Impact of the COVID-19 pandemic on cardiology fellowship training in a sub-Saharan African training centre: an African perspective

AIM

The impact of the COVID-19 pandemic on cardiology fellowship training in sub-Saharan Africa (SSA) is not known. This study aimed to determine the impact of the COVID-19 pandemic on fellowship training, and reviewed the adaptiveness of the existing training systems.

METHODS

We conducted a three-month data survey related to the cardiology fellows' clinical exposure at the Aga Khan University Hospital, Kenya, before the COVID-19 pandemic and compared it with a three-month period during the pandemic. Hospital data volumes for patients' contacts, ambulatory and catheterisation laboratory procedures recorded during the periods of March to May 2019 (three-months pre-COVID-19) and March to May 2020 (three-months during the COVID-19 pandemic) were analysed. A comparative fellows' logbook evaluation of recorded cases was also conducted for the two study time periods. In addition, fellows answered a survey questionnaire related to their roles and responsibilities in the hospital, their views on cardiology training during the COVID-19 pandemic and the pandemic's impact on their training.

RESULTS

There was a significant reduction in the volume of patients and cardiac procedures during the COVID-19 period compared to the pre-COVID-19 period. In the same line, the number of fellows' training episodes reduced significantly during the COVID-19 pandemic compared to their performances before the pandemic. Fellows felt that the COVID-19 crisis has had a moderate to severe impact on their fellowship training. They however noted an increase in the provision of virtual local and international meetings and conferences, which supported the training positively.

CONCLUSION

This study showed that the COVID-19 crisis resulted in a significant reduction in the total volume of patients and cardiac procedures and, in turn, the number of training episodes. This may have limited the fellows from achieving a great amount of skills base in highly technical skills by the end of their training. Opportunities for post-fellowship training in the form of continued mentorship and proctorship would be a valuable option for the trainees if there is a similar pandemic in the future.

Measurement of Equilibrium Angiotensin II in the Diagnosis of Primary Aldosteronism

BACKGROUND

Many medications (including most antihypertensives) and physiological factors affect the aldosterone/renin ratio (ARR) when screening for primary aldosteronism (PA). We sought to validate a novel equilibrium angiotensin II (eqAngII) assay and compare correlations between the aldosterone/angiotensin II ratio (AA2R) and the current ARR under conditions affecting the renin-angiotensin system.

METHODS

Among 78 patients recruited, PA was excluded in 22 and confirmed in 56 by fludrocortisone suppression testing (FST). Peripheral levels of eqAngII, plasma renin activity (PRA) and direct renin concentration (DRC) were measured.

RESULTS

EqAngII showed good consistency with DRC and PRA independent of PA diagnosis, posture, and fludrocortisone administration. EqAngII showed close (P < 0.01) correlations with DRC (r = 0.691) and PRA (r = 0.754) during FST. DRC and PRA were below their assays' functional sensitivity in 43.9% and 15.1%, respectively, of the total 312 samples compared with only 7.4% for eqAngII (P < 0.01). Bland-Altman analysis revealed an overestimation of PRA and DRC compared with eqAngII in a subset of samples with low renin levels. The AA2R showed not only consistent changes with the ARR but also close (P < 0.01) correlations with the ARR, whether renin was measured by DRC (r = 0.878) or PRA (r = 0.880).

CONCLUSIONS

Dynamic changes of eqAngII and the AA2R show good consistency and close correlations with renin and the ARR. The eqAngII assay shows better sensitivity than DRC and PRA assays, especially at low concentrations. Whether the AA2R can reduce the impact of some factors that influence the diagnostic power of the ARR warrants further study.

Vas Deferens Calcification in a Diabetic CKD: An Incidental Finding

Vas deferens calcification is a very rare condition. The causes can be categorized as inflammatory and non-inflammatory type. We are presenting such a non inflammatory type of bilateral vas calcification in a diabetic chronic kidney diseases (CKD) patient. Presented patient a 50 years old man admitted in Samorita Hospital Ltd., Dhaka, Bangladesh on 03 August 2014 in cabin - 537 with registration number 1904/14. He was labeled as Diabetes mellitus (DM), Hypertension (HTN), CKD & Urinary tract infection (UTI). Vas deferens calcification was diagnosed incidentally by X-ray KUB. Subsequently we have discussed all possible causes in this report. The purpose of presenting this rare imaging finding is to emphasize the under diagnosis of the disease and causes. It can also be diagnosed by simple, easily available and cheap investigations like Plain X ray KUB.

Diagnosis of Primary Aldosteronism by Seated Saline Suppression Test-Variability Between Immunoassay and HPLC-MS/MS

BACKGROUND

In primary aldosteronism (PA), excessive, autonomous secretion of aldosterone is not suppressed by salt loading or fludrocortisone. For seated saline suppression testing (SSST), the recommended diagnostic cutoff 4-hour plasma aldosterone concentration (PAC) measured by high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS is 162 pmol/L. Most diagnostic laboratories, however, use immunoassays to measure PAC. The cutoff for SSST using immunoassay is not known. We hypothesized that the cutoff is different between the assays.

METHODS

We analyzed 80 of the 87 SSST tests that were performed during our recent study defining the HPLC-MS/MS cutoff. PA was confirmed in 65 by positive fludrocortisone suppression testing (FST) and/or lateralization on adrenal venous sampling and excluded in 15 by negative FST. PAC was measured by a chemiluminescence immunoassay (PACIA) in the SSST samples using the DiaSorin Liaison XL analyzer, and receiver operating characteristics (ROC) analysis was performed to identify the PACIA cutoff.

RESULTS

ROC revealed good performance (area under the curve = 0.893; P < .001) of 4-hour postsaline PACIA for diagnosis of PA and an optimal diagnostic cutoff of 171 pmol/L, with sensitivity and specificity of 95.4% and 80.0%, respectively. A higher cutoff of 217 pmol/L improved specificity (86.7%) with lower sensitivity (86.2%). PACIA measurements strongly correlated with PAC measured by HPLC-MS (r = 0.94, P < .001).

CONCLUSIONS

A higher diagnostic cutoff for SSST should be employed when PAC is measured by immunoassay rather than HPLC-MS/MS. The results suggest that (i) PA can be excluded if 4-hour PACIA is less than 171 pmol/L, and (ii) PA is highly likely if the PACIA is greater than 217 pmol/L by chemiluminescence immunoassay. A gray zone exists between the cutoffs of 171 and 217 pmol/L, likely reflecting a lower specificity of immunoassay.

Abstract P2074: Improving Hypertension Control By Molecular Stratification Of First-Line Non-Responders Using RAAS Triple-A Testing

According to new European guidelines, first-line anti-hypertensive therapies include either an ACE inhibitor (ACEi) or an angiotensin receptor blocker (ARB) in a single pill combination with a calcium channel blocker (CCB) or a diuretic. Insufficient therapeutic effects could be caused by various factors ranging from compliance issues, patient specific PK/PD profiles, or secondary forms of hypertension resulting in blood pressure control rates in the range of 50% of patients on therapy. RAAS Triple-A testing is based on a high-throughput mass-spectrometry assay for quantification of Angiotensin I (Ang I), Angiotenisn II (Ang II) and Aldosterone in standard serum or plasma samples by RAAS equilibrium analysis. Obtained hormone levels are used to calculate markers for plasma-renin-activity (PRA-S), plasma angiotensin-converting-enzyme activity (ACE-S) and adrenal function (AA2-Ratio). The diagnostic performance of the AA2-Ratio in screening for primary aldosteronism (PA) has been compared to the aldosterone-to-renin ratio (ARR) as putative gold standard in resistant hypertensive patients, revealing major advantages of the AA2-Ratio especially in terms of usability and drug interference. A diagnostic scheme for the stratification of first-line non-responding hypertensive patients has been developed to improve the control rates for hypertension and to provide an easy-to-handle diagnostic tool for physicians involved in first-line treatment of hypertension. RAAS Triple-A analysis for the first time provides insights into a patient’s RAAS at the level of effector hormones, molecular regulation and patient specific pharmacologic responses to anti-hypertensive therapies and has the potential to result in significant changes in hypertension care in clinical practice by introducing personalized treatments based on an easy and effective diagnostic tool.

Abstract P3059: ACE S: A NOVEL ANGIOTENSIN BASED MARKER FOR MONITORING PHARMACOLOGIC ACTIVITY OF ACE INHIBITORS IN HYPERTENSIVE PATIENTS

Angiotensin-converting-enzyme-inhibitors (ACEi) are widely used for treating hypertension and cardiovascular diseases and block Angiotensin-II (Ang-II) formation from Angiotensin-I (Ang-I). The therapeutic response to ACE inhibition critically depends on in vivo pharmacologic efficacy and affected by dosing, patient compliance and patient specific compensatory mechanisms, all being relevant topics for the clinical management of hypertension.

Samples were collected from 19 hypertensive patients and 7 confirmed primary aldosteronism (PA) patients. Hypertensive patients were investigated at baseline and after 4 weeks on therapy with a single daily dose of perindopril. PA patients were sampled before and after 14 day administration of ramipril. All samples were analysed by LC-MS/MS based RAAS Triple-A testing which involves the calculation of ACE-S, the ratio between plasma equilibrium levels of Ang-II and Ang-I as a novel marker for circulating ACE activity. ACE activity was further measured by analyzing the time dependent conversion of spiked Ang-I (LC-MS/MS) and by performing a clinical colorimetric ACE assay. Treatment adherence was confirmed by quantification of plasma drug levels.

ACE-S was significantly lower in all patients on perindopril or ramipril therapy compared to baseline (MEDIANS: 0.35 vs. 2.75 pM/pM, p<0.001). While eqAng-II levels were increased up to 5-fold compared to baseline levels in a subset of patients due to renin up-regulation, ACE-S stayed significantly suppressed in all samples investigated. In contrast, ACE inhibition appeared to be less effective using classical enzymatic approaches assessing ACE activity.

The novel angiotensin based marker ACE-S can be used to monitor pharmacologic efficacy of ACE inhibitors independent of their chemical structure. As part of the RAAS Triple-A test that is currently validated in screening for secondary forms of hypertension, ACE-S has the potential to support the clinical management of first-line non-responders in terms of optimizing ACEi dosing and visualizing patient specific compensatory mechanisms, thereby improving the overall control rates in hypertension.

Endothelin-1 and angiotensin-II modulate urotensin-II vasoconstriction in rat aorta exposed to mercury

OBJECTIVES

The aim of this study was to evaluate the possible roles of endothelin-1 and angiotensin-II in urotensin-II vasoconstriction and in endothelial dysfunction induced by mercury.

BACKGROUND

Urotensin-II, the most potent vasoactive peptide, is entwined with the cardiovascular diseases and has been labelled as a new pathophysiological biomarker.

METHODS

Rat aortic rings were pre-incubated with sb-710411, bq-123, and captopril. Doses of human urotensin-II with increased concentrations were applied in all groups in the presence or absence of mercury chloride. In another set of the experiment, aortic rings were treated with a single dose of mercury chloride in the presence of each of the above blockers.

RESULTS

Angiotensin-II and endothelin-1 mediated the vascular responses to the peptide urotensin-II under conditions of both intact endothelium and endothelial impairments induced by mercury. Urotensin-II, angiotensin-II and endothelin-1 significantly participated in vascular responses to mercury chloride.

CONCLUSION

The novel finding was that urotensin-II is potentiated under the condition of endothelial dysfunction. Endothelin-1 and angiotensin-II pathways could be heavily exploited in modulating endothelial dysfunction impacts and peptide vascular actions (Tab. 1, Fig. 4, Ref. 30).

Aldosterone LC-MS/MS Assay-Specific Threshold Values in Screening and Confirmatory Testing for Primary Aldosteronism

CONTEXT

Current threshold values for primary aldosteronism (PA) diagnostic testing are based on measuring aldosterone (PAC) using immunoassays. Quantification of PAC by liquid chromatography-tandem mass spectrometry (LC-MS/MS) yields lower values.

OBJECTIVE

To compare aldosterone measurement by radioimmunoassay (RIA) with LC-MS/MS and evaluate performances of proposed LC-MS/MS-specific cutoffs for PA screening and confirmatory testing.

PATIENTS AND INTERVENTION

Forty-one patients underwent aldosterone/renin ratio (ARR) testing to screen for, and fludrocortisone suppression testing (FST) to confirm or exclude, PA. Renin (DRC) was measured by chemiluminescent immunoassay.

RESULTS

Median serum PACLC-MS/MS was 27.8% lower (P < 0.05) than plasma PACRIA in 164 pairs of FST samples. A positive correlation (Spearman coefficient, 0.894, P < 0.01; Pearson r coefficient, 0.861, P < 0.01) was observed between the two assays. Thirty-seven patients showed consistent FST diagnoses (29 positive, 8 negative), whereas four showed inconsistent FSTs by the two assays. Good agreement (κ coefficient, 0.736; P < 0.01) was observed between the current FST diagnostic PACRIA cutoff of 165 pmol/L and the proposed PACLC-MS/MS cutoff of 133 pmol/L. Among 37 patients with consistent FST results, no differences were observed in sensitivity (89.7% vs 93.1%) or specificity (87.5% vs 87.5%) for PA screening between the current ARR cutoff of 70 pmol/mU (PACRIA/DRC) and the proposed cutoff of 55 pmol/mU (PACLC-MS/MS/DRC).

CONCLUSIONS

Adjustment of the current cutoffs for PA diagnostic testing is necessary if PAC is measured by LC-MS/MS. Our preliminary results suggest that the proposed LC-MS/MS cutoffs for ARR and FST perform as well as current RIA cutoffs.

Comparison of Seated With Recumbent Saline Suppression Testing for the Diagnosis of Primary Aldosteronism

CONTEXT

Failure of plasma aldosterone suppression during fludrocortisone suppression testing (FST) or saline suppression testing (SST) confirms primary aldosteronism (PA). Aldosterone is often higher upright than recumbent in PA; upright levels are used during FST. In a pilot study (24 patients with PA), seated saline suppression testing (SSST) was more sensitive than recumbent saline suppression testing (RSST).

OBJECTIVE, DESIGN, AND PATIENTS

The current validation study involved 100 patients who underwent FST, RSST, and SSST, eight before and after unilateral adrenalectomy. Of the 108 FSTs, 73 confirmed and 18 excluded PA. Four patients with inconclusive FST lateralized on adrenal venous sampling, making a total of 77 with PA.

RESULTS

The area under the receiver operating characteristic (ROC) curve was greater for SSST than RSST (0.96 vs. 0.80; P < 0.01). ROC analysis predicted optimal cutoff aldosterone levels of 162 pmol/L for SSST and 106 pmol/L for RSST. At these cutoffs, SSST showed high sensitivity for PA (87%) that markedly exceeded that for RSST (38%; P < 0.001) but similar specificity (94 vs. 94%; not significant). SSST was more sensitive than RSST in detecting both unilateral (n = 28, 93% vs. 68%, P < 0.05) and bilateral (n = 40, 85% vs. 20%, P < 0.001) forms of PA. Only three SSST (vs. 9 RSST and 17 FST) results were inconclusive.

CONCLUSIONS

SSST is highly sensitive and superior to RSST in identifying both unilateral and bilateral forms of PA and has a low rate of false positives and inconclusive results. It therefore offers a reliable and much less complicated and expensive alternative to FST for confirming PA.

Abstract P251: Angiotensin Based Biomarkers for Molecular Profiling and Drug Efficacy Monitoring in Hypertension

RAAS Triple-A testing is a novel mass spectrometry based approach providing a comprehensive biochemical evaluation of the circulating renin-angiotensin-system (RAS) on the basis of equilibrium angiotensin levels and circulating aldosterone levels. In contrast to previous technologies involving complex sampling procedures, RAS-Equilibrium-Analysis combines the robustness and accuracy of LC-MS/MS based quantification with the versatility of serum sampling to generate a highly accurate readout containing multiple layers of information regarding the biochemical features of the circulating RAAS. Equilibrium Angiotensin I (Ang I), Angiotensin II (Ang II) and Aldosterone were simultaneously quantified in 500μl of standard collected serum samples from healthy volunteers or hypertensive patients receiving different anti-hypertensive first-line therapies. Stable-isotope labeled internal standards were used to control for analyte recovery. Following analyte extraction, samples were subjected to UPLC-MS/MS analysis and diagnostic ratios were calculated. ACE inhibitor therapy resulted in a significant reduction of the Ang II-to-Ang I-Ratio in equilibrium analysis, which was accompanied by an up-regulation of renin, as expected. Surprisingly, PRA showed a high correlation with the sum of equilibrium Ang I and Ang II, which was independent of ACE inhibitor treatment. While the ARR was strongly suppressed in the presence of ACE inhibitor treatment, the Aldosterone-to-Angiotensin II-Ratio (AA2-Ratio) was not affected, suggesting superior applicability in screening for primary aldosteronism (PA). RAAS Triple-A testing is a mass spectrometry based multiplex assay combining Ang I, Ang II and Aldosterone to diagnostic values that draw a comprehensive picture of a patient’s "RAAS Status". While the sum of Ang I and Ang II serves as a strong PRA surrogate marker, ACE activity and ACE inhibitor therapy efficacy can be monitored using the Ang II/Ang I-Ratio. On top, the AA2-Ratio serves as an advanced diagnostic marker for PA that might pave the way for patient screening without the need of withdrawing anti-hypertensive therapies.

Effect of Combined Hormonal Replacement Therapy on the Aldosterone/Renin Ratio in Postmenopausal Women

BACKGROUND

Plasma aldosterone/renin ratio (ARR) is the most popular screening test for primary aldosteronism (PA). Because both estrogen and progesterone (including in oral contraceptive agents) affect aldosterone and renin levels, we studied the effects of combined hormonal replacement therapy (HRT) on ARR; renin was measured as both direct renin concentration (DRC) and plasma renin activity (PRA).

METHODS

Fifteen normotensive, healthy postmenopausal women underwent measurement (seated, midmorning) of plasma aldosterone, DRC, PRA, electrolytes, and creatinine and urinary aldosterone, cortisol, electrolytes, and creatinine at baseline and after 2 weeks and 6 weeks of treatment with combined HRT (conjugated estrogens 0.625 mg and medroxyprogesterone 2.5 mg daily).

RESULTS

Combined HRT was associated with statistically significant increases in aldosterone [median (range): baseline, 150 (85 to 600); 2 weeks, 230 (129 to 790); 6 weeks, 434 (200 to 1200) pmol/L; P < 0.001 (Friedman test)] and PRA [2.3 (1.2 to 4.3), 3.8 (1.4 to 7.0), 5.1 (1.4 to 10.8) ng/mL/h, respectively; P < 0.001] but decreases in DRC [21 (10 to 31), 21 (10 to 39), and 14 (8.0 to 30) mU/L, respectively; P < 0.01], leading to increases in ARR calculated by DRC [7.8 (3.6 to 34.8), 11.4 (5.4 to 48.5), and 30.4 (10.5 to 90.2), respectively; P < 0.001]. The ARR calculated by DRC exceeded the cutoff value (70) in three patients after 6 weeks. There were no significant changes in ARR calculated by PRA [79 (26 to 184), 91 (23 to 166), and 88 (50 to 230), respectively; P = 0.282], plasma electrolytes and creatinine, or any urinary measurements.

CONCLUSION

The combined oral HRT used in this study is capable of significantly increasing ARR with a risk of false-positive results during screening for PA but only if DRC (and not PRA) is used to calculate the ratio.

Effect of Moxonidine on the Aldosterone/Renin Ratio in Healthy Male Volunteers

BACKGROUND

The most popular screening test for primary aldosteronism is the plasma aldosterone/renin ratio (ARR). Medications, dietary sodium, posture, and time of day all affect renin and aldosterone levels and can result in false-negative or false-positive ARRs if not controlled. Most antihypertensive medications affect the ARR and can interfere with interpretation of results. To our knowledge, no study has been undertaken to evaluate the effects of moxonidine on the ARR.

METHODS

Normotensive, nonmedicated male volunteers (n = 20) underwent measurement (seated, midmorning) of plasma aldosterone (by high-performance liquid chromatography-tandem mass spectrometry), direct renin concentration (DRC), plasma renin activity (PRA), cortisol, electrolytes and creatinine; and urinary aldosterone, cortisol, electrolytes and creatinine at baseline and after 1 week of moxonidine at 0.2 mg/d and a further 5 weeks at 0.4 mg/d.

RESULTS

Compared with baseline, despite the expected significant falls in both systolic and diastolic blood pressure, levels of plasma aldosterone [median, 134 (range, 90 to 535) pmol/L], DRC [20 (10 to 37) mU/L], PRA [2.2 (1.0-3.8) ng/mL/h], and ARR using either DRC [8.0 (4.4 to 14.4)] or PRA [73 (36 to 218)] were not significantly changed after either 1 [135 (98-550) pmol/L, 20 (11-35) mU/L, 2.0 (1.2-4.1) ng/mL/h, 8.8 (4.2 to 15.9), and 73 (32-194), respectively] or 6 weeks [130 (90-500) pmol/L, 22 (8 to 40) mU/L, 2.1 (1.0 to 3.2) ng/mL/h, 7.7 (4.3 to 22.4), and 84 (32 to 192), respectively] of moxonidine. There were no changes in any urinary measurements.

CONCLUSION

Moxonidine was associated with no significant change in the ARR and may therefore be a good option for maintaining control of hypertension when screening for primary aldosteronism.

Does ACTH improve the diagnostic performance of adrenal vein sampling for subtyping primary aldosteronism?

OBJECTIVE

Adrenal vein sampling (AVS) is used for determining treatment options for primary aldosteronism (PA), but is a difficult procedure. Adrenocorticotropic hormone (ACTH) infusion or bolus has been reported to improve AVS success rates by increasing cortisol secretion, but effects on lateralization are controversial. We therefore assessed the effects of ACTH in regard to AVS success and lateralization in our unit, after a change in protocol to ACTH-stimulated AVS.

SETTING

AVS was performed after overnight recumbency in patients with PA confirmed by fludrocortisone suppression testing. Bilateral sequential sampling was performed before and after an intravenous bolus of 250 mcg of ACTH. Lateralization was defined as an aldosterone/cortisol ratio in one adrenal vein at least twice peripheral, combined with a contralateral adrenal ratio no higher than peripheral (contralateral suppression).

RESULTS

In 47 AVS procedures, the median adrenal/peripheral cortisol gradient increased on the left (11·6 vs 18·2 μg/100 ml, P < 0·001) and right (15·6 vs 31·5 μg/100 ml, P < 0·001) after ACTH. A total of 34 of 47 studies were diagnostic pre-ACTH (six failing because of low aldosterone levels bilaterally and seven failing to cannulate one or both sides) vs 44 of 47 (P = 0·011) studies diagnostic post-ACTH (failure to cannulate one or both sides in 3). Concordance between diagnostic studies pre- and post-ACTH was 91%, but two bilateral cases became unilateral after ACTH and one unilateral case before ACTH was bilateral afterwards.

CONCLUSIONS

ACTH improved cortisol gradients and aldosterone secretion, resulting in a reduction in the proportion of nondiagnostic studies. There was a low proportion of discordance between pre- and post-ACTH diagnoses, the significance of which is unclear.

Abstract P612: The AA2-Ratio: Towards Improved Screening for Primary Aldosteronism

Background: Primary aldosteronism (PA) is a widely under-diagnosed, potentially curable and specifically treatable cause of hypertension. PA screening involves measuring the aldosterone-to-renin-ratio (ARR), but false negative results can occur in the setting of medications, which block the renin-angiotensin system (RAS). Withdrawing RAS blockers from patients with resistant hypertension is not without cardiovascular risk. A novel diagnostic approach, the aldosterone-to-angiotensin-II-ratio (AA2-Ratio), has the potential for less drug interference and improved reliability in PA screening and confirmation of diagnosis.

Methods: Serum samples from 80 patients undergoing PA confirmation testing were analyzed. Sampling was performed in a recumbent (7 a.m.) and in an upright (10 a.m.) position before and after 4 days of oral administration of fludrocortisone and salt loading. The concentrations of renin, aldosterone and equilibrium Angiotensin-II were determined and ARR and AA2-Ratios were calculated. The interference of ACE-inhibition with the AA2-Ratio was investigated in healthy volunteers receiving 10mg enalapril daily for 8 days.

Results: Renin concentration was undetectable in more than 40% of samples, while equilibrium Angiotensin-II was measurable in 98% of all 320 samples analyzed. Angiotensin-II levels were significantly higher in upright collected samples compared to samples collected in a recumbent position. Comparison of the ARR with the AA2-Ratio revealed a significantly larger diagnostic window for the AA2-Ratio. While the ARR was significantly suppressed by ACE-inhibitor treatment, the AA2-Ratio remained unaffected by ACE-inhibition.

Conclusion: The AA2-Ratio may be superior to the ARR in PA screening among hypertensive patients. Equilibrium Angiotensin-II levels show expected responses to posture and appear to outperform renin concentration as a marker for RAS activation in terms of sensitivity, giving a measurable readout even in clinical states characterized by markedly suppressed RAS activity. The stability of the AA2-Ratio in the presence of ACE-inhibition points to a potential use of the AA2-Ratio PA screening in hypertensive patients without ACE-inhibitor discontinuation.

Presentation and Treatment Outcomes of 100 Lupus Nephritis Patients: Single Center Study

Over a period of 3 years (January 2011 to December 2013) 100 cases of Lupus nephritis patients admitted in nephrology department of Bangabandhu Sheikh Mujib Medical University (BSMMU) were evaluated. Their clinical characteristics, biochemical parameters, renal histology according to WHO classification were categorized and their treatment modalities and outcome was observed. Among 100 patients, 84 were female and 16 were male, with F:M ratio 5:1. Mean age of female were 23±4 years and male were 29±4 years, mean BP in male was systolic 135±8 mmHg, diastolic 80±9mmHg and in female systolic was 130±7mmHg, diastolic 75±6 mmHg, mean Serum Creatinine for male was 180±12μmol/L and mean serum creatinine in female was 170±20μmol/L. Sixty five percent (65%) patient showed extra renal manifestation. All patients presented with proteinuria, among them 45% were nephrotic presentation, 25% patients presented with acute nephritic illness, 15% were nephritic nephrotic, 10% patients had rapidly progressing glomerulonephritis (RPGN), and 5% were with asymptomatic proteinuria. Renal biopsy of 100 patient according to WHO classification showed class I - 5%, class II - 20%, class III - 26%, class IV - 35%, class V - 8%, class VI - 6%. Immunosuppressive protocol used was prednisolone and cyclophorphamide in the majority of patients in class III to class VI LN patients. Few patients received prednisolone and mycophenolate mofetil. Twenty four percent (24%) patients were in complete remission during this study period and 12% developed end stage renal disease (ESRD). Seventy six percent (76%) patients passed through various stages of CKD, majority of them were in CKD stage IV and stage III, and few were in CKD stage I and stage II. About 70% of the participants had suffered from one or more complications, where majority were infections. Infections and renal failure were the leading cause of death in our study.

Does concomitant autonomous adrenal cortisol overproduction have the potential to confound the interpretation of adrenal venous sampling in primary aldosteronism?

OBJECTIVE

Demonstration of unilateral aldosterone production by adrenal venous sampling (AVS) is required to select appropriate candidates for adrenalectomy in patients with primary aldosteronism (PA). During AVS, aldosterone and cortisol levels are measured to assess successful cannulation and lateralization. In patients with aldosterone-producing adenoma (APA), concurrent autonomous cortisol secretion might confound AVS results.

DESIGN AND PATIENTS

We retrospectively examined results in eight patients with cortisol-producing adenoma (CPA), but without PA, who underwent AVS.

RESULTS

In all eight, cortisol was higher on the CPA side than contralateral (CL) (median 6·7-fold [range 2·4-27·2]; P = 0·012]). By cortisol criteria, CL catheter placement would have been labelled inadequate in six despite adrenal venous aldosterone levels markedly higher than peripheral (41·6-fold [7·2-510·5]; P < 0·001), suggesting successful cannulation. In all eight, adrenal venous aldosterone/cortisol (A/C) ratios on the CL side were indicative of increased aldosterone production (≥2 times peripheral), but in only three patients on the CPA side (difference CL side 44·5-fold [6·0-109·0] vs CPA side 1·65-fold [1·0-23·0]; P = 0·017). A/C ratios were higher on the CL vs the CPA side in seven (20·0-fold [4·7-76·0]).

CONCLUSION

These results in patients with CPA suggest that in patients with APA, concurrent autonomous unilateral cortisol hypersecretion could confound AVS accuracy by increasing cortisol levels (reducing A/C ratio) on the CPA side, while reducing levels (increasing A/C ratio and suggesting failed cannulation) on the CL side. Misclassification of PA subtype or repeat AVS could result, underscoring the importance of adequately assessing cortisol production prior to AVS and the need to consider alternatives.

Should aldosterone suppression tests be conducted during a particular phase of the menstrual cycle, and, if so, which phase? Results of a preliminary study

BACKGROUND

As renin and aldosterone levels vary during the menstrual cycle, and are critical criteria for interpretation of aldosterone suppression tests to confirm or exclude primary aldosteronism, outcome of testing may vary depending on the menstrual cycle phase. We assessed the effect of timing within the menstrual cycle on levels of renin, aldosterone and female sex steroids during fludrocortisone suppression testing (FST).

METHODS

In 22 women undergoing FST who experienced regular menstrual cycles, renin (measured as both plasma renin activity and direct renin concentration), aldosterone (mass spectrometry) and cortisol, progesterone, oestradiol, LH and FSH (immunoassay) levels were compared, relative to phase of cycle. Aldosterone levels were compared to those in age-matched males undergoing FST.

RESULTS

Progesterone (P < 0·0001) and aldosterone (P = 0·006) levels were higher in nine women (after one of 10 was excluded with anovulatory cycle) studied during the luteal phase than in the 12 studied during the follicular phase. All studied during the luteal phase had positive FST, and all three with negative FST were studied during the follicular phase. There were no significant differences in other parameters measured except FSH, which was higher (P = 0·02) during the follicular phase. Aldosterone was higher (P = 0·01) in women studied in the luteal (but not follicular) phase compared to men.

CONCLUSION

The menstrual cycle may affect the outcome of FST and other suppression testing used to diagnose primary aldosteronism. Larger patient numbers and preferably restudy of the same patient in both phases should clarify this and determine the optimum time in the cycle for testing.

Does contralateral suppression at adrenal venous sampling predict outcome following unilateral adrenalectomy for primary aldosteronism? A retrospective study

CONTEXT

In primary aldosteronism (PA), adrenal vein sampling (AVS) distinguishes unilateral and bilateral disease by comparison of aldosterone/cortisol (A/F) ratios. There is controversy about the criteria for interpretation, however, and in particular it is not clear whether contralateral suppression (CS) (defined as A/F(adrenal) ≤ A/F(peripheral) on the unaffected side) is important. We therefore performed a retrospective study to determine whether CS in surgically treated unilateral PA was associated with blood pressure (BP) and biochemical outcomes.

SETTING AND DESIGN

Patients who underwent unilateral adrenalectomy for PA after successful AVS were included if the lateralization index (A/F(dominant):A/F(nondominant)) was ≥ 2. Cases were reviewed at 6 to 24 months follow-up for outcomes with respect to the presence and degree of CS.

RESULTS

Sixty-six of 80 patients had CS. Baseline characteristics were similar. At postoperative follow-up, those with CS had lower systolic BP (SBP) (128 mm Hg vs 144 mm Hg, P = .001), a greater proportion with cure or improvement of hypertension (96% vs 64%, P = .0034), a greater proportion with biochemical cure of PA on fludrocortisone suppression testing (43 of 49 [88%] vs 4 of 9 [44%], P = .002) and were taking a lower median number of antihypertensive medications (0 vs 1.5, P = .0032). In a multivariate model, the degree of CS and preoperative SBP were both significantly correlated with postoperative SBP, but the lateralization index, sex, and age were not.

CONCLUSION

In this study, the presence of CS correlated with good BP and biochemical outcomes from surgery. This finding suggests that CS should be a factor in deciding whether to offer surgery for treatment of PA.

Seated saline suppression testing for the diagnosis of primary aldosteronism: a preliminary study

CONTEXT

Failure of aldosterone suppression by sodium loading during fludrocortisone suppression testing (FST) or saline suppression testing (SST) confirms primary aldosteronism (PA). We previously found recumbent SST (RSST) to lack sensitivity. Aldosterone levels can be higher upright (e.g. seated) than recumbent in patients with PA and upright levels are used during FST. We therefore hypothesized that seated SST (SSST) is more sensitive than RSST, especially for posture-responsive PA.

SETTING AND DESIGN

Of 66 patients who underwent FST (upright plasma aldosterone levels measured at 10am basally and after 4 days fludrocortisone 0.1 mg 6-hourly and oral salt loading), 31 underwent SST (aldosterone levels measured basally at 8am and after infusion of 2 L normal saline over 4h) both recumbent and seated in randomized order and at least 2 weeks apart.

RESULTS

FST confirmed PA in 23 of 31 patients (day 4 upright aldosterone level >165 pmol/L), excluded PA in three and was originally "inconclusive" in five. However, one with "inconclusive" FST had PA confirmed by lateralizing AVS and was reclassified "unilateral PA". Of 24 with confirmed PA (eight unilateral, 11 bilateral, and five undetermined subtype), 23 (96%) tested positive by SSST (4-h aldosterone level >165 pmol/L) compared with 8 (33%) by RSST (4-h plasma aldosterone level >140 pmol/L) (P < .001). RSST missed one unilateral, all bilateral, and four with as-yet undetermined subtype. RSST was positive in 7 of 10 (70%) posture-unresponsive vs one of 14 (7.1%) posture-responsive patients (P < .005).

CONCLUSION

These preliminary results suggest that seated SST may be superior to recumbent SST in terms of sensitivity for detecting PA, especially posture-responsive forms, and may represent a reliable alternative to FST.

Role of protocol biopsy in early graft dysfunction in renal transplant recipient

This study was designed to evaluate the role of protocol biopsy in renal allograft recipients. A total of thirty five kidney transplant recipients with a mean age of 35±5 years included in this study. Mean age of donor was 41±8 years. The study was performed from April 2008 to November 2009 in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Immunosuppressive protocol used for transplant patient was, Cyclosporine 8mg/kg/day, Mycophenolate mofetil (MMF) 500mg twice daily, Prednisolone 0.5mg/kg/day. Protocol biopsy done on day 0 (Peroperative), day 14 and day 90. Stains used H&E and PAS. Cyclosporine blood level was done on 7th and 14th postoperative day and monthly for 3 months. Serum creatinine was done daily for 14 days & then weekly upto 3 months. Among 35 patients 23(66%) showed normal graft function and 12(34%) early graft dysfunction. Aetiology of early graft dysfunction includes 50% clinical rejection, 17% acute tubular necrosis (ATN), 17% cyclosporine toxicity, 8% graft thrombosis and 8% recurrence of GN. Per operative protocol biopsy showed normal histology in 28(80%) cases, in 4 cases 11% glomeruli showed sclerosis and in 3 cases 9% glomeruli showed sclerosis. At 14th post operative day 60% patients showed normal histology, 14% had clinical rejection (elevated serum creatinine along with histological features of rejection), another 14% had sub clinical rejections (normal serum creatinine with histological changes), cyclosporine toxicity 5.6%, ATN 5.6%, and recurrent glomerulonephritis in 3% cases. Among clinical rejection, according to Banff numerical classification, Grade-1 (20%), Grade-2 (60%), Grade-3 (20%) and among sub clinical rejections Banff Grade-1 (80%), Grade-2 (20%). Biopsy after 3 months showed normal histology 54.28%, clinical rejection 11.42%, sub clinical rejection 5.7%, borderline change 5.7%, cyclosporine toxicity 5.7% & 2.8% recurrent glomerulonephritis. According to Banff numerical classification in clinical rejection Banff Grade-1 (25%), Grade-2 (50%) and Grade-3 (25%). Among subclinical rejection Banff Grade-1 (70%), Grade-2 (30%).

Factors affecting the aldosterone/renin ratio

Although the aldosterone/renin ratio (ARR) is the most reliable screening test for primary aldo-steronism, false positives and negatives occur. Dietary salt restriction, concomitant malignant or renovascular hypertension, pregnancy and treatment with diuretics (including spironolactone), dihydropyridine calcium blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor antagonists can produce false negatives by stimulating renin. We recently reported selective serotonin reuptake inhibitors lower the ratio. Because potassium regulates aldosterone, uncorrected hypokalemia can lead to false negatives. Beta-blockers, alpha-methyldopa, clonidine, and nonsteroidal anti-inflammatory drugs suppress renin, raising the ARR with potential for false positives. False positives may occur in patients with renal dysfunction or advancing age. We recently showed that (1) females have higher ratios than males, and (2) false positive ratios can occur during the luteal menstrual phase and while taking an oral ethynylestradiol/drospirenone (but not implanted subdermal etonogestrel) contraceptive, but only if calculated using direct renin concentration and not plasma renin activity. Where feasible, diuretics should be ceased at least 6 weeks and other interfering medications at least 2 before ARR measurement, substituting noninterfering agents (e. g., verapamil slow-release±hydralazine and prazosin or doxazosin) were required. Hypokalemia should be corrected and a liberal salt diet encouraged. Collecting blood midmorning from seated patients following 2-4 h upright posture improves sensitivity. The ARR is a screening test only and should be repeated once or more before deciding whether to proceed to confirmatory suppression testing. Liquid chromatography-tandem mass spectrometry aldosterone assays represent a major advance towards addressing inaccuracies inherent in other available methods.

Cardiac dimensions are largely determined by dietary salt in patients with primary aldosteronism: results of a case-control study

CONTEXT

Animal studies have demonstrated that dietary sodium intake is a major influence in the pathogenesis of aldosterone-induced effects in the heart such as left ventricular (LV) hypertrophy and fibrosis. LV hypertrophy is an important predictor for cardiovascular morbidity and mortality.

OBJECTIVE

We aimed to investigate the relationships between aldosterone and dietary salt and LV dimensions in patients with primary aldosteronism (PA).

DESIGN AND PARTICIPANTS

This case-control study included 21 patients with confirmed PA and 21 control patients with essential hypertension matched for age, gender, duration of hypertension, and 24-h systolic and diastolic blood pressure.

MAIN OUTCOME MEASURES

Patients were evaluated by echocardiography and 24-h urinary sodium (UNa) excretion while consuming their usual diets.

RESULTS

Patients with PA had significantly greater mean LV end-diastolic diameter, interventricular septum and posterior wall thicknesses, LV mass (LVM) and LV mass index, and end systolic and diastolic volumes than control patients. UNa significantly positively correlated with interventricular septum, posterior wall thicknesses, and LVM in the patients with PA but not in control patients. In a multivariate analysis, UNa was an independent predictor for LV wall thickness and LV mass among the patients with PA but not in patients with essential hypertension.

CONCLUSIONS

These findings emphasize the importance of dietary sodium in determining the degree of cardiac damage in those patients with PA, and we suggest that aldosterone excess may play a permissive role. In patients with PA, because a high-salt diet is associated with greater LVM, dietary salt restriction might reduce cardiovascular risk.

Quality of life in patients with bilateral primary aldosteronism before and during treatment with spironolactone and/or amiloride, including a comparison with our previously published results in those with unilateral disease treated surgically

BACKGROUND

Measurement of quality of life (QOL) allows assessment of the impact of a disease or treatment from the patient's perspective, including need for social, emotional, or physical support. We are not aware of any published QOL assessment in patients with bilateral primary aldosteronism (BPA), before or after commencing medical treatment (MT) with spironolactone and/or amiloride.

METHODS

Using the internationally validated Medical Outcomes Study Short Form 36 General Health Survey (SF-36), QOL was assessed in 21 patients with BPA at baseline (time of diagnosis), and at 3 and 6 months after commencing MT. QOL scores at baseline were compared with published normative values for the Australian population. The results of the current study were compared with those from our previous study showing reduced QOL in patients with unilateral primary aldosteronism (UPA) with normalization by 3 months after unilateral laparoscopic adrenalectomy.

RESULTS

Compared with the general population, patients with BPA showed significant reduction (P < 0.01) in four QOL domains--physical functioning, role limitations due to physical health problems, general health perceptions, and vitality. After 6 months (but not 3 months) of MT, statistically significant (P < 0.05) improvements were detected in all these domains of QOL. When compared with patients with UPA treated surgically, scores were significantly (P < 0.05) lower at 3 months for five domains (role limitations due to physical health, general health, role limitations due to emotional health, mental health, and vitality) but at 6 months for only one domain (role limitations due to emotional problems).

CONCLUSION

Subnormal QOL scores were improved after 6 months of MT in 21 patients with BPA, but more slowly and to a lesser degree than surgical treatment had previously been shown to improve QOL scores in 22 patients with UPA.

Effect of contraceptives on aldosterone/renin ratio may vary according to the components of contraceptive, renin assay method, and possibly route of administration

BACKGROUND

The most popular screening test for primary aldosteronism is plasma aldosterone/renin ratio (ARR). Because both estrogen and progesterone affect aldosterone and renin levels, we studied effects of two contraceptives commonly used in our population, one oral and one subdermal, on ARR, measuring renin as both direct renin concentration (DRC) and plasma renin activity (PRA).

METHODS

Normotensive, healthy women underwent measurement (seated, midmorning) of plasma aldosterone, DRC, PRA, electrolytes, and creatinine and urinary aldosterone, cortisol, electrolytes, and creatinine at baseline (menses) and after either 1) 3 wk treatment with oral ethinylestradiol plus drospirenone (n = 17) or 2) 1 wk and 6 wk treatment with subdermal etonogestrel (n = 15), a third-generation progestin.

RESULTS

Treatment with oral ethinylestradiol plus drospirenone was associated with significant increases in aldosterone [median (range) at baseline = 131 (85-590) pmol/liter; at 1 wk, 200 (130-784) pmol/liter; and at 3 wk, 412 (199-1010) pmol/liter (P < 0.001, Friedman test)] and PRA [2.1 (1.2-4.7), 3.6 (1.5-7.1), and 4.9 (1.5-10.8) ng/ml · h, P < 0.001] but decreases in DRC [22 (11-36), 21 (8.7-41), and 14 (8.5-39) mU/liter, P < 0.01] leading to increases in ARR calculated by DRC [6.6 (3.3-31.3), 10.9 (5.2-58.9), and 29.8 (5.1-88.5), P < 0.001]. There were no significant changes in ARR calculated by PRA, plasma electrolytes and creatinine, and all urinary measurements. In contrast, treatment with subdermal etonogestrel was associated with no significant changes in PRA, DRC, aldosterone, or ARR at either 1 or 6 wk.

CONCLUSION

The combined oral contraceptive ethinylestradiol plus drospirenone is capable of significantly increasing ARR with risk of false-positive results during screening for primary aldosteronism, but only if DRC is used to calculate the ratio. Subdermal etonogestrel had no effect on ARR after 6 wk.

Effects of two selective serotonin reuptake inhibitor antidepressants, sertraline and escitalopram, on aldosterone/renin ratio in normotensive depressed male patients

BACKGROUND

Plasma aldosterone to renin ratio (ARR) is the most popular screening test for primary aldosteronism (PAL). Certain medications are known to cause false-negative or -positive ARRs by affecting renin and aldosterone levels. There are no previously published data on the effects of antidepressants on ARR.

METHODS

Normotensive, depressed male patients (n = 26) underwent measurement (seated, midmorning) of plasma aldosterone, direct renin concentration (DRC), renin activity (PRA), electrolytes and creatinine and urinary aldosterone, cortisol, electrolytes, and creatinine at baseline and after 2 and 6 wk treatment with sertraline (n = 14) or escitalopram (n = 12).

RESULTS

For both antidepressants, treatment was associated with rises in aldosterone [sertraline: baseline, mean ± sd, 243 ± 34; 2 wk, 256 ± 33; 6 wk, 267 ± 34 pmol/liter (P < 0.01 by ANOVA); escitalopram, 261 ± 36, 269 ± 38, 282 ± 40 pmol/liter (P < 0.05)], DRC [19.5 ± 2.2, 33.5 ± 2.0, 39.0 ± 2.4 mU/liter (P < 0.001); 24.5 ± 2.4, 34.0 ± 2.7, 42.8 ± 2.4 mU/liter (P < 0.001)], and PRA [2.24 ± 0.21, 2.58 ± 0.26, 4.68 ± 0.42 ng/ml · h (P < 0.001); 4.31 ± 0.22, 5.57 ± 0.36, 6.42 ± 0.53 ng/ml · h (P < 0.001)]. ARR fell significantly whether calculated using DRC [sertraline, 13.7 ± 2.2, 7.5 ± 0.7, 6.8 ± 0.7 (P < 0.001); escitalopram, 11.5 ± 1.9, 8.0 ± 1.1, 6.6 ± 1.0 (P < 0.001)], or PRA [116.6 ± 15.8, 108.4 ± 15.6, 60.4 ± 6.2 (P < 0.001); 61.2 ± 8.1, 50.0 ± 7.7, 45.6 ± 6.0 (P < 0.01)].

CONCLUSION

Selective serotonin reuptake inhibitor antidepressants can significantly reduce ARR and therefore potentially increase the risk of false-negative results when screening for PAL. Further studies in hypertensive patients, including patients with confirmed PAL, are required.

Are women more at risk of false-positive primary aldosteronism screening and unnecessary suppression testing than men?

BACKGROUND

Because primary aldosteronism is not uncommon, specifically treatable and in some cases curable, and carries higher risks for cardiovascular morbidity and mortality than essential hypertension, screening hypertensive patients for its presence by measuring aldosterone to renin ratio (ARR) is increasingly common. A significantly higher false-positive ARR rate for women than men, resulting in unnecessary suppression tests has previously been reported.

METHODS

Using a new, highly accurate aldosterone assay and both of the currently widely used renin assays, ARR was measured in 19 normal, ovulating women at three time points in the menstrual cycle and compared with single measurements in 21 normal males of similar age.

RESULTS

ARRs in males were possibly too well down in the current normal range. Although normotensive and normokalemic, two women had raised ARRs in the luteal phase but only when direct renin concentration (DRC) was used. Their DRC levels were low at all sampling times [despite midrange plasma renin activity levels], whereas their progesterone and aldosterone levels were highest for the group. Saline suppression testing, performed in one of them, showed normal aldosterone suppressibility.

CONCLUSION

False-positive ARRs in normal women during the luteal phase only when DRC is used may explain the higher incidence of false-positive ARRs in hypertensive women than men and suggest the following: 1) plasma renin activity is preferable to DRC in determination of ARR and 2) new reference ranges for ARR that take into account gender and sex hormone levels are required.

The outcome of kidney transplants with multiple renal arteries

The use of grafts with multiple renal arteries has been considered a relative contraindication because of the increased incidence of vascular and urologic complications. The aim of this retrospective study is to determine whether the kidney grafts with multiple arteries have any adverse effect upon post transplant graft and patient survival. After reviewing the records of 35 adult kidney transplants done consecutively at Bangabandhu Sheik Mujib Medical University over a period of 3 years (Jan 2005 to Dec 2007). Mean age of recipients. 43.46±12.11 years and donors 40.33±11.46 years. Twenty patients (Group A) had grafts with single renal artery and 15 patients (Group B) had grafts with multiple renal arteries. The incidence of vascular complications, ureteral complications, post surgical haemorrhage, mean serum creatinine level and acute tubular necrosis in both Group A & B were observed. Complications developed in 15(43%) patients in this series. In Group A, 1(5%) developed post operative bleeding cause perinephric hematoma, 1(5%) technical obstruction of ureter, 1(5%) sloughed ureter, graft nephrectomy 1(5%) and acute tubular necrosis 1(5%) patient. In Group B, 2(13%) patients developed hematoma, urine leak 3(20%), sloughed ureter 1(6%), graft nephrectomy 1(6%) and acute tubular necrosis 3(20%) patients. Though the kidney grafts with multiple renal arteries have been considered a relative contraindication because of the increased risk of complication. In this series incidence of complication was 43%. The higher rate probably reflects the small number of living related donors.

Intrathoracic kidney in adult with an abnormal presentation

Intra thoracic kidney is a rare congenital anomaly. Pathologically thoracic renal ectopia is due to eventration of the diaphragm. Usually symptoms appear in infancy and rarely in adult with respiratory problems and with organ involved. This only patient presented with left sided chest pain and abdominal discomfort at the age of 52 years having repeated previous similar attack in the department of Cardiology. Chest X ray and ultrasonography of whole abdomen was done along with other routine investigations, which reveals an ectopic and elevated left kidney. Five percent of the renal ectopia is intrathoracic kidney. It usually is symptomatic in infantile age but adult presentation is also found.

Effect of atenolol on aldosterone/renin ratio calculated by both plasma Renin activity and direct Renin concentration in healthy male volunteers

BACKGROUND

The most popular screening test for primary aldosteronism (PAL) is the plasma aldosterone to renin ratio (ARR). Medications, dietary sodium, posture, and time of day all affect renin and aldosterone levels and can result in false-negative or -positive ARR if not controlled. Opinions are divided on whether beta-adrenoreceptor blockers significantly affect the ARR.

METHODS

Normotensive, nonmedicated male volunteers (n = 21) underwent measurement (seated, midmorning) of plasma aldosterone (by HPLC-tandem mass spectrometry), direct renin concentration (DRC), renin activity (PRA), cortisol, electrolytes, and creatinine and urinary aldosterone, cortisol, electrolytes, and creatinine at baseline, and after 1 wk (25 mg daily) and 4 wk (50 mg daily for three additional weeks) of atenolol.

RESULTS

Compared with baseline, levels of aldosterone, DRC, and PRA were lower (P < 0.001) after both 1 and 4 wk [median (25-75th percentiles): baseline, 189 (138-357) pmol/liter, 40 (30-46) mU/liter, and 4.6 (2.7-5.8) ng/ml x h; 1 wk, 166 (112-310) pmol/liter, 34 (30-40) mU/liter, and 2.6 (2.0-3.1) ng/ml x h; 4 wk, 136 (97-269) pmol/liter, 16 (13-23) mU/liter, and 2.1(1.7-2.6) ng/ml x h, respectively]. ARR was significantly higher after 1 wk compared with baseline when calculated using PRA [61 (30-73) vs. 65 (44-130), P < 0.01] but not DRC [5 (4-7) vs. 5 (4-8)]. At 4 wk, ARR calculated by both PRA [78 (49-125)] and DRC [8 (6-14)] were significantly higher (P < 0.001) compared with baseline, and cortisol levels were significantly lower [92 (68-100) vs. 66 (48-91) ng/ml, P < 0.01]. There were no changes in plasma sodium, potassium, creatinine, or any urinary measurements.

CONCLUSION

beta-Blockers can significantly raise the ARR and thereby increase the risk of false positives during screening for PAL.

Comparative assays of the rpoB gene for identification of Mycobacterium tuberculosis isolated from patients in Sudan

OBJECTIVES

To characterise mycobacterial clinical isolates based on amplification of the rpoB gene.

SETTING

One hundred and thirty-five mycobacterial isolates cultured from suspected pulmonary tuberculosis (TB) patients were identified phenotypically. Molecular characterisation of the isolates was performed based on amplification of the rpoB gene, using duplex polymerase chain reaction (DPCR), PCR-restriction fragment length polymorphism (RFLP) and nested PCR-based sequence analysis techniques.

RESULTS

The DPCR assay identified 129 of 135 (95.5%) clinical isolates as Mycobacterium tuberculosis complex species. Restriction enzyme analysis of the rpoB PCR product using Hind II identified 134 of the 135 (99.3%) isolates as M. tuberculosis complex, while nested PCR sequence analysis of the rpoB gene identified 133/133 examined isolates (100%) as M. tuberculosis species. No mycobacteria other than M. tuberculosis (MOTT) were detected among the studied isolates.

CONCLUSION

DPCR, PCR/RFLP Hind II and nested PCR sequence analysis of the rpoB gene techniques showed comparable efficiency in the characterisation of Mycobacterium isolates. Nested PCR sequence analysis of the rpoB gene was superior to PCR/RFLP for characterisation of suspected M. tuberculosis isolates, while the DPCR technique showed less sensitivity. As PCR-RFLP requires less sophisticated laboratory facilities than nested PCR sequence analysis, it would be more appropriate to be adopted for accurate characterisation of mycobacteria in countries with a weak infrastructure.

Relationship between acrosin activity of human spermatozoa and oxidative stress

AIM

To study the association between seminal oxidative stress and human sperm acrosin activity.

METHODS

It is a prospective study consisting of 30 infertile men and 12 fertile normozoospermic volunteers. A full history, clinical examination and scrotal ultrasound were done to exclude other related factors such as smoking and varicocele. Presence of white blood cells (WBCs) in semen samples was evaluated by peroxidase staining. Lipid peroxidation in spermatozoa was induced after incubating with ferrous sulphate (4 mmol/L) and sodium ascorbate (20 mmol/L). Induced peroxidation of spermatozoa was assessed by determining the production of thiobarbituric acid reactive substances (TBARS). Acrosin activity was measured using the gelatinolysis technique. The halo diameters around the sperm heads and the percentages of spermatozoa showing halo formation were evaluated. An acrosin activity index was calculated by multiplying the halo diameter by the halo formation rate.

RESULTS

A significant difference was observed in acrosin activity parameters and TBARS levels between samples with WBCs (1 multiply 10(6)/mL of ejaculate) and those without. This difference was also noted between the normozoospermic and the oligoasthenoteratozoospermic semen samples. The TBARS production by spermatozoa had a significant negative correlation with the acrosin activity index (r = -0.89, P 0.001).

CONCLUSION

The presence of oxidative stress in an individual with leukocytospermia and/or abnormal semen parameters is associated with impaired sperm function as measured by its acrosin activity.

A longitudinal study of schistosome intermediate host snail populations and their trematode infection in certain areas of Egypt

Seasonal variation of Biomphalaria alexandrina and Bulinus truncatus populations and their infection rates with schistosome and other trematode cercariae were studied longitudinally in four water courses located in Giza and Faiyoum Governorates. Abundance of both species varied from year to year and according to the type of habitat. The mean prevalence of Schistosoma mansoni in Biomphalaria was 0.29%, that of S. haematobium in Bulinus was 1.36%. Seasonal variations of age structure of the 2 vector snails were monitored throughout the survey period. Infection rates with schistosome and other trematodes among Bulinus and Biomphalaria increased with the increase in snail size. Data suggest the occurrence of an antagonistic interaction between schistosome and non-human cercariae, especially echinostome, in infected snails.

Infection of two lymnaeid snails with Fasciola gigantica in Giza, a field study

Population density of Lymnaea natalensis and L. columella and their natural infection with Fasciola gigantica were followed in two water bodies in Abu Rawash area, Giza Governorate over two years. L. natalensis snails were more abundant during December-February, while L. columella snails had high density during autumn. According to the snail size, we found that the reproduction of the two vector snails occurred in summer and early autumn. Fasciola was present in 0.6 and 2.0% of the examined L. natalensis and L. columella snails respectively. A high prevalence of F. gigantica in L. columella snails occurred in summer and early autumn, while their presence in L. natalensis was irregular. Naturally infected Lymnaea snails, with Fasciola, are usually of large size (> 10mm) of a given population sample. Other three types of trematode cercariae were found in both snail species; Xiphidiocercariae, Echinostomes and Amphistomes.

Screening for amyloid in subcutaneous fat tissue of Egyptian patients with rheumatoid arthritis: clinical and laboratory characteristics

OBJECTIVE

To screen for amyloid and to assess associated clinical and laboratory characteristics in Egyptian patients with rheumatoid arthritis (RA).

METHODS

Abdominal subcutaneous fat aspirates were consecutively collected from 112 patients (103 women, nine men) having RA for five years or more. To detect amyloid, fat smears were stained with Congo red and the concentration of amyloid A protein in fat tissue was measured. Clinical, radiological, and laboratory characteristics of the patients were assessed.

RESULTS

Amyloid was detected in eight (7%) of the fat smears stained with Congo red. Compared with the Congo red stain, the sensitivity for detecting amyloid by measurement of amyloid A protein in fat tissue was 75% and the specificity was 100%. The amount of amyloid found was small for both methods. The median disease duration of the eight amyloid patients was significantly longer (17 years) than that of the non-amyloid patients (10 years). Bronchopulmonary disease and constipation were more common, whereas proteinuria and chronic renal insufficiency were not. The number of swollen joints and the number of red blood cells were significantly lower in the amyloid group.

CONCLUSIONS

Quantification of amyloid A protein and staining with Congo red are strongly concordant methods of screening for amyloid in fat tissue. The prevalence of amyloid in Egyptian patients with RA is 7%. Proteinuria is not a discriminating feature, whereas long disease duration, constipation, bronchopulmonary symptoms, and a moderate to low number of red blood cells may help to identify the arthritic patients with amyloid.

Studies on the molluscicidal and larvicidal properties of Solanum nigrum L. leaves ethanol extract

Toxicological studies on three ethanol extract preparations of Solanum nigrum L. leaves were made on Biomphalaria alexandrina. Extract (A), made by soaking leaves powder over night in cold 70% ethanol, has the highest activity, (LC50 3.37 mg/L within 24 hr). This extract also showed larvicidal activity against larvae of two mosquito species, Aedes caspius and Culex pipiens, (LC50 51.29 and 125.89 mg/L within 24 hr, and 21.38 and 38.11 mg/L within 48 hr, respectively). Sunlight, pH, and turbidity did not affect the activity of this extract, but the molluscicidal activity seems to be correlated with the increase of temperature. The concentrated extract (1000 mg/L) can be stored at room temperature for six months without any change in its activity, but diluted solutions of this extract lost their activity after four weeks.

Abdominal trauma due to road traffic accidents in Qatar

OBJECTIVES

To measure the incidence and severity of abdominal trauma due to road traffic accidents (RTA) in Qatar.

PATIENT AND METHODS

Retrospective analysis of all patients admitted with documented abdominal trauma to the only acute General Hospital in the state of Qatar in the period 1991-1995.

RESULTS

In the 5-year period, 3744 patients were admitted following an RTA. Of these, 667 (17.8%) were admitted to the surgical intensive care unit (SICU) and 84 patients had abdominal injuries, constituting 0.45% of total number and 12.6% of patients admitted to SICU. Twenty-one (25%) of patients with abdominal trauma died. However, only nine patients died from the abdominal injury. Eight patients died due to hepatic injury and one patient due to splenic injury.

Melanocyte-conditioned medium stimulates while melanocyte/keratinocyte contact inhibits keratinocyte proliferation

The interaction between melanocytes and keratinocytes in epidermal tissue suggest a bidirectional interchange between these two cell types. Although keratinocytes appear to affect melanocyte function, there are no reported effects of melanocytes on keratinocytes. Using cell strains, we examined the effect of melanocytes on keratinocyte proliferation. Two conditioned medium techniques were used: one was a co-culture system, where both cell types, grown on separate surfaces shared a common volume of medium. The second was simply feeding keratinocytes melanocyte-conditioned medium. Mixed cultures (both cell types together in a monolayer) where also studied. Our results showed that melanocyte-conditioned medium and melanocytes in co-culture significantly stimulated keratinocyte proliferation as measured by bromodeoxyuridine incorporation assay. However, growth of both cell types together in culture did not affect the growth rate of either cell type. Our results showed that cultured human melanocytes produce one or more soluble factors that stimulate the growth of cultured keratinocytes.

Seasonal variation in molluscicidal activity of Solanum nigrum L

Solanum nigrum L. leaves and fruits were shown to have molluscicidal activities against snails transmitting schistosomiasis and fascioliasis. In the present study, their molluscicidal activity against adult Biomphalaria alexandrina snails was assessed to determine whether plants collected at various seasons would have different degrees of toxicity. Leaves and fruits of three S. nigrum varieties were collected from Faiyoum and/or Giza during the four seasons. Leaves collected in autumn had the highest effect (LC50-35.4) followed by spring (LC50 = 44.36), summer (LC50 = 46.7) and winter (LC50 = 100.4). Toxicity of plant extracts was also affected by other seasonal dependent factors. These are the duration of plant exposure to direct sunlight and the size of the fruits. S. nigrum (black fruits) was more toxic (LC50 = 18.1) than the other two types, S. nigrum v. vellosum (yellow fruits) (LC50 = 38.9) and S. nigrum v. juidaicum (red fruits) (LC50 = 34.7).

Urine levels of type 1 collagen cross-linked N-telopeptides and deoxypyridinoline correlate with disease activity in rheumatoid arthritis

OBJECTIVES

The aim of this study was to find out whether spot urinary concentrations of type 1 collagen cross-linked N-telopeptides (NTx) and deoxypyridinoline (Pyrilinks-D) can differentiate between active and inactive disease in rheumatoid arthritis (RA) and to investigate the extent to which they correlate with indices of disease activity.

METHODS

Using enzyme-linked immunosorbent assays, the concentrations of NTx and Pyrilinks-D were estimated in spot urine samples from 25 females with active disease, 25 females with inactive disease, and in 25 controls.

RESULTS

In Patients with active disease, urinary concentrations of NTx and Pyrilinks-D were significantly higher (p < 0.01) than in those with inactive disease or in healthy controls. In active disease there were significant positive correlation between urinary NTx and ESR, the swollen joint count, the tender joint count, and the patient's global assessment.

Rheumatic manifestations and immunological abnormalities in patients with chronic hepatitis C. A study in the Middle East

Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems. We compared the prevalence of extrahepatic clinical manifestations and immunological disorders in 40 patients with chronic hepatitis C and in 42 carefully matched healthy controls. Polyarthralgia or polyarthritis was the most common rheumatic manifestation (35%) in the cases, followed by cutaneous vasculitis (15%). Glomerulonephritis and xerophthalmia were uncommon, and none of the cases had systemic vasculitis. Immunological abnormalities included serum rheumatoid factor (47.5%), cryoglobulins (30%), and one or more antitissue antibodies (37.5%). The prevalences of polyarthralgia, cutaneous vasculitis, rheumatoid factor, cryoglobulinemia, and anti-tissue antibodies were significantly higher in the hepatitis C group than in the control group. Our data suggest that patients in the Middle East who present with features of rheumatic or autoimmune diseases should be screened for hepatitis C.

Randomised placebo-controlled crossover trial on effect of inactivated influenza vaccine on pulmonary function in asthma

BACKGROUND

Despite current recommendations, many people with asthma do not receive annual vaccination against influenza, partly because of concern that vaccine may trigger exacerbations. Colds can trigger exacerbations, which may be mistaken for vaccine-related adverse events. We undertook a double-blind placebo-controlled multicentre crossover study to assess the safety of influenza vaccine in patients with asthma, with allowance for the occurrence of colds.

METHODS

We studied 262 patients, aged 18-75 years, who recorded daily peak expiratory flow (PEF), respiratory symptoms, medication, medical consultations, and hospital admissions for 2 weeks before the first injection and until 2 weeks after the second injection. Order of injection (vaccine and placebo) was assigned randomly. There was an interval of 2 weeks between injections. The main outcome measure was an exacerbation of asthma within 72 h of injection (defined as a fall in PEF of >20%).

FINDINGS

Among 255 participants with paired data, 11 recorded a fall in PEF of more than 20% after vaccine compared with three after placebo (McNemar's test p=0.06); a fall of more than 30% was recorded by eight after vaccine compared with none after placebo (binomial test p=0.008). However, when participants with colds were excluded, there was no significant difference in the numbers with falls of more than 20% between vaccine and placebo (six vs three; binomial test p=0.51), although the difference for PEF decreases of more than 30% approached significance (five vs none; binomial test, p=0.06). This association was confined to first-time vaccinees.

INTERPRETATION

Our findings indicate that pulmonary-function abnormalities may occur as a complication of influenza vaccination. However, the risk of pulmonary complications is very small and outweighed by the benefits of vaccination.

Laboratory assessment of the molluscicidal and cercaricidal activities of the Egyptian weed, Solanum nigrum L

The molluscicidal properties of Solanum nigrum L. were tested against three Egyptian snail species (Biomphalaria alexandrina, Bulinus truncatus and Lymnaea natalensis), each an intermediate host of parasites causing human schistosomiasis or fascioliasis. The plant was collected in two regions within Egypt: Fayium and Giza. Snails were exposed for 24 and 48 h, to the dry powdered fruits and leaves or to crude water extracts of the powders, and mortality was recorded. The water extract of the leaves collected in Fayium (FLWE) had the highest molluscicidal activity, with median lethal concentrations (LC50) of 18.6 mg/litre for Bi. alexandrina, 14.5 mg/litre for Bu. truncatus and 17.7 mg/litre for L. natalensis. When Bi. alexandrina infected with Schistosoma mansoni were exposed to FLWE (20 or 25 mg/litre), they shed significantly fewer cercariae than unexposed snails (P < 0.02). The cercaricidal properties of FLWE were directly tested against S. haematobium, S. mansoni and Fasciola gigantica cercariae and a time-concentration relationship was observed; the concentrations needed to kill all cercariae (LC100) within 30 min of exposure were 30 mg/litre for both S. haematobium and S. mansoni and 40 mg/litre for F. gigantica.