Molecular strain typing of Mycobacterium tuberculosis complex in Bamako, Mali

OBJECTIVE

To identify strains of Mycobacterium tuberculosis complex (MTC) circulating in Bamako and to examine the relationship between the strains and their drug susceptibility profiles.

METHODS

Between 2006 and 2010, we conducted a cross-sectional study using spoligotyping to identify strains of MTC recovered from 126 tuberculosis (TB) patients under treatment in Bamako, Mali.

RESULT

Three members of the MTC were isolated: M. tuberculosis (71.4%), M. africanum (27.8%) and M. bovis (0.8%). Of these, three strains were found to be the most prevalent: M. tuberculosis T1 (MTB T1; 38.9%), M. africanum F2 (MAF2; 26.2%) and M. tuberculosis Latin American and Mediterranean 10 (MTB LAM 10; 10.3%). MAF2 and MTB LAM 10 strains have a lower risk of multidrug resistance (MDR) than MTB T1 (respectively OR 0.1, 95%CI 0.03-0.4 and OR 0.1, 95%CI 0.01-0.8). Age ≥ 32 years (OR 1.4, 95%CI 0.4-3.9), negative human immunodeficiency virus status (OR 0.4, 95%CI 0.1-2.5) and male sex (OR 4, 95%CI 0.9-16.5) were not associated with MDR. The prevalence of MDR among treatment and retreatment failure patients was respectively 25% and 81.8% compared to new patients (2.9%).

CONCLUSION

This study indicates a low level of primary drug resistance in Bamako, affirms the importance of using correct drug regimens, and suggests that the MTB T1 strain may be associated with the development of resistance.

Comparative evaluation of local and improved crop varieties through farmers’ participation on resource-poor farms in Afghanistan

The introduction of new crop varieties is important to improve farm productivity and increase food security in developing countries. This study was conducted to determine the performance of improved varieties of wheat (Triticum aestivum L.), rice (Oryza sativa L.), mungbean [(Vigna radiata (L.) Wilczek] and potato (Solanum tuberosum L.) in comparison to local varieties through farmers’ participatory evaluation. The study was conducted during three years (2006 to 2008) with 948 farmers’ participatory field trials across 18 districts in three Eastern provinces (Nangarhar, Laghman and Kunar) of Afghanistan. One or more improved varieties of wheat, rice, mungbean and potato were compared to the most popular local variety. Data were recorded on the grain yield of wheat, rice and mungbean, and the tuber yield of potato. On average, the improved varieties outyielded local varieties by 69, 57, 70 and 65% for wheat, rice, mungbean, and potato, respectively. Economic analysis in terms of net benefit demonstrated that the adoption of improved varieties resulted in additional incomes of US$ 1840, 1299, 574 and 790 ha-1 for wheat, rice, mungbean and potato, respectively. These findings underline the importance of on-farm farmers’ participatory technology evaluation in developing countries to disseminate new crop varieties to improve farm productivity.

Sonographic fetal biometry charts for a Pakistani cohort

This study aimed to develop growth centiles at different gestational weeks for fetal biparietal diameter, abdominal circumference, femur length and head circumference in a Pakistani cohort. Data were collected at a tertiary referral hospital from pregnant women at gestational ages 13-40 weeks referred for obstetric ultrasound as a part of routine antenatal care. A total of 1599 fetal sonographic biometric measurements were collected after screening for the inclusion criteria. For each measurement, separate regression models were derived to estimate the mean, standard deviation and reference percentiles at each week of gestational age for this cohort. The best fitting model for each variable was selected. These charts will help radiologists and clinicians in predicting dates of delivery, assessing fetal growth and identifying intrauterine fetal insufficiency in the Pakistani population.

Lung damage and airway remodelling in severe asthma

Severe asthma is a heterogeneous disease with substantial unmet clinical need. Airway damage and remodelling is a consequence of complex host-environment interactions and is considered to be the cardinal feature leading onto the development and persistence of airflow obstruction. In this review, we shall bring together recent insights into the causes of airway damage and remodelling that propose key roles for pathogens and mechanical damage in addition to allergens, underlying genetic susceptibility, inflammatory and structural cell interactions, and impaired resolution of damage. We shall consider the consequences of airway remodelling in terms of airway geometry, mechanics and clinical expression of disease. Understanding the causes and consequences of airway damage and remodelling will shed light upon the structure-function relationships required to begin to unravel the complexity of severe asthma and will enable us to target current and novel therapies as we begin to move towards realizing personalized medicine.

P1-07-03: Preanalytical Variables Affect Protein Expression in Formalin Fixed Paraffin Embedded Tissue – Assessment of Intrinsic Controls To Define Tissue Quality for Immunohistochemical Analysis

Background: Recently it has been shown that biospecimen handling and pre-analytical variables can dramatically affect biomarker assays of protein expression in tumor tissue. Phospho-proteins and even labile unmodified proteins have been suggested to show significant loss of expression due to prolonged time to formalin fixation. Here we assess 4 clinically relevant proteins (ER, PR, HER2 and Ki67) and 20 other proteins for changes as a function to the key preanalytic variables of ischemic time. The ultimate goal of our effort is to find a method to monitor the degradative effect of these variables by construction of a Tissue Quality Index (TQI).

Materials and Methods: Two different breast cancer cohorts were used in order to analyze the biomarkers and their change according to time to formalin fixation. The first cohort consists of 93 breast cancer specimens in 2 fold redundancy on a TMA with cell lines and controls. The time to formalin fixation for each breast cancer specimen was recorded and ranges from 25 to 415 minutes. The second cohort consists of 25 matched pairs of breast cancer biopsies and resections. The time to formalin fixation for the biopsies is minimal while the time to fixation for the resections, though not recorded, averages between 1 and 3 hours. Protein expression was measured using the AQUA method of quantitative immunofluorescence.

Results: ER alpha, PR, HER2 and Ki67 were each analyzed on the time to fixation array with 2 different antibodies commonly used in the clinical setting. Correlation of AQUA scores of these markers with time to formalin fixation revealed a trend towards loss of protein expression as a linear function of time to fixation without reaching statistical significance. Analysis of these 4 proteins on the matched pairs of biopsies and resections showed that tumor heterogeneity predominated over the effects of ischemic time. Toward identification of markers for a TQI, 20 biomarkers were analyzed on the time to fixation array. Both HIF1alpha and AKAP13 show a significant increase as a function of time to fixation, whereas pMAPK, histone 4 and pTyrosine 4G10 revealed a significant loss of expression. These trends were confirmed in the matched pair validation set with the execption of histone 4. A TQI is being built from these variables.

Conclusions: Ischemic time is a critical pre-analytical variable that impacts measurement of protein expression in tumor tissue. The 4 standard markers used clinically in breast cancer appear to show only moderate effects that appear less critical to measurement accuracy than the issue of tumor heterogeneity. We identified 4 proteins which show a significant change with increasing time to formalin fixation and should allow construction of a TQI for assessment of pre-analytic antigenic degradation.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-03.

Use of antipsychotics in patients with behavioural and psychiatric symptoms of dementia - a retrospective study

Aims and objectives

To review current practice of Antipsychotics prescribing in patients with Behavioural and Psychiatric symptoms of Dementia in secondary care hospital.

Methodology

This was a retrospective audit targeting all patients who were diagnosed with a dementing illness in a large secondary care hospital from September 2008 to December 2008 inclusive. Data was collected from patients’ health care records and central computer database. Current practice was then compared with the standards proposed by the NICE Guidelines (National Institute of Clinical Excellence, 2006).

Results

Out of 18 patients who were diagnosed with dementia, 66% (n = 12) were prescribed antipsychotics. Out of these, 66%(n = 8) were males and 34%(n = 4) were females. 75%(n = 9) had explicitly documented indications for antipsychotics use in their health care records with only 25% cases (n = 3) alternative treatment options such as psychosocial interventions were considered.

Discussions

with patients and/or the carers’ were documented in 50%(n=6) cases. Periodic reviews were carried out in 66% (n = 8) cases.

Conclusion

Antipsychotics are commonly used in behavioural and psychiatric symptoms of dementia. Considering higher risk of morbidity and mortality with antipsychotics use in this population group, it is of paramount importance that reasons for prescribing and discussion with patients and/or their carers should be clearly documented. If antipsychotics are prescribed patients should be reviewed on regular basis.

Management of rectal injury during robotic radical prostatectomy

OBJECTIVES

To review the incidence and management of rectal injury in 4400 consecutive cases of robotic radical prostatectomy at a single institution.

MATERIAL AND METHODS

From September 2001 to September 2009, 4400 patients underwent robotic radical prostatectomy. We reviewed the intraoperative and postoperative data from patients with rectal injuries. Once recognized, the rectal injuries were closed in 2 layers. Clear liquids were started the day after surgery. Healing of the vesicourethral anastomosis was confirmed by cystography 5-14 days postoperatively.

RESULTS

Rectal injuries were identified in 10 patients (0.2%). The mean patient age was 58.6 years (range 44-68), and the mean body mass index was 25.8 kg/m(2) (range 22-29). The mean prostate-specific antigen level was 7.1 ng/mL (range 0.9-14.8), and the mean prostate weight was 58.9 g (range 22-102). The clinical stage was T1c, T2a, and T2c in 7, 2, and 1 patient, respectively. The preoperative Gleason score was 6, 7, and 8 in 3, 3, and 4 patients, respectively. All rectal injuries were diagnosed and repaired intraoperatively. Of the 10 patients, 9 had an uneventful postoperative course. The average urethral catheterization time for these patients was 14 days (range 6-21). One patient had gross fecal spillage and developed a rectourethral fistula requiring a delayed diverting colostomy. No perioperative mortality occurred.

CONCLUSIONS

We found a low incidence of rectal injury during robotic radical prostatectomy. We have also demonstrated that rectal injuries can be managed primarily with meticulous closure with minimal morbidity.

Naga chilli: a potential source of capsaicinoids with broad-spectrum ethnopharmacological applications

Capsicum species are not only cultivated as vegetable and condiment crops but are also incorporated into a number of medicinal preparations in the ancient literature around the world. 'Naga chilli' or 'Bhoot Jolokia' (Capsicum chinense Jacq.) is a chilli variety indigenous to the northeast region of India and has been recognized as the hottest chilli in the world. It has also been used conventionally in treating various human ailments since time immemorial by the indigenous people of the northeast India. Despite being an important crop of the northeast India, the information on the biology and cultivation of Naga chilli is very scanty and scattered. The present article reviews the scientific literature on above aspects with particular emphasis on identifying the key regional issues which need to be addressed urgently by the policy makers in order to harness its potential as an important source of capsaicinoids. Further, an attempt has been made to collate the potential of capsaicinoids in various ethnopharmacological applications such as pain therapy, body temperature regulation, anti-obesity treatments, anticancer therapy and as antioxidant and antimicrobial agent. We anticipate that this literature analysis of traditional medicinal uses and experimental trials of Capsicum using modern scientific approaches shall provide a basis for suggesting important areas where sincere research efforts are warranted to bridge the gap between traditional medicinal knowledge and modern biomedical knowledge.

Helicobacter pylori infection in children: population-based age-specific prevalence and risk factors in a developing country

AIM

We estimated the prevalence, age of acquisition and risk factors for Helicobacter pylori (H. pylori) seroprevalence in children aged 1-15 years.

METHODS

Exposure was assessed using ELISA. Parents responded to a questionnaire regarding number of individuals sharing house, rooms, water source, latrines, housing and assessment of socioeconomic status (SES) by Hollingshead Index.

RESULTS

Serum of 1976 children was tested. Helicobacter pylori seropositivity in children aged 11-15 years was 53.5% (OR: 2.0, 95% CI: 1.58-2.5). It increased with moderate crowding index (CRI) of 2-4 to 45.9% (OR: 1.23, 95% CI: 0.92-1.63) and to 51.2% with CRI >4 (OR: 1.52, 95% CI: 1.12-2.06). In middle SES, seropositivity was 50.5% (331/655) (OR: 1.7, 95% CI: 1.29-2.35), whereas in lower SES, it was 47.1% (500/1062) (OR: 1.5, 95% CI: 1.1-2.0). Multivariate analysis showed that Helicobacter pylori seroprevalence was high in children aged 6-10 and 11-15 years (OR: 1.5, 95% CI: 1.2-1.9 and OR: 1.9, 95% CI: 1.56-2.47 respectively), in lower-middle SES (OR: 1.6, 95% CI: 1.2-2.1 and OR: 1.5, 95% CI: 1.10-2.0 respectively) and in uneducated fathers (OR: 1.58, 95% CI: 1.27-1.95).

CONCLUSION

Helicobacter pylori seropositivity increases with age, in low-middle SES and is related to father's educational status. Reducing H. pylori seroprevalence will require improvement in sanitary conditions and educational status of the population.

Partial versus radical nephrectomy for 4 to 7 cm renal cortical tumors

PURPOSE

Recent observations suggest that partial nephrectomy for small renal tumors may be associated with improved survival compared with radical nephrectomy. We evaluated survival in patients with 4 to 7 cm renal tumors in a bi-institutional collaboration.

MATERIALS AND METHODS

By combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering Cancer Center we identified 1,159 patients with 4.1 to 7.0 cm sporadic, unilateral, solitary, localized renal masses who underwent radical or partial nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models.

RESULTS

Of the 1,159 patients 873 (75%) and 286 (25%) were treated with radical and partial nephrectomy, respectively. Patients treated with partial vs radical nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%) and chronic kidney disease (15% vs 7%, each p <0.001). Median followup in survivors was 4.8 years (range 0 to 19). There was no significant difference in overall survival in patients treated with radical vs partial nephrectomy (p = 0.8). Of 943 patients with renal cell carcinoma those treated with radical nephrectomy were significantly more likely to die of renal cell carcinoma than those treated with partial nephrectomy (HR 2.16, 95% CI 1.04-4.50, p = 0.039) but this only approached statistical significance on multivariate analysis (HR 1.97, 95% CI 0.92-4.20, p = 0.079).

CONCLUSIONS

Results suggest that overall and cancer specific survival is not compromised when partial nephrectomy is done for 4 to 7 cm renal cortical tumors. With the benefit of preserving renal function our results support partial nephrectomy when technically feasible for renal tumors up to 7 cm.

Retrospective surveillance of HIV prevalence in blood donors can help in the selection of the best social group for blood donation in Mali

The National Centre for Blood Transfusion, Bamako, Mali has collected data that characterizes trend in HIV prevalence over 10 years by gender, age, occupation, marital status and donor category. These data help to describe national HIV prevalence and assist in formulating blood donation policies. Donations from 1993 to 2002 were categorized by donor age (decade), occupation (student, military and other), marital status (single, married and other), gender and donor status (volunteer, occasional and family). Comparisons were made using conservative estimates of donation frequency/donor category. Donations increased by more than 400%. By 1999, increased HIV prevalence in donations from women was consistently present. Donations from the age group of 30-39 years showed an increased prevalence beginning in 2000, which by 2002 was almost 10 times greater than in the low-prevalence (<20 years) group (5.9 vs. 0.6%). By 2000, both categories - students and military were less likely to be HIV positive than those from other occupational categories, and donations from married persons were less likely to be HIV positive by 1997. The highest prevalence was observed in the 'occasional' donor category, which increased to >14% by 2001; volunteer donation HIV positive peaked at 2.3% in 1999. HIV prevalence in blood donations in Bamako, Mali, demonstrates important trends from 1993 to 2002. The prevalence of > 14% in donations from occasional donors and significant trends by decade, gender, marital status and occupation argue for increased analysis of the blood donor population to improve blood safety and to understand the demographics of HIV infection in Mali.

Airway smooth muscle chemokine receptor expression and function in asthma

BACKGROUND

Chemokine receptors play an important role in cell migration and wound repair. In asthma, CCR3 and 7 are expressed by airway smooth muscle (ASM) and CCR7 has been implicated in the development of ASM hyperplasia. The expression profile of other chemokine receptors by ASM and their function needs to be further explored.

OBJECTIVE

We sought to investigate ASM chemokine receptor expression and function in asthma.

METHODS

ASM cells were derived from 17 subjects with asthma and 36 non-asthmatic controls. ASM chemokine receptor expression was assessed by flow cytometry and immunofluorescence. The function of chemokine receptors expressed by more than 10% of ASM cells was investigated by intracellular calcium measurements, chemotaxis, wound healing, proliferation and survival assays.

RESULTS

In addition to CCR3 and 7, CXCR1, 3 and 4 were highly expressed by ASM. These CXC chemokine receptors were functional with an increase in intracellular calcium following ligand activation and promotion of wound healing [CXCL10 (100 ng/mL) 34 +/- 2 cells/high-powered field (hpf) vs. control 29 +/- 1; P=0.03; n=8]. Spontaneous wound healing was inhibited by CXCR3 neutralizing antibody (mean difference 7 +/- 3 cells/hpf; P=0.03; n=3). CXC chemokine receptor activation did not modulate ASM chemotaxis, proliferation or survival. No differences in chemokine receptor expression or function were observed between ASM cells derived from asthmatic or non-asthmatic donors.

CONCLUSIONS

Our findings suggest that the chemokine receptors CXCR1, 3 and 4 modulate some aspects of ASM function but their importance in asthma is uncertain.

Airway wall geometry in asthma and nonasthmatic eosinophilic bronchitis

BACKGROUND

Variable airflow obstruction and airway hyperresponsiveness (AHR) are features of asthma, which are absent in nonasthmatic eosinophilic bronchitis (EB). Airway remodelling is characteristic of both conditions suggesting that remodelling and airway dysfunction are disassociated, but whether the airway geometry differs between asthma and nonasthmatic EB is uncertain.

METHODS

We assessed airway geometry by computed tomography (CT) imaging in asthma vs EB. A total of 12 subjects with mild-moderate asthma, 14 subjects with refractory asthma, 10 subjects with EB and 11 healthy volunteers were recruited. Subjects had a narrow collimation (0.75 mm) CT scan from the aortic arch to the carina to capture the right upper lobe apical segmental bronchus (RB1). In subjects with asthma and EB, CT scans were performed before and after a 2-week course of oral prednisolone (0.5 mg/kg).

RESULTS

Mild-moderate and refractory asthma were associated with RB1 wall thickening in contrast to subjects with nonasthmatic EB who had maintained RB1 patency without wall thickening [mean (SD) % wall area and luminal area mild-t0-moderate asthma 67.7 (7.3)% and 6.6 (2.8) mm(2)/m(2), refractory asthma 67.3 (5.6)% and 6.7 (3.4) mm(2)/m(2), healthy control group 59.7 (6.3)% and 8.7 (3.8) mm(2)/m(2), EB 61.4 (7.8)% and 11.1 (4.6) mm(2)/m(2) respectively; P < 0.05]. Airway wall thickening of non-RB1 airways generation three to six was a feature of asthma only. There was no change in airway geometry of RB1 after prednisolone. Proximal airway wall thickening was associated with AHR in asthma (r = -0.56; P = 0.02).

CONCLUSIONS

Maintained airway patency in EB may protect against the development of AHR, whereas airway wall thickening may promote AHR in asthma.

Granulocyte-macrophage colony-stimulating factor expression in induced sputum and bronchial mucosa in asthma and COPD

Background:

Granulocyte–macrophage colony-stimulating factor (GM-CSF) has been implicated as an important mediator in the pathogenesis of asthma and chronic obstructive pulmonary disease (COPD). However, the expression of GM-CSF and its receptor in airway samples in asthma and COPD across disease severity needs to be further defined.

Methods:

Sputum GM-CSF was measured in 18 control subjects, 45 subjects with asthma and 47 subjects with COPD. Enumeration of GM-CSF+ cells in the bronchial submucosa and airway smooth muscle bundle was performed in 29 control subjects, 36 subjects with asthma and 10 subjects with COPD.

Results:

The proportion of subjects with measurable GM-CSF in the sputum was raised in those with moderate (7/14) and severe (11/18) asthma, and in those with COPD GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage II (7/16), III (8/17) and IV (7/14) compared with controls (1/18) and those with mild asthma (0/13); p = 0.001. The sputum GM-CSF concentration was correlated with the sputum eosinophilia in subjects with moderate to severe asthma (r_s = 0.41; p = 0.018). The median (interquartile range) GM-CSF+ and GM-CSFR+ cells/mm² of submucosa was increased in severe asthma (1.4 (3.0) and 2.1 (8.4)) compared with those with mild to moderate asthma (0 (2.5) and 1.1 (5)) and healthy controls (0 (0.5) and 0 (1.6)), (p = 0.004 and p = 0.02, respectively).

Conclusions:

The findings support a potential role for GM-CSF in asthma and COPD and suggest that overexpression of GM-CSF in sputum and the bronchial mucosa is a particular feature of severe asthma.

End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

BACKGROUND

With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit.

METHODS

This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way ANOVA were used to compare differences in response between the groups.

RESULTS

One hundred and thirty-seven physicians and critical care nurses completed the survey. 'Brain death' was defined as an 'irreversible cessation of brainstem function' by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value < 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason.

CONCLUSIONS

There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians' and nurses' perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula.

The airway smooth muscle CCR3/CCL11 axis is inhibited by mast cells

BACKGROUND

Airway smooth muscle hyperplasia is a feature of asthma, and increases with disease severity. CCR3-mediated recruitment of airway smooth muscle progenitors towards the airway smooth muscle bundle has been proposed as one possible mechanism involved in airway smooth muscle hyperplasia. Mast cells are microlocalized to the airway smooth muscle bundle and whether mast cells influence CCR3-mediated migration is uncertain.

METHODS

We examined the expression of CCR3 by primary cultures of airway smooth muscle cells from asthmatics and nonasthmatics. CCR3 function was examined using intracellular calcium measurements, chemotaxis, wound healing, cell proliferation and survival assays. We investigated the recovery and function of both recombinant and airway smooth muscle-derived CCL11 (eotaxin) after co-culture with beta-tryptase and human lung mast cells.

RESULTS

Airway smooth muscle expressed CCR3. Airway smooth muscle CCR3 activation by CCL11 mediated intracellular calcium elevation, concentration-dependent migration and wound healing, but had no effect on proliferation or survival. Co-culture with beta-tryptase or mast cells degraded recombinant and airway smooth muscle-derived CCL11, and beta-tryptase inhibited CCL11-mediated airway smooth muscle migration.

CONCLUSIONS

CCL11 mediates airway smooth muscle migration. However co-culture with beta-tryptase or mast cells degraded recombinant and airway smooth muscle-derived CCL11 and inhibited CCL11-mediated airway smooth muscle migration. Therefore these findings cast doubt on the importance of the CCL11/CCR3 axis in the development of airway smooth muscle hyperplasia in asthma.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUND

UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).

METHODS

Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).

RESULTS

Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.

CONCLUSION

The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Pulmonary eosinophilia correlates with allergen deposition to the lower respiratory tract in a mouse model of asthma

BACKGROUND

Eosinophilic infiltration into the airways is frequently associated with allergic asthma; however, the role of antigen deposition in mediating this phenomenon has not been studied in detail.

OBJECTIVE

Using a murine model of ovalbumin (OVA) allergy, we examined how differential deposition of OVA during antigen challenge affects pulmonary eosinophilia, immune response and airway hyper-reactivity (AHR).

METHODS

Differential allergen deposition to the upper respiratory tract (URT) alone or combined upper and lower respiratory tract (ULRT) was accomplished by administering OVA intranasally to either anaesthetized or unanaesthetized mice, respectively. BALB/c mice (6-7 weeks old) were sensitized with OVA-alum via the intraperitoneal route, and then challenged intranasally using OVA, with or without anaesthesia. AHR, enumeration of inflammatory cells and quantitative measurement of inflammatory cytokines and chemokines in bronchoalveolar lavage fluid (BALF), lung histopathology and immune responses were subsequently assessed.

RESULTS

In sensitized animals challenged via the ULRT route, a profound eosinophilia and goblet cell hyperplasia was observed in lung tissue. Conversely, sensitized mice receiving an identical challenge dose via the URT route alone exhibited only negligible levels of inflammation. Interestingly, AHR and OVA-specific IgG(1) and IgE systemic responses were comparable between the two groups.

CONCLUSION

This study indicates that direct exposure of allergen in the deep lung is highly correlated with airway eosinophilia and lung inflammation, but does not correlate with AHR or immune response.

Inflammatory cell microlocalisation and airway dysfunction: cause and effect?

Airway inflammation is a critical feature of the airway diseases asthma and chronic obstructive pulmonary disease (COPD). There is emerging evidence that structural cells play a key role in the development and perpetuation of the inflammatory response and are pivotal in the development of the changes in the airway structures that lead to airway remodelling. To date, little attention has been given to the localisation of inflammatory cells to airway structures or the potential interactions between these intimately located cells. However, it is likely that interactions between inflammatory and structural cells in the airway contribute enormously to the pathophysiology of asthma and COPD. Indeed, recent evidence suggests that mast cells localised to the airway smooth muscle bundle may be important in the development of airway hyperresponsiveness in asthma. In the present article, the authors aim to summarise: 1) the current understanding of which inflammatory cells locate to airway structures; 2) the proposed mechanisms that may be involved in mediating this microlocalisation; 3) the possible consequences of interactions between inflammatory and structural cells; and 4) the pressing need to investigate whether modulating these interactions is beneficial in asthma and chronic obstructive pulmonary disease.

Pre-eclampsia is associated with airway hyperresponsiveness

Several large retrospective cohort studies demonstrate that pre-eclampsia is common in asthmatics. Whether airway hyperresponsiveness (AHR), a hallmark of asthma, is associated with pre-eclampsia is unknown. We measured AHR, using a methacholine challenge, and atopy in 19 women 3-60 months postpartum following pre-eclamptic or normotensive pregnancies. The geometric mean (95% CI) concentration of methacholine required to produce a >20% fall in the forced expiratory volume in 1 second (PC20 FEV1) was 8.9 (2.2-36) mg/ml in pre-eclamptics versus 72 (32-131) mg/ml in controls (P = 0.01) and 9 (1.9-40) mg/ml in atopic pre-eclamptics without asthma versus 54 (17-174) mg/ml (P = 0.038) in matched controls. Therefore, AHR was increased in women who have had pre-eclampsia. This association and its possible mechanisms warrant further investigation.

Long-Term Outcome After Radical Prostatectomy for Patients With Lymph Node Positive Prostate Cancer in the Prostate Specific Antigen Era

PURPOSE

While the incidence of lymph node positive prostate cancer has decreased during the prostate specific antigen era, the optimal treatment of these patients remains in question. We examined the impact of lymph node metastases on the outcome of patients following radical prostatectomy and investigated prognostic factors that affect survival.

MATERIALS AND METHODS

We identified 507 men treated with radical prostatectomy between 1988 and 2001 who had lymph node positive disease. Of the 507 patients 455 (89.7%) were treated with adjuvant hormonal therapy. Median followup was 10.3 years (IQR 6.1-13.5). Postoperative survival rates were estimated using the Kaplan-Meier method and the impact of various clinicopathological factors on outcome was analyzed using Cox proportional hazard regression models.

RESULTS

Ten-year cancer specific survival for patients with positive lymph nodes was 85.8% with 56% of the men free from biochemical recurrence at last followup. On multivariate analysis pathological Gleason score 8-10 (p = 0.004), positive surgical margins (p = 0.016), nondiploid tumor ploidy (p = 0.023) and 2 or greater positive nodes (p = 0.001) were adverse predictors of cancer specific survival. Tumor stage, year of surgery and total number of nodes removed did not significantly affect outcome. Adjuvant hormonal therapy decreased the risk of biochemical recurrence (p <0.001) and local recurrence (p = 0.004) but it was not associated with systemic progression (p = 0.4) or cancer specific survival (p = 0.4).

CONCLUSIONS

Radical prostatectomy may offer long-term survival to patients with lymph node positive prostate cancer. Gleason score, margin status, tumor ploidy and the number of involved nodes predict survival, while the role of adjuvant hormonal therapy continues to be defined.

Relation of cell viability and apoptosis with clinical remission following induction chemotherapy in ALL and AML

Evaluation of in vitro spontaneous apoptosis of acute leukemic blast cells after incubating for different time period and its correlation with clinical outcome is well documented in the literature. However, there is insufficient information available on the flowcytometric determination of cell viability immediately after separating blast cells and its correlation with the clinical response. In this study, we attempted to evaluate the relationship between viability of freshly isolated leukemic cells and the clinical response. Cell viability was evaluated in freshly isolated leukemic cells from 84 patients with acute leukemia (AL) using 7-Amino-Actinomycin D and was correlated with the clinical response following induction chemotherapy. Patients with ALL who achieved complete remission (CR) had significantly lower mean live cell (70.9%) compared to those patients who did not achieve CR (93.3%) (p=0.02). Furthermore, ALL responders had also significantly higher mean early apoptotic cell (19.4%) as compared to non responders (5%) (p=0.04). No significant difference was found in the mean live / early apoptotic cell count of responders and non responders of AML patients. The probability of obtaining CR in ALL patients was 3.7 and 2.7 times higher in those who had mean live cell count less than 70% and apoptotic cell count more than 10%, respectively. A lower cell viability and higher apoptosis in freshly isolated leukemic cells at the time of diagnosis may indicate a favorable response in patients with ALL but may not provide any sufficient information in predicting the response in AML patients to induction chemotherapy.

Reconstitution of immune responses occurs very rapidly after initiation of therapy for tuberculosis (43.54)

Introduction: Immune reconstitution syndrome is a potentially fatal sequelae of HAART therapy in 20% of patients with HIV and 3–5% with tuberculosis who begin treatment. The role of CD4+T cells in its pathogenesis is poorly understood.

Methods: This study was done under an IRB approved protocol to study MTb specific immunity. Groups based on HIV status and local or disseminated MTb were evaluated for CD4+ T cell counts, Purified Protein Derivative (PPD) induced proliferation and cytokine induction using intracellular cytokine staining for IFN γ, IL2, TNFα and CFSE dilution at predefined times before and after starting therapy.

Results: In preliminary results, the first 3 HIV negative patients with MTb exhibited striking increase in MTb specific immunity in the first week of therapy. Percentage of IFN γ producing CD4+T cells increased from 1.96 and 0.48 to 4.46 and 1.34, and of TNF α producing cells increased from 0.85 and 0.45 to 3.96 and 1.06 in 2 patients. Proliferative responses also showed marked increases. Percent dividing cells increased from 4.3, 4.4 and 16.3 at baseline to 36.9, 11.9 and 39.6 at 1 week and 54.8 and 72.3 at 4 weeks of therapy. Total number of CD4+ T cells also increased.

Conclusions: Tuberculosis like HIV causes quantitative and qualitative changes in CD4+T cells . These are rapidly reversed when therapy is begun .This data provides insight into the pathogenesis of the immune reconstitution syndrome.