Oncologist-led BRCA counselling improves access to cancer genetic testing in middle-income Asian country, with no significant impact on psychosocial outcomes

BACKGROUND

Identifying patients with BRCA mutations is clinically important to inform on the potential response to treatment and for risk management of patients and their relatives. However, traditional referral routes may not meet clinical needs, and therefore, mainstreaming cancer genetics has been shown to be effective in some high-income and high health-literacy settings. To date, no study has reported on the feasibility of mainstreaming in low-income and middle-income settings, where the service considerations and health literacy could detrimentally affect the feasibility of mainstreaming.

METHODS

The Mainstreaming Genetic Counselling for Ovarian Cancer Patients (MaGiC) study is a prospective, two-arm observational study comparing oncologist-led and genetics-led counselling. This study included 790 multiethnic patients with ovarian cancer from 23 sites in Malaysia. We compared the impact of different method of delivery of genetic counselling on the uptake of genetic testing and assessed the feasibility, knowledge and satisfaction of patients with ovarian cancer.

RESULTS

Oncologists were satisfied with the mainstreaming experience, with 95% indicating a desire to incorporate testing into their clinical practice. The uptake of genetic testing was similar in the mainstreaming and genetics arm (80% and 79%, respectively). Patient satisfaction was high, whereas decision conflict and psychological impact were low in both arms of the study. Notably, decisional conflict, although lower than threshold, was higher for the mainstreaming group compared with the genetics arm. Overall, 13.5% of patients had a pathogenic variant in BRCA1 or BRCA2, and there was no difference between psychosocial measures for carriers in both arms.

CONCLUSION

The MaGiC study demonstrates that mainstreaming cancer genetics is feasible in low-resource and middle-resource Asian setting and increased coverage for genetic testing.

SAT0188 HIGH-DOSE STEROIDS ARE IMPORTANT CONTRIBUTORS TO THE INFECTION BURDEN OF PATIENTS WITH LUPUS NEPHRITIS

Background:

Infection remains a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) and lupus nephritis (LN) treated with systemic immunosuppression (IS).

Objectives:

We sought to describe the infection profile in patients with LN treated with aggressive immunosuppression (induction and maintenance therapy) and to identify the associated risk factors.

Methods:

Patients with LN followed in the Nephrology Department of Fundeni Clinical Institute, were retrospectively reviewed for any infection that occurred from initiation of induction therapy. Infections were graded (1-5) according to the Common Terminology Criteria for Adverse Events. Infection site and type of microorganism were also recorded. Univariate and multivariate Cox proportional hazard regression analysis were performed in order to identify independent risk factors for infection.

Results:

The study cohort comprised 101 patients (86.1% females) with a mean age of 34 ± 14 years. Forty-eight patients (47.5%) had at least one infection with a total 92 episodes of infection occurring during a median follow-up of 17 months (IQR:8.5-52.5 months). The majority of patients (31 of 48) had infections during the first 12 months since IS treatment initiation. The most common site was lung infection (in 24.8% of patients), followed by urinary tract (20.8% of patients) and cutaneous/mucosal infections (11% of patients). Thirty-eight percent of patients had bacterial infections. Nineteen percent of patients had severe infections (grade 3 or higher) with 3.3% of infection-related deaths (3 patients). The most common induction regimen was cyclophosphamide in addition to corticosteroids (48.5%), with 44.6% of patients receiving pulse methylprednisolone and 45.5% of patients receiving more than 30 mg/d of prednisone as the maximum oral dose. In univariate Cox regression analysis, female gender (HR 3.34; 95% CI, 1.03-10.8, p=0.04), pulse methylprednisolone (HR 2.9; 95% CI, 1.6-5.24, p=0.001), high-dose (≥30 mg/day) oral corticosteroids (HR 4.22; 95% CI, 2.21-8.02,p=0.001) and SLEDAI score (HR 1.047; 95% CI, 1.012-1.084, p=0.008) were risk factors for infection. In multivariate Cox regression analysis, female gender (HR 6.35; 95%CI, 1.86-21.64,p=0.003), high-dose oral corticosteroids (HR 4.7; 95% CI, 2.25-9.87, p=0.003) and SLEDAI score (HR 1.046; 95% CI, 1.003-1.09, p=0.034) remained independent predictors of infection risk. Of the risk factors associated with severe infections (grade 3 or higher), in univariate analysis we identified younger age (HR 0.96, 95%CI, 0.92-0.99, p=0.035), neurological involvement (HR 2.59; 95%, 0.86-7.83, p=0.09), pulse methylprednisolone (HR 5.42; 95% CI, 1.79-16.35, p=0.003) and high-dose oral corticosteroids (HR 8.32; 95% CI, 2.4-28.77, p=0.001) as risk factors for infection. After multivariate adjustment, neurological involvement (HR 4.33; 95%, 1.29-14.51, p=0.01) and high-dose oral corticosteroids (HR 7.6; 95% CI, 1.6-35.39, p=0.01) were identified as independent predictors of infection risk.

Conclusion:

A high-dose oral corticosteroid regimen increased the risk for any infection and for severe infections by 4.7-fold and 7.6-fold, respectively. In addition, female gender and a higher SLEDAI score were identified as risk factors for any infection, while neurological involvement was associated with an increased risk for severe infections.

References:

[1]Jung JY, Yoon D, Choi Y, Kim HA, Suh CH. Associated clinical factors for serious infections in patients with systemic lupus erythematosus. Sci Rep. 2019;9(1):9704.

Disclosure of Interests: :

None declared

Histological predictors of renal outcome in lupus nephritis: the importance of tubulointerstitial lesions and scoring of glomerular lesions

Introduction Lupus nephritis (LN) affects nearly 60% of patients with systemic lupus erythematosus and up to 30% of them will progress to end-stage renal disease (ESRD), despite receiving aggressive immunosuppressive therapy. The prognostic value of ISN/RPS classification is controversial. Therefore, we aimed to identify clinical and pathological predictors of outcome in LN patients independent of this classification. Material and methods Thirty-seven patients with LN who underwent percutaneous kidney biopsy between 1997 and 2016 were included in this study. Twenty clinical and twenty histological variables were tested for their association with a composite end-point of doubling of serum creatinine, ESRD and death. Univariate and multivariate Cox proportional hazard regression analysis were performed to identify independent predictors of outcome. Results During a median follow-up period of 48 months (IQR: 17.5-120 months), 21.6% of patients reached the composite end-point. The overall survival rate of our cohort was 89% at one year, 86% at five years, 74% at 10 years and 64% at 20 years. Patients with Class IV LN showed the worst prognosis with 44% survival at 10 years, while those who additionally showed crescents and global sclerosis on kidney biopsy had an even lower survival of 21% and 0% at 10 years, respectively. After multivariate adjustment, we identified estimated glomerular filtration rate at baseline (HR, 0.91 per ml/min /1.73 m²; 95% CI, 0.84 to 0.99), 24-hour proteinuria at baseline (HR, 2.04 per g/d; 95% CI, 1.19 to 3.5), crescents (HR, 1.068 per %; 95% CI, 1.003 to 1.091), global sclerosis (HR, 1.036 per %; 95% CI, 0.984 to 1.091), presence of adhesions (HR, 9.2; 95% CI, 1.38 to 61.2) and tubulitis (HR, 13.1; 95% CI; 1.3 to 131) as independent predictors of outcome in our cohort of LN. Conclusions Our study identified glomerular (crescents, global sclerosis, adhesions) and tubulointerstitial (tubulitis) lesions, in addition to clinical variables (renal function, 24-hour proteinuria), as important predictors of renal outcome, independent of the ISN/RPS classification. We suggest that the ISN/RPS classification could be improved by a quantitative assessment of glomeruli with active and chronic lesions and by a greater emphasis given to tubulointerstitial lesions.

An intriguing association of Turner syndrome with severe nephrotic syndrome: searching for a diagnosis

Systemic lupus erythematosus (SLE) is a chronic disease caused by an aberrant autoimmune response, with a large spectrum of clinical manifestations. It strikingly affects women. Recent papers reveal that the men with Klinefelter syndrome (47, XXY) have a higher incidence of lupus than the men in the general population, similar with that of genotypic females. On the other hand, there is a great lack of information regarding the association of SLE with Turner syndrome, but it seems to be a lower risk for females with Turner to develop SLE. We present a rare association of a Turner syndrome with SLE, with negative immunology for SLE and with diagnosis made on renal biopsy. These data suggest that the presence of two X chromosomes may predispose to SLE, the ligand (CD40 ligand) for one of the genes that contributes to the pathogenesis of SLE being located on the X chromosome.

Noninvasive Markers of Improvement of Liver Steatosis Achieved by Weight Reduction in Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with insulin resistance and metabolic syndrome, which are linked to obesity. The aim of the study was to assess if weight reduction through 12 months of lifestyle intervention and exercise would lead to improvement of steatosis.

METHODS

In a prospective observational study 86 overweight subjects (51 men, 35 women) with steatosis were recruited, after excluding other etiologies. Patients were assigned a caloric goal and a daily fat goal. Physical activity focused on moderate-intensity activities. Blood samples (biochemistry, HOMA-IR, cytokine levels, steatotest) were collected at entry and months 6 and 12. All subjects underwent abdominal CT scan before commencement and after 12 months to assess visceral and subcutaneous adipose tissue (VAT/SAT) area.

RESULTS

After 12 months baseline descriptive characteristics (weight, BMI, waist circumference) decreased significantly. Biochemical parameters that decreased significantly were: GGT (40.0 ± 18.0 vs 31.1 ± 13; p = 0.01), ALT (58.5 ± 23.5 vs 32.7 ± 14.8; p = 0.001), cholesterol (236.4 ± 54.8 vs 204.8 ? 91; p = 0.05), LDL (160.1 ± 47.4 vs 125.3 ± 40; p = 0.05) and HOMA-R (4.86 ± 0.63 vs 3 ± 0.41; p = 0.018). Steatotest improved significantly (0.68 ± 0.16 vs 0.38 ± 0.14; p = 0.02). Modification of adipocytokines was significant for leptin (p = 0.018) and adiponectin (p = 0.003). Factors associated with regression of steatosis were weight, BMI, ALT, waist circumference, GGT, HOMA, leptin, VAT and steatotest. Multivariate logistic regression showed the following factors related to improved steatosis: BMI < 25 kg/m2, ALT < 42 U/L, leptin < 10.5 ng/ml and adiponectin > 8.4 μg/ml.

CONCLUSIONS

Overweight persons who achieve significant reductions in body weight through 12 months of physical activity and low caloric diet can decrease liver fat, VAT and SAT. Even in those with minimal weight loss ALT levels, steatosis, adipokines and cardiovascular risk factors improved.

Histological diagnosis and risk of renal vein thrombosis, and other thrombotic complications in primitive nephrotic syndrome

BACKGROUND

The risk of thromboembolic events is increased in patients with nephrotic syndrome (NS) as compared with other medical conditions and is a severe complication associated with significant morbidity and mortality. We aimed to assess the risk of renal vein thrombosis, and other venous thromboembolic events (VTE) in a large cohort of patients with NS and to identify the disease-specific risk for VTE.

PATIENTS AND METHODS

We performed a prospective observational study including consecutive adult patients with primitive NS admitted to our department. Clinical and biological data were obtained every six months during follow-up. Occurrence of VTE confirmed by imaging techniques was the primary study outcome.

RESULTS

We enrolled 191 patients (47±15 years, 53% men) with a median follow-up of 24 [IQR:12,36] months. During follow-up, 23 VTE occurred, of which 65.2% in the first six months. The disease-specific risk of VTE during the follow-up period was different across the histological groups, with the lowest risk in minimal change disease and IgA nephropathy and the highest in membranous nephropathy and membranoproliferative glomerulonephritis patients. In the subgroup of membranous, the severity of the subepithelial electron dense deposits did not correlate with the risk for VTE (p=0.5).

CONCLUSIONS

In this prospective study, the risk of VTE was higher in the first six months of follow-up in NS patients. The histological pattern seems to influence the risk of VTE in this setting.

Seroprevalence of toxoplasmosis among migrant workers from different Asian countries working in Malaysia

A serologic study of Toxoplasma antibodies among 501 foreign migrant workers in Malaysia was conducted in a plantation and detention camp. The highest prevalence rate of 46.2% was among Nepalese workers. Statistical analysis indicated the IgG positivity rate among local residents was significantly higher than the migrants studied (p < 0.05). The IgM positivity rate showed no significant difference between the two groups (p > 0.05). No significant difference in the prevalence rate was noted between the migrants and the local workers when grouped by agricultural and non-agricultural occupations (p > 0.05). The continuous introduction of these infections may influence the epidemiology and further compromise efforts in control and prevention. It is therefore important to monitor of non-notifiable diseases.

Frequency and prognostic significance of QT prolongation in chronic renal failure patients

Cardiovascular mortality and morbidity are high in chronic renal failure (CRF) patients. Previous studies on non-uraemic patients with heart failure (HF), hypertension or diabetes mellitus (DM) showed that QT and QTc prolongation and dispersion represent cardiovascular risk factors. The patients with long QT interval have more often ventricular premature beats and sudden death than those with normal QT interval. The aim of our study was to evaluate the frequency and predictive value of QT and QTc prolongation in CRF patients, included or not in a chronic dialysis programme. On 68 patients (M/F = 36/32, mean age = 47.6 years), with CRF we analyzed QT and QTc interval with a digital 12 lead electrocardiogram-CARDIAX. 8/68 patients (11.8%) had long QT interval (>0.45"). After having calculated QT corrected (QTc) interval according to the heart rate, 28/68 patients (41.2%) had QT prolongation (>0.45"). Multivariate statistical analysis of clinical factors, but also of biological, electrocardiographic, echocardiographic data and 24 hours of ECG and blood pressure monitoring showed that QT prolongation is statistically significant (p < 0.05) correlated with: number of years of renal failure (p = 0.0001), serum concentrations of potassium and calcium (p = 0.0001) and diastolic BP (p = 0.05). QT prolongation in CRF patients is not dependent on the level of uremia or the type of chronic renal substitution (hemodialysis or continuous ambulatory peritoneal dialysis). There were no statistically significant correlations between QT prolongation and serum concentrations of Mg, PO4, HCO3 and Hb. Long QT interval was not dependent either on the dipper/nondipper profile of mean BP values or ejection fraction of left ventricle. In our study long QT interval was not statistically significant correlated with arrhythmias or sudden death. Despite the high incidence of QT prolongation in CRF patients (41.2%), short-term consequences are not as severe as those in cardiac patients. This is possibly explained by the different pathogenic mechanisms of arrhythmia in CRF when electrolytic disorders are the main cause for the development of arrhythmia. During a mean follow-up of 3.8 months (3-5.5) there were no cases of sudden death on patients with QT prolongation, and arrhythmia incidence was not statistically significant higher than in subjects with normal QT interval.

Therapeutic efficiency of continuous renal replacement therapy--experience of a single Romanian center

We have studied 24 patients with acute renal failure (ARF) or acutization of chronic renal failure (CRF) caused by a variety of different disorders. A rapid decline in renal excretory function, fluid, electrolyte, and divalent ion disturbances determined us to initiate continuous renal replacement: continuous venovenous hemofiltration (CVVHF)--28 procedures in 15 patients and continuous venovenous hemodiafiltration (CVVHDF)--11 procedures in 11 patients. Mean duration of CVVHF was 21.6+/-6.9 h, with a mean blood flow rate of 116.9+/-16.4 ml/min and an ultrafiltration rate of 6.4+/-4.6 ml/min. Serum creatinine level decreased from 12.6 to 8.3 mg% and the concentration of urea from 237 to 166 mg%. Mean duration of hemodiafiltration was 24+/-8.5 h, with mean blood flow rate of 134+/-15.2 ml/min, mean dialysate flow of 35+/-7 ml/min and mean ultrafiltration rate of 5.6+/-2.1 ml/min. Serum creatinine level decreased from 11.6 to 6.36 mg% and the concentration of urea from 236 to 137 mg%. Survival rate was 79.2% (19/24 patients). Complete recover of renal function was achieved in 5 patients, partial recover in 5 patients and 9 patients were included in chronic dialysis. In 8/24 (30%) patients we encountered complications, such as hypotension in 2 cases, bleeding disorders in 5 cases or diselectrolithemias in 2 cases. As a consequence, continuous renal replacement therapy is efficient, having an acceptable rate of adverse effects in patients with ARF or acutization of CRF.

Therapeutic efficiency of continuous renal replacement therapy--experience of a single Romanian center

We studied 24 patients with acute renal failure (ARF) or acutization of chronic renal failure (CRF) caused by a variety of different disorders. A rapid decline in renal excretory function, fluid, electrolyte, and divalent ion disturbances determined us to initiate continuous renal replacement: continuous venovenous hemofiltration (CVVHF) - 28 procedures in 15 patients and continuous venovenous hemodiafiltration (CVVHDF) - 11 procedures in 11 patients. The mean duration of CVVHF was 21.6+/-6.9 h, with a mean blood flow rate of 116.9+/-16.4 ml/min and an ultrafiltration rate of 6.4+/-4.6 ml/min. The serum creatinine level decreased from 12.6 to 8.3 mg% and the concentration of urea from 237 to 166 mg%. The mean duration of hemodiafiltration was 24+/-8.5 h, with a mean blood flow rate of 134+/-15.2 ml/min, a mean dialysate flow of 35+/-7 ml/min and a mean ultrafiltration rate of 5.6+/-2.1 ml/min. The serum creatinine level decreased from 11.6 to 6.36 mg% and the concentration of urea from 236 to 137 mg%. Survival rate was 79.2% (19/24 patients). The complete recover of renal function was achieved in 5 patients, partial recover in 5 patients and 9 patients were included in chronic dialysis. In 8/24 (30%) patients we encountered complications, such as hypotension in 2 cases, bleeding disorders in 5 cases or diselectrolithemias in 2 cases. As a consequence, continuous renal replacement therapy is efficient, having an acceptable rate of adverse effects in patients with ARF or acutization of CRF.

Anemia in remote interior communities in Sarawak, Malaysia

A cross-sectional survey of 365 individuals, (51.9% males, 48.1% females; ages 5-85 years), from five remote interior communities in upper Rejang River basin Sarawak, Malaysia, found 24.4% were anemic. The range and mean of Hb concentration in male and female were: 7.2-17.0 mg/ml and 13.7 mg/ml and 7.9-15.7 mg/ml and 12.9 mg/ml respectively. Amongst the five tribes surveyed, the prevalence of anemia (range: 10.6-46.7%), was higher among the Penans (46.7%), Kenyahs (31.1%), Kajangs (27.8%) and Kayans (19.3%), than amongst the Ukits (10.6%). Anemia is more common among males >40 years and among adolescents and young reproductive females, as well as elderly females > 61 years old. Of the 83 anemic individuals, 6.0% and 3.6% had Trichuris trichiura or hookworm respectively; however there is no clear association with intestinal worm infection.

Intestinal parasitic infection among five interior communities at upper Rejang River, Sarawak, Malaysia

Intestinal parasitic infection among five interior communities at Bakun Valley, upper Rejang River, Sarawak, Malaysia, was investigated as part of a public health impact assessment of the proposed US$ 3 billion Bakun Hydroelectric Project. Coproparasitological examination of 355 stool samples from 7 of 16 villages representing 5 of 7 tribes in the area revealed infection rate of 41%. A higher infection rate was found among the settled Kayans (56%) than the seminomadic Penans (29%). Infection rate was high (68%) among children less than 14 years old. Trichuris trichiura accounted for more than 90% of all infections; less common were Ascaris lumbricoides, hookworms and Strongyloides stercoralis. Polyparasitism was found in 8% of the individuals surveyed with dual infection due to T. trichiura and A. lumbricoides being more common than dual infection with T. trichiura and hookworm. Women had higher infection rates (57%) than men (33%).

Risk factors associated with sexual dysfunction after transurethral resection of the prostate

BACKGROUND

The effect of transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH) on sexual function continues to be a controversial issue. The aim of this study was to evaluate sexual functions in Saudi patients suffering from BPH before and after TURP.

PATIENTS AND METHODS

The influence of TURP on libido, erection and ejaculation was prospectively studied in 179 patients undergoing TURP for BPH. The risk factors studied for erectile dysfunction (ED) were old age, polygamy, comorbidities, late presentation, intraoperative bleeding, intraoperative capsular perforation and bacteriuria. Patients reporting ED underwent intracavernosal injection (ICI) of 20-40 AA(1/4)g of prostaglandin E1 (PGE1) before and/or after surgery.

RESULTS

Before surgery, ED was present in 33/179 patients (18%) and was significantly associated with old age and comorbidities but not with polygamy or late presentation. In the patients with normal erection before surgery, dry ejaculation, ED and diminished libido developed after TURP in 71/134 (53%), 20/137 (15%), and 22/137 (16%), respectively. Postoperative ED was significantly associated with diminished libido (P=0.001), but not with postoperative dry ejaculation. The only significant risk factor associated with ED following TURP was capsular perforation. The response to ICI before and after TURP was comparable.

CONCLUSION

ED associated with TURP is most likely of neurogenic origin due to capsular perforation, or of psychogenic nature as suggested by the significant association with diminished libido.

Epidemiological screening of lymphatic filariasis among immigrants using dipstick colloidal dye immunoassay

We have recently reported that a dipstick colloidal dye immunoassay (DIA) that detect parasite antigens in human serum is sensitive and specific for the diagnosis of active infection of lymphatic filariasis. Rabbit polyclonal antibodies (RbBmCAg) labelled with a commercial dye, palanil navy blue was used to detect filarial antigenemia among Indonesian and Bangladeshi immigrant workers (N= 630) at oil palm estates at Hulu Trengganu District, Peninsular Malaysia. Microfilaremia with Brugia malayi were detected in 51 (8.10 %) individuals, of which 42 (6.67 %) were among the Indonesians and 9 (1.98 %) among the Bangladeshis. Microfilaremia with Wuchereria bancrofti were detected in 33 (5.24 %) individuals of which 15 (2.38 %) were among the Indonesians and 18 (2.86 %) among the Bangladeshis workers. The DIA detected 96 (15.24 %) antigenemic cases which comprise of all the microfilaremic cases and 15 (2.38 %) amicrofilaremic cases. The amicrofilaremic cases with filarial antigenemia consisted of 9 (1. 43 %) Indonesians and 6 (0.95%) Bangladeshis. We have used 6 ul of the RbBmCAg and diluted (1:10) patients' sera per dipstick which make the DIA reagent conservative. The DIA is a rapid test and can be read in approximate 2 hours.. Additionally, coloured dots developed in the DIA can be qualitatively assessed visually for intensity. The DIA does not require sophisticated equipment or radioactivity, and therefore suitable for field application.

Schistosomiasis malayensis-like infection among the Penan and other interior tribes (Orang Ulu) in upper Rejang River Basin Sarawak Malaysia

A serosurvey of various indigenous interior tribes (Orang Ulu) in upper Rejang River Basin Sarawak Malaysia, the site of a multibillion Ringgit hydroelectric power project, found 6.8% of the individual surveyed were seropositive for schistosomiasis, as determined by ELISA method using the soluble egg antigen of Schistosoma malayensis Baling strain. In all age group, the seroprevalence rate is higher (9.5%) in males than in females (4.5%) except for the 31-40 age group. Seroprevalence of schistosomiasis was found to increase with age with the above 60 age group having the highest rate followed by the 31-40 age group. Seroprevalence rate among the tribes ranges from 4.1% among the Penan to 11.6% among the Kajang. There was no seroevidence of schistosomiasis among the Ukits. A snail survey found four snail species including Brotia species, the intermediate host of the lung fluke Paragonimus westermani, however no schistosome snail host was identified. Although schistosomiasis malayensis-like infection may be endemic in the area, its public health significance remains undetermined.

Rickettsial infection in five remote Orang Ulu villages in upper Rejang River, Sarawak, Malaysia

People in 5 Orang Ulu villages in Sarawak, Malaysia were tested for rickettsial infection by Weil-Felix reaction and by indirect immunoperoxidase reaction. Of those surveyed 9.6% were positive for typhus. Of the positives, 3.8% were positive for tick typhus (7/11), scrub typhus (4/11) or endemic typhus (1/11). The incidence of typhus was higher among semi-nomadic Penans compared with the settled Kayans.

Post-Transplant Diabetes Mellitus in Kidney Transplant Recipients with Special Reference to Association with HLA Antigens

One hundred fifty three kidney transplant recipients whose grafts functioned for longer than one year were evaluated for evidence of post-transplant diabetes mellitus (PTDM). Twenty-six patients (17%) developed PTDM. Patients with PTDM were older than controls (mean age 49.4 vs 37.9 years). There was no demonstrable association between sex of patients and PTDM. The body mass index (BMI) was persistently higher in patients with PTDM compared to controls, although the difference did not amount to statistical significance. The association of PTDM with HLA-A28, A30 and B8 observed in other studies was not seen in our patients. Similarly, neither the positive association of HLA-DR3 and DR4, nor the negative association of HLA-B7 and DR2 seen in population-based studies of insulin dependent diabetes mellitus, were seen in our patients with PTDM. To our knowledge, this is the first report that has looked into the association of HLA antigens and PTDM in Saudi Arabia.

Convenient and versatile DNA extraction using agarose plugs for ribotyping of problematic bacterial species

We describe a convenient, versatile and safe method for preparing bacterial DNA for ribotyping analysis. In this method, extraction of bacterial DNA from Salmnonella typhi and Burkholderia pseudomallei. and subsequent restriction endonuclease digestion, was performed in agarose blocks/plugs thus minimizing shearing and loss of DNA, problems commonly associated with liquid phase phenol extraction. Digested DNA in the plugs was then electrophoresed directly, transferred to nylon membranes and hybridized with labeled rDNA probes in the usual manner to provide reproducible restriction patterns. This method is particularly useful for bacterial species where standard DNA extraction in the liquid phase using phenol has been problematic (e.g. B. pseudomallei) but can be used for any bacterial species. The DNA extracted within the agarose plugs can be stored for long periods and can be used in other, widely-used typing methods such as pulsed-field gel electrophoresis (PFGE) and PCR-based techniques. Embedding live cells directly in agarose plugs also minimizes the risk of exposure to these virulent human pathogens among laboratory workers.

Ureteric injuries: diagnosis, management, and outcome

OBJECTIVES

To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome.

METHODS

A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function.

RESULTS

The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in 5 cases. Of 36 cases with follow-up, complications developed in 9 cases (25%), 7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome adversely were pediatric age (< or =12 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury.

CONCLUSION

Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.

Evaluation of ELISA microtiter plate-based assays for the direct determination of isoproturon in water samples and soil extracts

Trials were carried out on the commercially available Millipore isoproturon ELISA microtiter plate tests and on laboratory assays developed by Hirst as part of a Joint European Union research project (BIOPTICAS). The lowest detectable dose (LDD) was determined as three times the standard deviation of the blanks. Depending on the calibration curves obtained on different days with different plates, the LDD varied from 0.020 to 0.064 microgram/L for the Millipore test and from 0.080 to 0.329 microgram/L for the Hirst test. The mean coefficients of variation within a single plate for triplicate determinations of standard solutions in the 0.05 to 0.5 microgram/L range were 5.5 and 3.6% for Millipore and Hirst respectively. Cross-reactivity was studied for mono- and di-demethylated isoproturon, chlortoluron, diuron and linuron. The highest cross-reactivity with both tests was that of mono-demethylated isoproturon (22% for Millipore, 4% for Hirst). This molecule was the only one to show significant cross-reactivity in the Hirst test, whereas in the Millipore test, the di-demethylated isoproturon also cross-reacted (4%). Natural water samples, 19 ground-, 53 lysimetric plate and 47 suction cup water samples, and 32 soil samples were also analysed with the ELISA tests. HPLC with a diode array detector was used as a validated control technique for the natural samples. For each water type, ELISA concentrations of both tests were significantly correlated with the HPLC values (r > or = 0.937; p < 0.001). For the soil extracts, the correlations were also significant (p < 0.001), but the scatter in the data was greater. Overall, the Millipore correlation coefficients were higher than those of Hirst.

The southern region renal transplant program at armed forces hospital, khamis mushayt

The Southern Region renal transplant program was established in February 1989. The appointment of a transplant co-ordinator and creation of a waiting list for the Southern Region as well as tissue typing of all patients in the region were important early steps. Between February 1989 and December 1995, 155 transplants were performed on 152 patients at the Armed Forces Hospital, Southern Region (AFHSR). Of them, 52 were cadaveric donor transplants and the remaining were from living related donors. The overall five-year actuarial patient and graft survival was 93% and 78% respectively. Of the 152 patients who were transplanted, 79 patients were from other hospitals in the region and 73 were from AFHSR. Maintenance immunosuppression consisted of cyclosporin, azathioprine and prednisolone. Use of the spouse as a donor was an early feature of this program. Our results compare favorably with results published from other centers. To cope with the increasing demand of transplantation in the Southern Region, we have to look into ways of increasing our transplant numbers to match the needs.

Short report: Electron microscopic demonstration of extracellular structure of Burkholderia pseudomallei

The occurrence of latency and relapse in human melioidosis suggests adaptations by Burkholderia pseudomallei that help to avoid the human immune response. Ruthenium red-stained preparations of bacterial cultures viewed by electron microscopy revealed three morphologically distinct variants; one with a very marked and another with a less electron-dense layer surrounding the cell wall, and a third variety devoid of such a structure. This structure may be attributable to a layer of polysaccharide, suggesting the presence of a glycocalyx that may aid in the survival of the organism during latency.

Enterobius vermicularis infection among children aged 1-8 years in a rural area in Malaysia

The infection rate and relationship of enterobiasis with socio-economic status were determined in children aged 1-8 years, living in a rural area in Malaysia. Of the 178 subjects 40.4% were infected with Enterobius vermicularis. The distribution of enterobiasis among these children were analyzed in relation to age groups and sex. The rate of infection was significantly higher in older children (5-7 years). The association of enterobiasis with other factors studied such as number of persons per house, household income per months and mother's employment status were not significant. The sensitivity of three successive days anal swabs compared to a single swab was found to be statistically significant.

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.

Prevalence of Enterobius vermicularis amongst adults living in hostels by six successive day examination

The prevalence of Enterobius vermicularis in four groups of adults, all trainee public health inspectors or public health nurses, aged 18-35 years and all living in hostels on campus was studied. The modified scotch tape technique was used and the subjects were taught to do the examination on themselves to detect the presence of eggs over a period of 6 successive mornings. Each was given an elaborately illustrated diagram on how and when to take the samples and given demonstration in groups. The samples were examined by trained people. Most of the subjects took samples on 6 consecutive days. Of the 119 subjects who returned samples, the overall prevalence of E. vermicularis was 9.2% and this was thought to be high for this particular age group. This was due to the higher prevalence (19.4%) in one group, whereas in the others the range was 3.5-8.0%. Based on the samples returned on the first day none of the subjects were detected as having the infection. After examination on 3 successive days (109 subjects) 10.1% were found to be infected (chi 2 = 10.704; d. f. = 1) and after examination on 6 successive days (72 subjects) 13.9% were found to be infected (chi 2 = 3.026; d. f. = 1). There was no significance between examination over 3 successive days and 6 consecutive days (chi 2 = 0.296; d. f. = 1). There was no difference in the prevalence between males and females.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibody to Pseudomonas pseudomallei exotoxin in sheep exposed to natural infection

Specific antibody to Pseudomonas pseudomallei exotoxin was detected in sheep sera exposed to natural infection. An enzyme-linked immunosorbent assay (ELISA) was used. Serum antitoxin was present in 49.3% of sera obtained from a flock of sheep naturally exposed to P. pseudomallei infection. Among these sera, 17.0% gave titers of 10,000. In contrast, serum antitoxin was present in only 6.0% of sera collected from sheep kept on a melioidosis-free farm. The ELISA reactivity of all positive sera could be completely absorbed with purified P. pseudomallei exotoxin. Similarly, preincubation of the exotoxin-coated wells with specific antiserum inhibited the ELISA reactivity of sheep sera. The results indicate that exotoxin is produced in vivo during infection by P. pseudomallei.

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.

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.

A competitive immunosorbent assay for detection of Pseudomonas pseudomallei exotoxin

The development of monoclonal antibody and enzyme-linked immunosorbent assay (ELISA) techniques has made possible the detection of specific antigens at extremely low concentrations. Diagnosis of recalcitrant diseases such as melioidosis depends upon either early isolation and identification of the causative organism or the identification of a specific marker antigen, Pseudomonas pseudomallei exotoxin, in serum; the latter is better because it allows more rapid and simple diagnosis. A method of detecting exotoxin concentrations of greater than 16 ng/ml by an ELISA based on a monoclonal antitoxin is here described; it is significantly more sensitive than the mouse lethality test (lower threshold 30 micrograms/ml) currently in use and an in-vitro cytotoxicity test (lower threshold 10 micrograms/ml) that we have developed and describe here.

Prevention of pulmonary injury in isolated perfused rat lungs by activated human neutrophils preincubated with anti-Mo1 monoclonal antibody

Neutrophil activation results in neutrophil adherence and may subsequently cause lung injury through the generation of oxidants, release of granule proteases, and generation of a variety of mediator substances. We hypothesized that inhibition of neutrophil adherence and subsequent lung sequestration would attenuate the lung injury caused by activated neutrophils. Using isolated perfused rat lungs, we determined if anti-Mo1 monoclonal antibody (binds to the alpha subunit of a neutrophil glycoprotein [gp 155.94] that facilitates adherence) would attenuate lung neutrophil sequestration and lung injury caused by human neutrophils stimulated by phorbol myristate acetate (PMA). PMA-stimulated neutrophils but not PMA or neutrophils alone caused lung injury as assessed by accumulation of 125I-bovine serum albumin into lung parenchyma and alveolar lavage fluid. Incubation of neutrophils with anti-Mo1 antibody prior to stimulation with PMA attenuated lung injury and neutrophil sequestration. Furthermore, a histological survey revealed that anti-Mo1 antibody inhibited neutrophils present in the lung from spreading following exposure to PMA. Anti-Mo1 antibody did not inhibit PMA-stimulated neutrophil release of granule constituents or toxic O2 metabolites as evidenced by lysozyme and lactoferrin release or the reduction of ferricytochrome c in the lung perfusate. The inhibition of lung injury caused by the anti-Mo1 antibody was not likely due to a nonspecific effect of the antibody, since another murine monoclonal antibody of the same class (anti-Mo5) did not inhibit lung neutrophil sequestration or lung injury. Thus, in this experimental model, interference with the close approximation of the neutrophil to its target site inhibited the ability of the activated human neutrophil to cause injury.

Plasmodium berghei: eosinophilic depression of infection in mice

The effects of eosinophilia on the course of Plasmodium berghei infection in mice were studied. Eosinophilia was induced by intravenous injection of Ascaris suum body fluid into the mice. Results indicated that eosinophils may play a role in the suppression of murine malaria. A significant reduction in parasitemias and increased survival time in eosinophilic mice occurred compared to mice not treated with A. suum body fluid. Reduction of parasitemia was effectively achieved when the mice were challenged with P. berghei, only after the level of eosinophils reached at least 10% of total white cell counts in the circulation. These findings may offer an additional explanation for the suppression of malaria in individuals with severe ascariasis.

Utilization of liposomes for correction of the metabolic and bactericidal deficiencies in chronic granulomatous disease

IgG-coated liposomes containing glucose oxidase (GO) in order to provide a means of generating H2O2 were prepared. Leukocytes from patients with chronic granulomatous disease (CGD) which are lacking a means of generating H2O2, ingested the IgG-coated liposomes and metabolic oxidative deficiencies of glucose-1-14C oxidation and iodination were normalized. Both of these activities have been shown to depend upon the availability of H2O2 within polymorphonuclear leukocytes. Improvement in the capacity to kill Staphylococcus aureus by chronic granulomatous disease leukocytes were observed under similar conditions. Thus, it is possible to restore the oxidative metabolic capacities to CGD leukocytes by the introduction of glucose oxidase containing liposomes to these cells.

Oxidative metabolic responses of rabbit pulmonary alveolar macrophages

During phagocytosis of opsonized lipopolysaccharide-coated paraffin oil droplets, rabbit alveolar macrophages reduced nitroblue tetrazolium, which effect was in part inhibitable with the use of superoxide dismutase. Exposure of cytochalasin-B-treated rabbit alveolar macrophages to opsonized zymosan led to the generation of superoxide, as quantitated by ferricytochrome C reduction. It was found that nitroblue tetrazolium in the presence of ferricytochrome C could in turn serve as scavenger of superoxide during stimulation of cytochalasin-B-treated rabbit alveolar macrophages. Following challenge with either opsonized zymosan or the membrane perturbant digitonin, rabbit alveolar macrophages released hydrogen peroxide into the extracellular medium. Employment of the surface membrane stimulant phorbol myristrate acetate led to activation of the hexose monophosphate shunt, which activity could be further enhanced in the presence of superoxide dismutase or attenuated in the presence of catalase. These studies demonstrate that rabbit alveolar macrophages release superoxide and hydrogen peroxide during surface membrane perturbation. In turn, hydrogen peroxide generation can stimulate the hexose monophosphate shunt.

Improvement of polymorphonuclear leucocyte oxidative and bactericidal functions in chronic granulomatous disease with 4-amino-4'-hydroxylaminodiphenyl sulphone

In an effort to restore oxidant-dependent capabilities to chronic granulomatous disease (CGD) polymorphonuclear leucocytes (PMN), we studied a dapsone derivative, 4-amino-4'-hydroxylaminodiphenyl sulphone (DDS-NOH), known to generate H2O2. After incubation of CGD PMN with 0.2 and 1.0 mM DDS-NOH for 30 min, the rate of glucose-1-14C oxidation via hexose monophosphate (HMP) shunt increased 2--4-fold and that of iodination of ingested zymosan particles 1.5--2.7-fold. Both effects could be further enhanced by superoxide dismutase (SOD) but inhibited by catalase. In three patients, 0.2 mM DDS-NOH improved in vitro killing of Staph. aureus. DDS-NOH 0.02 mM induced capping of Concanavalin A (Con A) receptor complexes suggesting interference by the drug with microtubule-associated function. Thus, optimal concentrations of DDS-NOH may be employed as an oxidant to improve metabolic and bactericidal functions of PMN from patients with CGD.