Immuno-affinity chromatography for purification of IgG from hyper-immune sera raised against 146S fraction of Foot and Mouth Disease Virus for diagnostic purposes

Immunoaffinity chromatography (IAC) is a fundamental isolation and purification tool which is incorporated in a substantial range of therapeutic and diagnostic applications. This study has reappraised the usefulness of immunoaffinity chromatography for the purification of polyclonal antibodies. Protein A based IAC is a convenient and reliable method for purification of IgG, from hyperimmunesera (HIS) raised in experimental animals such as rabbits, guinea pigs and mice to be utilized in pharmaceutics and diagnostics. The 146S fraction of Foot and Mouth Disease virus (FMDV) TCID50=10 5.6 was cultured on a baby hamster kidney cell line 21 (BHK-21), concentrated using salt precipitation method using PEG 6000, purified by size exclusion chromatography (SEC) using Sepharose-30 at 254nm absorbance. Purification of 146S FMDV was analyzed using 12% SDS-PAGE which provided two bands of light and heavy chains. The alum-based vaccine, consisting of ≥10μg of 146S FMDV, was applied in 10 male rabbits and 10 male guinea pigs and two animals of each group were taken as a negative control. The titer of serum was calculated using virus neutralization test. A Protein-A kit (Thermo scientific- 44667, 0528.2) was used to purify HIS raised against 146S FMDV and validated using 12% SDS PAGE in reducing condition. The data demonstrate that protein-A affinity chromatography is an efficient tool for the purification of antibodies from hyper-immune sera raised against 146S FMDV and can be used for the production of diagnostic kits e.g. Enzyme linked immuno-sorbent assay (ELISA) and radioimmunoassay.

P–076 Probability of sperm retrieval in azoospermic patients and mRNA expression profile of JMJD1A, TNP2 and PRM2 : in a subset of karachi population

Study question

To access successfulness of sperm retrieval by evaluating the mRNA expression profile of JMJD1A, TNP1, TNP2, PRM1 and PRM2 in patients undergoing surgical sperm retrieval procedure.

Summary answer

Probability of sperm retrieval in azoospermia is decreased when mRNA expression profile of JMJD1A TNP2 and PRM2 in testicular tissue is decreased.

What is known already

Studies have been done on expression of JMJD1A in non-obstructive azoospermic patients in other part of the world with smaller sample size but this is the first study in Pakistan with larger number of patients. Study design, size, duration: Crossectional study, 100 azoospermic patients coming for purpose of sperm retrieval by TESE or micro-TESE in Australian Concept Infertility Medical Center, Karachi,from March, 2018 to December, 2019

Participants/materials, setting, methods

All recruited azoospermic patients were evaluated by history, physical examination, and hormonal assessment. RNA was extracted by pureLink RNA Micro kit and mRNA expression of the JMJD1A, TNP1, TNP2, PRM1 and PRM2 genes was determined using innu-SCRIPT One Step RT_qPCR SyGreen kit. For quantitative variables independent t test and for categorical variables chi-square/ Fisher Exact test was used. Unadjusted and adjusted prevalence ratio were reported by using cox regression algorithm. Main results and the role of chance: The patients were categorized into (i) Group-I: Patients with successful sperm retrieval n = 42, (ii) Group-II: Patients with unsuccessful sperm retrieval n = 58. The patients were categorized into (i) Group-I: Patients with successful sperm retrieval n = 42, (ii) Group-II: Patients with unsuccessful sperm retrieval n = 58. Azoospermic men in the successful sperm retrieval group had significantly decreased expression of JMJD1A (P < 0.001), TNP2(P < 0.001), and PRM2 (P 0.008). In addition to this regarding hormonal parameters: FSH (P 0.004), LH(P < 0.001), TSH(P<.011) were significantly different in azoospermic men with successful and unsuccessful sperm retrieval. In multivariate analysis, after adjusting for the other covariates, a significant association was found between JMJD1A, TNP2, PRM2 and successful sperm retrieval (p-value <0.05).

Limitations, reasons for caution

It is unicentric and outcomes for fertilization were not assessed. Azoospermic patients from multi-centeres were difficult because of lack of facility of sperm retrieval procedures at these centers and it was difficult to follow the fertrilization outcome.

Wider implications of the findings: This will be useful for making the decision in azoospermic men to proceed for ICSI or not. In addition to this, the repetition of unnecessary surgical procedures can be avoided, as the azoospermic men often undergo number of rounds of ICSI, with the hope of becoming biological father.

Trial registration number

non-clinical trials

Correlation between the clinically diagnosed inflammatory process and periapical index scores in severely painful endodontically involved teeth

Aim

To assess and correlate three distinct states of severely painful endodontically derived inflammation with their depiction on periapical radiographs using periapical index (PAI) scores.

Methodology

During a period of 15 months, 368 consecutively enrolled patients with suspected endodontic emergency conditions were examined at the University of Zurich, Center of Dental Medicine. Cases with a severely painful (numeric rating scale, NRS‐11 > 6) endodontically involved tooth and a clear pulpal and apical diagnosis (n = 162) were selected (one tooth per patient). Teeth were divided into three groups according to the clinically diagnosed main location of the inflammatory process: level 1: pulp (positive response to cold test), level 2: periodontium (no response to cold without swelling) and level 3: periapical tissues (no response to cold with swelling). Periapical radiographs were obtained using a digital unit and analysed by two calibrated observers. For level 2, which had the highest PAI variance (n = 76), the PAI scores were further scrutinized regarding their dependence on tooth location and the duration of pain. Data were analysed using chi‐squared and non‐parametric tests, alpha = 0.05.

Results

Overall, the PAI scores correlated well with the clinically diagnosed main location of periapical inflammation (Spearman’s rho = 0.5131, P < 0.001), with level 1 having the lowest scores by far (P < 0.001) and level 2 having significantly lower scores compared to level 3 (P < 0.05). However, a PAI score of 5 was found in merely 3 teeth within the entire cohort, and 49% of the teeth in the level 2 group had no radiolucency (PAI < 3). Within level 2, the PAI scores were not dependent on tooth location but were substantially (P < 0.001) higher for teeth which had hurt for more than one week, and for root filled teeth.

Conclusions

For the analysed, severely painful endodontically involved teeth, the clinically diagnosed main location of inflammation was reflected by the periapical index. PAI scores were not significantly influenced by anatomical noise, yet in some cases under‐estimated the clinical situation.

THU0597 CORNEAL MELT - DON’T ALWAYS BLAME RHEUMATOID ARTHRITIS

Background:

Corneal melt is a rare inflammatory disease of the peripheral cornea; it may lead to perforation of the globe and visual failure. Corneal melt can be a manifestation of systemic vasculitis in patients with RA and other conditions, such as cancer. Without early and aggressive treatment it may be associated with a poor visual outcome and a high mortality. It has been reported in patients with stable RA.

Objectives:

A case report in a patient with long standing but well controlled Rheumatoid Arthritis (RA) and metastatic disease.

Methods:

A 75 year old male with a background of sero positive Rheumatoid Arthritis for more than 10 years presented to the Eye Casualty with a two week history of a painful left red eye. His other medical history was significant for Stage IIB poorly differentiated cancer of the left lower lobe. Left lower lobectomy with a patch of diaphragm resected. Intratumoural lymphovascular invasion noted. He completed Adjuvant Carboplatin/Vinorelbine chemotherapy September, 2017. He had DVT proximal left leg 22ndof September, 2017. Follow up CT in 2018 demonstrated a right renal upper pole lesion for which he was awaiting biopsy with?metastatic lung disease vs primary renal carcinoma. His RA was well controlled on Methotrexate 10mg weekly. He had been treated by the ophthalmology team for left marginal Keratitis for the prior 2 months with steroid eye drops without significant improvement. On presentation to ED, he described sharp eye pain, waking him from the sleep, associated with watery discharge and photophobia. Examination showed corneal melt in left eye involving 25% of inferior portion of the cornea and spastic entropion with injecting eye lashes. He had no active joints and there were no other signs of vasculitis. CRP was 4.1. He had a negative ANA and ANCA; viral swabs were negative. He was admitted under the medical team. Intravenous Methyl Prednisolone was started. The patient felt better after 5 days of Methyl Prednisolone. Left temporary tarsorrhaphy was done by Ophthalmology. Cyclophosphamide was initiated after discussion with Oncologist pending the result of the renal biopsy. Patient was discharged after 5 days of admission in the hospital

Results:

The renal biopsy was positive for metastatic Squamous cell carcinoma of lung. Cyclophosphamide was withdrawn and he was started on Carboplatin/Gemcitabine. The corneal melt improved with complete resolution of his visual symptoms.

Conclusion:

In this case, although the history of RA was felt by the ophthalmology team to be the most likely association with the corneal melt, we would argue the oncological diagnoses were likely the driving force behind the presentation.

References:

[1]Sule A, Balakrishnan C, Gaitonde S, Mittal G, Pathan E, Gokhale NS, et al. Rheumatoid corneal melt. Rheumatology (Oxford)2002;41:705–6.

[2]S. Yano, K. Kondo, M. Yamaguchi et al., “Distribution and function of EGFR in human tissue and the effect of EGFR tyrosine kinase inhibition,” Anticancer Research, vol. 23, no. 5, pp. 3639–3650, 2003.

Disclosure of Interests:

None declared

Persistent type 2 respiratory failure on background of advanced thymoma with lung metastases

We report a patient in her 60s with history of end-stage thymoma with bilateral lung metastases on palliative chemotherapy presented to the hospital with sudden shortness of breath initially treated for probable pulmonary embolism (PE) pending CT of the pulmonary arteries which was subsequently negative for PE. During this admission, she developed transient right-sided facial droop and slurred speech which resolved spontaneously; however, the patient became unresponsive and desaturated with severe decompensated type 2 respiratory failure. Patient was supported with non-invasive ventilation (biphasic positive airway pressure) for few days. Myasthenia gravis was suspected due to clinical features and confirmed by the high titre of acetylcholine receptor antibody titre.

Abstract P5-16-17: Titanium-coated polypropylene mesh for immediate implant-based breast reconstruction – Our initial experience

Background: The use of titanium-coated polypropylene mesh (TCPM) is an alternative to a-cellular dermal matrix for the implant based breast reconstruction by providing extra implant coverage especially in the lower half. The aim of our study was to analyze short-term outcomes of TCPM based implant breast reconstruction and compare the patient- and procedure-related factors to implant loss and surgical complications.

Methods: Between 2013and 2016, implant breast reconstructions after conservative mastectomies using TCMP was performed in 50 patients (with 58 reconstructions). Complications were divided into major (need for additional surgery), minor (conservative treatment), and implant loss. Univariate analyses were performed to determine the influence of the patient- and procedure-related factors on postoperative complications and implant loss.

Results: Fifty patients had therapeutic mastectomies with 8 of them also had contra lateral risk reducing mastectomies. With median follow-up of 17.5 months, four of 50 patients had implant loss. Reasons for implant loss were skin necrosis in 2 cases, infection in 1 case and necrosis with infection in another case. One of these patients had a revised reconstruction one year later. One additional patient required implant replacement because of capsule contracture. No risk factors were observed for patient-associated complications. Univariate analysis revealed an increased risk for implant loss in patients with skin necrosis (p &lt; 0.01).

Conclusions: This titanium-coated polypropylene mesh shows acceptable complication rates and its use in immediate implant breast reconstruction is safe and effective.

Citation Format: Munir A, Holt S, Huws A, Khan S, Shariaha Y, Khawaja S. Titanium-coated polypropylene mesh for immediate implant-based breast reconstruction – Our initial experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-17.

Abstract P2-01-22: The long term outcomes of Metasin RTqPCR intra-operative sentinel node analysis in early breast cancer

Background:

Axillary lymph node involvement is a prognostic factor in breast cancer and it is used to guide adjuvant therapy. Axillary clearance remains the standard of care in lymph node positive disease in most parts of the world. Usually this is performed as second procedure but immediate intra-operative node analysis allows clearance to be performed as part of the initial procedure where necessary.

The Metasin assay targets the breast epithelial cell markers CK19 and mammaglobin mRNA and detects the presence of breast tissue (metastatic disease) in the sentinel nodes. Evidence shows the Metasin assay to be fast (average assay time 41.2min) and accurate with a discordance rate below 4% compared with histology. The cost effectiveness of the assay has been reported in our previous studies.

Aim:

The aim of this study is to assess the risk of axillary recurrence following the use of the Metasin assay to guide axillary management.

Method:

This is a single centre retrospective study which included all patients presenting to a district general hospital with early clinically node negative breast cancer undergoing sentinel node biopsy between Oct 2011 and Dec 2014.

Alternate 2 mm slices of the node were examined intraoperatively using the Metasin assay and the remainder sent for histological examination. The results of the Metasin assay and histology were compared. The risk of axillary recurrence using the Metasin test to select patients for immediate axillary clearance was assessed.

Results:

1073 sentinel nodes from 545 patients were analysed during this three-year period. 2 patients were lost to follow up. 94 patients were node positive and underwent axillary clearance as part of their primary surgery. 449 patients had sentinel node biopsy with no further axillary procedure. There were 36 nodes (3.34%) with discordant results. Median follow up was 32 months (range 18 to 55 months).

Fourteen patients presented with recurrences (2.56%). The mean event free interval was 15 months. Of the 14 patients, 5 patients tested with Metasin had macrometastases and underwent immediate axillary clearance during the primary surgery. 7 patients were node negative and 2 patients were shown to have micrometastases. 11 patients recurred with distant metastases, 3 patients with local recurrence and 2 patients (0.36%) with axillary recurrences.

The two axillary recurrences occurred at 3 and 5 months after primary surgery. Both patients underwent Metasin intraoperative analyses of sentinel nodes which were negative. Subsequent histological examination confirmed no metastatic node involvement in one patient but micro-metastases in the other. Both of these patients had aggressive disease with local, axillary and distant metastasis and subsequently died of their disease.

Conclusions:

The Metasin assay is a reliable intraoperative test for sentinel node involvement and when used to guide surgical axillary management is associated with very low axillary recurrences (0.36% with a median follow up of 32 months).

Citation Format: Udayasankar S, Ashley E, Jenkins KS, Huws A, Sharaiha Y, Sai-Giridhar P, Thomas D, Munir A, Holt S, Khawaja S. The long term outcomes of Metasin RTqPCR intra-operative sentinel node analysis in early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-22.

Abstract P1-05-21: A comparison of oncotype DX recurrence scores in a screen detected vs a symptomatic cohort of patients with breast cancer: A UK experience

Background:

In the Western World, it has been stated that breast cancers detected on a screening program are indolent. There have been many recent publications stating that breast screening is overdiagnosing and therefore overtreating patients with breast cancer. With the advent of genomic testing, it can now be determined which patients have an aggressive tumor requiring systemic chemotherapy. We therefore conducted a retrospective study in the UK on patients having oncotype DX testing in both screen detected and symptomatic cancers.

Materials and Methods:

Patients in our institution undergoing oncotype DX testing for invasive breast cancer which was ER positive and node negative were part of this study. The detection of the breast cancer was documented as either a screening case or a symptomatic one. The recurrence scores of the oncotype DX testing was then compared in the screening versus the symptomatic cohort.

Results:

155 patients were included in this study. They underwent Oncotype DX testing between 2008 to 2016. The age of the patients ranged from between 31 years to 78 years. Eighty-nine patients were reported to have a low recurrence score; 45 had an intermediate score; and 21 had a high result. Fifty eight patients were screen detected, while 97 patients were symptomatic presentations. In the screening population, 32 patients had a low recurrence score; 22 had an intermediate result and 4 had a high recurrence score resulting in the latter groups being considered for chemotherapy. In the symptomatic cohort, 57 had a low recurrence score; 23 had an intermediate result; and 17 had a high score.

Conclusion:

The results of our study depict that even patients in a screeining cohort will have a high number of intermediate recurrence scores and some with a high recurrence score. This shows that the hypothesis that screening detects a majority of breast cancers which are indolent not requiring further systemic treatment should be looked at again in light of our results with genomic testing.

Citation Format: Khawaja S, Parab A, Thomas D, Huws A, Munir A, Udayasankar S, Sharaiha Y, Holt S. A comparison of oncotype DX recurrence scores in a screen detected vs a symptomatic cohort of patients with breast cancer: A UK experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-21.

Abstract P1-03-12: A simulation study depicting the inconsistency of adjuvant online compared to genomic testing when determining the benefit of chemotherapy

Background: Prognostic factors have been used for years to determine the benefit of adjuvant chemotherapy in breast cancer. However, reporting of the size and grade of the tumor are affected by interobserver variability in reporting. This can result in a change in the results of adjuvant online and an impact on decision making of chemotherapy. On the contrary, genomic testing such as oncotype Dx is reproducible. The purpose of our study was to assess the effect of pathological discordance on the adjuvant online results on a cohort of patients who also underwent oncotype Dx testing.

Materials and Methods: A total of 143 patients' histologies were included in this study. The results of the Phase III WSG-Plan B trial concerning central vs. local grade discrepancy rates were utilized to randomly change the grade of the tumors. 61 percent of grade 1 cancers were upgraded to grade 2 and 2% upgraded to grade 3. 4 percent of grade 2 cancers were downgraded to grade 1 and 26% were upgraded to grade 3. 1 percent of grade 3 cancers were downgraded to grade 1 and 25% were downgraded to grade 2. Likewise, change was made in the size of the tumor in 20 percent of patients. 8 to 10mm, 18-20, 28-30, and 48-50mm changed to 11, 21, 31 and 51mm respectively. 11-13mm, 21-23, 31-33, and 51-53mm was changed to 10, 20, 30, and 50mm. Ten percent of patients had the ER and Her 2 status changed.

Results: The simulation results showed that when the grade was only altered, the spearman correlation of the predicted 10 year mortality on adjuvant online with the original data was significantly changed from 1 to a result of 0.788. When the changed size was additionally added, the coefficient was 0.836. With the altered ER status, the result was 0.749 and with the Her 2 change, the spearman correlation was minimally changed to 0.742. The scattergrams showed a large number of outliers when the alteration in size was added to the altered grade.

Conclusion: Our simulation study confirms that with minimal changes in the clinical parameters because of the lack of perfect correlation between pathologist's results, there is a significant difference in the 10 year predicted mortality on adjuvant online. This is one step further in understanding the lack of correlation between adjuvant online and oncotype Dx, and the inconsistency of chemotherapy decision making with the sole use of adjuvant online.

Citation Format: Khawaja S, Thomas D, Udayasankar S, Munir A, Huws A, Sharaiha Y, Holt S. A simulation study depicting the inconsistency of adjuvant online compared to genomic testing when determining the benefit of chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-03-12.

Abstract P1-02-02: A review of 66 consecutive patients investigated for mammographic abnormalities by digital tomosynthesis guided vacuum assisted breast biopsy

OBJECTIVE: Vacuum-assisted breast biopsy (VABB) has replaced surgical biopsy for the assessment of mammographic abnormalities that are not evident clinically and or on ultrasound examination. The aim of this study was to determine the indications for, and accuracy of, vacuum-assisted breast biopsy (VABB) performed using digital breast tomosynthesis (DBT) guidance. (Hologic® Dimensions, Affirm guidance and Eviva handsets).

MATERIALS AND METHODS:

Design: Retrospective medical record and histopathologic review.

Patients and method: We introduced DBT guided VABB in June 2014 having previously investigated such patients using the prone table technique. This is a review of the first 66 consecutive patients investigated using this technique up to April 2105.

The following information was reviewed: Indication for VABB, (mammographic classification M1-5, type of abnormality – calcifications/mass/distortion), complications of the procedure itself, (failure to complete, infection, haematoma), the result of the multidisciplinary team (MDT) review of imaging/pathologic correlation and the outcome for the patient.

RESULTS: In one case it proved impossible to locate the lesion and this patient has been excluded from further analysis. The mean age of the patients was 57 years (30-80years). VABB was proposed for patients with lesions initially reported as highly suspicious (M5) 4 patients (6%), suspicious (M4) in 18 patients (28%), intermediate (M3) in 37 patients (57%) or benign (M2) in 6 patients (9%). Mean size of the lesion was 13mm (range 3-100mm). Forty-four patients (68%) presented with micro calcifications, 14 (21%) with distortions in and 7 (11%) with masses.

There were no complications (infection or haematoma) that required further management following the procedure.

Review by the MDT agreed that all biopsies were adequate and removed representative tissue from the lesion (No B1s). Review showed that the histology was benign and consistent in 30 (46%) patients all of whom were discharged to routine screening. 19 (29%) cases were reported as B3 (ADH, flat atypia, LCIS or ALH) in whom all the calcifications had been removed in 13 (20%) and the patients discharged and 6 (9%) went to open biopsy for residual calcifications all of whom were benign on final analysis. There was one (1.5%) radial scar reported as B4 that went to open excision and proved benign. 15 (23%) proved malignant (B5a, B5b) and went on to definitive treatment (with one patient entered into the LORIS low risk DCIS trial).

The procedure is quicker, more accurate (related to the higher resolution and larger window of the receptor plate) and involves less radiation exposure (often involving only one DBT exposure) when compared to performing the same procedure on the Hologic Platinum prone table.

CONCLUSION: DBT-guided VABB is an accurate, convenient and safe procedure.

Citation Format: Munir A, Moalla A, Williams HR, Thomas D, Huws AM, Holt SD. A review of 66 consecutive patients investigated for mammographic abnormalities by digital tomosynthesis guided vacuum assisted breast biopsy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-02-02.

Langerhans cell histiocytosis: a multisystem disorder

Langerhans cell histiocytosis can involve single or multiple organ/tissue systems and may go undiagnosed for years until it enters the clinician's differential diagnosis framework. We report on a young patient who initially presented with diabetes insipidus and subsequently with pyrexia of unknown origin. She progressed from single system Langerhans cell histiocytosis to multisystem involvement and remains in long-term remission following chemotherapy.

Effectiveness of rhizobacteria containing ACC deaminase for growth promotion of peas (Pisum sativum) under drought conditions

A series of experiments were conducted to assess the effectiveness of rhizobacteria containing 1-aminocyclopropane- 1-carboxylate (ACC) deaminase for growth promotion of peas under drought conditions. Ten rhizobacteria isolated from the rhizosphere of different crops (peas, wheat, and maize) were screened for their growth promoting ability in peas under axenic condition. Three rhizobacterial isolates, Pseudomonas fluorescens biotype G (ACC-5), P. fluorescens (ACC-14), and P. putida biotype A (Q-7), were selected for pot trial on the basis of their source, ACC deaminase activity, root colonization, and growth promoting activity under axenic conditions. Inoculated and uninoculated (control) seeds of pea cultivar 2000 were sown in pots (4 seeds/pot) at different soil moisture levels (25, 50, 75, and 100% of field capacity). Results revealed that decreasing the soil moisture levels from 100 to 25% of field capacity significantly decreased the growth of peas. However, inoculation of peas with rhizobacteria containing ACC deaminase significantly decreased the "drought stress imposed effects" on growth of peas, although with variable efficacy at different moisture levels. At the lowest soil moisture level (25% field capacity), rhizobacterial isolate Pseudomonas fluorescens biotype G (ACC-5) was found to be more promising compared with the other isolates, as it caused maximum increases in fresh weight, dry weight, root length, shoot length, number of leaves per plant, and water use efficiency on fresh and dry weight basis (45, 150, 92, 45, 140, 46, and 147%, respectively) compared with respective uninoculated controls. It is highly likely that rhizobacteria containing ACC deaminase might have decreased the drought-stress induced ethylene in inoculated plants, which resulted in better growth of plants even at low moisture levels. Therefore, inoculation with rhizobacteria containing ACC deaminase could be helpful in eliminating the inhibitory effects of drought stress on the growth of peas.

Clinical efficacy of intramuscular meglumine antimoniate alone and in combination with intralesional meglumine antimoniate in the treatment of old world cutaneous leishmaniasis

Treatment of cutaneous leishmaniasis is often difficult. Even though most cutaneous lesions will heal spontaneously, their duration cannot be predicted in an individual case. In general, only large, multiple or diffuse lesions of the face, head and neck need to be considered for therapeutic intervention. Pentavalent antimonials (sodium stibogluconate and meglumine antimoniate) administered intralesionally or parenterally (IM or IV) are the mainstays of systemic therapy despite the toxicity associated with their use. The objective of this study was to compare the clinical efficacy of intramuscular pentavalent antimonial compound meglumine antimoniate alone and in combination with intralesional therapy in the treatment of Old World cutaneous leishmaniasis. Study was conducted as a case controlled interventional prospective study. On the basis of demonstration of Leishmania tropica (LT) bodies in the skin slit smears/skin biopsies, 60 patients with cutaneous leishmaniasis were included in the study. The patients were randomly allocated to three groups of 20 patients each: group 1 treated with intramuscular injection of meglumine antimoniate (20 mg Sb/kg/day, maximum 850 mg) for 21 days; group 2 treated with intralesional injection of meglumine antimoniate (0.5 mL, 42.5 mg of Sb) into each lesion along with intramuscular injection of meglumine antimoniate (20 mg Sb/kg/day, maximum 850 mg) for 21 days; and group 3 as a control group. The patients were followed-up for therapeutic safety and efficacy at 10, 20 and 90 days. The rate of complete cure was 55% in group 1, 75% in group 2 and 10% of spontaneous cure cases in group 3. The conclusions derived from this study are limited by the relatively small number of patients. The combination of intramuscular meglumine antimoniate along with intralesional administration of the agent is superior therapy to intralesional administration of meglumine antimoniate alone.

Ineffectiveness of rosiglitazone therapy in Nelson's syndrome

BACKGROUND

Peroxisome proliferator-activated receptor (PPAR)-gamma agonists have been proposed as therapy to lower plasma ACTH in Cushing's disease. Cyclical secretion of ACTH may, however, explain some of the responses seen. Patients with Nelson's syndrome have persistently high levels of ACTH and may be a better model for examining new therapies to elevated ACTH levels.

OBJECTIVE

The objective of the study was to assess whether high-dose rosiglitazone therapy reduces circulating ACTH levels in Nelson's syndrome, a model of ACTH hypersecretion for which no established medical therapy exists.

DESIGN

The design was an open-label, prospective, nonrandomized study over 14 wk.

SETTING

The study was conducted at a university teaching hospital.

PATIENTS

Six patients with Nelson's syndrome participated in the study.

METHODS

Patients were assessed at -2, 0, 4, 8, and 12 wk. Rosiglitazone 12 mg/d was administered between 0 and 8 wk. PPAR-gamma immunoreactivity was assessed in pathological tissue.

OUTCOME MEASURE

Plasma ACTH was measured before (0830 h) and 120 min after morning dosing with hydrocortisone (HC).

RESULTS

One female withdrew prior to commencing therapy for personal reasons. There was no evidence that ACTH levels changed over time (P = 0.864). The average ACTH level was 1187 ng/liter (95% confidence interval 928-1446) for patients before the HC dose and 432 ng/liter (95% confidence interval 172-692) after the HC dose. PPAR-gamma immunoreactivity was positive in three ACTH-secreting tumors available.

CONCLUSIONS

Rosiglitazone 12 mg/d did not change circulating ACTH over time, despite PPAR-gamma receptor expression in the tumor tissue. However, this does not preclude the possibility that other patients may respond or that higher doses of rosiglitazone or more potent agonists might prove useful treatment.

Wernicke's encephalopathy in a non-alcoholic man: case report and brief review

Wernicke's encephalopathy, a serious neurological disorder caused by thiamine deficiency, is most commonly found in chronic alcoholics. We present a typical case of Wernicke's encephalopathy in a non-alcoholic man. Our patient presented with altered mental status, slurred speech, fever, vomiting and headache of one-week duration. An infectious etiology of the symptoms was ruled out by spinal fluid cultures. The patient improved dramatically within 24 hours of administration of thiamine.

Clinical results of the intra cytoplasmic sperm injection (ICSI) at Baqai Institute of Reproduction and Developmental Sciences (BIRDS)

OBJECTIVE

To analyse the results of the new revolutionary technique of Intra Cytoplasmic Sperm Injection (ICSI) for male infertility. Furthermore, to find out the ways of reducing cost of the expensive methods of Assisted Reproductive Techniques.

DESIGN

This is an analytical study of results of 71 patients (86 Cycles) of ICSI performed in first year of its launching in Baqai Institute of Reproduction and Developmental Sciences (BIRDS) from May 1997 to April 1998. Men with semen reports of parameters less than WHO criteria were treated including Azoospermic men.

RESULTS

After ICSI procedure a fertilisation rate of 58.9% was achieved in 86 cycles. A total of 17 clinical pregnancies were had from the transfer of fresh embryos. This includes three pregnancies from Surgical Sperm Collection in azoospermic men. Cost could be reduced by avoiding high dosage of drugs and by cutting out serial serum estrogen levels. Ultrasonic assessment for follicle monitoring is equally satisfactory.

CONCLUSION

ICSI proved to be the only successful treatment for men with poor semen quality. It is giving nearly 20% chances of fatherhood in a man who was labeled infertile previously. Results are promising and will be improving with time. The cost could be reduced to an extent by cutting down drug doses and laboratory investigations without compromising the results.

Toxoplasma gondii pneumonia in a pancreas transplant patient

A 41-year-old woman had fever of 3 days' duration. She had had pancreas transplantation 2 years previously and had recently completed a course of antirejection medication. Temperature spikes occurred during treatment with broad spectrum antibiotics. No obvious cause for the fever was found. The patient's condition worsened, with development of shortness of breath, bilateral pulmonary infiltrates on chest radiographs, sepsis, and shock. Fiberoptic bronchoscopy with bronchoalveolar lavage showed the presence of Toxoplasma gondii. Pyrimethamine and clindamycin were started, and the patient improved. Toxoplasma gondii occurs in contaminated food containing oocysts or cysts. Organ transplantation and blood transfusions are other routes of transmission. Most recent cases have occurred in human immunodeficiency virus (HIV) patients with reactivation of previous infection. Serology and tissue biopsies are used for diagnosis. Treatment includes a combination of pyrimethamine and sulfadiazine or trisulfapyrimidines.

What is the effect of riskshaw noise on its driver?

OBJECTIVE

Occupational hearing loss is common in the industrialized world. Road noise is a major contributor to perceived environmental noise. The objective of this study was to assess hearing loss in rickshaw drivers due to rickshaw noise.

METHODS

Hearing loss in rickshaw drivers and taxi drivers of Karachi who were 50 years of age or younger was estimated, with a Smith Hearing Screening (SHS) questionnaire that was modified, translated into the national language, Urdu and field tested prior to administration.

RESULTS

Interviews for 91 rickshaw drivers and 94 taxi drivers were completed. All subjects were male; mean ages were 34 and 33 years for rickshaw and taxi drivers respectively. None of the rickshaws were fitted with silencers. Rickshaw drivers were about thrice as likely to be screened as hearing impaired by the SHS questionnaire (RR 2.9, 95% confidence interval 1.6, 5.0), twice as likely to report tinnitus (RR 2.2, 95% confidence interval, 1.1, 3.3) and two and a half times as likely to have difficulty in following telephonic conversations (RR 2.4, 95% confidence interval 1.2, 4.8).

CONCLUSION

There is loss of hearing and tinnitus among rickshaw drivers that could be attributed to their trade. Use of silencers by rickshaw drivers could result in less hearing loss among rickshaw drivers and less noise in the environment for the other 11 million residents in the city.

Clinical scoring system: a valuable tool for decision making in cases of acute appendicitis

OBJECTIVE

Decision making in cases of acute appendicitis poses a clinical challenge specially in developing countries where advanced radiological investigations do not appear cost effective and so clinical parameters remain the mainstay of diagnosis. The aim of our study was to devise a scoring system from our local database and test its accuracy in the preoperative diagnosis of acute appendicitis.

METHODS

Clinical data from 401 patients having undergone appendectomy were collected to identify predictive factors that distinguished those with appendicitis from those who had a negative appendectomy. Ten such factors were identified and using Bayesian probability a weight was assigned to each and the results summated to get an overall score. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was then retrospectively applied to a second population of 99 patients in order to compare suggested actions (derived from the scoring system) to those actually taken by surgeons. The sensitivity, specificity and accuracy for the level of decision was then calculated.

RESULTS

Of the 99 patients, the method suggested immediate surgery for 65 patients, 63 of whom had acute appendicitis (3.1% diagnostic error rate). Of the 33 patients in whom the score suggested active observation, 18 had appendicitis. The accuracy of our scoring system was 82%. The method had a sensitivity of 78%, specificity 89% and a positive predictive value of 97%. The negative appendectomy rate determined by our study was 7% and the perforation rate 13%.

CONCLUSION

Scoring system developed from a local database can work effectively in routine practice as an adjunct to surgical decision making in questionable cases of appendicitis.

An outbreak of cutaneous leishmaniasis in an Afghan refugee settlement in north-west Pakistan

Cutaneous leishmaniasis (CL) due to Leishmania tropica appears to be an emerging disease in parts of north-east Afghanistan and north-west Pakistan. Timargara, an Afghan refugee camp of 17 years' standing, in the district of Dir, North West Frontier Province of Pakistan, experienced a major outbreak of CL in 1997 for the first time. As part of the investigation, each section of the camp was surveyed for CL. Around 38% of the 9200 inhabitants bore active lesions and a further 13% had scars from earlier attacks. According to interview statements, 99% of earlier infections had healed within the previous 2 years. To confirm the diagnosis, a sample of current CL lesions was examined parasitologically. Amastigotes were detectable by microscopy in only 36% of lesions. However, 48% of slide-negative cases produced positive cultures and some cases negative to both microscopy and culture were positive by PCR. Overall detection rate was about 80%. The sandfly Phlebotomus sergenti, a known vector of L. tropica, was captured within the camp, indicating local transmission. CL has not been reported from this area of Pakistan before. Although the majority of refugees left Afghanistan 2 decades ago, cross-border movement of men is common. The Afghanistan capital, Kabul, is currently experiencing a major epidemic of CL; infected migrant carriers from Kabul are probably the source of the outbreak in Timargara.

Effect of ibutilide, a new class III agent, on sustained atrial fibrillation in a canine model of acute ischemia and myocardial dysfunction induced by microembolization

The effect of ibutilide, a new Class III antiarrhythmic agent, upon acute onset atrial fibrillation was investigated in a closed-chest canine model of acute left ventricular (LV) dysfunction. Twenty-four anesthetized mongrel dogs, mean weight 24.9 +/- 4 kg were subjected to coronary artery microsphere embolization and volume loading, followed by attempted induction of atrial fibrillation (AF) by rapid atrial pacing. Acute ischemic LV dysfunction was successfully induced by embolization in all dogs, and caused significant (P < 0.02) decreases in LV systolic pressure, peak + dp/dt (and -dp/dt), stroke volume, and RR interval; whereas LV end diastolic pressure and QTc significantly increased. Sustained AF (> or = 30 min) was successfully induced in 15 of 24 dogs (62%) and unsustained AF (< 30 min) was induced in the remainder (38%). At 30 minutes after induction of sustained AF, 15 dogs were randomized to intravenous ibutilide (0.15 mg/kg, given as a 0.075 mg/kg bolus, followed by 0.075 mg/kg infusion over 1 hour; n = 7) or placebo (saline; n = 8). There were no statistically significant differences between the ibutilide and the placebo groups with respect to mean LV systolic pressure, LV end diastolic pressure, LV dp/dt, RR interval, or QTc interval during AF prior to infusion. All seven dogs receiving ibutilide converted to sinus rhythm after a median of 3 minutes (range 0.5-26 min), while only three of eight placebo dogs (P < 0.03) converted to sinus rhythm after a median duration of 30 minutes (range 15-60 min) (P < 0.04 for difference in time to conversion).(ABSTRACT TRUNCATED AT 250 WORDS)