Outbreak of viral hepatitis B in a rural community in India linked to inadequately sterilized needles and syringes

In India, virtually all outbreaks of viral hepatitis are considered to be due to faeco-orally transmitted hepatitis E virus. Recently, a cluster of 15 cases of viral hepatitis B was found in three villages in Gujarat State. The cases were epidemiologically linked to the use of inadequately sterilized needles and syringes by a local unqualified medical practitioner. The outbreak evolved slowly over a period of 3 months and was marked by a high case fatality rate (46.7%), probably because of concurrent infection with hepatitis D virus (HDV) or sexually transmitted infections. But for the many fatalities within 2-3 weeks of the onset of illness, the outbreak would have gone unnoticed. The findings emphasize the importance of inadequately sterilized needles and syringes in the transmission of viral hepatitis B in India, the need to strengthen the routine surveillance system, and to organize an education campaign targeting all health care workers including private practitioners, especially those working in rural areas, as well as the public at large, to take all possible measures to prevent this often fatal infection.

Activation of a cryptic splice-site in intron 24 leads to the formation of apolipoprotein B-27.6

Apo B expression is confined to the intestine and liver, and its secretion from these tissues is dependent on the expression of a lipid transfer protein, microsomal triglyceride transfer protein (MTP). Previously, we reported a model system for the study of apolipoprotein (apo B) biogenesis using heterologous expression in COS cells (Patel SB, Grundy SM. J. Lipid Res. 1995;36:2090-2103). We now report the characterization of the effects of a T-->C transition in the splice-site at +2 of intron 24 previously reported by Talmud et al. (J. Lipid Res. 1994;35:468-77). Using our heterologous expression system, we show that the mutation led to aberrant processing of intron 24, but normal processing of intron 25. The resultant translation of this mutant mRNA produced a truncated apo B protein of the size of apo B-27.6. Reverse transcription, polymerase chain reaction and sequencing of the amplified products were used to show that a cryptic donor splice-site within intron 24 was utilized, resulting in the generation of a novel hydrophilic 29 amino acid carboxyl-terminal tail. Co-expression of apo B-27.6 with microsomal triglyceride transfer protein (MTP) showed that this protein could bind MTP and resulted in the secretion of a lipoprotein particle with a buoyant density in the range 1.16-1.25 g/ml. These results indicate that this splice-site mutation leads to an activation of a downstream cryptic splice-site within intron 24, causing an insertion of 40 bases of intron 24 sequences into the mature RNA. This leads to a frame-shift of translation resulting in addition of 29 new amino acids at the carboxyl-terminus, before an in-frame stop translation codon is encountered, truncating the apo B at B-27.6.

Obesity in db and ob animals leads to impaired hepatic very low density lipoprotein secretion and differential secretion of apolipoprotein B-48 and B-100

Dyslipidemia secondary to obesity is commonly observed in both animals and humans. As it has been hypothesized that obesity can result in overproduction of VLDL, leading to the subsequent dyslipidemia, we have examined the triglyceride and apoB secretion rates in vivo in obese C57BI/ KsJ db/db and C57BI/6J ob/ob mice and their lean littermates. In ob/ob animals, obesity resulted in significantly lower, not higher, triglyceride secretion rates in both males (3.94 +/- 0.49 mg/h per g liver vs. 5.45 +/- 0.29 mg/h per g liver in lean littermates, P < 0.001) and females (4.29 +/- 0.81 mg/h per g liver vs. 5.25 +/- 0.59 mg/h/g liver, P < 0.001). For db/db, the obese females did not show a statistically significant triglyceride secretion rate compared to their lean littermates. Only the male db/db animals showed a significantly higher triglyceride secretion rate compared with lean littermates (5.50 +/- 1.1 mg/h per g liver vs. 3.37 +/- 0.36 mg/h/g liver, P < 0.001). Examination of the apolipoprotein B (apoB) secretion rates showed that for ob/ob animals and db/db obese females, apoB48 secretion was significantly decreased compared to that of normal littermates, with a small increase in apoB-100 secretion. Total apoB secreted, however, was not increased. Our data further suggest that the predominant cause of the dyslipidemia under these conditions is a defect in removal of VLDL from the circulation.

Interactions between microsomal triglyceride transfer protein and apolipoprotein B within the endoplasmic reticulum in a heterologous expression system

When apolipoprotein B (apoB) is expressed in heterologous cells, it is not secreted but retained and degraded within the endoplasmic reticulum (ER). We have previously characterized carboxyl-terminal truncated forms of apoB expressed in COS cells and have shown that these proteins were readily synthesized but retained within the ER and degraded, if the size of the truncated protein was larger than apoB 29. Below this size, the smaller the size of the apoB truncates, the greater the extent of secretion, although >50% of these smaller proteins were also degraded within the ER. In the present study, we demonstrate that this secretory defect can be overcome by coexpression with microsomal triglyceride transfer protein (MTP); moreover, this complementation is inversely related to the size of apoB. Secretion of apoBs larger than B29 required the coexpression of MTP and, in the presence of MTP, was oleate-responsive. MTP, in the presence or absence of oleate supplementation, had little or no effect on the secretion of the shorter truncates. We discovered, however, that MTP was physically associated with all forms of apoB intracellularly (B13-B41). The association of MTP with apoB 41 was stable to high salt washing, as well as to low pH, suggesting that these interactions may be hydrophobic in nature. In addition to the interaction with MTP, apoB was also found to be associated with calnexin, confirming previous studies, and with proteins bearing the KDEL retention signal. However, studies on overexpression of human calnexin and tunicamycin inhibition of glycosylation showed that interaction with calnexin was not necessary for the formation or secretion of apoB 41-containing lipoproteins; moreover, in the presence of MTP, the association of calnexin with apoB 41 was transient or absent. These data suggest that for apoB to attain a folded state sufficient to escape the quality control of the ER, it needs to obtain neutral lipid (supplied by MTP), as well as its ability to keep it packaged as a rudimentary lipoprotein, dependent on its size being larger than B29.

Dynamics of contraceptive practice amongst urban Indian women

BACKGROUND

Most studies on knowledge, attitude and practice regarding contraceptives have been conducted in rural areas and urban slums. In this study, a mixed urban population was surveyed.

SUBJECTS

Two thousand parous women from different social and educational backgrounds residing in the metropolis of Mumbai (Bombay), Maharashtra were included in the study.

RESULTS

Fifty per cent of illiterates, semi-literates and highschool educated, and 80% of college-educated couples said that they had no gender preferences for their children, but actual practice belied this. Regardless of the level of education, 25%, 75% and 95% of all couples were sexually active by 6 weeks, 3 months and 6 months after childbirth. Awareness regarding the availability of various contraceptives increased with education; 20% of all graduate couples used condoms or the rhythm method immediately after marriage. After the birth of their first child, 80% of educated couples used spacing methods whereas even after the birth of their third child more than 50% of the uneducated did not. The major complaint of the intrauterine device users was menorrhagia and abdominal pain, while that of pill users was nausea, giddiness and headache. Spacing methods were popular among the educated, and terminal ones among the uneducated. Steroidal contraceptive pills were not popular with any group, regardless of the level of education.

CONCLUSION

Education was the main variable in the decisions regarding the family size, spacing interval, contraceptive awareness, its use immediately after marriage and during the postpartum period.

Hepatocellular carcinoma: A review of 140 cases

Saudi Arabia appears to have an usually high incidence of hepatocellular carcinoma, which has been causally associated with a high prevalence of hepatitis B virus (HBV). Other risk factors, including hepatitis C virus (HCV) infection are currently not known. A study was undertaken to establish the risk factors and clinicopathological features of hepatocellular carcinoma in Saudi Arabia. The profiles of 140 patients with a biopsy-proven hepatocellular carcinoma were analyzed. Demographic data revealed a strong male preponderance (male:female = 5.7:1) and 114 patients (81.4%) were found to have or have had HBV infection. The data concerning HCV infection were incomplete, but suggest a causal association (nine of 33 patients). An absence of alcohol as a risk factor was noteworthy. Clinical jaundice and right upper quadrant abdominal pain were the most frequent presenting features. Abnormal liver function tests were present in 125 patients 989.3%) at diagnosis and serum alpha fetoprotein was elevated in 112 patients (80%). The majority of patients had locally advanced, inoperable disease and the prognosis was uniformly dismal. The median survical was 61 days.

Low-dose progestogen contraception and the nursing mother

Breast feeding, though an important and efficient contraceptive method, suffers from one major limitation: the contraceptive protection it offers the nursing mother ends abruptly without giving any physical indication of the return of fertility. Barrier methods and progesterone-only hormonal contraceptives, either in the oral, implant or injectable form, appear to be the primary contraceptive alternative for the nursing mother today. They neither adversely affect lactation, nor does the minute quantity of progesterone (NET or LNG) transferred to the infant affect its growth and physical well-being. Puerperal insertion of IUD carries an inherent risk of pelvic inflammatory disease, high expulsion rates and menorrhagia, once menses resume. Combination contraceptives affect both the quality and quantity of breastmilk; hence they are not recommended. Sterilization is a permanent method and therefore useful only when the family has been completed.

Can chronic maternal drug therapy alter the nursing infant's hepatic drug metabolizing enzyme pattern?

This study was carried out to investigate whether minute quantities of maternal drugs ingested over an extended period of time by a breast-feeding infant can alter the activity pattern of the infant's hepatic drug metabolizing enzyme (HDME). The HDME activity patterns of 12 breast-fed infants whose mothers were not on drug therapy were compared with those of 11 infants whose mothers had been taking 30 micrograms levo-norgesterel daily for 90 to 195 days (oral contraceptives group) and of 10 infants whose mothers had been taking ethambutol and isoniazid daily since pregnancy (tuberculosis group). As 6 beta hydroxycortisol in urine is considered to be a good and acceptable reflector of HDME activity, it was estimated from the infants' urine using enzyme-linked immunosorbent assay (ELISA) technique. A comparison of the patterns between 90 days of age and 195 days of age of the infants in the control group and the two study groups indicated an increase from 36.6 ng/mL to 58.4 ng/mL at 195 days in the control group. An initial decrease from 36.6 ng/mL to 26.2 ng/mL was noted with commencement of maternal levo-norgesterel therapy, followed by a slow and steady rise to 47.8 ng/mL at 195 days of age, with a shift in the peak from 120 to 135 days of infants age in the oral contraceptive group. A suppressed pattern with decreased levels of 6 beta hydroxycortisol ranging from 19.3 ng/mL to 26.5 ng/mL at 195 days was found in the tuberculosis group. The data were analyzed by two-way analysis of variance (ANOVA) coupled with Duncan's Multiple range test. Both treatment group showed significant differences from the control group at the 0.050 level. The HDME plays an important role in determining the final outcome of any drug in humans, as it controls the metabolism of drugs. Hence, alterations in its activity caused by the transfer of maternal drugs over a prolonged period of time could pose a serious problem to nurslings when they require drugs for their own benefit.

Heterologous expression of apolipoprotein B carboxyl-terminal truncates: a model for the study of lipoprotein biogenesis

Expression of proteins in cells that lack specific chaperones, or subunits required for correct assembly results in the degradation of these proteins early on after synthesis, probably in the endoplasmic reticulum (ER) or an ER-related compartment. We have explored heterologous expression as a model to study the complex process involved in the biogenesis of apolipoprotein B (apoB)-containing lipoproteins. As an initial step, a series of carboxyl-terminal truncated apoB in COS cells were expressed to characterize this system. ApoB proteins ranging from apoB-13 to apoB-41 were expressed. Truncates larger than apoB-29 were completely retained and degraded within the cells; hence these cells have a 'secretory defect' for the larger truncates. Degradation of these apoB proteins is likely to be in the endoplasmic reticulum or ER-related compartment, as shown by sensitivity to endo beta-N-acetylglucosaminidase, by lack of an effect on the degradation kinetics by brefeldin A treatment, and by ImmunoGold EM. Degradation in COS cells was not affected by a variety of protease inhibitors, including N-acetyl-leucyl-leucyl-norleucinal (ALLN). Addition of oleate to the culture medium did not alter their metabolic fate. In comparison to the larger truncates, apoB proteins less than apoB-29 were partially secreted; the majority of these, too, were also retained and degraded intracellularly in a similar compartment. Secreted apoB-17 protein was shown to have been processed correctly in the Golgi and was secreted as a minimally lipidated protein. This model, based on the expression of apoB truncates larger than B-29 in COS cells, may therefore allow for the identification and study of the requirements of specific factors that may be required for both apoB secretion and lipoprotein biogenesis by in vivo complementation of this 'secretory' defect.

Is time-interval between mini-pill ingestion and breastfeeding essential?

A study was conducted on four alternate days over an eight-day period in a group of 12 healthy, 20-35 year old exclusively breast feeding women who were interested in weaning their infants. On each study day the women ingested 150 micrograms levonorgestrel. Maternal blood and milk samples were collected at 2, 4, 6, and 8 hr intervals after LNG ingestion on the 1st, 3rd, 5th, and 8th day. A time-dependent decrease in maternal serum and increase in breast milk levels of LNG were observed. Maintaining a time interval between mini-pill intake and breastfeeding results in higher levels of LNG in breast milk, thereby exposing the infant to a bolus of LNG in a "single-delayed" feed.

At what 'infant-age' can levonorgestrel contraceptives be recommended to nursing mothers?

OBJECTIVE

Levonorgestrel (LNG), a low-dose progestin, does not affect lactation but like all drugs taken by breastfeeding mothers, it can be transferred to the infant via breast milk. How infants of various ages cope with this unwanted maternal drug would help in deciding when to recommend this method of contraception to breastfeeding mothers.

METHODS

The study was conducted in 30 exclusively breastfeeding mothers and their 4-, 12- and 24-week-old infants. The mothers daily received 30 micrograms LNG over a five-week period, thus exposing their infants to maternal LNG for that period.

RESULTS

Four-week-old infants could neither absorb nor metabolize LNG efficiently. Twelve-week-old infants could metabolize LNG more efficiently than absorb. Twenty-four-week-old infants could do both efficiently.

CONCLUSION

It is safe to introduce LNG to breastfeeding mothers at 12 weeks postpartum.

Structural studies on human muscle fatty acid binding protein at 1.4 A resolution: binding interactions with three C18 fatty acids

BACKGROUND

Muscle fatty acid binding protein (M-FABP) is one of a family of cytosolic lipid-binding proteins involved in fatty acid processing. In order to investigate the precise interactions between M-FABP and its ligands and to understand the structural basis of differential binding affinity, we have compared the structures of M-FABP in complex with three C18 fatty acids.

RESULTS

We describe the crystal structures of M-FABP in complex with n-octadecanoate (stearate), trans-delta 9-octadecenoate (elaidate) and cis-delta 9-octadecenoate (oleate). These structures were refined using least-squares positional and anisotropic temperature factor refinement to final R-factors of 11.4%, 12.1% and 13.2% respectively for all the data between 8.0 A and 1.4 A resolution.

CONCLUSIONS

Stearate, elaidate and oleate each adopt highly similar U-shaped conformations when they bind to M-FABP within a large interior binding cavity, which also contains 13 ordered water molecules. The atomic structure of the protein is virtually identical, regardless of the nature of the bound ligand. The fatty acid is thought to enter the interior cavity of the protein via a portal in its surface while interior solvent is released through a secondary opening. The ligand affinity can be correlated with the conformational energy and the solubility of the bound ligand.

A sensitive ELISA for 6 beta-hydroxycortisol in urine using enzyme penicillinase (beta-lactamase)

A sensitive and specific, enzyme labelled immunosorbent assay (ELISA) for 6 beta-hydroxycortisol in diluted urine using penicillinase was developed. 6 beta-Hydroxycortisol-21-hemisuccinate was conjugated with enzyme penicillinase. Antibody immobilized on a polyvinylchloride ELISA plate (Dynatech) was used for separation of bound from free ligand. The sensitivity of the assay was between 2.0-3.0 pg per well and recovery of 6 beta-hydroxycortisol from urine ranged between 85.0-108.0%. The assay is simple, rapid and precise.

Paraquat induced pulmonary fibrosis in three survivors

Pulmonary lesions following paraquat poisoning are believed to be almost invariably fatal. The three patients reports here survived despite persistent radiological change. One of the patients died after taking a larger dose of paraquat one year later, and at necropsy histological changes attributable to the two episodes of paraquat poisoning were apparent.

Clostridial pleuropulmonary infections: case report and review of the literature

Clostridia rarely cause pleuropulmonary infections in the absence of trauma. We report a case of intermittent bowel obstruction, clostridial bacteraemia and pneumonia with a fatal outcome. Only 16 cases have previously been reported. Clostridial infection of the lung has many features of an acute pneumonia and is almost always associated with a pleural effusion. Most cases are caused by Clostridium perfringens, though infections with other species have been reported. The prognosis is generally more favourable than in clostridial infection secondary to aspiration pneumonia or complicating empyema.