Outcome of Pregnancy in Renal Allograft Recipients: SIUT Experience

The course of pregnancy and its outcome was studied in renal allograft recipients. Between November 1985 and November 2005, a total of 1481 renal transplants were carried out at the Sindh Institute of Urology and Transplantation (SIUT); among them were 348 females, with 73 potential females for pregnancy. All patients received cyclosporine and prednisolone, with 82% also receiving azathioprine and 4 patients mycophenolate mofetil as a third immunosuppressant drug. We evaluated incidence of hypertension, diabetes, pre-eclampsia, urinary tract infection (UTI), rejection during pregnancy and during 3 months' postdelivery as well as outcomes of pregnancy. Among 73 potential candidates, 31 had 47 pregnancies, after an average of 31 months (8-86 months). Of 31 subjects, 21 subjects were hypertensive on one or two drugs prior to conception. A rise in blood pressure during pregnancy was noticed in 7 patients. Albuminuria from trace to 3+ appeared in 13 patients and glycosuria in one other. Blood sugar levels remained within normal range in all subjects. UTIs occurred during pregnancy in 7 patients. Among 47 pregnancies, 9 had abortions (7 spontaneous, 2 therapeutic) and 6 had preterm deliveries. The others were full-term deliveries: 12 via a lower segment caesarean section and 20 were normal vaginal deliveries. Average birth weight was 4.8 lbs. At an average follow-up of 38 months the serum creatinine values ranged from 0.94 to 2.3 mg %. One patient developed acute irreversible graft dysfunction soon after delivery. Our study demonstrated that pregnancy did not reduce renal graft survival, but newborns are at greater risk of premature birth and low birth weight.

The MRI diagnosis and management of incomplete intertrochanteric fractures of the femur

Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively. The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p > 0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment.

A prognostic model for prolonged event-free survival after autologous or allogeneic blood or marrow transplantation for relapsed and refractory Hodgkin's disease

There are several prognostic models for Hodgkin's disease (HD) patients, but none evaluating patient characteristics at time of blood and marrow transplantation (BMT). We developed a prognostic model for event-free survival (EFS) post-BMT based on HD patient characteristics measured at the time of autologous (auto) or allogeneic (allo) BMT. Between 1/1991 and 12/2001, 64 relapsed or refractory HD patients received an auto (n=46) or allo (n=18) BMT. A multivariate prognostic model was developed measuring time to relapse, progression or death. Median follow-up was 51.7 months; median EFS for auto and allo BMT was 36 and 3 months, respectively (P=0.001). Significant multivariate predictors of shorter EFS were chemotherapy-resistant disease, KPS <90 and > or =3 chemotherapy regimens pre-BMT. Patients with two to three adverse factors had significantly shorter EFS at 2 years (58 vs 11% in auto; 38 vs 0% in allo BMT patients). Despite a selection bias favoring auto BMT, the model was valid in both auto and allo BMT groups. We were able to differentiate patients at high vs low risk for adverse outcomes post-BMT. This prognostic model may prove useful in predicting patient outcomes and identifying high-risk patients for novel treatment strategies. Validation of this model in a larger cohort of patients is warranted.

Sixteen years follow up of achalasia: a prospective study of graded dilatation using Rigiflex balloon

Pneumatic balloon dilatation is the treatment of choice for esophageal achalasia. Rigiflex (Microvasive, Watertown, MA) polyethylene balloon dilators have been used with varying success and complications. The aim of this study was to evaluate the efficacy of graded balloon dilatation, to achieve symptomatic improvement in patients with achalasia. From January 1987 until the end of December 2003, 300 patients were evaluated and treated for achalasia, with 30 mm balloons. Patients who did not achieve satisfactory symptomatic responses during follow up underwent repeat dilatation with 35-mm balloons. They were studied at the onset then at 1 and 6 month intervals and then yearly for postdilatation symptom evaluation for dysphagia, regurgitation, night cough and heartburn. Baseline and 5-min postdilatation barium swallow studies were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. No patients developed cancer of the esophagus in 16 years follow up. Barium height, width, composite symptom score and weight improved significantly during follow up. Two patients, who needed repeat dilatation with 35-mm balloons, developed esophageal perforation; one was successfully managed with intensive medical care management, whereas the other patient died despite surgical intervention. The authors conclude that pneumatic balloon (Rigiflex) dilatation for achalasia of the esophagus is a successful first option, when applied in an incremental balloon size to achieve desired results in symptomatic relief.

Rituximab in Combination With Fludarabine Chemotherapy in Low-Grade or Follicular Lymphoma

Purpose

To evaluate the safety and efficacy of fludarabine plus rituximab in treatment-naïve or relapsed patients with low-grade and/or follicular non-Hodgkin's lymphoma.

Patients and Methods

This was an open-label, single-arm, single-center phase II study enrolling 40 patients. During the first week of the study, patients received two infusions of rituximab 375 mg/m2 administered 4 days apart. Seventy-two hours after the second infusion of rituximab, patients received the first of six cycles of fludarabine chemotherapy (25 mg/m2/d for 5 days on a 28-day cycle). Single infusions of rituximab were administered 72 hours before the second, fourth, and sixth cycles of fludarabine, and two infusions of rituximab were given 4 weeks after the last cycle of fludarabine. Treatment duration was 26 weeks.

Results

An overall response rate of 90% (80% complete response rate) was achieved in the intent-to-treat population. Similar response rates were seen in treatment-naïve and previously treated patients. The median duration of response has not been reached at 40+ months. The median follow-up time in this study is 44 months (range, 15 to 66 months). In patients positive for the 14;18 translocation in blood and/or marrow at enrollment, molecular remission was achieved in 88% of cases, with patients remaining negative for up to 4 years to date. Hematologic toxicity was manageable, and except for a 15% incidence of herpes simplex/zoster infections, infectious complications were rare. Nonhematologic toxicities were minimal.

Conclusion

Rituximab plus fludarabine was well tolerated and associated with an excellent complete response rate, including molecular remissions, in patients with low-grade or follicular lymphoma.

Goezia bangladeshi n. sp. (Nematoda: Anisakidae) from an anadromous fish Tenualosa ilisha (Clupeidae)

A total of 1432 hilsa shad, Tenualosa ilisha (=Hilsa ilisha) from 11 fresh water, brackish water and marine localities in Bangladesh yielded 13 adult Goezia bangladeshi n. sp., all specimens being found in the intestine of a single fish host caught in the lower Ganges. A total of 2372 Goezia juveniles were recovered from 490 infected fish (prevalence 34.2%). This is the first Goezia species recorded from Bangladesh, and it differs from other valid species by the number of caudal papillae (pre 7-9, para 3, post 6); encircled by tiny spines, the position of double papillae, the arrangement of body spines, and the length ratio of the intestinal caecum and the ventricular appendix (1: 3.33-4.72). Juveniles were free in the gut, embedded in the gut wall and encapsulated in mesenteries. Tenualosa ilisha serves as the definitive host, but the predominance of juveniles may indicate that piscivorous hosts may also serve as such. A list of the nominal Goezia species with important characters is provided.

Vascular applications of Spiral CT : an initial Experience

Since the clinical introduction of computed tomography (CT) in the mid 1970s, several technological and clinical advances have improved image quality and reduced scanning time. During the past decade technological breakthroughs have ushered in an exciting advance in medical imaging : spiral CT. Spiral CT technology with its high speed and volumetric data acquisition has spawned a new vascular imaging technique - spiral CT angiography which is noninvasive, accurate, faster and less expensive than conventional angiography. We report our experience of having performed 100 CT angiographies with 3-D reconstructions of various vascular territories of the body. Details of technique of data acquisition, methods of 3-D reconstruction and clinical applications are discussed.

Nerve growth factor-induced protein kinase C stimulation contributes to TrkA-dependent inhibition of p75 neurotrophin receptor sphingolipid signaling

Previous studies have established that reciprocal interactions between the low-affinity p75 nerve growth factor (NGF) receptor (p75(NTR)) and the high-affinity TrkA NGF receptor can dictate the cellular response to NGF. As the most important interaction, TrkA signaling was found to inhibit p75(NTR)-mediated sphingomyelinase (SMase) stimulation, ceramide production, and apoptosis. However, the mechanism by which TrkA counteracts p75(NTR)-coupled sphingolipid signaling is still unclear. Considering the stimulatory effect of NGF on protein kinase C (PKC) activity, we investigated the role of PKC in TrkA/p75(NTR) signaling interaction. In this study, we found that, in SK-N-BE cells, which selectively express p75(NTR), phorbol ester-induced PKC stimulation resulted in the abrogation of SMase stimulation and ceramide production induced by NGF. Moreover, in SK-N-BE neuroblastoma cells, which selectively express TrkA, NGF stimulated global PKC activity through two independent pathways involving phospholipase Cgamma (PLCgamma) and phosphoinositide-3 kinase (PI3K). In SH-SY5Y, another neuroblastoma cell line, which coexpresses TrkA and p75(NTR), NGF induced PKC stimulation through a TrkA/PI3K signaling pathway, whereas there was no ceramide production. However, in these cells, the inhibition of TrkA, PI3K, and PKC resulted in the restoration of NGF-induced ceramide production. Thus, our study demonstrates for the first time that TrkA interferes with p75(NTR) signaling through a PI3K/PKC-dependent mechanism.

3-D Spiral Computerised Tomographic Angiography in Evaluation of Potential Renal Donors

A total of 30 potential renal donors aged between 35 and 50 years were subjected to pre-operative 3-Dimensional Spiral Computerised Tomography (CT) angiography with the aim to assess its efficacy in the evaluation of renal vasculature. The investigations were carried out on a Philips Tomoscan AV Spiral CT scanner. Scan parameters included a collimation of 3 mm and table speed of 4 mm/sec. A total of 120 ml of non-ionic contrast was injected at a rate of 4 ml per second using a power injector. The axial images obtained were reconstructed at 2mm intervals and 3-D reconstruction was done using Surface Shaded Display (SSD) and Maximum Intensity Projection (MIP) protocols. CT angiography and its correlation with per-operative findings revealed 97 to 100% sensitivity and specificity in identifying the main and accessory renal arteries and veins. The angiogram also excluded the presence of pathologies like polycystic kidney, horse shoe kidney with a thick isthmus and occult renal cell carcinoma that would prevent the patient from being a donor. 3-D spiral CT angiography allows the radiologist to provide the transplant surgeon with precise pre-operative anatomy of the renal vasculature thus reducing the risks and complications associated with the harvesting procedure and increasing the chances of a successful outcome. Thus it is a fast, accurate, inexpensive and minimally invasive procedure that is becoming the modality of choice for the pre-operative evaluation of potential renal transplant donors.

Distribution of T4 TSH values in children--the Shifa experience

OBJECTIVE

To evaluate the distribution of Thyroxin (T4) and Thyroid Stimulating Hormone (TSH) values in children of various age groups attending our hospital.

METHOD

We have retrospectively reviewed the T4, TSH levels recorded at our hospital in children from birth to 5 years and evaluated the reference intervals for T4 TSH amongst different ages. Non parametric methods were used to establish a 97.5th, 95th, 50th, 5th and 2.5th centiles.

RESULTS

In T4 (n=1148) and TSH (n=1142) samples reviewed a TSH surge following delivery showed a sharp decline in the first 4 days of life. This was followed by a more gradual downward trend. Data on T4 estimations showed a similar but more gradual downward trend in advancing age groups. The 5th-95th centile reference range for TSH showed values between 1.7-22.5 (0-4 days; n=992), 0.6-13.3 (5-7 days; n=38), 0.9-14.0 (1 week-1 month; n=38), 0.5-13.6 (1 month-1 year, n=38) and 0.4-12.8 (1-5 years; n=38) microlU/mL. The 5th-95th centile reference range for T4 showed values between 10.7-25.0 (0-4 days; n=995), 6.5-20.4 (5-7 days; n=35), 8.0-18.1 (1 week-1 month; n=38), 6.0-16.1 (1 month-1 year; n=41), 6.9-15.3 (1-5 years; n=39) micro gm/dl.

CONCLUSION

We recommend using separate T4 and TSH reference values for children in different age groups. Further large-scale studies should be done in Pakistan to establish these reference values within age groups. A national center for neonatal thyroid screening is highly recommended.

HIV-1 protease processes procaspase 8 to cause mitochondrial release of cytochrome c, caspase cleavage and nuclear fragmentation

Infection of T cells with HIV-1 induces apoptosis and modulates apoptosis regulatory molecules. Similar effects occur following treatment of cells with individual HIV-1 encoded proteins. While HIV-1 protease is known to be cytotoxic, little is known of its effect on apoptosis and apoptosis regulatory molecules. The ability of HIV-1 protease to kill cells, coupled with the degenerate substrate specificity of HIV-1 protease, suggests that HIV-1 protease may activate cellular factor(s) which, in turn, induce apoptosis. We demonstrate that HIV-1 protease directly cleaves and activates procaspase 8 in T cells which is associated with cleavage of BID, mitochondrial release of cytochrome c, activation of the downstream caspases 9 and 3, cleavage of DFF and PARP and, eventually, to nuclear condensation and DNA fragmentation that are characteristic of apoptosis. The effect of HIV-1 protease is not seen in T cell extracts which have undetectable levels of procaspase 8, indicating a specificity and requirement for procaspase 8.

Correlation of Helicobacter pylori in dental plaque and gastric mucosa of dyspeptic patients

OBJECTIVE

To establish the prevalence of Helicobacter pylori colonization of dental plaque and its correlation with Helicobacter pylori infection of the antral mucosa in patients with symptomatic dyspepsia.

METHODS

Seventy eight adult dyspeptic patients undergoing upper gastrointestinal tract endoscopy were prospectively enrolled. Four air dried dental plaque cytology slides and four gastric antral mucosal biopsies were stained with Giemsa stain. CLO test was used for detection of urease activity of Helicobacter pylori in the dental plaque specimens and antral mucosal biopsies. Data on endoscopic findings and orodental hygiene were recorded.

RESULTS

Dental plaque colonization using CLO test and cytology was found to be 100% and 88% respectively. Antral biopsy for H. pylori was positive in 61% cases by CLO test and 57% cases on histopathology. Forty four out of 69 patients (63%) had both dental plaque and antral biopsy positive for H. pylori. No patient with negative dental plaque cytology was positive for H. pylori in gastric mucosa. A statistically significant correlation was found between H. pylori colonization of dental plaque and gastric antrum. The sensitivity and specificity of dental plaque cytology in diagnosing H. pylori antral colonization was 100% and 26% while the positive and negative predictive values were 64% and 100% respectively.

CONCLUSION

The prevalence of H. pylori in dental plaque of patients with dyspepsia was very high in our patients indicating it to be a major reservoir of infection.