Suturing techniques and postoperative management in penetrating keratoplasty in the United Kingdom

Aims

To report on the suturing techniques and aspects of postoperative management in penetrating keratoplasty in the United Kingdom.

Methods

A postal questionnaire was sent to 137 ophthalmic consultants identified from a Royal College of Ophthalmology database as having a special interest in anterior segment surgery. The questionnaire surveyed surgeon preferences for surgical and suturing technique for penetrating keratoplasty surgery, and the postoperative care of corneal grafts.

Results

In all, 68% of questionnaires were completed and returned: 73% of respondents used a Flieringa ring or equivalent, 94% routinely used cardinal sutures, with 50.5% removing them at the end of the procedure. The most common suturing technique for routine penetrating keratoplasty was a single continuous suture (35%). In these cases, a 10/0 nylon suture was used by 89%. Sixty-six percent changed their technique in high-risk cases, 52% used a 3-1-1 knot, and 75% made a distinction between a reef and granny knot, with 76% using a reef. Thirty percent buried the knots within the donor material, and 29% within the host tissue. Twenty-five percent had no routine time for graft suture removal, but 41% removed them between 1 and 2 years post-surgery. After suture removal, 98% used steroids and 88% used topical antibiotics. Thirty-four percent stopped topical steroids before suture removal, with 38% stopping topical steroids more than 3 months prior to suture removal.

Conclusion

This survey demonstrates that there is considerable variation in suturing techniques and postoperative care for penetrating keratoplasty. These significant variations in practice need to be considered when interpreting outcomes and research.

One-step fabrication of thermally stable TiO2/SiO2 nanocomposite microspheres by evaporation-induced self-assembly

The evaporation-induced self-assembly of mixed colloids has been employed to synthesize microspheres of TiO(2)/SiO(2) nanocomposites. Small-angle neutron/X-ray scattering and scanning electron microscopy experiments reveal the hierarchical morphology of the microspheres. Although the internal structure of the microspheres, consisting of solely silica nanoparticles, gets significantly modified with time because of the reduction in the high specific surface area by internal coalescence, the same for the composite microspheres remains stable over an aging time of 1 year. Such temporal stability of the composite microspheres is attributed to the inhibition of coalescence of the silica nanoparticles in the presence of titania nanoparticles. X-ray diffraction and thermogravimetric results show the improved thermal stability of the composite grains against the anatase-to-rutile phase transition. Such thermal stability is attributed to the suppression of the growth of titania nanoparticles in the presence of silica nanoparticles. The UV-vis results indicate the confinement effect of the TiO(2) nanoparticles in the silica matrix. A plausible mechanism has been elucidated for the formation of microspheres with different morphology during self-assembly.

An epidemiological investigation of mumps outbreak in a slum of Kolkata

An unexpected clustering of mumps cases were reported in a slum of Kolkata during early part of 2009. An epidemiological investigation was initiated with a view to assess the characteristics and determinants of the disease, and implications of such clustering of cases in a slum of Kolkata. Data were collected through house to house visit using predesigned schedule and epidemiological case sheet. The propagated outbreak existed for fifteen weeks yielding 104 clinical cases. On the whole, attack rate was 4.7%, the highest and lowest being in 6-10 years (11.68%) and above 15 years (0.94%), respectively. The parotid swelling was bilateral in 92.3% of cases; fever was the most common general symptom, reportedly present in 92.3% of study subjects. The overall mean duration of parotid swelling was 6.85 +/- 1.89 days. Morbidity from mumps far exceeds the mortality rate. Improved ventilation of living rooms, personal & oral hygiene; isolation of cases, upgradation of routine immunization, better nutrition etc. were recommended at family & community level and introduction of MMR vaccine in National Immunization Schedule was suggested.

Control of buckling in colloidal droplets during evaporation-induced assembly of nanoparticles

Micrometric grains of anisotropic morphology have been achieved by evaporation-induced self-assembly of silica nanoparticles. The roles of polymer concentration and its molecular weight in controlling the buckling behavior of drying droplets during assembly have been investigated. Buckled doughnut grains have been observed in the case of only silica colloid. Such buckling of the drying droplet could be arrested by attaching poly(ethylene glycol) on the silica surface. The nature of buckling in the case of only silica as well as modified silica colloids has been explained in terms of theory of homogeneous elastic shell under capillary pressure. However, it has been observed that colloids, modified by polymer with relatively large molecular weight, gives rise to buckyball-type grains at higher concentration and could not be explained by the above theory. It has been demonstrated that the shell formed during drying of colloidal droplet in the presence of polymer becomes inhomogeneous due to the presence of soft polymer rich zones on the shell that act as buckling centers, resulting in buckyball-type grains.

Prospective assessment of C4d deposits on circulating cells and renal tissues in lupus nephritis: a pilot study

Complement activation plays a key role in the pathogenesis of lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE). We prospectively evaluated 15 LN subjects and two control groups: 13 non-SLE renal subjects (control A) and 239 SLE subjects without LN (control B). All had C4d levels on circulating erythrocytes (E-C4d), reticulocytes (R-C4d) and platelets (P-C4d) measured by flow cytometry, while C4d deposition in renal tissue was semiquantitatively assessed in LN subjects and control A using immunoperoxidase staining. Compared with control A, LN biopsies had higher glomerular-C4d scores (p = 0.003), which were associated with more frequent granular glomerular immunofluorescence staining and electron dense deposits (p < 0.001). Compared with control A and B groups, LN subjects had higher E-C4d (p = 0.002 and p = 0.005) and R-C4d levels (p = 0.002 and p = 0.008), respectively. LN subjects were more likely to have P-C4d compared with control A (p = 0.016). In LN, only E-C4d correlated with National Institutes of Health (NIH) activity index (r = 0.55, p = 0.04). In conclusion, LN biopsies showed frequent glomerular-C4d staining associated with immune complex deposits. LN subjects had higher E-C4d and R-C4d levels compared with both control groups. E-C4d levels also correlated with NIH activity index. These findings suggest a potential role of C4d on circulating cells as a biomarker for lupus nephritis.

Validity of the WHO criteria for adolescent hypertension

BACKGROUND

WHO Second Task Force Criteria of adolescent hypertension (95th percentile for age) has been use for a long time and different studies have indicated wide variation of hypertension through out the world.

OBJECTIVE

To find out the validity of the WHO diagnostic criteria for adolescent hypertension.

METHODS

A cross-sectional study was undertaken in an urban slum of Chetla, Kolkata, among 1081 adolescent population (10-19 yrs of age). Initially 95th percentile values for age of systolic and diastolic blood pressure were calculated in different age groups and comparison was made between hypertensive subjects identified by the study values and the WHO reference values, using sensitivity and specificity parameters.

RESULTS

In all the different age groups, the diagnostic criteria of hypertension in the study had sensitivity 100%, but specificity varied in the different age groups i.e. 95.34% (10-12 years), 93.89% (13-15 years), 97.41% (16-18 years), 95.34% (10-18 years) and 100% (19 year).

CONCLUSION

Age specific reference values for blood pressure of adolescents should be formulated locally in different regions to aid in the identification of children with high blood pressure.

Template-assisted electrostatic spray deposition as a new route to mesoporous, macroporous, and hierarchically porous oxide films

A novel film coating technique, template-assisted electrostatic spray deposition (TAESD), was developed for the synthesis of porous metal oxide films and tested on TiO(2). Organic templates are codeposited with the titania precursor by electrostatic spray deposition and then removed during calcination. Resultant films are highly porous with pores casted by uniformly sized templates, which introduced a new level of control over the pore morphology for the ESD method. Employing the amphiphilic block copolymer Pluronic P123, PMMA latex spheres, or a combination of the two, mesoporous, macroporous, and hierarchically porous TiO(2) films are obtained. Decoupled from other coating parameters, film thickness can be controlled by deposition time or depositing multiple layers while maintaining the coating's structure and integrity.

High rate of prevalence of clock 3′UTR polymorphism rs1801260 and a novel variation: Association with diurnal preference

There are a number of reports which show CLOCK 3111 T/C SNP rs1801260 is associated with ‘eveningness’ circadian type, but the results are not consistent across different populations. The present study tried to address the effect of CLOCK polymorphisms on Diurnal preference in the South Indian population. 108 subjects were genotyped for rs1801260 polymorphism by direct sequencing. Demographic data was collected from genotypically stratified groups of subjects using a modified sleep wake cycle questionnaire. Data from the questionnaire recorded the subjects sleep wake pattern and their peak performance time of the day. The sequencing data was aligned and analyzed using Mutation Survey software for new mutations. We found a new variation in the 3′UTR region of the CLOCK gene (BankIt1368312 Seq1 HM626403, BankIt1368312 Seq2 HM626404) which may be a possible miRNA binding site. Our study found that CLOCK 3111 T/C polymorphism is negatively associated with Eveningness with a significance of 0.038. We found that the prevalence rate of rs1801260 is high and the ancestral genotype is associated with eveningness. Though the sample size was small this was a homogenous group from south India selected for the study. It is the first study in south Indian population to document the effect of CLOCK polymorphisms on Circadian rhythm.

Acute effects of 5-methyltetrahydrofolate on endothelial function and asymmetric dimethylarginine in patients with chronic heart failure

BACKGROUND AND AIMS

Folic acid enhances endothelial function in vascular disease states but its effects in chronic heart failure (CHF) are largely unknown. We studied the acute effects of i.v. methyltetrahydrofolate (5MTHF), the active metabolite of folic acid, on endothelial function and asymmetric dimethylarginine (ADMA) in CHF patients.

METHODS AND RESULTS

Twenty two CHF patients and 22 controls received one of the following three-step infusions (1h per each step) in a randomized, parallel group, placebo-control study: (1) active treatment (saline, 5MTHF, and 5MTHF+the endothelial nitric oxide inhibitor N(G)-monomethyl l-arginine, LNMMA); or (2) placebo (salinex3). Endothelium-dependent vasodilatation was assessed by pulse-wave analysis (salbutamol-mediated changes in augmentation index, AIx). 5MTHF did not exert any significant effects on endothelium-dependent vasodilatation both in controls [DeltaAIx post-salbutamol baseline -7.6% (-24.8/-4.1) vs. 5MTHF -5.5% (-16.7/-3.6), medians and interquartile range, and CHF patients [-1.8% (-17.3/+1.3) vs. -2.4% (-3.8/-1.2)]. However, a significant reduction in ADMA concentrations was observed in both groups [controls baseline 0.68micromol/L (0.64/0.77) vs. 5MTHF 0.65 (0.57/0.74); CHF baseline 0.76 (0.63/0.82) vs. 5MTHF 0.69 (0.66/0.71), P=0.05 for both vs. baseline and placebo. These effects persisted during co-infusion with LNMMA.

CONCLUSION

5MTHF did not affect endothelial function but significantly reduced serum ADMA concentrations both in CHF patients and controls. This suggests a direct effect of 5MTHF on ADMA metabolism.

Awareness regarding communicable diseases among the patients attending general out-patient department of a tertiary care hospital of Kolkata, India

OBJECTIVE

Communicable diseases continue to be a major problem in India, a large number of which can be prevented by health education, targeting specially the deficiencies and for which a baseline assessment is essential.

METHODS

This observational study included OPD patients who were selected by random sampling and interviewed. The age range varied from 20 - 50 years.

RESULTS

52.5% resided in rural areas. 80% were literates. Majority had per capita income below Rs 1000 per month. Awareness regarding symptoms, modes of transmission, prevention and management of the studied diseases were not satisfactory. Majority used apparently safe water. Mosquito-net use was more among literates. Media was the main source of information in urban areas, health functionaries in rural areas while relatives, friends and neighbours influenced the residents of both the areas and the finding was statistically significant.

CONCLUSIONS

An awareness development programme involving a combination of different health education methods is suggested.

Variations of adolescent blood pressure by multifactorial analysis in an urban slum of Kolkata

To find out the factors responsible for variations of adolescent blood pressure, a community-based cross-sectional study was undertaken among 1081 adolescents, aged 10-19 years, selected by simple random sampling in an urban slum of Kolkata, Chetla in 2003-04. Age, educational status, additional ghee/butter intake with diet, family history of hypertension, weight, height and body mass index were found to be associated with blood pressure in unifactorial analysis, hence these variables were considered for multifactorial analysis. All these independent variables were correlated with both systolic and diastolic blood pressure except additional ghee/butter intake with food. In stepwise multiple regression analysis, age, education, family history of hypertension, weight, height and body mass index contributed 64.6% of the total variation of systolic blood pressure, where weight alone contributed to 62.6% while 35.4% of variations remained unexplained. In case of diastolic blood pressure, 56.8% of the total variations were due to age, education, family history of hypertension, weight, height and body mass index, out of which weight alone contributed 56% while remaining 43.2% of total variations remained unexplained. Since single most important predictor of blood pressure was weight, regular aerobic physical activity, dietary modification, behavioral changes and health education are recommended for weight reduction and prevention of obesity.

Prevalence of hypertension and variation of blood pressure with age among adolescents in Chetla, India

This community-based cross-sectional study was carried out to determine the prevalence of hypertension and variation of blood pressure with age among adolescents in an urban slum of Chetla, Kolkata, India. A total of 1081 adolescents aged 10-19 years were involved in the study. The prevalence of hypertension was 2.9% (31) and highest prevalence (5.6%) was observed in the age group of 18-19 years. The mean systolic and diastolic blood pressure was higher in males than females. Among males and females, average increase of mean systolic blood pressure was found to be 2.26mmHg and 1.95mmHg per year respectively. The mean diastolic blood pressure increased by 1.55 mmHg and 1.42mmHg per year, respectively. The age spurt of rise in mean systolic blood pressure in males was found at 10-11, 13-14, and 16-17 years age groups, whereas in females it was observed in 12-13, and 17-18 years age groups. The age spurt of rise in mean diastolic blood pressure in males was observed in the age group 16-17 years and in females it was noted in the age group 11-12, and 17-18 years. In conclusion, blood pressure measurement should be done routinely during health check up of adolescents to initiate secondary level of prevention at the earliest.

An Epidemiological Study of Smoking Among Adult Males in a Rural Area of Hooghly District, West Bengal, India

A community-based cross-sectional study was undertaken in a rural community of West Bengal, India among 329 adult males, during April to June, 2004 to find out the prevalence, characteristics of smoking and attitude of smokers towards quitting. 29.8% (98), 61.7% (203) and 8.5% (28) were found to be current, never and former smokers respectively. Among current smokers, 79.4% had started smoking before the age of 24 years. 23% of smokers cited the reason for smoking was to concentrate at work and to relieve anger and frustration. 53.8% wanted to quit smoking but lack of willpower (28.2%) became the major hindrance to quitting. 58.9% were uncertain about continuing smoking. Smoking is commonly practised in rural area of West Bengal, starting at quite an early age; hence awareness and health education needs to be stressed, so that prevention can be initiated.

A study on catch up growth among low birth weight infants in an urban slum of Kolkata

OBJECTIVES

To study the catch up growth among low birth weight infants in relation to the normal birth weight counterparts in first six months of age.

METHODS

A longitudinal community based study was done in 2004 -05 in an urban slum of Chetla, Kolkata among 126 singleton live born babies. Growth pattern of these babies was followed up at 15+/-5 days interval by house visit till six months of age.

RESULTS

The incidence of low birth weight babies was 28.6%. 86.1% LBW infants caught up in length at 3rd month, 63.9% in chest circumference at 4th month, 66.7% in head circumference at 5th month, while 72.2% in weight at 6th month. Regular growth monitoring is essential for LBW babies to detect signs of growth faltering at the earliest.

Anthropometric correlates of adolescent blood pressure

A community based cross-sectional study was undertaken among 1081 adolescents to assess the relationship of adolescent blood pressure with weight, height and BMI in Chetla, Kolkata; data collection was done with a predesigned schedule along with recording of anthropometric measurements and blood pressure. Mean, correlation coefficient was used for statistical analysis. Systolic and diastolic blood pressure of both sexes increased with increase in weight, height and BMI with a significant positive linear correlation. Life style modification should be stressed upon from childhood.

Identification of predictive markers to differentiate ixabepilone from paclitaxel activity in ER-negative breast cancer patients

2525

Background: Ixabepilone (BMS-247550) is a microtubule stabilizing agent with demonstrable therapeutic value in taxane- refractory breast cancer (BC) patients. Biomarkers to predict either ixabepilone or paclitaxel activity in BC patients have previously been reported. However, markers that differentiate response to the two agents have yet to be identified. This study sought to discover predictive markers that will enable patient selection to differentially enhance response to ixabepilone or paclitaxel in ER-negative (ER-) patients. Materials and Methodologies: Pre-treatment gene expression profiles were generated for 62 ER- patients treated with ixabepilone in clinical study CA163080, and 51 ER- patients treated with T/FAC (paclitaxel and fluorouracil-doxorubicin-cyclophosphamide) in clinical study MDA133. Biomarkers differentially predictive of complete pathological response in breast were identified through gene set enrichment analysis (GSEA) or classification by threshold gradient descent (TGD). Gene knockdown by siRNA was used to study some of these candidate markers. Results: Four candidate models that differentiate response to ixabepilone treatment and taxane-containing therapy were identified. Two of the models, found by GSEA, are based on expression levels for single microtubule-related genes: transforming, acidic coiled-coil containing protein 3 (TACC3) and chromosome condensation protein G (HCAP-G). The potential of HCAP-G as a differential marker was supported by siRNA studies. Two of the models, found by TGD, are based on expression levels for 26 and 20 genes. Areas under the ROC curves for the models applied to each study separately are given in the table . Conclusions: We have identified four predictive models that differentiate response in a clinical trial of ixabepilone from that in a trial of T/FAC. A clinical trial is under way to further evaluate their utility for differentiating response to ixabepilone- and taxane-containing regimens.

[Table: see text]

[Table: see text]

Predictive biomarker discovery and validation for the targeted chemotherapeutic ixabepilone

3011

Background: Ixabepilone is a microtubule stabilizing agent with significant therapeutic value in breast cancer (BC) patients. To identify predictive biomarkers capable of identifying patients likely to receive optimal benefit from ixabepilone treatment, preclinical and clinical studies were carried out. Several biomarkers discovered using preclinical models were validated in a neoadjuvant BC clinical study ( CA163080 ) and one, estrogen receptor 1 (ER), was shown to double the pathological complete response (pCR) rate in patients treated with ixabepilone. To identify candidate sets of biomarkers that could further increase the pCR rate we have performed post-hoc analyses of the preclinical and clinical data. Methods: Eighteen BC cell lines were classified as sensitive or resistant (S/R) based on the IC50 values for ixabepilone treatment. Gene expression profiling of the BC cell lines was conducted and genes correlated with the S/R classification were identified using a k-Nearest Neighbors algorithm. Patients in clinical study CA163080 underwent a pretreatment core needle biopsy from which RNA was isolated and gene expression profiles generated (data available on 134 patients). Analyses using the preclinical and clinical markers were conducted using various statistical tools. Results: Several markers used in combination with ER were found to be capable of tripling the pCR to ixabepilone in CA163080. In addition to ER other predictive markers were identified that were as predictive as ER, including several genes whose expression is anti-correlated with ER and are part of the ER pathway. Finally, various sub-group analyses were performed and manifested the importance of clinical sample variation that needs to be considered for the analysis. Conclusions: Several single biomarkers identified from preclinical studies were validated in the clinical study CA163080 , demonstrating the utility of this approach. Such markers can be used in combination to better identify patients likely to respond to ixabepilone in future clinical trials. Furthermore, molecular response markers that can be tied to the mechanism of drug resistance can be used for further developing chemotherapy in drug development.

[Table: see text]

Cataract surgery by appointment--a pilot study

Background

"Cataract Surgery by Appointment" is a new method of delivery of cataract surgery that reduces the time a patient spends in hospital by their direct arrival at the operating theatre, having self-prepared for surgery, thus avoiding admission to the ward or time spent in the Day Case Unit. The patient can stay as little as 20 minutes from their arrival to going home. We describe the process in detail, and seek to evaluate the visual outcome, safety and patient satisfaction of same.

Methods

Visual outcome and safety data were obtained from patients' medical records, prospectively. Patients were also surveyed by a questionnaire to determine their satisfaction with the service and viability as a prospect for providing a more efficient cataract surgery service.

Results

In 2002, fifty-one eyes of 39 consecutive patients underwent "Cataract Surgery by Appointment". There were 16 male and 23 female. The pre-operative best-corrected visual acuity was 6/9 or better in 17 (33%) eyes. The post-operative best-corrected visual acuity was 6/9 or better in 44 (86%) eyes. There were no per-operative complications. Post-operative complications occurred in 3 (6%) eyes. The average number of days from surgery to final discharge was 14.5 days.

Twenty-eight (72%) completed questionnaires were returned. The results show that the majority of patients were satisfied with their overall experience of this mode of delivery for cataract surgery.

Conclusion

"Cataract Surgery by Appointment" performed under local anaesthesia by a skilled ophthalmic surgeon appears to be safe and effective for highly selected cases. This method of delivery gave a high level of patient satisfaction, and is the ultimate form of day case cataract surgery. The method may gain widespread use should per-operative intracameral pupil dilatation prove to be effective and acceptable. Attention should be paid to risk-stratification, so complex cases are allocated more time on the operating list.

Elevated levels of ornithine decarboxylase cooperate with Raf/ERK activation to convert normal keratinocytes into invasive malignant cells

Ornithine decarboxylase (ODC) overexpression coupled with activated Ras is fully sufficient to oncogenically transform primary keratinocytes. To determine the Ras effector pathways that represent the minimal essential contribution to full oncogenic transformation in this context, we evaluated the cooperativity of different Ras effector mutants with overexpressed ODC in an in vivo tracheal xenotransplantation assay for epithelial cell invasiveness. Primary keratinocytes, isolated from either K6/ODC transgenic mouse skin (expressing increased ODC) or from normal littermate skin were infected with retrovirus producing an activated RasV12 or partial loss-of-function effector mutants of RasV12 that selectively induce only the Raf/ERK, RalGDS, or the PI3-kinase signaling pathway. Whereas keratinocytes expressing a fully activated RasV12 are not invasive in tracheal xenotransplants, ODC-overexpressing keratinocytes acquire an invasive phenotype with additional expression of either RasV12 or activation of the Raf/ERK pathway. Independent of a mutated ras, elevated levels of ODC activate the Akt/mTOR signaling pathway as well as the Rho/Rac pathway in primary keratinocytes. Thus, Raf/ERK signaling is sufficient to cooperate with increased ODC activity in the conversion of normal keratinocytes to invasive cells. In order to promote invasiveness in keratinocytes, elevated levels of ODC may cooperate with Raf/ERK via activation of the Akt and Rho/Rac signaling pathway.

Imaging of osteo-odonto-keratoprosthesis by electron beam tomography

AIM

To describe the experience of using electron beam tomography (EBT) in imaging of osteo-odonto-keratoprosthesis (OOKP) to identify early bone and dentine loss which may threaten the viability of the eye.

METHODS

Seven patients with an OOKP in one eye underwent EBT. The OOKP lamina dimensions were measured on EBT and compared to the manual measurements at the time of surgery.

RESULTS

There was a high degree of resolution of the OOKP lamina noted with EBT. In particular, it identified three patients with a marked degree of thinning of the lamina edges. Two of these patients had OOKP that were allografts. The mean time from surgery to examination was 3.6 years (range 1.2-5 years) while the mean age of the patients was 56 years (range 31-79 years).

CONCLUSIONS

It is important to monitor regularly the dimensions and stability of the OOKP lamina as it will help detect cases that are at risk of extrusion of the optical cylinder and consequent endophthalmitis. Prophylactic measures can then be taken to prevent such serious complications from occurring. In this series, the authors found EBT to have excellent resolution and speed and they would support regular scanning of the OOKP lamina in all patients.

The osteo-odonto-keratoprosthesis (OOKP)

The osteo-odonto-keratoprosthesis (OOKP), although described over 40 years ago, remains the keratoprosthesis of choice for end-stage corneal blindness not amenable to penetrating keratoplasty. It is particularly resilient to a hostile environment such as the dry keratinized eye resulting from severe Stevens-Johnson syndrome, ocular cicatricial pemphigoid, trachoma, and chemical injury. Its rigid optical cylinder gives excellent image resolution and quality. The desirable properties of the theoretical ideal keratoprosthesis is described. The indications, contraindications, and patient assessment (eye, tooth, buccal mucosa, psychology) for OOKP surgery are described. The surgical and anaesthetic techniques are described. Follow-up is life-long in order to detect and treat complications, which include oral, oculoplastic, glaucoma, vitreo-retinal complications and extrusion of the device. Resorption of the osteo-odonto-lamina is responsible for extrusion, and this is more pronounced in tooth allografts. Regular imaging with spiral-CT or electron beam tomography can help detect bone and dentine loss. The optical cylinder design is discussed. Preliminary work towards the development of a synthetic OOKP analogue is described. Finally, we describe how to set up an OOKP national referral center.

Chronic lymphocytic leukaemia (CLL) in Central Africans

OBJECTIVE

To document the clinical and haematological features of chronic lymphocytic leukaemia (CLL) in Central Africans.

DESIGN

Prospective descriptive analysis.

SETTING

Tertiary referral teaching hospitals.

SUBJECTS

48 Zimbabweans and 27 Malawians formed the basis of this analysis.

RESULTS

There were 75 patients (40 males and 35 females) studied and their ages ranged from 32 to 78 years with a mean +/- s.d. of 56.8 +/- 10.1 years. The peak age incidence of 26.7% occurred between 60 to 64 year old and 21.3% were below 50 years. The major clinical findings included: splenomegaly (68%); hepatomegaly (37.3%); anaemia (34.7%); lymphadenopathy (33.3%) and nine (12%) patients were diagnosed incidentally. The majority of patients (78.7%) had Rai stage III and IV and only seven (9.3%) patients were in stage 0. Of the 32 patients treated with chemotherapy, 25.9% and 59.3% achieved complete or partial remissions respectively. Six patients were still alive after a follow up period of a mean +/- s.d of 39.3 +/- 24.4 months; five were lost to follow up after a mean +/- s.d period of 28.6 +/- 18.8 months and 16 were dead after a mean +/- s.d. period of 25.7 +/- 19.1 months. The main causes of death in the treated group were septicaemia in six, pneumonia in four and tuberculosis in three. In the untreated group of 43 patients, two refused therapy, four died shortly after diagnosis and 37 were lost to follow up.

CONCLUSIONS AND RECOMMENDATIONS

Although the study has disclosed that CLL is not rare in central Africans and its presentations are similar to cases reported in the literature, the majority of patients seek medical treatment late. Optimal therapy is impossible due to lack of chemotherapy and supportive services..Therefore, it is recommended that tertiary referral centers in African health systems should be equipped for better management of CLL patients.

Dobutamine stress echocardiography--methodology, clinical applications and current perspectives

Dobutamine stress echocardiography is often used as a non-invasive diagnostic modality for detection of coronary artery disease. In terms of accuracy it rivals SPECT scintigraphy. Application of non-coronary artery disease has made it an attractive diagnostic tool. However, like all diagnostic modalities it has its inherent limitations. Quantitation of stress echocardiography can resolve most of the problems surrounding its use.

Chronic myeloid leukaemia in central Africans

OBJECTIVES

To document the pattern of presenting clinical and haematological features of chronic myeloid leukaemia (CML) in central Africans and evaluate the clinical consequences of treating the disease with chemotherapy.

DESIGN

Prospective descriptive analysis of clinical and haematological data.

SETTING

Departments of Haematology of tertiary referral centres and teaching hospitals.

MATERIALS AND METHODS

Prospective clinical and haematological data were collected on 150 central Africans (90 Zimbabweans and 60 Malawians) using modern Coulter counters and standard up-to-date haematological procedures and the results analysed using predetermined criteria and the top-desk Scientific Calculator Model HP 48GX, Texas Instruments, USA.

RESULTS

There were 150 CML patients studied. Males predominated in a ratio of 1:5:1. The youngest patient was 10 years and the oldest 77 years with a mean +/- s.d. of 38.9 +/- 14.7 years. The peak age incidence of 47.3% occurred between 21 to 40 years. The Ph chromosome was found in 19 of the 20 patients studied. Although complaints attributed to splenic enlargement were the most common symptoms, several unusual clinical features were encountered viz: hepatomegaly (26%), bleeding (12%), significant lymphadenopathy (11.3%), purpura (3.3%), skin infiltration (2.7%), cardiac failure (2.7%) and 14.7% were diagnosed incidentally. Symptoms such as fatigue, headaches and weight loss were associated with greater degrees of leucocytosis, severe to gross splenomegaly and lower haemoglobin levels. The severe to gross splenomegaly which occurred in 68(45.3%) suggests that patients in this part of the world seek medical advice rather late in the disease. The median survival times of 65,47 and 39 months respectively for alpha interferon, hydroxyurea and busulphan are in agreement with those of previous larger series from other parts of the world.

CONCLUSIONS

The study has revealed that the presenting pattern of clinical and haematological features of CML is changing probably due to the advent of modern clinical practice coupled with increased physician density, greater awareness of disease among clinicians besides other reasons. However, optimal treatment is not possible for the majority of patients due to lack of chemotherapeutic agents and supportive care.

RECOMMENDATION

Referral centres in African health systems should be equipped for better management of CML patients.

Thyrotoxic periodic paralysis: an unusual presentation of weakness

Thyrotoxic periodic paralysis is a rare endocrine disorder seen predominantly in men of Asian origin. The case is reported of a patient who presented to the accident and emergency department with sudden onset of weakness of his lower limbs. Hypokalaemia was identified and treated with resolution of symptoms. Additional tests identified the patient as being thyrotoxic. He was treated with oral antithyroid drugs. It is important to consider the diagnosis of thyrotoxic periodic paralysis in patients presenting with acute onset of weakness. The report discusses the epidemiology, presentation, treatment, and complications of this condition.

[Glomerulonephritis in systemic vasculitis. Microscopic polyangiitis]

Die mikroskopische Polyangiitis (MPA) ist eine seltene Vaskulitis, welche definiert ist als Kleingefässvaskulitis ohne Granulombildung mit immunhistochemisch weitgehend fehlenden Immunkomplexablagerungen. Die MPA betrifft beide Geschlechter gleich häufig und tritt hauptsächlich in der fünften und sechsten Lebensdekade auf. Wir beschreiben eine Patientin mit diesem Krankheitsbild.

Role of chromatin disruption and histone acetylation in thyroid hormone receptor action: implications in the regulation of HIV-1 LTR

Thyroid hormone (TH) affects a wide variety of biological processes, from development to physiological function of different cells and organs. Alterations in plasma TH concentrations lead to developmental abnormalities and pathological consequences. Earlier studies have observed that plasma TH levels vary in AIDS patients such that low levels of TH correlate with survival rate. Furthermore, studies on the regulation of the human immunodeficiency virus type 1 (HIV-1) have shown that TH receptor (TR) is capable of binding to two regions within the long terminal repeat (LTR), which controls the transcription of HIV-1 genome. The frog oocyte is an in vivo system that allows microinjected DNA to be chromatinized in a process mimicking the process that occurs in somatic cells. Studies in the frog oocyte have provided in vivo evidence on the role of chromatin remodeling in transcriptional regulation by TR and have shown that TR utilizes similar mechanisms in the regulation of the HIV-1 LTR. That is, TR binds to LTR in chromatin in vivo and represses the LTR in the absence of TH by recruiting corepressor complexes containing histone deacetylases, and upon TH binding, TR causes chromatin remodeling and LTR activation.

Pythium perplexum isolated from soil in France: morphology, molecular characterisation and biological control

Pythium perplexum (F-926) was isolated from a soil sample taken in the Burgundy region in France. In 1907, it was mistakenly described by Bulter as P. vexans. Despite morphological resemblance, the comparison between the internal transcribed spacer 1 regions of the ribosomal DNA of the two fungi leaves no doubt of their different identities. P. perplexum was found to be highly pathogenic to cucumber seedlings. Damping-off disease of cucumber caused by P. perplexum can effectively be controlled by using the soil bacterium Serratia plymuthica (B-781). The details of the morphology and the molecular characterisation of P. perplexum and its biological control with S. plymuthica are described here.

[The application of external knee stabilizers - Influence on mechanical stabilization and physical performance]

The aim of the study was, to assess the influence of a knee brace on the development of anterior instability after anterior cruciate ligament rupture and to test aptitude for physical strain. 46 subjects with arthroscopically proven anterior cruciate ligament rupture were divided equally in a randomised order into two groups. Both groups carried out a standardized physical therapy program, while one group (0) received additional stabilization by means of a functional knee brace (SofTec, Bauerfeind). In addition, important features of the brace (stabilization capacity, safety perception and physical performance) were tested and compared to the non-braced contralateral leg among 23 healthy physical education students by means of a standardized scaled questionnaire (observational study). 0 showed lower (p < 0.05) development of the anterior instability by 46 % and lower (p < 0.05) reduction in circumference of the femur muscles by 25 %. Increasing the time interval between accident and beginning of the brace treatment, increased the difference of the therapeutical effect of the brace. In the observational study, the brace received a better evaluation regarding all test parameters. The reduction of developing anterior instability by means of a brace should facilitate - apart from an individual operation-time-arrangement - especially a conservative approach within the framework of anterior instability and physical activity. Aside from the improvement of the mechanical stabilization, indications for suitability in strain situations could be detected for the tested brace.

Characterisation of the yeast Pichia membranifaciens and its possible use in the biological control of Botrytis cinerea, causing the grey mould disease of grapevine

Pichia membranifaciens strain FY-101, isolated from grape skins, was found to be antagonistic to Botrytis cinerea, the causal organism of the grey mould disease of the grapevine. When grown together on solid as well as liquid media, the yeast brings about the inhibition of this parasitic fungus, coagulation and leakage of its cytoplasm, and suppression of its ability to produce the characteristic grey mould symptoms on the grapevine plantlets. In vitro experiments confirm that this yeast can be used as a biological control organism against B. cinerea. An account of the molecular characterisation of P. membranifaciens (complete sequence of the ITS region of its ribosomal DNA, GenBank accession No. AF 270935), as well as the interaction between B. cinerea and the yeast, are given here.

ITS region of the rDNA of Pythium longandrum, a new species; its taxonomy and its comparison with related species

Pythium longandrum (F-73.0) was isolated, from soil samples taken in Lille in northern France. Morphologically the fungus resembles closely Pythium rostratum, however its antheridial characters are unique. The oogonia of this species are provided with hypogynous and monoclinous antheridia. The antheridial cells are inflated and are probably the largest and longest for the genus. The internal transcribed spacer region of its nuclear ribosomal DNA indicates that it is entirely different from all other species of Pythium. This new species is characterized by its spherical to elongated sporangia, smooth-walled oogonia and hypogynous to monoclinous antheridia bearing long antheridial cells closely applied to the oogonia. Morphological features of this new species, together with the sequences of the ITS region of its nuclear ribosomal DNA and comparison with related species are discussed here.

A new species of Pythium with filamentous sporangia having pectinolytic activities, isolated in the Burgundy region of France

A new species, Pythium pectinolyticum (F-83.1), isolated from soil samples taken in the Burgundy region is being described here. This species is characterised by its filamentous non-inflated type of sporangia, smooth-walled mostly catenulate oogonia and very rare antheridia. This fungus is a very slow-growing organism on most of the solid media, but it grows well in liquid media and also on those containing pectin as the sole source of carbon. Morphological features are described here together with the sequences of the internal transcribed spacer 1 region of the nuclear ribosomal DNA of the fungus, its comparison with related species, and its pectinolytic behaviour.