Falls explain between-center differences in the incidence of limb fracture across Europe

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe.

Concentrations of Cu and Pb in the offshore and intertidal sediments of the west coast of Peninsular Malaysia

Malaysia is now a developing country and on her way towards being an industrialised one by the year 2020. Most of her industries and urban areas are located on the west coast of Peninsular Malaysia. In addition, the offshore area of the west coast is now one of the busiest shipping lanes in the world. These two phenomena make the intertidal and offshore areas of the west coast of Peninsular Malaysia interesting for scientific studies. Therefore, this study focused on both the offshore and intertidal sediments of the west coast of Peninsular Malaysia. Sampling for sediment samples were done from the northern to the southern ends of the peninsula and these sediment samples were analysed for Cu and Pb. It was found that total Cu concentrations ranged from 0.25 to 13.8 and 0.40 to 315 microg/g dry weight (dw) for offshore and intertidal sediments, respectively. For Pb, it ranged from 3.59 to 25.4 and 0.96 to 69.8 microg/g dw for the offshore and intertidal sediments, respectively. The ranges of Cu and Pb found from the west coast of Peninsular Malaysia were low in comparison to regional data. However, some intertidal areas were identified as receiving anthropogenic Cu and Pb. Geochemical studies revealed that the 'nonresistant' fraction for Pb contributed about 70.0% to 75.0% and 54.0% of the total Pb concentration in the offshore and intertidal sediments, respectively. As for Cu, the 'nonresistant' fraction contributed about 46.2% to 60.4% and 46.3% of the total Cu concentration in the offshore and intertidal sediments, respectively. The 'nonresistant' fraction contained mostly of anthropogenic metals besides natural origins. These 'nonresistant' percentages indicated that both the offshore and intertidal areas could have received anthropogenic-derived metals, which could be influenced by physico-chemical properties of the sediments. Although the present data indicated that contamination due to Cu and Pb in the west coast of Peninsular Malaysia especially in the offshore areas were not serious, regular biomonitoring studies along the west coast of Peninsular Malaysia are recommended.

A survey of blood lead levels among young Johannesburg school children

Studies conducted around the world have established beyond doubt that elevated childhood blood lead levels may lead to detrimental health effects. Research has shown that certain groups of South African children are at particular risk of elevated blood lead levels. Johannesburg is the largest urban complex in southern Africa, with a population of around 3 million and extensive industrial and manufacturing activity. Among the challenges posed in the city are rapid urbanization, extensive poverty, and inequity. Little information on the blood lead distribution of Johannesburg children is available. This study was undertaken to determine blood lead levels among children living in three areas of Johannesburg: inner city suburbs and the low-income townships of Alexandra and Westbury to the north and west of the city center, respectively. The results indicated that blood lead levels ranged from 6 to 26 micro g/dL, with a mean level of 11.9 micro g /dL. The blood lead levels of 78% of children equaled or exceeded 10 micro g/dL, the current international action level. Maternal educational status, the presence of smokers in the home, and living in an informal dwelling were among the factors associated with elevated blood lead levels.

Continent Gastric Pouch Bladder Replacement

The use of the stomach for bladder enlargement and replacement has been known since Sinaiko's work in a canine model. Mitchell et al later showed that the use of the stomach for bladder replacement and enlargement had many advantages especially in situations of acute acid loading and azotaemia. The advantages of using the stomach included protection against hyperchloraemic acidosis (due to net excretion of chloride), reduced mucus production and decreased urine infection rate, plus the elastic properties of the stomach. We report the use of part of the stomach as a continent urinary reservoir to replace a missing urinary bladder and we discuss the advantages and disadvantages of using the stomach in the urinary tract

Correlations between speciation of Cd, Cu, Pb And Zn in sediment and their concentrations in total soft tissue of green-lipped mussel Perna viridis from the west coast of Peninsular Malaysia

Total concentrations and speciation of cadmium (Cd), copper (Cu), lead (Pb) and zinc (Zn) in surface sediment samples were correlated with the respective metal measured in the total soft tissue of the green-lipped mussel Perna viridis, collected from water off the west coast of Peninsular Malaysia. The aim of this study is to relate the possible differences in the accumulation patterns of the heavy metals in P. viridis to those in the surface sediment. The sequential extraction technique was employed to fractionate the sediment into 'freely leachable and exchangeable' (EFLE), 'acid-reducible,' 'oxidisable-organic' and 'resistant' fractions. The results showed that significant (P<.05) correlations were observed between Cd in P. viridis and Cd in the sediment (EFLE fraction and total Cd), Cu in P viridis and Cu in the sediment (EFLE and 'acid-reducible' fractions and total Cu) and Pb in P viridis and Pb in the sediment ('oxidisable-organic' fraction and total Pb). No significant correlation (P > .05) was found between Zn in P viridis and all the sediment geochemical fractions of Zn and total Zn in the sediment. This indicated that Zn was possibly regulated from the soft tissue of P. viridis. The present results supported the use of P viridis as a suitable biomonitoring agent for Cd, Cu and Pb.

Tobacco smoking, nicotine, and nicotine and non-nicotine replacement therapies

Tobacco smoking is associated with an increased risk for the development of coronary and pulmonary vascular diseases and smoking cessation will greatly reduce this risk. Nicotine replacement and nonnicotine modalities have been used alone and in combination to help in smoking cessation. These treatment modalities appear to be safe in patients with known stable coronary artery disease.

[Effort phlebitis of the upper limb. Report of 5 cases]

Deep venous thrombosis (DVT) of upper limbs is extremely rare. DVT related to physical stress is a less known form. The purpose of this study was to outline the clinical pattern and laboratory features as well as the clinical course and outcome of this disease. The authors report 5 documented cases of upper limb DVT related to physical stress: 4 patients were hand workers and 1 was a young athletic man. None of the patients developed pulmonary embolism. Two patients had late sequelae. Treatment is based on prompt and early anticoagulation. Prevention can be achieved by contention, active physiotherapy and professional rehabilitation.

Primary polypseudophakia for cataract surgery in hypermetropic eyes: refractive results and long term stability of the implants within the capsular bag

AIM

To determine the long term visual and refractive results, and stability and complications of primary polypseudophakia using poly(methylmethacrylate) (PMMA) intraocular lenses (IOLs) for cataract surgery in hypermetropic eyes.

METHODS

Prospective study of 15 short or hypermetropic eyes undergoing phacoemulsification with primary polypseudophakia with two PMMA IOLs implanted within the capsular bag.

RESULTS

The spherical equivalent was reduced from a mean +4.87 (SD 3.00) dioptres (D) to -0.12 (1.40 D), and the deviation from the intended refraction was +0.005 (1.30) D, 23.6 (12.36) months post-implantation. The deviation from intended refraction was not statistically significant (p = 0.989; paired t test). Postoperative best corrected visual acuity (BCVA) was 6/12 or better in all eyes without macular or optic nerve co-morbidity. Interlenticular opacification (ILO) in the form of peripheral Elschnig pearls was seen in four (26.67%) eyes. A new type of ILO in the form of usually pigmented deposits in the central interface developed in five (33.33%) eyes and resulted in the appearance of Newton's rings in three. None of the eyes with ILO had any loss of BCVA or hyperopic shift. Six (40%) eyes were within 1 D from the intended refraction and 14 (93.33%) within 2 D. There was no statistically significant difference in the accuracy of the two intraocular lens calculation formulas used (SRK II and SRK/T).

CONCLUSION

Peripheral Elschnig pearl-type ILO can occur as a late complication of primary in the bag implantation of two PMMA IOLs. A new type of ILO is described. Both types of ILO have not to date resulted in deterioration of visual acuity in our cohort. Use of appropriate biometry techniques and IOL calculation formulas may yield more accurate refractive results.

Anti-inflammatory and anti-ulcer activity of Calligonum comosum in rats

The 10% ethanol extract of the aerial parts of Calligonum comosum (50--400 mg/kg, i.p.) significantly reduced the increase in hind paw oedema induced by carrageenan in rats. Following sub-acute oral administration of the extract (50 and 100 mg/kg, daily for 14 days), a significant anti-inflammatory activity in the cotton pellet model was observed. Pre-treatment with the extract (100, 200 and 400 mg/kg) produced a significant and dose-dependent inhibition to the acute gastric ulcers induced by phenylbutazone, indomethacin, 0.2 N NaOH and 80% ethanol.

Cryptococcus myelitis: atypical presentation of a common infection

Cryptococcus neoformans is associated with as much as 45% of meningitis in patients admitted for hospital care in Zimbabwe, and it is an important opportunistic infection in patients infected with the human immunodeficiency virus. Cases of cryptococcosis presenting as a spinal cord syndrome have been reported from Zimbabwe and South Africa, but these were all cases of Cryptococcus vertebral osteomyelitis. We describe 3 unusual patients who presented with a myelitis-like syndrome without vertebral osteomyelitis.

The immunopathology of actinomycetoma lesions caused by Streptomyces somaliensis

The immune responses in actinomycetoma lesions caused by Streptomyces somaliensis in Sudan were characterized by immunohistochemistry during 1997-1998. In sections stained with haematoxylin and eosin, the inflammatory reaction around the grain was of 2 types. In type I there were 3 zones: a neutrophil zone immediately around the grain, an intermediate zone containing mainly macrophages, and a peripheral zone consisting of lymphocytes and plasma cells. Zone 1 stained positively for CD15 (neutrophils), zone 2 for CD68 (macrophages) and CD3 (T lymphocytes), and zone 3 for CD20 (B lymphocytes). In the type II reaction, there was no neutrophil zone, the grains being surrounded only by macrophages and giant cells. This was confirmed by immunohistochemistry, which demonstrated the presence of CD3 positive cells. Immunoglobulins G and M and complement were demonstrated on the surface of the grain and on filaments inside the grain. Neutrophils and macrophages were recruited into the lesion by complement and were involved in the fragmentation of the grain. The cytokine profile in the lesion and regional lymph nodes was of a dominant Th2 pattern (interleukins-10 and 4).

One stage pull through for hirschsprung's disease

In order to compare one-stage versus multiple-stage pull-through for Hirschsprung disease (HD) and comment on transanal pull-through without laparotomy, we reviewed 35 patients operated on for HD in the last six years. Ages ranged from 1 week to 14 years with 16 patients presenting neonatally. Sixteen patients had multiple-stage and 19 single-stage pull-through. Twenty-one patients had the Swenson procedure, five the Duhamel, seven the Soave pull-through and two the Lister Martin procedure for total colonic aganglionosis.

We conclude that the one stage pull-through is effec-tive, saves the patient multiple operations, recurring costs and long hospital stays, and also saves both the patient and family the psychological trauma of colostomy.

Combined brachial plexus and vascular injury in the absence of bony injury

Neurovascular injury to the axillary vessels is well described in association with fracture or dislocation involving the shoulder joint or the humerus. Such injury however can also occur in the absence of bony injury. A case is presented of damage to the axillary artery and brachial plexus following blunt trauma. This case demonstrates that complex neurovascular damage can occur in the absence of fracture or dislocation. The importance of a thorough clinical assessment is highlighted and priorities with regard to diagnosis and management are discussed.

Diabetic glomerulopathy: pathogenesis and management

Although not all renal disease that diabetic patients develop is due to diabetic glomerulosclerosis, the great majority of patients progressing to advanced renal failure suffer from diffuse or nodular (Kimmelstiel Wilson's) diabetic glomerulosclerosis. This condition has become the single most frequent cause of end-stage renal failure in the Western world. Recent studies indicate that an interplay between genetic predisposition and other factors such as hyperglycemia, blood pressure, age, gender, smoking and ethnicity, predispose to nephropathy both in type 1 and type 2 diabetes mellitus. It has also become clear that trace albuminuria ("microalbuminuria") provides a unique opportunity to recognize incipient renal involvement early on, particularly in type 1 and less specifically in type 2 diabetes. Increasing evidence indicates that early intervention delays progression of nephropathy. Factors which promote progression of nephropathy include hypertension, proteinuria, smoking, poor glycemic control and, less certainly, high dietary protein intake and hyperlipidemia. The most important strategies to combat the medical catastrophe of increasing numbers of diabetic patients with end-stage renal failure include (i) prevention of diabetes (mainly type 2), (ii) glycemic control to prevent onset of renal involvement and (iii) meticulous antihypertensive treatment to avoid progression of nephropathy. Survival of diabetic patients on dialysis and after transplantation is inferior to that of non-diabetic patients, mainly because of high rate of cardiovascular death. There is consensus that in the absence of major vascular disease the best treatment is renal transplantation in the type 2 diabetic patient and combined kidney and pancreas transplantation in the type 1 diabetic patient.

New advances in the diagnosis of typhoid and detection of typhoid carriers

For effective management of typhoid, diagnosis of the disease must be done with speed and accuracy. Development of such a test would require antigens that are specific for typhoid diagnosis. Attempts at finding the specific antigen have been carried out throughout the years. The finding of such an antigen can lead to carrier detection as well. Candidate antigens have been used in the development of antigen or antibody detection tests with variation in sensitivity and specificity. Further characterization and understanding of the candidate antigens combined with use of innovative technologies will allow for the ideal test for typhoid and typhoid carriers to be within reach.

Massive upper GI bleeding in a child

Two year and seven month female child, known case of cerebral palsy, presented with sudden onset of hematemesis, which progressed to uncontrollable massive upper GI bleeding requiering devascularization and more than 36 blood transfusions.

Impaired glucose tolerance in vitamin D deficiency can be corrected by calcium

Vitamin D(3), via its active metabolite 1alpha,25-dihydroxyvitamin D(3), helps maintain normal calcium levels in the body. Apart from the maintenance of calcium homeostasis, the active form of vitamin D(3) is now known to be involved in a number of other functions including that of pancreatic beta cells. Low serum insulin levels and impaired glucose tolerance in a vitamin D-deficient state have been reported in experimental animals. Hypocalcemia is a major consequence of vitamin D deficiency. Whether the impairment observed is due to vitamin D deficiency per se or is secondary to low calcium is still a matter of controversy. The present study was conducted to delineate the roles of vitamin D and calcium in glucose intolerance associated with vitamin D deficiency in vivo. It was found that supplementation with either vitamin D(3) or high calcium alone to vitamin D-deficient rats could correct the defects. In addition, insulin sensitivity was found to be enhanced in the vitamin D-deficient group compared with vitamin D control or calcium-supplemented groups. Hence the present study demonstrates that calcium per se in the absence of vitamin D increases insulin secretion and normalizes intolerance to glucose seen in vitamin D deficiency.

The development of post-kala-azar dermal leishmaniasis (PKDL) is associated with acquisition of Leishmania reactivity by peripheral blood mononuclear cells (PBMC)

PKDL develops in about 50% of Sudanese patients treated for visceral leishmaniasis (kala-azar). Patients with kala-azar were entered into this study and followed for a period of up to 2 years. During follow up 12 patients developed PKDL and eight did not. Proliferative responses and cytokine production to Leishmania donovani and control antigens were measured in vitro using PBMC isolated at the time of diagnosis of kala-azar, after treatment of visceral leishmaniasis, during follow up, and at the time of diagnosis of PKDL. Proliferative responses and interferon-gamma (IFN-gamma) production were low at diagnosis and increased after treatment of kala-azar in both patients who developed (group 1) and those who did not develop PKDL later (group 2). In group 1, development of PKDL was always associated by an increased PBMC response to Leishmania antigen in proliferation and IFN-gamma production assays. There were no differences in Leishmania antigen-induced production of IL-4, IL-5 and IL-10 between or within the two groups. We have previously shown that Leishmania parasites spread to the skin during visceral leishmaniasis and proposed that PKDL was the result of an immunological attack on parasites, which have survived in the skin despite the drug treatment. The finding that PKDL develops after treatment of kala-azar as Leishmania-reactive T cells start to circulate in peripheral blood in sufficient numbers to be detected in in vitro assays supports this hypothesis.

Subcapsular hepatic and intraperitoneal bleed after administration of tissue plasminogen activator in a patient with acute myocardial infarction

Thrombolysis can sometimes cause life-threatening bleeding. In the case reported here, subcapsular hepatic and intraperitoneal bleeding developed after administration of tissue plasminogen activator (tPA) in a patient with acute myocardial infarction. Surgery was required in this patient to stop the bleed.

Cholangiocarcinoma in patients with primary sclerosing cholangitis: a multicenter case-control study

Patients with primary sclerosing cholangitis (PSC) have a significantly increased risk of developing cholangiocarcinoma (CCA). Risk factors for developing such a complication are not well defined. We conducted a multicenter, case-control study to determine the risk factors and possible predictors for CCA in patients with PSC. The demographic, clinical, and laboratory features of 26 PSC patients with CCA diagnosed over a 7-year period at eight academic centers were compared with 87 patients with PSC but no CCA (controls). There was no statistically significant difference in demographics, smoking, signs or symptoms or complications of PSC, indices of disease severity (Mayo Risk score or Child-Pugh score), frequency or duration or complications of inflammatory bowel disease (IBD), frequency of biliary surgery, or therapeutic endoscopy between the two groups. Alcohol consumption was significantly associated with CCA in patients with PSC (odds ratio: 2.95; 95% CI: 1.04-8.3). Serum carbohydrate antigen 19-9 (CA 19-9) was significantly higher in patients with CCA than those without (177 +/- 89 and 61 +/- 58 U/mL, respectively; P =.002). A serum CA 19-9 level > 100 U/mL had 75% sensitivity and 80% specificity in identifying PSC patients with CCA. In conclusion, alcohol consumption was a risk factor for having CCA in PSC patients. The indices of severity of liver disease were not associated with CCA in patients with PSC. Serum CA 19-9 appeared to have good ability to discriminate PSC patients with and without CCA.

Immunopathology of post kala-azar dermal leishmaniasis (PKDL): T-cell phenotypes and cytokine profile

In Sudan, post kala-azar dermal leishmaniasis (PKDL) caused by Leishmania donovani develops in half of the patients treated for visceral leishmaniasis (kala-azar). In most patients lesions heal spontaneously, but in others symptoms are severe and persist for years. This study examined the immunological response in lesions of PKDL patients by immunohistochemistry and compared the findings with results obtained using peripheral blood mononuclear cells (PBMCs). In all lesions, parasites or parasite antigen were present and provoked the formation of an inflammatory infiltrate consisting of a mixture of macrophages, lymphocytes, and plasma cells. In patients who had high interferon-gamma (IFNgamma) responses to Leishmania antigen in vitro, compact epithelioid granulomas were formed. The inflammatory cells were mainly CD3(+) and interleukin-10 (IL10) was the most prominent cytokine in the lesions. However, IFNgamma was found in all and IL4 in most lesions, in varying amounts. PBMCs from all patients responded to Leishmania antigen by IFNgamma production or proliferation. The results indicate that PKDL develops as a result of an influx of immunocompetent cells into skin, which harbours parasites. The inflammatory response to the parasites is complex. It involves several cell types and cytokines, of which some are antagonistic. It is conceivable that the balance between these cytokines determines the outcome of the disease.

Kala-azar in a high transmission focus: an ethnic and geographic dimension

In 1994-1996, we studied a group of 58 game wardens stationed in an area known to be highly endemic for visceral leishmaniasis (kala-azar) for evidence of infection with Leishmania donovani. Leishmania DNA was detected by the polymerase chain reaction in the peripheral blood of cases of active kala-azar, former patients with visceral leishmaniasis, patients, and asymptomatic subjects. Using the cloned antigen rk39, antibodies were detected in 44.2% of the game wardens while leishmanin skin test result was positive in 77% of our sample. It was shown that certain tribes from northern Sudan were more likely to develop subclinical infections, while those of the Baria tribe from southern Sudan and those of the Nuba tribe from western Sudan were more likely to develop visceral leishmaniasis. Whether this is due to genetic factors or previous exposure to Leishmania parasites remains to be elucidated.

Predictors of large esophageal varices in patients with cirrhosis

OBJECTIVE

Recent guidelines recommend that all cirrhotics undergo screening upper endoscopy to identify those patients at risk for bleeding from varices. However, this practice may not be cost effective as large esophageal varices are seen only in 9-36% of these patients. The aim of this study was to determine whether clinical variables were predictive of the presence of large esophageal varices.

METHODS

This is a retrospective analysis of cirrhotics who had a screening upper endoscopy during an evaluation for liver transplantation at three different centers and who had not previously bled from varices. A multivariate model was derived on the combined cohort using logistic regression. Three hundred forty-six patients were eligible for the study.

RESULTS

The prevalence of large esophageal varices was 20%. On multivariate analysis, splenomegaly detected by computed tomographic scan (odds ratio: 4.3; 95% confidence interval: 1.6-11.5) or by physical examination (odds ratio: 2.0; 95% confidence interval: 1.1-3.8), and low platelet count were independent predictors of large esophageal varices. On the basis of these variables, cirrhotics were stratified into high- and low-risk groups for the presence of large esophageal varices. Patients with a platelet count of > or = 88,000/mm3 (median value) and no splenomegaly by physical examination had a risk of large esophageal varices of 7.2%. Those with splenomegaly or platelet count < 88,000/mm3 had a risk of large esophageal varices of 28% (p < 0.0001).

CONCLUSIONS

Our data show that clinical predictors could be used to stratify cirrhotic patients for the risk of large esophageal varices and such stratification could be used to improve the cost effectiveness of screening endoscopy.

Detrimental subtype-specific endothelin-1 (ET-1) signaling in myocardial cells: the ET(A) mediated proliferation and ET(B)receptor down-regulation

Many physiological and pathological processes in the cardiac tissue have been shown to be associated with a release of endothelin (ET) peptides and with induction of specific ET-receptors and G-protein-coupled ion channels. However, the exact mechanism regulating ET-receptors in the myocardium is controversial. The response to ET-1, the most important member of the ET family, is rapidly attenuated by down-regulation of ET-receptors. The internalization of ET-1 bound to two subclasses of specific receptors (ET(A) and ET(B)) that are abundant in the myocardium has been hypothesized to activate and/or inhibit a variety of intracellular signal transducing systems. The [125I]ET-1, BQ-3020 and selective ET-antagonists were used to study the subtype-selective component of regulation of ET-1 receptors in myocardial membranes. We determined the characteristics of [125I]ET-1 binding and [3H]thymidine incorporation in whole cell saturation studies and measured Ca2+ channel induction and the total number of inactive Ca2+ channels in photoaffinity studies with [3H]azidopine. Here we demonstrate four important components of the complex ET-1 response in human, porcine and rat myocardium, leading to aberrant responses of cells. After ET-1 induction, adaptive subtype-ETB selective down-regulation predominated in human embryonic fibroblasts, in porcine membrane vesicles and in microsomal membranes of renal hypertensive rats, with preferential high affinity ET-1 binding to ETA receptors and with the resultant ETA mediated proliferative and mitogenic activation of human fibroblasts. The ET-1 induction was also accompanied by profound inactivation of Ca2+ channels in myocardial membranes.

The role of infection in atherosclerosis and coronary artery disease: a new therapeutic target

There is growing evidence that inflammatory processes may be involved in the development of atherosclerosis and its complications. Viral and bacterial pathogens have been implicated as possible causative factors in the pathogenesis of coronary artery disease (CAD) and restenosis after angioplasty. Antibiotic trials are now in progress to examine whether treatment of infection can prevent the complications of CAD. Atherosclerosis, the primary pathologic process in coronary artery disease (CAD), carotid artery disease, abdominal aortic aneurysm, and peripheral vascular disease, is no longer considered to be an obscure, slowly progressive, degenerative disease. Indeed, recent molecular studies on the atherosclerotic plaque have shown that the initiation, progression, and acute sequelae of atherosclerosis can be explained in part by a low-grade inflammatory process. Studies show that mediators of inflammation can be found at all stages of the life cycle of the atherosclerotic plaque. These include activated macrophages and lymphocytes, cytokines, growth factors, matrix degenerating proteinases, and tissue factor. It is hypothesized that risk factors such as hypertension, smoking, or elevated levels of low-density lipoprotein (LDL) cholesterol result in injury to the endothelial cell of the artery, and this injury initiates the inflammatory process. However, many patients with vascular disease do not have these established risk factors, and this observation has galvanized efforts to find new risk factors. Because inflammation is now considered to be an operative paradigm for atherosclerosis, it is not a major leap to the hypothesis that infectious agents, such as viral or bacterial, may play a role. Certainly this is not a new concept, and with the recent discovery that peptic ulcer disease, heretofore considered a disease of excess acid and reduced mucosal resistance, is caused by the ubiquitous bacterium Helicobacter pylori, interest in finding an infectious etiology for atherosclerosis has increased. Accordingly, the purpose of this discussion is to review in a historical manner the evidence that infectious agents-including herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), Enterovirus (adenovirus, Coxsackie virus), Chlamydia pneumoniae, and H. pylori-may play a role in atherosclerosis and its manifestations, especially as they relate to CAD.

The regressing role of surgery in the management of pancreatic pseudocysts in children

Full text is available as a scanned copy of the original print version.

Reappraisal of the anatomy of the anorectal musculature

Full text is available as a scanned copy of the original print version.

Antimicrobial effects of psidium guajava extract as one mechanism of its antidiarrhoeal action

A morphine-like spasmolytic action (not naloxone reversible; involving the inhibition of acetylcholine release) and also effects on the transmural transport of electrolytes (Na(+) and K(+)) and water have been reported as possible modes of the antidiarrhoeal action of polar fractions of Psidium guajava leaf extractives. The objective for this study was to verify if the reported modes of the antidiarrhoeal action should be broadened to include direct antimicrobial actions on some of the more common bacteria known to cause toxin-induced acute diarrhoea. Serial dilutions of a water-soluble, freeze-dried methanolic extract were tested on 10 such organisms, grown separately on nutrient agar plates, to determine the minimum inhibitory concentration (MIC) for each of these bacteria. These included the causative agents for (i) enteric fever (Salmonella typhi, Salmonella paratyphi A, Salmonella paratyphi B and Salmonella paratyphi C), (ii) food poisoning (Salmonella typhimurium and Staphylococcus aureus), (iii) dysentery (Shigella dysenteriae, Shigella flexneri and Shigella sonnei), and (iv) cholera (Vibrio cholerae). The growth of all these organisms was inhibited at the MIC of 10mg/ml of the extract, which is equivalent to 2.5μg/ml of active extractable flavonoids. The most sensitive organisms (MIC = 1mg/ml) were Staphylococcus aureus, Vibrio cholerae and Shigella flexneri.

Leishmania-specific T cells expressing interferon-gamma (IFN-gamma) and IL-10 upon activation are expanded in individuals cured of visceral leishmaniasis

Peripheral blood mononuclear cells (PBMC) from patients who have recovered from visceral leishmaniasis often respond to Leishmania antigens in vitro by production of both IL-4, IFN-gamma and IL-10. In order to establish the cellular sources of these cytokines, we activated cells from individuals with a history of visceral leishmaniasis with Leishmania antigen for 6 days in culture, and identified cytokine production at the single-cell level by flow cytometry. The cytokines were only found in CD3+ cells and among these mainly within the CD4+ subset. The percentage of cytokine-producing cells was compared in Leishmania-activated PBMC cultures from the previous patients and from individuals living in a village where leishmaniasis does not occur. The percentage of IL-10- and IFN-gamma-containing cells was significantly higher in the previous patients than in the controls, indicating that Leishmania-specific T cells producing IL-10 and/or IFN-gamma had been expanded as a result of the infection. The cytokine-producing cells in the previous patients could be divided into three types: (i) cells producing IFN-gamma only; (ii) cells producing IL-4 only; and (iii) cells producing IFN-gamma and IL-10 simultaneously. The first and second group of cells can be described as Th1- and Th2-type cells, respectively. The third group could be a regulatory subset of T cells important for maintaining a balance between Th1- and Th2-type cells in these individuals.

Rapid and reliable serological diagnosis of enteric fever: comparative sensitivity and specificity of Typhidot and Typhidot-M tests in febrile Malaysian children

The Typhidot test, which detects IgM and IgG antibodies to a Salmonella typhi-specific outer membrane protein, is as sensitive as, and more specific than, the Widal test in the diagnosis of enteric fever in Malaysian children. It is easier and quicker to perform. In order to increase diagnostic accuracy in an area of high endemicity, the Typhidot-M test has been developed in which IgG is first removed. This theoretically allows improved detection of IgM, and thus would differentiate new from recent infections. We evaluated both tests in 134 unselected febrile children admitted to the General Hospital Kota Bharu, Malaysia. The children were divided into two groups: (i) those who were blood and/or stool culture positive for S. typhi and/or who had clinical features strongly suggestive of enteric fever (n = 62); and (ii) those who were both culture-negative and had clinical evidence of another diagnosis (n = 72). The sensitivity and specificity of the Typhidot and Typhidot-M tests were identical at 90.3 and 93.1%, respectively. Both tests had comparable sensitivity but greater specificity than those of the Widal test (91.9 and 80.6%, respectively). When used together, a positive result for Typhidot and/or Typhidot-M was more specific than either test alone (95.2%) but specificity was lower (87.5%). We conclude that the Typhidot and Typhidot-M tests have comparatively high diagnostic accuracy, suggesting that IgM can be detected in children who may have a predominant IgG response to S. typhi. Using these tests in combination increases the negative predictive value but at the cost of a lower positive predictive value.

Serodiagnosis of Leishmania donovani infections: assessment of enzyme-linked immunosorbent assays using recombinant L. donovani gene B protein (GBP) and a peptide sequence of L. donovani GBP

The repetitive sequence of Leishmania major gene B protein (GBP) has previously been shown to be a useful tool in the diagnosis of cutaneous leishmaniasis (CL). Here, we have assessed enzyme-linked immunosorbent assays (ELISAs) using recombinant L. donovani GBP (rGBP) and a peptide sequence of L. donovani GBP (GBPP) in the diagnosis of L. donovani infections in Sudan. The sensitivity of the rGBP ELISA in diagnosing visceral leishmaniasis (VL) and post kala-azar dermal leishmaniasis (PKDL) was 92% and 93%, respectively. In contrast, the sensitivity of the GBPP ELISA was 55% for VL and 63% for PKDL. Plasma antibody reactivity of donors with VL and PKDL remained high for an extended period after the end of treatment. Antibody-reactivity to rGBP and GBPP was detected in 71% and 14% of plasma samples from CL patients, respectively. Plasma from healthy Sudanese donors living in an area endemic for malaria but free of leishmaniasis was negative in both assays.

T-cell response in human leishmaniasis

In the present communication we provide evidence for the existence of a Th1/Th2 dichotomy in the T-cell response to Leishmania antigens in human leishmaniasis. Our data suggest that the pattern of IL-4 and IFN-gamma response is polarised in these patients. Lymphocytes from individuals recovered from cutaneous leishmaniasis (CL) responded by IFN-gamma production following stimulation with Leishmania antigens whereas cells from patients recovered from visceral leishmaniasis (VL) showed a mixed pattern of IFN-gamma and IL-4 responses. The cells producing these cytokines were predominantly CD4+. Furthermore, IL-10 plays an important role in the development of post kala azar dermal leishmaniasis (PKDL) from VL. The balance between the parasitic-specific T-cell response plays an important regulatory role in determining the outcome of Leishmania infections in humans.

Increased osteoclast-like cells formation in long-term bone marrow cultures from patients with a spinal cord injury

Patients with a spinal cord section loose a significant amount of bone. After paraplegia, bone loss occurs below the lesional level and is the more dramatic in iliac bones and in the metaphyseal area of long bones. A peak of urinary calcium and hydroxyprolinuria is observed approximately 6 weeks after their lesion. To further understand the mechanisms underlying the bone damage, we used long-term bone marrow cultures to compare osteoclast-like (OCL-like) cell formation above and below the lesional level. Seven paraplegic, one quadriparetic, one quadriplegic patients and five normal subjects were investigated. Six weeks after their spinal cord section, the number of OCL-like cells formed in iliac bone marrow cultures was significantly greater than those formed in sternal bone marrow cultures for all paraplegic patients tested. No significant differences were seen between iliac and sternal bone marrow cultures for the quadriparetic, the quadriplegic patient, or for the five normal subjects. Conditioned media (CM) from iliac marrow of paraplegic patients increased OCL-like cell formation in normal bone marrow cultures. IL-1, TNF-alpha, IL-6, and PGE2 were measured in the CM after 3 weeks of culture. IL-6 was found to be significantly higher in iliac CM compared with sternal CM in six out of seven paraplegic patients. In two patients, addition of an anti-IL-6 monoclonal antibody to the marrow cultures significantly decreased the number of OCL-like cells formed at 3 weeks. We conclude that paraplegia caused by a cord section locally induces an increase in the capacity of progenitors to form OCL-like cells in long-term bone marrow cultures. A locally increased IL-6 production in the marrow below the lesional level could be partly responsible for this observation.

Humoral and cellular immune responses to synthetic peptides of the Leishmania donovani kinetoplastid membrane protein-11

Native kinetoplastid membrane protein-11 (KMP-11), purified from crude extracts of Leishmania donovani parasites, activates T cells from individuals who have recovered from visceral leishmaniasis. In this work we used three 38-mer peptides spanning the amino acid sequence of the L. donovani KMP-11 as solid-phase ligands in enzyme-linked immunosorbent assays (ELISAs) and as stimulating antigens in lymphoproliferative assays in order to evaluate humoral and cellular immune responses to well-defined sequences of the protein. Antibody reactivity against the three peptides was measured in plasma from 63 Sudanese visceral leishmaniasis patients (VL) and the percentage of patients with anti-KMP-11 antibodies in ELISA were 37% (KMP-11-1), 30% (KMP-11-2) and 58% (KMP-11-3). The fraction of VL patients with measurable antibody reactivity in one or more of the three ELISAs was 79%. Cross-reactivity to the KMP-11 peptides was detected in plasma from Sudanese patients suffering from Leishmania major infections and in plasma from Sudanese and Danish patients infected with Plasmodium falciparum. In lymphoproliferative assays, 10 of 17 PBMC isolates from donors previously infected with L. donovani showed a response to one or more of the three KMP-11 peptides.

The Leishmania promastigote surface antigen-2 (PSA-2) is specifically recognised by Th1 cells in humans with naturally acquired immunity to L. major

The promastigote surface antigen-2 (PSA-2) is a Leishmania parasite antigen, which can induce Th1-mediated protection against murine leishmaniasis when used as a vaccine. To evaluate PSA-2 as a human vaccine candidate the specific T-cell response to PSA-2 was characterised in individuals immune to cutaneous leishmaniasis. Peripheral blood mononuclear cells from Sudanese individuals with a past history of self-healing cutaneous leishmaniasis proliferated vigorously in response to PSA-2 isolated from Leishmania major, whereas the antigen did not activate cells from presumably unexposed Danes. Peripheral blood mononuclear cells from individuals with previous L. major infection had varying proliferative responses to PSA-2 derived from L. donovani promastigotes. Peripheral blood mononuclear cells activated by PSA-2 from L. major produced high amounts of interferon-gamma and tumour necrosis factor-beta, and little interleukin-4, thereby showing a Th1 cytokine pattern. Parallel cultures showed clear Th1 and Th2 response patterns to purified protein derivative of tuberculin or tetanus toxoid, respectively. Flow cytometric analysis revealed that PSA-2 induced blastogenesis in the CD3 positive population and that these cells were the major source of interferon-gamma. The results show that Th1-like cells recognising PSA-2 are expanded during infection by L. major and that they maintain their Th1-like cytokine profile upon reactivation in vitro. Since immunity to cutaneous leishmaniasis is mediated by antigen-specific Th1-like cells, PSA-2 might be considered a vaccine candidate for human leishmaniasis.

Recurrent colonic volvulus in children

Recurrent intestinal obstruction caused by colonic volvulus is a rare cause of intestinal obstruction in children. Because the condition is self rectifying at times, the diagnosis can be missed or delayed. The authors present two patients, one with sigmoid volvulus and the other with sigmoid and cecal volvulus, and discuss the diagnosis and management of this condition in children. In view of the recurring nature of this condition, the authors believe that nonoperative treatment of this condition in children has no place beyond the emergency situation and that the definitive treatment should always be surgical.

Susceptibility pattern of Streptococcus pneumoniae among pre-school children in Kota Bharu, Malaysia

Streptococcus pneumoniae (S. pneumoniae) is the most common bacterial cause of pneumonia, meningitis, and otitis media, with the highest incidence among young children and the elderly. S. pneumoniae was once routinely susceptible to penicillin, but since the mid-1980s the incidence of resistance to penicillin and other antimicrobial agents has been increasing all over the world. To optimize empirical regimens and initial therapy for S. pneumoniae infections, clinical healthcare providers must be informed about the prevalence and pattern of drug resistance among the isolates in their communities. No such data are available for the Malaysian population. Therefore, this study was designed to determine the antibiotic susceptibility pattern of S. pneumoniae among colonized pre-school children in Kota Bharu, Malaysia. Pharyngeal swabs were collected from children 1 month to 6 years of age. S. pneumoniae isolates were identified according to the standard and tested for penicillin resistance with a 1-microgram oxacillin disk by the Kirby-Bauer disk diffusion methods. Of 355 nasopharyngeal specimens obtained from kindergarten students, in-patients and pediatric clinics over a period of 1 year, S. pneumoniae was isolated from 36 (10 per cent). All isolates, except one, were susceptible to penicillin. The resistant isolates was susceptible to erythromycin, chloramphenicol and cephalosporins.

Modulation of fluorouracil cytotoxicity by interferon-alpha and -gamma

Because interferons (IFN)-alpha and -gamma individually have increased fluorouracil (FUra) cytotoxicity in several in vitro models, we studied the effects of FUra combined with IFN-alpha + gamma in HT29 colon cancer cells. A 96-hr exposure to IFN-alpha (500 units/ml) plus IFN-gamma (10 units/ml) and a 72-hr exposure to 0. 25-1 microM FUra (hr 24-96) inhibited cell growth and colony formation in an additive or more-than-additive fashion. When cells were exposed to IFN-alpha + gamma and FUra, free FdUMP levels became detectable, whereas [3H]FUra-RNA incorporation decreased. Exposure to IFN-alpha + gamma, FUra, or the combination decreased dTTP pools to 58%, 43%, and 17% of control, respectively. A marked increase in the dATP to dTTP ratio was seen with FUra with or without IFN-alpha + gamma. Thymidylate synthase catalytic activity was reduced to 28% and 24% of control with FUra with or without IFN-alpha + gamma, suggesting that the enhanced dTTP depletion must be due to another mechanism. FUra-mediated thymidylate synthase inhibition was accompanied by a 124-fold increase in total deoxyuridylate immunoreactivity and a 31-fold increase in dUTP pools, but the addition of IFN-alpha + gamma attenuated the accumulation. Treatment with IFN-alpha + gamma and FUra individually interfered with nascent DNA chain elongation, whereas the three-drug combination produced the most striking effects. IFN-alpha + gamma plus FUra produced the greatest amount of single-strand breaks in nascent DNA and dramatically decreased net DNA synthesis. IFN-alpha + gamma with or without FUra produced double-strand breaks in parental DNA. These results suggest that dTTP depletion, dATP/dTTP imbalance, pronounced inhibition of DNA synthesis, and damage to nascent and parental DNA contribute to the enhanced cytotoxicity with the triple combination.

High levels of plasma IL-10 and expression of IL-10 by keratinocytes during visceral leishmaniasis predict subsequent development of post-kala-azar dermal leishmaniasis

Some patients develop post-kala-azar dermal leishmaniasis (PKDL) after they have been treated for the systemic infection kala-azar (visceral leishmaniasis). It has been an enigma why the parasites cause skin symptoms after the patients have been successfully treated for the systemic disease. We report here that PKDL development can be predicted before treatment of visceral leishmaniasis, and that IL-10 is involved in the pathogenesis. Before treatment of visceral leishmaniasis, Leishmania parasites were present in skin which appeared normal on all patients. However, IL-10 was detected in the keratinocytes and/or sweat glands of all patients who later developed PKDL (group 1) and not in any of the patients who did not develop PKDL (group 2). Furthermore, the levels of IL-10 in plasma as well as in peripheral blood mononuclear cell culture supernatants were higher in group 1 than in group 2.

Recurrent colonic volvulus in children

Recurrent intestinal obstruction caused by colonic volvulus is a rare cause of intestinal obstruction in children. Because the condition is self rectifying at times, the diagnosis can be missed or delayed. The authors present two patients, one with sigmoid volvulus and the other with sigmoid and cecal volvulus, and discuss the diagnosis and management of this condition in children. In view of the recurring nature of this condition, the authors believe that nonoperative treatment of this condition in children has no place beyond the emergency situation and that the definitive treatment should always be surgical.