Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update

Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.

Outbreak of aplastic crises in sickle cell anaemia associated with parvovirus-like agent

Since 1952, 112 children with sickle cell anaemia (SCA) in Jamaica have had an aplastic crisis. Outbreaks occurred in 1956, 1960, 1065-67, 1971-73, and 1979-80. Most cases occurred in children under 10 years of age, and an aplastic crisis in a patient over the age of 15 years is rare. There were 38 cases in 1979-80 and stored serum specimens from 28 of these were available for virus studies. Evidence for infection with a parvovirus-like agent was found in 24 of these 28 cases. Viral antigen was detected in 2 patients, both of whom demonstrated seroconversion. Seroconversion during 1980 was detected in a further 7, increasing amounts of antibody during the convalescent period were found in 5, antibody was found in 2 of 4 patients from whom only an acute phase specimen was available and the remaining 10 were antibody positive in the only convalescent phase sample available for testing. Antibody was found in 4 of 94 controls with the SS genotype (in retrospect 2 of these may have had an aplastic crisis) and in 17% of 48 controls with a normal haemoglobin (AA) genotype. The results accord with the possibility that the parvovirus-like agent is the principal cause of aplastic crisis in SCA.

Effect of liver transplantation on QT interval prolongation and autonomic dysfunction in end-stage liver disease

Both a prolonged QT interval and disturbance of autonomic nervous system function are markers of poor prognosis in patients with diabetes mellitus and alcoholic liver disease (ALD). We studied the prevalence of abnormal QT interval and autonomic nervous system dysfunction in 53 consecutive patients with end-stage liver disease before and after orthotopic liver transplantation (OLT). The maximum QT interval in any lead (QTmax) was assessed by two independent observers. The QTmax, corrected for heart rate (QTcmax) was prolonged in 44 patients (83%), although increased QT dispersion was not found. There was a significant correlation between the QTcmax and Child-Pugh score but not with etiology. Evidence of parasympathetic dysfunction was present in 41 patients (77%), and sympathetic dysfunction was present in 20 patients before OLT. Fifty-two patients underwent transplantation. There was significant improvement in the QTcmax interval after OLT (P < .001); 32 of the 44 patients with prolonged QTcmax ( > 440 milliseconds) improved. Repeat testing was not performed in 7 patients, because they had died or had not undergone transplantation. Indices of parasympathetic function improved in 27 patients after OLT, but no improvement was observed in 8. Improvement in sympathetic dysfunction was observed in 13 of the 19 patients tested. There was no association between QTcmax, autonomic dysfunction, and survival. These results suggest that both prolonged QTcmax and some tests of autonomic function are temporary and arise as a consequence of liver dysfunction.

Hepatocyte transplantation followed by auxiliary liver transplantation--a novel treatment for ornithine transcarbamylase deficiency

We report the first successful use of hepatocyte transplantation as a bridge to subsequent auxiliary partial orthotopic liver transplantation (APOLT) in a child antenatally diagnosed with severe ornithine transcarbamylase (OTC) deficiency. A total of 1.74 x 10(9) fresh and cryopreserved hepatocytes were administered intraportally into the liver over a period of 6 months. Immunosuppression was with tacrolimus and prednisolone. A sustained decrease in ammonia levels and a gradual increase in serum urea were observed except during episodes of sepsis in the first 6 months of life. The patient was able to tolerate a normal protein intake and presented a normal growth and neurological development. APOLT was successfully performed at 7 months of age. We conclude that hepatocyte transplantation can be used in conjunction with APOLT as an effective treatment for severe OTC-deficient patients, improving neurodevelopmental outcomes.

Contribution of extracranial lymphatics and arachnoid villi to the clearance of a CSF tracer in the rat

The objective of this study was to determine the relative roles of arachnoid villi and cervical lymphatics in the clearance of a cerebrospinal fluid (CSF) tracer in rats. 125I-labeled human serum albumin (125I-HSA; 100 micrograms) was injected into one lateral ventricle, and an Evans blue dye-rat protein complex was injected intravenously. Arterial blood was sampled for 3 h. Immediately after this, multiple cervical vessels were ligated in the same animals, and plasma recoveries were monitored for a further 3 h after the intracerebroventricular injection of 100 micrograms 131I-HSA. Tracer recovery in plasma at 3 h averaged (%injected dose) 0.697 +/- 0.042 before lymphatic ligation and dropped significantly to 0.357 +/- 0. 060 after ligation. Estimates of the rate constant associated with the transport of the CSF tracer to plasma were also significantly lower after obstruction of cervical lymphatics (from 0.584 +/- 0. 072/h to 0.217 +/- 0.056/h). No significant changes were observed in sham-operated animals. Assuming that the movement of the CSF tracer to plasma in lymph-ligated animals was a result of arachnoid villi clearance, we conclude that arachnoid villi and extracranial lymphatic pathways contributed equally to the clearance of the CSF tracer from the cranial vault.

Roselle (Hibiscus sabdariffa) seed oil is a rich source of gamma-tocopherol

The antioxidant potential of roselle (Hibiscus sabdariffa L.) extracts was studied. Different plant organs, including seeds, stems, leaves, and sepals, were analyzed with respect to their water-soluble antioxidant capacity, lipid-soluble antioxidant capacity, and tocopherol content, revealing that roselle seeds are a good source of lipid-soluble antioxidants, particularly gamma-tocopherol. Roselle seed oil was extracted and characterized, and its physicochemical parameters are summarized: acidity, 2.24%; peroxide index, 8.63 meq/kg; extinction coefficients at 232 (k(232)) and 270 nm (k(270)), 3.19 and 1.46, respectively; oxidative stability, 15.53 h; refractive index, 1.477; density, 0.92 kg/L; and viscosity, 15.9 cP. Roselle seed oil belongs to the linoleic/oleic category, its most abundant fatty acids being C18:2 (40.1%), C18:1 (28%), C16:0 (20%), C18:0 (5.3%), and C19:1 (1.7%). Sterols include beta-sitosterol (71.9%), campesterol (13.6%), Delta-5-avenasterol (5.9%), cholesterol (1.35%), and clerosterol (0.6%). Total tocopherols were detected at an average concentration of 2000 mg/kg, including alpha-tocopherol (25%), gamma-tocopherol (74.5%), and delta-tocopherol (0.5%). The global characteristics of roselle seed oil suggest that it could have important industrial applications, adding to the traditional use of roselle sepals in the elaboration of karkade tea.

Role of adenosine A2A receptor in cerebral ischemia reperfusion injury: Signaling to phosphorylated extracellular signal-regulated protein kinase (pERK1/2)

Following brain ischemia reperfusion (IR), the dramatic increase in adenosine activates A2AR to induce further neuronal damage. Noteworthy, A2A antagonists have proven efficacious in halting IR injury, however, the detailed downstream signaling remains elusive. To this end, the present study aimed to investigate the possible involvement of phospho-extracellular signal-regulated kinase (pERK1/2) pathway in mediating protection afforded by the central A2A blockade. Male Wistar rats (250-270 g) subjected to bilateral carotid occlusion for 45 min followed by a 24-h reperfusion period showed increased infarct size corroborating histopathological damage, memory impairment and motor incoordination as well as increased locomotor activity. Those events were mitigated by the unilateral intrahippocampal administration of the selective A2A antagonist SCH58261 via a decrease in pERK1/2 downstream from diacyl glycerol (DAG) signaling. Consequent to pERK1/2 inhibition, reduced hippocampal microglial activation, glial tumor necrosis factor-alpha (TNF-α) and brain-derived neurotropic factor (BDNF) expression, glutamate (Glu), inducible nitric oxide synthase (iNOS) and thiobarbituric acid reactive substances (TBARS) were evident in animals receiving SCH58261. Additionally, the anti-inflammatory cytokine interleukin-10 (IL-10) increased following nuclear factor (erythroid-derived 2)-like 2 (Nrf-2). Taken all together, these events suppressed apoptotic pathways via a reduction in cytochrome c (Cyt. c) as well as caspase-3 supporting a crucial role for pERK1/2 inhibition in consequent reduction of inflammatory and excitotoxic cascades as well as correction of the redox imbalance.

Posttransplantation chronic hepatitis in fulminant hepatic failure

Non-A, non-B or seronegative hepatitis is the leading indication for liver transplantation in patients with fulminant hepatic failure (FHF). We examined protocol annual review liver allograft biopsy specimens in consecutive adult patients transplanted for FHF in an attempt to determine the extent of the histological changes. One hundred eleven biopsy specimens from 41 patients transplanted for fulminant seronegative hepatitis and 34 from a comparison group of 16 patients transplanted for other causes of FHF (11 paracetamol overdose, 2 idiosyncratic drug reaction, 3 Wilson's disease) were available. Specimens were analyzed using standard proforma without knowledge of the original diagnosis. Chronic hepatitis was present in 29 patients (71%) transplanted for fulminant seronegative hepatitis (23 mild, 3 moderate, and 3 severe) compared with 5 patients (31%, all mild) transplanted for other causes of FHF. Twenty-five patients (61%) grafted for seronegative FHF had fibrosis (13 mild, 9 moderate, and 3 severe) in contrast to 4 fibrosis (25%) (all mild) in the comparison group. Excluding early allograft failure because of primary graft nonfunction or vascular complications, six patients with seronegative FHF required retransplantation (2 = chronic rejection; 1 = severe hepatitis with panacinar necrosis, resembling original liver; and 3 = chronic hepatitis with precirrhotic fibrosis and prominent cholestasis of unknown cause). One patient in the comparison group had a second graft (chronic rejection). Posttransplantation chronic hepatitis is more frequent and severe in patients transplanted for seronegative hepatitis. Graft survival may be adversely influenced by the development of chronic hepatitis, which may represent persistent or recurrent disease.

Historical epidemiology of hepatitis C virus in select countries-volume 4

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

SCH58261 the selective adenosine A(2A) receptor blocker modulates ischemia reperfusion injury following bilateral carotid occlusion: role of inflammatory mediators

In the present study, the effects of SCH58261, a selective adenosine A(2A) receptor antagonist that crosses the blood brain barrier (BBB) and 8-(4-sulfophenyl) theophylline (8-SPT), a non-selective adenosine receptor antagonist that acts peripherally, were investigated on cerebral ischemia reperfusion injury (IR). Male Wistar rats (200-250 g) were divided into four groups: (1) sham-operated (SO), IR pretreated with either (2) vehicle (DMSO); (3) SCH58261 (0.01 mg/kg); (4) 8-SPT (2.5 mg/kg). Animals were anesthetized and submitted to occlusion of both carotid arteries for 45 min. All treatments were administered intraperitoneally (i.p.) post carotid occlusion prior to exposure to a 24 h reperfusion period. Ischemic rats showed increased infarct size compared to their control counterparts that corroborated with histopathological changes as well as increased lactate dehydrogenase (LDH) activity in the hippocampus. Moreover, ischemic animals showed habituation deficit, increased anxiety and locomotor activity. IR increased hippocampal glutamate (Glu), GABA, glycine (Gly) and aspartate (ASP). SCH58261 significantly reversed these effects while 8-SPT elicited minimal change. IR raised myeloperoxidase (MPO), tumor necrosis factor-alpha (TNF-α), nitric oxide (NO), prostaglandin E₂ (PGE₂) accompanied by a decrease in interleukin-10 (IL-10), effects that were again reversed by SCH58261, but 8-SPT elicited less changes. Results from the present study point towards the importance of central blockade of adenosine A(2A) receptor in ameliorating hippocampal damage following IR injury by halting inflammatory cascades as well as modulating excitotoxicity.

Resistance of Pseudomonas pseudomallei to normal human serum bactericidal action

The effect of human normal serum (HNS) on Pseudomonas pseudomallei was determined. It is apparent from our data that the organism is resistant to the normal serum bactericidal mechanism. Ancillary experiments to confirm this serum-resistant property of P. pseudomallei were done by examining the effects of growth phase conditions of the bacteria (i.e., logarithmic and stationary phases) and different buffered systems used as diluent in our bactericidal assay. Results obtained showed similar degree of resistance to serum bactericidal killing by 5 strains of the organisms tested. The possible survival advantage of serum-resistance property to P. pseudomallei as bacterial pathogens known to invade the blood stream is discussed.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Reduced DNA topoisomerase II activity in ataxia-telangiectasia cells

Considerable evidence supports a defect at the level of chromatin structure or recognition of that structure in cells from patients with the human genetic disorder ataxia-telangiectasia. Accordingly, we have investigated the activities of enzymes that alter the topology of DNA in Epstein Barr Virus-transformed lymphoblastoid cells from patients with this syndrome. Reduced activity of DNA topoisomerase II, determined by unknotting of P4 phage DNA, was observed in partially purified extracts from 5 ataxia-telangiectasia cell lines. The levels of enzyme activity was reduced substantially in 4 of these cell lines and to a lesser extent in the other cell line compared to controls. DNA topoisomerase I, assayed by relaxation of supercoiled DNA, was found to be present at comparable levels in both cell types. Reduced activity of topoisomerase II in ataxia-telangiectasia is compatible with the molecular, cellular and clinical changes described in this syndrome.

Increased apoptosis of bone marrow cells and preserved proliferative capacity of selected progenitors predict for clinical response to anti-inflammatory therapy in myelodysplastic syndromes

To determine the relation of apoptosis and clonal proliferation in the bone marrow (BM) to the effectiveness of a therapeutic protocol described to downmodulate monokine activity in patients with myelodysplastic syndromes (MDS). Prior to protocol therapy, BM stroma was cultivated and selected CD34(+) cells were studied in stroma and cytokine-dependent clonogenic assays. The TUNEL assay was used to establish the degree of apoptosis occurring in the marrow and CD34(+) population. The effectiveness of oral ciproloxacin 500 mg b. i.d., pentoxifylline 800 mg t.i.d., and dexamathasone 4 mg t.i.d. (CPD) antiinflammatory therapy was correlated with the intensity of cell apoptosis and proliferation of BM progenitor cells. Seventeen patients were studied. Twelve patients (10 transfusion dependent) received therapy for a median of 99 days (range 49-284). Toxicity caused four patients to discontinue the drug combination. Six patients fulfilled response criteria. Four patients became transfusion independent, and 50% reduction in the need for blood transfusions was noted in one patient. Blood parameters of one untransfused patient increased by >30%. Blood count remained unsupported in three patients, even at a median of 12 months after trial discontinuation. Apoptosis of marrow cells and selected CD34(+) progenitors was detected in a median of 49.5% (range 3. 6%-90%) and 10.6% (range 3.6%-100%; p < 0.01), respectively. In patients who responded to therapy, the median apoptosis rate in the bone marrow population was 71%, in contrast to the nonresponder's rate of 13% (p = 0.002). Overall clonogenic growth of selected precursors corresponded significantly with response to CPD protocol (p = 0.004). In some patients with MDS, ineffective hematopoiesis is related to high apoptotic index despite proliferation of the CD34(+) precursors. These patients seem to benefit from CPD cytokine modulatory therapeutic strategy.

A defect in DNA topoisomerase II activity in ataxia-telangiectasia cells

DNA topoisomerase type I and II activities were determined by serial dilution in nuclear extracts from control and ataxia-telangiectasia lymphoblastoid cells. Topoisomerase I activity, assayed by relaxation of supercoiled plasmid DNA, was found to be approximately the same in both cell types. In order to remove interference from topoisomerase I, the activity of topoisomerase II was measured by the unknotting of knotted P4 phage DNA in the presence of ATP. The activity of topoisomerase II was markedly reduced in two ataxia-telangiectasia cell lines, AT2ABR and AT8ABR, compared to controls. This reduction in activity was detected with increasing concentration of protein and in time course experiments at a single protein concentration. A third cell line, AT3ABR, did not have a detectably lower activity of topoisomerase II when assayed under these conditions. The difference in topoisomerase II activity in the ataxia-telangiectasia cell lines examined may reflect to some extent the heterogeneity observed in this syndrome.

Inhibition of macromolecular synthesis in cultured macrophages by Pseudomonas pseudomallei exotoxin

Pseudomonas pseudomallei exotoxin was found to be a potent inhibitor of protein and DNA synthesis in cultured macrophages. Inhibition of DNA synthesis occurred at toxin concentrations as low as 1-2 micrograms/ml and inhibition of 3H-thymidine uptake was almost complete at concentrations of 8 micrograms/ml or more. A close correlation between cell damage and inhibition by DNA synthesis was observed. For protein synthesis, inhibition was obtained at much lower doses (0.06-2.0 micrograms/ml) of the toxin. At similar toxin concentrations, DNA synthesis was marginally affected. Further, it was shown that protein synthesis inhibition occurred almost immediately after incubation, reaching its maximal inhibitory effect of 70% after 6 hr. DNA synthesis, however, was minimally affected by a similar toxin concentration even after 10 hr of incubation. The inhibition of macromolecular synthesis in macrophages by P. pseudomallei exotoxin may be relevant to its modulatory effect on the host defense mechanism.

Isolated limb infusion with cytotoxic agent for treatment of localized refractory cutaneous T-cell lymphoma

We described a 57-yr-old male diagnosed with cutaneous T-cell lymphoma that had failed multiple treatment options, as his disease was mainly confined to one limb. We attempted a novel approach in this condition using a technique of intra-arterial limb infusion with cytotoxic agent Melphalan (ILI) which has been proven beneficial in management of localised malignant melanoma. This treatment approach was well tolerated with mild myelosuppression and moderate limb toxicity. However, a significant improvement has been noted in the affected limb. This case demonstrated the successful use of isolated limb infusion with Melphalan in the management of localised cutaneous T-cell lymphoma. However, this result needs to be confirmed and further study is recommended. We are unaware there have been similar cases reported in the literature.

Strategies to manage hepatitis C virus infection disease burden-Volume 4

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

Basic fibroblast growth factor corrects proliferative derangement of bone marrow stroma and CD34(+) population following allogeneic stem cell transplantation

OBJECTIVE

Following stem cell transplantation (SCT), the integrity of the hematopoietic microenvironment is important for the recovery of bone marrow. We studied the effects of basic fibroblast growth factor (bFGF) on the proliferation of clonogenic progenitors and bone marrow stroma from patients receiving cytokine-mobilized allogeneic stem cell transplants (SCT).

MATERIALS AND METHODS

Patient bone marrow mononuclear cells were studied at a minimum of 6 months after transplantation. Control and patient samples were divided into two fractions, one to establish the adherent stroma layers (SL) and the other to select for the progenitor population. SL from normal subjects or from patients were supplemented with 0 (control), 2, or 20 ng/mL bFGF in combination with heparan sulfate, and the resulting area of the dish covered by stroma was quantitated in each group. At 3 weeks of culture, a monocellular suspension was prepared by exposing SL to 0.1% trypsin. Cells then were cultured in the colony-forming unit fibroblast (CFU-F) assay, which was supplemented with 0 (control), 2, or 20 ng/mL bFGF. With the second fraction, CD34(+) cells were selected with paramagnetic beads, and 1 x 10(4) cells were incubated in cross-culture studies on preformed SL from patient or control origin (with or without the addition of bFGF). SL adherent CD34(+) cells were covered with agar and cultured for 6 days. Aggregates of >20 cells were scored as blastic colonies (CFU-bl).

RESULTS

At 3 weeks of culture, the median surface area of dishes covered by monoloayers from 13 patients was 40% (range 10-50% vs normal 55%, range 30-60%; p = 0.00006) and improved significantly, matching control values, in dishes supplemented with bFGF. Addition of bFGF to stroma monolayers had no effect on the number of CFU-F in both patient and control samples. Selected CD34(+) cells from patients receiving transplants and cultured on normal stroma gave significantly fewer CFU-bl than control samples (median 36, range 3-121 vs 147, range 10-184; p = 0.006), but colony numbers corrected following exposure to bFGF. Normal CD34(+) cells proliferated poorly on stroma from patients (median CFU-bl 37.5, range 6-84; p = 0.02), but also expanded significantly following bFGF supplementation (104, range 6-117; p = 0.001).

CONCLUSIONS

Following SCT, poor SL and CD34(+) proliferation can be corrected by addition of bFGF.

DNA replication and repair in ataxia telangiectasia cells exposed to bleomycin

A marked increase in sensitivity to bleomycin was observed in two ataxia telangiectasia (AT) lymphoblastoid cell lines compared to that in cell lines from two normal individuals. This sensitivity was obtained at two different concentrations of bleomycin. While normal cells showed a rapid recovery of ability to divide, there was no indication of such a recovery in AT cells up to 120 h after bleomycin treatment. A similar level of breakage of DNA occurred in both cell types after incubation with bleomycin. The rate of repair of these breaks was also the same. DNA synthesis was found to be more resistant to bleomycin in AT cells than in control cells. The latter data are in keeping with results previously obtained using ionizing radiation.

Prevalence of antibodies to Pseudomonas pseudomallei exotoxin and whole cell antigens in military personnel in Sabah and Sarawak, Malaysia

Sera from 420 military personnel serving in Sabah and Sarawk, Malaysia, were tested for antibodies to Pseudomonas pseudomallei exotoxin and whole cell antigens by enzyme-linked immunosorbent assay procedure (ELISA). Data showed that 54.4% of serum samples were positive for antibodies to P. pseudomallei exotoxin and 65.7% were positive for antibodies to the whole cell antigens. Samples gave much lower titers for anti-exotoxin antibodies compared to titers against crude whole cell antigens. The incidence of antibody to exotoxin was highest in the age groups ranging from 26 to 32 years, where the positive rates were higher than 40% and 30% for military personnel serving in Sarawak and Sabah, respectively.

Urinary TNF-like weak inducer of apoptosis (TWEAK) as a biomarker of lupus nephritis

BACKGROUND

Renal involvement in systemic lupus erythematosus (SLE), known as lupus nephritis (LN), is a common and severe complication and a major predictor of poor outcome. Long-term survival in SLE can be improved with early diagnosis and prompt treatment of LN. A number of biochemical markers are currently used to clinically assess disease activity in patients; however, they lack sensitivity and specificity for differentiating renal activity and damage in LN. A reliable clinical biomarker that can forecast LN flare and which could be sequentially followed would help to optimize initiation and escalation of therapy at the time of active or relapsing disease.

OBJECTIVE

This study was carried out to investigate the value of urinary tumor necrosis factor (TNF)-like weak inducer of apoptosis (uTWEAK) as a biomarker for active lupus nephritis.

PATIENTS AND METHODS

A total of 44 patients with SLE fulfilling the 1997 revised criteria for the classification of SLE as well as 11 age and sex-matched healthy controls were included in this study and subjected to full medical history taking, clinical examination, routine laboratory investigations, measurement of uTWEAK level as well as renal biopsy for patients with active LN.

RESULTS

The uTWEAK levels were significantly higher in SLE patients with active LN compared to those without or with inactive renal disease and normal healthy subjects.

Ataxia-telangiectasia cell extracts confer radioresistant DNA synthesis on control cells

We have investigated in greater detail the radioresistant DNA synthesis universally observed in cells from patients with ataxia-telangiectasia (A-T). The approach employed in this study was to permeabilize cells with lysolecithin after gamma-irradiation and thus facilitate the introduction of cell extract into these cells. This permeabilization can be reversed by diluting the cells in growth medium. Cells treated in this way show the characteristic inhibition (control cells) or lack of it (A-T cells) after exposure to ionizing radiation. Introduction of A-T cells extracts into control cells prevented the radiation-induced inhibition of DNA synthesis normally observed in these cells. A-T cell extracts did not change the level of radioresistant DNA synthesis in A-T cells. Control cell extracts on the other hand did not influence the pattern of inhibition of DNA synthesis in either cell type. It seems likely that the agent involved is a protein because of its heat lability and sensitivity to trypsin digestion. It has a molecular weight (MW) in the range 20-30 000 D. The development of this assay system for a factor conferring radioresistant DNA synthesis on control cells provides a means of purifying this factor, and ultimately an approach to identifying the gene responsible.

Cryopreservation of the bone marrow from patients with acute myeloid leukaemia leads to functional abnormalities

We compared the performance of the stroma (SL) and haematopoietic progenitors before (group A) or following cryopreservation from patients in complete remission (CR) of acute myeloid leukaemia before autologous transplantation (AML) (group B), to similarly treated normal cells (groups A and B). From each group, fibroblastic (F) colony-forming units (CFU) and SL were established and their growth quantitated. Upon confluence of SL, 1 x 10(4)selected CD34+ cells from patient or control samples (of group A and B) were seeded on pre-formed SL from AML or control group A and B layers and adhesive precursors were scored for the formation of blastic (-b1) CFU (>20 cells). Lastly, CD34+ cells from the 4 progenitor sources were cultured in the presence of growth factors and scored for the production of granulocyte-macrophage (GM) CFU, erythroid burst forming units (BFU-E) and mixed colonies (CFU-MIX). In the patients, CFU-F numbers were decreased and by 5 wk SL failed to reach confluence. Group A AML CD34+ progenitors gave a mean of 119.2 (SD 80.4) CFU-bl/10(4) CD34+ cells, but following cryopreservation these numbers declined (83.2, SD 72.71; p = 0.009). Although AML SL prior to cryopreservation supported control CFU-bl adequately, contrary to the norm, this property decreased in group B stroma (mean 50.9/10(4)CD34+ cells, SD 49.33; p =(0.02). Group B AML samples gave significantly fewer CFU-MIX and BFU-E than pre-freezing cultures and than control samples at the first 2-growth factor combination but numbers improved following further addition of cytokines. We conclude that cryopreservation of the bone marrow of patients in CR of AML results in an inhibition of the proliferation of the CD34+ precursors. It also modifies the stroma, leading to reductions in the support of normal clones.