Renal allograft pathology with C4d immunostaining in patients with graft dysfunction

Renal allograft biopsy is the gold standard for diagnosis of rejection. Incorporation of C4d as a marker for humoral rejection is a major addition for Banff Schema, 2005. We evaluated the pattern of C4d staining in indicated renal allograft biopsies from January 2005 to December 2009. Of the 67 biopsies analyzed, 21 were C4d-positive. They were 11 cases of acute rejection, seven chronic rejection and one biopsy each of acute tubular necrosis, BK virus nephropathy and normal biopsy. Morphologic features like peritubular capillary dilatation, tubulitis and interstitial inflammation were seen more frequently in C4d-positive biopsies and this was statistically significant. C4d positivity was noted in 50% of the chronic rejection cases indicating a humoral component in the pathogenesis of chronic rejection. There was no significant difference in the serum creatinine levels of C4d-positive and -negative patients, either at the time of biopsy or during the follow-up. This study supports the role of C4d immunostaining in confirming histologically diagnosed acute and chronic humoral rejections and in detecting histologically unsuspected cases.

Flocculation of dimorphic yeast Benjaminiella poitrasii is altered by modulation of NAD-glutamate dehydrogenase

A strategy to control flocculation is investigated using dimorphic yeast, Benjaminiella poitrasii as a model. Parent form of this yeast (Y) exhibited faster flocculation (11.1 min) than the monomorphic yeast form mutant Y-5 (12.6 min). Atomic force microscopy revealed higher surface roughness of Y (439.34 rms) than Y-5 (52 rms). Also, the former had a zeta potential of -65.97+/-3.45 as against -50.21+/-2.49 for the latter. Flocculation of both Y and Y-5 could be altered by supplementing either substrates or inhibitor of NAD-glutamate dehydrogenase (NAD-GDH) in the growth media. The rate of flocculation was promoted by alpha-ketoglutarate or isophthalic acid and decelerated by glutamate with a statistically significant inverse correlation to corresponding NAD-GDH levels. These interesting findings open up new possibilities of using NAD-GDH modulating agents to control flocculation in fermentations for easier downstream processing.

Invasive pneumococcal disease in Kanti Children's Hospital, Nepal, as observed by the South Asian Pneumococcal Alliance network

BACKGROUND

Pneumonia accounts for approximately 2 million deaths annually among children aged <5 years, with most of these deaths occurring in Africa and southern Asia. The South Asian Pneumococcal Alliance (SAPNA) network in Nepal is generating local epidemiological data to assist in the development of national and regional policies for prevention of pneumococcal and Haemophilus influenzae (Hib) disease.

METHODS

Children aged 2 months to 5 years with suspected invasive bacterial disease were recruited from Kanti Children Hospital, Kathmandu, Nepal. Specimens of blood, CSF, and normally sterile body fluids were cultured, and analysis of antimicrobial susceptibility patterns and serotyping of Streptococcus pneumoniae isolates were performed. CSF specimens were also tested for S. pneumoniae and Hib antigens by a latex agglutination test and an immunochromatographic test of pneumococcal antigen (NOW S. pneumoniae Antigen Test; Binax).

RESULTS

A total of 2528 children with suspected invasive bacterial disease were recruited, of whom 82% had pneumonia, 9.6% had meningitis, 2% had very severe disease, and 0.4% had bacteremia; the remainder received another diagnosis. Before hospitalization, 26.7% had received antibiotic treatment. Fifty children had S. pneumoniae identified as the etiological agent of invasive disease. Of 2461 blood cultures performed, 22 were positive for S. pneumoniae. Of 33 cases of S. pneumoniae meningitis, 11 were detected by CSF culture, and 21 were detected by latex agglutination and pneumococcal antigen tests. The rate of detection of S. pneumoniae in CSF was 3.6% by culture, compared with 7.8% by latex agglutination and 10% by pneumococcal antigen testing. The rate of detection of H. influenzae in CSF was 1.7% by culture and 6.5% by latex agglutination. The most common serotypes found were 1, 5, 2, and 7F, followed by 12A, 19B, and 23F. Of all the invasive isolates, 3.8% were resistant to penicillin, and 68% were resistant to trimethoprim-sulfamethoxazole.

CONCLUSIONS

The SAPNA network has identified Hib and pneumococci as causes of significant disease in Nepal.

Effect of race on the safety and efficacy of pemetrexed (P) therapy in locally advanced and metastatic non-small cell lung cancer (NSCLC)

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Background: P is a multitargeted antifolate active in NSCLC. While a number of clinical trials have evaluated P safety and efficacy in general patient populations, little is known of the possible impact of race on the utility of P therapy in NSCLC. The objective of this post-hoc analysis was to evaluate the effect of race on the safety and efficacy of P (single-agent or in combination) in patients with locally advanced and metastatic NSCLC. Methods: Data from 6 trials with at least 5% non-Caucasian patients were pooled for analyses. One Phase III trial evaluated P in a second-line setting. All other trials used P in Phase II first-line settings. Patients were given at least one dose of P (single-agent or in combination) at 600 mg/m2 (59 patients) or 500 mg/m2 (469 patients) every 21 days. Demographic, safety, and efficacy data were stratified broadly by race, to either Caucasian or non-Caucasian groups. Kaplan-Meier method was used to estimate median survival. The Cox model was used to calculate the hazard ratio (HR) for survival, adjusting for significant prognostic factors, including disease stage, performance status, gender, and line of treatment. Results: Results are summarized in the data table below. The adjusted HR for survival (non-Caucasian versus Caucasian) was 0.89 (p=0.365). Conclusions: In this post-hoc analysis of results from clinical trials using P therapy in NSCLC, race did not have a statistically significant impact on response rate, disease control rate, or survival. However, P therapy appeared to be better tolerated by non-Caucasian patients.

[Table: see text]

No significant financial relationships to disclose.

Ewing′s sarcoma with cutaneous metastasis - a rare entity: Report of three cases

Ewing's sarcoma (ES) is a small round cell tumor, usually arising from flat bones and diaphyseal region of long bones. It is commonly found in the first two decades of life. It is curable when diagnosed in the localized stage and requires multimodality treatment. ES is a chemosensitive tumor. It metastasizes commonly to lung, pleura and other bones. Less common sites of metastasis are lymph nodes, CNS and liver. Skin metastasis is extremely uncommon. It occurs in up to 9% of all patients with cancer. Growth pattern of cutaneous metastasis is unpredictable and may not reflect that of primary tumor. We hereby report three cases of Ewing's sarcoma that developed skin metastasis.

Antifungal antibiotics

The search for new drugs against fungal infections is a major challenge to current research in mycotic diseases. The present article reviews the current types of antifungal infections, the current scenario of antifungal antibiotics, and the need and approaches to search for newer antifungal antibiotics and antifungal drug targets.

Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes: a bench study

BACKGROUND

Tracheotomy has been used to assist in weaning patients from mechanical ventilation. Some patients fail to be weaned from the ventilator despite tracheostomy. We hypothesized that removing the inner cannula from the tracheostomy tube would decrease the tube's imposed work of breathing (WOB(IMP)).

METHODS

The hypothesis was tested using a lung model, by measuring the change in WOB(IMP) when the inner cannula was removed. A mechanical lung model was developed using a test lung to simulate a spontaneously breathing patient. WOB(IMP) was measured with a commercially available lung mechanics monitor. Shiley size 6, 8, and 10 nonfenestrated tracheostomy tubes were tested with the inner cannula in and out. Breathing conditions were simulated using tidal volumes (V(T)) of 300 and 500 mL matched with breathing frequencies of 12, 24, and 32 breaths per minute, by using a ventilator to simulate spontaneous breathing through one side of the test lung.

RESULTS

Under all the tested breathing conditions, WOB(IMP) for each of the 3 tracheostomy tubes was significantly reduced (p < 0.05) when the inner cannula was removed. Also, as simulated spontaneous inspiratory flow demand increased (ie, as V(T) and/or frequency were increased), WOB(IMP) also increased, and vice versa. With the cannula removed, WOB(IMP) was not significantly different between the size 6 and 8 tubes nor between the size 8 and 10 tubes when V(T) was 300 mL and frequency was 12 breaths per minute.

CONCLUSIONS

There was a significant decrease in WOB(IMP) with each tube when the inner cannula was removed. WOB(IMP) increased with an increase in inspiratory flow demand (ie, increase in V(T) and/or frequency), as well as when tube size decreased. In weaning a tracheostomized patient from mechanical ventilation, increasing the internal diameter of the tube by removing the inner cannula may be beneficial. Further study is needed to determine if these findings are clinically important.

Review: uveitis and immunosuppressive drugs

Uveitis, inflammation of the eye, is a common occurring disease resulting from a wide variety of traumatic and immunogenic insults and, in most cases, can be treated successfully by corticosteroids. However, corticosteroids have severe side effects. Alternative therapy is using nonsteroidal anti-inflammatory agents like indomethecin, diclofenac and flurbiprofen. The uveitic cases are prominent in the third world countries, and many of the patients are not responsive or become refractory to steroidal or nonsteroidal therapy. Therefore, there is another class of compounds "immunosuppressive drugs" found to be successful in treating uveitis. These include cyclosporin A, tacrolimus, and sirolimus. However, being immunosuppressive they also have side effects. Therefore, the effective therapy with lower side effects is the treatment with combination of these drugs in lower dosages. Cyclosporin A plus sirolimus or tacrolimus in threshold doses alleviate signs of uveitis with lower incidence of side effects.

Vecuronium pharmacokinetics and pharmacodynamics during hypothermic cardiopulmonary bypass in infants and children

PURPOSE

To determine the effect of moderate and deep hypothermic cardiopulmonary bypass (CPB) on the pharmacokinetic and pharmacodynamic behaviour of vecuronium in infants and children.

METHODS

We studied 12 patients undergoing surgery for congenital heart disease under narcotic-nitrous oxide anesthesia. Neuromuscular blockade was maintained constant (TI 4-10% by Datex electromyograph) by adjusting a vecuronium infusion. Plasma vecuronium concentrations (Cpss) were analysed by HPLC to describe a pseudosteady-state during each of the pre-CPB, CPB and post-CPB phases. Paired arterial blood samples were taken 20 min apart after at least 20 min of constant infusion.

RESULTS

Nine cases were analysed, mean age 20 mo, mean weight 9 kg. Three patients had deep and six moderate hypothermia. In the pre-CPB phase Cpss fell into two groups (mean +/- SD: 330 +/- 42 ng x ml(-1); 127 +/- 27 ng x ml(-1); P < 0.001); similarly the clearances showed a bimodal distribution (mean +/- SD: 5.08 +/- 0.94; 11.51 +/- 0.2 ml x min(-1) x kg(-1) P < 0.001), although in different patients. During CPB this bimodal distribution disappeared. Vecuronium infusion rate (VIR) decreased by 84% and 92% from pre-CPB to CPB phase in deep and moderate hypothermia groups respectively (P < 0.05), paralleled by decreases in Cpss of 36% (P > 0.05) and 52% (P < 0.05).

CONCLUSION

Changes in vecuronium requirements and plasma concentrations during CPB demonstrate that vecuronium pharmacokinetics and pharmacodynamics are both affected by hypothermic CPB in infants. The finding of bimodal distributions for plasma vecuronium and vecuronium clearance highlights the need for individual monitoring of neuromuscular blockade in this age group.

Is paediatric day case tonsillectomy desirable? The parents' perspective

Tonsillectomy is the most commonly performed otolaryngological procedure in most units. There is considerable financial pressure to perform paediatric tonsillectomy as a day case. Responding to concern that day case tonsillectomy might not be welcomed by parents or felt to be in the best interests of the patients, we carried out an audit of paediatric tonsillectomy, by means of a questionnaire for parents and nursing staff to complete while 32 consecutive patients underwent tonsillectomy as inpatients. Although eight parents (25%) felt that day surgery should be an option, none of those surveyed felt that on this occasion their child was well enough to be discharged home six hours postoperatively. Furthermore, no child in the audit fulfilled all the essential discharge criteria at six hours. In this area, at least, it appears parents do not uniformly welcome paediatric day case tonsillectomy.

Anterior uveitis associated with latanoprost

PURPOSE

To report the association of anterior uveitis with the use of latanoprost.

METHODS

We studied four patients with complicated open-angle glaucoma who had anterior uveitis associated with the use of latanoprost. The uveitis was unilateral and occurred only in the eye receiving latanoprost in three patients. In one patient, latanoprost was used in both eyes, and the uveitis was bilateral. Four of five eyes had a history of prior inflammation and/or prior incisional surgery. All patients were rechallenged with the drug.

RESULTS

The uveitis improved after cessation of latanoprost with or without topical corticosteroids. It recurred after rechallenging with latanoprost in all eyes.

CONCLUSION

There is a possible association between latanoprost and anterior uveitis. Topical prostaglandin analogs may be relatively contraindicated in patients with a history of uveitis or prior ocular surgery. This association may also be possible in eyes that have not had previous uveitis or incisional surgery.