Is the enthesitis-related arthritis subtype of juvenile idiopathic arthritis a form of chronic reactive arthritis?

OBJECTIVE

Enteric organisms are known to trigger reactive arthritis. The enthesitis-related arthritis (ERA) form of juvenile idiopathic arthritis (JIA) clinically resembles reactive arthritis. Therefore, we looked for a role of enteric bacteria in ERA.

METHODS

Synovial fluid (SF) was obtained from 26 patients with ERA and 10 patients with rheumatoid arthritis (RA). Blood specimens were also obtained from patients with ERA and from 10 normal individuals. Lymphocyte proliferation assays were done on whole blood and SF mononuclear cells using as antigens crude lysates of the enteric bacteria Salmonella typhimurium, Yersinia enterocolitica, Shigella flexneri and Campylobacter jejuni. Crude lysate of Escherichia coli was used as a control antigen. HLA-B27 typing was done using the polymerase chain reaction. Homing of gut-specific T cells (CD103+) to the synovial compartment was studied using tri-colour flow cytometry. The antigen-specific cytokine profile was determined by flow cytometry.

RESULTS

Antigen-specific lymphoproliferative responses were observed in 14 of 26 patients. Among these patients, 12 showed a response in SF (four each to S. typhimurium and C. jejuni, and in two each to S. flexneri and Y. enterocolitica), and two patients in blood (S. typhimurium in both). None of the healthy controls showed a response in the blood. Lymphoproliferative responses in SF were more frequent in patients with JIA (12/26) than in controls with RA (1/10, P < 0.05). Patients with an antigen-specific response had a higher ratio of SF/blood CD103+ T cells compared with those with no antigen-specific response (P < 0.01). Antigen-specific as well as mitogen-stimulated cytokine production showed a Th1 bias.

CONCLUSION

Enteric bacteria may have a role in exacerbation of disease in patients with ERA. The immune response in patients with ERA is Th1-dominant.

Fatal pulmonary oedema following laparoscopic chromopertubation

The body of a 30-year-old woman was received for autopsy. The available medical case records mentioned that she had been married for the past 3 years and had had primary infertility. She had undergone a diagnostic-cum-operative laparoscopy under general anaesthesia in a private nursing home. On laparoscopy, the internal genital organs were normal except for a fimbrial cyst on each side. Chromopertubation was done using methylene blue dye along with diagnostic dilatation and curettage. The patient was extubated and shifted to the recovery room. About 15 minutes later she developed cyanosis and became unconscious. She died despite sustained efforts at resuscitation.

Increased expression of basic fibroblast growth factor in skin of patients with systemic sclerosis

Increased collagen deposition is a hallmark of systemic sclerosis (SSc). Several fibrogenic cytokines play a role in this sclerosis. The role of basic fibroblast growth factor (bFGF), the most potent fibrogenic cytokine, is poorly understood in SSc. Skin biopsies from forearm of 13 patients with SSc and 3 normal individuals were analyzed by immunohistochemistry using avidin biotin-system to amplify the signal. In addition serum levels of bFGF were also measured in 30 patients including these 13 and 23 healthy controls. Thirteen patients with SSc were all females and had a median age of 26.5 years, median disease duration of 2.25 years. Of these thirteen, seven had diffuse and six had limited disease. The skin biopsies from patients showed increased expression of bFGF in the basal layer of epidermis, dermis (periappendageal, perivascular, matrix tissue) as compared to normal tissues. The expression of bFGF did not correlate with duration of disease or skin score. In contrast, only low levels of bFGF were detectable in 4/30 sera from SSc patients as compared to 3/23 from healthy controls (p = ns). Overexpression of bFGF in skin of patients with SSc along with normal serum levels suggests that bFGF probably acts in an autocrine or paracrine manner in fibrogenesis.

Health promotion behaviors of Gujurati Asian Indian immigrants in the United States

The purpose of this paper was to examine the health promotion behaviors of Asian Indians, one of the fastest-growing immigrant groups in the United States. The sample consisted of 261 respondents randomly selected from the Charotar Patidar Samaj, a national Gujarati Association membership directory. Health promotion behaviors were obtained using the Health Promotion Lifestyle Profile II. Respondents demonstrated lower scores in physical activity and nutrition and higher scores in the areas of interpersonal skills and spiritual growth domain of the health promotion behaviors. Physical inactivity was the highest among adults of 25-50 years of age. A significant difference existed between males and females in the domain of health responsibility. Females were more responsible for their health and reported medical problems to a physician more often than their male counterparts. They also educated themselves about health promotion behaviors through reading and watching TV programs. Study results support previous research findings and make an important contribution to understanding the Asian Indian's health-promoting lifestyle behaviors.

Bone marrow abnormalities in HIV disease

Bone marrow abnormalities are frequently observed in HIV infected individuals at all stages of the disease. The most common abnormal finding is dysplasia affecting one or more cell lines. Erythroid dysplasia is the most common type of dysplasia and is recognized in over 50% of HIV infected patients, abnormal granulocytic and megakaryocytic development is encountered in one-third of patients. Plasma cells are strikingly increased in bone marrow of HIV infected patients. It may represent a physiological response to antigenic stimulation by viruses, other infective agents or secondary to dysregulated B-cell proliferation due to HIV. Herein we present a review discussing the various bone marrow abnormalities associated with the HIV disease.

Study of bone marrow abnormalities in patients with HIV disease

AIM

Present work was carried out to study the bone marrow abnormalities in patients with HIV/AIDS and to find their association with peripheral hematological abnormalities.

METHODS

Seventy four patients of HIV/AIDS were included in the study. The patients had anemia, leucopenia, thrombocytopenia or pyrexia of unknown origin (PUO) as indications for bone marrow examination. A complete blood count, relevant biochemical investigations, HIV RNA load and CD4 positive lymphocyte counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and those without AIDS according to NACO criteria.

RESULTS

Majority of patients (72.9%) had AIDS. Bone marrow was normocellular in 78.95% of non-AIDS and 74.55% of AIDS, hypocellular in 5.26% of non-AIDS and 7.27% of AIDS, hypercellular in 15.79% of non-AIDS and 18.18 % of AIDS patients. Myelodysplasia was present in 21.05% of non AIDS and 36.46% of AIDS and the most common series affected was granulocytic (15.79% of total in non-AIDS and 30.9% in AIDS). Dysplasia was statistically significantly associated with lower CD4 count (p = 0.031) and anemia (p = 0.013). Myelodysplasia was apparent even before patients developed anemia (16.67%). Increased plasma cells in bone marrow were observed in 57.89% of non-AIDS and 65.45% of AIDS, whereas decreased lymphoid cells were seen in 36.84% of non AIDS and 60.00% of AIDS patients.

CONCLUSIONS

Myelodysplasia is found in 32.43% of cases of HIV/AIDS and is more common in AIDS than in non AIDS patients. Granulocytic series is most commonly associated with evidence of dysplasia. Myelodysplasia is more common in patients with CD4 count < 200/microl and in patients with anemia. 54.05% of patients had decreased lymphoid cells in bone marrow and it was more commonly seen in AIDS than in non AIDS.

Metformin therapy in women with polycystic ovary syndrome

OBJECTIVE

To determine the clinical, biochemical, hormonal, and ultrasonographic effects of 6 months of metformin therapy in women with polycystic ovary syndrome (PCOS) and compare with pretherapy parameters.

METHOD

50 Indian women with PCOS, 25 unmarried and 25 married, infertile women, were enrolled in this prospective clinical study. After a baseline workup, including body mass index (BMI), waist hip ratio (WHR), Ferriman Gallwey hirsutism scoring, menstrual pattern, levels of fasting insulin, lipids, oral glucose tolerance test (OGTT), serum gonadotropins, estradiol (E2), testosterone, androstenedione, sex hormone binding globulin (SHBG), and dehydroepiandrosterone sulphate (DHEAS), patients were given 1000 gm of metformin for 6 months and then reevaluated.

RESULT

In 41 of 50 women who completed treatment, significant improvement in BMI, WHR, menstrual cyclicity (80.5%), ovulation rate (66%), and pregnancy rate (28%) was noted. Statistically significant decrease in lutenising hormone (LH) and LH/FSH ratio with an increase in follicle stimulating hormone (FSH) levels were seen. Levels of high-density lipoprotein (HDL) cholesterol (Chol) increased along with a decrease in total cholesterol. Improvement was noted in ovarian volume, stromal thickness, and number of follicles. There was no change in hirsutism, acne, levels of other sex steroid hormones, and lipids.

CONCLUSION

A 6-month course of metformin therapy may improve menstrual cyclicity and fertility in women with PCOS.

Methotrexate induced accelerated nodulosis

Methotrexate induced accelerated nodulosis (MIAN) is a rare but unique side effect of methotrexate therapy. There is paucity of data from our country about this entity. We analyzed 14 cases of MIAN and studied its association with gender, rheumatoid factor positivity and dose and duration of methotrexate. Fourteen patients (8 females), 12 with rheumatoid arthritis (8 seropositive), one each with juvenile idiopathic (JIA) and psoriatic arthritis (PsA) were detected to have MIAN during study period. All the patients presented with acute onset of multiple nodules. Radial border of fingers was the most commonly involved site. Disease was inactive in all but two patients at the time of appearance of MIAN. There was no association of MIAN with gender, rheumatoid factor positivity, disease duration, cumulative dose and duration of methotrexate therapy. Two patients each were treated with colchicine, D-penicillamine or hydroxy-chloroquine for 3-6 months without any response. We conclude that MIAN is a benign side effect of methotrexate treatment.

Eosinophilic fasciitis

Eosinophilic fasciitis presents with skin thickening involving the extremities, and sparing the hands. Raynaud's phenomenon is usually absent. It can be precipitated by undue exertion and is characterized by eosinophilia and infiltration of skin and subcutaneous tissue by mixed inflammatory infiltrate including eosinophils. We present a young man who developed eosinophilic fasciitis following severe gymnastic activity.

Personal cancer prevention and screening practices among Asian Indian physicians in the United States

This study examines personal cancer prevention and screening practices of Asian Indian physicians. Asian Indians are the third largest group of Asian Pacific Islanders (APIs) residing in the United States. Using a cross-sectional study approach, we investigated cancer prevention and screening practices of 254 randomly selected Asian Indian physicians in the United States. Results showed that prevalence of conventional risk factors were low, e.g., smoking, alcohol consumption. Nutrition-related behaviors indicated 31-48% met the Food Guide Pyramid's recommendations for daily intake of fruits, vegetables, low fat/cholesterol diet, and grains. Certain cancer prevention and screening practices failed to meet age appropriate recommendations of leading health agencies. For men age 50 and over, only 27% ever had a flexible sigmoidoscopy and 25% ever had a fecal occult blood test (FOBT); 84% of women age 40 and over ever had a mammogram and 87% of women ever had a Papanicalou (Pap) smear. With respect to cancer screening behaviors, the respondents were less likely to engage in these preventive screenings (with the exception of mammography) than the general US population and the APIs (except Pap smears). Additionally, our respondents were less likely than other physicians to practice cancer screening behaviors. Results support the need to promote regular cancer prevention and screening among Asian Indian physicians.

Pregnancy with Chronic Kidney Disease: Outcome in Indian Women

BACKGROUND

Fetal survival and the risk of accelerated renal damage are the two major concerns with pregnancies complicated by chronic kidney disease. Although fetal survival has increased significantly due to improved antenatal and neonatal services, the maternal and neonatal morbidity is still considerable.

METHODS

This retrospective analysis of 51 pregnancies was conducted at a tertiary care center in India to estimate the risk of obstetrical complications, perinatal morbidity and mortality, and the effect of pregnancy on renal function in women with different types and severity of renal disease.

RESULTS

The type of renal disease and the degree of renal insufficiency did not have a significant effect on the chances of successful pregnancy outcome once the pregnancy had progressed beyond the first trimester. The risk of prematurity was significantly increased when the diastolic blood pressure was >/= 90 mm Hg at conception (OR 8.3, CI 1.6-41.5). All patients with a diastolic blood pressure > 100 mm Hg delivered preterm. Hypertension worsened in 16 (35.5%) women during pregnancy, of which 13 had to be terminated preterm because of uncontrolled blood pressure. Serum creatinine deteriorated during pregnancy in 32.5%, the percentage increase showing a significant inverse correlation to the baseline creatinine clearance.

CONCLUSIONS

Hypertension at conception was a significant independent factor influencing the gestational age at delivery. The baseline renal function did not correlate with the risk of acceleration of hypertension during pregnancy. However, the deterioration of renal function during pregnancy had a significant inverse correlation to basal creatinine clearance.

Low levels of anti-histone antibodies in north Indian children with juvenile rheumatoid arthritis

BACKGROUND & OBJECTIVES

Early onset pauciarticular disease with uveitis is distinctly uncommon in Indian children with juvenile rheumatoid arthritis (JRA). The occurrence of anti-histone antibodies (AHA) in serum is strongly associated with presence of uveitis. There is a paucity of information from India on the levels of AHA in patients of JRA. In this study, an attempt was made to evaluate the levels of IgG and IgM antibodies to histones in children with JRA in north India.

METHODS

Serum samples of 148 children with JRA (84 boys, 64 girls) were collected. Clinical details including onset, symptoms and course of the disease in each patient were recorded. Detailed eye examination including slit lamp examination was done in all patients at presentation and yearly thereafter to rule out uveitis. The presence of antihistone IgG and IgM antibodies was studied by ELISA. Antinuclear antibodies (ANA) were measured by indirect immunofluorescence using HEP-2 cells as substrate at a screening dilution of 1:40.

RESULTS

Of the 148 children, 54 had pauciarticular (12 early onset and 42 late onset), 64 polyarticular and 30 systemic onset disease respectively. ANA were present in two children. AHA were raised in 15 (10%) children, of whom 10 had IgM antibodies, 3 had IgG and 2 had both isotypes. None of the children with early onset pauciarticular disease had uveitis, ANA or AHA.

INTERPRETATION & CONCLUSION

The low occurrence of AHA and uveitis in our subset of patients with JRA is in contrast to that reported from Western countries. The low occurrence is unlikely due to technical reasons as the antigen that has been used consistently showed significant binding to serum from patients with systemic lupus erythematosus (SLE). This is in accordance with the rarity of early onset pauciarticular disease and chronic uveitis in these patients. More studies from other parts of the country are required to validate this observation.

Community needs and strengths assessments as an active learning project

The Community Needs and Strengths Assessment Project (CNSAP) incorporated development of needs and strengths assessment research into an undergraduate Community Health course as an active learning project--one of seven principles for effective practice in undergraduate education. Community needs and strengths assessments prove useful to health educators primarily in planning programs and promoting effective public relations. Assessments also help to identify and diagnose health problems and to evaluate programs. Through the CNSAP students completed a process health educators use to identify gaps between current and required programs and to prioritize assets and resources based on community needs and strengths. The CNSAP focused on mastery of four skills required for completing a needs and strengths assessment: identifying data sources, conducting primary data collection from a target audience, analyzing data and prioritizing identified needs and strengths, and abstracting information concisely. The project, which included substantial community involvement, helped students identify needs and strengths necessary for addressing community health problems and concerns.

Primary Sjogren's syndrome: rarity in India

OBJECTIVE

Primary Sjogren's syndrome (SS) is rarely reported from India. We have studied the clinical spectrum and immunological profile of patients with primary SS.

METHODS

A prospective analysis of patients with primary Sjogren's syndrome fulfilling San Francisco criteria, seen at our clinic in the last 10 years was carried out.

RESULTS

The study included 26 patients, 21 being women. The presenting symptoms included dry eyes, dry mouth, and arthritis/arthralgia. Extra-glandular manifestations were glomerulonephritis, vasculitis, renal tubular acidosis and peripheral neuropathy. The important laboratory abnormalities were hypergammaglobulinaemia (16/20), antinuclear antibodies (18/26), anti-La (11/19) and anti-Ro (10/19). Minor salivary gland provided a definitive diagnosis in 16/26 (60%).

CONCLUSION

The prevalence of primary Sjogren's syndrome is rare even in tertiary care rheumatology clinics. The clinical and immunological profile as seen here is similar to that reported in Western countries.

Injuries to preschool children and infection control practices in childcare programs

Injuries represent the leading cause of death for children aged 0 to 12 years, and exposure to blood or bodily fluids at the time of injury may pose a health and safety problem. More than 800,000 injuries were reported in 2000, and many occurred in childcare programs. This survey examined rate, type, and extent of injuries in centers and the infection control practices employed by staff. Participants included 131 children aged six weeks to seven years, enrolled in two childcare programs in an urban setting. Eight hundred ninety-seven injury reports with 1,023 (126 simultaneous) injuries were recorded over a one-year period. Results indicated the majority of injuries (39%) were for bites and 11% were self-inflicted. Injuries were classified as minor (99%) or moderate (1%) with 73% receiving first aid by staff. Bleeding from injuries was minimal in 14% of injuries, while no injuries reported moderate or severe bleeding. The rate of medically attended (first aid treatment) injury was 5.31 per 100,000 child hours. Injury rates decreased with age in the center (P = .001), were higher for males (P = .036), and occurred most frequently in the morning (P = .001). Age, gender, and time of the day were significant predictors of injuries in the multivariate model.

Does cyclophosphamide benefit relapsing thrombotic thrombocytopenic purpura?

Thrombotic thrombocytopenic purpura (TTP) is a rare disease. A high index of suspicion is required for early diagnosis and treatment. It can present in acute as well as chronic forms. Cyclophosphamide has been reported to be beneficial in relapsing TTP. Herein a case of acute TTP evolving into relapsing phase of the disease is presented. Cyclophosphamide in our case achieved partial remission without the need for plasma exchange therapy. The rationale of cyclophosphamide in management of relapsing TTP is discussed.

The F158V polymorphism in FcgammaRIIIA shows disparate associations with rheumatoid arthritis in two genetically distinct populations

OBJECTIVES

To investigate the association of the FcgammaRIIIA gene with rheumatoid arthritis (RA) in two genetically distinct groups: a white group from the United Kingdom and a northern Indian group.

METHODS

The distributions of the two alleles of the FcgammaRIIIA F158V polymorphism were determined in 398 white patients from the United Kingdom and 63 Indian patients with RA and compared with those from 289 United Kingdom and 93 Indian healthy controls, respectively.

RESULTS

Among the Indian patients, the frequency of the rare 158V allele and the proportion of 158VV homozygotes were reduced (relative risk (RR)=0.3, 95% confidence interval (95% CI) 0.1 to 1.1, p<0.06), reaching statistical significance for carrying the 158VV phenotype relative to 158FV or FF (RR=0.2, 95% CI 0.05-0.9, p<0.02). Conversely, no significant deviation in allelic frequencies was noted between the patients and controls from the United Kingdom.

CONCLUSIONS

The 158VV phenotype showed a weak protective effect against developing RA in the Indian group. However, this sample was small (resulting in a low power for statistical analysis) and no independent confirmation was found in the larger white United Kingdom group. Thus the FcgammaRIIIA locus is unlikely to be of major importance in causing RA.

Autoantibodies against cytoskeletal proteins in rheumatoid arthritis

We determined the prevalence and antigenic specificity of autoantibodies against cytoskeletal proteins in patients affected with various autoimmune diseases. Sera collected from patients with rheumatoid arthritis, systemic lupus erythematosus or progressive systemic sclerosis, and normal volunteers, were examined for the presence of autoantibodies against cytoskeletal proteins by indirect immunofluorescence and enzyme-linked immunosorbent assay (ELISA). Patients with rheumatoid arthritis had the highest reactivity to cytoskeletal antigens on immunofluorescence assays using isolated muscle myofibrils (41/50) and L929 cells (37/50). Antigen-specific ELISA revealed significant immunoreactivity against actin (11/50) and myosin (15/50). In nine patients, immunoreactivity was seen against multiple cytoskeletal antigens. We concluded that the prevalence of IgG autoantibodies against cytoskeletal antigens, especially myofibrillar components actin and myosin, is elevated in patients with rheumatoid arthritis.

Predictors of social support, acceptance, health-promoting behaviors, and glycemic control in African-Americans with type 2 diabetes

Chronic illness is particularly important in older African-Americans because this population comprises the fastest growing segment of that ethnic group. This study explored relationships among personal factors (education and co-morbidity), mental health, and physical functioning on social support, social support on acceptance and health-promoting behaviors, acceptance on health-promoting behaviors, and health-promoting behaviors on HgbA1c. Face-to-face interviews were conducted using a convenience sample of 63 African-Americans from a community clinic. Participants were asked their highest level of education and to indicate their chronic conditions. Other instruments used were: Health Survey (SF-36), Personal Resource Questionnaire (PRQ-85), Revised (IAD-R) scale (Acceptance), and Health-Promoting Lifestyle Profile II. Glycemic control was measured using glycosylated hemoglobin. Physical functioning was the only significant predictor of social support (beta = .30, p = .03). In turn, social support predicted acceptance (beta = .32, p = .01) and health behaviors beta = .39, p = .002).

Arthritis in sarcoidosis

AIMS AND METHODS

Sarcoidosis is systemic granulomatous disorder. Articular manifestations have received little attention in the literature. Case records of patients with sarcoidosis, presenting with articular symptoms between 1990-1999, were retrospectively analysed.

RESULTS

Twenty nine patients, 15 males and 14 females, median age 44 years (range 15-67 years) and median duration of articular symptoms of eight months diagnosed clinically (n=9) and on biopsy (n=20) were studied. Twenty five patients had arthritis as the presenting manifestation. Fifteen patients had chronic arthritis (> six months). Lofgren's syndrome was seen in 7% of the patients. Acute arthritis was episodic (n=4), more common in males (M:F = 9:5), predominantly affected lower limb joints and mimicked reactive arthritis. Chronic arthritis was more frequently observed in females (M:F = 1:2) and presented with involvement of bilateral symmetric hand joints, mimicking rheumatoid arthritis. Extra-articular manifestations like neuropathy and constitutional symptoms were observed in acute arthritis. Skin plaque, splenomegaly and interstitial lung disease were seen with chronic arthritis. At a median follow up of 12 months, 10/14 and 5/15 achieved complete remission whereas 2/14 and 9/15 achieved partial remission of the articular symptoms in the acute and chronic groups, respectively.

CONCLUSION

Arthritis in sarcoidosis is an early manifestation of disease and may mimic reactive or rheumatoid arthritis. Unsatisfactory response in chronic arthritis highlights the need for immunosuppressive drugs in addition to steroids.

Isolation and characterization of Escherichia coli tolC mutants defective in secreting enzymatically active alpha-hemolysin

This study describes the isolation and characterization of a unique class of TolC mutants that, under steady-state growth conditions, secreted normal levels of largely inactive alpha-hemolysin. Unlike the reduced activity in the culture supernatants, the cell-associated hemolytic activity in these mutants was identical to that in the parental strain, thus reflecting a normal intracellular toxin activation event. Treatment of the secreted toxin with guanidine hydrochloride significantly restored cytolytic activity, suggesting that the diminished activity may have been due to the aggregation or misfolding of the toxin molecules. Consistent with this notion, sedimentation and filtration analyses showed that alpha-hemolysin secreted from the mutant strain has a mass greater than that secreted from the parental strain. Experiments designed to monitor the time course of alpha-hemolysin release showed delayed appearance of toxin in the culture supernatant of the mutant strain, thus indicating a possible defect in alpha-hemolysin translocation or release. Eight different TolC substitutions displaying this toxin secretion defect were scattered throughout the protein, of which six localized in the periplasmically exposed alpha-helical domain, while the remaining two mapped within the outer membrane-embedded beta-barrel domain of TolC. A plausible model for the secretion of inactive alpha-hemolysin in these TolC mutants is discussed in the context of the recently determined three-dimensional structure of TolC.

Epidemiology of undernutrition

OBJECTIVE

The present study was undertaken to find out the magnitude of the problem of under nutrition among the children under 5 years of age and also to identify the important factors influencing the nutritional status of the children.

METHODS

30 cluster sampling technique had been applied in the study. A total of 600 children below five years of age were covered. Twenty under five children from each cluster were chosen for the study which was carried out during January to February '97. As per IAP criteria a total of 60.29% children were undernourished and 3.92% were severely undernourished. According to NCHS standard 46.57% & 6.86% children had weight below-2SD and -3SD respectively.

RESULTS

A statistically significant relationship was found between the different age groups and nutritional status of under 5 children. Severe degree of malnutrition had highest prevalence under two years of age. The influence of variables like age, sex, religion, literacy status of parents and morbidity of the children were significantly associated with malnutrition.

CONCLUSION

Practice of exclusive breast feeding, introduction of timely complementary feeding, education for maintaining personal hygiene, proper implementation of UIP immunization, periodic deworming, standard case management of diarrhoea and ARI as well as continuation of feeding during illness may reduce malnutrition of under-five children.

Plasmid mediated antibiotic resistance in Klebsiella pneumoniae

Klebsiella pneumoniae species (108) isolated from tertiary care hospitalized patients were investigated for antibiotic resistance patter. 74% isolates were from urine, 13.5% from pus, 4.5% from blood and 8% from sputum. The resistance pattern of the organisms to various antibiotics were as follows: ampicillin 93.3%, cefotaxime 70%, ceftazidime 81%, gentamicin 68.5%, amikacin 63.75%, netilmicin 74%, norfloxacin 55%, ofloxacin 53%, chloramphenicol 82%, tetracycline 85%, sulphamethoxazole 96%, trimethoprim 94%. 2-4 drug resistance was found in 34.5%, 5-8 drug resistance was in 25.1% and 9-12 drug resistance was found in 40.4% of strains. Out of 65 strains, 25 strains could be successfully conjugated. Common drugs which were transferred to transconjugants were sulphamethoxazole, trimethoprim, gentamicin, netilmicin, amikacin, chloramphenicol, tetracycline, ampicillin, cefotaxime and ceftazidime. A large plasmid of 98.7% kb could be demonstrated in these strains by alkali denaturation method and agarose gel electrophoresis.

Anti-cardiolipin and anti-beta2 glycoprotein I antibodies in Indian patients with systemic lupus erythematosus: association with the presence of seizures

The aim of this study was to examine whether the clinical features of antiphospholipid antibody syndrome are associated with anti-cardiolipin and anti-beta2 glycoprotein I antibodies in Indian patients with SLE. Seventy-six patients (71 females), who fulfilled 1982 ACR criteria for SLE, were prospectively studied for the clinical features of antiphospholipid antibody syndrome (APS), and their sera were analysed for the presence of IgG/IgM/IgA anti-cardiolipin antibodies (aCL) by an in-house ELISA and, in 65 of them, for the presence of IgG anti-beta2 glycoprotein I antibodies (anti-beta2 GPI) by a commercial kit. Thirty-nine (51%) patients were positive for aCL, all of which were positive for IgG aCL, either alone (79.6%) or along with IgM and/or IgA. Twenty-seven (69.3%) out of 39 aCL-positive and seven (26.9%) out of 26 aCL-negative sera were positive for IgG antibodies to beta2 GPI. There was a significant correlation (r = 0.66, P < 0.05) between the levels of aCL and anti-beta2 GPI antibodies. Forty-one patients had features of definite or suggestive APS. Thrombocytopenia, recurrent pregnancy loss and CNS manifestations (seizures eight, infarct one) were seen in 20, 13 and nine patients, respectively. Thrombosis of the peripheral vessels was seen in only one patient. Only the presence of seizures was significantly associated with the presence of aCL and anti-beta2 GPI antibodies (P < 0.05). The characteristic association of definite APS (recurrent pregnancy loss and arterial/venous thrombosis) was lacking.

The TolC protein of Escherichia coli serves as a cell-surface receptor for the newly characterized TLS bacteriophage 1 1Edited by B. Holland

The TolC protein of Escherichia coli is implicated in a variety of diverse cellular functions, including antibiotic efflux and alpha-hemolysin secretion. An incidental role of TolC is to facilitate the entry of the bacteriophage TLS and colicin E1 into the bacterial cell. Despite the resolution of TolC's atomic structure, the roles of specific residues in its diverse functions are unknown. Here, we describe a genetic strategy for isolating missense tolC mutations that abolish the bacteriophage receptor activity of the TolC protein without influencing its role in antibiotic efflux. These spontaneous mutations affected two regions of the TolC protein and included base-pair substitutions, insertions, and deletions. Comparison of the TolC sequence with those of its homologues revealed two hypervariable stretches that were predicted to represent loops. Interestingly, all but one of the TolC alterations preventing phage binding were located in these two hypervariable regions, which are likely to be exposed on the cell surface. This was substantiated by the recently solved three-dimensional structure of TolC. Curiously, all the phage-resistant TolC mutants showed varying degrees of resistance to colicin E1, suggesting the involvement of overlapping regions of TolC in colicin E1 import and phage binding. The phage used in this study, TLS, was earlier reported as a strain of U3. However, we show here that, unlike the previously reported lipopolysaccharide-specific U3 phage, this phage displays a distinctly different host range and discrete morphological features and, in addition to utilizing TolC as receptor, it requires the inner core of a lipopolysaccharide.

Reproductive health needs and care seeking behaviour of pavement dwellers of Calcutta

An unabated growth of street dwellers in the city of Calcutta is reported to be due to twin reasons like, migration of rural poor people as well as uncontrolled fertility among these poor settlers of the city. A community-based study on reproductive health, fertility and related care seeking behaviour was studied among a sample of women of child bearing age living on streets of Calcutta. Besides, the quite common conditions like leucorrhoea (28.5%), menstrual irregularities (12.3%), infertility (2.5%) and STDs (1.3%) were also reported. But most of these illnesses (three-fourth) were uncared for, and the remaining one-fourth sought treatment from govemment institutions, private agencies or even from untrained practitioners (quacks). The reproductive behaviour of street dwelling women was characterised by early marriage, teenage pregnancies, and scarce use of contraceptives (32%) as well as frequent abortions (2.8%). Very few pregnant women received adequate antenatal care (3.8%). Coverage of tetanus toxoid immunisation (68.5%) and proper iron and folic acid supplementation (16.7%) were also poor. Whereas, antenatal care was received mostly from government health institutions (71%), home delivery (ie, on street) was a common practice and conducted mostly by untrained birth attendants (51.8%).

Intragenic suppressors of an OmpF assembly mutant and assessment of the roles of various OmpF residues in assembly through informational suppressors

We employed two separate genetic approaches to examine the roles of various OmpF residues in assembly. In one approach, intragenic suppressors of a temperature-sensitive OmpF assembly mutant carrying a W214E substitution were sought at 42 degrees C, or at 37 degrees C in a genetic background lacking the periplasmic folding factor SurA. In the majority of cases (58 out of 61 revertants), the suppressors mapped either at the original site (position 214) or two residues downstream from it. In the remaining three revertants that were obtained in a surA background, an alteration of N230Y was located 16 residues away from the original site. The N230Y suppressor also corrected OmpF315 assembly at 42 degrees C in a surA(+) background, indicating that the two different physiological environments imposed similar assembly constraints. The specificity of N230Y was tested against five different residues at position 214 of mature OmpF. Clear specificity was displayed, with maximum suppression observed for the original substitution at position 214 (E214) against which the N230Y suppressor was isolated, and no negative effect on OmpF assembly was noted when the wild-type W214 residue was present. The mechanism of suppression may involve compensation for a specific conformational defect. The second approach involved the application of informational suppressors (Su-tRNA) in combination with ompF amber mutations to generate variant OmpF proteins. In this approach we targeted the Y40, Q66, W214, and Y231 residues of mature OmpF and replaced them with S, Q, L, and Y through the action of Su-tRNAs. Thus, a total of 16 variant OmpF proteins were generated, of which three were identical to the parental protein, and two variants carrying W214Q and Y231Q substitutions were similar to assembly-defective proteins isolated previously (R. Misra, J. Bacteriol. 175:5049-5056, 1993). The results obtained from these analyses provided useful information regarding the compatibility of various alterations in OmpF assembly.

Overexpression of protease-deficient DegP(S210A) rescues the lethal phenotype of Escherichia coli OmpF assembly mutants in a degP background

Replacement of OmpF's conserved carboxy-terminal phenylalanine with dissimilar amino acids severely impaired its assembly into stable trimers. In some instances, interactions of mutant proteins with the outer membrane were also affected, as judged by their hypersensitivity phenotype. Synthesis of all mutant OmpF proteins elevated the expression of periplasmic protease DegP, and synthesis of most of them made its presence obligatory for cell viability. These results showed a critical role for DegP in the event of aberrant outer membrane protein assembly. The lethal phenotype of mutant OmpF proteins in a degP null background was eliminated when a protease-deficient DegP(S210A) protein was overproduced. Our data showed that this rescue from lethality and a subsequent increase in mutant protein levels in the envelope did not lead to the proper assembly of the mutant proteins in the outer membrane. Rather, a detergent-soluble and thermolabile OmpF species resembling monomers accumulated in the mutants, and to a lesser extent in the parental strain, when DegP(S210A) was overproduced. Interestingly, this also led to the localization of a significant amount of mutant polypeptides to the inner membrane, where DegP(S210A) also fractionated. These results suggested that the DegP(S210A)-mediated rescue from toxicity involved preferential sequestration of misfolded OmpF monomers from the normal assembly pathway.

Anti-keratin antibodies in patients with rheumatoid arthritis

As the proportion of patients with rheumatoid arthritis (RA) who have anti-keratin antibodies (AKA) varies in different ethnic groups, we studied its occurrence in a hospital populations with RA and its association with different disease variables. Sera from 84 consecutive patients with RA, 100 healthy controls and 85 disease controls (polyarticular juvenile rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis) were tested for AKA by an indirect immunofluorescence assay that used rat esophagus as substrate. The proportion of patients with RA who had AKA (47/84) was higher than in healthy controls (2/100; P < 0.001) and in disease controls (2/85; P < 0.001). The frequency of AKA positivity was higher among patients who had severe disease (P < 0.05) and rheumatoid factor. Anti-keratin antibody is present in 56 per cent of our patients with RA and is associated with severe disease.

Role of IgM & IgA rheumatoid factors in complement activation in patients with juvenile rheumatoid arthritis

We studied the relationship between the degree of complement activation in juvenile rheumatoid arthritis (JRA) with the levels of circulating IgM and IgA rheumatoid factors (RF). Forty children with JRA and 25 matched controls were included in the study. Levels of C3d (a degradation product of complement component C3), circulating immune complexes (CICs), IgM RF and IgA RF were measured by ELISA. Levels of C3d, CICs, IgM RF and IgA RF were elevated in patients with JRA as compared to controls. Levels of C3d had a linear relationship with levels of CICs (P < 0.05) but not with levels of circulating IgM RF and IgA RF. Thus, complement activation occurs in children with JRA and is associated with raised levels of CICs but not with levels of circulating IgM and IgA RF. Circulating IgM and IgA RF have little, if any, role in complement activation observed in patients with JRA.

Colonic bacteria express an ulcerative colitis pANCA-related protein epitope

Bacteria are a suspected pathogenic factor in inflammatory bowel disease, but the identity of the relevant microbial species remains unresolved. The pANCA autoantibody is associated with most cases of ulcerative colitis (UC) and hence reflects an immune response associated with the disease process. This study addresses the hypothesis that pANCA identifies an antigen(s) expressed by bacteria resident in the human colonic mucosa. Libraries of colonic bacteria were generated using aerobic and anaerobic microbiologic culture conditions, and bacterial pools and clonal isolates were evaluated for cross-reactive antigens by immunoblot analysis using the pANCA monoclonal antibody Fab 5-3. Two major species of proteins immunoreactive to pANCA monoclonal antibodies were detected in bacteria from the anaerobic libraries. Colony isolates of the expressing bacteria were identified as Bacteroides caccae and Escherichia coli. Isolation and partial sequencing of the B. caccae antigen identified a 100-kDa protein without database homologous sequences. The E. coli protein was biochemically and genetically identified as the outer membrane porin OmpC. Enzyme-linked immunosorbent assay with human sera demonstrated elevated immunoglobulin G anti-OmpC in UC patients compared to healthy controls. These findings demonstrate that a pANCA monoclonal antibody detects a recurrent protein epitope expressed by colonic bacteria and implicates colonic bacterial proteins as a target of the disease-associated immune response.

Clinical relevance of IgA rheumatoid factor (RF) in children with juvenile rheumatoid arthritis

This study proposed to investigate the prevalence and clinical relevance of serum immunoglobulin A (IgA) rheumatoid factor (RF) in juvenile rheumatoid arthritis (JRA) as published reports vary in their conclusion. Sera of 82 children with JRA and 25-age and sex-matched healthy children were measured for IgA RF by an enzyme linked immunoassay using human IgG as the antigen. Forty-three percent of the disease population were positive and the prevalence in pauciarticular, polyarticular and systemic onset was 9/18 (50%), 21/47 (44.7%) and 5/17 (27.7%) respectively when mean + 2SD of normal was taken as the cut-off value. By defining the upper limit of normal as mean + 6SD, 16/47 (34%) were positive in the polyarticular as compared to 2/18 (11.1%) in pauciarticular and 1/17 (5.8%) of systemic onset disease groups. The prevalence in the polyarticular subset with the upper cut-off limit was significantly higher than the pauciarticular and the systemic onset group (P < 0.05). Furthermore, the mean level of IgA RF was significantly higher in the polyarticular group compared to the mean level in the systemic onset group (P < 0.05). The mean level of IgA RF was also significantly higher (P < 0.05) in 61 children with active diseases.

Evidence for activation of the alternate complement pathway in patients with juvenile rheumatoid arthritis

OBJECTIVE

Complement activation has been shown to occur in patients with juvenile rheumatoid arthritis (JRA). Since the two pathways of complement are activated by different stimuli (the alternate pathway by microbial products and IgA, and the classical pathway by immune complexes), we decided to study the relative contribution of the two pathways of complement activation in patients with JRA.

METHODS

In 56 patients with JRA, plasma levels of C3 and C4 were measured by turbidimetric assays, and those of C4d, factor Bb and sC5-9 complex by solid-phase enzyme immunoassays. Levels beyond the mean +/- 2 S.D. of normal were considered abnormal.

RESULTS

Plasma C3 and C4 levels were decreased in one patient each. The C4d values were increased in 17 patients, whereas levels of factor Bb were elevated in 42 patients and levels of sC5-9 complex were elevated in 51 patients. The values of factor Bb and sC5-9 had a linear correlation (r = 0.75), but there was no significant correlation between C4d and sC5-9 levels (r = 0.36).

CONCLUSION

Complement activation in JRA is initiated predominantly by the alternate pathway and culminates in the formation of terminal membrane attack complex.

Complement degradation product C3d in urine: marker of lupus nephritis

OBJECTIVE

To examine whether serum and urine C3d, a degradation product of C3, correlate with renal and extrarenal lupus activity.

METHODS

Serum and urinary C3d levels were measured by ELISA in 15 healthy individuals and 24 patients with systemic lupus erythematosus (SLE) (8 with inactive disease, 7 with active but nonrenal disease, 9 with active lupus nephritis). Disease activity variables like serum C3, C4, and anti-dsDNA antibodies were also measured.

RESULTS

The median serum C3d levels were significantly higher (p < 0.01) in patients with active (26 arbitrary units/ml; AU/ml) and inactive SLE (27 AU/ml) compared to healthy controls (11.25 AU/ml); levels were comparable in patients with active renal and extrarenal SLE. On the other hand, urine C3d was elevated only in patients with active SLE; its level was highest in patients with active lupus nephritis (0.87 AU/ml) compared to patients with active extrarenal diseases (0.31 AU/ml; p < 0.05), to patients with inactive lupus nephritis (0.06 AU/ml; p < 0.001), or to levels in healthy individuals (0.06; p < 0.001). Urine C3d showed stronger correlation with disease activity score (SLE Disease Activity Index) than serum C3, C4, anti-dsDNA antibodies, and serum C3d.

CONCLUSION

Urine C3d is a good index of active lupus, particularly lupus nephritis.

Modeling the X-Ray Timing Properties of Cygnus X-1 Caused by Waves Propagating in a Transition Disk

We show that waves propagating in a transition disk can explain the short-term temporal behavior of Cygnus X-1. In the transition-disk model, the spectrum is produced by saturated Comptonization within the inner region of the accretion disk where the temperature varies rapidly with radius. Recently, the spectrum from such a disk has been shown to fit the average broadband spectrum of this source better than that predicted by the soft-photon Comptonization model. Here we consider a simple model in which waves are propagating cylindrically symmetrically in the transition disk with a uniform propagation speed (cp). We show that this model can qualitatively explain (1) the variation of the power spectral density with energy, (2) the hard lags as a function of frequency, and (3) the hard lags as a function of energy for various frequencies. Thus, the transition-disk model can explain the average spectrum and the short-term temporal behavior of Cyg X-1.