Rethinking HDL-C: An In-Depth Narrative Review of Its Role in Cardiovascular Health

The interplay between HDL-C and LDL levels are closely intertwined with the cardiovascular system. High-Density Lipoprotein Cholesterol (HDL-C) is a well-known biomarker traditionally being interpreted as higher the HDL-C levels, minimal the risk of adverse cardiovascular disease (CVD) outcomes. However, recent research has unveiled a more complex relationship between HDL-C levels and cardiovascular outcomes, including genetic influences and potential risks associated with extremely high HDL-C levels. Intriguingly, extremely high HDL-C levels have been linked to unexpected cardiovascular risks. Up To date research suggests that individuals with genetically linked ultra-high HDL-C levels may depict an increased susceptibility to CVD, challenging the conventional realm that higher HDL-C is always beneficial. The mechanisms underlying this mystery are not fully understood but may involve HDL particle functionality and composition. In a nutshell, the relationship between HDL-C levels and cardiovascular outcomes is multifactorial. While low HDL-C remains a recognized risk factor for CVD, the genetic determinants of HDL-C levels add complexity to this association. Furthermore, extremely high HDL-C levels may not exhibit the expected protective benefits and may even pose unprecedented cardiovascular risks. A comprehensive understanding of these dynamics is essential for advancing our knowledge of CVD risk assessment and developing targeted therapeutic interventions. Further studies are needed to unravel the intricacies of HDL-C's role in cardiovascular health and disease.

Treating Pulmonary Arterial Hypertension With Sotatercept: A Meta-Analysis

Pulmonary arterial hypertension (PAH) results from proliferative remodeling and narrowing of the pulmonary vasculature. Sotatercept is a first-in-class fusion protein that has recently garnered attention for showing improvements in patients with PAH. This meta-analysis of randomized controlled trials (RCTs) assesses the overall efficacy of Sotatercept in treating PAH. PubMed, Google Scholar, and Clinicaltrials.gov were searched using relevant keywords and MeSH terms. Studies were included if RCTs compared Sotatercept with placebo in patients with PAH. Our comprehensive literature search yielded 3,127 results, of which two RCTs with 429 patients were included in this meta-analysis. The patients were on background therapy for PAH. Results of the meta-analysis show that when compared with placebo, Sotatercept improved the six-minute walk distance (mean difference [MD] 34.99; 95% confidence interval [CI] 19.02-50.95; P < 0.0001), the World Health Organization (WHO) functional class (odds ratio [OR] 2.50; 95% CI 1.50-4.15; P = 0.0004), and pulmonary vascular resistance (PVR, MD -253.90; 95% CI -356.05 to -151.75; P < 0.00001). However, reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP, MD -1563.14; 95% CI -3271.93 to 145.65; P = 0.07) was not statistically significant in the Sotatercept group versus placebo. In conclusion, Sotatercept improves the six-minute walk distance, WHO functional class, and PVR in patients with PAH receiving background therapy. However, the effect on NT-proBNP levels was not statistically significant. More research is needed to assess the clinical relevance of these findings.

Clinical Efficacy and Safety of Bempedoic Acid in High Cardiovascular Risk Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Bempedoic acid (BA) is the new addition to lipid-lowering medications. This systematic review and meta-analysis of randomized controlled trials (RCTs) assess the clinical efficacy and safety of BA in high cardiovascular (CV) risk patients along with its effects on low-density lipoprotein cholesterol (LDL-C) and total cholesterol. PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov were searched for RCTs comparing BA with placebo, reporting CV outcomes. Seven RCTs with a total of 17,816 patients were selected for the analysis. Results showed that BA significantly reduced the risk of MACE (RR 0.87, 95% CI 0.80-0.94; P = 0.007), nonfatal myocardial infarction (RR 0.73; 95% CI 0.62-0.85; P < 0.0001), hospitalization for unstable angina (RR 0.69; 95%CI 0.54-0.88; P = 0.003), coronary and noncoronary revascularization (RR 0.82; 95%CI 0.73-0.92; P = 0.0007) and (RR 0.41; 95%CI 0.18-0.96; P = 0.04), respectively. However, BA increased the risk of gout (RR 1.55; 95% CI 1.26-1.90; P < 0.0001), hyperuricemia (RR 1.94; 95% CI 1.73-2.18; P < 0.00001) and worsening renal function (RR 1.34; 95%CI 1.21-1.48; P < 0.00001). BA also reduced LDL-C (MD -22.38%; 95% CI -25.94 to - 18.82; P < 0.00001) and total cholesterol (MD -13.86%; 95% CI -15.82 to -11.91; P < 0.0000) compared with placebo. Bempedoic acid is an addition to the arsenal of lipid-lowering drugs used in patients that are statin intolerant or need additional lipid-lowering therapy.

Exploring alternative approaches to precision medicine through genomics and artificial intelligence - a systematic review

The core idea behind precision medicine is to pinpoint the subpopulations that differ from one another in terms of disease risk, drug responsiveness, and treatment outcomes due to differences in biology and other traits. Biomarkers are found through genomic sequencing. Multi-dimensional clinical and biological data are created using these biomarkers. Better analytic methods are needed for these multidimensional data, which can be accomplished by using artificial intelligence (AI). An updated review of 80 latest original publications is presented on four main fronts-preventive medicine, medication development, treatment outcomes, and diagnostic medicine-All these studies effectively illustrated the significance of AI in precision medicine. Artificial intelligence (AI) has revolutionized precision medicine by swiftly analyzing vast amounts of data to provide tailored treatments and predictive diagnostics. Through machine learning algorithms and high-resolution imaging, AI assists in precise diagnoses and early disease detection. AI's ability to decode complex biological factors aids in identifying novel therapeutic targets, allowing personalized interventions and optimizing treatment outcomes. Furthermore, AI accelerates drug discovery by navigating chemical structures and predicting drug-target interactions, expediting the development of life-saving medications. With its unrivaled capacity to comprehend and interpret data, AI stands as an invaluable tool in the pursuit of enhanced patient care and improved health outcomes. It's evident that AI can open a new horizon for precision medicine by translating complex data into actionable information. To get better results in this regard and to fully exploit the great potential of AI, further research is required on this pressing subject.

Karyotype patterns, clinical features, and parental ages of three predominant live born autosomal trisomies of Northeast Malaysia

Chromosomal abnormality is one of the causes of congenital disorders among newborns. Despite aneuploidy being the major cause of first trimester miscarriages, very few aneuploidies such as trisomies of chromosomes 13, 18 and 21 survive to birth. The results of 4,064 patients referred for cytogenetic analysis at Human Genome Centre, Universiti Sains Malaysia, Kelantan, Malaysia between 2008 and 2019 were reviewed. We retrospectively investigated the karyotype patterns, clinical features and parental ages of the three common live-born autosomal trisomies such as trisomy 13, trisomy 18 and trisomy 21. The relative frequency of cases with the total sample received and cultured was calculated in each group and compared with those reported elsewhere. Between 2008 and 2019, a total of 1034 live-born trisomic cases which accounted for 25.4% of the 4064 total referred cases and 73.7% of 1403 suspected trisomy cases, were identified, with age ranging from newborns to 57 years. Down syndrome was the commonest aneuploidy (857 cases; 21.1%) followed by Edwards syndrome (133 cases; 3.3%) and Patau syndrome (44 cases; 1.1%). The number of diagnosed cases for each of the trisomies was fairly stable from year to year. About two-thirds of both maternal and paternal ages were ≥ 35 years. This is the first cytogenetic report on the common live-born autosomal trisomies in the North-Eastern region of Malaysia. The prevalence of trisomies 21 was found to be higher compared to an earlier study in the North-Western region of Malaysia, wherein also, advanced maternal age was a significant risk factor.

Zymogen-poor acinic cell carcinoma of the soft palate with high-grade transformation

Acinic cell carcinoma is an uncommon malignant salivary gland tumour accounting for approximately 6-7% of all salivary gland neoplasms. The key diagnostic feature of acinic cell carcinoma is the presence of acinar cell differentiation characterised by cytoplasmic zymogen secretory granules. This tumour shows a variety of growth patterns, including solid, microcystic, follicular and papillary cystic patterns. Acinic cell carcinoma is typically a cytologically low-grade malignancy. Acinic cell carcinomas with high-grade transformation (HGT) are exceedingly rare and are reported to have a more aggressive clinical course than conventional acinic cell carcinoma. This is a case report of this uncommon entity with high-grade transformation arising on the soft palate in a 64-year-old woman.

Clinical implications of conventional cytogenetics, fluorescence in situ hybridization (FISH) and molecular testing in chronic myeloid leukaemia patients in the tyrosine kinase inhibitor era - A review

Chronic myeloid leukaemia (CML) provides an illustrative disease model for both molecular pathogenesis of cancer and rational drug therapy. Imatinib mesylate (IM), a BCR-ABL1 targeted tyrosine kinase inhibitor (TKI) drug, is the first line gold standard drug for CML treatment. Conventional cytogenetic analysis (CCA) can identify the standard and variant Philadelphia (Ph) chromosome, and any additional complex chromosome abnormalities at diagnosis as well as during treatment course. Fluorescence in situ hybridization (FISH) is especially important for cells of CML patients with inadequate or inferior quality metaphases or those with variant Ph translocations. CCA in conjunction with FISH can serve as powerful tools in all phases of CML including the diagnosis, prognosis, risk stratification and monitoring of cytogenetic responses to treatment. Molecular techniques such as reverse transcriptase-polymerase chain reaction (RT-PCR) is used for the detection of BCR-ABL1 transcripts at diagnosis whereas quantitative reverse transcriptase-polymerase chain reaction (qRTPCR) is used at the time of diagnosis as well as during TKI therapy for the quantitation of BCR-ABL1 transcripts to evaluate the molecular response and minimal residual disease (MRD). Despite the excellent treatment results obtained after the introduction of TKI drugs, especially Imatinib mesylate (IM), resistance to TKIs develops in approximately 35% - 40% of CML patients on TKI therapy. Since point mutations in BCR-ABL1 are a common cause of IM resistance, mutation analysis is important in IM resistant patients. Mutations are reliably detected by nested PCR amplification of the translocated ABL1 kinase domain followed by direct sequencing of the entire amplified kinase domain. The objective of this review is to highlight the importance of regular and timely CCA, FISH analysis and molecular testing in the diagnosis, prognosis, assessment of therapeutic efficacy, evaluation of MRD and in the detection of BCR-ABL1 kinase mutations which cause therapeutic resistance in adult CML patients.

Association between POLG and XRCC1 gene polymorphisms and keratoconus occurrence among Egyptian patients

BACKGROUND

Keratoconus is a progressive disorder distinguished by thinning of the corneal tissue and bulging forward into a cone-shaped fashion. Yet its etiology, which is multifactorial, despite intensive research remains elusive. Corneal exposure a reactive oxygen species causing oxidative DNA damage has been reported to be associated with KC and therefore suggesting that DNA base excision repair mechanism might lie behind the pathogenesis of the disease.

METHODS

We studied the association of three variants in two BER genes (XRCC1 and POLG) and QC occurrence in a cohort of patients from Egypt. Genotyping of the three variants was performed using PCR and restriction enzymes analysis.

RESULTS

We observed that A allele and A/A genotype of the c.1196A>G variant in the XRCC1 gene were significantly associated with increased KC occurrence while the G allele was associated with decreased KC occurrence. Similarly, the A/A genotype of the c.-1370T>A polymorphism in the POLG gene and the A allele were associated with increased occurrence of KC, while T/A genotype and the T allele were accompanied with decreased occurrence of KC. On the other hand, no association was observed between the c.580C>T variant in the XRCC1 gene and KC occurrence among the studied group of patients.

CONCLUSION

Our results suggest that c.1196A>G variant of the XRCC1 and c.-1370T>A variant of the POLG gene may be involved in KC pathogenesis and might be considered as a genetic risk factors of the disease among Egyptian population.

The effect of platelet-rich plasma as a scaffold in regeneration/revitalization endodontics of immature permanent teeth assessed using 2-dimensional radiographs and cone beam computed tomography: a randomized controlled trial

AIM

To assess the outcomes of platelet-rich plasma as a scaffold in regenerative/revitalization endodontics (RET) using cone beam computed tomography (CBCT) and 2-dimensional radiographs.

METHODOLOGY

Twenty-six healthy patients with mean age of 12.66 ± 4.47, and immature permanent anterior teeth with necrotic pulps, were randomly allocated to two groups, whereby RET was performed using platelet-rich plasma (PRP, test group) and blood clot (BLC, control group). Changes in root length (RL), root dentinal thickness (RDT), apical foramen width (AFW) and radiographic root area (RRA), were assessed using both radiographic methods, whilst changes in periapical area diameter (PAD) were assessed using CBCT, over a period of 12 months. T-test and chi-square/Fisher's exact tests were used to compare continuous and categorical data between BLC and PRP groups, respectively. Changes in RL, RDT, AFW, RRA and PAD were examined by comparing the two groups (PRP versus BLC) using multilevel modelling, considering the clustering effect of repeated measures of several teeth originating from the same participant.

RESULTS

Changes in RL, RDT, AFW, RRA and PAD, over time, were found to be significant for both groups. There was, however, no difference between the RET techniques (PRP versus BLC), using both radiographic and CBCT methods. The results of both assessment techniques (CBCT and 2-dimensional radiographic methods) were highly consistent (overall ICC ranged between 0.80 and 0.94). In addition, a significant effect of baseline PAD was found on RL, RRA and AD at 12 months (RL effect = -0.68, P < 0.001; RRA effect = -1.91, P = 0.025; AD effect = 0.08, P = 0.024).

CONCLUSION

The current study highlights successful and comparable clinical and radiographic outcomes of RET techniques using PRP and BLC. Standardized and calibrated 2-dimensional radiographic assessment was as effective as CBCT in assessing RET outcomes; therefore, the routine use of CBCT in RET is not recommended. Although an effect of baseline periapical lesion diameter on root development outcomes, at 12 months, were observed, more studies are recommended in order to assess such an effect.

Molecular sex identification of dry human teeth specimens from Sokoto, Northwestern Nigeria

BACKGROUND

The advent of molecular techniques has revolutionized the ability of scientists to estimate the sex of individuals. Forensic odontology plays an important role in establishing the sex of victims with bodies mutilated beyond recognition due to major disaster. The genetic difference between males and females is defined by the presence or absence of the Y-chromosome. The use of alphoid-repeat primers in sex estimation was first applied on dried blood. Generally, the X, Y alphoid repeats blind test attest to the accuracy of genetic testing, and also point the potential for occasional error in morphometric sexing.

AIM

To estimate genetic sex of dry human teeth specimens from Sokoto, Northwestern Nigeria, using polymerase chain reaction (PCR).

MATERIALS AND METHODS

A single-blind study of DNA analysis for sex estimation of nine dry human teeth specimens from Sokoto, Northwestern Nigeria, through PCR, using alphoid repeats primers, was undertaken.

RESULTS

The genetic sex of each group of the teeth samples were accurately (100%) identified. For each group of teeth, PCR Sensitivity = 100%, Specificity = 0%, Predictive value of positive test = 100%, Predictive value of negative test = 0%, False positive rate = 0%, False negative rate = 0%, Efficiency of test = 100%. Fisher's exact probability test P = 1. Z-test: z- and P values were invalid.

CONCLUSION

This study has demonstrated the successful use of alphoid-repeat primers in genetic sex identification of human dry teeth samples from Sokoto, Northwestern Nigeria. This is the first known study estimating the sex of human dry teeth specimens by means of PCR in Nigeria. There is need for further studies in Nigeria to complement the findings of this study.

Prevalence of Group A beta-haemolytic Streptococcus isolated from children with acute pharyngotonsillitis in Aden, Yemen

OBJECTIVES

To estimate the prevalence of Group A beta-haemolytic streptococcus (GAS) and non-GAS infections among children with acute pharyngotonsillitis in Aden, Yemen, to evaluate the value of a rapid diagnostic test and the McIsaac score for patient management in this setting and to determine the occurrence of emm genotypes among a subset of GAS isolated from children with acute pharyngotonsillitis and a history of acute rheumatic fever (ARF) or rheumatic heart disease (RHD).

METHODS

Group A beta-haemolytic streptococcus infections in school-aged children with acute pharyngotonsillitis in Aden, Yemen, were diagnosed by a rapid GAS antigen detection test (RADT) and/or GAS culture from a throat swab. The RADT value and the McIsaac screening score for patient management were evaluated. The emm genotype of a subset of GAS isolates was determined.

RESULTS

Group A beta-haemolytic streptococcus pharyngotonsillitis was diagnosed in 287/691 (41.5%; 95% CI 37.8-45.3) children. Group B, Group C and Group G beta-haemolytic streptococci were isolated from 4.3% children. The RADT had a sensitivity of 238/258 (92.2%) and specificity of 404/423 (95.5%) against GAS culture. A McIsaac score of ≥4 had a sensitivity of 93% and a specificity of 82% for confirmed GAS infection. The emm genotypes in 21 GAS isolates from children with pharyngitis and a history of ARF and confirmed RHD were emm87 (11), emm12 (6), emm28 (3) and emm5 (1).

CONCLUSION

This study demonstrates a very high prevalence of GAS infections in Yemeni children and the value of the RADT and the McIsaac score in this setting. More extensive emm genotyping is necessary to understand the local epidemiology of circulating strains.

Information needs of family members of critically ill patients in intensive care unit of a tertiary hospital

BACKGROUND AND AIMS. The experience in intensive care unit (ICU) has created an intense emotional situation both to patients and their family members. The aim of this study was to determine the family members information needs of critically ill patients in ICU.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted on 200 family members of patients admitted in ICU. A face to face interview was conducted and a self-report questionnaire of the Critical Care Family Needs Inventory (CCFNI) was used.

RESULTS

Findings reported CCFNI five sub-attributes that ranked from highest to lowest included: support (mean 39.13 ± 6.189); proximity (mean 27.17 ± 3.384); information (mean 24.25 ± 3.093); assurance (mean 22.67 ± 1.862) and comfort (mean 16.24 ± 2.776). There were no significant differences in needs between family members with different gender (p >0.05). However, there were significant differences in support needs between family members with admission to ICU with (t=-2.111; p <0.05). There were significant differences in assurance needs (F=3.542; p <0.05) and information needs (F=3.681; p <0.05) between family members with age. There were no significant differences in needs between family members with different education level (p >0.05) whereas assurance needs were significant differences with education level of (F=3.542; p <0.05).

CONCLUSION

The results suggest that family members perceived support and proximity as the most crucial need. Comfort need was viewed as least important. Although this study was conducted in a tertiary hospital, the findings could still provide insight for nurses to improve the delivery of care to patients and family members.

Nucleotide excision repair proteins and their importance for radiation‐enhanced transfection

PURPOSE

Irradiated cells transfect more efficiently than unirradiated cells because of a radiation-induced increase in plasmid integration. However, the molecular mechanism is unclear. Because of recent observations that nucleotide excision repair (NER) proteins can be involved in certain types of recombination in yeast, it was hypothesized that NER proteins might play a role in this radiation-enhanced integration.

MATERIALS AND METHODS

Hamster and human cells with inactivating mutations in NER genes were irradiated at doses from 0 to 6 Gy and then immediately transfected with a linearized selectable marker plasmid. Transfection-enhancement ratios (TERs) were calculated as the ratio of the number of drug-resistant colonies in unirradiated cells to the number of transfectants in irradiated cells, corrected for cytotoxicity from radiation.

RESULTS

Transfection into unirradiated rodent cells was unaffected by NER mutation status. Transfection into unirradiated human cells, however, was increased by NER mutation. The TERs were 5 and 100 for CHO and primary human fibroblasts, respectively, after exposure of the cells to 6 Gy. Mutations in ERCC1, XPA, XPB, XPC, XPF, XPG and CSB dramatically reduced TER. Mutations in ERCC1, XPC, XPF, XPG and CSB suppressed transfection so that the TER was significantly below 1.

CONCLUSIONS

The mechanism of radiation-enhanced plasmid integration was distinct from that of plasmid integration in unirradiated cells, and NER gene products were critical for enhanced integration to occur.

Identification of proteins in the hamster DNA end‐binding complex

PURPOSE

To identify the protein components of the DNA end-binding complex in hamster cells.

MATERIALS AND METHODS

DNA end-binding complexes were identified as follows. Nuclear extracts from Chinese hamster ovary cells (0.5-1.0 microg protein/lane) were incubated with 0.5 ng 32P-labelled probe (144 bp) for 20 min at room temperature in the presence of 1 microg closed circular pUC18 plasmid, a non-specific competitor in a final volume of 20 microl. The electrophoretic mobility of the protein-DNA complexes was analysed by electrophoresis in 5% polyacrylamide gels subjected to autoradiography. Antibodies to various DNA repair-associated proteins were added to the DNA end-binding complex reaction and a supershift identified DNA end-binding complex components. These were confirmed by Western analysis of purified DNA end-binding complex contents.

RESULTS

Using both supershift and Western analysis, the following proteins were identified in the DNA end-binding complex: Ku70, Ku80, DNA-dependent protein kinase catalytic subunit, DNA ligase IV, X-ray cross complementing protein 4, meiotic recombination protein 11 (Mre11), Werner's syndrome protein, Bloom's syndrome protein, p53, poly(ADP-ribose) polymerase, replication protein A (RPA) 14, and RPA32, ataxia telangiectasia mutant, c-Abl, Rad50, Nijmegen breakage syndrome protein 1 (NBS1), and DNA ligase III were not detected in the binding complex by any assay. Using a combination of electro-elution and autoradiography, it was estimated that the single DNA end-binding complex contains at least 15 proteins whose molecular weights of the DNA end-binding proteins ranged from 620 to 12 kDa.

CONCLUSIONS

A combination of both a supershift assay and Western analysis of the DNA end-binding complexes has identified 12 of at least 15 proteins present in the DNA end-binding complex of Chinese hamster ovary cells. This protein complex contains Mre11, but not Rad50 or NBS1, suggesting that under some conditions, Mre11 might function independently of Rad50 and NBS1.

Human telomerase reverse transcriptase expression in oral carcinogenesis--a preliminary report

Human telomerase reverse transcriptase (hTERT), the catalytic subunit of telomerase, is strongly associated with telomerase activity implicated in cellular immortalization and tumorigenesis. In situ detection of hTERT will aid in determining the localization of telomerase positive cells. The aim of this study was to detect hTERT protein expression in multistep oral carcinogenesis using paraffin embedded tissue samples, and to study the relationship of hTERT expression with different histological stages in oral carcinogenesis. Normal (n = 4), hyperplastic (n = 4), dysplastic (n = 4) and neoplastic (n = 10) oral epithelia representing different histological stages in oral carcinogenesis were included in the study. hTERT protein detection was done by immunohistochemistry (IHC) technique. Nuclear staining intensities were noted and the hTERT-labelling index was determined. Dysplastic and neoplastic oral epithelia showed an increased percentage of hTERT positive cells (Grade 4: > 50% positive staining nuclei) with intense staining in the basal, parabasal and superficial layers of the epithelia, unlike normal oral mucosa which showed intense staining only in the basal and parabasal cell layers, which are the normal proliferative progenitor compartments. hTERT protein expression was elevated with the corresponding advancement of the histological stages of oral carcinogenesis, from normal to hyperplasia to dysplasia to carcinoma. There seems to be an upregulation of hTERT protein expression during the progression of oral cancer, therefore, this may indicate the feasibility of IHC detection of hTERT protein in oral carcinogenesis as a potential diagnostic or prognostic marker.

Prevalence of blindness and low vision in Malaysian population: results from the National Eye Survey 1996

BACKGROUND

A national eye survey was conducted in 1996 to determine the prevalence of blindness and low vision and their major causes among the Malaysian population of all ages.

METHODS

A stratified two stage cluster sampling design was used to randomly select primary and secondary sampling units. Interviews, visual acuity tests, and eye examinations on all individuals in the sampled households were performed. Estimates were weighted by factors adjusting for selection probability, non-response, and sampling coverage.

RESULTS

The overall response rate was 69% (that is, living quarters response rate was 72.8% and household response rate was 95.1%). The age adjusted prevalence of bilateral blindness and low vision was 0.29% (95% CI 0.19 to 0.39%), and 2.44% (95% CI 2.18 to 2.69%) respectively. Females had a higher age adjusted prevalence of low vision compared to males. There was no significant difference in the prevalence of bilateral low vision and blindness among the four ethnic groups, and urban and rural residents. Cataract was the leading cause of blindness (39%) followed by retinal diseases (24%). Uncorrected refractive errors (48%) and cataract (36%) were the major causes of low vision.

CONCLUSION

Malaysia has blindness and visual impairment rates that are comparable with other countries in the South East Asia region. However, cataract and uncorrected refractive errors, though readily treatable, are still the leading causes of blindness, suggesting the need for an evaluation on accessibility and availability of eye care services and barriers to eye care utilisation in the country.

An unusually aggressive case of endometriosis showing p53 expression

A 43 year old woman who underwent a hysterectomy and bilateral salpingo-oophorectomy for secondary dysmenorrhoea was found to have bilateral ovarian endometriosis. During the following four years she developed a series of tumour-like vaginal masses, which were locally excised, a pelvic mass causing acute large bowel obstruction, which necessitated an emergency Hartmann's procedure, and a further pelvic mass causing hydronephrosis with a non-functioning kidney. Pathological examination of all the resected specimens showed endometriosis with abundant stromal and glandular elements. Immunoreactivity for p53 protein was detected within endometriotic foci from the initial oophorectomy as well as the latest resection specimens. Immunostaining for p53 may help identify potentially aggressive cases of endometriosis for proactive treatment.

Comparison between Toxoplasma gondii DNA and specific immunoglobulins during pregnancy

Early diagnosis of toxoplasmosis in pregnant women can be of great help in early intervention and prevention of congenital disorders that usually lead to fetal death. The purpose of the present study was to evaluate nested PCR amplification of the B1 gene of Toxoplasma gondii before and after treatment and in comparison to serological follow-up during treatment. The efficiency of treatment on the bases of PCR detection of T. gondii DNA was statistically significant, while it was insignificant when anti-toxoplasma specific IgM and IgG antibodies were used. PCR detection of T. gondii DNA when performed on whole blood is a rapid, sensitive and specific diagnostic procedure and is a valuable tool for establishing the diagnosis of T. gondii infection in women before or during pregnancy.

Assay for hepatitis C virus in peripheral blood mononuclear cells enhances sensitivity of diagnosis and monitoring of HCV-associated hepatitis

Hepatitis C virus (HCV) is a major etiological factor in chronic hepatitis affecting up to 24% of blood donors in Egypt. Since fluctuating levels of HCV RNA loads, including undetectable values, have been frequently observed in sera of chronic hepatitis patients, this study was designed to assess the sensitivity of PCR amplification for the plus- and minus-RNA strands in peripheral blood mononuclear cells (PBMC) compared to single serum PCR assay. Since the latter test detects viremia in only 79.5% of seropositive cases, the highest sensitivity for HCV diagnosis was achieved (93.20% when applying the combined triple test including PCR amplification of plus-strand in serum, together with plus-strand in PBMC and minus-strand in PBMC. The results of this study indicate that the triple test provides significant information on extrahepatic replication of HCV in a sizable sample of seropositive subjects (429 cases) and improves the assessment of HCV viremia. The cost/effectiveness and speed were upgraded by using capillary/air rapid thermal cycler. The use of the triple assay in HCV diagnosis and post-therapy monitoring is recommended.

Determination of malathion residues in some medicinal plants by liquid chromatography with gas chromatographic/mass spectrometric confirmation

A method for determining malathion residues by reversed-phase liquid chromatography (LC) using methanol only as mobile phase is described. Malathion [diethyl(dimethoxyphosphinothiol)succinate] was applied on marjoram, mint, and chamomile. Residues were detected in fresh and dry crops by LC and confirmed by gas-LC/mass spectrometry. Average recovery of malathion was 85%. Residues detected in fresh marjoram, mint, and chamomile were 0.18, 0.23, and 0.083 mg/kg, respectively. Residues detected in dry marjoram and mint were 0.024 and 0.050 mg/kg, respectively. No malathion residues were detected in dry chamomile. The minimum detectable concentration with this method is 0.013 mg/kg. The study suggests it is safe to use malathion up to 2 sprays per season provided the crop is harvested not less than 3 weeks from the last spray.

Juvenile hormone acid: evidence for a hormonal function in induction of vitellogenin in larvae of Manduca sexta

In the tobacco hornworm (Manduca sexta), vitellogenin (Vg), the major yolk protein precursor, and its mRNA are first detectable in the prepupal stage; and production of both can be enhanced by methoprene, a juvenile hormone (JH) analog. Competence to respond to methoprene is acquired after ecdysteroid-initiated commitment for metamorphosis. Here we show that acquisition of competence requires prior exposure to JH-II acid in addition to ecdysteroid. Application of 20-hydroxyecdysone or RH5992, an ecdysteroid analog, to isolated abdomens from feeding larvae (precommitment) results in exposure of the dorsal vessel (EDV), a sign of metamorphic commitment--but such abdomens do not make Vg in response to methoprene. However, injection of JH-II acid along with 20-hydroxyecdysone into isolated abdomens causes Vg production in response to methoprene. Methoprene acid similarly induces competence to respond to methoprene. Northern blot analysis confirmed that Vg transcripts are present in fat body only if isolated abdomens were pretreated with both ecdysteroid, and JH-II acid or methoprene acid. The latter two can induce competence even in precocious prepupae resulting from removal of the corpora allata (the glands that produce JH) from early penultimate larvae. JH-III acid and related metabolites such as farnesol, farnesoic acid, and methyl farnesoate do not induce competence. Hitherto, JH acids have been regarded as precursors or catabolites of JHs. Here we show for the first time that JH acid has a hormonal function that cannot be performed by JH itself.

Inter- and intra-observer variation in the reporting of cervical smears: specialist cytopathologists versus histopathologists

One hundred and ten cervical smears were circulated to five specialist consultant cytopathologists and five consultant histopathologists. Of these smears, 100 were randomized and re-circulated. The cytopathologists reported endocervical cells and wart virus infection more frequently than the histopathologists, although neither group showed good inter-observer agreement for either assessment. Apart from smear adequacy and the presence of endocervical cells, both groups showed good intra-observer agreement in all the parameters measured. This suggests that overall individuals were applying their own personal criteria with consistency over time, although a previous study had shown considerable lack of inter-observer agreement among the histopathologists on the grade of dyskaryosis and the management recommendation. The results indicate that specialist cytopathologists bring a different viewpoint to the reporting of cervical smears than histopathologists. They also show a lack of standardization in the reporting of smears despite the guidelines issued by the British Society for Clinical Cytology.

The effects of tamoxifen on the uterus

The main uterine effect of prolonged tamoxifen use is an increased incidence of proliferative abnormalities of the endometrium. These form an overlapping pathological spectrum ranging from simple hyperplasia to invasive malignancy, with hyperplastic endometrial polyps and polyp-cancers occupying the intermediate ground. The factors involved in the genesis of these lesions remain poorly understood but a combination of inherited factors and cumulative tamoxifen dosage may be important.

Ulcerating rheumatoid nodule of the vulva

A case of an ulcerating rheumatoid nodule of the vulva in a 76 year old woman with rheumatoid arthritis complicated by Felty's syndrome is reported. The patient presented with a mass in the vulval region. On clinical examination, she had an ulcerated mass associated with inguinal lymphadenopathy. These findings resulted in a clinical diagnosis of invasive carcinoma of the vulva and an excision biopsy was carried out. On microscopic examination, the lesion showed the characteristic features of a rheumatoid nodule with ulceration of overlying epidermis. Adjacent vessels showed inflammation and fibrinoid necrosis of their walls suggestive of a vasculitis. Awareness of the possibility of ulceration in rheumatoid nodules may facilitate diagnosis and avert unduly aggressive treatment.

Postcaesarean section uterovesical fistula lined by persistent intermediate trophoblast

We report a unique case of a postcaesarean section uterovesical fistula lined by intermediate trophoblast. The patient, a 42-year-old woman, presented with cyclical haematuria, and she had had a lower segment caesarean section 1 year previously. She was found to have uterovesical fistula, which was excised. On microscopic examination the fistula tract was lined by intermediate trophoblast characterised by cells with abundant eosinophilic cytoplasm, occasional multiclefted nuclei, and cytoplasmic immunoreactivity for epithelial cytokeratins and human placental lactogen. This finding has not, to our knowledge, been previously described and indicates that the survival of third trimester intermediate trophoblast is independent of pregnancy.

Juvenile hormone-dependent LHPI and RNA synthesis in Melanoplus sanguinipes long hyaline tubule: events associated with the "insensitive period"

Juvenile hormone (JH) regulation of the synthesis of LHPI, the major secretory protein of the long hyaline tubule in the male accessory reproductive gland (MARG) of Melanoplus sanguinipes, was examined by in vitro radiolabeling and immunoprecipitation. In MARG taken from normal insects JH III immediately stimulates production of immunospecific LHPI. In contrast, JH III does not initially promote synthesis of LHPI in MARG of allatectomized insects. Only after prior exposure to the hormone [for 24 hr when applied in vivo (topically) or 16 hr under in vitro conditions] is LHPI synthesis enhanced by JH III in the MARG of allatectomized insects. These results suggest that in the prolonged absence of JH III the MARG are "switched off," that is, lose their sensitivity to the hormone. Sensitivity is regained during the 24- or 16-hr "lag phase." Use of the translational inhibitor cycloheximide confirmed the existence of the lag phase in JH III-mediated LHPI synthesis. JH III stimulates RNA synthesis in a dose-dependent manner in the long hyaline tubule at concentrations < 64 nM. Above this level, RNA synthesis was depressed. Actinomycin D given simultaneously with JH III inhibited RNA synthesis, but not the synthesis of LHPI in the long hyaline tubule. It is suggested that understanding the nature of the lag phase will facilitate clarification of the mechanism of action of JH in the MARG.

Pathology of endometrium treated with tamoxifen

AIMS

To determine the type of endometrial abnormalities associated with prolonged tamoxifen treatment and to investigate the correlation between tamoxifen dose and any abnormalities detected.

METHODS

Endometria from 19 prospectively collected breast cancer patients treated with tamoxifen were ascribed a pathological diagnosis and the findings compared with those in a control group matched for age and presentation. The abnormalities were related to cumulative tamoxifen dose.

RESULTS

The two asymptomatic treated patients had generalised simple endometrial hyperplasia at necropsy. No endometrial abnormalities were seen at necropsy in the two control cases. Of the 17 patients treated with tamoxifen who underwent surgery for gynaecological symptoms, 11 had hyperplastic endometrial polyps characterised by epithelial metaplasias and patchy periglandular condensation of stroma. Two women had primary endometrial malignancies with myometrial invasion, and three women, one of whom had previously presented with a benign polyp, had an endometrial polyp-cancer on a background of hyperplasia. Endometrial malignancies were confined to women who had taken more than 35 g of tamoxifen. The control group included no endometrial polyp-cancers, only one patient with an endometrial polyp, four women with endometrial hyperplasia and four with primary endometrial malignancy.

CONCLUSIONS

These findings support a link between prolonged tamoxifen treatment and endometrial malignancy and identify a subgroup of patients--that is, those who have taken more than 35 g of tamoxifen, who may be at increased risk of endometrial cancer. The spectrum of pathological findings in patients treated with tamoxifen suggests that the drug promotes endometrial growth and that endometrial polyps may be an important intermediate step in endometrial carcinogenesis.

Cushing's syndrome associated with recurrent endometrioid adenocarcinoma of the ovary

Ectopic production of adrenocorticotrophic hormone (ACTH) by malignant neoplasms is a well recognised cause of Cushing's syndrome but is extremely rare in ovarian carcinoma. A patient who underwent surgery for ovarian carcinoma followed by a course of chemotherapy is reported. The tumour was a bilateral moderately differentiated endometrioid adenocarcinoma and contained numerous chromogranin immunoreactive endocrine cells as well as small foci of ACTH immunoreactivity. She subsequently presented with Cushing's syndrome in association with extensive pelvic recurrence of the tumour.

Interobserver variation in the diagnosis and grading of dyskaryosis in cervical smears: specialist cytopathologists compared with non-specialists

AIMS

To compare the assessment of dyskaryosis in cervical smears made by specialist consultant cytopathologists and consultant general histopathologists.

METHODS

One hundred and ten cervical smears were circulated to 10 observers from five district general hospital histopathology departments and five major departments of cytopathology. Their responses were analysed by five consultant general histopathologists and five consultant specialist cytopathologists. In 54 of the 110 cases, the histology of a corresponding cervical biopsy specimen was compared with the smear assessments.

RESULTS

Specialist cytopathologists were more consistent than non-specialists when diagnosing and grading dyskaryosis. They chose the higher grades of dyskaryosis more frequently than the non-specialists. The cytopathologists recommended referral for colposcopy more frequently, but if they asked for a repeat smear, they wanted it done within three months more frequently than the histopathologists. The specialists were more frequently in agreement with the biopsy grade of intra-epithelial neoplasia than the non-specialists, whose smear diagnoses tended to underestimate the severity of the histopathological abnormality.

CONCLUSIONS

This study has shown major differences between specialist and non-specialist cytopathologists in the diagnosis and grading of cervical smears and in the recommended management of patients with abnormal smears. These differences may result in uneven clinical management of women with smear abnormalities. It is therefore important to explore possible strategies for standardising the reporting of cervical smears, such as centralisation of screening services, accreditation in cytopathology for non-specialist consultants, and the value of participation in external quality assessment schemes.

Immunocytochemical localization of oestrogen and progesterone receptors in primary adenocarcinoma of the cervix

Archival material from 47 primary invasive adenocarcinomas of the uterine cervix was examined using an immunocytochemical technique for detection of oestrogen receptor and progesterone receptor in paraffin-wax embedded tissues. Immunostaining for oestrogen receptor was noted within tumour cells in 12 cervical adenocarcinomas while 13 tumours contained progesterone receptor. Eleven cervical adenocarcinomas expressed both oestrogen and progesterone receptor simultaneously. There was no association between steroid receptor status and major histological subtype, grade of tumour, clinical stage or age of patient at presentation. However, oestrogen receptor immunoreactivity was associated with disease-free survival. This preliminary study raises the possibility that, as in breast carcinoma, steroid receptor status may be a useful prognostic factor in adenocarcinoma of the cervix.

Oestrogen receptor protein and mRNA in adenocarcinoma of the uterine cervix

We have investigated the oestrogen receptor (ER) status of 20 cervical adenocarcinomas by immunocytochemistry for ER protein and non-isotopic in situ hybridisation for ER mRNA. Both methods, which are applicable to paraffin sections, were developed and validated in breast carcinomas with known ER content. Six cervical adenocarcinomas contained immunocytochemically demonstrable ER protein; all contained ER mRNA, but staining was less intense in poorly differentiated areas of four tumours. This disparity between protein and mRNA detection needs further investigation as does the possibility that oestrogens may play a role in the pathogenesis of cervical adenocarcinoma.

Current views on CIN

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Cone biopsy causes cervical endometriosis and tubo-endometrioid metaplasia

Cervices from 42 hysterectomies performed from 1 to 91 months (mean 12.2) following conization were re-examined in order to assess the possible effects of post-traumatic regeneration on the endocervix. Twenty-nine (69%) showed a continuum of abnormalities in which the shared finding was the presence of tubo-endometrioid glands, accompanied in many cases by varying amounts of endometrial-type stroma. Thus, 18 post-conization cervices (43%) showed endometriosis, and a further 11 cases (26%) contained tubo-endometrioid glands without demonstrable endometrial-type stroma. These abnormalities were situated at the healed cone biopsy site, either superficially within the new transformation zone and/or within the cone biopsy scar. Post-conization cervical endometriosis occurred from 2 to 91 months (mean 17.8) and tubo-endometrioid metaplasia 2-24 months (mean 11.0) after the cone biopsy. It is concluded that cervical endometriosis and tubo-endometrioid metaplasia are common complications of conization, and that they represent aberrant differentiation following injury. The demonstration of endometriosis and tubo-endometrioid metaplasia in 69% of post-conization cervices has implications for the interpretation of cervical biopsies and smears from this group of women.

20-Hydroxyecdysone mediated activation of larval haemolymph protein uptake by fat body cells of Corcyra cephalonica (Insecta)

Evidence is presented here to show that 20-hydroxyecdysone is essential for the activation of the larval fat body for differential uptake of larval haemolymph proteins (LHPs). By using radiolabelled LHPs it is shown that the fat body cells of Corcyra cephalonica selectively incorporate LHPs during late-larval and prepupal development. Fluorographic analysis of the labelled fat body proteins from prepupal stage separated on sodium dodecyl-sulphate polyacrylamide gels suggests that the LHPs are sequestered without any degradation. Although, during the last larval instar the uptake of all the three LHPs (LHP 1, LHP 2 and LHP 3) by the fat body cells is very low, 20-hydroxyecdysone treatment of early, mid or late-last instars causes a significant increase in uptake of all the three LHPs. However, the response to hormone treatment was more pronounced in late-last instar when compared to early and mid-last instar.

Bilateral virilizing sclerosing stromal tumours of the ovary in a pregnant woman with Gorlin's syndrome: implications for pathogenesis of ovarian stromal neoplasms

A woman with Gorlin's syndrome who had become pregnant following clomiphene therapy presented in early pregnancy with bilateral ovarian sclerosing stromal tumours which were associated with profound virilization. Pre- and post-operative hormone profiles indicated androgen production by the tumours. Ovarian sclerosing stromal tumours have not previously been reported as occurring bilaterally or in association with Gorlin's syndrome. We discuss the questions raised by this unusual case regarding the pathogenesis of ovarian stromal neoplasms.

Reporting cervical intra-epithelial neoplasia (CIN): intra- and interpathologist variation and factors associated with disagreement

Eight histopathologists, based at different hospitals, who had previously examined 100 consecutive colposcopic cervical biopsies were circulated with the results of the initial study. The slides were then 'reblinded' and re-examined by the pathologists who, as before, assigned them into one of six diagnostic categories. The degree of interpathologist agreement for the seven observers who returned usable responses was characterized by kappa statistics and compared to the corresponding figures for the same observers from the previous study. Although some of the observers showed significant alterations in their diagnostic practices there was persistent poor agreement for CIN 1 and 2, mediocre agreement for CIN 3 and excellent agreement for invasive carcinoma. Intra-observer agreement was consistently better than inter-observer agreement for each of the diagnostic categories. Significant differences were found among observers in the degree of intra-observer variability. The 20 cases in which there was most disagreement were re-examined by one of the authors who compared these with 20 biopsies which caused little disagreement. Disagreement was considered to be associated with florid papilloma-virus changes, basal cell hyperplasia and severe inflammation in varying combinations. On the basis of these findings we suggest changes in the terminology of CIN lesions.

Infiltrative myeloid metaplasia: an unusual cause of gastric outlet obstruction

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