15 Retinopathy in patients with mucopolysaccharidosis

The mucopolysaccharidoses are a group of inherited metabolic disorders resulting in abnormal degradation of glycosaminoglycans within lysosomes. Ophthalmic manifestations resulting in visual loss include corneal clouding, optic neuropathy and raised intraocular pressure, and retinopathy which occurs in MPS type I, II, III, IV. While corneal clouding may be stabilised with early treatment with HSCT or surgically treated with a corneal transplant, there is currently no known effective treatment for retinopathy.We conducted a prospective observational study of patients with MPS who underwent fundus examination, OPTOS imaging, OCT, and electroretinography.76 patients with MPS were studied, comprised of 45 MPSI, 9 MPSII, 13 MPSIV and 9 MPSVI patients. The age range was 3- 58 years of age. OPTOS imaging was performed in 65 individuals, OCT in 61, and electrodiagnostic assessments in 37 patients. Ten patients (7 MPSI, 3 MPS II) had fundoscopic signs of retinopathy, of which 5 had abnormal ERGs. Twenty one patients (17 MPSI, 2 MPSII, 2 MPSVI) had abnormalities on ERG, of which 5 had concurrent fundoscopic evidence of retinopathy. The onset of retinopathy in MPS patients was observed over a broad age range, with initial detection occurring between 2 and 53 years of age.Retinopathy can be diagnosed on examination, imaging, or ERG in MPS patients as young as 2 years of age. The development of novel medicines, such as gene therapy, have potential to stabilise or improve retinopathy in the future. Therefore, phenotypic and natural history information pertaining to retinopathy in MPS is extremely valuable.

How Did Mortality Rates from Covid-19 Differ between Vaccinated and Unvaccinated People in a Tertiary Level Hospital of Bangladesh?

This study aims to find out the difference in mortality rates between vaccinated & non-vaccinated Covid-19 positive patients who were admitted in a tertiary centre (Ward and Intensive care unit) of Bangladesh. Retrospective analysis of data over 6 weeks in February 2022- March 2022, 100 confirmed Covid-19 positive patients were included- 50 patients from ICU and 50 patients from ward irrespective of age, gender, vaccination status and co-morbidities. Seventy five percent (75.0%) of all confirmed Covid-19 positive patients were vaccinated. Mortality among vaccinated people was less compared to non-vaccinated population 41.3% vs. 52%. Interestingly it was found pregnancy was the most significant risk factor in childbearing age female group- 86.7% of patients (pregnant and peripartum) required Intensive care admission and mortality was 40.0% although none of them had any recorded co-morbidities. Again, mortality among vaccinated was significantly less (35.7%) compared to 100.0% mortality among unvaccinated. Mortality rate among patient admitted in intensive care was significantly high compared to patients treated in ward- 72.0% vs. 16.0%. In ICU 83.0% of patients who died were vaccinated (90.0% had 2 doses and 10.0% had 3 doses). On the other hand, 87.5% who died in ward were unvaccinated. Among the survivors from intensive care units- 93.0% were vaccinated compared to 7.0% unvaccinated. Pre-existing co-morbidities increased mortality (59.0%) compared to 40.9% mortality in patients without any previous medical conditions. We found vaccination against Covid-19 reduces the rate of death irrespective of co-morbidities or severity of disease. Recovery rate was significantly increased in vaccinated patients requiring intensive care support. Pregnancy was found to be the most important risk factor for Intensive care admission and mortality in otherwise healthy childbearing age females and mortality was significantly high (100.0% though limited data availability) in unvaccinated. These results require further revalidation on larger population.

Extensively drug-resistant typhoid fever; it's not that simple: a case report

Multi-drug resistant strains of Salmonella typhi (S. typhi) has remained endemic in developing countries for the last two decades. With irrational use of antibiotics, an extensively drug-resistant (XDR) strain of S. typhi, sensitive only to Carbapenems and Azithromycin, has evolved which was first reported in Sindh, Pakistan, in 2018. Most of the cases of XDR S. typhi infection treated with antibiotics improve without any complications. Failure to respond to appropriate antibiotics should raise the suspicion of visceral abscesses. Splenic abscess is a rare complication of S. typhi infection. A patient with splenic abscess due to XDR S. typhi has been reported who responded to prolonged antibiotic treatment. We report the case of a young boy from Peshawar with multiple splenic abscesses due to XDR S. typhi which did not respond to percutaneous aspiration and culture-guided antibiotics for two weeks. Eventually, he had to undergo splenectomy. He has remained afebrile since then.

Predictors of Mortality in Patients With Dengue Fever: Insights From a Comparative Analysis

Objective To determine the clinical and biochemical predictors of mortality in patients with dengue fever. Methods This was an analytical, cross-sectional study conducted at Hayatabad Medical Complex, Peshawar, Pakistan. The study participants were patients admitted to the hospital for the management of dengue fever. Clinical parameters (age, gender, duration of hospital stay, and the presence of complications) and biochemical parameters [white blood cells count (WBC), platelet count, serum c-reactive protein (CRP) level, serum alanine aminotransferase (ALT) level, and serum creatinine] were recorded. These parameters were compared between the survivors and non-survivors of dengue fever. Results Out of 115 patients, the majority (n=82, 71.3%) were up to 45 years and the mean age was 38.40 ± 18.1 years. Most of the patients (n=105, 91.3%) survived. On univariate logistic regression analysis, age more than 45 years [odds ratio (OR) 0.141, 95% confidence interval (CI) 0.034 - 0.585, p = 0.007), leukocytosis (> 11,000/mcL) (OR 0.187, 95% CI 0.049 - 0.719, p = 0.015), and acute kidney injury (creatinine > 1.5 mg/dL) (OR 0.124, 95% CI 0.029 - 0.531, p = 0.005)] at the time of admission reduced the likelihood to survive. Leukocytosis and acute kidney injury remained significant independent predictors of mortality on multivariate logistic regression analysis. [(OR 0.201, 95% CI 0.042 - 0.960, p = 0.044) and (OR 0.148, 95% CI 0.026 - 0.857, p = 0.033) for survival, respectively]. Gender, duration of inpatient stay, thrombocytopenia (platelets < 30,000/mcL), and acute liver injury (ALT > 200 IU/L) were not associated with mortality from dengue fever. Conclusion Age over 45 years, leukocytosis, and acute kidney injury at presentation increased the likelihood of mortality from dengue fever in this study. Gender, duration of hospital stay, thrombocytopenia, and acute liver injury did not affect the odds of mortality.

Crimean-Congo Hemorrhagic Fever Case Series: a Chronology of Biochemical and Hematological Parameters

Introduction

Crimean-Congo hemorrhagic fever (CCHF) is a widespread tick-borne zoonotic disease. Sporadic outbreaks of CCHF occur in endemic regions, including Pakistan. The clinical spectrum of the illness varies from asymptomatic seroconversion to severe disease which may end in death. The treatment is supportive, including blood and blood products. There is multi-organ involvement in CCHF including acute hepatitis, thrombocytopenia, coagulopathy, acute kidney injury (AKI), and encephalopathy. Hematological and biochemical parameters may identify patients at substantial risk of worse outcomes. Early detection of the disease and forecasting the clinical course may be helpful. This case series aims to evaluate the trends of hematological and biochemical parameters among the survivors and non-survivors of CCHF.

Methods

All consecutive patients aged 16 years and above admitted to the isolation unit of Hayatabad Medical Complex, Peshawar, Pakistan between 1^st July and 30^th July 2022 with the diagnosis of CCHF were included in this case series. The diagnosis of CCHF was made by detecting viral ribonucleic acid by a polymerase chain reaction. For all patients, age, gender, address, occupation, clinical presentation, history of contact with animals, and travel history were recorded. All the vitals were taken regularly. The hematological (complete blood count) and biochemical parameters (serum creatinine, alanine aminotransferase (ALT), and C-reactive protein (CRP)) were documented daily. The blood group was determined for all the cases.

Results

Out of 17 cases, the majority (16 cases, 94.1%) were male and butchers (eight cases, 47.1%) by profession. All cases had significant contact with animals. Four patients (23.5%) died. Three out of the four non-survivors (75%) had ALT < 5 times the upper limit of normal with a static pattern of liver enzymes without much decline in ALT till death. One non-survivor (25%) had marked elevation of ALT at presentation, which had a declining trend till death. Seven out of 13 survivors (53.8%) had moderate to marked elevation in the level of ALT at presentation. The ALT showed a downward trend during the course of illness in all these patients. The remaining survivors (six out of 13, 46.2%) had a mild elevation of ALT and 50% of them showed improvement in the ALT level during hospitalization. All patients had thrombocytopenia at presentation. None of the non-survivors showed a persistent increase in the platelet count, and three cases remained severely thrombocytopenic at the time of death. However, the trend in platelet count among all the survivors was increasing. The CRP level in the majority (three out of four cases, 75%) of the non-survivors remained elevated till death, while all survivors showed a progressive decline in CRP level. A majority (11 out of 17 cases) had blood group B. Half of the non-survivors (two out of four cases) and the majority of the survivors (nine out of 13 cases) had blood group B. AKI was found in all non-survivors, while all the survivors had normal renal function throughout the course.

Conclusion

A persistently raised ALT and CRP level, a persistently low or decreasing platelet count, and AKI were associated with mortality. Blood group B was the commonest blood group among patients of CCHF, which is not reflective of the blood group distribution of the general population from which this case series has been reported.

Dengue Fever, Crimean-Congo Hemorrhagic Fever, and COVID-19 Triple Co-infection: Out of the Frying Pan Into the Fire

In developing countries, infectious diseases are thriving due to poor hygiene, inadequate public health infrastructure, and socio-cultural factors. Generally, infections are due to a single pathogen, but due to the shared risk factors for transmission, co-infections are not uncommon. The severity and outcome of infections are adversely affected by co-infection. Co-infections present as diagnostic and therapeutic enigmas because of the complex interaction between different pathogens involved and distorted host responses. The southeast Asian region, particularly Pakistan, is known for unique combinations of different infections.

We present a distinctive case of triple co-infection of dengue virus, Crimean-Congo hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. The index case was a 60-year-old gentleman who presented with fever, cough, shortness of breath, bruises, and hemoptysis. He had thrombocytopenia, deranged liver and renal function, coagulopathy, and infiltrates in both lung fields. Subsequent investigations revealed a positive polymerase chain reaction for ribonucleic acid of dengue virus, Crimean-Congo Hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. He received supportive treatment including antibiotics, blood products, ribavirin, and supplemental oxygen. He developed multi-organ failure and succumbed to the triple co-infection. This case will act as a wake-up call for clinicians, public health authorities, and infectious disease specialists to plan before the volcano of co-infections erupts.

Acute Kidney Injury Following Posaconazole for Mucormycosis: SARS-CoV-2 as a Back-Seat Driver

Viruses have been implicated in the causation of several systemic illnesses, either directly or by immune modulation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not an exception. Due to altered immune regulation, it is often associated with novel clinical manifestations and complications which have not been reported before. SARS-CoV-2 induces a pro-inflammatory state which makes the patient vulnerable to developing a variety of previously unreported adverse reactions to medications. Coronavirus disease 2019 (COVID-19) and its treatment have provided a fertile ground for various opportunistic infections including mucormycosis. The standard treatment for mucormycosis is surgical debridement and liposomal amphotericin B. Triazole antifungals such as posaconazole and isavuconazonium are the second-line agents for those intolerant to first-line therapy. Posaconazole is safer than amphotericin B as far as renal adverse effects are concerned.

We report the case of a 60-year-old lady with type 2 diabetes mellitus, hypertension, ischemic heart disease, and osteoarthritis. She had severe COVID-19 requiring non-invasive ventilation four months ago. She presented with right rhino-orbital swelling, diplopia, and serosanguinous discharge from the right nostril. She had right third, sixth, and seventh cranial nerve palsies. Magnetic resonance imaging revealed right maxillary, ethmoid, and frontal sinusitis. Biopsy from the right nostril confirmed mucormycosis. Having normal renal and liver functions, she was started on oral posaconazole as she had an allergic reaction to a test dose of 1 mg amphotericin B (non-liposomal) in 20 mL of 5% dextrose water infused over 30 minutes. On day five, she developed acute kidney injury requiring renal replacement therapy. Her posaconazole was stopped. As she was not improving with conservative treatment, an ultrasound-guided, percutaneous renal biopsy was performed from the left kidney. The renal biopsy revealed thrombotic microangiopathy. She was started on liposomal amphotericin B as decided by the multidisciplinary team. Her renal function improved, and she continued on liposomal amphotericin B.

We conclude that thrombotic microangiopathy, in this case, was likely due to posaconazole. This is a novel adverse effect presumably of posaconazole. This case report will alert physicians to be vigilant of the renal adverse effects of posaconazole in patients who have had COVID-19. Patients who develop renal injury while on posaconazole should undergo an early renal biopsy to ascertain the exact histopathology.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Polymyositis: The Comet Tail After COVID-19

Infectious agents have been implicated in the pathogenesis of autoimmune disorders for decades. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is no exception. This became evident as the pandemic evolved. Once considered a respiratory pathogen only, SARS-CoV-2 is now linked to a variety of autoimmune rheumatic disorders such as rheumatoid arthritis, systemic lupus erythematosus, reactive arthritis, spondyloarthropathies, vasculitis, and inflammatory myopathy. Although the exact cause for muscle injury in the setting of coronavirus disease 2019 (COVID-19) is not established, autoimmune inflammatory damage is the most accepted mechanism. Moreover, SARS-CoV-2 can cause direct muscle damage and indirectly through a cytokine storm. Inflammatory polymyositis in relation to COVID-19 has seldom been reported in developing countries.

Here, we report a unique case of inflammatory polymyositis in a 52-year-old lady. The patient presented with muscle weakness, generalized body aches, and fatigue occurring four months after recovering from mild COVID-19. She had muscle weakness of Medical Research Council (MRC) grade 3/5 involving the shoulders and pelvic girdle with elevated muscle enzymes. Electromyography revealed an active irritable myopathic process consistent with inflammatory polymyositis. She underwent magnetic resonance imaging-guided muscle biopsy from the right thigh which revealed findings consistent with inflammatory myopathy. She was offered prednisolone and azathioprine. After four weeks of treatment, she had a remarkable improvement in her muscle strength to MRC grade 5/5.

985 A QUALITY IMPROVEMENT PROJECT ON CALL BELL IN REACH IN AN ACUTE OLDER PERSON MEDICINE WARD (AGE &gt; 85 YEARS)

Introduction

Call bell within reach of patients is an important part of quality care and standard in the National Inpatient Falls Audit. Initial data collection showed 56% of patients had call bell in reach indicating potential for improvement Understanding the problem: Discussion with stakeholders included: Healthcare support worker, nurses & doctors of all grades, physio, and occupational therapist.

Aim

We aimed to improve call bell reach-ability from 56% to 95% or more for patients on the ward.

Method

Data were collected from 2 bays (Total 10 beds) on the ward three times a week for 2 weeks after implementation of each change assuming it should roughly reflect the whole ward. Balancing measure Inpatient falls on the ward (weekly data for the ward). Changes 1st Change: Stickers in medical notes as a reminder 2nd Change: Teaching session to staff nurses 3rd Change: A short video posted in a closed social group of ward 4th Change: Make a component in the safety huddle & reminder in daily nursing handover.

Results

After the 4th PDSA cycle, the call bell in reach was 93.88% which was sustained improvement. Inpatient fall did not show any specific correlation with call bell reach-ability and specific fall data for those 10 beds was not available separately Learning: • Teaching is effective but it may not be able to involve all the staff especially when staffing is not consistent. Despite attending the teaching, implementation of gained knowledge from the teaching session may not sustain. • Social media can be used to improve patient care provided that it’s closed media & no patient confidentiality is hampered but again may not be a solution. • Reminding the staff of the importance was our most effective change, possibly because of its proximity to patient care immediately being delivered afterward.

Extensively Drug-Resistant Salmonella typhi Infection: From Pill to Scalpel

Water-borne infections like typhoid fever are common in the developing world. The emergence of extensively drug-resistant Salmonella typhi (XDR S. typhi) is of great concern for both local and global public health. Fever, diarrhea, and abdominal pain are the commonest manifestations of typhoid fever. Abdominal pain may be due to ileal and colonic inflammation/ulceration and mesenteric lymphadenitis. Sometimes, abdominal pain in typhoid is due to ileal perforation leading to peritonitis, and acute appendicitis which needs urgent surgical intervention. Delayed surgical intervention can result in morbidity and sometimes even death.

We report a case of XDR S. typhi infection in a 17-year-old female who presented with fever and abdominal pain. During the course of the hospital stay, while she was on appropriate antibiotics, her abdominal pain worsened due to acute appendicitis. She underwent an appendectomy and had an uneventful recovery. This is the first case, to our knowledge, of acute appendicitis caused by XDR S. typhi.

Although appropriate antibiotics are the mainstay of treatment for typhoid fever, physicians should be mindful that surgical consultation may be necessary in certain cases.

Novel Ta/chitosan-doped CuO nanorods for catalytic purification of industrial wastewater and antimicrobial applications

Novel tantalum (Ta) and chitosan (CS)-doped CuO nanorods (NRs) were synthesized using a single step co-precipitation route. Different concentrations (2 and 4%) of Ta were used in fixed amounts of CS and CuO to examine their catalytic activity and antimicrobial potential. For critical analysis, synthesized NRs were systematically examined using XRD, FTIR HRTEM, EDS, UV-Vis and PL spectroscopy. The XRD technique revealed the monoclinic structure of CuO while an increase in its crystallite size (from 15.5 to 18.5 nm) was observed upon doping. FTIR spectra were examined to study the functional groups of CuO where peaks at 514 cm-1 and 603 cm-1 confirmed the formation of CuO NRs. PL spectra depicted the charge transfer efficiency of the synthesized samples. The presence of dopants (Ta and CS) and constituent elements (Cu, O) was detected using EDS spectra. Additionally, the pH based catalytic performance of fabricated NRs revealed 99.7% dye degradation of toxic methylene blue (MB) dye in neutral media, 99.4% in basic media and 99.5% in acidic media along with promising antibacterial activities for Gram negative/positive bacteria, respectively upon doping of Ta (4%) into CS/CuO. The adsorption energies of CuO co-doped with CS/Ta led to the creation of stable structures that were investigated theoretically using density functional theory.

COVID-19 Associated Illnesses From Alveoli to Glomeruli: A Case Report

Hypoxemic respiratory failure is the most frequent complication of severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection. Coronavirus disease-19 (COVID-19) is no longer considered a standalone respiratory infection. It can involve other organs, including kidneys by direct invasion or indirectly through immune activation, cytokine storm, microthrombi and hemodynamic instability. Multiorgan involvement carries a worse prognosis in COVID-19.

Tubulopathy is the most frequently reported renal pathology, followed by glomerulopathies. Among the glomerulopathies, immunoglobulin A (IgA) nephropathy is less often reported. Differentiating tubulopathy from glomerulopathy is important from the management and prognostic point of view. Laboratory investigations, including urine microscopy, cannot predict glomerulopathy as a cause of renal involvement. Therefore, it is important to proceed with renal biopsy early to make a definite diagnosis.

We report a case of a 33-year-old male who presented three weeks after recovery from COVID-19 with proteinuric acute kidney injury. Subsequent renal biopsy revealed IgA nephropathy.

A Patient With Fever, Loose Motions and Jaundice: Hickam’s Dictum or Occam's Razor

Infectious diseases like malaria, typhoid, leptospirosis, and dengue fever are the leading causes of morbidity and mortality in developing countries like Pakistan. Although rare, it is possible to have coinfection with organisms that are endemic in a region, causing diagnostic and therapeutic dilemmas.

Leptospirosis is caused by Gram-negative spirochetes. Leptospira are widely distributed and are transmitted by contamination of water and food by the urine of infected animals like rodents. Leptospirosis is characterized by fever, body aches, abdominal pain, and hepatic and renal involvement. Laboratory abnormalities include cytopenia, elevated bilirubin, alanine aminotransferase, and abnormal renal function tests.

Typhoid fever is caused by Salmonella typhi (S. typhi), which is transmitted by fecal contamination of drinking water and food items. The clinical manifestations of typhoid fever include fever, abdominal pain, and diarrhea. Laboratory abnormalities include cytopenia and mildly deranged liver function tests. A strain of S. typhi resistant to all antibiotics except azithromycin and carbapenems was isolated in 2016 in Pakistan.

Most of the clinical manifestations and laboratory abnormalities of leptospirosis and typhoid fever overlap. There have been case reports of coinfection of S. typhi and Leptospira, but there is no report of coinfection of extensively drug-resistant (XDR) S. typhi and Leptospira. We present a case of a 20-year-old man with fever, loose motions, and jaundice from Peshawar, Pakistan who had coinfection of Leptospira and XDR S. typhi. The attending physicians should adopt Hickam’s dictum instead of Occam's razor approach.

Co-infection With Dengue Virus and Extensively Drug-Resistant Salmonella typhi

In South Asia, infectious diseases are associated with significant morbidity and mortality. Malaria, typhoid, and dengue are the most common infectious diseases, and patients may be co-infected with these diseases, resulting in diagnostic and treatment dilemmas.

Dengue is caused by the Arboviridae family of viruses and is transmitted by Aedes aegypti. Dengue virus has four serotypes and the symptoms of dengue fever mimic those of other infectious diseases such as malaria, chikungunya, Zika virus disease, influenza A, enteric fever, and coronavirus disease 2019, which are also prevalent in areas of frequent dengue fever outbreak. Dengue fever is characterized by fever, severe myalgia, retro-orbital pain, skin rashes, and bone pain, which is why dengue fever is also referred to as breakbone fever. Patients with secondary dengue virus infection more commonly present with abdominal pain when compared with those with primary dengue virus infection.

Salmonella typhi causes enteric fever, which is a human infection with no animal reservoir, but the symptoms of enteric fever closely resemble those of dengue fever. Concurrent infections with multiple organisms are especially difficult to diagnose.

In this report, we present the case of a 15-year-old boy from Peshawar, Pakistan, who was co-infected with the dengue virus and extensively drug-resistant Salmonella typhi. To the best of our knowledge, this is the first reported case of co-infection with dengue virus and extensively drug-resistant Salmonella typhi. 

The Effect of Tocilizumab on Inflammatory Markers in Survivors and Non-survivors of Severe COVID-19

OBJECTIVE

To determine the effects of tocilizumab (TCZ) on inflammatory markers, laboratory indices; and short-term outcome in patients with severe COVID-19.

STUDY DESIGN

Cross-sectional analytical study. Place and Duration of the Study: Hayatabad Medical Complex, Peshawar, Pakistan from 10th June till 31st August 2020.

METHODOLOGY

Fifty-four patients with severe COVID-19 fulfilled the inclusion criteria and were included. All patients had received TCZ (4 mg/kg) in addition to standard treatment. Serum C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer levels, full blood count, and liver function tests (LFTs) were checked before and 24 hours after receiving TCZ. Short-term outcome, defined as survival at day 28, was determined from hospital record/telephonic contact. Paired t-test was employed to assess the statistical significance of mean differences between the pre- and post-TCZ variables, considering a p-value of <0.05 as significant.

RESULTS

Overall, the mean pre- and post-TCZ CRP was 18.7 ± 10.7 and 10.2 ± 8.6 mg/dl (p <0.001). It was 18.0 ± 10.3 and 10.3 ± 8.8 mg/dl (p=0.003) in survivors; and 19.4 ± 11.4 and 10.2 ± 8.7 mg/dl (p=0.005) in non-survivors, respectively. Overall, mean D-dimer level decreased from 12.5 ± 23 to 10.3 ± 12.2 µg/ml following TCZ (p=0.643); it decreased from 15.8 ± 29.8 to 11.4 ± 10.6 µg/ml (p=0.612) in survivors; and 9.0 ± 12.8 to 9.2 ± 14.1 µg/ml (p=0.961) in non-survivors, respectively. There were no significant differences in the pre- and post-TCZ LDH levels overall and between the groups. The 28-day mortality was 46.3%.

CONCLUSION

Tocilizumab results in a significant reduction in CRP, while mean change in LDH and D-dimers was not substantial. The mean change in inflammatory markers did not predict survival. Key Words: Tocilizumab, COVID-19, Biomarkers, Outcome, Mortality.

Repeated Covid-19 Infection Exists: A Case Series From Pakistan

BACKGROUND

Protection against SARS-CoV-2 in infected individuals of COVID-19 is lacking. We report a case series of repeated infections of SARS-CoV-2.

METHODS

A total of 12 patients were identified with repeated infections for SARS-CoV-2 from 25 April 2020 to 16 March 2021 from Pakistan. Repeated infection was defined as diagnosis of the SARS-CoV-2 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests in the first and second phase of infection after complete recovery from the first phase of infection with a negative RT-PCR.

RESULTS

Of the 12 participants, 75% (n=9) were male and mean age of the participants were 40.1±9.7 years. Mean duration between the first and second phase of infection was 184±68.9 days. Patients presenting with mild infection in the first phase largely developed moderate to severe infection in the second phase. None of them were vaccinated.

CONCLUSION

The pandemic of COVID-19 is on the rise and repeated infection from SARS-CoV-2 is occurring.

ABO / Rh-D Blood types and susceptibility to Corona Virus Disease-19 in Peshawar, Pakistan

OBJECTIVES

To determine the association between ABO/Rh-D blood types and susceptibility to SARS-CoV-2 infection in Pakistan.

METHODS

In this cross-sectional study, 1935 confirmed cases of COVID-19 were included using consecutive sampling. Age and gender-matched sample of 1935 blood donors was used as a comparison group. Chi-square test and binary logistic regression were used for inferential statistics.

RESULTS

Significantly higher proportion of blood type-B was observed in COVID-19 group (35.9% vs 31.9%, p=0.009). Blood type-AB was found more frequently (14.2% vs 11.8%, p=0.03) in the comparison group. The Rh-D Positive blood types were 93.3% in COVID-19 group and 94.9% in comparison group (p=0.03). The odds of blood type-B, AB and Rh-D positive to test positive for SARS-CoV-2 were 1.195 (95% CI 1.04 - 1.36, p=0.009), 0.80 (95% CI 0.66 - 0.97, p=0.03) and 0.75 (95% CI 0.57- 0.98, p = 0.03), respectively. Blood types A and O did not have significant association with SARS-CoV-2 PCR result (p = 0.22 and 0.88, respectively).

CONCLUSIONS

There is significant association between blood types B & AB and susceptibility to COVID-19. There is no association between blood types A and O with COVID-19. Rh- D positive blood types are less susceptible to COVID-19.

The Effect of Tocilizumab on Inflammatory Markers in Survivors and Non-survivors of Severe COVID-19

OBJECTIVE

To determine the effects of tocilizumab (TCZ) on inflammatory markers, laboratory indices; and short-term outcome in patients with severe COVID-19.

STUDY DESIGN

Cross-sectional analytical study. Place and Duration of the Study: Hayatabad Medical Complex, Peshawar, Pakistan from 10th June till 31st August 2020.

METHODOLOGY

Fifty-four patients with severe COVID-19 fulfilled the inclusion criteria and were included. All patients had received TCZ (4 mg/kg) in addition to standard treatment. Serum C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer levels, full blood count, and liver function tests (LFTs) were checked before and 24 hours after receiving TCZ. Short-term outcome, defined as survival at day 28, was determined from hospital record/telephonic contact. Paired t-test was employed to assess the statistical significance of mean differences between the pre- and post-TCZ variables, considering a p-value of <0.05 as significant.

RESULTS

Overall, the mean pre- and post-TCZ CRP was 18.7 ± 10.7 and 10.2 ± 8.6 mg/dl (p <0.001). It was 18.0 ± 10.3 and 10.3 ± 8.8 mg/dl (p=0.003) in survivors; and 19.4 ± 11.4 and 10.2 ± 8.7 mg/dl (p=0.005) in non-survivors, respectively. Overall, mean D-dimer level decreased from 12.5 ± 23 to 10.3 ± 12.2 µg/ml following TCZ (p=0.643); it decreased from 15.8 ± 29.8 to 11.4 ± 10.6 µg/ml (p=0.612) in survivors; and 9.0 ± 12.8 to 9.2 ± 14.1 µg/ml (p=0.961) in non-survivors, respectively. There were no significant differences in the pre- and post-TCZ LDH levels overall and between the groups. The 28-day mortality was 46.3%.

CONCLUSION

Tocilizumab results in a significant reduction in CRP, while mean change in LDH and D-dimers was not substantial. The mean change in inflammatory markers did not predict survival. Key Words: Tocilizumab, COVID-19, Biomarkers, Outcome, Mortality.

Does Working in a COVID-19 Receiving Health Facility Influence Seroprevalence to SARS-CoV-2?

Objective In this study, we aimed at comparing the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in healthcare workers (HCWs) in coronavirus disease 2019 (COVID-19) receiving and non-COVID-19 receiving hospitals in Peshawar, Pakistan. Methods This cross-sectional analytical study was conducted in a COVID-19 receiving hospital (hospital 'A') and a non-COVID-19 receiving hospital (hospital 'B'). Using stratified random sampling, 1,011 HCWs (439 from hospital 'A' and 572 from hospital 'B') were recruited to participate in the study. Immunoglobulin G/immunoglobulin M (IgG/IgM) antibodies were checked using Elecsys® (Roche, Basel, Switzerland) Anti-SARS-CoV-2 immunoassay. The chi-squared test was used to compare frequencies, and the binary logistic regression model was used to predict the association between study variables' seropositivity to SARS-CoV-2. A p-value of <0.05 was considered statistically significant. Results The overall seroprevalence to SARS-CoV-2 antibodies in the two hospitals was 30.76%. It was 28.2% in hospital 'A' and 32.7% in hospital 'B' (p=0.129). The seroprevalence in HCWs having direct contact with COVID-19 patients was higher (33.1%) in non-COVID-19 receiving hospital versus 23.8% in COVID-19 receiving hospital (p=0.034). Seroprevalence was highest among administrative staff (44.0%), followed by nurses (30.8%), residents (19.8%), and consultants (17.8%) (p=0.001). As compared to consultants, the administrative and nursing staff were 3.398 and 3.116 times more likely to have positive antibodies, respectively. There were no significant differences in the seroprevalence between the respective categories of staff of the two hospitals. Conclusions The non-COVID-19 receiving hospital had a higher proportion of seropositive HCWs than the COVID-19 receiving hospital. The HCWs in the non-COVID-19 receiving hospital who had direct contact with patients had significantly higher seroprevalence. Seroprevalence was highest for administrative staff followed by nursing staff, residents, and consultants. Regardless of the COVID-19 status of the healthcare facility, all HCWs shall be trained on, and consistently follow, the proper protocols for donning and doffing of personal protective equipment (PPE).

Mortality of Patients With Severe COVID-19 in the Intensive Care Unit: An Observational Study From a Major COVID-19 Receiving Hospital

Objective To determine the mortality of patients with severe COVID-19 in the intensive care unit (ICU) in relation to age, gender, co-morbidities, ventilatory status, and length of stay (LOS). Methods This was a cross-sectional study based on data retrieved for 204 patients admitted to the ICU of Hayatabad Medical Complex, Peshawar, Pakistan, from April to August 2020. Study variables were age, gender, co-morbid conditions, ventilatory status, and length of stay (LOS). The data were analyzed using SPSS version 21 (IBM Corp., Armonk, NY). The independent t-test and the chi-square test were used to compare the means and frequencies of variables. Multivariate regression analysis was used to predict the likelihood of mortality. Results The overall mortality was 77%. Non-invasive ventilation (NIV) was administered to 61.8% of patients. Mortality was higher for invasive mechanical ventilation (IMV) (93.6% vs 66.7%, p<0.001) and for over 60 years (87.3% vs 72.3%, p=0.019). Mortality without co-morbidities was 75.2%. Comparative mortality rates for at least one co-morbidity (79.7%), diabetes mellitus (80.0%), hypertension (100%), diabetes mellitus and hypertension both (87.1%), and chronic obstructive pulmonary disease (75%) were insignificant. The LOS for survivors was longer (8.9±8.9 versus 5.4±5.2 days, p=0.017). The LOS < 24h was associated with higher mortality (85.9% vs 72.9%, p=0.040). On multivariable regression, the likelihood of mortality was high for IMV (7.330, 95% CI 2.667 - 20.143, p<0.001) and elderly (>60 years) patients (2.607, 95%CI 1.063 - 6.394, p=0.036). Mortality decreased with LOS longer than 24h (0.412, 95%CI 0.173 - 0.982, p=0.045). Co-morbidities did not have any effect on mortality. Conclusions Age more than 60 years and IMV were independent risk factors for higher mortality. Longer ICU stay, specifically more than 24 hours, was associated with lower mortality but LOS less than 24 hours might not have a causal relationship with mortality. The odds of survival were not affected by co-morbidities.

Lessons from the field: Gender roles and researcher reflexivity in smoking cessation in South Asia

Background

In South Asia, dual epidemics of smoking and tuberculosis (TB) have contributed to a high burden of lung disease. To address these health risks, the TB & Tobacco study uses the TB diagnosis as a teachable moment and implements a behaviour support counselling intervention, conducted by TB health workers, for patients in Bangladesh, Nepal and Pakistan. In this region, smoking tobacco is perceived as problematic for women, and being confronted with questions on smoking from a health professional may be uncomfortable for men and women. Anticipating these challenges, we incorporated gender sensitivity into training of health workers.

Methods

During implementation of the cessation support in routine TB care, a process evaluation assessed interactions between participants and the intervention through interviews with health workers and patients with TB participating in the cessation program. This presentation focusses on a retrospective self-reflection on how we conceptualized gender roles based on prior research, and how research findings partially challenged these assumptions.

Findings

While parts of our interview findings point towards smoking as a stigmatized practice for women and some men in South Asia as expected, several male and female respondents across socio-economic and geographical spheres contradicted this assumption. We discovered that health workers’ self-efficacy and perceived smoking stigma among health workers influenced whether they discussed smoking with women or minors. Many patients, on the other hand, told us that they were interested in receiving help to cure their TB and were willing to talk to about smoking with their health workers and their family members.

Conclusions

Patients in this study were more open to talking about smoking than anticipated. When including gender sensitivity into the standard training for health workers, we should be careful not to increase doubts in health workers about addressing smoking with women.

Extracellular Vesicles Released by Human Induced-Pluripotent Stem Cell-Derived Cardiomyocytes Promote Angiogenesis

Although cell survival post-transplantation is very low, emerging evidence using stem cell therapy for myocardial repair points toward a primary role of paracrine signaling mechanisms as the basis for improved cardiac function, decreased fibrosis, and increased angiogenesis. Recent studies have demonstrated that extracellular vesicles (EVs) such as exosomes secreted by stem cells stimulate angiogenesis, provide cytoprotection, and modulate apoptosis. However, the angiogenic potential of EVs secreted from human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM), a terminally differentiated cell type, has not been elucidated yet. Therefore, the main objective of this study is to isolate, characterize, and evaluate the in vitro angiogenic potential of EVs collected from hiPSC-CM conditioned media. The hiPSC-CM were cultured for 2 weeks and EVs were isolated from cell culture medium. Isolated EVs were characterized by transmission electron microscopy (TEM), nanoparticle tracking analysis, and immunoblotting. Furthermore, the angiogenic potential of these EVs was evaluated by tube formation, wound-healing, and cell-proliferation assays in bovine aortic endothelial cells (BAEC). In addition, gene expression levels of growth factors was evaluated in hiPSC-derived endothelial cells (hiPSC-EC) treated with hiPSC-CM-derived EV (CM-EVs) to assess their role in promoting angiogenesis. TEM imaging of CM-EVs showed a presence of a double-membrane bound structure, which is a characteristic of EV. Nanoparticle tracking analysis further confirmed the size and shape of the secreted particles to be consistent with EVs. Furthermore, EV-specific markers (CD63 and HSP70) were enriched in these particles as illustrated by immunoblotting. Most importantly, BAEC treated with 100 μg/ml of CM-EVs showed significant increases in tube formation, wound closure, and cell proliferation as compared to control (no-EVs). Finally, treatment of hiPSC-EC with CM-EVs induced increased expression of pro-angiogenic growth factors by the endothelial cells. Overall, our results demonstrated that EVs isolated from hiPSC-CM enhance angiogenesis in endothelial cells. This acellular/cell-free approach constitutes a potential translational therapeutic to induce angiogenesis in patients with myocardial infarction.

Abstract 550: Exosomes Released by Human Induced Pluripotent Stem Cell-Cardiomyocytes Induce In-Vitro Angiogenesis: A New Strategy for Cell-Free Therapeutics

Due to the poor regenerative properties of cardiac tissue, acute ischemic events can lead to progressive terminal heart failure unless cardiac regeneration can be stimulated. Recent evidence using stem cell therapy in the heart demonstrates a greater role of their paracrine signaling potential, as cell survival post-transplantation is very low. The main objective of this study was to characterize exosomes secreted by human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) and evaluate their in vitro angiogenic potential. HiPSC-CMs were cultured under normal conditions with exosome-free serum. Isolated exosomes were characterized by TEM, NTA, and immunoblotting. Angiogenic potential was assessed by wound-healing, proliferation, and tube formation assays using bovine aortic endothelial cells (BAECs). TEM imaging showed secretion of exosomes for hiPSC-CMs, as confirmed by the size and shape of the isolated particles. The size of exosomes was determined to be 71.4 nm (mode), within the characteristic exosomal range. Immunoblot analysis of exosome lysate demonstrated enrichment of known exosome-specific protein markers (CD63 and Hsp70). Most importantly, BAECs treated with exosomes showed significant (p < 0.05) increases in migration, proliferation, and tube formation, as compared to the no exosome control. Overall, our results demonstrate that treating BAECs with exosomes isolated from hiPSC-CMs enhances angiogenesis. Overall, this study demonstrates the angiogenic potential of human iPSC-CM- derived exosomes. The cell-free therapeutics using exosomes constitutes a novel innovative approach for future clinical therapy to induce angiogenesis in the post-ischemic heart.

Blue light-induced immunosuppression in Bactrocera dorsalis adults, as a carryover effect of larval exposure

Detrimental effects of ultraviolet (UV) light on living organisms are well understood, little is known about the effects of blue light irradiation. Although a recent study revealed that blue light caused more harmful effects on insects than UV light and blue light irradiation killed insect pests of various orders including Diptera, the effects of blue light on physiology of insects are still largely unknown. Here we studied the effects of blue light irradiation on cuticular melanin in larval and the immune response in adult stage of Bactrocera dorsalis. We also evaluated the effects of blue light exposure in larval stage on various age and mass at metamorphosis and the mediatory role of cuticular melanin in carryover effects of larval stressors across metamorphosis. We found that larvae exposed to blue light decreased melanin contents in their exoskeleton with smaller mass and delayed metamorphosis than insects reared without blue light exposure. Across metamorphosis, lower melanotic encapsulation response and higher susceptibility to Beauveria bassiana was detected in adults that had been exposed to blue light at their larval stage, thereby constituting the first evidence that blue light impaired adult immune function in B. dorsalis as a carryover effect of larval exposure.

Borderline intellectual functioning and psychosis: Adult Psychiatric Morbidity Survey evidence

Borderline intellectual functioning (BIF) is associated with several neuropsychological deficits. We used national data to establish the prevalence of psychosis and psychotic symptoms, and the role of potential mediators. The BIF group were more than twice as likely to have probable psychosis (adjusted odds ratio (OR)=2.3, 95% CI 1.4-4.0) and to report hallucinations (adjusted OR = 2.9, 95% CI 1.9-4.4) but not persecutory ideation. Salient mediators were depressive symptoms and the cumulative total of life events. Our findings suggest mechanisms other than drug use that are contributing to the strong relationship between BIF and severe mental illness and that may be amenable to treatment.

Further evidence for the association of distinct amino acid residues with in vitro and in vivo growth of infectious bursal disease virus

A cell-culture-adapted reverse genetics strain of very virulent infectious bursal disease virus (IBDV) of chickens, designated as BD-3tcC, having four amino acid substitutions (Gln253His, Asp279Asn, Ala284Thr and Ser330Arg) in the capsid protein VP2 was tested for its genetic stability during serial passage in chickens and chicken embryo fibroblast (CEF) cell culture. Results of in vitro and in vivo experiments demonstrated that all four introduced mutations in BD-3tcC remained stable during serial passage in CEF cell culture, but during passage in chickens, amino acid residues at position 253 and 284 reverted from histidine to glutamine and threonine to alanine, respectively. In a parallel experiment, the same substitutions also occurred in a conventionally attenuated vaccine strain D-78 on serial passage in chickens. However, no reversion or substitution took place at positions 279 and 330 during in vivo passage of the mutant virus BD-3tcC or vaccine virus D-78. The findings provide conclusive evidence that while IBDV requires histidine and threonine at positions 253 and 284 for cell culture adaptation, glutamine and alanine at these positions are selected preferentially during in vivo replication.

Change in heritability estimates due to half-sib family selection in the maize variety Pahari

This research was carried out at the Agriculture Research Farm, Khyber Pakhtunkhwa Agricultural University, Peshawar, and the Cereal Crops Research Institute, Pirsabak, Nowshera, during 2009 and 2010. Half-sib families (HS) derived from the maize variety Pahari in spring crop seasons 2009 and 2010 were developed at the Cereal Crops Research Institute. All HS families were detasseled well before pollen shedding. At maturity, each family was harvested and shelled separately. During the summer crop of seasons 2009 and 2010, these HS families were evaluated in 12 x 12 and 11 x 11 partially balanced lattice square arrangements at the Khyber Pakhtunkhwa Agricultural University, Peshawar, for various flowering and yield traits, respectively. The data on days to mid-silking, anthesis, anthesis-silking interval, 100-grain weight, and grain yield were recorded. The results revealed significant differences among families for all traits in both cycles. High heritability (0.88) was observed for days to mid-silking in cycle 0 (C₀), while moderate heritability (0.42) was recorded for 100-grain weight in C₁. The selection differential was quite reasonable and varied according to the traits of interest. The observed response for grain yield in C₀ (815.74 kg/ha) was greater than the expected response (681.76 kg/ha).

The role of geranylgeranylated proteins in human mesangial cell proliferation

The Rho family of guanine 5'-triphosphatases (GTPases) play a key role in regulating cell proliferation, tubulointerstitial fibrosis, and glomerular hemodynamics. The post-translational prenylation of RhoGTPases by the addition of a geranylgeranyl moiety is critical for cellular localization and signaling activity. This study investigates the effects of (i) inhibiting geranylgeranylation (GG) in human mesangial cell (HMC) proliferation and apoptosis, using GGTI 298, a specific inhibitor of GG and (ii) lovastatin, an HMG-coacetyl A-reductase inhibitor, which depletes the availability of prenylation substrates. HMC proliferation was assessed using an assay of viable cell number and measuring bromodeoxyuridine (BrdU) incorporation. Hoechst 33342 staining was used to determine apoptosis. Extracellular signal-regulated protein kinase (Erk)1/2 and Akt activation were analysed by Western blotting. Rho activation was determined using the Rhotekin pull-down assay. Immunocytochemistry was performed to study the effects on the actin cytoskeleton and RhoA localization. GGTI 298 (10-20 muM) and lovastatin (5-10 muM) potently inhibited platelet-derived growth factor and serum-stimulated HMC proliferation and induced apoptosis. These effects of lovastatin were attenuated by co-incubation with geranylgeranylpyrophosphate. C3 exoenzyme, a clostridial toxin that specifically targets Rho also inhibited BrdU incorporation and promoted apoptosis. GGTI 298 increased cytosolic expression of RhoA, prevented RhoA activation, and inhibited the activation of Erk1/2 and the survival protein Akt. GGTI 298, lovastatin, and C3 exoenzyme inhibit HMC proliferation and promote apoptosis. Inhibiting GG increases cytosolic RhoA expression, disrupts the actin cytoskeleton, and inhibits RhoA activation. These results suggest that targeting geranylgeranylated proteins with statins or GGTI 298 is a promising therapeutic strategy in human mesangioproliferative renal disease.

Time clustering of high titre insulin autoantibodies (IAA) in the cord blood of infants born to non-diabetic mothers

Insulin autoantibodies (IAA) are markers for autoimmune insulitis, and are reported in up to 100% of diabetic children before the age of five years, but in fewer than 1% of their controls. Their origins are unknown. In this report a cluster of high titre IAA in cord blood is reported, distinct from the low titre 'non-specific' binding previously described. The distributions of displaceable insulin binding measured in adults (Group A, n = 79), adolescents (Group B, n = 19), primary school children (Group C, n = 32) and third trimester pregnant women (Group D, n = 60) were all unimodal, normal and not different from each other (A = 0.57+/-0.64%, B = 0.87+/-0.45%, C = 0.81+/-0.87% and D = 0.35+/-0.48%). The distribution of insulin binding in the cord sera of consecutive newborns (n = 428) born between October and the following May, however, was bimodal. The first distribution, included 400 sera, was symmetrical and not different (0.79+/-0.45%) from groups A, B, C and D. The second distribution comprised the remaining 28 sera (7% of the total sample) with insulin-displaceable binding values in an IDW-validated radio assay ranging from 2.2% to 31.1%. The appearance of IAA was not HLA-restricted, but the frequency of IAA+ samples was seen to vary over five consecutive months. The timing is consistent with acute viral infection, but the implications for future insulin dependent diabetes will await long-term follow-up of the children and mothers involved.

Improved flow cytometric detection of HLA alloantibodies using pronase: potential implications in renal transplantation

BACKGROUND

Flow cytomeric crossmatch (FCXM) has grown in popularity and has become the "standard of practice" in many programs. Although FCXM is the most sensitive method for detecting alloantibody, the B cell FCXM has been problematic. Difficulties with the B cell FCXMs have been centered around high nonspecific fluorescence background owing to Fc-receptors present on the B cells and autoantibodies. To improve the specificity and sensitivity of the B cell FCXM, we utilized the proteolytic enzyme pronase to remove Fc receptors from lymphocytes before their use in FCXM.

METHODS

Lymphocytes isolated from peripheral blood, spleen, or lymph nodes were treated with pronase and then used in a three-color FCXM. A total of 167 T- and B cell FCXMs using pronase-treated and untreated cells were performed. Testing used serial dilutions of HLA allosera (22 class I and 6 class II), with the titer of each antibody at one dilution past the titer at which the complement-mediated cytotoxicity anti-human globulin crossmatch became negative.

RESULTS

After pronase treatment, the actual channel values of the negative control in both T cell and B cell FCXMs declined from 78+/-10 to 57+/-4 (P<0.05) and 107+/-11 to 49+/-3 (P<0.00001), respectively. Pronase treatment resulted in improved sensitivity of the T and B cell FCXM in detecting class I antibody by 20% and 80%, respectively. In no instance was a false-positive reaction observed. In this study, pronase treatment improved the specificity of B cell FCXM for detecting class II antibodies from 75% to 100% (P=0.03). In no instance was a false-negative reaction recorded. Lastly, on the basis of these observations we re-evaluated three primary transplant recipients who lost their allografts because of accelerated rejection. One of the patients was transplanted across negative T and B cell FCXM, whereas the other two patients were transplanted across a positive T cell, but negative B cell, FCXM. After pronase treatment, T and B cell FCXMs of each patient became strongly positive, and donor-specific anti-HLA class I antibody was identi. fied in each case.

CONCLUSION

Utilization of pronase-treated lymphocytes improves both the sensitivity and specificity of the FCXM.

Infection and inflammation induce LDL oxidation in vivo

Epidemiological studies have shown an increased incidence of coronary artery disease in patients with chronic infections and inflammatory disorders. Because oxidative modification of lipoproteins plays a major role in atherosclerosis, the present study was designed to test the hypothesis that the host response to infection and inflammation induces lipoprotein oxidation in vivo. Lipoprotein oxidation was measured in 3 distinct models of infection and inflammation. Syrian hamsters were injected with bacterial lipopolysaccharide (LPS), zymosan, or turpentine to mimic acute infection, acute systemic inflammation, and acute localized inflammation, respectively. Levels of oxidized fatty acids in serum and lipoprotein fractions were measured by determining levels of conjugated dienes, thiobarbituric acid-reactive substances, and lipid hydroperoxides. Our results demonstrate a significant increase in conjugated dienes and thiobarbituric acid-reactive substances in serum in all 3 models. Moreover, LPS and zymosan produced a 4-fold to 6-fold increase in conjugated diene and lipid hydroperoxide levels in LDL fraction. LPS also produced a 17-fold increase in LDL content of lysophosphatidylcholine that is formed during the oxidative modification of LDL. Finally, LDL isolated from animals treated with LPS was significantly more susceptible to ex vivo oxidation with copper than LDL isolated from saline-treated animals, and a 3-fold decrease occurred in the lag phase of oxidation. These results demonstrate that the host response to infection and inflammation increases oxidized lipids in serum and induces LDL oxidation in vivo. Increased LDL oxidation during infection and inflammation may promote atherogenesis and could be a mechanism for increased incidence of coronary artery disease in patients with chronic infections and inflammatory disorders.

Paget's disease of bone: diagnosis and treatment update

Paget's disease is a metabolic bone disease characterized by excessive bone resorption and formation due to activated osteoclasts. Although Paget's disease is a high bone turnover state, the excess bone that is formed lacks the structural stability of normal bone. Complications from Paget's disease include deformity, fracture, and pain. Although still unclear, both prevalence and severity of Paget's disease seem to be declining. Recent progress has focused on the environmental as well as genetic etiologies for this disease. Many studies indicate a role for viral infectious agents, whereas others point to a recently identified candidate gene on chromosome 18q. Therapy with bisphosphonate drugs is the treatment of choice. With newer and more powerful agents from this family now available, the majority of patients affected by Paget's disease can achieve sustained remission and avoid complications.

Non-ionizing radiation exposure causing ill-health and alopecia areata

Three cases of occupational exposure to radio-frequency and microwave radiation were seen at the out-patient clinic, Hospital Universiti Sains Malaysia. They presented with run-down symptoms of neck strain associated with throbbing headache, irritability, loss of appetite, fatigue, memory difficulties, and numbness of extremities. They also presented with alopecia areata which is felt to be causally linked to the radiation exposure.