A study of hospitalized COVID-19 patients with AKI in a setting of multiracial developing country

BACKGROUND

The commonest indication for hospitalization in COVID-19 patients is hypoxemia or severe respiratory symptoms. However, COVID-19 disease may result in extrapulmonary complications including kidney-related pathology. The reported incidence of renal involvement related to COVID infection varies based on geographical location.

OBJECTIVE

This study aimed to assess the incidence rate of AKI in hospitalized COVID-19 patients and identify risk factors and prognostic predictors.

METHOD

In this retrospective study, we recruited hospitalized COVID-19 patients from January 2021 until June 2021 at the University Malaya Medical Center. The inclusion criteria were hospitalized for ≥ 48 h with confirmed COVID-19 infection and at least 18 years old. Patient demographic and clinical data were collected from electronic medical records. The staging of AKI was based on criteria as per KDIGO guidelines.

RESULTS

One thousand five hundred twenty-nine COVID patients fulfilled the inclusion criteria with a male-to-female ratio of 759 (49.6%) to 770 (50.3%). The median age was 55 (IQR: 36-66). 500 patients (32.7%) had diabetes, 621 (40.6%) had hypertension, and 5.6% (n = 85) had pre-existing chronic kidney disease (CKD). The incidence rate of AKI was 21.1% (n = 323). The percentage of COVID patients in different AKI stages of 1,2 and 3 were 16.3%, 2.1%, and 2.7%, respectively. Fifteen hospitalized patients (0.98%) required renal replacement therapy. 58.8% (n = 190) of AKI group had complete recovery of kidney function. Demographic factors included age (p < 0.001), diabetes (p < 0.001), hypertension (p < 0.012), CKD (p < 0.001), and vaccination status (p = 0.042) were associated with an increased risk of developing AKI. We found that the AKI cohort had statistically significant lower platelet counts and higher ferritin levels than the non-AKI cohort. AKI is a risk predictor of prolonged hospitalization (p < 0.001) and higher mortality rates (P < 0.001).

CONCLUSION

AKI is a common clinical complication among hospitalized COVID-19 patients. The etiology of AKI is multifactorial and may have an adverse impact on patient morbidity and mortality.

Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement

INTRODUCTION

Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events.

METHODS

We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity.

RESULTS

The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients.

CONCLUSIONS

Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.

Viewpoint: Clinicians' Perspectives on How Disease Modifying Drugs for Alzheimer's Disease Impact Specialty Care

Clinicians specialized in the diagnosis and management of persons living with early-stage Alzheimer's disease need to enable access, for those meeting criteria, to the new class of disease modifying drugs (DMDs). These drugs act on amyloid β42 and delay progression of symptoms. Thus, there will be interest from patients and families. Over the short term, the use of antibodies administered intravenously with serial MRIs to detect amyloid-related imaging abnormalities (ARIA) may require participation in structured phase 4 studies or in registries with third party funding for support staff and MRI scans. In the mid term, the availability of oral anti-amyloid therapy, likely with lower risk of ARIA, may transform clinical practice to a model of screening suitable patients using plasma biomarkers, with a subsequent rapid referral to a specialized memory clinic. Eventually, the biological profile of patients for amyloid, tau, and inflammation will determine which type of DMD to use. We are optimistic that clinicians will gain confidence with the use DMDs and answer the increasing needs of our aging population.

White Matter Hyperintensity as a Vascular Contribution to the AT(N) Framework

The AT(N) framework enables the classification of an individual within the biological Alzheimer's disease (AD) continuum by pairing the cognitive stage with the biomarker status of amyloid-beta (Aβ, A), tau (T) and neurodegeneration (N). AD is a multifactorial disease that may involve different pathogenic mechanisms such as cerebrovascular disease (CVD). Therefore, biomarkers of these mechanisms can be added to the AT(N) framework to enhance the biomarker characterization of individuals within the AD continuum. In AD, white matter hyperintensities (WMH) which are postulated to develop as a result of chronic ischemia from small vessel CVD are shown to play a role in the aetiology. However, the interplay of WMH with Aβ and tau pathophysiology in AD remains unclear. In this review, we summarized the studies that evaluated the associations between WMH and AD pathophysiology (Aβ and tau). We found that the evidence supporting the association of WMH with Aβ was mixed, and this may be explained by the relative contributions of WMH due to its differential load and anatomical distribution. More studies are also needed to determine the association of WMH with tau pathology. Future longitudinal studies with harmonized methodologies to quantify WMH and account for the anatomical differences of WMH are required to validate the relationship between WMH and AT(N) biomarkers. This will allow a clearer understanding of the utility of WMH as a vascular biomarker in the AT(N) framework. Novel CVD biomarkers will also have the potential to further elucidate the contributions of CVD to the AD pathophysiology.

Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery

Limited sample size, incomplete measures, and inadequate risk adjustment adversely influence accurate health care quality measurements, surgical quality measurements, and accurate comparisons among hospitals. Since these measures are linked to resources for quality improvement and reimbursement, improving the accuracy of measurement has substantial implications for patients, clinicians, hospital administrators, insurers, and purchasers. The team examined risk-adjusted differences of postoperative cardiac events among 20 geographically dispersed, community-based medical centers within an integrated health care system and compared it with the National Surgical Quality Improvement Program (NSQIP) hospital-specific differences. The exposure included the hospital at which patients received noncardiac surgical care, with stratification of patients by the acuity of surgery (elective vs. urgent/emergent). Among 157,075 surgery patients, the unadjusted risk of cardiac event per 1000 ranged among hospitals from 2.1 to 6.9 for elective surgery and from 10.3 to 44.5 for urgent/emergent surgery. Across the 20 hospitals, hospital rankings estimated in the present analysis differed significantly from ranking reported by NSQIP (P for difference: elective, P = 0.0001; urgent/emergent, P < 0.0001) with significantly and substantially lower variation after risk adjustment. Current surgical quality measures may not adequately account for limitations of sample size, data capture, adequate risk adjustment, and surgical acuity in a given hospital, particularly for rare outcomes. These differences have implications for quality reporting and may introduce bias into hospital comparisons, particularly for hospitals with incomplete capture of their patients' baseline risk and acuity.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

Identification of novel candidate autoantibodies in Alzheimer's disease

BACKGROUND AND PURPOSE

Accumulated failures in Alzheimer's disease (AD) clinical trials have highlighted an urgent need to identify additional biomarkers involved in AD. Recently, mounting evidence reported that autoantibodies are ubiquitous in human sera. However, it is unknown whether autoantibodies are upregulated in amyloid-tau biomarker-confirmed AD.

METHODS

A total of 40 subjects with mild dementia (Clinical Dementia Rating = 1) were stratified into AD (n = 16) and non-AD (n = 24) groups according to their cerebrospinal fluid levels of tau and Aβ₄₂ . Their sera were collected and analyzed using a microarray containing > 1600 potential human autoantigens. Autoantibodies that were present exclusively in the AD group were identified and selected using the penetrance-based fold change method with the following criteria: penetrance fold change_(AD)  ≥ 2, frequency_(AD)  ≥ 15% and frequency_(non-AD)  = 0%.

RESULTS

All controls and samples passed the quality control criteria and were further used for biomarker analysis. Six autoantibodies with elevated responses to the following autoantigens were found exclusively in the AD group: nucleosome assembly protein 1-like 3 (31.3%, 5/16 subjects) and microtubule-associated protein 4, pantothenic acid kinase 3, phosphoinositide-3-kinase regulatory subunit 1, protein tyrosine phosphatase type IVA member 1 and SRY (sex-determining region Y)-box 15 (all 18.8%, 3/16 subjects).

CONCLUSIONS

Although some identified autoantigens are linked to AD and cognitive dysfunction, the increased autoantibody levels have not been reported in AD. Autoantibodies may provide deeper insights into the pathogenesis of AD and serve as diagnostic biomarkers; their corresponding antigens can be further studied to assess their potential as therapeutic targets.

Aβ1-42 increases the expression of neural KATP subunits Kir6.2/SUR1 via the NF-κB, p38 MAPK and PKC signal pathways in rat primary cholinergic neurons

ATP-sensitive potassium channels (KATP) may mediate a potential neuroprotective role in Alzheimer's disease (AD). Given that exposure to Aβ1-42 in cultured primary cholinergic neurons for 72 h significantly upregulates the expression of KATP subunits Kir6.2/SUR1, we aim to study the underlying signal transduction mechanisms that are involved in Aβ_1-42-induced upregulation of KATP subunits Kir6.2/SUR1. In the present study, we first identified the primary cultured rat cortical and hippocampal neurons using immunocytochemistry. 0.5 μM NF-κB inhibitor SN-50, 2 μM p38MAPK inhibitor SB203580 or 2 μM PKC inhibitor Chelerythrine chloride (CTC) were then added in three separate groups, followed by 2 μM Aβ_1-42 30 min later in all 3 groups. Western Blot was performed 72 h later to detect the expression of KATP subunits Kir6.2/SUR1. We found that Aβ_1-42 significantly increased the level of KATP subunits Kir6.2/SUR1 expression at 72 h when compared with the control group ( p < 0.05). However, when compared with the Aβ_1-42 group, the level of KATP subunits Kir6.2/SUR1 expression at 72 h significantly decreased in the SN50 + Aβ_1-42 group, SB203580 + Aβ_1-42 group, and the CTC + Aβ_1-42 group ( p < 0.05). Our findings suggest that the NF-κB, p38 MAPK, and PKC signal pathways are partially involved in the upregulation of KATP subunits Kir6.2/SUR1 expression induced by Aβ_1-42 cytotoxicity in neurons, which supports a potential theoretical basis of targeting these signal pathways in the treatment of AD.

Antimicrobial susceptibilities and random amplified polymorphic DNA-PCR fingerprint characterization of Candida glabrata, Candida parapsilosis and Candida rugosa from two major hospitals in Kuala Lumpur, Malaysia

The purpose of this study is to characterize 3 non-albicans Candida spp. that were collected from two major hospitals in a densely populated area of Kuala Lumpur for their susceptibilities to azole and genetic background. Fifteen non-albicans Candida clinical isolates in two major hospitals in Kuala Lumpur area of Malaysia were collected by convenience sampling during 2007 and 2010. The genetic diversity of 15 non-albicans Candida species comprising C. glabrata (n = 5), C. parapsilosis (n = 5) and C. rugosa (n = 5) were assessed by RAPD-PCR typing. Strains were initially identified using biochemical tests and CHROMagar Candida medium. Fluconazole and voriconazole susceptibilities were determined by E-test method. Commercial kits were used for DNA extraction and amplification with RAPD primers (OPA02, OPA03 and OPA08). PCR conditions were optimized and simultaneous identification was possible by agarose gel electrophoresis of PCR products and the bands obtained were analyzed using BioNumerics Applied Maths v.6.6 software. The RAPD primers used in this study generated 100% polymorphic profile. Cluster analysis using the RAPD-PCR profile showed 12.5-25% similarity among the strains. The genetic diversity was based on the strain susceptibility towards both the azoles, site of isolation and place according to their unique banding patterns. In contrast, strains susceptible to azoles were found to be genetically similar with clonal dissimilarity. The use of OPA02, OPA03 and OPA08 primers in differentiating non-albicans Candida spp. underscores the higher resolution of RAPD-PCR as a reliable tool for strain/species level differentiation.

The combination of apolipoprotein E4, age and Alzheimer's Disease Assessment Scale - Cognitive Subscale improves the prediction of amyloid positron emission tomography status in clinically diagnosed mild cognitive impairment

BACKGROUND AND PURPOSE

Randomized clinical trials involving anti-amyloid interventions focus on the early stages of Alzheimer's disease (AD) with proven amyloid pathology, using amyloid positron emission tomography (amyloid-PET) imaging or cerebrospinal fluid analysis. However, these investigations are either expensive or invasive and are not readily available in resource-limited centres. Hence, the identification of cost-effective clinical alternatives to amyloid-PET is highly desirable. This study aimed to investigate the accuracy of combined clinical markers in predicting amyloid-PET status in mild cognitive impairment (MCI) individuals.

METHODS

In all, 406 MCI participants from the Alzheimer's Disease Neuroimaging Initiative database were dichotomized into amyloid-PET(+) and amyloid-PET(-) using a cut-off of >1.11. The accuracies of single clinical markers [apolipoprotein E4 (ApoE4) genotype, demographics, cognitive measures and cerebrospinal fluid analysis] in predicting amyloid-PET status were evaluated using receiver operating characteristic curve analysis. A logistic regression model was then used to determine the optimal model with combined clinical markers to predict amyloid-PET status.

RESULTS

Cerebrospinal fluid amyloid-β (Aβ) showed the best predictive accuracy of amyloid-PET status [area under the curve (AUC) = 0.927]. Whilst ApoE4 genotype (AUC = 0.737) and Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-Cog) 13 (AUC = 0.724) independently discriminated amyloid-PET(+) and amyloid-PET(-) MCI individuals, the combination of clinical markers (ApoE4 carrier, age >60 years and ADAS-Cog 13 > 13.5) improved the predictive accuracy of amyloid-PET status (AUC = 0.827, P < 0.001).

CONCLUSIONS

Cerebrospinal fluid Aβ, which is an invasive procedure, is most accurate in predicting amyloid-PET status in MCI individuals. The combination of ApoE4, age and ADAS-Cog 13 also accurately predicts amyloid-PET status. As this combination of clinical markers is cheap, non-invasive and readily available, it offers an attractive surrogate assessment for amyloid status amongst MCI individuals in resource-limited settings.

Genetic diversity, antifungal susceptibility and enzymatic characterisation of Malaysian clinical isolates of Candida glabrata

Candida glabrata has been reported as the second or third most common yeast species isolated from patients with vaginitis and invasive candidiasis. This study was aimed to determine the genetic diversity, antifungal susceptibility and enzymatic profiles of C. glabrata isolated from vaginal and blood samples in the Medical Microbiology Diagnostic Laboratory, University Malaya Medical Centre. A random amplified polymorphic DNA (RAPD) analysis method, using M13 and (GTG)₅ primers, was used for strain differentiation of C. glabrata isolates. Antifungal susceptibility testing of C. glabrata isolates was determined using E-test against amphotericin B, caspofungin, fluconazole and voriconazole and microbroth dilution method against clotrimazole. The enzymic profiles of C. glabrata were determined using APIZYM semi-quantitation kit and egg-yolk agar method. A total of 14 RAPD patterns were identified amongst C. glabrata isolates investigated this study. Susceptibility to amphotericin B, caspofungin, fluconazole and voriconazole was noted. Approximately one third of the isolates demonstrated resistance to clotrimazole (MIC>=1 µg/ml). A single isolate of C. glabrata was resistant to caspofungin (MIC:1.5 µg/ml). Enzymatic activities of acid and alkaline phosphatase, aminopeptidases, esterase and lipase and phospholipase were detected in the C. glabrata isolates. The genetic diversity and antifungal susceptibility profiles of C. glabrata isolates were presented in this study. Continued surveillance and monitoring of the incidence and antifungal resistance in C. glabrata isolates is necessary.

Comparison of Anyplex II RV16 assay with conventional methods for detection of respiratory viruses

Early detection of viral etiologies of acute respiratory tract infections of patients affects management and disease control in pediatric patients. In this study, the performance of Anyplex II RV16 assay (Seegene, Seoul, Korea) was evaluated by comparing with viral culture and direct immunofluorescence staining of clinical specimens for detection of respiratory viruses in patients. A total of 168 respiratory specimens were collected from 122 patients from November 2012 to May 2013 at the time of admission to the University of Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia. The Anyplex II RV16 assay, viral culture, and direct immunofluorescence staining were positive in 74.4%, 18.5% and 14.9% of the specimens, respectively. HRV was the predominant virus detected by the Anyplex II RV16 assay. In 47 cases, two or more respiratory viruses were detected by the Anyplex II RV16 assay, which were missed by conventional methods. The performance of the Anyplex II RV16 assay was better than viral culture and direct immunofluorescence staining of clinical specimens for the detection of respiratory viruses. The implementation of the Anyplex II RV16 assay in hospital laboratories will provide rapid diagnosis of major viral infections of the respiratory tract.

Identification of immunogenic proteins of Candida parapsilosis by serological proteome analysis

AIMS

Systemic candidiasis is the leading fungal bloodstream infection, and its incidence has been on the rise. Recently, Candida parapsilosis has emerged as an increasingly prevalent fungal pathogen, but little is known about its antigenic profile. Hence, the current work was performed to discover immunogenic proteins of C. parapsilosis using serological proteome analysis.

METHODS AND RESULTS

Cell wall proteins extracted from C. parapsilosis were resolved by two-dimensional electrophoresis followed by immunoblotting using antisera from experimentally infected mice. Mass spectrometry analysis of the 32 immunoreactive protein spots resulted in the identification of 12 distinct proteins. Among them, 11 proteins were known antigens of Candida albicans, whereas Idh2p was identified for the first time as an immunogenic protein of Candida species. Recombinant Idh2p was expressed in Escherichia coli, and its antigenicity was verified by immunoblot analysis.

CONCLUSIONS

An immunoproteomic approach was successfully applied to identify immunogenic proteins of C. parapsilosis, with Idh2p as a novel candidate antigen. The identified antigens may serve as potential biomarkers for development of diagnostic assay and/or vaccine for C. parapsilosis.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work represents the first immunoproteomic analysis of C. parapsilosis, which provides new insights into host-pathogen interactions and pathogenesis of C. parapsilosis. The immunogenic proteins could be studied as biomarker candidates for C. parapsilosis.

Fusarium sp. infection in a patient with Acute Lymphoblastic Leukaemia

In the past two decades, Fusarium species have been increasingly recognized as serious pathogens in immunocompromised patients. The outcome of fusariosis in the context of severe persistent neutropaenia has been almost universally fatal. The treatment of fusariosis in immunocompromised patients remains a challenge and the prognosis of systemic fusariosis in this population remains poor. This report presents a case of fatal fusariosis in a 37- year-old patient who was diagnosed with precursor-B cell Acute Lymphoblastic Leukaemia (ALL).

Candida albicans isolates from a Malaysian hospital exhibit more potent phospholipase and haemolysin activities than non-albicans Candida isolates

This study was aimed at determining the phospholipase and haemolysin activity of Candida isolates in Malaysia. A total of 37 Candida clinical isolates representing seven species, Candida albicans (12), Candida tropicalis (8), Candida glabrata (4), Candida parapsilosis (1), Candida krusei (4), Candida orthopsilosis (1) and Candida rugosa (7) were tested. In vitro phospholipase activity was determined by using egg yolk plate assay whereas in vitro haemolysin activity was tested by using blood plate assay on sheep blood Sabouraud's dextrose agar (SDA) enriched with glucose. Phospholipase activity was detected in 75% (9 out of 12) of the C. albicans isolates. Among the 25 non- C. albicans Candida isolates, phospholipase activity was detected in only 24% of these isolates. The phospholipase activity of C. albicans was significantly higher than that of the non- C. albicans Candida isolates (P=0.002). Haemolysin activity was detected in 100% of the C. albicans, C. tropicalis, C. glabrata, C. krusei, C. parapsilosis, and C. orthopsilosis isolates while 75% of the C. krusei isolates and 12.3% of the C. rugosa isolates showed haemolysin activity. The haemolytic activity of C. albicans was significantly higher than that of the non- C. albicans Candida isolates (P=0.0001).The findings in this study indicate that C. albicans isolates in Malaysia may possess greater virulence potential than the non-albicans species.

Hepatitis B seroprevalence among University of Malaya Students in the Post-universal Infant Vaccination Era

AIM

A nationwide HBV vaccination for neonates in the Expanded Programme on Immunization (EPI) was implemented in Malaysia in 1989. The objective of this study was to investigate the prevalence of HBsAg, anti-HBs and anti-HBc among the new student intakes in the Faculties of Medicine and Dentistry, University of Malaya from 2005 to 2011.

MATERIALS AND METHODS

All new students enrolled for undergraduate and postgraduate courses were screened for HBV infection. Serum samples collected were tested for the presence of HBsAg, anti-HBs and anti-HBc with the use of fully automated analysers. Statistical analyses were done using Open Epi version 2.3.1

RESULTS

The overall HBsAg prevalence among the 2923 new intakes was 0.62%. The HBsAg prevalence rate was 1.08% (15/1390) for those born before 1989 and only 0.20% (3/1533) among those born in or after 1989. By year of testing, HBsAg prevalence declined steadily from 1.27% (5/394) in 2005 to 1.20% (5/418) in 2006, 0.95% (4/421) in 2007, 0.49% (2/410) in 2008, 0.49% (2/407) in 2009 and finally 0% in both 2010 (0/445) and 2011 (0/428). Although 66.14% of those vaccinated during infancy had no demonstrable immunity at the time of screening, only 6 (0.39%) students were found to have anti-HBc, including the 3 who were HBsAg positive.

CONCLUSION

These findings suggested effective prevention of HBV transmission with the universal and voluntary vaccination programs in Malaysia.

Penicilliosis in lupus patients presenting with unresolved fever: a report of 2 cases and literature review

Penicilliosis is a rare occurrence among non human immunodeficiency virus (HIV) infected patients. We report here two cases of Penicillium marneffei infection in patients with systemic lupus erythematosus (SLE). Both patients had a recent flare of lupus and were on immunosuppressive drugs when they presented with prolonged fever without an obvious foci of infection, unresponsive to broad-spectrum antibiotics. They were leucopaenic upon admission, with rapid deterioration during the course of the illness. Diagnosis of penicilliosis via fungal isolation from blood culture was delayed resulting in the late initiation of antifungal agents. While both patients ultimately recovered, the delay in diagnosis led to a prolonged hospital stay with increased morbidity. Clinicians should be aware of this uncommon but emerging fungal pathogen in SLE patients and maintain a high index of suspicion in diagnosing this potentially fatal but treatable disease.

CBL mutation-related patterns of phosphorylation and sensitivity to tyrosine kinase inhibitors

Recurrent homozygous CBL-inactivating mutations in myeloid malignancies decrease ubiquitin ligase activity that inactivates SRC family kinases (SFK) and receptor tyrosine kinases (RTK). However, the most important SFK and RTK affected by these mutations, and hence, the most important therapeutic targets, have not been clearly characterized. We compared SFK and RTK pathway activity and inhibitors in acute myeloid leukemia cell lines containing homozygous R420Q mutation (GDM-1), heterozygous deletion (MOLM13) and wild-type (WT) CBL (THP1, U937). As expected with CBL loss, GDM-1 displayed high KIT expression and granulocyte-macrophage colony-stimulating factor (GM-CSF) hypersensitivity. Ectopic expression of WT CBL decreased GDM-1 proliferation but not cell lines with WT CBL. GDM-1, but not the other cell lines, was highly sensitive to growth inhibition by dasatinib (dual SFK and RTK inhibitor, LD50 50 nM); there was less or no selective inhibition of GDM-1 growth by sunitinib (RTK inhibitor), imatinib (ABL, KIT inhibitor), or PP2 (SFK inhibitor). Phosphoprotein analysis identified phosphorylation targets uniquely inhibited by dasatinib treatment of GDM-1, including a number of proteins in the KIT and GM-CSF receptor pathways (for example, KIT Tyr721, STAT3 Tyr705). In conclusion, the promiscuous effects of CBL loss on SFK and RTK signaling appear to be best targeted by dual SFK and RTK inhibition.

A large exposure to Brucella melitensis in a diagnostic laboratory

BACKGROUND

Brucella species are easily transmitted by aerosols and can be acquired in the laboratory.

AIM

To report the management of a large exposure to Brucella melitensis that occurred over six days in a hospital diagnostic laboratory.

METHODS

Fifty-one exposed staff were managed according to Centers for Disease Control and Prevention guidelines. A further 96 non-exposed laboratory staff were tested for seroprevalence. Testing was carried out using the Brucella sp. serum agglutination test.

FINDINGS

Twenty-seven people had high-risk exposure and 24 had low-risk exposure. High-risk staff were offered post-exposure prophylaxis. Twelve (44.4%) agreed to this, of whom eight (66.7%) completed the course. Overall compliance with serological follow-up at baseline, 2, 4, 6 weeks and 8 months was 45.9%. Despite this poor compliance there were no clinical brucellosis cases and no seroconversion in the 47.1% of staff tested at 8 months. Brucella sp. seroprevalence among all staff tested was 3/147 (2.0%).

CONCLUSION

Lack of experience with Brucella spp. and lack of policies for handling potentially hazardous organisms contributed to this prolonged exposure. As compliance with current recommendations may be poor, the optimum frequency of serological follow-up and target groups for prophylaxis should be reassessed. Laboratories in low- or non-endemic areas must prepare for potential isolation of Brucella spp. The impact of human brucellosis in Malaysia requires further study.

Short and long-term outcome of patients with severe acute kidney injury requiring renal replacement therapy

BACKGROUND

Severe acute kidney injury (AKI) occurs in 2-7% of all hospital admissions and is an independent poor prognostic marker. Nevertheless, information on the long-term outcome of AKI and the factors influencing this is limited.

AIM

To describe the short- and long-term outcome of patients requiring renal replacement therapy (RRT) for severe AKI and to examine factors affecting patient survival and renal recovery.

DESIGN AND METHODS

Single centre retrospective analysis of 481 consecutive patients over a period of 39 months.

FOLLOW-UP

12 months.

PRIMARY AND SECONDARY OUTCOMES

overall mortality and RRT dependency at 30 days, 90 days and 1 year.

RESULTS

Survival at 30 days, 90 days and 1 year was 54.4, 47.2 and 37.6%, respectively. RRT independency at 30 days, 90 days and 1 year was 35.2, 27.2 and 25.8%, respectively. Of those RRT independent at 90 days, 55% had ongoing chronic kidney disease. There were two distinct groups of patients: Group A (haemofiltration in ITU) and Group B (intermittent haemodialysis in the renal unit). Patient survival was worse in Group A while RRT independence was higher. Independent predictors of survival included renal cause of AKI and lower CI score in Group A and renal or post-renal cause of AKI, younger age and the absence of malignancy in Group B. Independent predictors of renal recovery included the presence of sepsis in Group A and pre- or post-renal cause of AKI in Group B.

CONCLUSIONS

The short- and long-term survival outcome of severe AKI requiring RRT remains poor. Among those who survive, a significant number either continue to require RRT or have residual renal impairment necessitating ongoing follow-up.

Tsukamurella tyrosinosolvens intravascular catheter-related bacteremia in a haematology patient: a case report

Tsukamurella spp. are a rare but important cause of intravascular catheter-related bacteremia in immunocompromised patients. The organism is an aerobic, Gram-positive, weakly acid-fast bacillus that is difficult to differentiate using standard laboratory methods from other aerobic actinomycetales such as Nocardia spp., Rhododoccus spp., Gordonia spp., and the rapid growing Mycobacterium spp. We report a case of Tsukamurella tyrosinosolvens catheter-related bacteremia in a 51-year-old haematology patient who responded to treatment with imipenem and subsequent line removal. 16srRNA sequencing allowed for the prompt identification of this organism.

CpG methylation patterns and decitabine treatment response in acute myeloid leukemia cells and normal hematopoietic precursors

The DNA hypomethylating drug decitabine maintains normal hematopoietic stem cell (HSC) self-renewal but induces terminal differentiation in acute myeloid leukemia (AML) cells. The basis for these contrasting cell-fates, and for selective CpG hypomethylation by decitabine, is poorly understood. Promoter CpGs, with methylation measured by microarray, were classified by the direction of methylation change with normal myeloid maturation. In AML cells, the methylation pattern at maturation-responsive CpG suggested at least partial maturation. Consistent with partial maturation, in gene expression analyses, AML cells expressed high levels of the key lineage-specifying factor CEBPA, but relatively low levels of the key late-differentiation driver CEBPE. In methylation analysis by mass-spectrometry, CEBPE promoter CpG that are usually hypomethylated during granulocyte maturation were significantly hypermethylated in AML cells. Decitabine treatment induced cellular differentiation of AML cells, and the largest methylation decreases were at CpG that are hypomethylated with myeloid maturation, including CEBPE promoter CpG. In contrast, decitabine-treated normal HSC retained immature morphology, and methylation significantly decreased at CpG that are less methylated in immature cells. High expression of lineage-specifying factor and aberrant epigenetic repression of some key late-differentiation genes distinguishes AML cells from normal HSC and could explain the contrasting differentiation and methylation responses to decitabine.

Identification of local clinical Candida isolates using CHROMagar Candida™ as a primary identification method for various Candida species

The objective of our study was to study the effectiveness of CHROMagar Candida™ as the primary identification method for various clinical Candida isolates, other than the three suggested species by the manufacturer. We studied 34 clinical isolates which were isolated from patients in a local teaching hospital and 7 ATCC strains. These strains were first cultured in Sabouraud dextrose broth (SDB) for 36 hours at 35ºC, then on CHROMagar plates at 30ºC, 35ºC and 37ºC. The sensitivity of this agar to identify Candida albicans, Candida dubliniensis, Candida tropicalis, Candida glabrata, Candida rugosa, Candida krusei and Candida parapsilosis ranged between 25 and 100% at 30ºC, 14% and 100% at 35ºC, 56% and 100% at 37ºC. The specificity of this agar was 100% at 30ºC, between 97% and 100% at 35ºC, 92% and 100% at 37ºC. The efficiency of this agar ranged between 88 and 100% at 30ºC, 83% and 100% at 35ºC, 88% and 100% at 37ºC. Each species also gave rise to a variety of colony colours ranging from pink to green to blue of different colony characteristics. Therefore, the chromogenic agar was found to be useful in our study for identifying clinical Candida isolates.

In vitro activity of fluconazole and voriconazole against clinical isolates of Candida spp. by E-test method

The in vitro susceptibility of clinical Candida isolates towards fluconazole and voriconazole was determined using the E-test method. A total of 41 clinical isolates recovered from patients since 2004 until 2009 from two local hospitals in Kuala Lumpur, Malaysia were used. These comprised Candida tropicalis, Candida albicans, Candida krusei, Candida parapsilosis, Candida rugosa, Candida dubliniensis and Candida glabrata. Strains from American Type Culture Collection were used as quality control. Lawn cultures of the isolates on RPMI-1640 agar medium supplemented with 2% glucose were incubated with the E-test strips at 35ºC for 48 h. Our results show that 71% were susceptible to fluconazole and 90% were susceptible to voriconazole. All strains of C. krusei were resistant to fluconazole and 50% were susceptible in a dose-dependent manner to voriconazole. There were 66% and 33% of C. glabrata that were resistant to fluconazole and voriconazole. Our study revealed that majority of the clinical Candida isolates was susceptible to fluconazole and voriconazole with a small percentage being resistant to both the drugs.

Clinical outcome following B cell depletion therapy in eight patients with refractory idiopathic inflammatory myopathy

OBJECTIVE

To assess the efficacy of B lymphocyte depletion therapy (BCDT) in patients with refractive idiopathic inflammatory myopathy (IIM).

METHODS

Eight patients thought to have IIM were treated with BCDT utilising rituximab. Five were treated as part of an open label trial and three on the basis of perceived clinical need. Rituximab (1 gram) and methylprednisolone (100 mg) were given as intravenous infusions on days 0 and 14. The primary efficacy outcome at 6 months was 15% improvement in muscle strength and 30% reduction in CPK.

RESULTS

Two patients with Jo-1 antibody positive dermatomyositis (DM) demonstrated a clinical response. Both achieved >30% improvement in CPK. In one, the CPK remained within the normal range for 10 months, the other had a normalised CPK and stabilisation of lung function tests for 36 months. Muscle strength by myometry, however, did not achieve the primary outcome, although, patient 1, demonstrated an improvement of 20% at 8 months (the patient had elective surgery of the hand during the study period). Jo-1 antibody levels fell modestly in both patients but remained detectable. Re-evaluation of three patients revealed that one had inclusion body myositis, one had sporadic muscular dystrophy and one subsequently developed nodular sclerosing lymphoma. All except one patient showed adequate B cell depletion with re-population occurring 3- >42 months after BCDT. One patient did not deplete and died of an unrelated cause.

CONCLUSIONS

This study emphasizes the importance of identifying and selecting the appropriate sub-group of patients with IIM most likely to respond to BCDT.

Isoflurane and Propofol Have Similar Effects on Spinal Neuronal Windup at Concentrations that Block Movement

BACKGROUND

We investigated the actions of isoflurane and propofol on neuronal windup in the spinal cord of intact rats. We hypothesized that propofol would depress windup more than isoflurane.

METHODS

In a cross-over design, rats received 0.8 and 1.2 minimum alveolar concentration (MAC) isoflurane and 0.8 and 1.2 ED50 (effective dose(50%)) of propofol, as recordings were made from single units in the lumbar cord (n = 13). Electrical stimuli were applied (20 stimuli at 0.1, 1, and 3 Hz). Neuronal responses were analyzed for those occurring in the C-fiber range (100-400 ms after each stimulus), combined C-fiber and afterdischarge range (100-1000 ms) and the 100-333 ms range for the 3 Hz stimuli. Absolute windup was also calculated (the sum of action potentials for 20 stimuli - 20 x response to the first stimulus).

RESULTS

At 1 Hz, total action potentials (mean, standard error) summed across the 20 stimuli (100-1000 ms range) were 571 +/- 106 and 742 +/- 214 for isoflurane (at 0.8 and 1.2 MAC) and 586 +/- 148 and 641 +/- 143 for propofol (at 0.8 and 1.2 ED50), respectively (P = NS); corresponding values for the 0.1 Hz stimuli were 345 +/- 104, 370 +/- 108, 430 +/- 86, and 403 +/- 106 (P = NS), and for the 3 Hz stimuli (100-333 ms range) were 266 +/- 66, 333 +/- 76, 343 +/- 85, and 252 +/- 72 (P = NS). Absolute windup in the 100-1000 ms range was greater for 1.2 MAC isoflurane at 1 Hz (445 +/- 82, P < 0.01), when compared with absolute windup at 0.8 MAC isoflurane and 0.8 and 1.2 ED50 propofol (232 +/- 31, 88 +/- 65, and 210 +/- 41, respectively).

CONCLUSIONS

These data suggest that isoflurane and propofol have similar effects on neuronal windup in the spinal cord, although there was enhanced absolute windup at 1.2 MAC isoflurane for the 1 Hz stimulus.

Candida rugosa, an emerging fungal pathogen with resistance to azoles: geographic and temporal trends from the ARTEMIS DISK antifungal surveillance program

Candida rugosa is a fungus that appears to be emerging as a cause of infection in some geographic regions. We utilized the extensive database of the ARTEMIS DISK Antifungal Surveillance Program to describe the geographic and temporal trends in the isolation of C. rugosa from clinical specimens and the in vitro susceptibilities of 452 isolates to fluconazole and voriconazole. C. rugosa accounted for 0.4% of 134,715 isolates of Candida, and the frequency of isolation increased from 0.03% to 0.4% over the 6.5-year study period (1997 to 2003). C. rugosa was most common in the Latin American region (2.7% versus 0.1 to 0.4%). Decreased susceptibility to fluconazole (40.5% susceptible) was observed in all geographic regions; however, isolates from Europe and North America were much more susceptible (97 to 100%) to voriconazole than those from other geographic regions (55.8 to 58.8%). C. rugosa was most often isolated from blood and urine in patients hospitalized at the Medical and Surgical inpatient services. Notably, bloodstream isolates were the least susceptible to both fluconazole and voriconazole. C. rugosa should be considered, along with the established pathogens Candida krusei and Candida glabrata, as a species of Candida with reduced susceptibility to the azole antifungal agents.

In vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and Cryptococcus gattii to five antifungal drugs

The in vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and C . gattii to five antifungal drugs (amphotericin B, flucytosine, fluconazole, itraconazole and ketoconazole) were determined using the Etest method. None of the Malaysian isolates was resistant to amphotericin B and ketoconazole. Isolates resistant to flucytosine, fluconazole and itraconazole were observed in this study. Minimum inhibition concentrations (MICs) of > or = 32 microg ml(-1) against flucytosine, > or = 64 microg ml(-1) against fluconazole and > or = 1 microg ml(-1) against itraconazole were noted in four (8.3%), two (4.2%) and one (2.1%) isolates respectively. There was no significant difference in the MICs for both Cryptococcus species (P > 0.05), indicating that C. gattii was as susceptible as var. grubii to all the antifungal drugs tested. No significant difference in the MICs for both Cryptococcus species collected from 1980 to 1990 and 2002 to 2004 were observed (P > 0.05).

Molecular subtyping of clinical isolates of Candida albicans and identification of Candida dubliniensis Malaysia

The genotypes of 221 recent isolates of Candida albicans from various clinical specimens of 213 patients admitted to the University Malaya Medical Centre, Malaysia was determined based on the amplification of a transposable intron region in the 25 S rRNA gene. The analyses of 178 C. albicans isolated from nonsterile clinical specimens showed that they could be classified into three genotypes: genotype A (138 isolates), genotype B (38 isolates) and genotype C (2 isolates). The genotyping of 43 clinical isolates from sterile specimens showed that they belonged to genotype A (29 isolates), genotype B (10 isolates), genotype C (2 isolates) and genotype D (2 isolates). The overall distribution of C. albicans genotypes in sterile and nonsterile specimens appeared similar, with genotype A being the most predominant type. This study reported the identification of C. dubliniensis (genotype D) in 2 HIV-negative patients with systemic candidiasis, which were missed by the routine mycological procedure. The study demonstrated the genetic diversity of clinical isolates of C. albicans in Malaysia.

Association of antinucleosome antibodies with disease flare in serologically active clinically quiescent patients with systemic lupus erythematosus

OBJECTIVE

To identify the prevalence of serologically active clinically quiescent (SACQ) patients in a cohort of 290 patients with systemic lupus erythematosus (SLE). We investigated if the presence of anti-double-stranded DNA (anti-dsDNA) or antinucleosome (anti-NCS) antibodies during the SACQ period was associated with future flares.

METHODS

SACQ patients defined as clinically inactive for 6 months (global British Isles Lupus Activity Group index [BILAG] scores <6) and serologically active (anti-dsDNA antibodies >50 units/ml on at least 2 occasions by enzyme-linked immunosorbent assay [ELISA]) were identified. Patient sera collected during the defined SACQ period were also tested for anti-NCS antibodies (ELISA). We retrospectively reviewed patient clinical details and episodes of flare using the BILAG activity index.

RESULTS

Twenty-seven (9%) patients were SACQ. Seventeen (81%) patients experienced a flare (total of 91 flares, up to 12 flares per person) in the next 5 years. Median duration to first flare was 15 months (range 2-46). Time to first flare after SACQ period was significantly correlated with the presence of anti-NCS (P = 0.0012), high anti-NCS antibody titers (P = 0.0006), and anti-dsDNA titers 5 times above the normal limit (P = 0.02). Patients with higher absolute anti-NCS antibody titers showed a significant correlation with the number of flares (r = 0.57, P = 0.007).

CONCLUSION

A minority of patients with SLE are SACQ. The majority of these patients experience a flare in the next 5 years and close followup is recommended. Anti-NCS antibodies may be a better predictor than anti-dsDNA antibodies for future flares.

Oral candidal species among smokers and non-smokers

OBJECTIVE

To determine the various oral Candidal species among healthy Malaysian adults.

DESIGN

Case-control study.

PLACE AND DURATION OF STUDY

This study was collaborated between the Department of Medical Microbiology, Faculty of Medicine and Department of Oral Pathology, Oral Medicine and Periodontology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia, between September 2002 till January 2004.

PATIENTS AND METHODS

One hundred adults (50 smokers and 50 non-smokers), aged between 40 and 70 years were studied. Swabs and carbohydrate assimilation (Saboraud Dextrose Agar, Corn Meal Agar, API 20C AUX System) were performed. Specimens were collected from dorsum of the tongue, buccal mucosa and commissures (right and left each). Colony forms were established by positive colony forming units, on SDA medium (24-48 hours). Germ tube test for (true/pseudohyphae) growth was done on Corn Meal Agar Medium. Candida biotypes were evaluated by API 20C AUX system, which had a numerical 7 digit profile, added to evaluate a definite Candida species.

RESULTS

Thirty-five percent of Malaysian adults harbored Candida intraorally. Candidal species identified among 100 subjects had C. albicans (27) 77%, C. glabrata (3) 8%, C. famata, C. tropicalis, C. krusei, C. lusitaniae and C. guilliermondii (1) 3% each. Thirty-three positive cases comprised of 35 species i.e. two cases had two species each. Fifty seven percent of these were smokers and 43% non-smokers. These included 40% Chinese, 36% Malays and 24% Indians. Species were, however, not specified according to intra-oral sites i.e. buccal, commissural mucosa and dorsum of tongue.

CONCLUSION

On this series C. albicans is the most common species found in the oral cavity of Malaysian adults. It is equally frequent in smokers and non-smokers, but showed a predilection for the ethnic Chinese group.

Repeated B cell depletion in treatment of refractory systemic lupus erythematosus

OBJECTIVES

To report the clinical outcome and safety profile of repeated B cell depletion in seven patients with refractory systemic lupus erythematosus (SLE).

METHODS

Since June 2000, seven patients with refractory SLE had repeated cycles of B cell depletion (18 cycles in total, up to three cycles per patient) because of disease relapse. The clinical response (assessed by the British Isles Lupus Activity Guide (BILAG) activity index), duration of B cell depletion, and adverse events in these patients was reviewed.

RESULTS

Four patients (Nos 1, 2, 3, 6) had three cycles of treatment and three (Nos 4, 5, 7) had two cycles. Four of the seven patients (Nos 1, 3, 5, 6) improved. The mean global BILAG scores dropped from 15 to 6 at 5-7 months. The median duration of clinical response and B cell depletion was 13 months and 6 months, respectively. After the third cycle, 2/4 patients (Nos 1 and 2) improved. The median duration of clinical benefit was 12 months. Most patients tolerate re-treatment very well.

CONCLUSION

Re-treatment with B cell depletion of patients with severe SLE is safe and may be effective for 6-12 months on average.

The mycological and molecular study of Hortaea werneckii isolated from blood and splenic abscess

Hortaea werneckii is an environmental dematiaceous fungus found in the halophilic environment. It causes tinea nigra. We report the isolation of H. werneckii from blood and splenic abscess of two patients with acute myelomonocytic leukaemia. H. werneckii grew at room temperature but not at 37 degrees C, it was identified by biochemical tests, growth characteristics and the presence of conspicuous collarette intercalary on dividing yeast cells. The use of specific oligonucleotide primer Hor-F (5'-TGGACACCTTCA TAACTCTTG-3') and Hor-R (5'-TCACAACGCTTAGAGACGG-3') confirmed the two isolates were H. werneckii. The sequence for 281 nucleotide of HW299 and HW403 were 99% identical but differed only in one nucleotide. In vitro anti-fungal susceptibility testing showed that the isolates were resistant to amphotericin B and flucytosine.

Impact of the Expanded Program of Immunization against hepatitis B infection in school children in Malaysia

The implementation of the Expanded Program of Immunization (EPI) in 1989 has dramatic impact on hepatitis B virus (HBV) infection in school children in Malaysia. A cross-sectional seroprevalence study of HBV infection in 190,077 school children aged 7-12 years from 1997 to 2003 showed a steady decline of HBV surface antigen (HBsAg) prevalence rate from 2.5% for children born in 1985 to 0.4% among school children born in 1996. The overall prevalence of HBsAg was 0.6%, 0.7% in males and 0.6% in females. Over 92.7% of school children had been vaccinated with HBV vaccine, in which 93.7% were vaccinated under the EPI and 6.3% on voluntary basis. The school children vaccinated under EPI had a 0.4% HBsAg carrier rate, which was significantly lower than school children vaccinated on a voluntary basis (HBsAg carrier rate 1.3%) and non-vaccinated school children (HBsAg carrier rate 2.7%), suggesting that HBV vaccination of infants was the most effective measure in preventing vertical transmission of HBV in the hyperendemic region.

Salmonellosis in persons infected with human immunodeficiency virus: a report of seven cases from Malaysia

Persons infected with human immunodeficiency virus (HIV) have an increased risk of salmonellosis when compared to the general population. We describe seven such patients with Salmonella bacteremia, of whom two had recurrent salmonellosis. In the latter two cases the infection was unusually severe, characterized by widespread infection, bacteremia and relapse, despite standard antimicrobial therapy. HIV-infected individuals will benefit from education on the source of Salmonella, mode of acquisition and prevention through safe food handling and food preparation practices. Because of the difficulty of eradicating Salmonella infection in patients with acquired immunodeficiency syndrome, long-term suppressive treatment with antimicrobials is warranted.

An outbreak of acute haemorrhagic conjunctivitis in Melaka, Malaysia

This paper reports a second outbreak of acute haemorrhagic conjunctivitis due to coxsackievirus A24 in peninsular Malaysia. Between June 2002 and early October 2003, 10,327 patients, comprising 3,261 children and 7,066 adults, were treated for acute conjunctivitis in 11 government health clinics in the Melaka Tengah district of the state of Melaka. The figure grossly underestimates the size of the outbreak; as no patients treated in private clinics in the same district were included. Institution and household surveillance showed that the commonest presenting clinical feature of the illness was eye-discharge (91.2%), followed by foreign body sensation (81.8%), pain (78.3%) and subconjunctival haemorrhage (74.4%). The mean duration of illness was 6.5 and five days for patients with and without subconjunctival haemorrhage respectively.

Scopulariopsis brevicaulis infection in a patient with acute myeloid leukemia

Scopulariopsis brevicaulis is a soil fungus normally associated with onychomycosis. It causes subcutaneous infection in immunocompromised patients and is rarely isolated from blood. A case of systemic Scopulariopsis brevicaulis infection was reported in a patient with acute myeloid leukemia. The patient developed persistent fever that did not respond to wide spectrum antibiotics and amphotericin B. Scopulariopsis brevicaulis was the only pathogen isolated from blood cultures. The fever subsided with itraconazole and there was no recurrence of fungal infection with prolonged maintenance of oral itraconazole.

Evaluation of three commercial rapid tests for detecting antibodies to human immunodeficiency virus

Determine HIV-1/2, Chembio HIV-1/2 STAT-PAK and PenTest are simple/rapid tests for the detection of antibodies to HIV-1 and HIV-2 in human whole blood, serum and plasma samples. The assay is one step and the result is read visually within 15 minutes. Using 92 known HIV-1 reactive sera and 108 known HIV-1 negative sera, the 3 HIV tests correctly identified all the known HIV-1 reactive and negative samples. The results indicated that Determine HIV-1/2, Chembio HIV-1/2 STAT-PAK and PenTest HIV are as sensitive and specific (100% concordance) as Microparticle Enzyme Immunoassay. The data indicated that these 3 HIV tests are effective testing systems for diagnosis of HIV infection in a situation when the conventional Enzyme Immunoassay is not suitable.

Dermatophytes isolated from patients in University Hospital, Kuala Lumpur, Malaysia

A total of 576 dermatophytes were isolated from patients with a variety of skin infections from January 1993 to May 2000. Ten species of dermatophytes were identified: Epidermophyton floccosum (0.7%), Microsporum audouinii (1.1%), M. canis (3.1%), M. gypseum (0.3%), Trichophyton concentricum (3.5%), T. equinum (0.2%), T. mentagrophytes (36.1%), T. rubrum (53.8%), T. verrucosum (0.2) and T. violaceum (1.0%). The body sites most frequently affected by dermatophytes were the buttocks, nails and trunk. Anthropophilic dermatophytes made up 60.1% of the isolates; the most common species was T. rubrum, T. mentagrophytes and M. canis were the two main zoophilic dermatophytes. T. mentagrophytes was isolated from all body sites except the scalp. M. canis was found to be associated with domestic dogs and was not isolated from ethnic Malays. The only geophilic dermatophyte was M. gypseum, an uncommon dermatophyte associated with tinea pedis.

Retrospective review of spinal versus epidural anaesthesia for caesarean section in preeclamptic patients

A 5-year retrospective survey of anaesthesia for caesarean section for mild/moderate and severe preeclampsia was performed, covering the period between 1 January 1996 and 31 December 2000. One hundred and twenty-one cases of non-labouring preeclamptic patients receiving spinal or epidural anaesthesia for caesarean section were included for analysis. Comparisons were made of the lowest blood pressures recorded before induction of anaesthesia, during the period from induction to delivery and the period from delivery to the end of operation. The decreases in blood pressure were similar after spinal and epidural anaesthesia. The use of intravenous fluids and ephedrine were also comparable in the two anaesthetic groups. There was no difference in maternal or neonatal outcome. Our result supports the use of spinal anaesthesia in preeclamptic women.

Trends in obstetric anaesthesia and analgesia over a ten year period in the University Malaya Medical Centre, Kuala Lumpur

Available data for obstetric care in the University Malaya Medical Centre, Kuala Lumpur from 1987 to 1999 were reviewed. Despite incomplete data, we were able to determine fairly well the practice of obstetric anaesthesia and analgesia in the unit, and the changes over the years. There was a decline in the use of general anaesthesia for both elective and emergency caesarean sections from 41.3% and 69.4% respectively in 1995 to 21.6% and 26.9% respectively in 1999. By 1999, regional anaesthesia had become the most common method of anaesthesia administered in both elective (14.3% epidural and 63.5% spinal) and emergency (30.2% epidural and 42.6% spinal) caesarean sections. The percentage of patients delivering vaginally who received epidural analgesia appeared to have stabilised at about 8 to 9% in the last few years, with a gradual decline in the total instrumental delivery rate from a high of about 12% to the pre-epidural rate of 7%.

Non-sporulating Chrysosporium: an opportunistic fungal infection in a neutropenic patient

We report a case of an invasive infection with non-sporulating Chrysosporium species in a patient who was treated with chemotherapy for relapsed acute lymphoblastic leukemia. This patient presented with a persistent lobar pneumonia, skin lesions, and possible involvement of the central nervous system. The patient responded to treatment with amphotericin B and oral itraconazole.

Systemic Candida infection in University hospital 1997-1999: the distribution of Candida biotypes and antifungal susceptibility patterns

A total of 102 Candida species were isolated from blood cultures from January 1997 to October 1999. Using assimilation of carbohydrate test, 52 (51.0%) of the Candida sp. were identified as C. parapsilosis, 25.5% (26) were C. tropicalis. C. albicans made up 11.8% (12), 6.9% (7) were C. rugosa, 3.8% (4) C. glabrata and 1% (1) C. guilliermondii. No C. dubliniensis was found in the study. In vitro antifungal susceptibility tests showed that all Candida species were sensitive to nystatin, amphotericin B and ketoconazole. Although all isolates remained sensitive to fluconazole, intermediate susceptibility was found in 3 C. rugosa isolates. Antifungal agents with high frequency of resistance were econazole, clotrimazole, miconazole and 5-fluorocytosine. Candida species found to have resistance to these antifungal agents were non-C. albicans.

Fire during thoracic surgery

A 67-year-old male with bilateral lung lesions presented for median sternotomy. One-lung ventilation was complicated by arterial desaturation. Continuous positive airway pressure with oxygen was applied to the non-ventilated lung to relieve the hypoxaemia. However, the cotton gauze packed inside the operative site was ignited by the electrocautery. The burning gauze was immediately removed without any complication. We report a case of electrocautery-induced fire during thoracic surgery done in supine position and discuss its implication on the choice of oxygen enrichment therapy during one-lung ventilation.

Effects of estrogens in vitro and in vivo on cartilage growth in the tilapia (Oreochromis mossambicus)

To study the effects of estrogens on cartilage growth in the tilapia Oreochromis mossambicus, an epiceratobranchial cartilage radioisotope incorporation assay was employed to measure proteoglycan synthesis and prechondrocyte proliferation by incorporation of radiolabeled sulfate and thymidine, respectively. Cartilage explants were cultured with estrogens with or without recombinant bovine insulin-like growth factor-I (IGF-I). In vitro experiments using the natural teleost estrogen, 17beta-estradiol (E2), showed a trend toward inhibition of sulfate incorporation and an inhibition of thymidine incorporation at higher doses (10 micrograms/ml), but not at physiological levels. E2 also showed a trend toward inhibition of sulfate and thymidine incorporation in the presence of IGF-I. Similar results were found with other estrogenic compounds in vitro: ethinylestradiol, diethylstilbestrol (DES), genistein, and nonylphenol. Ethinylestradiol inhibited sulfate and thymidine incorporation at 1000 ng/ml in the presence of IGF-I. DES inhibited thymidine incorporation at 1000 ng/ml in untreated or IGF-I-exposed cartilage. Genistein inhibited sulfate incorporation at 100 micrograms/ml in IGF-I-exposed cartilage and inhibited thymidine uptake at 1, 10, and 100 micrograms/ml in untreated and IGF-I-exposed cartilage. Nonylphenol inhibited sulfate uptake at 100 microM in untreated and IGF-I-exposed cartilage. Nonylphenol alone at 10 and 100 microM inhibited thymidine uptake. In IGF-I-exposed cartilage nonylphenol inhibited thymidine uptake at 100 microM. Fish receiving estrogen injections (E2 or DES) in vivo at a concentration of 2 micrograms/g body weight showed increased sulfate incorporation by cartilage in vitro. Stimulation in vivo by estrogens, in contrast to the inhibition by high doses in vitro, may be a result of the influence of estrogen on pituitary growth hormone release.