Giant cell arteritis: recent advances and guidelines for management

This article reviews some of the recent work in epidemiology and pathology of giant cell arteritis (GCA), with particular regard to the immuno-histochemical findings in temporal artery biopsy (TAB) specimens. The diagnostic as well as prognostic role of biopsy histology is discussed. The role of novel imaging techniques e.g. duplex ultrasonography and FDG-PET scanning in diagnosis and staging of disease extent is reviewed. Existing evidence on the treatment is also discussed to propose guidelines on management of GCA.

The Chakaria food system study: household-level, case-control study to identify risk factor for rickets in Bangladesh

OBJECTIVE

A comprehensive, multiround survey of local food systems in a rickets-endemic area of Bangladesh was conducted to identify household-level risk factors for rickets.

DESIGN

A household-level, case-control study was conducted in a rickets-endemic area, Chakaria, with planned comparisons between households with one or more rachitic child and neighboring households with no affected children.

SETTING

A rickets-endemic area of southeastern Bangladesh, Chakaria.

SUBJECTS AND METHODS

An interview-based survey was conducted in six villages in Chakaria with 199 households with at least one child showing physical signs consistent with rickets and 281 households with no affected children.

RESULTS

Households with rachitic children in Chakaria had more children, more pregnant or lactating women, and fewer adults than unaffected households in that community. Affected households tended to rely on farming for their livelihood and tended to have less economic activity as indicated by less outstanding debt than their neighbors. Households with rickets were at significantly greater risk of pneumonia than were other households. Calcium undernutrition was severe and widespread in Chakaria due to a food system that offered very little of the element in accessible forms. Household diets were based on cereals and starchy vegetables. Rice and fish constituted the major source of calcium for most households, although dairy products, when used, were very important calcium sources, particularly for young children. In fact, the use of dairy products was the only household choice that led to substantial increases in the calcium intakes of children, and households that used dairy products tended to show increased calcium intakes for all of their members.

CONCLUSIONS

The risk of a Chakarian household having a child with rickets appeared to be related to its economic status. Although this might be expected to be manifest as limitations in food access and/or use, rickets households failed to show a dietary pattern associated with rickets. Calcium undernutrition was prevalent and, thus, would appear to be a predisposing factor for rickets; however, calcium undernutrition was prevalent in Chakarian households with and without rickets. Therefore, it is probable that another precipitating factor(s) play a role(s) in the etiology of rickets in Chakaria.

Effect of high-dose intravenous immunoglobulin on suppression of alloantibodies against hla in highly sensitized transplant candidates

Sensitization can present a virtually insurmountable barrier to kidney transplantation. Ten to twenty percent of patients on waiting lists for renal transplantation have developed broadly reactive cytotoxic antibodies against HLA antigens caused by pregnancy, blood transfusion, or a prior failed allograft. These sensitized end-stage renal disease patients often wait more than 5 years for a kidney to be offered. Potent immunosuppressives, plasma exchange and/or immunoadsorption have been used but the risk of infection limited their use. Some reports, have demonstrated in small numbers of patients the use of Intravenous Immunoglobulin (IVIG) as potential modality for the treatment of these sensitized patients. The goal of this study was to investigate the extent of the efficacy and to assess the utility of this modality of treatment on a relatively larger number of patients. The study included 11 patients with end stage renal disease who were waiting for living related renal allotransplantation. All patients had persistently positive crossmatches with their living related donors and PRA titer >/=20%. They received IVIG for a period of two weeks and a total of 6 doses. None of these patients, however, attained significant suppression of anti-HLA antibodies titer or a negative crossmatch reaction. We found that IVIG alone couldn't effectively inhibit preformed anti-HLA antibodies to allow successful renal transplantation.

Factor Analysis of Responses to the Irrational Beliefs Scale in a Sample of Iraqi University Students

In a study of irrational beliefs within a university population, 282 male and 238 female students responded to the 33-item Students' Irrational Beliefs Scale, and their responses were factor analyzed. Analysis suggested six dimensions could explain 39.5% of the variance. These dimensions were Perfectionism, Negativism, Blame Proneness, Escapism, Anxious Over Concern, and Absolute Demands.

Food consumption, energy and nutrient intake and nutritional status in rural Bangladesh: changes from 1981-1982 to 1995-96

OBJECTIVE

To determine and evaluate changes in nutritional status, food consumption, energy and nutrient intake in rural Bangladesh, using appropriate statistical analyses.

DESIGN

Repeated cross-sectional surveys. Two seasons in 1981-1982 and 1995-1996.

SETTING

Two villages with different production patterns.

SUBJECTS

Anthropometric measurements of 1883 individuals, food consumption data of 404 households.

METHODS

Repeated measurements of one-day food weighing and anthropometry in two seasons in 1981-1982 and 1995-1996. Mixed model analyses were used to evaluate and quantify temporal changes and their interactions with determinants.

RESULTS

Prevalence of underweight children decreased from 82 to 70% (P=0.015), wasted children from 34% to 18% (P=0.009) and chronic energy deficient adults decreased from 78 to 64% (P<0.0001). Intake of fish and green leafy vegetables increased from (l.s. mean+/-s.e.) 23+/-3.0 to 40+/-1.8 g/person/day (P<0.001) and from 28+/-4.5 to 41+/-2.7 g/person/day (P=0.019), respectively. Rice intake remained unchanged: 463+/-12 g raw/person/day in 1981-1982 and 450+/-7.3 g raw/person/day in 1995-1996 (P=0.355). Calcium and iron intakes increased by 40% (P<0.0001) and 16% (P=0.0002), respectively, whereas vitamin A intake remained unchanged.

CONCLUSIONS

Nutritional status improved and intakes of nutrient dense food groups, fat, iron and calcium increased from 1981-1982 to 1995-1996.

Food chain aspects of arsenic contamination in Bangladesh: effects on quality and productivity of rice

The total arsenic content of 150 paddy rice samples collected from Barisal, Comilla, Dinajpur, Kaunia, and Rajshahi districts, and from the BRRI experimental station at Rajshahi city in the boro and aman seasons of 2000 was determined by hydride generation-inductively coupled plasma emission spectroscopy (ICP). Arsenic concentrations varied from 10 to 420 microg/kg at 14% moisture content. Rice yields and grain arsenic concentrations were 1.5 times higher in the boro (winter) than the summer (monsoon) season, consistent with the much greater use of groundwater for irrigation in the boro season. Mean values for the boro and aman season rices were 183 and 117 microg/kg, respectively. The variation in arsenic concentrations in rice was only partially consistent with the pattern of arsenic concentrations in drinking water tube wells. There was no evidence from yield or panicle sterility data of arsenic toxicity to rice. Processing of rice (parboiling and milling) reduced arsenic concentrations in rice by an average of 19% in 21 samples collected from households. Human exposure to arsenic through rice would be equivalent to half of that in water containing 50 microg/kg for 14% of the paddy rice samples at rice and water intake levels of 400 g and 4 L/cap/day, respectively.

Live-donor renal transplantation at the Urology & Nephrology Center of Mansoura: 1976-1998

Based on more than 1,200 living donor transplants performed at the Urology & Nephrology Center at Mansoura University between 1976-1998, we report: 1. The overall graft survival rate was 75.8% and 51.9% at 5 and 10 years, respectively, with a projected half-life of 10.7 years. 2. Three factors acted as independent variables that significantly influenced graft survival: the number of HLA mismatches, the number of acute rejection episodes and the presence of posttransplant hypertension. a. Grafts with 2 or fewer HLA-A, -B and -DR mismatches had a significantly better survival rate. b. The incidence and the number of early acute rejection episodes had a significant negative impact on graft survival. c. A significant reduction in graft survival was associated with hypertension uncontrolled by or newly developed after transplantation. 3. Bilharziasis had no impact on the outcome. 4. Despite improvements in tissue matching and immunosuppression, an important proportion of grafts is still lost following living-donor kidney transplantation. 5. Efforts must be directed to identify better regimens, which can provide adequate immunosuppression and minimal nephrotoxicity.

A safe, effective, herbal antischistosomal therapy derived from myrrh

Schistosomiasis is a widespread helminthic disease. Treatment of schistosomiasis is based on chemotherapy with praziquantel, which is the drug of choice. Since resistance to praziquantel has been demonstrated, alternative drugs must be considered. Myrrh is an oleo-gum resin from the stem of the plant Commiphora molmol. This study was carried out on 204 patients with schistosomiasis. The drug was given at a dose of 10 mg/kg of body weight/day for three days, and induced a cure rate of 91.7%. Re-treatment of cases who did not respond with a dose of 10 mg/kg of body weight/day for six days gave a cure rate of 76.5%, increasing the overall cure rate to 98.09%. The drug was well tolerated, and side effects were mild and transient. Twenty cases provided biopsy specimens six months after treatment and none of them showed living ova.

Infections in children under 5 years old and latrine cleanliness

The aim of this study is to assess the cleanliness of the latrine and its relation to occurrence of disease in children under 5 years old. A stratified random sample of 1327 households was conducted in 11 villages in Upper Egypt. It included a sub-sample of 541 children under 5 years living in households with latrines. The latrine cleanliness was assessed and its relationship to disease occurrence within a period of 2 weeks. Thirty-three percent (33.1%) of children under 5 years old with latrines in their household had infections, compared to 28.3% of those without latrines in the house. Infection with diarrhoea was found most in houses with latrine and water tap. A relation was found between latrine cleanliness score and presence of flies, house building material and maternal education, but none with occurrence of infection in children under 5 years old within a period of 2 weeks.

Numerical computation of distortions in magnetic fields and induced currents in physiological solutions produced by microscope objectives

Identifying distortions produced by commonly employed microscope objectives and their components in uniform DC and 60 Hz AC magnetic fields is important in imaging studies involving exposure of cells to spatially uniform or nonuniform magnetic fields. In this study, DC and 60 Hz AC magnetic flux densities were numerically computed in the presence of finite element models of various components of commonly utilized microscope objectives, as well as a model of a complete objective. Also computed were the distortions in the current density induced by an applied time-varying magnetic field in a physiological buffer contained within a Petri dish. We show that the magnetic flux density could be increased up to 65% in the presence of the nickel-chrome plating of an objective housing and that the presence of ferromagnetic components like a screw or spring could produce peaks that are 7% higher than the undistorted value of magnetic flux density. In addition, a slight tilt of 1% in the objective with respect to the magnetic field could cause a 93% deviation in magnetic flux density from the unperturbed value. These results correlate well with previously published experimental measurements that showed the presence of significant and sometimes asymmetric distortions in both DC and 60 Hz magnetic fields. Moreover, this study further reports that induced current density changed up to 37% compared to values in the absence of the objective. The existence of distortions in applied magnetic fields and induced currents could affect the interpretation of results of cell function studies if it is assumed that the cells are exposed to uniform magnetic flux densities in the presence of a microscope objective. Such assumptions of uniform magnetic flux density could also account for the lack of reproducibility in several studies that examined changes in intracellular calcium by imaging techniques.

Self-reported adolescents’ health and gender:an Egyptian study

To identify self-reported health problems among adolescents, a multistage, stratified random sample of 1002 adolescents from preparatory and secondary schools in Cairo [67.6% of the total sample] and the rural district of Qaliubia [32.4%] was surveyed. Of 863 completed questionnaires analysed, 54% were from males and 46% from females [age range: 12-18 years]. The study showed that more boys than girls perceived their health as very healthy whereas more girls considered their health to be average. Significantly, more adolescent females reported weekly occurrence of abdominal pain, headache, dizziness, backache, morning tiredness, sleep disturbance and nervousness. Awareness-raising of parents and adolescents is necessary to allow determination of the relationship between gender and health.

The optimum dose of nicotinamide for protection of pancreatic beta-cells against the cytotoxic effect of streptozotocin in albino rat

BACKGROUND

The natural course of Insulin Dependent Diabetes Mellitus is characterized by progressive destruction of insulin producing beta-cells of the pancreas resulting from an autoimmune process. The toxic effect of some beta-cells toxins like streptozotocin (used to produce animal models of IDDM) has been associated with the oxidative stress due to enhanced DNA repair and NAD depletion in damaged beta-cells. This activity of streptozotocin has been prevented with the use of nicotinamide.

METHODS

A light microscopic study was designed to determine the optimum dose of nicotinamide required for protection of pancreatic beta-cells against the toxicity of streptozotocin. 35 adult male albino rats were divided into five equal groups A, B, C, D and E. the duration of study was 14 days. The animals in experimental groups C, D and E received a single intraperitoneal injection of nicotinamide 250 mg/Kg, 350 mg/Kg and 500 mg/Kg respectively on day one. Animals in group A and B acted as normal control and diabetic control respectively. All the animals except those in group A received simultaneous injection of streptozotocin 32 mg/Kg body weight intraperitoneally in a single dose. Fasting blood glucose was assessed and the animals weighed before starting the treatment, after 48 hours and at the end of the experimental period. Histological studies were carried out at the end of the study period.

RESULTS

The blood glucose level and the final body weight of the animals in group C matched the values in diabetic control. Histologically the pancreas had generally reduced beta-cells mass (P < 0.001) with altered morphology. The animals in group D showed impaired glucose tolerance at 48 hours but were normoglycaemic at the end of the study period. There was some loss of beta-cells but a significant number of these cells (P < 0.05) showing normal morphology were saved. The animals in group E had normal number of beta-cells having normal morphological features. The final body weight and fasting blood glucose of these animals matched the values in normal control (group A).

CONCLUSIONS

These data suggest that the optimum dose of nicotinamide in regard to prevention against the beta-cytotoxic effect of streptozotocin in albino rat is 500 mg/Kg body weight.

Self-reported adolescents' health and gender: an Egyptian study

To identify self-reported health problems among adolescents, a multistage, stratified random sample of 1002 adolescents from preparatory and secondary schools in Cairo (67.6% of the total sample) and the rural district of Qaliubia (32.4%) was surveyed. Of 863 completed questionnaires analysed, 54% were from males and 46% from females (age range: 12-18 years). The study showed that more boys than girls perceived their health as very healthy whereas more girls considered their health to be average. Significantly, more adolescent females reported weekly occurrence of abdominal pain, headache, dizziness, backache, morning tiredness, sleep disturbance and nervousness. Awareness-raising of parents and adolescents is necessary to allow determination of the relationship between gender and health.

Detection and prediction of acute heart transplant rejection with the myocardial T2 determination provided by a black-blood magnetic resonance imaging sequence

OBJECTIVES

This study aimed to determine whether the myocardial T2 relaxation time, determined using a black-blood magnetic resonance imaging (MRI) sequence, could predict acute heart transplant rejection.

BACKGROUND

The use of black-blood MRI sequences allows suppression of the confusing influence of blood signal when myocardial T2 is calculated to detect myocardial edema.

METHODS

A total of 123 investigations, including cardiac MRI and myocardial biopsy, were performed 8 +/- 11 months after heart transplantation. Myocardial T2 was determined using an original inversion-recovery/spin-echo sequence.

RESULTS

A higher than normal T2 (> or = 56 ms) allowed an accurate detection of the moderate acute rejections evidenced at baseline biopsy (> or = International Society for Heart and Lung Transplantation grade 2): sensitivity, 89% and specificity, 70% (p < 0.0001). T2 was increased in grade 2 (n = 11) compared with grade 0 (n = 49, p < 0.05), grade 1A (n = 34, p < 0.05) and grade 1B (n = 21, p < 0.05); T2 was further increased in grade 3 (n = 8) compared with grade 2 (p < 0.05). In addition, in patients without rejection equal to or greater than grade 2 at baseline, a T2 higher than normal (> or = 56 ms) was correlated with the subsequent occurrence of equal or greater than grade 2 rejection within the next three months: sensitivity 63% (12/19) and specificity 78% (64/82) (p = 0.001).

CONCLUSIONS

Myocardial T2 determined using a black-blood MRI sequence, is sufficiently sensitive to identify most of the moderate acute rejections documented with biopsy at the same time, but is also a predictor of the subsequent occurrence of such biopsy-defined rejections.

A comparison of the overall first-pass kinetics of thallium-201 and technetium-99m MIBI in normoxic and low-flow ischaemic myocardium

The specific impact of ischaemia on the myocardial kinetics of thallium-201 and technetium-99m 2-methoxy-2-isobutylisonitrile (MIBI) remains a matter of debate. Using an isolated heart model perfused with red blood cell-enhanced perfusate, we compared the overall first-pass kinetics of 201Tl and MIBI under haemodynamically stable conditions of low-flow ischaemia (> 50% reduction in normal coronary flow and a > or = 20 mmHg fall in systolic contraction pressure, n = 10) and normoxia (n = 11). For both 201Tl and MIBI, we found that under ischaemic conditions (as compared with normoxia) there was a higher initial net extraction fraction (201Tl: 0.78 +/- 0.03 vs 0.72 +/- 0.06, P = 0.006; MIBI: 0.49 +/- 0.10 vs 0.39 +/- 0.11, P = 0.03), a lower clearance rate in the 30 min following extraction (% decrease in cardiac uptake: 201Tl: 30 +/- 12 vs 47 +/- 14, P = 0.02; MIBI: 5 +/- 5 vs 13 +/- 11, P = 0.02) and a higher retention fraction at 30 min (20lTl: 0.54 +/- 0.10 vs 0.39 +/- 0.12, P = 0.004; MIBI: 0.46 +/- 0.08 vs 0.33 +/- 0.12, P = 0.01). Multivariate analyses, however, revealed that all myocardial kinetic parameters of both tracers were dependent only on coronary flow rates, without any additional significant impact of the presence of ischaemia or states of contractility or oxidative metabolism. We conclude that the myocardial fractional retention of both 201Tl and MIBI is strongly correlated with the decrease in coronary flow during ischaemia. This inverse relationship with coronary flow derives from both the flow-dependent increase in the initial myocardial extraction and the decrease in the subsequent myocardial washout of the tracers.

Circulating cytokines and CD30 in normal human pregnancy and recurrent spontaneous abortions

Concentrations of the T-helper (Th) 1 cytokines interleukin (IL)-2, tumour necrosis factor (TNF) -alpha, TNF-beta and interferon-gamma, Th2 cytokines IL-4, IL-5, IL-6, IL-10 as well as those of soluble CD30 in sera have been examined during the three trimesters of gestation, at delivery in normal pregnancy, and at the time of spontaneous abortion in women with a history of unexplained recurrent spontaneous abortion (RSA). Significantly higher concentrations of the Th2 cytokines IL-6 and IL-10 were found at normal delivery than in women with RSA, and conversely significantly increased concentrations of the Th1-type cytokine TNF-alpha were found in RSA as compared with successful pregnancy. In abortion-prone women who had a successful pregnancy, significantly higher concentrations of IL-6 and significantly lower concentrations of TNF-alpha were found as compared with abortion-prone women who had another abortion, supporting the notion that Th2- and Th1-bias are associated with successful and unsuccessful pregnancy respectively. Serum CD30 concentrations did not correlate with the outcome of pregnancy. These findings support observations drawn from experiments on the cytokine secretion profiles of peripheral blood mononuclear cells and decidual lymphocytes which suggest that normal pregnancy is Th2-biased and that unexplained RSA is associated with Th1-type reactivity.

Dipyridamole and exercise SPET provide different estimates of myocardial ischaemic areas: role of the severity of coronary stenoses and of the increase in heart rate during exercise

In patients unable to perform a maximal exercise test, dipyridamole single-photon emission tomography (SPET) has a higher capacity than exercise SPET to detect coronary artery disease (CAD). However, in patients with myocardial ischaemia who are able to perform a maximal exercise test, it is not known whether these two tests may be equally used to assess the areas of myocardial ischaemia. This study was aimed at comparing the results provided by dipyridamole and exercise SPET in CAD patients with documented exercise myocardial ischaemia. Forty CAD patients who had undergone exercise thallium-201 SPET and who had myocardial ischaemia documented by an unequivocally positive exercise test underwent an additional 201Tl SPET study after dipyridamole infusion and low-level (40 W) exercise. The extent of defects was compared between the two tests and predictors of discrepant results were sought among data from exercise testing and coronary angiography. The extent of SPET defects was equivalent between the two tests in only 11 patients (28%), larger defects being observed with exercise in 18 [average difference: 12%+/-5% of left ventricle (LV)] and with dipyridamole in 11 (average difference: 15%+/-11% of LV). The best independent predictors of discrepancies between the two tests were: (1) increase in heart rate at exercise SPET, with defects being smaller at exercise than after dipyridamole in none of the patients with an increase >60 bpm (0/14), but in 42% of the others (11/26; P=0.004); and (2) an ischaemic territory related to a <70% coronary stenosis, for which SPET defects were always induced at exercise (10/10) but in only 30% (3/10) with dipyridamole (P=0.0004). Exercise and dipyridamole SPET provide different estimates of myocardial ischaemic areas. Dipyridamole allows the unmasking of perfusion abnormalities in patients who have low increases in heart rate at exercise SPET. However, dipyridamole is also much less efficient at inducing perfusion abnormalities in the ischaemic areas supplied by coronary stenoses of intermediate severity at rest angiography.

Nutritional rickets without vitamin D deficiency in Bangladesh

To understand nutritional rickets in Bangladesh better, 14 rachitic and 13 'unaffected' children were evaluated. Seventy per cent of children with active rickets had no evidence of either vitamin D deficiency or familial rickets. Rickets in Bangladesh is probably related to calcium deficiency. Abnormalities in 'unaffected' children suggest that subclinical calcium insufficiency is common.