Awareness of lipid guideline recommendations for high-risk patients amongst primary care physicians in Canada

Background

Lipid guidelines for cardiovascular (CV) risk reduction have evolved in recent years, particularly since the introduction of PCSK9 inhibitors. In many jurisdictions, CV risk management is provided by primary care physicians (PCPs). We surveyed Canadian PCPs regarding their awareness and implementation of the 2021 Canadian Cardiovascular Society (CCS) lipid guideline recommendations for patients following an acute coronary syndrome (ACS) or for those with diabetes but without CV disease.

Methods and results

From a national database of PCPs with interest and/or experience in CV medicine, we invited PCPs to complete a survey regarding lipid management in high-risk patients. A committee of PCPs and specialists with lipid expertise including several co-authors of the 2021 CCS lipid guidelines had designed the survey to probe awareness and practice patterns. A total of 203 PCPs from across Canada completed the survey between January and March 2022. 23.6% of respondents had previously prescribed a PCSK9 inhibitor. Almost all (96.5%) PCPs concurred that a post-ACS patient should be seen by their PCP within 4 weeks of hospital discharge (79.3% within 2 weeks). Almost half (45.3%) responded that discharge summaries provided inadequate information relevant for PCPs, and 43% felt that lipid management post-ACS was the primary responsibility of specialists. More than half (56%) articulated challenges when seeing a post-ACS patient, related to inadequate discharge information, complexities of polypharmacy and duration of therapies, and managing perceived or real statin intolerance. 62% correctly identified the LDL-C intensification threshold of 1.8 mmol/L in post-ACS patients, while 79% considered that PCSK9 inhibitors were indicated only for those patients who were already receiving statins plus ezetimibe or had substantially elevated LDL-C levels. 55.2% were able to correctly identify clinical features associated with greatest absolute benefit of PCSK9 inhibitors in post-ACS patients. For patients with diabetes but without ASCVD, 80% of PCPs incorrectly believed that PCSK9 inhibitors were indicated for LDL-C levels above threshold despite statin therapy, and only 42% correctly identified the LDL-C threshold for treatment intensification of 2.0 mmol/L.

Conclusion

While PCPs are aware of the urgency regarding lipid management in post-ACS patients, many encounter challenges after hospital discharge, frequently deferring lipid management to specialists. Thus, almost one year following publication of the 2021 CCS lipid guidelines, substantial knowledge gaps remain regarding intensification thresholds and treatment options for patients post-ACS or for those with diabetes. Innovative and effective knowledge translation programs are urgently required.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen Canada

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background

Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy.

Objectives

This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared.

Methods

Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups.

Results

In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months.

Conclusion

The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Correlation Between Inflammation and Oxidative Stress in Normocholesterolemic Coronary Artery Disease Patients ‘on’ and ‘off’ Atorvastatin for Short Time Intervals

AIM OF THE STUDY

To assess whether variations in antioxidant and anti-inflammatory parameters occur with short term administration and discontinuation of atorvastatin in normocholesterolemic coronary artery disease (CAD) patients.

METHODS

Forty CAD patients with near normal serum cholesterol levels (total cholesterol <240 mg/dl, LDL cholesterol <130 mg/dl) were continuously enrolled and randomized to groups A and B (20 patients taking atorvastatin) and groups C and D (20 patients not taking atorvastatin). Atorvastatin (10 mg/day) was continued in group A, withdrawn in group B and started in groups C and D for 6 weeks. Thereafter atorvastatin was withdrawn in group A and C, restarted in group B, and continued in group D for further 6 weeks. CRP, FRAP and TBARS were assessed at baseline, 6 weeks and 12 weeks in all the groups.

RESULTS

Baseline CRP, TBARS and FRAP levels were significantly different (p < 0.05) between groups A and B and C and D at the time of enrollment, indicating lower levels of oxidative stress (FRAP-172.40 +/- 23.41 nmol Fe(2+)/l vs 142.62 +/- 15.73 nmol Fe(2+)/l and TBARS-3.66 +/- 1.14 nmol/ml vs 6.11 +/- 1.85 nmol/ml) and low grade inflammation (CRP-1.38 +/- 0.69 mg/l vs 3.19 +/- 1.77 mg/l) in statin treated groups. In group B, discontinuation resulted in increase in CRP (2.87 +/- 0.98 mg/l) and TBARS (5.75 +/- 1.35 nmol/ml) and decrease in FRAP (133.132 +/- 13.32 nmol Fe(2+)/l) and whereas group A patients did not show significant variation in values compared to baseline (CRP-1.36 +/- 0.33 mg/l, FRAP-155.45 +/- 19.51 and TBARS-4.22 +/- 0.81). Administration of atorvastatin caused a marked reduction in oxidative stress and inflammation in groups C and D (CRP-1.13 +/- 0.99 mg/l and 1.73 +/- 1.60 mg/l, FRAP-166.54 +/- 34.11 and 177.44 +/- 13.31 nmol Fe(2+)/l, TBARS-4.66 +/- 2.33 and 3.55 +/- 1.25 nmol/ml respectively). The values returned to pretreatment levels on discontinuation of the drug in group C (CRP-2.61 +/- 1.28 mg/l, FRAP-138.49 +/- 19.62 nmol Fe(2+)/l, TBARS-6.13 +/- 0.74 nmol/ml) whereas the decline was maintained in group D (CRP-1.62 +/- 1.48 mg/l, FRAP-173.07 +/- 9.03 nmol Fe(2+)/l, TBARS-3.75 +/- 1.03 nmol/ml).

CONCLUSION

Administration and withdrawal of atorvastatin caused changes in markers of oxidative stress which closely correlated with changes in marker of inflammation. Further, the salutary effects were of quick onset, but were rapidly reversed on withdrawal of atorvastatin.

Lactose maldigestion in different age groups of north Indians

Lactase activity with age has been reported in a wide variety of population globally. However, most of these studies in human have ignored to assess age stratified lactose maldigestion. Therefore, the present study was planned to determine lactose maldigestion in different age groups of north Indians adults. Two hundred apparently healthy north Indians (age rage 10-80 years) were subjected to a 50g lactose hydrogen breath test by standard method using a Model 12 Microlyzer from Quintron, USA. The percentage of lactose maldigestion was calculated for different age groups with an interval of 10 years. The results of this study revealed that the frequency of lactose maldigestion did not differ significantly among the age groups. Thus, this study suggests that lactose maldigestion is not associated with age stratification among north Indians.

Necrotizing periorbital Fusarium infection--an emerging pathogen in immunocompetent individuals

Fungal infections of the skin and deeper tissues of the periorbital region are quite rare. We report a case of a localized, deep periorbital necrotizing Fusarium infection in an otherwise healthy, elderly lady. Since the clinical features and histopathological findings of Fusarium infection are by no means characteristic, the definitive diagnosis was achieved with the help of microbiological examination of cultured organisms. A combined medical and surgical therapy led to adequate control of infection. To conclude, localized, deep periorbital necrotizing soft tissue infection by Fusarium in an immunocompetent lady is not reported in literature. One should have a high index of suspicion for emerging fungal pathogens in the differential diagnosis of necrotizing orbital or adnexal conditions, even in an immunocompetent patient. The histologic findings of septate, branching hyphae and vascular invasion cannot distinguish Fusarium species from various other moulds such as Aspergillus species; microbiologic studies are essential for confirming the diagnosis.

Graded balloon atrial septostomy in severe pulmonary hypertension

BACKGROUND

The prognosis of patients with severe primary pulmonary hypertension is poor. The role of balloon atrial septostomy as a palliative procedure in these patients is not well defined. We retrospectively analyzed our data regarding the safety, clinical outcome and survival benefit of graded balloon atrial septostomy in patients with severe pulmonary hypertension.

METHODS AND RESULTS

Eleven patients (7 males), aged 6 to 30 years (mean age 16.2+/-8.9 years), with severe pulmonary artery hypertension (mean pulmonary artery pressure of 76+/-16.9 mmHg) and refractory congestive heart failure and/or recurrent syncope underwent balloon atrial septostomy. Graded balloon dilatation under echocardiographic guidance and arterial oxygen saturation monitoring was done in all the patients. Procedure-related mortality was 18.2%. Significant acute hemodynamic improvement was seen in the survivors (pre-balloon atrial septostomy cardiac index 1.88+/-0.48 L/min/m2; post-balloon atrial septostomy cardiac index 2.18+/-0.37 L/min/m2, p<0.009). Patients were followed up for a mean period of 20.3 months after the procedure (range: 3 months-5 years). There was functional improvement and increased exercise tolerance in all the patients for a mean follow-up period of 14.6 months (NYHA functional class 3.62+/-0.69 to 2+/-0.50). The estimated probability of survival in this cohort at 1 year was only 48%; but 7 of 8 patients (87%) who survived the procedure were alive at 1 year.

CONCLUSION

We conclude that balloon atrial septostomy improves clinical status, hemodynamic variables and possibly also improves survival in selected patients with severe pulmonary artery hypertension. It remains a definite palliative option for refractory primary pulmonary hypertension. However, the procedure-related risks are high in very sick patients and, therefore, balloon atrial septostomy may be advocated early in the course of the disease.

Management of cardiomyopathy resulting from incessant supraventricular tachycardia in infants and children

BACKGROUND

Radiofrequency ablation is considered to be the treatment of choice in patients with ventricular dysfunction related to incessant supraventricular tachycardia. However, reservations regarding its use in infants and children prompted us to try alternative strategies for this group.

METHODS AND RESULTS

Eight children (age range: 1 day to 10 years) were diagnosed to have tachycardia-related ventricular dysfunction in the past 6 years. They presented with symptoms of palpitation, dyspnea and/or generalized swelling over the body of 3 months to 2 years'duration. The cardiothoracic ratio at presentation was 64% (52%-70%) and ejection fraction was 22.2% (15%-45%). In 7 patients tachycardia was diagnosed to be ectopic atrial and in 1 it was permanent junctional reciprocating tachycardia. Six of these children were managed with intravenous/oral amiodarone in combination with digoxin (3) and/or propranolol (2). In one child addition of amiodarone to digoxin and propranolol led to polymorphic ventricular tachycardia, and amiodarone was withdrawn. Only one child underwent radiofrequency ablation as the first choice because regular follow-up was not possible due to logistic reasons. Sinus rhythm with normalization of ventricular function was achieved in 6 of the 7 children treated medically. One child continued to have frequent episodes of tachycardia and underwent successful radiofrequency ablation of a high right atrial ectopic focus. Two out of the 6 patients on amiodarone could be managed with only digoxin and propranolol after their ventricular function had returned to normal. A third patient relapsed on stopping amiodarone and underwent successful radiofrequency ablation of a left atrial ectopic tachycardia.

CONCLUSIONS

Short-term amiodarone in combination with digoxin/propranolol is a safe and effective treatment strategy for infants/children with tachycardiomyopathy. Control of tachycardia is achieved in the majority, leading to recovery of ventricular function. This approach may avoid unnecessary ablations in children or at least postpone it till the procedure would be safer.

Are drugs and catheter ablation effective for treating ventricular arrhythmias in populations that cannot afford implantable cardioverter defibrillators?

Despite recent advances, ventricular arrhythmias continue to pose a therapeutic challenge, especially to the clinician in the developing world. Although the implantable cardioverter defibrillator (ICD) has improved survival in both primary and secondary prevention trials, it still remains a costly modality for the developing world. Even though certain subgroups stand to benefit unequivocally in survival from the ICD, there are others in whom this therapy may not offer a survival benefit over empiric antiarrhythmic drug therapy with amiodarone. The utility of optimized drug therapy (including either amiodarone or sotalol, b-blockers, and angiotensin-converting enzyme inhibitors) needs to be compared with the ICD in a randomized manner in these lower-risk patients with ventricular arrhythmias. The role of conventional catheter ablation techniques is mostly adjunctive to drugs and ICDs, although the newer mapping and ablation techniques may offer greater promise in the future.

Aneurysm of the vein of galen in neonates: report of four cases

In neonates, aneurysm of the vein of Galen often masquerades as cyanotic congenital heart disease. We report 4 cases of neonates presenting with malformation of the vein of Galen at our insititution. An increased awareness of this entity seems warranted.

Etiology and management of sustained ventricular tachycardia

Ventricular tachyarrhythmias secondary to a variety of underlying cardiovascular problems pose a therapeutic challenge to the clinician. The initial presentation may be as sudden cardiac death, which underlies its public health problem. The underlying conditions predisposing to this arrhythmia include ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmiogenic right ventricle dysplasia and certain postoperative states including corrective surgery for tetralogy of Fallot and valve replacement. Other causes include prolonged QT syndrome, idiopathic right and left ventricle tachycardia and bundle branch re-entry tachycardia. Ischaemic heart disease is the most common cause of ventricular tachycardia and therapy has evolved considerably over the past two decades. The development of and refinements in the implantable cardioverter-defibrillator (ICD) have introduced a new dimension in therapeutic options and markedly improved survival in these patients. Insights in the dichotomy between arrhythmia suppression and total mortality have reoriented drug therapy with a decrease in the use of sodium channel blockers. beta-blockers have emerged as antiarrhythmic drugs in their own right and their synergistic effects with amiodarone have strengthened the antiarrhythmic drug arm. The role of these drugs in patients with hemodynamically stable ventricular tachycardia, especially in relatively preserved ventricles needs to be explored. Catheter ablation techniques have provided curative therapy in patients with idiopathic and bundle branch reentry tachycardia. Further advances in radiofrequency ablation, including use of newer mapping techniques, promise a greater role for ablation of ischemic ventricular tachycardia in the future. A hybrid approach consisting of drugs, catheter ablation and/ or ICD may provide effective therapeutic approach in some situations. Further innovations and technologic developments promise a further reorientation in therapy towards identification and treatment of the underlying arrhythmogenic substrate.

Aortic valve balloon dilatation in a newborn for critical aortic stenosis diagnosed during fetal life

A young primigravida was diagnosed to have a fetus with critical aortic stenosis at 30 weeks' gestation. A decision to follow-up the fetus till term was taken as there was no evidence of congestive heart failure. Post-natal retrograde aortic valve balloon dilatation was performed 36 hours after birth. There was marked improvement in left ventricular function and the baby is doing well at 1-year follow-up. The need for accurate assessment of intracardiac anatomy during fetal life in critical aortic stenosis and its impact on therapeutic interventions is highlighted.

Differences in the microtubule organization between normal and cml granulocytes after stimulation with chemotactic peptide

Chemotaxis of polymorphonuclear leukocytes (PMNL) from chronic myeloid leukemia (CML) patients followed in a gradient of a chemotactic peptide n-formyl-methionyl-leucyl-phenylalanine (fMLP) is consistently defective in all the phases of the disease. Chemoattractant-induced polymerization of cytoskeletal proteins (actin and tubulin) plays a major role in regulation of cell shape and cellular motility. To study the role of microtubules in defective chemotaxis, we have compared fMLP-induced alterations in organization of microtubules in PMNL from CML patients with those from normal subjects by laser confocal microscopy. Our analysis shows differences in microtubule organization between normal and CML PMNL and suggests that both nucleation of new microtubule and elongation of pre-existing microtubules are essential for PMNL chemotaxis.

Does treatment change the outcome of seizures and computerized tomographic lesions in intracranial granulomas?

In children, intracranial granuloma diagnosed on computerized tomography (CT) scan and presenting with seizures as the sole manifestation has traditionally been treated with antitubercular (ATB) therapy or albendazole (Alb) in addition to antiepileptic drugs (AED). This study was conducted to determine whether AED therapy alone or specific treatment (ATB + Alb) influences the outcome of seizures and the CT lesion. Sixty-eight children presenting with seizures along with intracranial granuloma on CT scan were selected for the study. They were randomly divided into two groups. Group A (n = 34) was treated with AED alone and group B (n = 34) received antitubercular therapy and albendazole in addition to AED. Seizure type was noted and electroencephalogram (EEG) and CT scan were done in all. They were followed up for a period of 2 to 9 years, during which a record of seizure count and type was maintained. CT scans were repeated at 3 monthly intervals and EEGs were repeated whenever indicated. Four patients in each group were lost to follow-up. Seizures persisted in four out of 30 in group A and six out of 30 in group B. There was no statistically significant difference (p > 0.05) in the outcome of seizures in the two groups. Taking the whole group together (n = 60), of the 13 who had presented with multiple seizures at onset, epilepsy was a sequela in five (p < 0.05); and of the 17 in whom the lesion had calcified, seizures persisted in seven (p < 0.05), irrespective of treatment modality. In conclusion, though specific treatment did not alter the outcome of seizures, children with multiple seizures at presentation and calcification of CT lesion had epilepsy as a sequela.

Histopathologic changes are not specific for diagnosis of gastric antral vascular ectasia (GAVE) syndrome: a review of the pathogenesis and a comparative image analysis morphometric study of GAVE syndrome and gastric hyperplastic polyps

We studied the nonspecific nature of the histologic findings in the gastric antral vascular ectasia (GAVE) syndrome by using a morphometric comparison with common gastric lesions including hyperplastic polyps and gastritis. Five clinicopathologically confirmed cases of GAVE syndrome and 41 cases of gastric hyperplastic polyps were diagnosed during a 5-year interval at Summa Health Systems (Akron, Ohio). These cases, as well as 16 randomly selected cases of nonspecific gastritis and 9 normal gastric antral biopsy specimens, were evaluated. A semiquantitative comparison of the light microscopic findings believed to be essential in diagnosis of GAVE syndrome, including vascular hyperplasia, mucosal vascular ectasia, intravascular fibrin thrombi, and fibromuscular hyperplasia, was performed. Image analysis morphometric measures of the area ratio (vascular area/total biopsy area), mean vascular area, and number of ectatic vessels per square millimeter of tissue were performed on the CAS 200 Image Analyzer (Becton Dickinson, San Jose, Calif). By morphometric and statistical parametric analysis, several histopathologic variables, including area ratio, mean vascular area, mucosal vascular ectasia, and fibromuscular hyperplasia, did not confidently differentiate the histologic features of gastric hyperplastic polyp from those of GAVE syndrome, but did apparently differentiate GAVE syndrome from gastritis and normal gastric mucosa. The propensity of gastric hyperplastic polyps to undergo prolapse changes and prolapse as one proposed mechanism for development of the GAVE syndrome lesion probably accounts for this morphologic similarity. Specific diagnostic histopathologic changes probably do not exist for the GAVE syndrome.

Phagocyte chemoattractant receptors

Myeloid cells are attracted and activated by a variety of chemoattractants that bind to G protein-coupled receptors. In the past few years, the receptors for the classical chemoattractants (fMLF, C5a, PAF) and the chemotactic cytokines, known as C-X-C and C-C chemokines, have been cloned from myeloid cells. This review briefly describes recent advances in structure-function relationships of chemotactic receptors in human leukocytes as well as activation of signaling pathways and regulation of receptor function. In neutrophils, the binding of chemoattractants mainly activates the Gi2 protein inducing PIP2 hydrolysis and activation of the MAP kinase pathway. The C-C chemokine receptor, CC CKR5, and a chemokine receptor homologue, named fusin, have been shown to be the major cofactors for HIV-1 entry in macrophages and T cells. Recent studies suggest that the phosphorylation of chemoattractant receptors is a key event that regulates their biological function.

Internalization and recycling of the C5a anaphylatoxin receptor: evidence that the agonist-mediated internalization is modulated by phosphorylation of the C-terminal domain

The C5a anaphylatoxin receptor is a member of the G protein-coupled receptor family involved in chemoattraction and activation of myeloid cells, as well as in host defence against infection by Pseudomonas aeruginosa. Upon challenge by C5a, the C5a receptor undergoes a rapid phosphorylation on serine residues in the carboxyl-terminal region. In this study, we used cells stably transfected with either the wild-type C5a receptor, or mutants affected in their capacity to be phosphorylated, to examine the role played by phosphorylation in the intracellular trafficking of the C5a receptor. Upon agonist binding, the wild-type receptor was rapidly internalized into endosomes that cluster near the nucleus after 10 minutes. Internalization of a non-phosphorylable mutant was severely impaired relative to wild-type receptor, whereas a mutant phos-phorylated on serine 327 and/or serine 338, showed a rate of internalization intermediate between that of wild-type receptor and that of the non-phosphorylable mutant. Under continuous exposure to C5a and in the absence of protein synthesis, the C5a receptor was maintained in a highly phosphorylated state but was not degraded. Confocal microscopy and ligand-binding studies indicated that internalized receptors were recycled to the plasma membrane. During this process, receptors were dephosphorylated with kinetics that correlated with the kinetics of receptor recovery on the cell surface. Altogether, our data suggest that phosphorylation plays a key role in the intracellular trafficking of the C5a receptor. Phosphoryl-ated receptors might be recognized by an adaptor protein that interacts with the endocytic machinery.

Genital tuberculosis--a major pelvic factor causing infertility in Indian women

OBJECTIVE

To study the effect of tuberculosis, a common infectious disease in the Indian subcontinent, on the female pelvic factor and its subsequent effect on female fertility.

DESIGN

Retrospective case studies.

SETTING

Department of Infertility Management and Assisted Reproduction, Jaslok Hospital and Research Centre, Bombay, India.

PATIENT(S)

Three hundred women, between the ages of 25 and 35 years, with tubal factor as a cause of their infertile state.

RESULT(S)

One hundred seventeen women with a tubal factor were found to have tuberculosis as the cause of tubal blockage. On laparoscopy, 49.5% were found to have simple tubal blockage, 15.3% showed tubo-ovarian masses, and 23.9% had a frozen pelvis. Seventy-five percent complained of menstrual irregularities, thus indicating endometrial involvement; 25.6% of these women underwent an IVF procedure. The pregnancy rate after IVF-ET was 16.6% per transfer.

CONCLUSION(S)

This study highlights the fact that tuberculosis, a chronic infectious disease, is one of the major etiologic factors of female tubal infertility, especially on the Indian subcontinent.

Monoclonal antibody 14E recognizes an antigen common to human oligodendrocytes, Schwann cells, Bergmann glia, and a subpopulation of reactive glia

The monoclonal antibody 14E immunocytochemically stains the nuclear membrane of oligodendrocytes but not myelin in tissue sections of adult normal human white matter. The nuclear membranes of Schwann cells in human peripheral nerve and cerebellar Bergmann glia were also visualized with this antibody. In actively demyelinating multiple sclerosis plaques the 14E antibody stained increased numbers of oligodendrocytes and the nuclei, perikarya and cell processes of hypertrophic glia, which were often multinucleate. Scattered small groups of these hypertrophic glia were present in areas of dense astrogliosis in acute plaques. The 14E-positive hypertrophic cells could be either a subpopulation of reactive astrocytes or bipotential glial precursors.

Monitoring of cyclosporine concentrations by using dry blood-spot samples

We modified the Incstar Cyclo Trac SP kit to enable its use with dry blood-spots on filter paper. The recovery ranged from 92 to 106%. Dilution studies have shown excellent linearity and parallelism throughout the range of the assay. Precision is demonstrated by within-assay CV's of 6.6 and 4.3% at 96 and 342 micrograms/L respectively and between-assay CV's of 9.1 and 7.0% at 138 and 506 micrograms/L respectively. A comparison study (n = 209) with whole blood assay gave a correlation coefficient of 0.97, a slope of 1.04, and an intercept of 13.2. Whole blood and dry blood-spot cyclosporine assays on heart, kidney, liver, and lung transplants were also compared.