of TB and Chest Diseases and Department of Pathology at our hospital from January 2006 to August 2007. 50 asthmatic and 46 COPD patients were selected. A detailed history and clinical examination, routine laboratory investigations, pulmonary function testing, Chest X-ray PA and lateral view, HRCT Thorax, biochemical and cellular analysis of sputum was carried out in all cases. Quality control and procedures of pulmomary function test were performed according to the European Respiratory Society guidelines.

RESULTS

Bronchial wall thickening, bronchiectasis and air trapping correlated well with disease severity in asthmatics while all abnormal HRCT finding correlate well with disease severity in COPD patients. The levels of MMP-9 and TIMP-1 increased significantly with increasing disease severity in both asthmatic and COPD groups. The MMP-9/TIMP-1 ratio decreased with increasing disease severity in both groups. The major source of MMP-9 in human lungs is macrophages, neutrophils and eosinophils. Macrophages and neutrophils were also the source of TIMP-1.

CONCLUSION

Asthma and COPD are characterised by an imbalance between MMP-9 and TIMP-1. COPD patients showed a higher prevalence of HRCT findings which correlate with their lower MMP-1/TIMP-1 ratio than asthmatics supporting fact that the destruction and fibrosis of alveolar walls are more prominent in COPD. MMP-9/TIMP-1 ratio is associated with magnitude of HRCT findings in asthma and COPD and suggests that level of these markers reflect the extent of structural changes of airway.

Food Intake Recording Software System, version 4 (FIRSSt4): a self-completed 24-h dietary recall for children

The Food Intake Recording Software System, version 4 (firsst4), is a web-based 24-h dietary recall (24 hdr) self-administered by children based on the Automated Self-Administered 24-h recall (ASA24) (a self-administered 24 hdr for adults). The food choices in firsst4 are abbreviated to include only those reported by children in US national surveys; and detailed food probe questions are simplified to exclude those that children could not be expected to answer (e.g. questions regarding food preparation and added fats). ASA24 and firsst4 incorporate 10 000+ food images, with up to eight images per food, to assist in portion size estimation. We review the formative research conducted during the development of firsst4. When completed, firsst4 will be hosted and maintained for investigator use on the National Cancer Institute's ASA24 website.

How to engage children in self-administered dietary assessment programmes

Effectively assessing children's dietary intake is essential for understanding the complex relationships among dietary behaviours and obesity. Dietary assessment accuracy decreases when children are unable or unmotivated to complete accurate self-reports. Technology-based assessment instruments for children's self-report of diet can be enhanced in light of developments in media psychology and communication science. To motivate children to complete a dietary assessment, researchers could use animated, customisable agents; embed the assessment process into a video game; or add narratives to encourage self-reporting behaviour. To improve accuracy, the intake environment could be recreated virtually; training sessions could be interspersed to improve portion estimation; and implicit attitudinal measures could be incorporated as a control or to increase validity. Research is needed to evaluate possible methods of enhancing children's self-reporting motivation and accuracy. The main challenge remains how to engage children without biasing their reporting.

Effectiveness of educational interventions in improving clinical competence of residents in an internal medicine residency program in Pakistan

INTRODUCTION

Medical education is a continuously evolving field. Training institutes and programs should have a process in place to gather continuous feedback and then make appropriate modifications in order to provide education and training effectively. Our study aimed to assess the effect of a quality improvement cycle approach in using various educational interventions within a residency. Effects were measured on the key educational outcomes of residents; medical knowledge, skills and professional attitudes using results of postgraduate examination with both written and clinical skills components.

METHODOLOGY

A number of educational interventions were implemented which included changes in work hours with increased time for self-study, new educational activities including a Residents Hour, a Residents Slide Session, Grand Rounds and Journal Clubs, Clinico-pathological conferences, and a two- week postgraduate course for senior residents. Newer and improved assessment tools were also implemented, including an annual in-training mock exam based on the format of the postgraduate examination. Pass rates in postgraduate examinations (Fellow of College of Physicians and Surgeons exam and Member of Royal College of Physicians exam) were compared before and after the interventions to assess the effectiveness of the interventions.

RESULTS

The first group of residents after introduction of the educational interventions completed residency training in 2001. Postgraduate exam pass rates (sometimes after two or more attempts) were 59.2% (42 of 71 graduates) before 2001 and 86.4% (38 of 44 graduates after 2001 (p = 0.002). The number of candidates passing the examinations in either their first or second attempts before 2001 was 17 of 42 (40.5%), which increased to 33 of 38 (86.8%) after 2001 (p = <0.001).

CONCLUSIONS

Our study describes a number of interventions that were successful in bringing about an improvement in the performance of our residents. These can serve as a guide for postgraduate training programs, particularly those of Internal Medicine, in implementing strategies to strengthen training and enhance the performance of trainees.

Introgression of cotton leaf curl virus-resistant genes from Asiatic cotton (Gossypium arboreum) into upland cotton (G. hirsutum)

Cotton is under the constant threat of leaf curl virus, which is a major constraint for successful production of cotton in the Pakistan. A total of 3338 cotton genotypes belonging to different research stations were screened, but none were found to be resistant against the Burewala strain of cotton leaf curl virus (CLCuV). We explored the possibility of transferring virus-resistant genes from Gossypium arboreum (2n = 26) into G. hirsutum (2n = 52) through conventional breeding techniques. Hybridization was done manually between an artificial autotetraploid of G. arboreum and an allotetraploid G. hirsutum, under field conditions. Boll shedding was controlled by application of exogenous hormones, 50 mg/L gibberellic acid and 100 mg/L naphthalene acetic acid. Percentage pollen viability in F(1) hybrids was 1.90% in 2(G. arboreum) x G. hirsutum and 2.38% in G. hirsutum x G. arboreum. Cytological studies of young buds taken from the F(1) hybrids confirmed that they all were sterile. Resistance against CLCuV in the F(1) hybrids was assessed through grafting, using the hybrid plant as the scion; the stock was a virus susceptible cotton plant, tested under field and greenhouse conditions. All F(1) cotton hybrids showed resistance against CLCuV, indicating that it is possible to transfer resistant genes from the autotetraploid of the diploid donor specie G. arboreum into allotetraploid G. hirsutum through conventional breeding, and durable resistance against CLCuV can then be deployed in the field.

Physical care of people suffering from schizopphrenia on risperidone long acting injectable depot

Background

People with severe mental illness neglect their physical health needs. They smoke a lot, they drink a lot and they don’t do exercise. They eat unhealthy food and put on weight. Unfortunately, the antipsychotic medication don’t help and some of the drugs are associated with side effects which make these problems worse.

Methods

Medical notes of patients who has been on risperidone long term injectable depot for a year, from the first of January till the 30th 2008 were reviewed and information were input on the form.

Results

65 notes were reviewed. 70% males. 70% between 18-50 years. The following was done baseline:

The following were done on six monthly maintenance measures:

Discussion

Only 50% of patients had physical examination. Only quarter of patients had their BP, pulse and ECG done as a baseline. There was no regular physical follow up and investigation and the investigation which were done sporadically. Physical co-morbidity was 50% of the sample while physical examination and investigations were done in less than half of the sample.

Conclusions

Proper physical assessment and regular follow up should be adopted.

Promotion of healthy living and eating, exercise and monitoring weight should be advised.

Cryptococcosis in organ transplantation

Opportunistic infection is one of the important cause of graft dysfunction after organ transplantation. It usually occurs one year after post transplantation in a immunocompromised transplant recipient. Among the opportunistic infections fungal infection is important cause of graft dysfunction as well as increase morbidity and mortality of post transplant recipient. Cryptococcosis is the third most common invasive fungal infection in an organ transplant recipient next to Candidiasis and Aspergillosis. A 27 years young male is known case of live related renal allograft recipient on immunosuppression for last one and half years. Patient was admitted with irregular fever, severe headache, nausea and vomiting in the department of Nephrology on July 2007. After admission patient was thoroughly evaluated and clinically found features of meningitis. Subsequent investigation report revealed swollen of 3rd ventricle on CT scan brain and growth of Cryptococcus in CSF culture and diagnosis was made post renal transplant cryptococcal meningitis. Treatment was given with Injection Amphotericin B along with immunosuppression and other supportive measured. But inspite of treatment, within few days after diagnosis patient was underwent coma and died. In conclusion, cryptococcal meningitis is a serious invasive fungal infection in post transplant immunocompromised recipient and responsible for graft lose and increase morbidity of the transplant patients.

Validity and reliability of the Migraine-Treatment Optimization Questionnaire

Our aim was to establish the validity and reliability of a patient-rated Migraine Treatment Optimization Questionnaire (M-TOQ) in primary care. Patients who met International Classification of Headache Disorders, 2nd edn criteria for migraine completed a 19-item questionnaire containing candidate items for the M-TOQ, and three questionnaires designed to test convergent/construct validity [Migraine Disability Assessment Scale (MIDAS), Headache Impact Test (HIT)-6 and Migraine-Specific Quality of Life Scale (MSQoL)]. A 15-item (M-TOQ-15) and a five-item (M-TOQ-5) questionnaire were derived. Two hundred and fifty-three adult patients were recruited. Five treatment optimization domains were identified: functioning, rapid relief, consistency of relief, risk of recurrence and tolerability; with Cronbach alphas of 0.70-0.84. The Cronbach alpha for M-TOQ-15 was 0.85, and it correlated well with MIDAS, HIT-6 and MSQoL (r = 0.33-0.44). The Cronbach alpha for M-TOQ-5 was 0.66, and it also correlated well with the three questionnaires (r = 0.33-0.41). The utility of the M-TOQ for assessing treatment benefit in research (M-TOQ-15) and primary care (M-TOQ-5) should be further validated.