Parental [correction of Perinatal] consanguinity: a risk factor for developmental delay in Pakistani children

OBJECTIVE

To investigate the association of parental consanguinity and delayed development in terms of gross motor, fine motor, speech and social aspects in their children.

METHODS

One hundred and seventy seven children (age 15 days--72 months) were evaluated for their developmental status utilizing the Denver Developmental Screening Test (DDST). An unmatched case-control study design was used. Case group consisted of 94 children and control group 83 children. Odds ratios were calculated for parental consanguinity and delay in gross and fine motor, speech and social development in their children, for cases and controls, utilizing Binary Multiple Logistic Regression Analysis. Acquired delay was excluded through detailed birth history in both cases and control group respectively.

RESULTS

Univariate analysis showed high significant Odds ratios for all areas of developmental delay (viz. gross and fine motor, speech and social development), between cases and controls (p < .001). At the multivariate analysis level however, our results showed no increased risk of parental consanguinity on delayed gross and fine motor, speech and social development in their children.

CONCLUSION

Our results show no increased risk of parental consanguinity on delayed gross and fine motor, speech or social development (as measured by the DDST), in their children.

CD38 expression as an important prognostic factor in B-cell chronic lymphocytic leukemia

CD38 is a transmembrane glycoprotein expressed on the surface of leukemic cells in a significant percentage of patients with B-cell chronic lymphocytic leukemia (B-CLL). A recent study suggested that CD38 expression has prognostic value in CLL. Peripheral blood samples from 218 patients with B-CLL were analyzed by flow cytometry for CD38 expression on CD5/19(+) leukemic cells. Various patient characteristics were studied including age, sex, Rai and Binet stages, splenomegaly, hepatomegaly, hemoglobin (Hgb) level, beta-2 microglobulin (beta2M) level in the serum, number of nodal sites involved with disease, and length of survival. The Kaplan-Meier method was used to construct survival curves, and the log-rank statistic was used to compare these curves. CD38 was expressed in 20% or more of leukemic cells in 43% of the patients. Patients with high CD38 expression (20% or more) had significantly shorter survival times (P =.00005). Multivariate analyses showed that CD38 expression is an important prognostic factor associated with high incidence of lymph node involvement (P =.004), lower hemoglobin level (P =.001), hepatomegaly (P =.05), and high beta2M level (P =.00005). CD38 expression identified a group of patients with aggressive disease that was considered by Rai staging to be early-stage disease (Rai stages 0-II). Patients with CD38(+) samples have significantly aggressive disease regardless of their clinical stage. Measurement of CD38 expression by flow cytometry should become a routine test in the evaluation of patients with CLL.

Influence of beta-adrenergic antagonists, H1-receptor blockers, analgesics, diuretics, and quinolone antibiotics on the cellular accumulation of the anticancer drug, daunorubicin: P-glycoprotein modulation

BACKGROUND

Treatment of patients with several drugs simultaneously may result in modulation of the naturally expressed P-glycoprotein (Pgp) at different tissues. With this possibility in mind, we have assessed the ability of different classes of drugs to modulate Pgp function in vitro. Modulation of the Pgp function was studied at in vitro drug concentrations comparable to therapeutic blood levels of the drugs.

MATERIALS AND METHODS

Human blood brain barrier endothelial cells and human colon adenocarcinoma cells were transduced or transfected with the multidrug resistance gene (MDR1) to express Pgp. The uptake of fluorescent substrates of Pgp, Rhodamine 123 and daunorubicin, into these cells and NIH3T3/MDR1 and MDCK/MDR1 cells was measured by flow cytometry and in monolayers in the presence and absence of the different drugs.

RESULTS

From the tested six H1-receptor blockers, seven beta-adrenergic antagonists, four analgesics, ten diuretics and five quinolons, five drugs inhibited Pgp at therapeutic blood levels and two at somewhat higher concentrations. Significant synergism for blocking Pgp could be demonstrated for several drugs.

CONCLUSION

We conclude that administration of several drugs which modulate the function of Pgp to patients may adversely affect the natural function of this efflux pump and may cause drug-drug interactions induced side effects.

Activation of c-Jun NH2-terminal kinase/stress-activated protein kinase (JNK/SAPK) is critical for hypoxia-induced apoptosis of human malignant melanoma

Mitogen-activated protein kinase (MAPK) signaling was examined in malignant melanoma cells exposed to hypoxia. Here we demonstrate that hypoxia induced a strong activation of the c-Jun NH2-terminal kinase (JNK), also termed stress-activated protein kinase (SAPK), in the melanoma cell line 530 in vitro. Other members of the MAPK family, e.g., extracellular signal-regulated kinase and p38, remained unaffected by the hypoxic stimulus. Activated JNK/SAPK could also be observed in the vicinity of hypoxic tumor areas in melanoma metastases as detected by immunohistochemistry. Functional analysis of JNK/SAPK activation in the melanoma cell line 530 revealed that activation of JNK/SAPK is involved in hypoxia-mediated tumor cell apoptosis. Both a dominant negative mutant of JNK/SAPK (SAPKbeta K-->R) and a dominant negative mutant of the immediate upstream activator of JNK/SAPK, SEK1 (SEK1 K-->R), inhibited hypoxia-induced apoptosis in transient transfection studies. In contrast, overexpression of the wild-type kinases had a slight proapoptotic effect. Inhibition of extracellular signal-regulated kinase and p38 pathways by the chemical inhibitors PD98058 and SB203580, respectively, had no effect on hypoxiainduced apoptosis. Under normoxic conditions, no influence on apoptosis regulation was observed after inhibition of all three MAPK pathways. In contrast to recent findings, JNK/SAPK activation did not correlate with Fas or Fas ligand (FasL) expression, suggesting that the Fas/FasL system is not involved in hypoxia-induced apoptosis in melanoma cells. Taken together, our data demonstrate that hypoxia-induced JNK/SAPK activation appears to play a critical role in apoptosis regulation of melanoma cells in vitro and in vivo, independent of the Fas/FasL system.

Plasma angiotensin II, renin activity and serum angiotensin-converting enzyme activity in non-insulin dependent diabetes mellitus patients with diabetic nephropathy

The renin-angiotensin system (RAS) has been unequivocally implicated as a mediator of diabetic complications. The present study was designed to evaluate the RAS in non-insulin dependent diabetic patients with diabetic nephropathy. Plasma renin activity, plasma angiotensin II and serum angiotensin-converting enzyme (ACE) activity were measured in 45 non-insulin dependent diabetes mellitus (NIDDM) patients and 15 healthy non-diabetic controls. Diabetics were subdivided into 15 normoalbuminuric NIDDM subjects, 15 NIDDM patients with microalbuminuria and 15 diabetics with macroalbuminuria. Mean plasma renin activity for macroalbuminuric diabetics (0.65+/-0.10 ng/ml/hr) was significantly reduced than the controls (1.28+/-0.37 ng/ml/hr) (P<0.001), the diabetic group with microalbuminuria (1.08+/-0.48 ng/ml/hr) (P<0.05) and normoalbuminuric patients (1.56+/-0.82 ng/ml/hr) (P<0.001). A significant negative correlation was obtained between serum creatinine and plasma renin activity (r=-0.842, p<0.001) in macroalbuminuric NIDDM patients. Plasma angiotensin II was significantly decreased in non-complicated diabetics compared to healthy controls (4.36+/-1.49 pg/ml vs 14.87+/-3.48 pg/ml respectively, p<0.001). Non-insulin dependent diabetic patients with nephropathy had significantly higher plasma angiotensin II levels (28.99+/-5.88 pg/ml) than non-complicated diabetics (p<0.001). Serum ACE activity was increased in 53.3% of NIDDM patients. All diabetic groups showed increased serum ACE activity (normoalbuminuric NIDDM 114.9+/-28.3 nmol/min/ml, microalbuminuric NIDDM 127.9+/-31.2 nmol/min/ml and macroalbuminuric NIDDM 127.0+/-29.3 nmol/min/ml) when compared to the normal control group (76.3+/-16.5 nmol/min/ml) (p<0.001). No significant difference in serum ACE activity was obtained between normoalbuminuric and nephropathic diabetics or between diabetics with and without retinopathy. No significant correlation was obtained between serum ACE activity and blood pressure, blood glucose level and duration of diabetes. Thus plasma renin activity is decreased in diabetic nephropathy and negatively correlates with serum creatinine. Plasma angiotensin II is decreased in normoalbuminuric diabetics and elevated in diabetic nephropathy. Serum ACE activity is raised in NIDDM patients with no relation to albumin excretion rate. The role of increased ACE activity in NIDDM remains to be established.

Influence of antipsychotic, antiemetic, and Ca(2+) channel blocker drugs on the cellular accumulation of the anticancer drug daunorubicin: P-glycoprotein modulation

We investigated the effect of antiemetic, antipsychotic, and Ca(2+) blocker drugs on the function of P-glycoprotein (Pgp) in vitro and compared inhibitory concentrations with therapeutic blood levels. Human colon adenocarcinoma (Caco-2) and human blood-brain barrier endothelial cells were transfected or transduced to express Pgp, and the uptake of rhodamine123, calcein AM, or daunorubicin was measured by flow cytometry in the presence of the drugs. NIH3T3/MDR1 cells were used for reference testing. Results of the flow cytometric studies were supported by cell proliferation and monolayer permeability studies. Thirty-five drugs are included in this study, of which 13 modulate the function of Pgp at the therapeutic blood concentration and 8 at a concentration 2 to 4 times higher. Two drugs, which block the function of Pgp only partially at therapeutic blood concentrations, blocked the function of Pgp completely if used concomitantly. Based on these in vitro experiments, we conclude that administration of several drugs that modulate the function of Pgp simultaneously may adversely affect the natural function of this efflux pump and may cause drug-induced side effects in patients.

Immunophenotypes in adult acute lymphocytic leukemia. Role of flow cytometry in diagnosis and monitoring of disease

Flow cytometry has revolutionized the study of hematopoietic cells. Immunophenotyping by multiparameter flow cytometry supplements conventional morphologic diagnosis by providing information on cell lineage and differentiation in ALL and helps monitor disease by improving sensitivity in detecting minimal residual disease. The use of multiple MoAbs and multicolor study by flow cytometry has revealed heterogeneity among ALL and mixed-lineage acute leukemia, which are assigned to the same diagnostic categories by morphology. As technology has improved, clinical and research applications of flow cytometry have expanded to include evaluation of nuclear markers, oncogene proteins, apoptosis, cytokine receptors, and drug resistance. Expanded identification of MoAbs against leukemia-specific markers and the use of QFCM be a significant in managing patients with ALL in the future. In addition, flow cytometry and flow cytometric sorting will be combined more and more with other technologies, such as molecular probing or fluorescence in situ hybridization (FISH). The sorting of rare malignant cells based on immunophenotype and subsequent confirmation by PCR or FISH has already been proven feasible. Ultimately, it is hoped that further definition of subgroups of ALL by immunophenotyping using prognostically significant markers and the use of hybrid technologies of flow cytometry and molecular analysis or cytogenetics will improve treatment strategies for patients with ALL.

11q23 abnormalities in patients with acute myelogenous leukemia and myelodysplastic syndrome as detected by molecular and cytogenetic analyses

11q23 chromosomal abnormalities and rearrangement of the mixed lineage leukemia (MLL) gene are important prognostic factors in acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS). However, the presence of 11q23 abnormalities does not always correlate with that of MLL gene rearrangement. We retrospectively compared the occurrence of 11q23 abnormalities (measured by karyotyping) and MLL gene rearrangement (measured by Southern blotting) in bone marrow from 311 consecutive adult patients with AML or MDS. 11q23 abnormalities were found in 18 patients (5.8%), of whom 7 (39%) did not have the MLL gene rearrangement. MLL gene rearrangement was detected in 35 patients (11.2%). Of these 35 patients, only 11 (31%) had cytogenetic evidence of 11q23 abnormalities. None of the 21 patients with chronic myelomonocytic leukemia had 11q23 abnormalities or MLL gene rearrangement. 11q23 abnormalities were associated with shorter survival than was a diploid karyotype. Both cytogenetic and molecular studies should be performed to detect 11q23 abnormalities in patients with AML or MDS.

Osteopoikilosis--a case report

Osteopoikilosis is a rare, inheritable, sclerosing bone dysplasia; sometimes mistaken for osteoblastic bone metastases. We report a case in a 25 year-old lady.

HUKM instrumentation system in surgical treatment of adolescent idiopathic scoliosis--an early experience

Between May 1992 through October 1998, twenty-two patients who had adolescent idiopathic scoliosis were treated using Universiti Kebangsaan Malaysia (UKM) spinal instrumentation and fusion. The minimum length of follow-up was 2 years with an average of 2.9 years. Nineteen patients were female and three patients were male. The mean age at the time of the operation was 16.2 years (range, 13 to 24 years). The average blood loss was 1,878 ml and the average operating time was 291 minutes. The mean pre-operative curve was 61.2 degrees, with a range of 40 degrees to 90 degrees. The average post-operative correction of the Cobb's angle was 53.5 per cent, with a range of 33 per cent to 81 per cent. Post-operative immobilization consisted of a maximum of six months in a body cast. There were no neurological injuries, no deep wound infections, and no evidence of pseudoarthroses. Only three complications occurred and these did not disturb the progress of the fusion. This technique safely achieves the objectives of scoliosis correction, and is cost-effective in the treatment of adolescent idiopathic scoliosis.

Tuberculosis of the distal end of the radius mimicking a giant-cell tumour

We report a case of a lady presenting with a lesion in the distal radius with classical radiological features of a giant-cell tumour. These tumours are often resected without preliminary histological confirmation. A biopsy done in this patient showed it to be tuberculosis.

Proximal third femoral shaft fractures in children: prevention of angular deformities using bilateral Thomas splints

This is a prospective study to look at the outcome of unilateral proximal third femoral shaft fractures in children treated with a bilateral Thomas splint in the Department of Orthopaedic Surgery Universiti Kebangsaan Malaysia between the period of January 1996 and June 1998. Eighteen children aged between 2 years and 12 years old with unilateral proximal third fractures of the femoral shaft were treated using a bilateral Thomas splint. Angular deformities were measured using a goniometer metric scale before and after Thomas splints. The percentage of varus tilt corrected ranged from 17% to 72% with an average correction of 29% from the initial deformity and the difference was statistically significant (p < 0.05). The percentage of posterior tilt corrected ranged from 19% to 60% with the average correction of 20% from the initial deformity. The difference was statistically significant (p < 0.05). From this study, we conclude that bilateral Thomas splints can give a better correction of angular deformity for proximal third femoral shaft fractures in children below twelve years of age.

Trypanocidal activity of organotin chlorides on Trypanosoma brucei-infected mice

The organotin compounds dibutyltin (DBTC) and diphenyltin dichlorides (DPTC) were tested for trypanocidal activity on a Trypanosoma brucei-infected mice model. At a dose of 10 mg DBTC and 15 mg DPTC/kg/day for five consecutive days, they cleared the parasites from the peripheral blood of the infected mice. Subinoculation of some healthy mice with the homogenates of liver, spleen, kidney, cerebrospinal fluid and blood from the mice considered cured, showed a few cases of relapse. The LD50 of DBTC and DPTC are 90 mg/kg and 75 mg/kg respectively.

Clinical pharmacology studies in patients with renal impairment: past experience and regulatory perspectives

The objective of this report is to provide a regulatory perspective on the quality of pharmacokinetic studies in renal impairment (RI) studies submitted in support of new drug applications (NDAs) or supplements to NDAs (sNDAs) submitted to the Food and Drug Administration (FDA). Fifty-one NDA and 20 sNDA submissions reviewed between 1996 and 1997 by the Office of Clinical Pharmacology and Biopharmaceutics were evaluated for the following: (1) whether an RI study was conducted; (2) contribution of the renal clearance to the overall clearance in subjects without renal impairment; (3) degree of plasma protein binding (%PB) in subjects without renal impairment; (4) dose proportionality of single and multiple doses; (5) study design, including dosing regimen; (6) definition of renal impairment; (7) stratification of renal functions; (8) number of subjects/group; (9) data analysis and interpretation; and (10) impact on labeling. Results of the analysis indicated that 67% of the NDAs and 30% of supplemental NDAs contained RI-studies (34/51 for NDAs and 6/20 for sNDAs). No obvious differences in the pharmacokinetic characteristics (e.g., percentage excreted unchanged in urine and %PB) were observed between drugs for which RI studies were conducted versus those not conducted. Most studies conducted were designed as single dose (70%). Seventy-five percent of the studies used doses within the therapeutic dosage range of the drug. The measured 24-hour creatinine clearance was most often used to assess the renal function. Stratification of renal function ranged from one to five groups, with 6 to 8 subjects enrolled per group. In most studies conducted (38/40), data were analyzed by point estimate using ANOVA. Results of RI studies were adequately reflected in the labeling. The survey reveals that RI study design can be improved for regulatory review purposes. In part based on this analysis, the FDA has prepared a guidance that provides recommendations on the design, analysis, and impact on dosing and labeling for RI studies to include recommendations on when RI studies do not need to be performed. The guidance proposes an equivalence approach with confidence intervals, as opposed to a point estimate approach, to assess the impact of RI on systemic exposure measures.

The accuracy of urinary cytology in daily practice

BACKGROUND

Most studies of urinary cytology have been research analyses designed to test the method itself, and many claim that the high diagnostic yields in these studies cannot be achieved in daily practice. The authors examined the clinical and pathologic records in three hospital pathology practice settings--academic, community, and cancer referral settings--to determine the diagnostic yield of urinary cytology under daily clinical conditions.

METHODS

Records of consecutive urinary cytology specimens from 1672 patients reported from the years 1990-1994 were reviewed and correlated with histologic and clinical information. Initial analyses were based on the records themselves, without review of pathologic specimens. Subsequently, a subset of specimens was reviewed to determine reasons for noncorrelations.

RESULTS

Results confirmed that the diagnostic sensitivity and specificity of urinary cytology for high grade transitional cell neoplasms, as reported in the daily practice of pathology, are very high (79% and >95%, respectively). Disaggregated cells from low grade transitional cell neoplasms usually lack recognizable features of neoplasia, and attempts to classify such lesions cytologically result in low diagnostic yield, with an overall sensitivity of 26%. Of these 1672 patients, 707 had insufficient clinical information for analysis, despite diligent and persistent efforts to acquire it.

CONCLUSIONS

The diagnostic yield of consultations based on urinary cytology in the daily practice of pathology is high, regardless of whether the practice setting is referral-based or community-based. The available information indicates that in approximately 79% of patients with high grade transitional cell neoplasms, the neoplasms can be detected using urinary cytology. Conversely, a negative result is predictive of no cancer in more than 90% of cases. Sensitivity for detecting low grade urothelial lesions is low; however, most of these are easily detected cystoscopically. The authors' inability to acquire sufficient information to determine diagnostic yield in a large percentage of their cases was disturbing to them. Not only did this deficiency render their analyses incomplete, but lack of easily accessible follow-up and the apparent low priority for quality assurance activities among pathologists in all types of practice settings is likely to significantly reduce the feedback required for pathologists to acquire and maintain expertise in this very difficult area.

Osteosarcoma in a sixteen-month old boy

We report a case of a sixteen-month old boy with osteosarcoma of the left humerus. To the best of our knowledge this is the youngest case reported in Malaysia. This case illustrates that osteosarcoma although rare does occur in a very young child. The child died six weeks after presentation due to disseminated disease.

A new minimally invasive technique to show nerve ischaemia in diabetic neuropathy

AIMS/HYPOTHESIS

Experimental studies have shown that abnormalities of nerve microcirculation are important factors in the pathogenesis of diabetic neuropathy but there have been few clinical studies. We have applied microlightguide spectrophotometry to measure intravascular oxygen saturation (HbO2%) and blood flow in human sural nerve.

METHODS

We studied ten patients with mild-moderate sensory motor diabetic neuropathy, nine patients without neuropathy and nine control subjects. We took 300 measurements of oxygen saturation under direct visual control through a 1.9 mm rigid endoscope over three regions of the nerve. Spectrophotometric measurements of nerve fluorescence were taken after an intravenous injection of sodium fluorescein and the rate of increase in nerve fluorescence (rise time) was used as an indicator of nerve blood flow.

RESULTS

Nerve oxygen saturation was reduced in patients with neuropathy compared with control subjects (67.1 +/- 2.2% vs 76.7 +/- 2.1%, p = 0.006). Fluorescein rise time was prolonged in patients with neuropathy compared with the control group (48.5 +/- 7.0 s vs 14.0 +/- 3.1 s, p = 0.001) suggesting impaired nerve blood flow. There was a correlation between rise time, nerve oxygen saturation, glycaemic control and sural nerve sensory conduction velocity (p < 0.01).

CONCLUSION/INTERPRETATION

The combination of microlight-guide spectrophotometry and micro-endoscopy provides a valuable minimally invasive technique for clinical investigation of nerve microcirculation. We have shown reduced nerve oxygenation and impaired blood flow in diabetic neuropathy and these findings strongly support a central role of microvascular disease in the pathogenesis of diabetic neuropathy.

Combined microlightguide spectrophotometry and microendoscopy for measurement of oxygen saturation in peripheral nerves

Microlightguide measurements of the spectral composition of backscattered light may be used to determine local tissue oxygen saturation and monitor tissue perfusion using intravenous injection of fluorescein dye as a contrast agent. We have used a combination of microlightguide spectrophotometry and microendoscopy to measure intravascular oxygen saturation (HbSaO2%) and monitor blood flow in the sciatic nerve of 12 healthy male Sprague-Dawley rats. The microlightguide and endoscope combination is a relatively new measurement technique. The aims of this study were to determine whether microlightguide spectrophotometry and microendoscopy could be used to measure HbO2 and blood flow in peripheral nerves and to compare the measurements made using the flexible lightguide with the endoscope-lightguide combination. We found no significant difference between the two types of measurement over similar regions of the nerve. mean SaO2% values 77.1% (95% CI = 75.4-78.8) and 78.8% (95% CI = 77.5-80.1) respectively. During a period of hypoxia there was a similar fall in both arterial and nerve oxygen saturation. Following injection of fluorescein, the rate of increase in nerve fluorescence was used as a measure of perfusion. The combination of microlightguide spectrophotometry and microendoscopy allows the exact site of measurement to be directly visualized. The minimally invasive nature of this technique may allow its application to the study of peripheral nerves in human subjects in conditions such as diabetic neuropathy where vascular factors are thought to have an important role in aetiology.

Therapeutic strategies against epilepsy in Mediterranean countries: a report from an international collaborative survey

A collaborative survey was performed to compare prescribing strategies for the treatment of epilepsy in Mediterranean countries, based on analysis of 500 questionnaires compiled by physicians in 14 different countries. For partial seizures, carbamazepine was the drug of choice in most countries, whereas the second choice of drug differed widely. For primarily generalized tonic-clonic seizures, valproic acid was usually preferred, but other drugs used widely in some countries included phenobarbital, phenytoin and carbamazepine. Lamotrigine was the most popular second-line drug for primarily generalized tonic-clonic seizures in the European countries. In patients where the initial drug failed, switching to an alternative monotherapy was usually the preferred strategy, but advocates of early use of combination therapy exceeded 30% in the respondents of seven countries. Most respondents, in all countries except Turkey, did not prescribe drugs to prevent recurrence of febrile seizures; however, intermittent prophylaxis with a benzodiazepine was advocated by a considerable number of physicians, and continuous prophylaxis was prescribed by a significant minority of respondents in France, Syria and Tunisia. New drugs were rarely used as first-line treatment due to high cost and inadequate experience. Overall, this survey indicates that there is a wide variability in therapeutic practices between and within countries. This information may be useful for the implementation of national educational activities and for the design of pragmatic trials aimed at comparing different therapeutic strategies.

Prospective, randomized trial comparing pain and complications between diathermy and scissors for closed hemorrhoidectomy

PURPOSE

The aim of this study was to assess pain and complication rates after closed hemorrhoidectomy with the use of either scissors or diathermy excision.

METHODS

Ninety-one consecutive patients were prospectively randomly assigned by use of sealed envelopes to Group A (diathermy dissection; n = 44) or Group B (scissors dissection; n = 47). The resulting hemorrhoidal pedicle after hemorrhoidal dissection was transfixed and buried under the mucosa, which was closed with 3-0 chromic catgut.

RESULTS

The median time taken for surgery was ten minutes in both groups. The range for Group A was 5 to 25 minutes, and the range for Group B was 5 to 20 minutes. There were no statistically significant differences in the pain scores between the two groups for any of the seven postoperative days studied. The median number of pethidine injections in Group A was 1 and in Group B was 0 (P < 0.009). The number of oral analgesic tablets used was 8 (range, 4-10) and 14 (range, 0-10) for Groups A and B, respectively (P < 0.001). The number of tubes of topical lignocaine jelly used was 14 (range, 0-22) and 14 (range, 7-88) in Groups A and B, respectively. Two patients in each group developed secondary hemorrhage, but no patient had anal stricturing.

CONCLUSION

No excessive complications are seen with closed hemorrhoidectomy, and diathermy seems to require less postoperative analgesic medicine than scissors for closed hemorrhoidectomy except in the first 24 hours.

Ultrasound-detected hepatic periportal thickening in patients with prolonged pyrexia

Hepatic periportal thickening (HPT) detected by ultrasonography has been established as a reliable tool for measuring hepatic morbidity due to schistosomiasis. During ultrasonographic examination of patients with prolonged pyrexia, we frequently noticed minimal grades of HPT in patients without a history of schistosomiasis. This led to ultrasonographic studies of conditions other than schistosomiasis in which HPT may occur. Subjects included 460 patients with Schistosoma haematobium infection, 107 urban patients with prolonged pyrexia without previous exposure to schistosomiasis, and 288 healthy controls unexposed to schistosomiasis. Grade I HPT was more prevalent (P < 0.001) in patients with pyrexia (56.1%) than in those with S. haematobium (32.2%) and was more frequent (P < 0.001) in patients with S. haematobium than in controls (11.1%). Typhoid fever was the most common febrile illness causing HPT. Grade II lesions were rare in patients with pyrexia (2.8%) or schistosomiasis (0.9%). Grade III lesions were present in only one patient with S. haematobium. Mild grades of HPT can occur in infectious diseases other than schistosomiasis. Cellular infiltration in the portal tract from chronic infectious diseases can frequently give the ultrasonographic appearance of grade I HPT.

[Unverricht-Lündborg disease: clinical and electrophysiologic study of 19 Maghreb families]

We describe clinical, electrophysiological and genetic features in 44 patients with Unverricht-Lündborg disease from 19 families living in North African countries (Tunisia, Algeria and Morocco). The mean age of patients was 25.3 years; mean age was at onset 11.3 years. The disease began more frequently with seizures (91 per cent) or myoclonus (80 p. 100) than ataxia (16 p. 100). Subsequently myoclonus and generalized seizures were present in all patients, cerebellar signs were absent in four cases. EEG findings included normal background activity (90 p. 100), spontaneous fast generalized spikes (93 p. 100) and photosensitivity (70 p. 100). Antiepileptic polytherapy (clonazepam and/or phenobarbital and/or valporic acid) was used in 84 per cent of cases. Antiepileptic drugs were more effective in controlling epileptic seizures (less than one seizure/month in 60 p. 100) than myocloni which persisted daily in 64 p. 100 of cases. Mean duration of the disease was 13.5 years. One patient died of status epilepticus. Consanguinity was noted in 17 families (first degree in 15 families). Linkage to chromosome 21q 22.3 was confirmed in 11 families. We noted an inter and intrafamilial variability of clinical signs and disease course.

A PCR amplification method reveals instability of the dodecamer repeat in progressive myoclonus epilepsy (EPM1) and no correlation between the size of the repeat and age at onset

Progressive myoclonus epilepsy of the Unverricht-Lundborg type (EPM1) is a rare, autosomal recessive disorder characterized by onset at age 6-16 years, generalized seizures, incapacitating myoclonus, and variable progression to cerebellar ataxia. The gene that causes EPM1, cystatin B, encodes a cysteine proteinase inhibitor. Only a minority of EPM1 patients carry a point mutation within the transcription unit. The majority of EPM1 alleles contain large expansions of a dodecamer repeat, CCC CGC CCC GCG, located upstream of the 5' transcription start site of the cystatin B gene; normal alleles contain two or three copies of this repeat. All EPM1 alleles with an expansion were resistant to standard PCR amplification. To precisely determine the size of the repeat in affected individuals, we developed a detection protocol involving PCR amplification and subsequent hybridization with an oligonucleotide containing the repeat. The largest detected expansion was approximately 75 copies; the smallest was approximately 30 copies. We identified affected siblings with repeat expansions, of different sizes, on the same haplotype, which confirms the repeat's instability during transmissions. Expansions were observed directly; contractions were deduced by comparison of allele sizes within a family. In a sample of 28 patients, we found no correlation between age at onset of EPM1 and the size of the expanded dodecamer. This suggests that once the dodecamer repeat expands beyond a critical threshold, cystatin B expression is reduced in certain cells, with pathological consequences.

A Shannon entropy analysis of immunoglobulin and T cell receptor

In 1970, before any antigen-bound immunoglobulin structure had been solved, Elvin Kabat proposed that regions of high amino acid diversity would be the antigen binding sites of immunoglobulin (Kabat, 1970). Conversely, sites of low variability were proposed to be structural, framework regions. This variability was defined by Wu and Kabat as the number of different amino acids found at a site divided by the relative frequency of the most common amino acid at that site (Wu and Kabat, 1970). Several groups have subsequently devised improvements of Kabat-Wu variability analysis (Litwin and Jores, 1992). While these methods are somewhat better than Kabat-Wu, they still suffer from Kabat-Wu's basic limitation: they account for only the most common one or two amino acids in estimating diversity. This leads to underestimates of low diversities and exaggerations of high diversities. Shannon information analysis eliminates serious bias and is more stable than Kabat-Wu and second generation measures of diversity (Jores et al. 1990; Wu and Kabat, 1970). Statistical reliability can be measured using Shannon analysis, and Shannon measurements can be provided with error estimates. Here we use Shannon's method to analyze the amino acid diversity at each site of T cell receptor Valpha and Vbeta to identify complementarity determining regions and framework sites. Our results reveal that the T cell receptor is significantly more diverse than immunoglobulin-suggesting T cell receptor has more than the previously-discovered four complementarity determining regions. These new complementarity determining regions may represent a larger antigen combining site, additional combining sites, or an evolutionary strategy to avoid inappropriate interaction with other molecules.

Evaluation of an ultrasonographic score for urinary bladder morbidity in Schistosoma haematobium infection

An ultrasonographic urinary bladder morbidity score was developed and tested in 510 patients with schistosomiasis haematobia, and then evaluated for screening 1,134 randomly selected children from villages endemic for Schistosoma haematobium. The ultrasonographic urinary bladder morbidity score had four grades ranging from normal to marked thickening of the urinary bladder wall or any polyps or masses. Among both patients and randomly screened subjects, the ultrasonographic score was greater (P = 0.01 and P < 0.01) in males than in females. Children examined in the clinic had higher (P = 0.03) ultrasonographic scores than adults. Infected subjects in communities were more likely (P < 0.001) to have urinary bladder morbidity than uninfected subjects, and clinic patients with egg counts > or = 20 eggs/10 ml of urine had higher (P = 0.03) ultrasonographic urinary bladder morbidity scores than those with lighter infections. The geometric mean egg count was higher (P = 0.04) in clinic patients with grade II and III lesions than in those with grade 0 and I lesions. There was progressive improvement of the grade of urinary bladder morbidity scores in patients treated with praziquantel at each follow-up examination (P < 0.001) and there was a positive relationship (P < 0.01) between urinary bladder morbidity scores and ultrasonographic-detected renal back pressure changes. The ultrasonographic urinary bladder morbidity score objectively measured the severity of urinary bladder morbidity and correlated with intensity of S. haematobium infection in our subjects. It can be used in evaluating both morbidity in patients and in community surveys and in following the outcome of chemotherapy.

Identification of nucleotide sequences that regulate transcription of the MCF13 murine leukemia virus long terminal repeat in activated T cells

The region downstream of the enhancer (DEN) of the long terminal repeat of the mink cell focus-forming murine leukemia virus is important for viral pathogenicity. Another important activity of DEN is its control of transcription in activated T cells, and we have determined that an NF-kappaB site is critical for this activity.

Evaluation of doctors trained at Diarrhoea Training Unit of National Institute of Child Health, Karachi

Diarrhoeal diseases are a major contributory factor for high infant mortality and morbidity in Pakistan. To overcome this, Government of Pakistan launched a National Programme for Control of Diarrhoeal Disease. A Diarrhoea Training Unit (DTU) was established at the National Institute of Child Health, Karachi, where apart from proper case management, 17 training workshops were held between July, 1989 to July, 1991. Eighty-five doctors from various facilities in Sindh were trained in proper management of diarrhoea and establishment of Oral Rehydration Therapy (ORT) units in their regions. Evaluation of DTU training, assessment of the knowledge of trained doctors, case management and function of ORT Units were done between September, 1992 and October, 1993. Two teams each consisting of a doctor and a lady health visitor, visited 30 such facilities. An observation check list was used for assessing the ORT unit and diarrhoea case management and a test questionnaire for the knowledge of facility physician and paramedic. Of the 29 facilities, 17 had DTU trained doctors. ORT corner had been established in 26, weighing scales were used in 21, record keeping in eight and soap and water was available for hand washing in seven centres. The presence of untrained doctors provided an opportunity to compare the two groups. Dehydration assessment was fairly good, weight was recorded in fewer cases than desirable, case management was similar in the two groups, except for infrequent use of antibiotics by the trained group. Prevention was poorly advised. Physicians' knowledge in both groups was similar but deficient in advising the use of ORS, feeding in diarrhoea and nutritional assessment. The trained ones had significantly better knowledge about drugs and this was reflected in their case management. Paramedic case management were similar to those in doctors. The study thus showed positive and beneficial effects of training.

Sagodana based verses rice based oral rehydration solution in the management of acute diarrhoea in Pakistani children

This study was carried out to compare the efficacy of a cereal based ORS (prepared with 50 G of sagodana (cereal), 3.5 G/L sodium chloride, 1.5 G/L potassium chloride, 2.9 G/L trisodium citrate) with rice based oral rehydration solution (using same amounts of rice and electrolytes) for treatment of diarrhoea. One hundred and twelve children aged 3 months to 2 years with watery diarrhoea of less than 5 days duration with mild to moderate dehydration and no sepsis, were included in the study. The amount of ORS intake, stool volume and frequency were similar in both groups. Clinical success was seen in 79% of rice ORS group and 81% in sagodana group. Both can be used as a cereal based ORS in the management of acute diarrhoea in communities where it is culturally accepted and used as a weaning diet.

CTLA4Ig inhibits alloantibody responses to repeated blood transfusions

Allosensitization is a fundamental problem that limits the effectiveness of blood transfusions. Patients who receive multiple transfusions of blood or blood components frequently develop alloantibodies against donor alloantigens. Allosensitized patients are refractory to further transfusion and difficult to transplant successfully. CTLA4Ig fusion protein, which blocks the CD28-B7 costimulatory pathway in T-lymphocyte activation, was tested for its capacity to inhibit allosensitization to blood transfusions. Groups of LEW (RT1') rats were transfused with ACI blood (RT1a) together with L6 (a human immunoglobulin G1 [IgG1] antibody as isotype control) or CTLA4Ig in different doses (0.004, 0.02, 0.1, and 0.5 mg). Rats were retransfused with ACI blood after 28 and 84 days without any additional CTLA4Ig therapy. Weekly sera samples were tested for alloantibody against donor leukocytes using flow cytometry. CTLA4Ig caused a dose-dependent decrease in the IgM alloantibody response against donor major histocompatibility complex (MHC) class I antigens. In addition, 0.02-, 0.1-, and 0.50-mg doses of CTLA4Ig totally inhibited the IgG responses to the first transfusion, and this immunosuppressive effect persisted for the second and third transfusions. To study the capacity of CTLA4Ig to prevent a secondary immune response, three groups of LEW rats were transfused with ACI blood with no accompanying treatment. Animals were retransfused 28 days later with ACI blood together with L6 control antibody or 0.5 or 2.5 mg CTLA4Ig. CTLA4Ig, but not L6, prevented an increase in IgG alloantibody response despite repeated transfusions. The effects of CTLA4Ig treatment on helper T-lymphocyte proliferation was tested by limiting dilution analysis (LDA). Peripheral blood cells taken 30 days after blood transfusion and CTLA4Ig treatment contained significantly decreased donor-specific T-lymphocyte precursors compared with L6-treated rats. These data support the idea that blocking the B7/CD28 signal of T-lymphocyte activation by CTLA4Ig treatment at the time of transfusion may be an important therapeutic tool to inhibit alloantibody responses to blood transfusions.

Immunohistochemical manifestations of unilateral kidney ischemia

Events in the early post-transplant period have been correlated with increased renal allograft loss. Immunologic reactions and ischemic injury have been implicated in this process. While the immunologic aspects of allograft injury have been studied extensively, ischemic effects remain less well understood. To study the effects of ischemia in rats with different genetic backgrounds without the introduction of an alloimmune response, a clamp was placed on the vascular pedicle of the left kidney for 60 min. The short-term effects (1 wk) of ischemia were studied in groups of PVG (RT1c), LEW (RT1), DA (RT1a) and WR (RT1u) rats, Immunoperoxidase staining demonstrated limited infiltration of monocytes, macrophages, and T-cells accompanied by upregulation of low levels of MHC class II antigens on tubular epithelial cells, peritubular capillaries, and interstitial cells in kidneys of PVG and WF rats. Kidneys of LEW and DA rats had greater influxes of monocytes, macrophages, and T cells in addition to higher amounts of MHC class II antigens upregulation on tubular epithelium and interstitial cells. The long-term effects of ischemia were studied in kidneys of WF rats. These kidneys had a progressive increase in infiltrating T cells, monocytes, macrophages and MHC class II expression on the tubular epithelium and the interstitial cells at 14, 30, and 90 d after the ischemic insult. The differences in MHC class II expression between ischemic kidneys of PVG and LEW rats were not associated with differences in production of mRNA for IL-2, IFN-gamma, and TNF-alpha. In summary, transient renal ischemia in the absence of an allogeneic immune response triggers a progression of inflammatory responses, including leukocyte infiltration, cytokine production and MHC class II antigen upregulation which appears to be strain-dependent.

Inhibition of complement, evoked antibody, and cellular response prevents rejection of pig-to-primate cardiac xenografts

Complement (C) inhibition alone using a recombinant soluble form of complement receptor type 1 (sCR1) prevents hyperacute rejection but not subsequent irreversible accelerated acute rejection of discordant pig-to-cynomolgus monkey cardiac xenografts, which occurs within 1 week. To inhibit accelerated acute rejection, which is associated with a rise in serum xenoreactive antibody (Ab) and a cellular infiltrate, triple therapy with standard immunosuppressive agents (cyclosporine, cyclophosphamide, and steroids [CCS]) was combined with continuous C inhibition using sCR1. Each of two monkeys that received sCR1 + CCS showed minimal evidence of rejection when killed on days 21 and 32 in comparison to a monkey that received sCR1 + subtherapeutic CCS (rejected at 11 days) and a control that received CCS alone (rejected at 38 min). Prolonged xenograft survival was associated with low Ab levels and a minimal cellular infiltrate, suggesting that combined inhibition of C, xenoreactive Ab responses, and cellular immunity may be a useful approach in overcoming the immune barriers to discordant xenotransplantation.

Chronic venous insufficiency: mechanisms and management

CVI is a common disease with significant morbidity that results from venous hypertension of the extremities. Increased perfusion pressure probably traps excessive numbers of white blood cells in the capillaries. Activated leukocytes subsequently damage capillary endothelium, increase capillary permeability, and cause ischemia of the overlying skin as a result of leakage of fibrinogen and formation of a fibrin cuff. Diagnosis of CVI is not difficult because its clinical manifestations are usually evident. Vascular compression therapy remains the foundation of medical management for CVI. Refractory cases may require a combined medical and operative approach.

Cytokine control of parasite-specific anergy in human urinary schistosomiasis. IL-10 modulates lymphocyte reactivity

Humans chronically infected with schistosomiasis usually have impaired parasite Ag-specific lymphocyte proliferation and IFN-gamma production that may facilitate persistence of the parasite while producing little clinical disease. The mechanisms that contribute to the immunologic hyporesponsiveness in these patients remain undefined. IL-10 has been shown to exert an inhibitory effect on cell-mediated immunity. To determine whether endogenous IL-10 has a role in regulating parasite-specific anergy in schistosomiasis, neutralizing anti-IL-10 added to PBMC from Schistosoma haematobium patients' enhanced adult worm (SWAP)- or egg Ag (SEA)-driven lymphocyte proliferation and/or IFN-gamma production by 2- to &gt;100-fold in 32 of 38 subjects. In contrast, anti-IL-10 failed to significantly augment the mycobacterial Ag, purified protein derivative (PPD)-driven lymphocyte proliferation, or IFN-gamma production in 9 or 10 of 14 individuals, respectively. SWAP or SEA triggered IL-10 release from PBMC of both patients and healthy individuals; however, CD4+ cells were a significant source of IL-10 only in infected subjects. PPD relative to SWAP induced fivefold less IL-10 release by CD4+ cells (p &lt; 0.01). A possible mechanism whereby IL-10 suppressed Ag-specific T cell responses was demonstrated by the ability of SWAP and not PPD to suppress B7 expression on PBMC. Anti-IL-10 completely inhibited the parasite Ag-induced down-regulation of B7 expression. These studies indicate that IL-10 contributes to parasite Ag-induced T cell hyporesponsiveness observed in patients with chronic schistosomiasis hematobia.

Cytokine control of parasite-specific anergy in human urinary schistosomiasis. IL-10 modulates lymphocyte reactivity

Humans chronically infected with schistosomiasis usually have impaired parasite Ag-specific lymphocyte proliferation and IFN-gamma production that may facilitate persistence of the parasite while producing little clinical disease. The mechanisms that contribute to the immunologic hyporesponsiveness in these patients remain undefined. IL-10 has been shown to exert an inhibitory effect on cell-mediated immunity. To determine whether endogenous IL-10 has a role in regulating parasite-specific anergy in schistosomiasis, neutralizing anti-IL-10 added to PBMC from Schistosoma haematobium patients' enhanced adult worm (SWAP)- or egg Ag (SEA)-driven lymphocyte proliferation and/or IFN-gamma production by 2- to >100-fold in 32 of 38 subjects. In contrast, anti-IL-10 failed to significantly augment the mycobacterial Ag, purified protein derivative (PPD)-driven lymphocyte proliferation, or IFN-gamma production in 9 or 10 of 14 individuals, respectively. SWAP or SEA triggered IL-10 release from PBMC of both patients and healthy individuals; however, CD4+ cells were a significant source of IL-10 only in infected subjects. PPD relative to SWAP induced fivefold less IL-10 release by CD4+ cells (p < 0.01). A possible mechanism whereby IL-10 suppressed Ag-specific T cell responses was demonstrated by the ability of SWAP and not PPD to suppress B7 expression on PBMC. Anti-IL-10 completely inhibited the parasite Ag-induced down-regulation of B7 expression. These studies indicate that IL-10 contributes to parasite Ag-induced T cell hyporesponsiveness observed in patients with chronic schistosomiasis hematobia.

Oil of bitter orange: new topical antifungal agent

BACKGROUND

Superficial dermatophyte infection is one of the most common dermatologic diseases. Some of these infections are extremely resistant to therapy.

METHODS AND PATIENTS

Sixty patients participated in this study; they were classified into three groups (20 patients in each). All groups had comparable numbers of patients with tinea corporis, cruris, and pedis. Group 1 was treated with a 25% emulsion of oil of bitter orange (OBO) three times daily; group 2 was treated with 20% OBO in alcohol three times daily and group 3 was treated with pure OBO, once daily. Clinical and mycologic examinations were performed before therapy and every week until a complete cure had occurred.

RESULTS

In group 1, 80% of patients were cured in 1 to 2 weeks and 20% in 2 to 3 weeks. In group 2, 50% were cured in 1 to 2 weeks, 30% in 2 to 3 weeks and 20% in 3 to 4 weeks. In group 3, 25% of patients did not continue the trial. Of the remaining patients, 33.3% were cured in one week, 60% in 1 to 2 weeks, and 6.7% in 2 to 3 weeks. Oil of bitter orange produced no side effects except mild irritation seen with the use of the pure form.

CONCLUSIONS

An in vitro study showed that OBO (natural product) exerts fungistatic and fungicidal activity against a variety of pathogenic dermatophyte species. It is a promising, cheap, and available topical antifungal therapeutic agent.

Dinoflagellate bloom in tropical fish ponds of coastal waters of the South China Sea

Red tide of dinoflagellate was observed in brackish water fish ponds of Terengganu along the coast of the South China Sea during the study period between January 1992 to December 1992. The nearby coastal moat water facing the South China Sea is the source of water for fish pond culture activities of sea bass during the study period. An examination of water quality in fish ponds during the study period indicated that both the organic nutrients were high during the pre-wet monsoon period. The source of the nutrients in coastal water was believed to be derived from the agro-based industrial effluents, fertilizers from paddy fields and untreated animal wastes. This coincided with the peak production of dinoflagellate in the water column in October 1992. The cell count ranges from 8.3 to 60.4×10.4×10(4)/l during the bloom peak period and the bloom species were compared entirely of non-toxic dinoflagellates with Protoperidinium quinquecorne occurring >90% of the total cell count. However, both cultured and indigenous fish species were seen to suffer from oxygen asphyxiation (suffocation due to lack of oxygen). The bloom lasted for a short period (4-5 days) with a massive cell collapse from subsurface to bottom water on the sixth day. The productivity values ranged from 5-25 C g/ l / h with a subsurface maximum value in October 1992. Two species of Ciliophora, Tintinnopsis and Favella, were observed to graze on these dinoflagellates at the end of the bloom period.

Factors Influencing Pyrethroid Resistance in a Permethrin-Selected Strain of the Soybean Looper, Pseudoplusia includens (Walker)

Cytochrome P450 monooxgenase activity toward p-nitroanisole was measured in larvae of three strains of soybean looper, Pseudoplusia includens (Walker), including a laboratory susceptible (S) strain, a resistant (R) strain selected for several generations with permethrin, and a nonselected (NS) strain from the same field collections as the R strain. Activity was significantly higher in R strain larvae than in the S and NS strains (1.8- and 1.4-fold, respectively), and there was no significant difference between activity in the S and NS strains. Resistance to the alpha-cyano pyrethroids deltamethrin and cypermethrin was similar to or higher than that observed with permethrin (RR = 70.0, 62.4, 145.3 and 12.1, 32.3, and 27.0 for permethrin, deltamethrin, and cypermethrin in R and NS strains, respectively). The R strain was less resistant (RR = 4.3) to tefluthrin, a pyrethroid with a fluorinated-phenyl alcohol moiety, and a nonester (ether) pyrethroid, BRC 429 (RR = 17.7). Piperonyl butoxide (PB) significantly increased the toxicity of each insecticide tested in the R and NS strains. In addition, penetration of 14C-cypermethrin was decreased significantly at 24 hr after treatment when R strain larvae were pretreated with PB, with 21.1% of the applied dose unpenetrated in PB-treated larvae and 7.6% unpenetrated in larvae not treated with PB.