Elevated anti-alpha-enolase antibody levels in Kawasaki disease

OBJECTIVE

By functioning as a heat-shock protein (HSP), alpha-enolase has an important role in the pathophysiology of multivariant vasculitis. Kawasaki disease (KD) is a type of vasculitis occurring primarily in children. The role of alpha-enolase in KD was assessed by measuring anti-alpha-enolase antibody (Ab) titres in patients with KD and the usefulness of anti-alpha-enolase Ab as a diagnostic tool in atypical KD patients was evaluated.

METHODS

Anti-alpha-enolase Ab titres were measured by using an enzyme-linked immunosorbent assay (ELISA) in seven normal control patients, nine febrile control patients and 14 KD patients (10 typical KD, four atypical KD). A standard deviation (SD) of 3 above the mean of the normal control group was considered to be positive reactivity. Western blotting using recombinant human alpha-enolase was performed in four KD patients and three normal controls.

RESULTS

With the positive reactivity limited to +3 SD over the mean (>0.6), 10 out of 14 patients (71%) were positive at the acute onset and 12 out of 14 patients (85.7%) were positive before discharge. In total, 12 out of 14 patients (85.7%) were positive either at acute onset or before discharge. All four atypical KD patients showed positive reactivity. Specific positive bands against recombinant human alpha-enolase were detected by western blotting in all four KD patients, but no reactivity was seen in three patients with normal controls.

CONCLUSION

This is the first study to demonstrate that autoantibodies against the alpha-enolase are present in the sera of KD patients. We suggest that anti-alpha-enolase Ab should be a good candidate for a diagnostic tool in atypical KD.

Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma

BACKGROUND

Case reports of human rights violations have focused on individuals' experiences. Population-based quantification of associations between rights indicators and health outcomes is rare and has not been documented in eastern Burma.

OBJECTIVE

We describe the association between mortality and morbidity and the household-level experience of human rights violations among internally displaced persons in eastern Burma.

METHODS

Mobile health workers in conflict zones of eastern Burma conducted 1834 retrospective household surveys in 2004. Workers recorded data on vital events, mid-upper arm circumference of young children, malaria parasitaemia status of respondents and household experience of various human rights violations during the previous 12 months.

RESULTS

Under-5 mortality was 218 (95% confidence interval 135 to 301) per 1000 live births. Almost one-third of households reported forced labour (32.6%). Forced displacement (8.9% of households) was associated with increased child mortality (odds ratio = 2.80), child malnutrition (odds ratio = 3.22) and landmine injury (odds ratio = 3.89). Theft or destruction of the food supply (reported by 25.2% of households) was associated with increased crude mortality (odds ratio = 1.58), malaria parasitaemia (odds ratio = 1.82), child malnutrition (odds ratio = 1.94) and landmine injury (odds ratio = 4.55). Multiple rights violations (14.4% of households) increased the risk of child (incidence rate ratio = 2.18) and crude (incidence rate ratio = 1.75) mortality and the odds of landmine injury (odds ratio = 19.8). Child mortality risk was increased more than fivefold (incidence rate ratio = 5.23) among families reporting three or more rights violations.

CONCLUSIONS

Widespread human rights violations in conflict zones in eastern Burma are associated with significantly increased morbidity and mortality. Population-level associations can be quantified using standard epidemiological methods. This approach requires further validation and refinement elsewhere.

Prevalence of Plasmodium falciparum in active conflict areas of eastern Burma: a summary of cross-sectional data

Background

Burma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown.

Methods

Plasmodium falciparum (Pf) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf^®). Pf prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate Pf prevalence by age, sex, and dry vs. rainy season.

Results

9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 – 8.6; 2004: 7.1%, 95% CI: 6.9 – 7.3; 2005:10.5%, 95% CI: 9.3 – 11.8 and 2006: 9.3%, 95% CI: 8.2 – 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 – 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 – 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 – 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 – 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 – 8.8; to 12.4%, 95% CI: 9.4 – 15.4).

Conclusion

Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.

Increased serum levels of macrophage migration inhibitory factor in patients with Kawasaki disease

OBJECTIVE

To determine whether serum levels of macrophage migration inhibitory factor (MIF) increase in patients with Kawasaki disease (KD) and also correlate with other inflammatory indices.

METHODS

Serum samples from 10 patients with KD, 15 normal healthy subjects, and seven febrile control subjects were assayed for MIF by enzyme-linked immunosorbent assay (ELISA).

RESULTS

There was a significant increase in the serum levels of MIF in the acute stage of KD [113.06 (range 20.6-157.36) ng/mL] compared with those in the subacute stage [28.11 (8.57-143.48) ng/mL, p<0.01], normal controls [12.95 (8.40-18.67) ng/mL, p<0.001], and febrile controls [36.58 (21.31-59.67) ng/mL, p = 0.01]. The increase in MIF correlated with an increase in interleukin-6 (IL-6) (r = 0.52, p = 0.047).

CONCLUSION

MIF may be a useful marker in the acute stage of KD and may provide important clues to the pathogenesis of this disease.

Depression in vascular dementia is quantitatively and qualitatively different from depression in Alzheimer's disease

BACKGROUND/AIMS

To compare the prevalence and characteristics of depression in vascular dementia (VaD) and Alzheimer's disease (AD) after adjusting for dementia severity and gender.

METHODS

One hundred and eight pairs of VaD and AD patients matched for dementia severity and gender were assessed.

RESULTS

Major depressive disorder (MDD) was more prevalent in the VaD group than in the AD group (20.4% in VaD, 10.2% in AD, p = 0.04, Cochran-Mantel-Haenszel, CMH, test) regardless of the dementia severity and gender. The odds ratio for developing MDD in the VaD group versus the AD group was estimated to be 2.20 (95% confidence interval = 1.02-4.74). Neurovegetative symptoms such as 'felt tired and weak all the time' (30.6% in VaD, 13.9% in AD, p = 0.003, CMH test) and 'changed weight without trying' (16.7% in VaD, 6.5% in AD, p = 0.02, CMH test) were more prevalent in the VaD group than in the AD group.

CONCLUSION

Depression in VaD was quantitatively and qualitatively different from that in AD regardless of the severity of dementia and gender; depression was more prevalent, severer and more retarded and vegetative in VaD than in AD.

Responding to AIDS, tuberculosis, malaria, and emerging infectious diseases in Burma: dilemmas of policy and practice

Beyrer and colleagues discuss infectious disease threats in Burma and suggest policy options for responding to them.

Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma

OBJECTIVES

To estimate mortality rates for populations living in civil war zones in Karen, Karenni, and Mon states of eastern Burma.

METHODS

Indigenous mobile health workers providing care in conflict zones in Karen, Karenni, and Mon areas of eastern Burma conducted cluster sample surveys interviewing heads of households during 3-month time periods in 2002 and 2003 to collect demographic and mortality data.

RESULTS

In 2002 health workers completed 1290 household surveys comprising 7496 individuals. In 2003, 1609 households with 9083 members were surveyed. Estimates of vital statistics were as follows: infant mortality rate: 135 (95% CI: 96-181) and 122 (95% CI: 70-175) per 1000 live births; under-five mortality rate: 291 (95% CI: 238-348) and 276 (95% CI: 190-361) per 1000 live births; crude mortality rate: 25 (95% CI: 21-29) and 21 (95% CI: 15-27) per 1000 persons per year.

CONCLUSIONS

Populations living in conflict zones in eastern Burma experience high mortality rates. The use of indigenous mobile health workers provides one means of measuring health status among populations that would normally be inaccessible due to ongoing conflict.

Comparison of esophageal acid exposure at 1 cm and 6 cm above the squamocolumnar junction using the Bravo pH monitoring system

The aim of this study was to assess the quantitative differences of acid exposure at 1 cm and 6 cm above the squamocolumnar junction (SCJ) using two radiotelemetry pH capsules affixed to the esophageal mucosa. Ten normal subjects and 10 endoscopy-negative gastroesophageal reflux disease (GERD) patients without hiatus hernia (ages 20-54, 12 male) were studied for a 24-h period using the Bravo pH monitoring system. pH capsules were placed 1 cm and 6 cm above the SCJ. Interpretable data for at least 14 h was obtained in 18 of the 20 subjects (9 normal, 9 GERD). Two failures occurred secondary to early capsule dislodgement. Median esophageal acid exposure was significantly increased at 1 cm above the SCJ compared to 6 cm above the SCJ during the total, upright and postprandial time periods in both normal and GERD subjects. During a 2 h postprandial period the esophageal acid exposure was 8-fold greater in GERD subjects and 5-fold greater in normal subjects 1 cm above the SCJ compared to 6 cm above the SCJ. Confident measurement of esophageal acid exposure at a fixed position 1 cm above the SCJ is feasible with the Bravo system. Acid exposure was significantly higher 1 cm above the SCJ compared to 6 cm above the SCJ in both GERD patients and controls. These findings suggest that measurement of acid exposure 1 cm above the SCJ may improve accuracy of pH monitoring by detecting acid reflux events confined to the distal esophagus.

BioWarehouse: a bioinformatics database warehouse toolkit

BACKGROUND

This article addresses the problem of interoperation of heterogeneous bioinformatics databases.

RESULTS

We introduce BioWarehouse, an open source toolkit for constructing bioinformatics database warehouses using the MySQL and Oracle relational database managers. BioWarehouse integrates its component databases into a common representational framework within a single database management system, thus enabling multi-database queries using the Structured Query Language (SQL) but also facilitating a variety of database integration tasks such as comparative analysis and data mining. BioWarehouse currently supports the integration of a pathway-centric set of databases including ENZYME, KEGG, and BioCyc, and in addition the UniProt, GenBank, NCBI Taxonomy, and CMR databases, and the Gene Ontology. Loader tools, written in the C and JAVA languages, parse and load these databases into a relational database schema. The loaders also apply a degree of semantic normalization to their respective source data, decreasing semantic heterogeneity. The schema supports the following bioinformatics datatypes: chemical compounds, biochemical reactions, metabolic pathways, proteins, genes, nucleic acid sequences, features on protein and nucleic-acid sequences, organisms, organism taxonomies, and controlled vocabularies. As an application example, we applied BioWarehouse to determine the fraction of biochemically characterized enzyme activities for which no sequences exist in the public sequence databases. The answer is that no sequence exists for 36% of enzyme activities for which EC numbers have been assigned. These gaps in sequence data significantly limit the accuracy of genome annotation and metabolic pathway prediction, and are a barrier for metabolic engineering. Complex queries of this type provide examples of the value of the data warehousing approach to bioinformatics research.

CONCLUSION

BioWarehouse embodies significant progress on the database integration problem for bioinformatics.

Pathophysiology of gastroesophageal reflux disease

From a pathophysiologic viewpoint, GERD results from the excessive reflux of gastric contents into the distal esophagus. Under normal conditions, this is prevented as a function of the antireflux barrier at the EGJ, the integrity of which is dependent on the delicate interplay of a host of anatomic and physiologic factors, including the integrity of the LES, TLESR, and anatomic degradation of the EGJ inclusive of but not limited to hiatus hernia. Considerable investigative focus is aimed at describing the subtle aberrations of the EGJ that may contribute to the root causes of GERD. The net result is an increased number of reflux events, an increasing diversity of potential mechanisms of reflux, and a diminished ability of the stomach to selectively vent gas, as opposed to gas and gastric juice, during TLESR. Once reflux occurs, the duration of resultant esophageal acid exposure is determined by the effectiveness of esophageal acid clearance, the dominant determinants of which are peristalsis, salivation, and, again, the anatomic integrity of the EGJ. Approximately half of patients who have GERD have abnormal acid clearance and the major contributor to this is hiatus hernia. Abnormalities of acid clearance probably are the major determining factor influencing which patients who have GERD are most prone to developing esophagitis as opposed to symptomatic GERD. In summary, GERD is a multifactorial process involving physiologic and anatomic abnormalities. These abnormalities exhibit a complicated interplay that degrades the ability of the EGJ to contain gastric juice within the stomach and to clear the esophagus of gastric juice effectively once reflux has occurred.

Bravo capsule placement in the gastric cardia: a novel method for analysis of proximal stomach acid environment

BACKGROUND

Intragastric pH monitoring is currently done using catheter-based pH systems. This study assessed the feasibility of proximal intragastric pH recording with the Bravo wireless pH monitoring system using novel methodology.

METHODS

Nine asymptomatic volunteers and 9 symptomatic patients were studied. One pH capsule was positioned under direct endoscopic visualization so that the device straddled the squamocolumnar junction (SCJ) with the attachment well positioned on squamous mucosa and the pH electrode 1.5-2 cm distal to the SCJ. A second capsule was placed 6 cm proximal to the SCJ. The signal from each capsule was recorded by a separate receiver synchronized for time.

RESULTS

Successful placement and interpretable recording for >42 h from both pH capsules was achieved in 16 (88%) of 18 subjects. Data capture were 98.3% in the cardia and 97.7% in the esophagus. Two failures occurred due to premature capsule detachment (one esophageal and one gastric). The acid environment in the cardia was similar in asymptomatic controls and symptomatic patients and exhibited less meal-related buffering than is typical of more distal intragastric recordings. In addition, nadir gastric cardia pH was almost always less than nadir esophageal pH during reflux events.

CONCLUSIONS

Twenty-four hour gastric cardia pH monitoring is feasible with the Bravo system and can be added to esophageal pH monitoring to assess concomitant cardia acidity. Instantaneous cardia pH defines the potential nadir esophageal pH during reflux events.

Comparison of the Bravo wireless and Digitrapper catheter-based pH monitoring systems for measuring esophageal acid exposure

INTRODUCTION

We compared esophageal acid exposure data obtained during simultaneous esophageal pH studies using the Bravo wireless and the Slimline catheter-Mark III Digitrapper pH systems.

METHODS

Twenty-five asymptomatic subjects underwent endoscopy with endoclip placement at the squamocolumnar junction (SCJ) and manometry to localize the lower esophageal sphincter (LES). A Bravo capsule was placed 6 cm above the SCJ and a Slimline catheter 5 cm above the LES. Relative positions were checked fluoroscopically. Synchronized pH data were compared by manual extraction into Excel spreadsheets. An in vivo pH reference was established with swallows of orange juice (pH 3.88).

RESULTS

Median acid exposure time was greater with the Slimline compared to the Bravo system (Slimline, 3.4%; Bravo, 1.76%, p < 0.05) but electrode positions were similar. The dominant source of discrepancy between systems was an offset in recorded pH values around pH 4 as evidenced by the recorded values of the swallowed orange juice. Bench-top testing suggested that this offset was mainly attributable to the software designed to compensate for the difference in electrode recording characteristics between room and body temperature. After adjusting the pH data sets to accurately reflect actual orange juice pH, acid exposure between systems was similar (Slimline, 0.90%; Bravo, 1.15%).

CONCLUSION

The Slimline system on average over-recorded esophageal acid exposure compared to the Bravo system largely because of a flawed software scheme for electrode thermal calibration. Accuracy of pH data sets from both systems can be improved by scrutiny for artifacts and use of an in vivo pH reference.

Endoluminal therapy for gastroesophageal reflux disease: is the evidence for efficacy any stronger?

Gastroesophageal reflux disease is a common disorder often requiring chronic treatment. Joining the conventional options of antisecretory medications and fundoplication, endoluminal therapies have emerged in recent years. These techniques have entered US and European markets, claiming effectiveness comparable with antireflux surgery. Nevertheless, a paucity of data is available to support that efficacy, even as more devices are coming onto the market. This review examines published reports of endoluminal reflux therapies from January 2004 to January 2005. After another year, there are still no compelling data supporting the efficacy of any of the available endoluminal treatments.

Factors influencing cardiac auscultation proficiency in physician trainees

INTRODUCTION

We assessed the accuracy of physician trainees in identifying different cardiac sounds and examined the factors influencing their cardiac auscultation proficiency.

METHODS

A total of 106 physicians in the Family Medicine Training Programme were asked to identify 10 cardiac sounds played sequentially on the Littmann electronic stethoscope, which functioned as a surrogate patient. Their auscultation accuracy was scored numerically out of a maximum of 10. Demographical data of the physicians was collected prospectively.

RESULTS

The mean (+/-SD) auscultation proficiency score of the study population was 4.0 +/- 1.7. Physicians who graduated in 1994 or earlier fared significantly poorer than those who obtained their Bachelor of Medicine and Bachelor of Surgery degrees between 1995 and 2000 (p-value equals 0.02). Auscultation proficiency was not related to current practice, previous years of primary care, cardiology, internal medicine or paediatric medicine postings, or cumulative years of postings. Normal heart sounds were most accurately identified. Prosthetic cardiac sounds were better identified than other extra-cardiac sounds while systolic murmurs were more accurately identified than diastolic murmurs. Tachycardia had the lowest identification rate.

CONCLUSION

Our data suggest that cardiac auscultation skill declined with time, being significantly impaired eight years after graduation. We suggest that there is a need for retraining in the form of continuing medical education to address not only new knowledge and skills, but also basic skill competency.

Systematic review: Is there excessive use of proton pump inhibitors in gastro-oesophageal reflux disease?

BACKGROUND

Proton-pump inhibitors are often recommended for continuous use in gastro-oesophageal reflux disease, but this may not be necessary in all patients.

AIM

To ascertain the level of evidence for alternative strategies for proton-pump inhibitor treatment in gastro-oesophageal reflux disease.

METHODS

We searched for observational or interventional studies examining alternatives to continuous proton-pump inhibitor treatment in gastro-oesophageal reflux disease.

RESULTS

Non-randomized studies suggest that some patients with gastro-oesophageal reflux disease, including some with erosive oesophagitis, may be adequately maintained on proton-pump inhibitor therapy given less frequently than once daily. However, the results may not be generalizable. Four high quality randomized-controlled trials compared 'on-demand' proton-pump inhibitor and placebo treatment in endoscopy-negative reflux disease; all found this effective for most patients. One high quality randomized-controlled trial found intermittent courses of a proton-pump inhibitor or H2-receptor antagonist in erosive oesophagitis or endoscopy-negative reflux disease adequate for almost half of the patients studied. Up to 80% of patients on continuous high-dose proton-pump inhibitor treatment for gastro-oesophageal reflux disease can be 'stepped down' to less intensive therapy.

CONCLUSIONS

On-demand proton-pump inhibitor treatment may be appropriate in endoscopy-negative reflux disease. In gastro-oesophageal reflux disease, patients taking more than once daily or high-dose proton-pump inhibitor treatment, a step down to once daily or standard dose therapy should be attempted.

Esophagogastric junction morphology predicts susceptibility to exercise-induced reflux

BACKGROUND AND AIM

Although strenuous exercise has been reported to increase gastroesophageal reflux, there are few data exploring the mechanism behind this relationship. The aim of this study was to use vigorous exercise as a provocation for strain-induced reflux and examine the correlation between endoscopically assessed EGJ integrity and exercise-induced reflux.

METHODS

Ten controls and 10 GERD patients were studied for a 2-day period using the wireless Bravo pH monitoring system. The subjects were randomly assigned to perform 60 min of exercise on day 1 or 2 consuming the same diet on both days. Exercise consisted of 30 min of running and 30 min of 5 resistance exercises. Subjects underwent endoscopy to grade the EGJ "flap valve" and manometry to measure basal LES pressure.

RESULTS

Nineteen subjects completed the 2-day study with 100% data capture during exercise. Median acid exposure was increased more than threefold for both controls and GERD patients during exercise when compared to nonexercise periods. In addition, a strong correlation existed between EGJ grade and % time pH < 4 during exercise while there was not a significant correlation between LES pressure and EGJ grade. These findings were present even after exclusion of hiatus hernia patients (flap valve grade 4).

CONCLUSIONS

Exercise caused a threefold increase in esophageal acid exposure in both controls and GERD patients. The degree of exercise-induced reflux is strongly correlated with EGJ morphology and this supports the hypothesis that anatomical integrity of the EGJ is of cardinal importance in preventing strain-induced reflux.

Parental compliance with after hours telephone triage advice: nurse advice service versus on-call pediatricians

To compare parental compliance with after-hours triage advice provided by telephone advice nurses and on-call pediatricians, a randomized controlled trial was undertaken at a university general pediatrics practice that enrolled parents or guardians calling for after-hours advice. Advice calls were randomized to a call center advice nurse or the on-call pediatrician. Parental compliance with the triage advice and agreement of the parental report of advice with the pediatrician/nurse report of advice given was evaluated. There were 566 participants in the pediatrician and 616 in the nurse group. Compliance with advice (pediatrician v. nurse) was not significantly different for emergent/urgent care (75.8% v. 72.6%) and self care (74.3% v. 77.2%) but was significantly higher in the pediatrician group for office care (51.5% v. 29.6%; 95% CI of difference, 8.9%-34.2%). Overall agreement between the caller reported and physician or nurse advice was 84.5% for emergent/ urgent, 42.7% for office care, and 93.7% for self-care.

Does telephone triage delay significant medical treatment?: Advice nurse service vs on-call pediatricians

BACKGROUND

Advice nurse call centers are used to ensure access to medical advice, thereby potentially reducing the costs of health services.

OBJECTIVE

To determine if medical advice from advice nurses and on-call physicians delays significant medical treatment in a general pediatrics population.

DESIGN

Randomized controlled trial.

SETTING

A university general pediatrics faculty practice.

PARTICIPANTS

Parents or guardians calling for after-hours advice regarding their children.Intervention After-hours medical advice calls were randomized at the time of the call to an advice nurse or an on-call pediatrician.

MAIN OUTCOME MEASURES

The proportion of callers who sought medical care not advised by the advice nurse or on-call pediatrician and the proportion who received unadvised significant care.

RESULTS

There were 1182 advice calls: 566 in the pediatrician group and 616 in the advice nurse group. There were no significant differences in the types of telephone triage advice in the physician and advice nurse groups. There was no significant difference in the proportion of callers who sought unadvised care (108 [19.9%] in the physician group vs 110 [19.0%] in the advice nurse group) or in the proportion of callers who received unadvised significant care (23 [4.2%] in the physician group vs 25 [4.3%] in the advice nurse group).

CONCLUSIONS

The proportions of callers who sought unadvised medical care and who received unadvised significant care were not significantly different in the advice nurse and pediatrician groups. This suggests that advice nurses do not delay significant medical treatment when compared with pediatricians.

Medical management of Barrett's esophagus

Barrett's metaplasia of some extent is found commonly in patients with GERD. Detection is possible only by endoscopy and biopsy of the columnar appearing mucosa; no symptoms or signs distinguish patients with Barrett's metaplasia from those without. The management goals in patients with Barrett's are to alleviate reflux symptoms and to control the risk of adenocarcinoma. Symptom control is achieved primarily with PPIs. Acid inhibition does not, however, cause regression of Barrett's metaplasia and has not been shown to reduce the risk of esophageal adenocarcinoma. The risk of adenocarcinoma is managed by surveillance with endoscopy and biopsy searching for dysplastic change. LGD merits more intense surveillance. The optimal management of HGD, however, remains controversial, as evidenced by the multitude of ablation therapies that have been introduced recently. These techniques will be discussed in depth in subsequent articles in this volume.

Synthesis and characterization of high-quality double-walled carbon nanotubes by catalytic decomposition of alcohol

We report the synthesis of high-quality double-walled carbon nanotubes without defects by catalytic decomposition of alcohol over an Fe-Mo/Al2O3 catalyst; the synthesized DWNTs have outer diameters in the range of 1.52-3.54 nm and an average interlayer distance of 0.38 nm between graphene layers.