The epidemic forest reveals the spatial pattern of the spread of acute respiratory infections in Jakarta, Indonesia

Acute respiratory infection (ARI) is a communicable disease of the respiratory tract that implies impaired breathing. The infection can expand from one to the neighboring areas at a region-scale level through a human mobility network. Specific to this study, we leverage a record of ARI incidences in four periods of outbreaks for 42 regions in Jakarta to study its spatio-temporal spread using the concept of the epidemic forest. This framework generates a forest-like graph representing an explicit spread of disease that takes the onset time, spatio-temporal distance, and case prevalence into account. To support this framework, we use logistic curves to infer the onset time of the outbreak for each region. The result shows that regions with earlier onset dates tend to have a higher burden of cases, leading to the idea that the culprits of the disease spread are those with a high load of cases. To justify this, we generate the epidemic forest for the four periods of ARI outbreaks and identify the implied dominant trees (that with the most children cases). We find that the primary infected city of the dominant tree has a relatively higher burden of cases than other trees. In addition, we can investigate the timely ( R t ) and spatial reproduction number ( R c ) by directly evaluating them from the inferred graphs. We find that R t for dominant trees are significantly higher than non-dominant trees across all periods, with regions in western Jakarta tend to have higher values of R c . Lastly, we provide simulated-implied graphs by suppressing 50% load of cases of the primary infected city in the dominant tree that results in a reduced R c , suggesting a potential target of intervention to depress the overall ARI spread.

The impact of government pandemic policies on the vulnerability of healthcare workers to SARS-CoV-2 infection and mortality in Jakarta Province, Indonesia

INTRODUCTION

Healthcare workers (HCWs) are on the frontlines of the COVID-19 pandemic, putting them at a higher risk of infection and disease than non-HCWs. We analysed the effects of government policies for the public and for HCWs on the likelihood of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality among HCWs during the first 8 months of the pandemic in Jakarta province, the capital city and COVID-19 hotspot in Indonesia.

METHODS

We conducted a retrospective cohort study using secondary data from the Jakarta provincial government from March to October 2020, which included sociodemographic characteristics, symptoms, comorbidities and COVID-19 diagnosis history for all cases. A generalized linear mixed-effect regression model was used to determine the effect of each month on the odds ratio (OR) of COVID-19 cases and deaths for HCW compared with non-HCW, assuming that monthly trends were influenced by varying government policies.

RESULTS

A total of 894,487 suspected and confirmed COVID-19 cases in health facilities in Jakarta province were analysed. The OR of confirmed cases for HCW was 2.04 (95% CI 2.00-2.08; p < .001) compared to non-HCW. Despite this higher OR for infection, the case fatality rate (2.32 per 100) and OR (1.02, 95% CI 0.93-1.11; p = .65) of COVID-19 deaths for HCW were similar to those of non-HCW. We observed a trend towards a lower number of COVID-19 patients in hospitals and lower odds of COVID-19 cases among HCWs during the April-to-July 2020 phase compared to the August-to-October phase. This chronologically aligned with more extensive policies to support hospital-based, community-based and well-being-related actions to protect HCW.

CONCLUSIONS

HCW had higher odds of having SARS-CoV-2 infection, yet similar odds of death from COVID-19, as compared to non-HCW. Government policies with collective efforts to prevent hospital overcapacity during high transmission and burden periods of the pandemic should be prioritized.

Determinant Factors of Mortality in Pre-elderly and Elderly Patients With COVID-19 in Jakarta, Indonesia

OBJECTIVES

This study aimed to identify risk factors associated with coronavirus disease 2019 (COVID-19) mortality in pre-elderly and elderly individuals in Jakarta, Indonesia.

METHODS

We employed a case-control study design, utilizing secondary data from the Epidemiology Surveillance, Immunization Prevention, and Disease Control Sections of the DKI Jakarta Provincial Health Office, collected from December 2020 to January 2021. The study included 188 cases and an equal number of controls. Cases were COVID-19 patients confirmed to have died, as reported by hospitals and communities and subsequently verified by healthcare workers. Control subjects were patients who completed a 14-day isolation period and had been officially declared recovered by healthcare professionals. The dependent variable was the mortality of COVID-19 patients in the January 2021 period. The independent variables consisted of demographic data (age and sex), clinical symptoms (cough, runny nose, anosmia, diarrhea, headaches, abdominal pain, muscle pain, and nausea/vomiting), and comorbidities (hypertension, heart disease, and diabetes). Multivariate analysis was conducted using multiple logistic regression.

RESULTS

The multiple logistic regression analysis revealed several factors associated with COVID-19 fatalities in Jakarta: age of 60 years or older (odds ratio [OR], 4.84; 95% CI, 3.00 to 7.80), male (OR, 2.38; 95% CI, 2.41 to 3.68), dyspnea (OR, 3.93; 95% CI, 2.04 to 7.55), anosmia (OR, 0.13; 95% CI, 0.04 to 0.46), and heart disease (OR, 4.38; 95% CI, 1.04 to 18.46).

CONCLUSIONS

The control and prevention of COVID-19 among elderly individuals require particular vigilance. When a COVID-19 case is detected within this demographic, prompt treatment and medication administration are crucial to mitigate the presenting symptoms.

DETERMINANT FACTORS OF COVID-19 MORTALITY IN EAST JAKARTA IN 2021

Background: The Corona Virus Disease (COVID-19) pandemic, which lasted for more than a year in Indonesia, has caused various negative impacts, including rapid inter-individual transmission, followed by an increasing number of cases and even death. The total number of deaths from COVID-19 in East Jakarta from November-January 2021 was 30%. Purpose: This study aims to determine the factors that influence deaths from COVID-19 in East Jakarta. Methods: The study was conducted using a quantitative method and a case-control design with secondary data from November 2020 to February 2021 in East Jakarta. The incidence number of COVID-19 cases is 0.3 per 100,000 population, while the variables assessed were age, sex, respiratory symptoms, hypertension, cardiovascular diseases, and Chronic Obstructive Pulmonary Disease (COPD). The case sample was 74 people with COVID-19 who had died, while the control was 74 people who lived. Furthermore, the total sampling technique was used in the case group, while simple random sampling was employed in the control and data analysis was performed using the Chi-Square test. Results: Factors related to the incidence of COVID-19 death in this study were age with p-value = 0.01; OR = 3.99 95%CI 1.88 – 8.47 and male gender with p-value = 0.01; OR = 2.41 95%CI 1.25 – 4.68. Other factors analyzed, namely the presence of symptoms in the respiratory tract, comorbid hypertension, cardiovascular and COPD, did not have a significant relationship (p value> 0.05). Conclusion: Age and gender are factors associated with COVID-19 deaths in East Jakarta City between November 2020 and January 2021.

Pandemic inequity in a megacity: a multilevel analysis of individual, community and healthcare vulnerability risks for COVID-19 mortality in Jakarta, Indonesia

INTRODUCTION

Worldwide, the 33 recognised megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and healthcare factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning 2 March 2020 to 31 August 2021.

METHODS

This retrospective cohort included residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data and disease prevalence from Jakarta Health Office surveillance records, and collected subdistrict level sociodemographics data from various official sources. We used multilevel logistic regression to examine individual, community and subdistrict-level healthcare factors and their associations with COVID-19 mortality.

RESULTS

Of 705 503 cases with a definitive outcome by 31 August 2021, 694 706 (98.5%) recovered and 10 797 (1.5%) died. The median age was 36 years (IQR 24-50), 13.2% (93 459) were <18 years and 51.6% were female. The subdistrict level accounted for 1.5% of variance in mortality (p<0.0001). Mortality ranged from 0.9 to 1.8% by subdistrict. Individual-level factors associated with death were older age, male sex, comorbidities and age <5 years during the first wave (adjusted OR (aOR)) 1.56, 95% CI 1.04 to 2.35; reference: age 20-29 years). Community-level factors associated with death were poverty (aOR for the poorer quarter 1.35, 95% CI 1.17 to 1.55; reference: wealthiest quarter) and high population density (aOR for the highest density 1.34, 95% CI 1.14 to 2.58; reference: the lowest). Healthcare factor associated with death was low vaccine coverage (aOR for the lowest coverage 1.25, 95% CI 1.13 to 1.38; reference: the highest).

CONCLUSION

In addition to individual risk factors, living in areas with high poverty and density, and low healthcare performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.

Seroprevalence of antibodies against SARS-Cov-2 in the high impacted sub-district in Jakarta, Indonesia

Background

Understanding the actual prevalence of COVID-19 transmission in the community is vital for strategic responses to the pandemic. This study aims to estimate the actual infection of COVID-19 through a seroprevalence survey and to predict infection fatality rate (IFR) in Tanjung Priok, the hardest-hit sub-district by the COVID-19 in Jakarta, Indonesia.

Methods

We conducted a venous blood sampling (phlebotomy) to 3,196 individuals in Tanjung Priok between Nov 23, 2020, and Feb 19, 2021 to detect their antibodies against SARS-CoV-2. Using an enumerator-administered questionnaire, we collected data on the respondents’ demographic characteristics, COVID-19 test history, COVID-19 symptoms in the last 14 days, comorbidities, and protective behaviours during the last month. We employed descriptive analysis to estimate the seroprevalence and IFR.

Findings

The prevalence of Antibody against SARS-CoV-2 was 28.52% (95% CI 25.44–31.81%), with the result being higher in females than males (OR 1.20; 95% CI 1.02–1.42). By the end of the data collection (February 9, 2021), the cumulative cases of COVID-19 in Tanjung Priok were reported to be experienced by 9,861 people (2.4%). Those aged 45–65 were more likely to be seropositive than 15–19 years old (OR 1.42; 95% CI 1.05–1.92). Nearly one third (31%) of the subjects who developed at least one COVID-19 symptom in the last 14 days of the data collection were seropositive. The estimated IFR was 0.08% (95% CI 0.07–0.09), with a higher figure recorded in males (0.09; 95% CI 0.08–0.10) than females (0.07; 95% CI 0.06–0.08), and oldest age group (45–65) (0.21; 95% CI 0.18–0.23) than other younger groups.

Conclusion

An under-reporting issue was found between the estimated COVID-19 seroprevalence and the reported cumulative cases in Tanjung Priok. More efforts are required to amplify epidemiological surveillance by the provincial and local governments.

Hubungan Komorbid Hipertensi dengan Kematian pada Kasus Konfirmasi COVID-19 di DKI Jakarta, Maret-Agustus 2020

Pandemi COVID-19 berdampak pada kesehatan masyarakat dan sosial ekonomi. Sampai dengan 31 Januari 2021 dilaporkan 1.078.314 kasus COVID-19 dengan 29.998 kematian (CFR: 2,78%) dari 510 kabupaten di 34 provinsi di Indonesia dengan kasus yang tertinggi dilaporkan dari DKI Jakarta sebanyak 269.718 kasus dengan 4.267 kematian.  Berdasarkan Riset Kesehatan Dasar tahun 2018 prevalensi hipertensi di DKI Jakarta 10,17 %, lebih tinggi dibandingkan prevalensi hipertensi nasional (8,36%). Penelitian ini bertujuan untuk mengetahui besarnya hubungan antara komorbid hipertensi dengan kematian COVID-19 di DKI Jakarta dengan menghitung Hazard Rasio (HR). Desain penelitian ini kohort retrospektif dengan menggunakan data sekunder dari laporan COVID-19 dinas kesehatan provinsi DKI Jakarta periode Maret-Agustus 2020 dengan kriteria inklusi kasus konfirmasi COVID-19 yang dilaporkan pada periode Maret-Agustus 2020, bertempat tinggal di DKI Jakarta dengan data variabel yang diteliti lengkap. Data dianalisis menggunakan regresi cox proporsional hazard. Hasil penelitian didapatkan bahwa kasus COVID-19 dengan komorbid hipertensi mempunyai risiko 2,2 kali mengalami kematian dibandingkan dengan kasus COVID-19 tanpa komorbid hipertensi (HR 2,2 Pv < 0,001 95% CI 1,66-3,87) setelah dikontrol variabel perancu komorbid gagal ginjal kronik, kelompok usia, gejala klinis sesak nafas, malaise dan pneumonia. Hal ini menunjukkan perlunya perhatian khusus untuk pencegahan dan penatalaksanaan kasus COVID-19 dengan komorbid hipertensi untuk menurunkan risiko kematian.

Integration of symptomatic, demographical and diet-related comorbidities data with SARS-CoV-2 antibody rapid diagnostic tests during epidemiological surveillance: a cross-sectional study in Jakarta, Indonesia

OBJECTIVES

Affordable options for COVID-19 epidemiological surveillance are needed. Virus detection by reverse transcription-PCR (RT-PCR) is sensitive but costly, and antigen-based rapid diagnostic tests (RDTs) are cheap but with reduced sensitivity; both detect current infection but not exposure. RDT-IgM/IgG antibodies to SARS-CoV-2 detect exposure but have poor sensitivity for current infection. We investigated if the integration of symptomatic, demographical and diet-related comorbidities data with antibody RDTs improves their potential to assess infection rates in addition to exposure, thereby broadening their utility for surveillance.

DESIGN

We conducted a cross-sectional study using data from community surveillance for SARS-CoV-2. Health workers collected nasopharyngeal swabs for RT-PCR and RDT antigen assessments and venous blood for RDT-IgM/IgG from symptomatic and asymptomatic persons. Data on age, gender, contact history, symptoms (ie, fever, cough, runny nose, sore throat, headache, dyspnoea and diarrhoea), diet-related comorbidities (ie, diabetes and hypertension) and chest radiology were collected.

SETTING

High-risk communities in Jakarta, Indonesia, in May 2020.

PARTICIPANTS

343 community members' data were included.

OUTCOME MEASURES

RDT-IgM/IgG sensitivity, specificity and predictive values and area under receiver operating characteristic curve for RT-PCR positivity using RDT results alone and in combination with other predictors, including symptom components derived from principal component analysis.

RESULTS

There were 24 PCR-confirmed infections. RDT-IgM/IgG-positive tests were associated with infection (OR 10.8, 95% CI 4.43 to 26.4, p<0.001) with an area under the curve (AUC) of 0.708% and 50% sensitivity, 91.5% specificity, 30.8% positive predictive value (PPV) and 96.1% negative predictive value (NPV). RDT results combined with age, gender, contact history, symptoms and comorbidities increased the AUC to 0.787 and yielded 62.5% sensitivity, 87.0% specificity, 26.6% PPV and 96.9% NPV.

CONCLUSIONS

SARS-CoV-2 RDT-IgM/IgG results integrated with other predictors may be an affordable tool for epidemiological surveillance for population-based COVID-19 exposure and current infection, especially in groups with outbreaks or high transmission.

Using syndromic measures of mortality to capture the dynamics of COVID-19 in Java, Indonesia, in the context of vaccination rollout

BACKGROUND

As in many countries, quantifying COVID-19 spread in Indonesia remains challenging due to testing limitations. In Java, non-pharmaceutical interventions (NPIs) were implemented throughout 2020. However, as a vaccination campaign launches, cases and deaths are rising across the island.

METHODS

We used modelling to explore the extent to which data on burials in Jakarta using strict COVID-19 protocols (C19P) provide additional insight into the transmissibility of the disease, epidemic trajectory, and the impact of NPIs. We assess how implementation of NPIs in early 2021 will shape the epidemic during the period of likely vaccine rollout.

RESULTS

C19P burial data in Jakarta suggest a death toll approximately 3.3 times higher than reported. Transmission estimates using these data suggest earlier, larger, and more sustained impact of NPIs. Measures to reduce sub-national spread, particularly during Ramadan, substantially mitigated spread to more vulnerable rural areas. Given current trajectory, daily cases and deaths are likely to increase in most regions as the vaccine is rolled out. Transmission may peak in early 2021 in Jakarta if current levels of control are maintained. However, relaxation of control measures is likely to lead to a subsequent resurgence in the absence of an effective vaccination campaign.

CONCLUSIONS

Syndromic measures of mortality provide a more complete picture of COVID-19 severity upon which to base decision-making. The high potential impact of the vaccine in Java is attributable to reductions in transmission to date and dependent on these being maintained. Increases in control in the relatively short-term will likely yield large, synergistic increases in vaccine impact.

Geographical heterogeneity and socio-ecological risk profiles of dengue in Jakarta, Indonesia

The aim of this study was to assess the role of climate variability on the incidence of dengue fever (DF), an endemic arboviral infection existing in Jakarta, Indonesia. The work carried out included analysis of the spatial distribution of confirmed DF cases from January 2007 to December 2018 characterising the sociodemographical and ecological factors in DF high-risk areas. Spearman's rank correlation was used to examine the relationship between DF incidence and climatic factors. Spatial clustering and hotspots of DF were examined using global Moran's I statistic and the local indicator for spatial association analysis. Classification and regression tree (CART) analysis was performed to compare and identify demographical and socio-ecological characteristics of the identified hotspots and low-risk clusters. The seasonality of DF incidence was correlated with precipitation (r=0.254, P<0.01), humidity (r=0.340, P<0.01), dipole mode index (r= -0.459, P<0.01) and Tmin (r= -0.181, P<0.05). DF incidence was spatially clustered at the village level (I=0.294, P<0.001) and 22 hotspots were identified with a concentration in the central and eastern parts of Jakarta. CART analysis showed that age and occupation were the most important factors explaining DF clustering. Areaspecific and population-targeted interventions are needed to improve the situation among those living in the identified DF high-risk areas in Jakarta.

Clinical characteristics and mortality associated with COVID-19 in Jakarta, Indonesia: A hospital-based retrospective cohort study

Background

Data on COVID-19-related mortality and associated factors from low-resource settings are scarce. This study examined clinical characteristics and factors associated with in-hospital mortality of COVID-19 patients in Jakarta, Indonesia, from March 2 to July 31, 2020.

Methods

This retrospective cohort included all hospitalised patients with PCR-confirmed COVID-19 in 55 hospitals. We extracted demographic and clinical data, including hospital outcomes (discharge or death). We used logistic regression to examine factors associated with mortality.

Findings

Of 4265 patients with a definitive outcome by July 31, 3768 (88%) were discharged and 497 (12%) died. The median age was 46 years (IQR 32-57), 5% were children, and 31% had >1 comorbidity. Age-specific mortalities were 11% (7/61) for <5 years; 4% (1/23) for 5-9; 2% (3/133) for 10-19; 2% (8/638) for 20-29; 3% (26/755) for 30-39; 7% (61/819) for 40-49; 17% (155/941) for 50-59; 22% (132/611) for 60-69; and 34% (96/284) for ≥70. Risk of death was associated with higher age, male sex; pre-existing hypertension, diabetes, or chronic kidney disease; clinical diagnosis of pneumonia; multiple (>3) symptoms; immediate ICU admission, or intubation. Across all ages, risk of death was higher for patients with >1 comorbidity compared to those without; notably the risk was six-fold increased among patients <50 years (adjusted odds ratio 5.87, 95%CI 3.28-10.52; 27% vs 3% mortality).

Interpretation

Overall in-hospital mortality was lower than reported in high-income countries, probably due to younger age distribution and fewer comorbidities. Deaths occurred across all ages, with >10% mortality among children <5 years and adults >50 years.

Factors Associated with Death in COVID-19 Patients in Jakarta, Indonesia: An Epidemiological Study

BACKGROUND

Coronavirus Disease 2019 is an emerging respiratory disease that is now a pandemic. Indonesia is experiencing a rapid surge of cases but the local data are scarce.

METHODS

this is an analysis using data from the ongoing recapitulation of Epidemiological Surveillance (ES) by the Provincial Health Office of Jakarta from March 2nd to April 27th 2020. We evaluated demographic and clinical characteristics of all confirmed cases in association with death.

RESULTS

of the 4,052 patients, 381 (9.4%) patients were deceased. Multivariable analysis showed that death was associated with older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.02, 1.05, per year increase; p<0.001), dyspnea (OR 4.83; 95% CI 3.20, 7.29; p<0.001), pneumonia (OR 2.46; 95%CI 1.56, 3.88; p<0.001), and pre-existing hypertension (OR 1.86; 95% CI 1.24, 2.78; p=0.003). Death was highest in the week of April 6th 2020 and declined in the subsequent weeks, after a large-scale social restriction commenced.

CONCLUSION

older age, dyspnea, pneumonia, and pre-existing hypertension were associated with death. Mortality was high, but may be reduced by lockdown.

Evidence-based case report: acute diabetic complication risks of Ramadan fasting in type 2 diabetics

AIM

to investigate causal relationship between Ramadan fasting and acute diabetic complications in adult controlled type 2 diabetics.

METHODS

a Pubmed's Clinical Queries and Embase search was conducted and resulted in 2 useful articles: 1 systematic review and 1 cohort study to be critically appraised.

RESULTS

the incidence of acute diabetic complications is higher during Ramadan, with the relative risk for adult type 2 diabetics who fast during Ramadan is 1.36 and number needed to harm 50.

CONCLUSION

Ramadan fasting was related with acute diabetic complications in adult controlled type 2 diabetics, but the risk was only slightly higher. It is acceptable for type 2 diabetics to fast during Ramadan.

Role of HFE gene mutations on developing iron overload in beta-thalassaemia carriers in Egypt

A case-control study aimed to determine the prevalence of C282Y, H63D and S65C mutations of the HFE gene in beta-thalassaemia carriers and investigate their influence on iron absorption. A total of 41 beta-thalassaemia carriers and 40 control subjects without haemoglobinopathies were screened for the C282Y, H63D and S65C mutations by polymerase chain reaction-restriction fragment-length polymorphism. The iron status in these subjects was studied and correlated with the HFE gene mutations. H63D, S65C and C282Y allele frequencies were 30.5%, 13.4% and 7.3% respectively in beta-thalassaemia carriers and 10.0%, 2.5% and 0.0% respectively in the control group. Compound heterozygosis was found in 10 carriers (24.4%). The transferrin saturation level was high in compound heterozygote cases. Our study has shown that the HFEgene mutations are common in Egypt among beta-thalassaemia carriers compared with normal controls.

Numerical studies of biocontrol efficacies of foliar plant pathogens in relation to the characteristics of a biocontrol agent

A previously published generic mathematic model has been used in a numerical study to understand the dynamics of foliar pathogens in relation to mechanisms, and timing and coverage of biocontrol agent (BCA) applications. With the model parameter values used, it was demonstrated that a BCA possessing either competition or induced resistance as the main mechanism of biological control was more effective in reducing disease development than a BCA with either mycoparasitism or antibiosis as its mechanism. Application coverage, ranging from 50 to 90%, had little effect on biocontrol efficacy, particularly for a BCA with competition and induced resistance as the main mechanism of biocontrol. Conversely, delayed application of BCA had more profound effects on biocontrol efficacy for those with competition or induced resistance as their main mechanism than those with mycoparasitism and antibiosis. Biocontrol efficacy was greatest for a single BCA combining competition with mycoparasitism or antibiosis. The efficacy for a single BCA combining induced resistance with competition critically depended on application time; the efficacy was greatly reduced for delayed applications. The present study suggests that development of an effective strategy for BCA application is critically dependent upon our quantitative understanding of several key biocontrol processes and their interactions. Without reliable quantitative estimation of these processes, it is impossible to make quantitative predictions about biological control and hence to optimize BCA application strategies.

Nocturnal electrobioimpedance volumetric assessment in diabetic men with erectile dysfunction before and after tadalafil intake

Nocturnal electrobioimpedance volumetric assessment (NEVA) is a procedure that can measure penile volume changes together with the number and duration of nocturnal erectile events. This study was conducted to evaluate the different NEVA patterns in diabetic patients with erectile dysfunction (ED), and demonstrate the extent to which tadalafil may affect the characteristics of nocturnal penile erections in these patients. Therefore, 38 patients with noninsulin-dependent diabetes and ED participated in this study. They were assessed with history intake including evaluation by the abridged five-item version of International Index of Erectile Function, clinical and psychiatric assessment and NEVA for three consecutive nights where placebo was given on the second night and tadalafil on the third night. In all, 14 potent males were taken as a control group. Data were analyzed using t-test. Results showed normal patterns in only six (16%) patients (central organic group), while abnormal patterns were observed in the remaining 32 (84%) patients (peripheral organic group). These abnormal patterns showed significant decrease in both the number (P=0.0001) and duration (P=0.03) of erectile events compared to those of controls. The percentage of penile blood volume change over baseline also decreased significantly (P=0.0002) relative to controls. Veno-occlusive dysfunction was the main pathology (23 patients, 72%) as suggested by NEVA. Tadalafil did not significantly change basal nocturnal penile tumescence results in either the central organic or control groups, but it did so significantly in the peripheral organic group (P=0.02 for duration change and P=0.01 for % blood volume change). In conclusion, NEVA may suggest some evidence about the pathophysiology of an underlying vasculogenic cause, thus directing towards the next specific step needed for a precise diagnosis. Tadalafil improves nocturnal erections in diabetic patients with peripheral but not central organic impotence.

Satisfaction with the malleable penile prosthesis among couples from the Middle East--is it different from that reported elsewhere?

No studies from the Middle East have investigated the psychosexual aspects of penile prosthesis. Therefore, several questions were used herein to address satisfaction with the use of malleable penile prosthesis among couples from this geographic area, as an option to treat erectile dysfunction (ED). A total of 50 patients who underwent the insertion of AMS 650 and Acu-form penile prostheses and their partners were evaluated with a retrospective clinical record review, as well as patient and partner questionnaires. In all, 70% of the patients and 57% of the partners were satisfied with the prosthesis. There was an increase in frequency of intercourse, sexual desire, and ability to achieve orgasm. Dislike for the device was the most common cause for nonsatisfaction of patients with the device, while sense of unnaturalness was that for partners. Results from this evaluation highlight the obvious need for proper preoperative counseling for both the patient and his partner to minimize unrealistic expectations. They also emphasize the importance of careful screening of both psychosocial and psychosexual aspects of the couple based on cultural ethnic background, since these are important predictors of the therapeutic outcome of prosthesis insertion. Efforts to extend information about ED to the public may be useful to reduce patients' exaggerated embarrassment about this problem and make their partners actively involved in the treatment.

Brain nitric oxides synthase in major pelvic ganglia of aged (LETO) and diabetic (OLETF) rats

This study was conducted to evaluate the effects of aging and diabetes mellitus (DM) on brain nitric oxide synthase (bNOS) expression in major pelvic ganglia (MPG) of rats. Otsuka Long Evans Tokushima Fatty rats (12, 30, and 70 weeks old), which are genetic models with non-insulin-dependent DM (NIDDM), and age-matched nondiabetic Long Evans Tokushima Otsuka controls were used. The MPG of all rats in this study were subjected to cryo-sectioning and staining with bNOS polyclonal AB and rhodamine-conjugated rabbit IgG. Fluorescence intensities of the stained neurons were assessed in randomly selected fields per each specimen. Animals of both groups revealed significant decline in the staining intensity of their neurons with aging and the progress of DM, but diabetic rats showed more decline than controls. In conclusion, both aging and NIDDM could decrease bNOS expression in rat MPG. However, NIDDM has a more evident effect than aging on that expression. The decrease in bNOS may cause a disturbance in functions of the target pelvic structures of these ganglia under both conditions.

Helicobacter pylori genetic diversity within the gastric niche of a single human host

Isolates of the gastric pathogen Helicobacter pylori harvested from different individuals are highly polymorphic. Strain variation also has been observed within a single host. To more fully ascertain the extent of H. pylori genetic diversity within the ecological niche of its natural host, we harvested additional isolates of the sequenced H. pylori strain J99 from its human source patient after a 6-year interval. Randomly amplified polymorphic DNA PCR and DNA sequencing of four unlinked loci indicated that these isolates were closely related to the original strain. In contrast, microarray analysis revealed differences in genetic content among all of the isolates that were not detected by randomly amplified polymorphic DNA PCR or sequence analysis. Several ORFs from loci scattered throughout the chromosome in the archival strain did not hybridize with DNA from the recent strains, including multiple ORFs within the J99 plasticity zone. In addition, DNA from the recent isolates hybridized with probes for ORFs specific for the other fully sequenced H. pylori strain 26695, including a putative traG homolog. Among the additional J99 isolates, patterns of genetic diversity were distinct both when compared with each other and to the original prototype isolate. These results indicate that within an apparently homogeneous population, as determined by macroscale comparison and nucleotide sequence analysis, remarkable genetic differences exist among single-colony isolates of H. pylori. Direct evidence that H. pylori has the capacity to lose and possibly acquire exogenous DNA is consistent with a model of continuous microevolution within its cognate host.

Comparison of genetic divergence and fitness between two subclones of Helicobacter pylori

Helicobacter pylori has a very plastic genome, reflecting its high rate of recombination and point mutation. This plasticity promotes divergence of the population by the development of subclones and presumably enhances adaptation to host niches. We have investigated the genotypic and phenotypic characteristics of two such subclones isolated from one patient as well as the genetic evolution of these isolates during experimental infection. Whole-genome genotyping of the isolates using DNA microarrays revealed that they were more similar to each other than to a panel of other genotyped strains recovered from different hosts. Nonetheless, they still showed significant differences. For example, one isolate (67:21) contained the entire Cag pathogenicity island (PAI), whereas the other (67:20) had excised the PAI. Phenotypic studies disclosed that both isolates expressed adhesins that recognized human histo-blood group Lewis(b) glycan receptors produced by gastric pit and surface mucus cells. In addition, both isolates were able to colonize, to equivalent density and with similar efficiency, germ-free transgenic mice genetically engineered to synthesize Lewis(b) glycans in their pit cells (12 to 14 mice/isolate). Remarkably, the Cag PAI-negative isolate was unable to colonize conventionally raised Lewis(b) transgenic mice harboring a normal gastric microflora, whereas the Cag PAI-positive isolate colonized 74% of the animals (39 to 40 mice/isolate). The genomic evolution of both isolates during the infection of conventionally raised and germ-free mice was monitored over the course of 3 months. The Cag PAI-positive isolate was also surveyed after a 10 month colonization of conventionally raised transgenic animals (n = 9 mice). Microarray analysis of the Cag PAI and sequence analysis of the cagA, recA, and 16S rRNA genes disclosed no changes in recovered isolates. Together, these results reveal that the H. pylori population infecting one individual can undergo significant divergence, creating stable subclones with substantial genotypic and phenotypic differences.

Transforming growth factor (beta1) in testes of aged and diabetic rats: correlation with testicular function

This study was conducted to evaluate the expression of transforming growth factor-beta1 (TGF-beta1) in testis with aging and progress of diabetes mellitus (DM) and correlated this with testicular function. Zucker diabetic fatty rats (15, 40, and 75 weeks old) were used as models for non-insulin-dependent DM. The controls were age-matched nondiabetic Zucker fatty rats. Serum testosterone levels and daily sperm production were evaluated. Testicular tissue was immunostained with anti-TGF-beta1. Labeled cells were assessed and the staining intensity was estimated. The 15-week control and diabetic animals showed the lowest levels of staining intensity but this started to increase significantly in the older animals of both categories. However, the diabetic animals had significantly deeper intensities relative to controls at the different age groups. These changes in TGF-beta1 expression were negatively correlated with both testosterone and sperm production. Therefore, aging and DM enhanced the expression of TGF-beta1 in testis, and this was parallel with progress of both conditions, although DM seems to be predominant. These alterations in TGF-beta1 expression may be related to changes in testicular function associated with both conditions.

The effectiveness of guidelines in reducing inappropriate CT scans of the paranasal sinuses

An effective system for scoring pathological changes on CT scans of the paranasal sinuses has been developed by Lund & Mackay. We have performed an audit using 100 outpatients with nasal symptoms and found that adherence to guidelines prior to ordering CT scans of the paranasal sinuses correlates with an increased average Lund & Mackay score. Using these guidelines has also reduced the number of inappropriate CT scan requests.

Microvascular testicular blood flow as evaluated by laser Doppler flowmetry after the surgical induction of varicocele

This study was conducted to evaluate the changes in microvascular testicular blood flow (microvascular TBF), which may be associated with varicocele. The pathology was developed through partial ligation of left renal vein in 4 groups of rats. Controls of each group underwent sham surgery. It was observed that microvascular TBF dropped and its vasomotion became inhibited once the left renal vein was partially ligated as studied by laser Doppler flowmetry (LDF). Four to five minutes later, blood flow rose to the pretreatment level and that of controls. Vasomotion reappeared with a uniform frequency and amplitude. At different periods of varicocele bearing (1, 3, 6, and 14 weeks) microvascular TBF was reevaluated. Vasomotion appeared intact without any abnormalities in the 4 groups. To examine the response of testicular microvasculature after surgical creation of the varicocele to pharmacological stimulation another group of animals received human chorionic gonadotropin (hCG) treatment 6 weeks after varicocele creation. Vasomotion was inhibited in these animals. In conclusion, LDF is a suitable tool to evaluate microvascular TBF in vivo. It can detect acute changes in blood flow that may happen at surgical induction of varicocele. In addition, the vasculature of the testis with a surgically induced varicocele can still respond to hCG stimulation.

Helicobacter pylori strain-specific differences in genetic content, identified by microarray, influence host inflammatory responses

Helicobacter pylori enhances the risk for ulcer disease and gastric cancer, yet only a minority of H. pylori-colonized individuals develop disease. We examined the ability of two H. pylori isolates to induce differential host responses in vivo or in vitro, and then used an H. pylori whole genome microarray to identify bacterial determinants related to pathogenesis. Gastric ulcer strain B128 induced more severe gastritis, proliferation, and apoptosis in gerbil mucosa than did duodenal ulcer strain G1.1, and gastric ulceration and atrophy occurred only in B128+ gerbils. In vitro, gerbil-passaged B128 derivatives significantly increased IL-8 secretion and apoptosis compared with G1.1 strains. DNA hybridization to the microarray identified several strain-specific differences in gene composition including a large deletion of the cag pathogenicity island in strain G1.1. Partial and complete disruption of the cag island in strain B128 attenuated induction of IL-8 in vitro and significantly decreased gastric inflammation in vivo. These results indicate that the ability of H. pylori to regulate epithelial cell responses related to inflammation depends on the presence of an intact cag pathogenicity island. Use of an H pylori whole genome microarray is an effective method to identify differences in gene content between H. pylori strains that induce distinct pathological outcomes in a rodent model of H. pylori infection.

Improving standards in the treatment of acute otitis externa by the use of a treatment protocol and open access to aural toilet

A prospective audit of the procedure and outcome in the management of acute otitis externa was undertaken in our unit. The first cycle demonstrated a heterogeneous approach and clinical isolation of junior staff. A questionnaire survey of local general practitioners highlighted clinical confusion over the use of topical medication and a need for improved access to facilities for aural toilet. General practitioner liaison and education was an essential component in formulating a change in practice. In particular, open access for aural toilet was introduced and utilization encouraged. Following changes in practice, the second cycle of the audit showed that treatment protocols were effective and adhered to by junior staff.

A whole-genome microarray reveals genetic diversity among Helicobacter pylori strains

Helicobacter pylori colonizes the stomach of half of the world's population, causing a wide spectrum of disease ranging from asymptomatic gastritis to ulcers to gastric cancer. Although the basis for these diverse clinical outcomes is not understood, more severe disease is associated with strains harboring a pathogenicity island. To characterize the genetic diversity of more and less virulent strains, we examined the genomic content of 15 H. pylori clinical isolates by using a whole genome H. pylori DNA microarray. We found that a full 22% of H. pylori genes are dispensable in one or more strains, thus defining a minimal functional core of 1281 H. pylori genes. While the core genes encode most metabolic and cellular processes, the strain-specific genes include genes unique to H. pylori, restriction modification genes, transposases, and genes encoding cell surface proteins, which may aid the bacteria under specific circumstances during their long-term infection of genetically diverse hosts. We observed distinct patterns of the strain-specific gene distribution along the chromosome, which may result from different mechanisms of gene acquisition and loss. Among the strain-specific genes, we have found a class of candidate virulence genes identified by their coinheritance with the pathogenicity island.

Ultra-structural changes in collagen of penile tunica albuginea in aged and diabetic rats

Tunica albuginea (TA) of the penis, which has an important role in mechanism of erection, is composed mainly of collagen bundles. Both aging and diabetes mellitus (DM) were reported to be associated with many alterations in collagen content and architecture in several body tissues. So, the aim of this work was to evaluate the effects of both conditions on the collagen bundles of penile TA in rats. Our diabetic models were three groups of Zucker Diabetic Fatty (ZDF) rats with non-insulin-dependent DM (NIDDM) aged 15, 40 and 75 weeks. Their age-matched controls were Zucker Fatty (ZF) rats. TA were excised from the side of mid-penile shaft and were examined by scanning electron microscopy using chemical digestion to extract collagen components. With aging, only the (70 w) ZF rats showed a significant increase in both thickness (P < 0.005) and loss of undulation of its bundles (P < 0.005) compared with the younger animals. In ZDF animals, a significant gradual increase in bundle thickness (P < 0.005) and loss of its undulation (P < 0.005) were found as the disease progressed to 40 w duration. Comparing these two parameters between both study groups showed that DM animals had significantly higher bundle thickness (P < 0.005) with loss of its undulation (P < 0.005) than controls starting from 40 w old. In conclusion, with progress of both aging and NIDDM, an increase in both thickness and loss of undulation of collagen bundles of penile TA was appreciated. The association of DM with aging could represent a cofactor effect that ultimately led to a greater impact on architecture of the bundles. The resulting changes may explain the compromised rigidity of the penis during erection under both conditions.

COPII: a membrane coat formed by Sec proteins that drive vesicle budding from the endoplasmic reticulum

In vitro synthesis of endoplasmic reticulum-derived transport vesicles has been reconstituted with washed membranes and three soluble proteins (Sar1p, Sec13p complex, and Sec23p complex). Vesicle formation requires GTP but can be driven by nonhydrolyzable analogs such as GMP-PNP. However, GMP-PNP vesicles fail to target and fuse with the Golgi complex whereas GTP vesicles are functional. All the cytosolic proteins required for vesicle formation are retained on GMP-PNP vesicles, while Sar1p dissociates from GTP vesicles. Thin section electron microscopy of purified preparations reveals a uniform population of 60-65 nm vesicles with a 10 nm thick electron dense coat. The subunits of this novel coat complex are molecularly distinct from the constituents of the nonclathrin coatomer involved in intra-Golgi transport. Because the overall cycle of budding driven by these two types of coats appears mechanistically similar, we propose that the coat structures be called COPI and COPII.

Outbreak of paralytic poliomyelitis in Finland: widespread circulation of antigenically altered poliovirus type 3 in a vaccinated population

An outbreak of 9 cases of paralytic poliomyelitis and 1 non-paralytic case occurred in Finland between August, 1984, and January, 1985, after two decades of freedom from the disease attributable to a successful immunisation programme. During the outbreak poliovirus type 3 was isolated from the patients, from about 15% of healthy persons tested, and from sewage water. At least 100 000 persons were estimated to have been infected. With 1.5 million extra doses of inactivated poliovirus vaccine to children under 18 years of age and an oral poliovirus vaccine campaign covering about 95% of the entire population in February-March, 1985, the outbreak was halted in February, 1985. Impaired herd immunity to the epidemic strain of poliovirus type 3, which differed from the type 3 vaccine strains in both immunological and molecular properties, was important in the emergence of this outbreak. The inactivated poliovaccine that had been used in the vaccination programme was relatively weakly immunogenic, especially as regards the type 3 component. Whether continuous antigenic variation of poliovirus type 3 has wider epidemiological implications is not known.

Variants of polyoma-transformed BHK21 cells unresponsive to fibronectin

To investigate the relation between cell-substratum adhesion and cell-spreading we have isolated variants of anchorage-independent cells which fail to adhere to fibronectin. The variants are poorly adhesive both to fibronectin and serum, show dramatically altered morphology in culture and are unable to spread on any protein-coated surface yet tested.

The leprous testis

A clinical investigative study of 148 male leprous patients demonstrated the presence of testicular lesions in 35 cases. Semen analysis revealed marked oligo-athenozoospermia in 10 cases and azoospermia in 25 cases. Testicular biopsies from leprous testes showed different histologic patterns ranging from spermatogenic arrest to complete hyalinization of both seminiferous tubules and interstitial tissue. Histochemical staining for neurovascular supply revealed degenerative nerve change in addition to altered permeability of the testicular capillaries. There was good correlation between the results of semen analysis and histological and histochemical examination of testicular biopsies.

Methotrexate and fertility in men

The possible deleterious effects of folic acid antagonist methotrexate on the fertility potential have been investigated in 26 male psoriatic patients. Examination for semen, testicular histology, and spermatogenic function using radioactive phosphorus revealed that methotrexate had no unfavorable effect on male fertility. A long follow up of the patients and their offspring is needed to exclude the possible teratogenic effect of the drug.