The family planning "know-do" gap among married women of reproductive age in urban Pakistan

OBJECTIVE

To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.

DESIGN

This was a cross-sectional survey of randomly selected 7288 MWRA (16-49 years) to identify predictors of the know-do gap in FP using a logistic regression model.

RESULTS

More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25-35 years: OR 1.45, 95% CI 1.09-1.94; >35 years: OR 3.02, 95% CI 1.90-4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11-2.42; Saraiki: OR 1.66, 95% CI 1.01-2.71; other minorities: OR 2.37, 95% CI 1.63-3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13-1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06-1.98). Conversely, women were more likely to use contraceptives if they had >10 years of schooling (OR 0.66, 95% CI 0.46-0.94), with each increasing number of a living child (OR 0.68, 95% CI 0.62-0.75) and each increasing number of contraceptive method known (OR 0.93, 95% CI 0.88-0.98).

CONCLUSION

The predictors associated with the FP know-do gap among MWRA should be considered when planning future strategies to improve the contraceptive prevalence rate in Pakistan.

Discovery of serum biomarkers for diagnosis of tuberculosis by NMR metabolomics including cross-validation with a second cohort

Background

Tuberculosis (TB) is a disease with worldwide presence and a major cause of death in several developing countries. Current diagnostic methodologies often lack specificity and sensitivity, whereas a long time is needed to obtain a conclusive result.

Methods

In an effort to develop better diagnostic methods, this study aimed at the discovery of a biomarker signature for TB diagnosis using a Nuclear Magnetic Resonance based metabolomics approach. In this study, we acquired ¹H NMR spectra of blood serum samples of groups of healthy subjects, individuals with latent TB and of patients with pulmonary and extra-pulmonary TB. The resulting data were treated with uni- and multivariate statistical analysis.

Results

Six metabolites (inosine, hypoxanthine, mannose, asparagine, aspartate and glutamate) were validated by an independent cohort, all of them related with metabolic processes described as associated with TB infection.

Conclusion

The findings of the study are according with the WHO Target Product Profile recommendations for a triage test to rule-out active TB.

Active and prospective latent tuberculosis are associated with different metabolomic profiles: clinical potential for the identification of rapid and non-invasive biomarkers

Although 23% of world population is infected with Mycobacterium tuberculosis (M. tb), only 5-10% manifest the disease. Individuals surely exposed to M. tb that remain asymptomatic are considered potential latent TB (LTB) cases. Such asymptomatic M. tb.-exposed individuals represent a reservoir for active TB cases. Although accurate discrimination and early treatment of patients with active TB and asymptomatic M. tb.-exposed individuals are necessary to control TB, identifying those individuals at risk of developing active TB still remains a tremendous clinical challenge. This study aimed to characterize the differences in the serum metabolic profile specifically associated to active TB infected individuals or to asymptomatic M. tb.-exposed population. Interestingly, significant changes in a specific set of metabolites were shared when comparing either asymptomatic house-hold contacts of active TB patients (HHC-TB) or active TB patients (A-TB) to clinically healthy controls (HC). Furthermore, this analysis revealed statistically significant lower serum levels of aminoacids such as alanine, lysine, glutamate and glutamine, and citrate and choline in patients with A-TB, when compared to HHC-TB. The predictive ability of these metabolic changes was also evaluated. Although further validation in independent cohorts and comparison with other pulmonary infectious diseases will be necessary to assess the clinical potential, this analysis enabled the discrimination between HHC-TB and A-TB patients with an AUC value of 0.904 (confidence interval 0.81-1.00, p-value < 0.0001). Overall, the strategy described in this work could provide a sensitive, specific, and minimally invasive method that could eventually be translated into a clinical tool for TB control.

Case Series: Seventeen Year Institutional Review of Placental Chorangiomas

Introduction/Objective

Chorangioma is a rare tumor occurring in less than 0.5 - 1% of all pregnancies. Small chorangiomas (&lt; 4cm) are mostly asymptomatic and incidental. Large chorangiomas (&gt; 4 cm) may be associated with various fetal complications and complicated pregnancies. The aim of our study is to assess the ultrasound detection rate of these lesions.

Methods

A retrospective study of chorangioma cases seen at Vidant Medical Center between 2003 to 2019 was conducted. Size of the lesion, detection on prenatal imaging, gestational weeks at delivery, maternal age and pregnancy related fetal and maternal complications were analyzed.

Results

A total of 25761 placentas were examined from 2003 to 2019 in Vidant Medical Center. Out of these only thirty-nine cases (0.15%) of chorangioma were found. 41% of these women were above 30 years of age. 36 patients were non-Hispanic. 92.3 % (36 cases) of these lesions were less than 4cm and 7.6 %(3 cases) were above 4 cm, with only one recent case of 7.0 cm in greatest dimension. 92% of the total patients presented with complicated pregnancies. Preeclampsia, preterm delivery, gestational hypertension and intrauterine growth retardation were among the most common complications observed. 3 patients presented with oligohydramnios. Interestingly, none of the lesions were detected on prenatal ultrasound.

Conclusion

Large chorangiomas(&gt;4 cm) are rare but are known to be associated with adverse fetal outcomes. Our seventeen year institutional review shows the largest chorangioma to be 7 cm in greatest dimension. Regular ultrasound monitoring is required to pick up these benign lesions early and prevent adverse outcomes. A retrospective review is needed to determine why the lesions in our study were not detected radiographically.

Long-Term Rupture Risk in Patients with Unruptured Intracranial Aneurysms Treated with Endovascular Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

Surveillance imaging of previously unruptured, coiled aneurysms remains routine even though reports of rupture of these aneurysms are extremely rare.

PURPOSE

We performed meta-analysis to examine long-term rupture risk over ≥1-year follow-up duration in patients with unruptured intracranial aneurysm who underwent endovascular therapy.

DATA SOURCES

Multiple databases were searched for relevant publications between 1995 and 2018.

STUDY SELECTION

Studies reporting outcome of long-term rupture risk over ≥1-year follow-up in treated patients with unruptured intracranial aneurysms were included.

DATA ANALYSIS

Random effects meta-analysis was used, and results were expressed as long-term rupture rate per 100 patient-year with respective 95% CIs. For ruptured aneurysms during follow-up, data were collected on size and completeness of initial Treatment.

DATA SYNTHESIS

Twenty-four studies were identified. Among 4842 patients with a mean follow-up duration of 3.2 years, a total of 12 patients (0.25%) experienced rupture of previous unruptured intracranial aneurysms after endovascular treatment. Nine of these 12 patients harbored aneurysms that were large, incompletely treated, or both. A total of 2 anterior circulation, small, completely coiled aneurysms subsequently ruptured. The long-term rupture rate per 100 patient-year for unruptured intracranial aneurysms treated with endovascular therapy was 0.48 (95% CI, 0.45-0.51). Retreatment was carried out in 236 (4.9%) of these 4842 patients.

LIMITATIONS

A limitation of the study is that a lack of systematic nature of follow-up and mean follow-up duration of 3.2 years are not sufficient to make general recommendations about aneurysm followup paradigms.

CONCLUSIONS

Given a 5% retreatment rate, postcoil embolization spontaneous rupture of previously unruptured, small- and medium-sized, well-treated aneurysms is exceedingly rare.

P3380Longitudinal assessment of coronary atherosclerosis according to baseline and changes of serum hemoglobin level

Introduction

Little is known regarding the impact of serum hemoglobin level changes (Δ hemoglobin) on coronary plaque volume. This study evaluated the association between Δ hemoglobin and coronary plaque volume change (PVC) using serial coronary computed tomographic angiography (CCTA).

Methods

A total of 830 subjects (61±10 years, 51.9% male) who underwent serial CCTA with available hemoglobin levels were analyzed from the Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry. The median inter-scan period was 3.2 (2.5 to 4.4) years. Quantitative assessment of coronary plaques was performed at both scans. All participants were stratified into four groups based on the quartile of baseline hemoglobin levels. Annualized PVC was defined as total PVC divided by inter-scan period. Plaque progression (PP) was defined as plaque volume at follow-up minus plaque volume at index >0.

Results

Baseline total plaque volume (mm3) was not different among all groups (group I [lowest]: 34.1 (0.0–127.4) vs. group II: 28.8 (0.0–123.0) vs. group III: 49.9 (5.6–135.0) vs. group IV [highest]: 34.3 (0.0–130.7); p=0.235). During follow-up, Δ hemoglobin was related to annualized PVC (β:−0.114; p=0.001) and PP (odds ratio: 0.868; 95% confidence interval: 0.770–0.978; p=0.020). Multiple linear regression models showed that Δ hemoglobin significantly impacted on annualized PVC in only the composite of I and II groups.

Conclusion

Based on serial CCTA findings, Δ hemoglobin independently impacted on coronary PVC in individuals with low to normal baseline hemoglobin level.

Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations

BACKGROUND

Pulmonary arteriovenous malformations (PAVMs) generate a right-to-left shunt. Impaired gas exchange results in hypoxaemia and impaired CO2 clearance. Most patients compensate effectively but some are dyspneic, and these are rarely the most hypoxaemic.

AIM

To test degrees of concurrent pathology influencing exercise capacity.

DESIGN

Replicate, sequential single centre, prospective studies.

METHODS

Cardiopulmonary exercise tests (CPETs) were performed in 26 patients with PAVMs, including individuals with and without known airflow obstruction. To replicate, relationships were tested prospectively in an independent cohort where self-reported exercise capacity evaluated by the Veterans Specific Activity Questionnaire (VSAQ) was used to calculate metabolic equivalents (METs) at peak exercise (n = 71). Additional measurements included oxygen saturation (SpO2), forced expiratory volume in 1 s (FEV1), vital capacity (VC), fractional exhaled nitric oxide (FeNO), haemoglobin and iron indices.

RESULTS

By CPET, the peak work rate was only minimally associated with low SpO2 or low arterial oxygen content (calculated as CaO2=1.34 × SpO2 × haemoglobin), but was reduced in patients with low FEV1 or VC. Supranormal work rates were seen in patients with severe right-to-left shunting and SpO2 < 90%, but only if FEV1 was >80% predicted. VSAQ-calculated METS also demonstrated little relationship with SpO2, and in crude and CaO2-adjusted regression, were lower in patients with lower FEV1 or VC. Bronchodilation increased airflow even where spirometry was in the normal range: exhaled nitric oxide measurements were normal in 80% of cases, and unrelated to any PAVM-specific variable.

CONCLUSIONS

Exercise capacity is reduced by relatively mild airflow limitation (obstructive or restrictive) in the setting of PAVMs.

Mycobacterium oryzae sp. nov., a scotochromogenic, rapidly growing species is able to infect human macrophage cell line

Gram-stain-positive, acid-fast-positive, rapidly growing, rod-shaped bacteria (designated as strains JC290T, JC430 and JC431) were isolated from paddy cultivated soils on the Western Ghats of India. Phylogenetic analysis placed the three strains among the rapidly growing mycobacteria, being most closely related to Mycobacterium tokaiense 47503T (98.8 % 16S rRNA gene sequence similarity), Mycobacterium murale MA112/96T (98.8 %) and a few other Mycobacterium species. The level of DNA-DNA reassociation of the three strains with M. tokaiense DSM 44635T was 23.4±4 % (26.1±3 %, reciprocal analysis) and 21.4±2 % (22.1±4 %, reciprocal analysis). The three novel strains shared >99.9 % 16S rRNA gene sequence similarity and DNA-DNA reassociation values >85 %. Furthermore, phylogenetic analysis based on concatenated sequences (3071 bp) of four housekeeping genes (16S rRNA, hsp65, rpoB and sodA) revealed that strain JC290T is clearly distinct from all other Mycobacteriumspecies. The three strains had diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylinositol, phosphatidylinositolmannosides, unidentified phospholipids, unidentified glycolipids and an unidentified lipid as polar lipids. The predominant isoprenoid quinone for all three strains was MK-9(H2). Fatty acids were C17 : 1ω7c, C16 : 0, C18 : 1ω9c, C16 : 1ω7c/C16 : 1ω6c and C19 : 1ω7c/C19 : 1ω6c for all the three strains. On the basis of phenotypic, chemotaxonomic and phylogenetic data, it was concluded that strains JC290T, JC430 and JC431 are members of a novel species within the genus Mycobacterium and for which the name Mycobacterium oryzae sp. nov. is proposed. The type strain is JC290T (=KCTC 39560T=LMG 28809T).

Lapatinib-based therapy for women with advanced/metastatic HER2 positive breast cancer

BACKGROUND

Lapatinib alone or in combination with other agents, mostly capecitabine is used for patients with advanced/metastatic HER2 positive breast cancer (HER2(+)BC) after progression on trastuzumab based therapy. Here we report our experience with lapatinib based therapy in this setting.

MATERIAL AND METHODS

67 consecutive patients received lapatinib based therapy. 58 (86.6%) received lapatinib + capecitabine (LC), 7 (10.4%) with other agents and 2 (3.0%) as single agent lapatinib. Data was collected from patients' records retrospectively.

RESULTS

Objective response to lapatinib based therapy in 64 evaluable patients was 64.0% in all patients and 64.0% in patients who received LC. Median progression free survival and overall survival were 10 and 27 months in all patients and 10 and 17 months in patients who received LC, respectively. 16 (24.0%) patients had dose delay > 1 week and/or dose reduction.

CONCLUSION

Lapatinib based therapy is an effective treatment for women with advanced/metastatic HER2(+)BC after prior exposure to trastuzumab. It yields meaningful response rates, progression free and overall survival. Some patients require dose adjustments.

Analysis of a metalloporphyrin antioxidant mimetic (MnTE-2-PyP) as a radiomitigator: prostate tumor and immune status

Due to radiation-induced immune depression and development of pathologies such as cancer, there is increasing urgency to identify radiomitigators that are effective when administered after radiation exposure. The main goal of this study was to determine the radiomitigation capacity of MnTE-2-PyP[Mn(III) tetrakis (N-ethylpyridinium-2-yl) porphyrin], a superoxide dismutase (SOD) mimetic, and evaluate leukocyte parameters in spleen and blood. C57BL/6 mice were total-body exposed to 2 Gy γ-rays (Co-60), i.e., well below a lethal dose, followed by subcutaneous implantation of 5 × 10(5) RM-9 prostate tumor cells and initiation of MnTE-2-PyP treatment (day 0); interval between each procedure was 1-2 h. The drug was administered daily (12 times). Tumor progression was monitored and immunological analyses were performed on a subset per group on day 12. Animals treated with MnTE-2-PyP alone had significantly slower tumor growth compared to mice that did not receive the drug (P < 0.05), while radiation alone had no effect. Treatment of tumor-bearing mice with MnTE-2-PyP alone significantly increased spleen mass relative to body mass; the numbers of splenic white blood cells (WBC) and lymphocytes (B and T), as well as circulating WBC, granulocytes, and platelets, were high compared to one of more of the other groups (P < 0.05). The results show that MnTE-2-PyP slowed RM-9 tumor progression and up-regulated immune parameters, but mitigation of the effects of 2 Gy total-body irradiation were minimal.

Validity of neonatal jaundice evaluation by primary health-care workers and physicians in Karachi, Pakistan

OBJECTIVE

The purpose of this study was to validate primary health-care workers' and physicians' visual assessment of neonatal hyperbilirubinemia in Karachi, Pakistan.

STUDY DESIGN

We compared primary health-care workers' and physicians' clinical identification of jaundice in infants <60 days old.

RESULT

Primary health-care workers identified 1- to 20-day-old neonates with hyperbilirubinemia > or =15 mg per 100 ml (260 micromol l(-1)) with 83.3% sensitivity and 50.5% specificity; neonates aged 1 to 6 days were identified with 76.2% sensitivity and 60.7% specificity. Physicians identified neonates aged 1 to 20 days with hyperbilirubimemia > or =15 mg per 100 ml (260 micromol l(-1)) with 51.4% sensitivity and 90.7% specificity, and neonates aged 1 to 6 days with 50% sensitivity and 88.5 % specificity. The primary health-care workers' and physicians' assessments showed fair interobserver agreement (kappa statistic 0.29).

CONCLUSION

Primary health-care workers identified hyperbilirubinemic neonates with adequate sensitivity. With proper training and supervision, their assessment could improve the referral of hyperbilirubinemic neonates in low-resource settings in the developing world.

Gastric cancer risk predisposition and prognostic significance of vascular endothelial growth factor (VEGF) gene polymorphisms in an Omani population

4568

Background: VEGF plays a central role in the angiogenesis, tumor growth and metastasis. VEGF gene polymorphisms at various loci and gastric cancer (GC) risk predisposition and their prognostic significance were studied previously with controversial results Methods: We analyzed three VEGF polymorphisms (+405 G>C, -460T>C, and +936C>T) by extraction of genomic DNA from peripheral blood of 130 GC patients and 130 control subjects followed by VEGF genotyping using PCR-RFLP analysis and the determination of the polymorphisms GC risk predisposition and their prognostic significance Results: There was no significant association between the VEGF polymorphisms and gastric cancer risk. There was a significant correlation between +405 C/C genotype and poor tumor differentiation (p=0.007) and lymph node metastasis (p=0.03) and 460T/T genotype and poor differentiation (p=0.03) with statistical trend for lymph node involvement (p=0.05). VEGF gene polymorphisms had no significant effect on survival, but VEGF +405 G/G genotype had lower survival with hazard ratio 1.6 [95% CI, 0.9–2.9] compared to VEGF +405 CC/GC combined genotype (p=0.04). Multivariate analysis showed that disease stage at diagnosis, and +405 G/G genotype were independent variables of adverse prognostic significance. There were no associations between the common six haplotypes identified and GC risk predisposition and survival. Conclusions: The current study suggests that VEGF polymorphisms in GC patients may have predictive and prognostic significance.

No significant financial relationships to disclose.

Antibiotic prescribing practices in primary and secondary health care facilities in Uttar Pradesh, India

BACKGROUND

Emerging antibiotic resistance in common pathogens is a worldwide problem known to be related to inappropriate overuse of antibiotics. Wide variability in antibiotic use throughout the world is because of various factors, including socio-cultural differences.

OBJECTIVE

To study the rate of antibiotic prescribing for common outpatient illnesses and the various disease, patient, physician and health facility characteristics, which influence this in primary and secondary healthcare settings in Uttar Pradesh.

METHODS

After sampling of health facilities - both private and government, rural and urban, a cross-sectional survey of prescriptions for patients presenting with runny or blocked nose, cough, sore throat, diarrhoea or fever without localizing symptoms was conducted. Information on disease, patient, physician and facility characteristics was collected. Outcome factors: antibiotic prescription and group of antibiotic prescribed. No intervention was made.

RESULTS

Overall antibiotic prescription rate was 81.8%. It was significantly higher in urban private than in government settings, and higher in rural than in urban settings. Presence of fever prompted antibiotic use across all strata. Lower age of patients and higher socioeconomic status were associated with higher antibiotic use. Patient requests for antibiotics were very rare. Specialist practices with staff with higher qualifications and better opportunities for updating knowledge were associated with lower antibiotic prescribing. Government health-facilities with larger staff complement and better infrastructure was associated with lower prescribing rates. The most common antimicrobial agents used were the penicillin, sulfonamides and fluoroquinolones. Injection use paralleled antibiotic use.

CONCLUSIONS

These data on overprescribing of antibiotics can be used to design educational programs for physicians working in these settings.

Efficacy of Isoniazid Prophylaxis in Renal Allograft Recipients

The efficacy of isoniazid (INH) prophylaxis in renal allograft recipients who are on long-term immunosuppression in a region highly prevalent for tuberculosis (TB) was studied. INH (300 mg/d in patients weighing more than 35 kg and 5 mg/kg/d in patients with <35 kg body weight) together with Pyridoxine 50 mg/d for 1 year was started in randomly assigned renal allograft recipients. Occurrence of clinical tuberculosis during the initial 2 years posttransplantation was observed in the risk group and patients at no risk. Risks were defined as acute rejection episodes and exposure to antirejection therapy, past history of TB completely or incompletely treated, radiological evidence of past tuberculosis, history of tuberculosis in close contacts. Among 480 patients registered in the study, INH prophylaxis was given to 219 randomly assigned renal allograft recipients. Results were compared among patients developing TB during the initial 2 years posttransplantation in both the groups. Risk factors were analyzed for comparison in both groups. No significant difference was observed in terms of past history of TB, TB in close contacts, episodes of acute rejection during the initial 3 months, and comorbidities such as cytomegalovirus infection, hepatitis C virus infection, and posttransplant diabetes. One patient from the INH group and 10 patients from the non-INH group developed TB during the initial 2 years posttransplantation (P < .0001). None of patients required discontinuation of INH. INH was observed to be safe and effective as a chemoprophylactic agent in renal allograft recipients.

Outcome of Pregnancy in Renal Allograft Recipients: SIUT Experience

The course of pregnancy and its outcome was studied in renal allograft recipients. Between November 1985 and November 2005, a total of 1481 renal transplants were carried out at the Sindh Institute of Urology and Transplantation (SIUT); among them were 348 females, with 73 potential females for pregnancy. All patients received cyclosporine and prednisolone, with 82% also receiving azathioprine and 4 patients mycophenolate mofetil as a third immunosuppressant drug. We evaluated incidence of hypertension, diabetes, pre-eclampsia, urinary tract infection (UTI), rejection during pregnancy and during 3 months' postdelivery as well as outcomes of pregnancy. Among 73 potential candidates, 31 had 47 pregnancies, after an average of 31 months (8-86 months). Of 31 subjects, 21 subjects were hypertensive on one or two drugs prior to conception. A rise in blood pressure during pregnancy was noticed in 7 patients. Albuminuria from trace to 3+ appeared in 13 patients and glycosuria in one other. Blood sugar levels remained within normal range in all subjects. UTIs occurred during pregnancy in 7 patients. Among 47 pregnancies, 9 had abortions (7 spontaneous, 2 therapeutic) and 6 had preterm deliveries. The others were full-term deliveries: 12 via a lower segment caesarean section and 20 were normal vaginal deliveries. Average birth weight was 4.8 lbs. At an average follow-up of 38 months the serum creatinine values ranged from 0.94 to 2.3 mg %. One patient developed acute irreversible graft dysfunction soon after delivery. Our study demonstrated that pregnancy did not reduce renal graft survival, but newborns are at greater risk of premature birth and low birth weight.

Switchability of neoral and equoral according to Food and Drug Administration rules and regulations

According to the US Food and Drug Administration (FDA), if a drug product contains a drug substance that is chemically identical and is delivered to the site of action at the same rate and extent as another drug product, then it is equivalent and can be substituted (switchable) for that drug product. Methods used to define bioequivalence as stated by the FDA rules (FDA 21 CFR 320, 24) are (1) pharmacokinetic (PK) studies in healthy volunteers, (2) comparative clinical trials, and (3) pharmacodynamic (PD) studies (bioactivity). We evaluated the switchability of Equoral (IVAX-USA) with Neoral (Novartis Switzerland using all FDA rules. In a single oral dose, we undertook a comparative bioavailability study of Equoral (IVAX, USA) Neoral (Novartis, USA), and Neoral (Novartis UK). The pharmacokinetics of Equoral and Neoral were determined with blood levels at 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 10, 12, 16, 24, 30, 36, 42, and 48 hours. The area under curve (AUC), AUC extrapolated to infinity (AUC0-inf), rate of absorption (Tmax), extent of absorption (Cmax), half time (t1/2) of Equoral and Neoral were all within the 90% confidence interval of 80% to 125% boundaries. A comparative multinational multicenter clinical trial in stable renal transplant patients included 70 patients (22 women and 48 men) of mean age of 33 years (range, 26 to 43) was performed in Turkey, Lebanon, and Pakistan. In this study the ratios of LSM and the 90% confidence intervals for the Nontransformed/Parameters (AUC0-t, AUCinf, Tmax, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, which are within the 80% to 125% FDA acceptance range. For immunosuppressive drugs, the site of action is the lymphocyte and the measurable response is the decrease in lymphocyte count caused by the relative concentration of the drug in the lymphocyte. In a controlled switch, fixed-dose study, both Equoral and Neoral achieved the same concentration in the lymphocytes and caused the same degree of lymphocyte count reduction. The results of the testing (bioavailability-bioequivalence, clinical studies, and pharmacodynamic-bioactivity) required by FDA for interchangeability ("switchability") of immunosuppressive agents suggests that Neoral and Equoral are switchable.

The pharmacokinetics of equoral versus neoral in stable renal transplant patients: a multinational multicenter study

We studied the pharmacokinetics (PKs) of the new generic cyclosporine formulation, Equoral capsules, after the switch from original formulation Neoral capsules in stable renal transplant patients. The study was carried out in accordance with the basic principles defined in the US 21 CFR Part 312.20 and the principles of the Declaration of Helsinki. The study included clinically stable first renal transplant patients maintained on cyclosporine with no rejection episode during the past 6 months. Hematology, biochemistry, and urine chemistry were determined on day 7, and day 21. The patients were all switched to Neoral (lot number 416MFD0601) on day 0 when the first sparse sampling PK was performed. On day 14 a 12-hour PK profile included predose, 30 minutes; 1 hour; 1 hour 30 minutes; 2 hours; 3 hours; 4 hours; 5 hours; 6 hours; 8 hours; 10-hours and 12-hour samples. Cyclosporine levels were determined using a CYA kit (Abbott TDx). On day 15 the patients were switched from Neoral capsules to Equoral capsules (lot 5T111014) at an equivalent dosage (mg/mg). The second sparse sampling PK was performed on day 21 and a 12-hour PK was performed on day 28. On the morning of day 29 patients were switched from Equoral capsules to Neoral capsules at an equivalent dosage (mg/mg). Additional concentrations were measured on days -7, 18, and 35. Safety parameters were monitored at each visit. The pharmacokinetics of both formulations were equivalent. The mean AUC for Neoral and Equoral was 2856 and 2892, respectively. The ratios of LSM and the 90% confidence intervals for the in-transformed parameters (AUC o-t, AUC inf, and Cmax) of Equoral and Neoral SGC were 98% and 95%, respectively, suggesting that Equoral and Neoral SGC are bioequivalent.

Scavenger receptor class B type I in high-density lipoprotein metabolism, atherosclerosis and heart disease: lessons from gene-targeted mice

The scavenger receptor class B type I (SR-BI) is a multi-ligand receptor that can mediate the binding and bi-directional lipid transfer between high-density lipoproteins (HDLs) and cells. It is expressed in a variety of tissues, including the liver, and in macrophages in atherosclerotic plaques. The physiological role of SR-BI has been tested in vivo by the genetic manipulation of SR-BI levels in mice. Mice lacking SR-BI exhibit impaired hepatic-selective HDL cholesterol uptake and increased atherosclerosis, suggesting that SR-BI is required for hepatic reverse cholesterol transport and normally protects against atherosclerosis. Surprisingly, elimination of SR-BI in apolipoprotein E knockout mice results in rapid development of occlusive coronary artery disease, accompanied by spontaneous myocardial infarction, reduced heart function and early death, which points to a role for SR-BI in protection against coronary heart disease. The in vivo role of macrophage SR-BI has been less clear. We have used bone-marrow transplantation to demonstrate that bone-marrow-derived SR-BI also normally protects against atherosclerosis in low-density lipoprotein receptor knockout mice. These results suggest that SR-BI may have multiple protective effects against atherosclerosis in different tissues.

Significance of p53, Bcl-2, and HER-2/neu protein expression in Omani Arab females with breast cancer

Racial disparity in the presentation of breast cancer and the outcome of its treatment is well established. However, the causes remain unexplained. The scarcity of reports about the prognostic significance of p53, bcl-2, and HER-2/neu in Arab females with breast cancer has been the impetus to this study. We evaluated the prognostic significance of altered expression of p53, bcl-2, HER-2/neu in Omani Arab females with non-metastatic breast cancer with correlation to other established prognostic factors. We have retrospectively analyzed the immunohistochemical expression of p53, HER-2/neu and bcl-2 in paraffin embedded blocks of 72 females diagnosed with invasive breast cancer between 1992 and 2002. The expression of the above proteins was correlated with other prognostic factors and univariate and multivariate analysis was carried out for all prognostic factors. Overexpression of p53 significantly correlated with younger age (<40), pre-menopausal status, poor differentiation with inverse correlation with bcl-2 expression. Expression of bcl-2 immunopostivity significantly correlated to low histological grade and positive estrogen and progesterone receptor status. On univariate and multivariate p53 overexpression and lack of bcl-2 immunostaining resulted in worse survival outcome, but not Her-2/neu overexpression. Expression patterns of p53 and bcl-2 are independent predictors of survival in Omani Arab population which may help to stratify these patients into different risk groups.

Recruiting the community for supporting end-stage renal disease management in the developing world

Although the incidence of new end-stage renal disease (ESRD) patients in Pakistan is estimated at 100 patients per million (ppm), the prevalence of those alive on renal replacement therapy (RRT) is around 40 ppm, reflecting the severe shortage of facilities. A national program was launched in 1998 to provide free RRT, but the funds were extremely limited, leading to the flourishing of suboptimal treatment in private dialysis and transplant centers. The Sindh Institute of Urology and Transplantation (SIUT), started as a small unit in 1975, took the lead in recruiting nongovernmental funds for RRT. Through the devotion of several groups, it was possible to raise funds from individuals, pharmaceutical firms, and other organizations, which permitted the development of SIUT into an independent, large, and fully equipped institution that provides free RRT including dialysis and transplantation to many thousands of patients. This prompted the government to increase its contributions to encourage SIUT to pursue its unique path.

Evaluation of the FASTPlaqueTB assay for direct detection of Mycobacterium tuberculosis in sputum specimens

SETTING

Sputum samples were collected from suspected tuberculosis patients attending out-patient clinics at the Ojha Institute of Chest Diseases, Karachi, Pakistan.

OBJECTIVE

To evaluate the performance of the FASTPlaqueTB assay for rapid diagnosis of pulmonary tuberculosis.

DESIGN

A comparative study of 584 sputum samples using acid-fast smear microscopy, Lowenstein-Jensen culture and FASTPlaqueTB.

RESULTS

A total of 514 samples yielded complete results. Seventy specimens were lost to analysis due to the overgrowth of contaminants. The addition of antimicrobials inhibited growth of gram-positive contaminants, and reduced the overall contamination rate from 18.2% to 7.2%. Mycobacterium tuberculosis was isolated from 175 smear-positive and 70 smear-negative specimens. FASTPlaqueTB detected M. tuberculosis in 81.6% of specimens, with a specificity of 97.7%. The sensitivity and specificity of the assay for smear-positive specimens were respectively 87.4% and 88.2%. For smear-negative specimens, the sensitivity of the assay was 67.1% and the specificity was 98.4%. The combined sensitivity of smear and FASTPlaqueTB for M. tuberculosis was 90%. Test results were available in 48 hours.

CONCLUSION

FASTPlaqueTB is a sensitive and specific test for rapid diagnosis of pulmonary tuberculosis in high prevalence areas. The test is sensitive enough to confirm a large number of clinically suspected smear-negative cases and improve case finding.