An objective way to predict remission and relapse in Cushing disease using Bayes' theorem of probability

OBJECTIVE

In this study on patients with Cushing disease, post-transsphenoidal surgery (TSS), we attempt to predict the probability of remaining in remission, at least for a year and relapse after that, using Bayes' theorem and the equation of conditional probability. The number of parameters, as well as the weightage of each, is incorporated in this equation.

DESIGN AND METHODS

The study design was a single-centre ambispective study. Ten clinical, biochemical, radiological and histopathological parameters capable of predicting Cushing disease remission were identified. The presence or absence of each parameter was entered as binary numbers. Bayes' theorem was applied, and each patient's probability of remission and relapse was calculated.

RESULTS

A total of 145 patients were included in the study. ROC plot showed a cut-off value of the probability of 0.68, with a sensitivity of 82% (range 73-89%) and a specificity of 94% (range 83-99%) to predict the probability of remission. Eighty-one patients who were in remission at 1 year were followed up for relapse and 23 patients developed relapse of the disease. The Bayes' equation was able to predict relapse in only 3 out of 23 patients.

CONCLUSIONS

Using various parameters, remission of Cushing disease can be predicted by applying Bayes' theorem of conditional probability with a sensitivity and a specificity of 82% and 94%, respectively. This study provided an objective way of predicting remission after TSS and relapse in patients with Cushing disease giving a weightage advantage to every parameter.

Early Bone Mineral Density Changes and Endocrinal Dysfunction in Childhood Brain Tumor Patients: A Prospective Study

PURPOSE/OBJECTIVE(S)

Reduced bone mineral density (BMD) and hormonal dysfunction are considered as a late effect of cranial radiation (RT). Only few studies have reported the occurrence of these problems soon after the diagnosis of brain tumor or RT initiation, emphasizing that these are not necessarily the late effects of RT. Thus, we conducted the study to analyze the incidence of low BMD and hormonal dysfunction prior to or within 6 months of RT (early change) in children with brain tumors.

MATERIALS/METHODS

The study was conducted as a part of intramural funding program at a tertiary care center in India. Childhood and adolescent brain tumor patients were advised for dual energy X-ray absorptiometry scan (DXA) and hormonal evaluation prior to RT. In some patients, first DXA was done within 6 months of RT due to logistics. To see the effect of radiation, we have planned to repeat hormonal evaluation after 6 and 12 months and DXA after 12 months of RT.

RESULTS

Twenty-five patients were analyzed. Median age at diagnosis was 11 years with a male to female ratio of 5.2:1. Medulloblastoma was the commonest diagnosis (n = 12), followed by glioma (n = 8), pineal tumors (n = 3) and ependymoma (n = 2). Nineteen and six patients underwent DXA before RT and within 6 months of RT respectively. For BMD assessment, Z score was calculated at hip and lumbar spine. BMD was defined as low (Z score = -1 to-1.99), very low (Z score = -2 to -2.5) and secondary osteoporosis (Z score ≤ -2.5). Median Z score at femur neck and spine was -2 and -1.9 respectively. Overall; 6, 3 and 9 patients had normal, low and very low BMD respectively. Seven patients had secondary osteoporosis (Table 1). Two patients with secondary osteoporosis had low vitamin D levels. None of the patient had compression fracture. On statistical analysis, no correlation was found between BMD changes and age, sex and site of the tumor. Pre RT endocrinal assessment (N = 25) was done by tanner staging and serum hormonal levels (GH, T3/T4/TSH, ACTH, cortisol and prolactin). Gonadal hormonal assessment was done in children with early or delayed puberty. Three patients were found to have endocrinal abnormality before RT (precautious puberty, central hypothyroidism and low sex hormones in 1 patient each). Follow up DXA and hormonal evaluation are awaited to see the effect of RT.

CONCLUSION

The index study is one of the very few studies evaluating the early changes in BMD and hormonal dysfunction soon after brain tumor diagnosis or within 6 months of RT. We observed that a significant proportion of children had reduced BMD and hormonal dysfunction before RT, highlighting the importance of early assessment and referral to the specialist for better quality of life. Table 1: BMD and endocrinal dysfunction before or within 6 months of RT.

Utility of myxedema score as a predictor of mortality in myxedema coma

OBJECTIVE

Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking.

DESIGN AND METHODS

All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients.

RESULTS

A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine.

CONCLUSION

Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.

Unravelling a novel, promising and convenient tool for differential diagnosis of delayed puberty: GnRHa-stimulated inhibin B (GnRH-iB)

BACKGROUND

Etiological diagnosis of delayed puberty is difficult. Despite availability of various basal and stimulation tests differentiation between constitutional delay in puberty and hypogonadotropic hypogonadism is still challenging.

OBJECTIVE

To elucidate the role of GnRH agonist-stimulated inhibin B (GnRH-iB) for the differential diagnosis of delayed puberty.

STUDY DESIGN

Participants were recruited into "exploratory cohort" (n = 39) and "validation cohort" (n = 16). "Exploratory cohort" included children with spontaneous puberty and patients with hypogonadotropic hypogonadism. "Validation cohort" constituted children who presented with delayed puberty.

INTERVENTION AND OUTCOME

GnRHa (Triptorelin) stimulation test along with measurement of inhibin B level at 24 h after GnRHa injection was performed in all the study participants. Cut-offs for GnRH-iB were derived from the "exploratory cohort". These cut-offs were applied to the "validation cohort". Basal LH, basal inhibin B(INH-B), GnRHa-stimulated LH at 4 h (GnRH-LH) and GnRH-iB were evaluated for the prediction of onset of puberty on prospective follow-up.

RESULTS

GnRH-iB at a cut-off value of 113.5 pg/ml in boys and 72.6 pg/ml in girls had 100% sensitivity and specificity for the documentation of puberty. In the "validation cohort" basal LH, basal INH-B, GnRH-LH, and GnRH-iB had a diagnostic accuracy of 68.75%, 81.25%, 68.75% and 93.75% respectively, for the prediction of onset of puberty. Basal LH, basal INH-B and GnRH-LH used alone or in combination were inferior to GnRH-iB used alone.

CONCLUSION

GnRHa-stimulated inhibin B (GnRH-iB) is a convenient and easily employable test for the differentiation of constitutional delay in puberty from hypogonadotropic hypogonadism.

CTRI REGISTRATION NO

CTRI/2019/10/021570.

Remission in Cushing's disease is predicted by cortisol burden and its withdrawal following pituitary surgery

AIM

To ascertain the predictors of remission and relapse in patients of Cushing's disease (CD) undergoing pituitary transsphenoidal surgery (TSS).

METHODS

Patients with CD subjected to TSS over 35 years at a tertiary care center were included. Patients were grouped into remission and persistent disease at 1 year after surgery, and were further followed up for relapse. Demographic, clinical, biochemical, histological, radiological and post-operative follow-up parameters were analyzed.

RESULTS

Of the 152 patients of CD, 145 underwent TSS. Remission was achieved in 95 (65.5%) patients at 1 year. Patients in remission had shorter duration of symptoms prior to presentation (p = 0.009), more frequent presence of proximal myopathy (p = 0.038) and a tumor size of < 2.05 cm (p = 0.016) in comparison to those with persistent disease. Post-TSS, immediate post-operative 0800-h cortisol (< 159.85 nmol/L; p = 0.001), histological confirmation of tumor (p = 0.045), duration of glucocorticoid replacement (median 90 days; p = 0.001), non-visualization of tumor on MRI (p = 0.003), new-onset hypogonadism (p = 0.001), 3-month 0800-h cortisol (< 384.9 nmol/L; p = 0.001), resolution of diabetes (p = 0.001) and hypertension (p = 0.001), and recovery of hypothalamic-pituitary-adrenal axis (p = 0.018) favored remission. In logistic regression model, requirement of glucocorticoid replacement (p = 0.033), and resolution of hypertension post-TSS (p = 0.003) predicted remission. None of the parameters could predict relapse.

CONCLUSION

The study could ascertain the predictors of remission in CD. Apart from the tumor characteristics, surgical aspects and low post-operative 0800-h cortisol, the results suggest that baseline clinical parameters, longer glucocorticoid replacement, and resolution of metabolic complications post-TSS predict remission in CD. Long-term follow-up is essential to look for relapse.

Dysregulated mitogen-activated protein kinase pathway mediated cell cycle disruption in sporadic parathyroid tumors

OBJECTIVES

The study was designed to evaluate expression profiling of mitogen-activated protein kinase (MAPK) signalling pathway genes in sporadic parathyroid adenoma.

METHODS

Expression of MAPK signalling pathway genes including activated transcription factors and cell cycle regulatory genes was analysed by real-time PCR- based array in parathyroid adenoma (N = 20) and normal parathyroid tissue (N = 4).

RESULTS

MAPK signalling pathway as studied by PCR array revealed that a total of 22 genes were differentially expressed (≥ twofold change, p ≤ 0.05) in parathyroid adenoma. Up-regulated genes were ARAF, MAPK12, CREBBP, MYC, HSPB1, HRAS, CDK4, CCND1, and E2F1, and down-regulated genes were MAP4K1, DLK1, MAP3K4, MAPK10, MAPK8, ATF2, SMAD4, MEF2C, LAMTOR3, FOS, CDKN2A CDKN2B, and RB1. The present study revealed that ERK1/2 signalling pathway with up-regulation of HRAS, ARAF, and MEK1 genes and up-regulation of positive regulators of cell cycle (CCND1, CDK4, and E2F1) and down-regulation negative regulators of cell cycle (CDKN2A, CDKN2B, and RB1) made highly dysregulated MAPK signalling pathway in parathyroid adenoma. Expression of CDK4 was positively associated with plasma PTH level (r = 0.60, p = 0.04) and tumor weight (r = 0.80, p = 0.02) of the adenoma patients, respectively. Expression of CDKN2A was correlated negatively with PTH level (r = - 0.52, p = 0.04) of the adenoma patients.

CONCLUSION

The current study revealed that ERK pathway and associated cell cycle regulator genes are dysregulated in sporadic parathyroid adenoma.

New Limit on the Permanent Electric Dipole Moment of ^{129}Xe Using ^{3}He Comagnetometry and SQUID Detection

We report results of a new technique to measure the electric dipole moment of ^{129}Xe with ^{3}He comagnetometry. Both species are polarized using spin-exchange optical pumping, transferred to a measurement cell, and transported into a magnetically shielded room, where SQUID magnetometers detect free precession in applied electric and magnetic fields. The result from a one week measurement campaign in 2017 and a 2.5 week campaign in 2018, combined with detailed study of systematic effects, is d_{A}(^{129}Xe)=(1.4±6.6_{stat}±2.0_{syst})×10^{-28}  e cm. This corresponds to an upper limit of |d_{A}(^{129}Xe)|<1.4×10^{-27}  e cm (95% C.L.), a factor of 5 more sensitive than the limit set in 2001.

Effect of Linagliptin on Incretin-axis and Glycaemic Variability in T1DM

BACKGROUNDS AND OBJECTIVES

Short-term studies have demonstrated potential therapeutic efficacy of dipeptidyl peptidase 4 inhibitors (DPP4 inhibitors) in patients with poorly controlled T1DM. In this study we evaluated the effect of DPP4 inhibitor, linagliptin, on glycaemic control and variability, and incretinaxis in well controlled T1DM patients to mitigate the effect of glucotoxicity on incretin secreting cells.

METHODS

Twenty T1DM patients were randomized to receive either linagliptin (10 patients, dose-5 mg/day) or placebo (10 patients), in addition to insulin for 3 months. HbA1C, continuous glucose monitoring (CGM) and mixed meal test (MMT) were performed before and at the end of the study period.

RESULTS

HbA1C reduction and change in glycaemic variability and insulin requirement in the linagliptin group did not attain the level of statistical significance. The increase in AUC GLP1 (Area under curve for GLP1) and decrease in AUC glucagon (Area under curve for glucagon) during the MMT in linagliptin group were also statistically insignificant.

INTERPRETATIONS AND CONCLUSIONS

Linagliptin is not effective in reducing HbA1C and glycaemic variability in relatively well controlled T1DM patients.

Epidemiology and resistance pattern of bacterial isolates among cancer patients in a Tertiary Care Oncology Centre in North India

OBJECTIVES

To examine the epidemiology of microbiologically documented bacterial infection and the resistance pattern, among cancer patients undergoing treatment at RGCIRC, Delhi.

DESIGN AND SETTING

Retrospective observational study in which culture reports obtained over 1 year in 2013, were analyzed.

RESULTS

13329 cultures were obtained over 1 year in 2013 and were analyzed. 23.6 % samples showed positive culture with majority being gram negative isolates (67.9 %). E. coli was the commonest gram negative isolate (49.4%) followed by klebsella (29.7%) and Staph. aureus was the commonest gram positive isolate. There was high incidence of ESBL in blood and urine (87.2% & 88.5%) and BLBLI were also high (78% & 83.9%). Carbapenem resistance was comparatively low (10%) and colistin sensitivity was quiet high (> 95%).

CONCLUSIONS

Prevalence of MRSA and VRE in our institute is very less, whereas prevalence of ESBLs and BLBLI isolates amongst gram negative infections is around 80%. Gram negative isolates had poor sensitivity to cephalosporins and fluoroquinolones.

Epidemiology of bacterial isolates among pediatric cancer patients from a tertiary care oncology center in North India

BACKGROUND

Infections are a major cause of morbidity and mortality in pediatric oncology. Resistance pattern of bacterial isolates determine empiric antibiotic therapy and influence outcome.

AIMS

This study was planned to determine profile of bacterial isolates and their antibiotic resistance pattern among pediatric cancer patients.

DESIGN

It was a retrospective, single institutional study.

MATERIALS AND METHODS

The study was carried out in the department of pediatric hematology-oncology of a tertiary care cancer centre in north India over a period of 24 months (2012-2014). Microbiological data pertaining to pediatric cancer patients, less than 18 yrs of age was analysed.

RESULTS

Hence, 238 bacterial isolates were cultured from among 1757 blood, urine and other specimens. Gram negative bacteria were the most common (74%) pathogens identified and E. coli and Klebsiella comprised 80% of them. A high incidence of extended spectrum beta lactamase producing organisms (84%), beta-lactam beta-lactamase inhibitor (78%) and carbapenem resistance was observed (29%). Blood stream infection with multi-drug resistant Klebsiella was associated with high mortality. The gram positive bacteria isolated were predominantly staphylococcus aureus and were antibiotic sensitive. Reduction in the number of culture positive isolates in the second year of our study was probably due to rigorous implementation of infection control measures.

CONCLUSION

These results on microbiologic profile and antibiotic sensitivity pattern of the isolates will be extremely helpful in revision of antibiotic guidelines for our patients and in developing strategies for coping with high prevalence of multi-drug resistance. Antibiotic stewardship and strict implementation of infection control practices will be important components of this effort.

Vitamin D levels during and after resolution of ketoacidosis in children with new onset Type 1 diabetes

AIM

To study the effect of ketoacidosis on measured 25-hydroxyvitamin D3 in children with new onset Type 1 diabetes.

METHODS

Measurement of pH and bicarbonate levels was carried out in children with newly diagnosed Type 1 diabetes at presentation with ketoacidosis. 25-hydroxyvitamin D3 estimation was carried out at presentation (timepoint 1) and 1 month later (timepoint 2). There was no significant difference in the mean (±sd) 25-hydroxyvitamin D3 levels [35.39 (±25.79) vs 39.63 (±48.03) nmol/L; P = 0.661) at the two timepoints in the study.

RESULTS

Correlation analysis revealed a positive correlation between bicarbonate levels and timepoint 1, i.e. the lower the bicarbonate levels, the lower were the timepoint 1 levels and vice versa (correlation coefficient 0.538, P = 0.001). Timepoint 2 levels also showed a positive correlation with serum bicarbonate levels with a correlation coefficient of 0.379 (P = 0.032). None of the variables other than bicarbonate,.(age, gender, BMI, pH or time), was found to have the predictive ability for timepoint1 levels. Similarly for predicting timepoint 2 levels, BMI was found to have independent predictive ability in addition to bicarbonate.

CONCLUSIONS

Severe ketoacidosis, as judged by bicarbonate but not pH, may transiently lower 25-hydroxyvitamin D3 levels in children with new onset Type 1 diabetes. Persistence of low 25-hydroxyvitamin D3 levels after resolution of ketoacidosis suggests a state of permanent vitamin D deficiency in our patient population.

Influence of 4- and 6-color flow cytometers and acquisition/analysis softwares on the determination of lymphocyte subsets in HIV infection

BACKGROUND AND OBJECTIVES

Lymphocyte immunophenotyping provides valuable information for the diagnosis and monitoring of patients with cellular immunodeficiencies, such as HIV/AIDS. In this study, we have assessed the influence of 4-color and 6-color flow cytometers, and respective analytical softwares on the enumeration of lymphocytes in HIV infected individuals.

METHODS

The expression of various cell surface markers on lymphocytes was measured from the EDTA blood of 66 HIV infected patients on the FACSCalibur (4-color) and FACSCanto (6-color) flow cytometers. Percentage of lymphocytes expressing a particular cell surface marker was analyzed on FACSCalibur using the Cell Quest Pro software (v 5.2), while the analysis on FACSCanto was done using FACSCanto (v 1.0.3) and FACSDiva (v 4.1) softwares respectively.

RESULTS

The data shows significantly higher mean CD3 T-cell counts on FACSCalibur, Cell Quest Pro (1,864 +/- 1,044 cells/microl) as compared to FACSCanto (1,840 +/- 1,040 cells/microl) (P < 0.05). The CD4 T-cell counts were also higher on FACSCalibur, Cell Quest Pro (885 +/- 770 cells/microl), and FACSDiva (892 +/- 773 cells/microl) versus FACSCanto (867 +/- 767 cells/microl) (P < 0.05). FACSCalibur, Cell Quest Pro, and FACSDiva showed similar values except for CD8 T-lymphocytes where FACSDiva had significantly lower values (P < 0.05). The B-cell counts were unaffected when either of the instruments or softwares were used, while the natural killer (NK) cells (CD16 + 56 positive cells) showed similar trend like CD3 and CD4 counts with significant differences in the mean cell counts between FACSCalibur, Cell Quest Pro (240 +/- 165 cells/microl), and FACSDiva (238 +/- 163 cells/microl) versus FACSCanto with higher NK cell counts (260 +/- 176 cells/microl).

CONCLUSIONS

The enumeration of lymphocyte subsets was comparable between FACSCalibur, Cell Quest Pro, and FACSDiva, based analysis and it was significantly different than FACSCanto software based analysis. Our observations suggest that FACSDiva software should be preferred over the FACSCanto software for immunophenotyping on FACSCanto flow cytometer and the laboratories should report the instrument and software used for the specimen analysis while reporting immunophenotyping results.

Biochip array-based analysis of plasma cytokines in HIV patients with immunological and virological discordance

Assessment of cytokines in body fluids or cells provides important information in understanding the disease process and designing treatment strategies. Recent introduction of antibody-based protein arrays have provided investigators simultaneous and specific detection of multiple analytes in a single sample using minimum volumes. In this study, we used a biochip array system capable of measuring 12 cytokines and growth factors (IL-2, IL-4, IL-6, IL-8, IL-10, IL-1alpha, IL-1beta, IFN-gamma, TNF-alpha, monocyte chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGF) and epidermal growth factor (EGF)) in HIV patients with immunological and virological discordance (discordant) to find out differences if any, in their plasma cytokine profiles when compared with concordant HIV-infected individuals. A sandwich chemiluminescent assay was performed with plasma specimens of 110 HIV patients (55 discordant, 55 concordant) and 22 normal healthy individuals followed by enzyme-linked immunosorbent assay (ELISA) to the confirm levels of cytokines and growth factors that showed significant differences in the two groups. The discordant HIV patients showed significantly higher levels of plasma VEGF (P = 0.001) and EGF (P = 0.034) levels when compared with concordant patients. Overall, the patients showed significantly higher levels of TNF-alpha, MCP-1 and VEGF when compared with the normal healthy controls (P < 0.05). ELISA for VEGF (P < 0.001) and EGF (P = 0.004) confirmed the comparison obtained with biochip array, between the discordant and concordant patients. The results of cytokine quantitation by biochip array and ELISA confirmed that this technology is not only comparable but also has a good potential in the future applications involving measurement of multiple cytokines with limiting specimens.

Bcl2 and ROS1 expression in human meningiomas: an analysis with respect to histological subtype

Tumors of the central nervous system account for approximately 9% of all primary neoplasm in humans, while tumors of covering elements, the meninges, account for 13-19% and constitute the second largest group of brain tumors. These are known to exhibit a variety of chromosomal abnormalities besides change in the expression level of certain oncogenes. Among oncogenes, bcl2, an anti-apoptotic factor and ROS1 that encodes a protein with a structure similar to the epidermal growth factor (EGF) and insulin receptor and has a tyrosine kinase activity, have been shown to be associated with many malignant tumors. In the present study we have analysed the expression of bcl2 using immuno-histochemistry and ROS1 expression by reverse-transcription coupled with polymerase chain reaction (RT-PCR) of the transcript using primers specific for the intra-cellular domain and then tried to correlate the findings with the subtype of the meningioma defined on the basis of histology. Out of the six bcl2 positive cases in our study, there were three transitional tumors, two fibroblastic and one recurrent meningioma subtype. bcl2 seemed to be more consistently expressed in the cytoplasm of spindle cell component of meningiomas. Thirteen meningiothelial meningiomas did not show any staining for bcl2. ROS1 gene expression could be detected in 4 tumors all of those were Grade-I meningothelial meningiomas. One of the malignant meningioma included in the study was clearly negative for bcl2 as well as ROS1. Thus bcl2 and ROS1 oncogene expression in meningiomas are not concurrent and neither can be ascribed to any histologic subtype or grade of tumor.

Incidence of lamivudine resistance associated mutations in pol-gene of HIV-1 in patients from north India: a preliminary report

Screening of drug-resistant variants is very important for the effective clinical management of HIV-infected patients and development of new strategies. The present study was aimed to detect codon-184 mutations in the pol-gene of HIV leading to resistance to lamivudine (3-TC) by nested cum ARMS-PCR approach in 10 treated and 9 treatment naive patients. For correlation the whole blood CD4/CD8 cell counts and the soluble TNFRII levels in plasma were also determined. Of the 19 patients tested, mutant variants were observed in 2 patients (Met Val in one and Met Val & lle in second) both being treated with 3-TC. No mutations were detected in the treatment-naive patients. The results confirmed that, drug resistant variants of codon-184 emerge rapidly in patients receiving 3-TC containing regimens including our population, which is mainly infected with subtypeC of the virus that could be detected along with wild viral population using sensitive approaches such as ARMS-PCR.

Efficacy of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors for prevention of stroke

OBJECTIVE

To determine if 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are effective in preventing fatal and nonfatal strokes in patients at increased risk of coronary artery disease.

DESIGN

Meta-analysis of randomized controlled trials. Clinical trials were identified by a computerized search of MEDLINE (1983 to June 1996), by an assessment of the bibliographies of published studies, meta-analyses and reviews, and by contacting pharmaceutical companies that manufacture statins. Trials were included in the analysis if their patients were randomly allocated to a statin or placebo group, and reported data on stroke events. Thirteen of 28 clinical trials were selected for review. Data were extracted for details of study design, patient characteristics, interventions, duration of therapy, cholesterol measurements, and the number of fatal and nonfatal stroke events in each arm of therapy. Missing data on stroke events were obtained by contacting the investigators of the clinical trials.

MAIN RESULTS

Among 19,921 randomized patients, the rate of total stroke in the placebo group was 2.38% (90% nonfatal and 10% fatal). In contrast, patients who received statins had a 1.67% stroke rate. Using an exact stratified analysis, the pooled odds ratio (OR) for total stroke was 0.70 (95% confidence interval [CI] 0.57, 0.86; p =.0005). The pooled OR for nonfatal stroke was 0.64 (95% CI 0.51, 0.79; p =.00001), and the pooled OR for fatal stroke was 1.25 (95% CI 0.71, 2.24; p =.4973). In separate analyses, reductions in total and nonfatal stroke risk were found to be significant only for trials of secondary coronary disease prevention. Regression analysis showed no statistical association between the magnitude of cholesterol reduction and the relative risk for any stroke outcome.

CONCLUSIONS

The available evidence clearly shows that HMG-CoA reductase inhibitors reduce the morbidity associated with strokes in patients at increased risk of cardiac events. Data from 13 placebo-controlled trials suggest that on average one stroke is prevented for every 143 patients treated with statins over a 4-year period.

Clinical and laboratory evolution of a culture-confirmed case of human granulocytic ehrlichiosis

A 74-year-old man from suburban New York City, who was hospitalized because of chest pain and fever, was diagnosed as having human granulocytic ehrlichiosis on the eighth hospital day. Although leukocyte and platelet counts were normal on admission, they fell to abnormally low values then normalized prior to specific therapy against the human granulocytic ehrlichiosis agent. Intracytoplasmic inclusions suggestive of Ehrlichia were observed in up to six percent of granulocytes, and the human granulocytic ehrlichiosis bacterium was cultured in an HL 60 human promyelocytic cell line. The patient improved dramatically within 24 hours of doxycycline treatment, after failing to improve on various beta lactam antimicrobial agents. He was discharged from the hospital 14 days after admission. Because human granulocytic ehrlichiosis was not diagnosed until his eight hospital day, clinical and laboratory parameters prior to specific treatment were available. This case illustrates the clinical and laboratory evolution of the infection with human granulocytic ehrlichiosis agent in humans.