Pneumonia hospitalizations and mortality in children 3 - 24-month-old in Nigeria from 2013 to 2020: Impact of pneumococcal conjugate vaccine ten valent (PHiD-CV-10)

Pneumococcal conjugate vaccine ten valent (PCV 10) was introduced into Nigeria in three phases. Phase 3 introduction started in August 2016. However, its impact on pneumonia admissions and mortality among vaccinated Nigerian children has not been determined. Data in the period before PCV-10 introduction (3 August 2013-2 August 2016), and after (3 August 2017-2 August 2020) were retrospectively extracted from the medical charts of eligible patients aged 3-24 months with hospitalized radiological pneumonia at the University College Hospital (UCH), Ibadan; National Hospital (NH), Abuja; and Federal Teaching Hospital (FTH), Gombe, allowing for an intervening period of 1 year. Proportions of the patients with hospitalized pneumonia and case fatality rates were determined during both periods. The results were compared using z-test, multiple logistic regression analysis and p < .05 was considered significant. Adjusted pneumonia hospitalization rates between the two periods increased at the NH Abuja (10.7% vs 14.6%); decreased at the UCH, Ibadan (8.7% vs 6.9%); and decreased at the FTH, Gombe (28.5% vs 18.9%). Case fatality rates decreased across all the sites during the post-PCV introduction period: NH Abuja, from 6.6% to 4.4% (p = .106); FTH, Gombe, 11.7% to 7.7% (p = .477); and UCH, Ibadan, 2.0% to 0% (p = .045); but only significant at Ibadan. Overall, proportion of hospitalized pneumonia cases decreased after 3 years of PCV 10 introduction into the National Immunization Programme in Nigeria. The case fatality rate during post-PCV 10 introduction decreased at all the three sites, but this difference was significant at the UCH, Ibadan.

Two-year follow-up of 196 interstitial lung disease patients after ICU stay

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9-15.5 and OR 12.6, 95% CI 4.9-32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

First report of pediatric hematopoietic stem cell transplantation activities in the eastern mediterranean region from 1984 to 2011: on behalf of the pediatric cancer working committee of the eastern mediterranean blood and marrow transplantation group

To describe the hematopoietic stem cell transplantation (HSCT) activities for children in the Eastern Mediterranean (EM) region, data on transplants performed for children less than 18 years of age between 1984 and 2011 in eight EM countries (Egypt, Iran, Jordan, Lebanon, Oman, Pakistan, Saudi Arabia and Tunisia) were collected. A total of 5187 transplants were performed, of which 4513 (87%) were allogeneic and 674 (13%) were autologous. Overall, the indications for transplantation were malignant diseases in 1736 (38.5%) and non-malignant in 2777 (61.5%) patients. A myeloablative conditioning regimen was used in 88% of the allografts. Bone marrow (BM) was the most frequent source of stem cells (56.2%), although an increasing use of PBSC was observed in the last decade. The stem cell source of autologous HSCT has shifted over time from BM to PBSC, and 80.9% of autologous HSCTs were from PBSCs. The donors for allogeneic transplants were matched-related in 94.5% of the cases, and unrelated transplants, mainly cord blood (99%) in 239 (5.5%) cases. This is the first report to describe the pediatric HSCT activities in EM countries. Non-malignant disorders are the main indication for allogeneic transplantation. Frequency of alternate donor transplantation is low.

Factors associated with adolescent malnutrition among Nigerian students

Objectives: The objective of this study was to determine the factors associated with malnutrition among adolescents. Design: This was a cross-sectional study conducted among adolescents (10-19 years) in secondary schools. A multistage sampling technique was employed.Setting: Senior secondary schools in The Abuja Municipal area council, Federal Capital Territory, Nigeria. Participants: A total of 1700 students from 8 selected schools. All schools in the Abuja Municipal Area council (AMAC) were stratified into urban and rural schools. Eight schools were selected by balloting from a list of schools obtained from the Education centre. A school was selected from each of the four major districts of AMAC and four schools were selected from the rural making a total of 8 schools. Although the consent of the school authorities was obtained, individual subject also consented to the study before being enrolled.Study: The study excluded those adolescents who were physically challenged thus limiting physical activity. Sociodemographic information was obtained using an interviewer administered questionnaire. Subject’s height and weight was taken using the floor-type height (H) and weight (W) measuring scale model ZT-120 using Massachusetts Department of Public Health Protocol. Main outcome measure: The nutritional status was determined using the formula: BMI= W/H2, where W=weight (in kilograms) and H=height (in meters). The age and sex specific height and BMI percentile for each subject was determined using the 2007 WHO Height and BMI growth charts for age 5-19 years. The students were then classified into one of the following categories using previously used standards: normal, stunted, wasted, overweight or obese. Data was analyzed using SPSS version 17 statistical package. A regression analysis of all investigated factors was done to determine those with significant association to malnutrition.Results: The mean age was 14.43±1.94 years; male 688, female 862, M:F ratio 1.1.3. Mean BMI, weight and height were 20.31±3.07kg/m2, 51.07±10.80 kg, and 157.88±9.33 cm. The prevalence of overweight, stunting, obesity and wasting was documented as 13.2% (205/1550), 11.3% (175/1550), 2.6% (41/1550) and 1.7% (27/1550) respectively. Low social class, male gender, hawking after school and rural setting were associated with stunting (p<0.05) and female gender and watching Television for more than 3 hours daily were associated with overweight (p<0.05). Obesity occurred more in urban areas.Bangladesh Journal of Medical Science Vol.15(2) 2016 p.243-248

Vitamin D status and hospitalisation for childhood acute lower respiratory tract infections in Nigeria

BACKGROUND

Acute lower respiratory tract infection (ALRTI) is the leading cause of childhood deaths in most developing countries, including Nigeria. Vitamin D is associated with innate immunity and may play a role in the control of infections. Case-control studies, including a small study from Nigeria, show inconsistent results for the association between vitamin D status and risk of ALRTI.

AIMS

To examine the relationship between vitamin D status and hospitalization for ALRTI in Nigerian children.

METHODS

Fifty children aged 2-60 months hospitalised with ALRTI were studied prospectively. ALRTI was diagnosed on the basis of modified WHO criteria. Each patient was matched with controls for age and gender. The controls were enrolled either from children attending well-child clinics or general clinics without evidence of respiratory infection or admitted to the hospital for elective surgery. A structured questionnaire collected data on demography, health, diet, duration of exposure to sunlight and percentage of body surface exposed to sunlight (according to type of clothing) while outdoors, and potential risk factors for ALRTI. Serum 25-hydroxyvitamin D [25(OH)D] concentration was measured using a chemiluminescenceimmuno-assay. The differences between cases and controls in serum 25(OH)D concentrations, association between vitamin D status and ALRTI and risk factors for vitamin D deficiency were assessed.

RESULTS

Mean (SD) 25(OH)D concentrations in patients and controls were similar [61·5 (25·8) vs 63·1 (22·9) nmol/L,P = 0·95].25% of all 100 subjects studied had serum 25(OH)D<50 nmol/L. In a multiple conditional logistic regression model, only lower percentage of body surface area exposed to sunlight was associated with increased risk of ALRTI. The percentage of body surface area exposed to sunlight while outdoors (P = 0·028) and vitamin D supplement use (P = 0·009) were independent determinants of vitamin D deficiency in the overall study population.

CONCLUSIONS

ALRTI was not associated with vitamin D status, but was associated with less exposure to sunlight. Exposure to sunlight and vitamin D supplementation contributed to vitamin D status in this population.

Strokes in children with sickle cell disease at the National Hospital Abuja Nigeria

Background: Strokes occur in sickle cell disease (SCD), and are associated with significant morbidity and mortality.Objectives: To determine the prevalence of strokes amongst childrenwith SCD, and document the major clinical features, complications, effect of treatment with chronic transfusion therapy (CTT) and outcome.Methods: A descriptive retrospective study of SCD children with strokes seen at the National Hospital Abuja, Nigeria over a 2.5 year period from January 2009 – June 2012. Data was collected by scrutinizing case files obtained from the hospital medical records unit. Information obtained included demographic data, clinical features, packed cell volume (PCV), brain imaging, long term neurologic deficits, effect of CTT, stroke recurrence and outcome.Results: There were 31 children with strokes among 596 children with SCD documented in the register, giving a prevalence of 5.2%. Twenty six (26) case notes were retrieved. There were 12 males and 14 females, M: F ratio of 0.9:1; mean age was 6.4 years (SD 3.4) range: 1 year 7 months – 14 years; mean PCV at the time of strokes was 21.1% (SD 3.9) range 14 –29%. All (100%) had Haemoglobin SS on electrophoresis. Presentationswere convulsions 18, inability to use limbs 11, weakness of limbs 10; long term neurological deficits were hemiplegia 11, cognition loss 11. Three (3) children had no deficits. Brain imaging (Computed Tomography Scan and Magnetic Resonance Imaging) done in 16 (61.5%) children showed cerebral atrophy in 10, acute cerebral infarcts in 9, chronic cerebral infarcts in 6, acute intra cranial haemorrhage in 1 and normal imagings in 4 children. Twelve (12) children (46.2%) children had recurrences of stroke ranging in number from 1 to 4, which occurred 6 months to 3 years afterthe initial stroke. There were no statistical significant differences between the children with recurrences of stroke compared to those without regarding the age, sex, weight or PCVs p > 0.05. Fifteen (15) children (57.7%) wereenrolled in CTT. Two (2) out of 7 children (28.6%) that had regular CTT had stroke recurrence; compared to 5 out of 11 children (45.4%) with no CTT (p > 0.05). Four (4) out of 6 (66.7%) children with irregular CTT and 1 of 2 children who stopped CTT had stroke recurrence.Outcome: 17 children were alive, 7 were lost to follow up, 1 died and 1 was referred to another center.Conclusion: Strokes were an important cause of morbidity in Nigerianchildren with SCD, with major long term neurologic deficits. CTT appearedbeneficial in preventing stroke recurrences. Primary prevention strategy by Trans Cranial Doppler ultrasound studies of the cerebral arteries, with the aim of promptly initiating appropriate preventive therapy for stroke is strongly advocated.Key words: Sickle cell disease, Stroke, Children, Chronic Transfusion Therapy

Community acquired bacteremia in young children from central Nigeria--a pilot study

BACKGROUND

Reports of the etiology of bacteremia in children from Nigeria are sparse and have been confounded by wide spread non-prescription antibiotic use and suboptimal laboratory culture techniques. We aimed to determine causative agents and underlying predisposing conditions of bacteremia in Nigerian children using data arising during the introduction of an automated blood culture system accessed by 7 hospitals and clinics in the Abuja area.

METHODS

Between September 2008 and November 2009, we enrolled children with clinically suspected bacteremia at rural and urban clinical facilities in Abuja or within the Federal Capital Territory of Nigeria. Blood was cultured using an automated system with antibiotic removing device. We documented clinical features in all children and tested for prior antibiotic use in a random sample of sera from children from each site.

RESULTS

969 children aged 2 months-5 years were evaluated. Mean age was 21±15.2 months. All children were not systematically screened but there were 59 (6%) children with established diagnosis of sickle cell disease and 42 (4.3%) with HIV infection. Overall, 212 (20.7%) had a positive blood culture but in only 105 (10.8%) were these considered to be clinically significant. Three agents, Staphylococcus aureus (20.9%), Salmonella typhi (20.9%) and Acinetobacter (12.3%) accounted for over half of the positive cultures. Streptococcus pneumoniae and non-typhi Salmonellae each accounted for 7.6%. Although not the leading cause of bacteremia, Streptococcus pneumoniae was the single leading cause of all deaths that occurred during hospitalization and after hospital discharge.

CONCLUSION

S. typhi is a significant cause of vaccine-preventable morbidity while S. pneumoniae may be a leading cause of mortality in this setting. This observation contrasts with reports from most other African countries where non-typhi Salmonellae are predominant in young children. Expanded surveillance is required to confirm the preliminary observations from this pilot study to inform implementation of appropriate public health control measures.

Hepatitis B and C virus co-infection in Nigerian patients with HIV infection

INTRODUCTION

We set out to determine the seroprevalence of hepatitis B and hepatitis C viruses among human immunodeficiency virus infected individuals and its impact on pattern of presentation.

METHODOLOGY

A serological study for hepatitis B and hepatitis C viruses was performed on 260 HIV-positive individuals. These patients were tested for the presence of hepatitis B surface antigen and anti-hepatitis C virus (HCV) antibody.

RESULTS

Thirty (11.5%) patients tested positive for hepatitis B surface antigen, six (2.3%) tested positive for anti-hepatitis C virus antibody, four (1.5%) were positive for both hepatitis B surface antigen and anti-hepatitis C virus and the overall prevalence was 15.4% . Individuals younger than 40 years of age were more affected, and the odds ratio of a female being co-infected was 1.2, 25% versus 75% p value = 0.03. The prevalence of HIV and hepatitis co-infection rises with age except for hepatitis C. There was no significant difference in the mean levels of liver enzymes (AST, ALT) among the various groups. The groups differ significantly in their mean CD4 count: it was lowest for those co-infected with hepatitis B and hepatitis C; 106 cells/mm(3), 171 cells/mm(3) for those with HIV alone; and the highest value of 260 cells/mm(3) was obtained in those who tested positive for anti-HCV. Scarification marks and multiple blood transfusions were more common among those infected. There was no case of intravenous drug abuse identified.

CONCLUSION

This low frequency of HIV/HCV co-infection is probably due to the uncommon intravenous drug abuse in this population. Co-infection with hepatitis B virus is common among our HIV-infected patients and should be a major consideration in the initiation and choice of therapy.

Examining the effectiveness of a peer-led education programme for Type 2 diabetes and cardiovascular disease in a Bangladeshi population

AIMS

The aim of this study was to assess an adapted version of the X-PERT Programme for Type 2 diabetes within a Bangladeshi population.

METHODS

Bangladeshi adults, living in the UK, with Type 2 diabetes participated in a diabetes educational session based on an adapted version of the X-PERT Programme. Participants attended a session, led by a trained peer educator and carried out in Sylheti. All participants who registered on the course were telephoned or visited in person the day before the course as a reminder.

RESULTS

Registration to attend the course was excellent. However, actual attendance rates were 58% (42/72) out of those registered. Once participants attended, overall they enjoyed attending the sessions and felt they benefited as they understood more about how to better self-manage their condition. Those aspects of the sessions that were most enjoyed were group discussions and interactive posters to explain diabetes. Participants requested a home-based exercise guide, which was developed by the research team. The study was underpowered to show behaviour change, but did demonstrate a trend to improvement in self-care activities. All participants reported recommending the course to others.

CONCLUSIONS

There was an excellent response in terms of registration for the course. However, the time to attend the course appeared to be a barrier to participants. Nevertheless, for those attending the course, responses were very positive. The amended X-PERT Programme could be used as a component of a package to improve outcome and self-management for people with diabetes in the Bangladeshi community.

Intervention, recruitment and evaluation challenges in the Bangladeshi community: experience from a peer lead educational course

Background

The incidence of Type 2 diabetes is increasing worldwide and diabetes is four times more common among ethnic minority groups than among the general Caucasian population. This study reflects on the specific issues of engaging people and evaluating interventions through written questionnaires within older ethnic minority groups.

Methods

The original protocol set out to evaluate an adapted version of the X-PERT^® patient program using questionnaires and interviews.

Results

Questionnaires, even verbally completed, were unsuccessful and difficult to administer as participants found the questionnaire structure and design difficult to follow and did not perceive any benefit to completing the questionnaires. The benefits of attending the course were also poorly understood by participants and in many cases people participated in coming to the course as a favour to the researcher. Engaging participants required word of mouth and the involvement of active members of the community.

Conclusion

Peer led courses and their evaluation in older ethnic minority communities needs a very different approach for that in younger Caucasian patients. A structured approached to evaluation (favoured by western educational system) is inappropriate. Engaging participants is difficult and the employment of local well known people is essential.

Allogeneic bone marrow transplantation in beta-thalassaemia--single centre study

OBJECTIVE

To evaluate outcome of allogeneic BMT in beta-Thalassaemia at the Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan from August 2001 to November 2003.

METHODS

Nineteen patients with beta-Thalassaemia underwent allogeneic BMT/PBSC transplantation from HLA identical sibling donors. Patients were classified in three groups according to Pesaro (Italy) risk classification. Class-I (n = 9) and Class-II (n = 7) patients received conditioning with busulphan/cyclophosphamide, whereas Class-III (n = 3) patient received conditioning with hydroxyurea, azathioprine, fludarabine, along with Bu14 / Cy 200. Cyclosporine, prednisolone and methotrexate were given for GvHD prophylaxis. Stem cells dose infused was >4.0 x 10(8)/kg body weight of the patient.

RESULTS

Engraftment was achieved in all Class-I patients, whereas in Class-II and Class-III , graft rejection was observed in one patient from each class. Median time to achieve absolute neutrophil recovery (> 0.5 x 10(9)/l) was 13 days, platelet count (> 20 x 10(9)/1) was 15 days and reticulocyte count (>0.5%) was 15 days. Acute GvHD was observed in 15 patients. One patient developed grade IV GvHD (liver and skin) and died within 30 days post BMT. Post transplant infectious complications were pseudomonas septicemia, disseminated fungal infection, CMV pneumonia and tuberculosis. Three patients died of these complications during post transplant period (31-90 days). Median stay in hospital was 25 days.

CONCLUSION

Allogeneic BMT is the only curative therapy for beta-Thalassaemia patients, however the success rate can be increased if the patients are selected carefully and transplanted at an early age.

Diversity of hemagglutination phenotypes among P-fimbriated wild-type strains of Escherichia coli in relation to papG allele repertoire

Data regarding the hemagglutination (HA) patterns of the three variants (classes I, II, and III) of the Escherichia coli adhesin PapG are conflicting. These HA patterns usually have been assessed for each papG allele separately with recombinant strains in slide HA assays. We rigorously evaluated an alternative microtiter tray HA assay and then used it to assess the HA of four erythrocyte types (human A1P1 and OP1, rabbit, and sheep erythrocytes) by multiple wild-type E. coli strains representing the four naturally occurring combinations of the papG alleles, i.e., class I plus III, class III only, class II plus III, and class II only. The microtiter tray HA assay displayed significantly better reproducibility of intraobserver (83%) and interobserver (86%) results than did slide HA assays (39 and 73%, respectively). Novel findings from the study of 32 wild-type P-fimbriated strains included reproducible determinations of phenotypic diversity among different papG categories, among strains within each papG category, and from day to day for individual strains. There was also substantial overlap of phenotypes between papG categories I plus III and III only and between II plus III and II only. A class III papG recombinant strain's HA pattern differed significantly from that of the wild-type class III strains. These data demonstrate that HA phenotypes of wild-type P-fimbriated E. coli strains can be reproducibly assessed by a microtiter HA assay and that they correspond broadly to papG genotype but in a more complex and varied fashion than previously recognized.

Effect on cardiovascular function and iron metabolism of the acute removal of 2 units of red cells

BACKGROUND

The collection from a donor of 2 red cell units at one time would decrease recipient exposure to viruses and alloantigens. If the donor is a large person, the blood volume lost and the postdonation hemoglobin and/or hematocrit should be within acceptable limits. If the donor is a large person, the blood volume lost and the postdonation hemoglobin and/or hematocrit should be within acceptable limits. The effect on cardiovascular function and iron metabolism requires description.

STUDY DESIGN AND METHODS

Manual 2-unit erythropheresis was performed on eight donors, with the plasma returned. Donors had treadmill testing of maximum aerobic power (VO2max) before donation, 24 hours after, and 8 to 11 weeks after. Serial samples were drawn for iron metabolism studies.

RESULTS

Donors weighed 61.2 to 74.8 kg, and 9.6 to 11.4 percent of their blood volume was removed. Mean VO2max decreased from 84 percent of that predicted before donation to 74 percent 24 hours afterward. By 8 to 11 weeks, hemoglobin returned to acceptable donor levels and mean VO2max was 92 percent of that predicted. Mean hemoglobin fell from 14.4 to 11.7 g per dL (144 to 117 g/L) and rose to 13.9 g per dL (139 g/L) at 16 weeks. At 16 weeks, serum iron (120 +/- 47 vs. 83 +/- 33 micrograms/dL [21 +/- 8 vs. 15 +/- 6 mumol/L]), ferritin (40 +/- 24 vs. 18 +/- 10 ng/mL [40 +/- 20 vs. 20 +/- 10 micrograms/L]), and free erythroprotoporphyrin (19 +/- 5 vs. 28 +/- 5 micrograms/dL [0.34 +/- 0.09 vs. 0.50 +/- 0.09 mumol/L]) differed significantly from baseline levels. No major donor symptoms occurred.

CONCLUSION

Two-unit erythropheresis was done with blood volume loss and postdonation hemoglobin no worse than those that would occur in a 50-kg donor donating 450 mL. Cardiovascular effects and donor symptoms were mild. Two-unit red cell donations would be clinically advantageous, and they warrant further studies of both utility and donor safety.

Chemoattractant activity of Entamoeba histolytica for human polymorphonuclear neutrophils

The ability of axenic Entamoeba histolytica trophozoites and amoebic protein preparations to stimulate chemotaxis of human polymorphonuclear neutrophils (PMN) was evaluated. Virulent E. histolytica (strain HM1:IMSS) stimulated chemotaxis (delta distance = 0.55 +/- 0.02 mm, P less than 0.01 vs. control medium). Sonicated (100 micrograms protein/ml) or homogenized (500 micrograms protein/ml) virulent amoebae also significantly stimulated PMN chemotaxis, whereas preparations of the nonpathogenic "Entamoeba-like" Laredo strain did not stimulate chemotaxis. Preparations of subcellular fractions of E. histolytica demonstrated maximal stimulation of PMN chemotaxis existed in nonvesiculated membranes and the supernatant from plasma membranes.

Multiple plasma exchanges successfully maintain a young adult patient with Crigler-Najjar syndrome type I

Plasmapheresis has been shown to reduce total and free bilirubin levels in acute exacerbations of Crigler-Najjar syndrome, type I (CNS-TI), but its effectiveness in long-term management has not been reported. An 18-year-old (yo) male with CNS-TI, who required prolonged daily high-intensity phototherapy to prevent cerebral nervous system symptoms, developed increasingly frequent bouts of confusion, nausea, and vomiting associated with free bilirubin concentrations (fbcs) greater than 10-15 nmol/L. Pending consideration of orthotopic liver transplantation, plasma exchange (approximately 3 liters per procedure) was begun in 12/84 using the IBM/COBE 2997 with 5% albumin as replacement fluid. Frequency of treatments was guided by twice weekly fbcs, with plasma exchange for fbc greater than 10-15 nmol/L. Pre-exchange and postexchange fbcs ranged from 27.5 to 11 nmol/L and 9.2 to 2 nmol/L, respectively. Seventy-two exchanges were performed over a 28 month period. Irreversible CNS damage did not occur, and the patient underwent successful liver transplantation in April of 1987, with complete correction of his metabolic disorder. He remains well 18 months following transplantation.

Deletion of antigens of the Lewis a/b blood group family in human prostatic carcinoma

The expression of antigens of the blood group Lewis a/b family were studied in a series of 42 prostatectomy specimens from patients with adenocarcinoma clinically confined to the prostate; 19 of these were later reclassified as pathologic Stage C. Staining of normal or hyperplastic versus neoplastic epithelium was assessed in routinely processed, paraffin-embedded tissue using murine monoclonal antibodies and an avidin-biotin immunoperoxidase technique. Antigens screened and the antibodies used to recognize them were Lewis a (CF4C4), Lewis b and Type 1 H (NS10), monosialosyl Lewis a I (19.9), and disialosyl Lewis a and monosialosyl Lewis a II (FH7). FH7 strongly stained the benign epithelium of all 39 Lewis positive cases, suggesting that the sialyltransferase responsible for synthesis of FH7-reactive determinants is highly active in benign prostatic tissue. When compared to the reactivity of benign epithelium in Lewis positive cases, the staining of the carcinomas was markedly reduced in 18 cases (46%) and absent in 16 cases (41%). This reduction or loss of staining of the malignant epithelium was observed for all antibodies that stained the corresponding benign epithelium of each case. In only five of the cases (13%) was the intensity of staining in the carcinoma equal to that of the surrounding benign epithelium. No cases in this latter group had recurrence of disease, whereas in the other staining groups 25-33% of the cases had recurrences; median follow-up for the entire group was 78 months. No correlation was apparent between Gleason score and the staining pattern with these antigens. In summary, antigens of the Lewis a/b family are deleted in a high percentage of cases of prostatic adenocarcinoma.

A new polymorphic determinant on HLA-DQ molecules

In man, the immune response genes are located within the HLA-D/DR region, and the gene products, the Ia antigens, are expressed on B lymphocytes, monocytes, and a percentage of null cells and activated T lymphocytes. We recently identified a human Ia antigen, K19, which appeared to be limited in its expression to B lymphocytes, and to be preferentially expressed on the more mature cells within this population. This work was facilitated by a monoclonal antibody. HK-19, which recognized a monomorphic determinant of this Ia molecule. We now report the characterization of a second monoclonal antibody, HK-13, which recognized the same molecule as HK-19, but only on cells from some individuals. The greater affinity of HK-13 allowed more complete characterization of the K19/K13 molecule. This characterization included cytofluorography, two-dimensional gel electrophoresis, tryptic peptide mapping, and partial N-terminal amino acid sequencing, and indicated that K19 and K13 were epitopes on HLA-DQ (DC) molecules. The pattern of reactivity of HK-13 on a panel of typing cells did not correlate with any of the known HLA-DQ polymorphic determinants. Thus, HK-13 is a new polymorphic determinant of the HLA-DQ series.

Preservation of antithrombin III activity in stored whole blood

Antithrombin III (AT-III) is the major inhibitor of thrombin, Factor Xa, and other coagulation enzymes. Congenital and acquired deficiencies of AT-III are thought to contribute to thrombosis and disseminated intravascular coagulation. Because a recent report suggested reduced AT III in stored blood, we evaluated blood bank storage effects. Serial samples were taken from 6 units of whole blood drawn into citrate-phosphate-dextrose-adenine over 42 days, and assays for AT-III functional activity were performed on the same day. The values (mean +/- SD) were as follows: day 0,91.8 +/- 10.7 percent; day 2, 101.9 +/- 10.7 percent; day 8, 107.3 +/- 7.4 percent; day 15, 118.9 +/- 11.1 percent; day 22, 105.4 +/- 9.8 percent; day 35, 93.4 +/- 8.8 percent; and day 42, 97.4 +/- 7.5 percent. The rise from day 0 to day 15 was significant but presumably secondary to interassay variation because analysis of frozen aliquots showed no significant change when all samples from each unit were assayed in one batch. Immunoassay of AT-III also showed no change with storage. The results indicate AT-III retains functional activity in whole blood stored at 2 to 6 degrees C for 42 days, and AT-III replacement does not require fresh blood or fresh-frozen plasma. Low values may reflect individual donor differences or dilution of plasma by anticoagulant.

A unique DR-related B cell differentiation antigen

The Ia or class II molecules in both mouse and man are the basis for the genetic control of the immune response. In addition to DR, other class II antigens have been described in man. We describe a new human Ia antigen K19, recognized by three monoclonal antibodies (HK-9, HK-19, and HK-20). This antigen has the general biochemical characteristics of an Ia antigen but is different from a DR antigen. Further, this antigen is found only on mature B lymphocytes and not on monocytes and activated T cells. Thus, this antigen may represent a new Ia-like molecule that is preferentially expressed on mature B cells.

A unique DR-related B cell differentiation antigen

The Ia or class II molecules in both mouse and man are the basis for the genetic control of the immune response. In addition to DR, other class II antigens have been described in man. We describe a new human Ia antigen K19, recognized by three monoclonal antibodies (HK-9, HK-19, and HK-20). This antigen has the general biochemical characteristics of an Ia antigen but is different from a DR antigen. Further, this antigen is found only on mature B lymphocytes and not on monocytes and activated T cells. Thus, this antigen may represent a new Ia-like molecule that is preferentially expressed on mature B cells.