Cryptococcosis in organ transplantation

Opportunistic infection is one of the important cause of graft dysfunction after organ transplantation. It usually occurs one year after post transplantation in a immunocompromised transplant recipient. Among the opportunistic infections fungal infection is important cause of graft dysfunction as well as increase morbidity and mortality of post transplant recipient. Cryptococcosis is the third most common invasive fungal infection in an organ transplant recipient next to Candidiasis and Aspergillosis. A 27 years young male is known case of live related renal allograft recipient on immunosuppression for last one and half years. Patient was admitted with irregular fever, severe headache, nausea and vomiting in the department of Nephrology on July 2007. After admission patient was thoroughly evaluated and clinically found features of meningitis. Subsequent investigation report revealed swollen of 3rd ventricle on CT scan brain and growth of Cryptococcus in CSF culture and diagnosis was made post renal transplant cryptococcal meningitis. Treatment was given with Injection Amphotericin B along with immunosuppression and other supportive measured. But inspite of treatment, within few days after diagnosis patient was underwent coma and died. In conclusion, cryptococcal meningitis is a serious invasive fungal infection in post transplant immunocompromised recipient and responsible for graft lose and increase morbidity of the transplant patients.

Education and risk for acute myocardial infarction in 52 high, middle and low-income countries: INTERHEART case-control study

OBJECTIVE

To determine the effect of education and other measures of socioeconomic status (SES) on risk of acute myocardial infarction (AMI) in patients and controls from countries with diverse economic circumstances (high, middle, and low income countries).

DESIGN

Case-control study.

SETTING

52 countries from all inhabited regions of the world.

PARTICIPANTS

12242 cases and 14622 controls.

MAIN OUTCOME MEASURES

First non-fatal AMI.

RESULTS

SES was measured using education, family income, possessions in the household and occupation. Low levels of education (< or =8 years) were more common in cases compared to controls (45.0% and 38.1%; p<0.0001). The odds ratio (OR) for low education adjusted for age, sex and region was 1.56 (95% confidence interval 1.47 to 1.66). After further adjustment for psychosocial, lifestyle, other factors and mutually for other socioeconomic factors, the OR associated with education < or =8 years was 1.31 (1.20 to 1.44) (p<0.0001). Modifiable lifestyle factors (smoking, exercise, consumption of vegetables and fruits, alcohol and abdominal obesity) explained about half of the socioeconomic gradient. Family income, numbers of possessions and non-professional occupation were only weakly or not at all independently related to AMI. In high-income countries (World Bank Classification), the risk factor adjusted OR associated with low education was 1.61 (1.33 to 1.94), whereas it was substantially lower in low-income and middle-income countries: 1.25 (1.14 to 1.37) (p for interaction 0.045).

CONCLUSION

Of the SES measures we studied, low education was the marker most consistently associated with increased risk for AMI globally, most markedly in high-income countries.

Successful oral tolerance induction in severe peanut allergy

BACKGROUND

Peanut allergy is common, potentially severe and rarely resolves causing impaired quality of life. No disease-modifying treatment exists and there is therefore a need to develop a therapeutic intervention.

AIMS OF THE STUDY

The aim of this study was to investigate whether peanut oral immunotherapy (OIT) can induce clinical tolerance to peanut protein.

METHODS

Four peanut-allergic children underwent OIT. Preintervention oral challenges were performed to confirm clinical allergy and define the amount of protein required to cause a reaction (dose thresholds). OIT was then administered as daily doses of peanut flour increasing from 5 to 800 mg of protein with 2-weekly dose increases. After 6 further weeks of treatment, the oral challenge was repeated to define change in dose threshold and subjects continued daily treatment.

RESULTS

Preintervention challenges confirmed peanut allergy and revealed dose thresholds of 5-50 mg (1/40-1/4 of a whole peanut); one subject had anaphylaxis during challenge and required adrenaline injection. All subjects tolerated immunotherapy updosing to 800 mg protein and i.m. adrenaline was not required. Each subject tolerated at least 10 whole peanuts (approximately 2.38 g protein) in postintervention challenges, an increase in dose threshold of at least 48-, 49-, 55- and 478-fold for the four subjects.

CONCLUSIONS

We demonstrated a substantial increase in dose threshold after OIT in all subjects, including the subject with proven anaphylaxis. OIT was well tolerated and conferred protection against at least 10 peanuts, more than is likely to be encountered during accidental ingestion.

Potentially modifiable risk factors associated with myocardial infarction in China: the INTERHEART China study

BACKGROUND

Lifestyle changes associated with the rapidly developing economy increase cardiovascular disease (CVD), myocardial infarction (MI) and cardiovascular risk factors (CVRFs) in China.

OBJECTIVE

To assess and compare regionally, and with other regions of the world, distribution of the nine INTERHEART CVRFs, their relationship to MI and the CVD epidemic in China in order to determine how this may influence the future of CVD in China.

METHODS

Patients with first acute MI (n = 3030) and age- and sex-matched controls (n = 3056) were enrolled from 26 centres in China.

RESULTS

Northern Chinese had higher rates of smoking and hypertension, whereas southern Chinese reported lower fruit and vegetable intake and higher rates of depression. Compared with other regions, participants from China were older, with lower body mass index and waist to hip ratios, lower total and low-density lipoprotein cholesterol levels, ApoB lipoprotein and ApoB to ApoA-1 ratios, but higher high-density lipoprotein cholesterol and ApoA-1. All nine INTERHEART CVRFs, education and income were significantly associated with MI in the Chinese cohort. There was significant heterogeneity in the strength of association between certain CVRFs and MI for China versus other regions, with stronger associations for the Chinese for diabetes (OR 5.10 vs 2.84), depression (2.27 vs 1.37) and permanent stress (2.67 vs 2.06); and lower for the Chinese for abdominal obesity (1.33 vs 2.62) (p for heterogeneity, all <0.001).

CONCLUSIONS

Diabetes and psychosocial factors have strong associations with risk of MI in China, indicating that future increases in these risk factors with societal change in China may hasten rapid increases in CVD.

Ewing tumors of the chest wall: Local control and long-term outcomes

e21501

Background: Primary sarcomas of the lungs and mediastinum are rare and few data are reported on treatment and results of therapy. Methods: We reviewed our experience from 1980 and 2008 including 31 patients (pts). Pts characteristics: median age 41 (19–80 y), male/female 19/12; symptoms at diagnosis: dyspnoea (42%), chest and shoulder pain (39%), cough (35%), hemophtoae (13%), discomfort (10%). 4 pts had a previous history of mediastinal radiation for Hodgkin's and non-Hodgkin's linfomas. 5 mediastinal tumours were located as follows: 2 in anterior part, 1 in posterior and 2 in the middle (sarcomas of the heart). 26 lung sarcomas presented as a singular mass in 23 cases and as a metastatic disease in 3. Results: In 20/31 cases the tumour was immediately resected (3 mediastinal masses and 17 lung sarcomas). In 8/31 cases only biopsy was possible. FNA was done in 25 pts. Neoadjuvant chemotherapy was performed in 4 cases (3 resected). Resection was complete in 11/23 cases and in 12/23 incomplete. The histology were: peripheral nerve tumour 7, leiomyosarcoma 4, MFH 2, fibrosarcoma 2, liposarcoma 1, angiosarcoma 2, undifferentiated sarcoma 1, solitary fibrous tumour 2, rhabdomyosarcoma 2, synovialsarcoma 2, pulmonary artery sarcoma 1, pleuropolmonary blastoma 1, malignant hemangiopericytoma 1, mixoid chondrosarcoma 1, ectopic osteosarcoma 1, aggressive fibromatosis 1. Only 4 pts received neoadjuvant chemotherapy, 11 adjuvant CT, 5 exclusive CT + RT for inoperable disease. Radiotherapy was completed in 26 pts (21 adjuvant). Local relapse or metastatic progression were recorded in 16/23 pts and 12 received one or more lines of palliative CT. Data about survival are disposable only for the more recently recorded pts (1998–2008: 17 pts). Of these only 8 are alive (2 with disease). Volume of disease, complete resection and grading are the dominant prognostic factors. Conclusions: Primary sarcomas of the lungs and mediastinum have a very severe prognosis. Surgical resection is the fundamental therapy, but in the future the role of neoadjuvant CT will increase.

No significant financial relationships to disclose.

Stem cells in liver regeneration, fibrosis and cancer: the good, the bad and the ugly

The worldwide shortage of donor livers to transplant end stage liver disease patients has prompted the search for alternative cell therapies for intractable liver diseases, such as acute liver failure, cirrhosis and hepatocellular carcinoma (HCC). Under normal circumstances the liver undergoes a low rate of hepatocyte 'wear and tear' renewal, but can mount a brisk regenerative response to the acute loss of two-thirds or more of the parenchymal mass. A body of evidence favours placement of a stem cell niche in the periportal regions, although the identity of such stem cells in rodents and man is far from clear. In animal models of liver disease, adopting strategies to provide a selective advantage for transplanted hepatocytes has proved highly effective in repopulating recipient livers, but the poor success of today's hepatocyte transplants can be attributed to the lack of a clinically applicable procedure to force a similar repopulation of the human liver. The activation of bipotential hepatic progenitor cells (HPCs) is clearly vital for survival in many cases of acute liver failure, and the signals that promote such reactions are being elucidated. Bone marrow cells (BMCs) make, at best, a trivial contribution to hepatocyte replacement after damage, but other BMCs contribute to the hepatic collagen-producing cell population, resulting in fibrotic disease; paradoxically, BMC transplantation may help alleviate established fibrotic disease. HCC may have its origins in either hepatocytes or HPCs, and HCCs, like other solid tumours appear to be sustained by a minority population of cancer stem cells.

Attributes of adult stem cells

While cultured embryonic stem (ES) cells can be harvested in abundance and appear to be the most versatile of cells for regenerative medicine, adult stem cells also hold promise, but the identity and subsequent isolation of these comparatively rare cells remains problematic in most tissues, perhaps with the notable exception of the bone marrow. The ability to continuously self-renew and produce the differentiated progeny of the tissue of their location are their defining properties. Identifying surface molecules (markers) that would aid in stem cell isolation is a major goal. Considerable overlap exists between different putative organ-specific stem cells in their repertoire of gene expression, often related to self-renewal, cell survival and cell adhesion. More robust tests of 'stemness' are now being employed, using lineage-specific genetic marking and tracking to show production of long-lived clones and multipotentiality in vivo. Moreover, the characterization of normal stem cells in specific tissues may provide a dividend for the treatment of cancer. The successful treatment of neoplastic disease may well require the specific targeting of neoplastic stem cells, cells that may well have many of the characteristics of their normal counterparts.

Multi-method evaluation of a paediatric ambulatory care unit (PACU): impact on families and staff

AIM

To assess the impact of a purpose-built, short stay paediatric ambulatory care unit (PACU) on the patient journey and perceptions of parents, staff and referrers.

METHODS

Multi-method evaluation, including a parent survey (n = 104), patient journey mapping (n = 10), staff interviews (n = 10), a referrer survey (n = 16), routine activity analysis, and a comparison with the A&E service (A&E parent survey: n = 41).

RESULTS

Almost all parents attending PACU (94%) were satisfied with the service and significantly more likely to feel "very" satisfied than parents attending A&E (PACU: 51%, A&E: 31%; p = 0.03). Further, over three quarters (77%) of PACU parents preferred the new model to traditional A&E services. They reported receiving sufficient information (93%), reduced anxiety (55% anxious before service, 13% anxious after; p<0.001), "quick" waiting times (median: 35 min), and enhanced confidence (87%) and understanding (89%) in dealing with their ill child. The number of stages in the patient journey was reduced from six ("traditional" A&E pathway) to four (PACU pathway). Staff and referrers reported this was a "superior" model to A&E, but that improvements were required around appropriate referrals and the need for more multi-disciplinary protocols and liaison.

CONCLUSION

Our study suggests that the PACU model is perceived to be an effective alternative to standard A&E services for the assessment and early management of acutely ill children and their families attending a hospital. It is highly valued by users, staff and referrers and enhances the patient journey. Lessons learnt include the need to enhance multi-disciplinary processes and clarify the role of this form of acute care provision in the wider healthcare system.

Unilateral epididymo-orchitis: a rare complication of MMR vaccine

We report the case of an 18-year-old male patient with epididymo-orchitis following MMR vaccine. Salivary gland involvement, meningitis/encephalitis are well-known complications of the MMR vaccine, but involvement and infection of the testis is a rarity. A search for this complication on the medical databases showed no reported cases in the UK.

Association of tuberculosis with vasculitis retinae

Retinal vasculitis is one of the common causes of blindness among the young adult in this subcontinent. Causes of retinal vasculitis are variable and it is one of the common ocular manifestations of tuberculosis. This case control study was carried out on 45 patients with retinal vasculitis of different age groups. All the patients were purposively selected from the department of ophthalmology, Bangabandhu Sheikh Mujib Medical University and National Institute of Ophthalmology Dhaka. This study reveals that vasculitis retinae is a disease of younger age group (68.9%). Mean+/-SD age of cases were 31.84+/-10.82 years. It occurs more in male (75.6%) and male female ratio is 3.09:1, single or both eye may involve. Retinal vasculitis occurs more in middle socio-economic status persons (62.2%). It present with floaters (58.9%), hazy media (60%), vitreous haemorrhage (57.8%) and retinal haemorrhage (42.2%). All 45 subjects both cases and control groups were tested with Mantoux test. 18(40%) subjects of cases and 13(28.9%) subjects of control group were found positive Mantoux test. It was observed that the association of tuberculosis with vasculitis retinae is not statistically significant. As tuberculosis is common in this country, further specific and extensive study over a longer period of time is necessary for understanding the role of tuberculosis in retinal vasculitis patients.

The influence of different hormone concentration and combination on callus induction and regeneration of Rauwolfia serpentina L. Benth

The influence of media composition on callus induction and subsequent regeneration of Rauwolfia serpentina L. Benth has been studied. High frequency (96.43%) callus induction was obtained when nodal segments from in vitro raised shoots were cultured on MS medium supplemented with 0.5 mg L(-1) BA and 2.0 mg L(-1) NAA. The callus differentiated into adventitious shoots when it was subcultured on MS medium supplemented with 2.0 mg L(-1) BA with 0.2 mg L(-1) NAA. Regenerated shoots were best rooted on half-strength MS medium with 1.0 mg L(-1) each of IBA and IAA.

Mass propagation of Rauwolfia serpentina L. Benth

A protocol for mass propagation through axillary bud proliferation was established for Rauwolfia serpentina L. Benth. (Apocynaceae). MS medium supplemented with 1.5 mg L(-1) BA and 0.2 mg L(-1) NAA elicited the maximum number of shoots (4 multiple shoots) from nodal explants. These adventitious shoots were best rooted on half strength MS medium supplemented with 1.0 mg L(-1) each of IBA and IAA. The in vitro raised plants were acclimatized in glass house and successfully transplanted to field condition with almost 95% survival.