Role of four-dimensional computer tomography (4D-CT) in non-localising and discordant first-line imaging in primary hyperparathyroidism

BACKGROUND

Accurate preoperative localisation of parathyroid adenoma is imperative for the success of minimally invasive parathyroidectomy (MIP).

OBJECTIVE

Our study aimed to evaluate the role of four-dimensional computer tomography (4D-CT) scan as an imaging modality in patients with failed and discordant localisation reported in the first-line imaging modalities (ultrasonography and 99mTc-MIBI-SPECT/CT).

METHODS

This is a prospective cohort study performed at a university teaching centre from March 2013 to July 2021. All patients with primary hyperparathyroidism who had failed localisation by ultrasonography and 99mTc-MIBI-SPECT/CT (SpCT), or discordance between them, had 4D-CT performed in this study.

RESULTS

One hundred and two sporadic cases of pHPT with failed/discordant first-line imaging had 4D-CT imaging prior to parathyroidectomy. In 102 patients, 105 parathyroid adenomas were reported on histopathology. 4D-CT was able to localise 78% of them to the correct side and 64% to the correct quadrant in 102 patients, as compared with US (correct side 21%, correct quadrant 16%) and 99mTc-MIBI-SPECT/CT (correct side 36%, correct quadrant 31%). 4D-CT had a sensitivity, precision, accuracy and F1 score for correct quadrant localisation as 79%, 81%, 66% and 80%; and for correct side localisation as 82%, 98%, 80% and 89%, respectively. 4D-CT was able to identify three ectopic adenomas (two in superior mediastinum and one in the oesophageal wall) which were not detected on US or SpCT.

CONCLUSION

4D-CT was found to be sensitive and accurate in preoperative localising of the diseased parathyroid glands after failed/discordant US and SpCT. This led to more patients being offered MIP as the primary surgery and improved operative outcomes.

P–256 Time Lapse Imaging (TLI) acquired morphokinetic variables, nucleation errors and cleavage abnormalities are associated with live birth and may aid in de-selection of transfer embryos

Study question

May the observation by TLI of morphokinetics, nucleation errors and cleavage abnormalities assist in de-selecting embryos before embryo transfer?

Summary answer

The combine predictive power of the association between the three biomarkers and live birth may aid in embryo de-selection

What is known already

Morphokinetic parameters and cleavage biomarkers are associated with treatment outcomes following in vitro fertilization (IVF). Nucleation errors observed by TLI have also been associated with IVF outcomes. It is also shown that nucleation error self-repair in pre-implantation embryos occurs, resulting in euploid blastocysts and live births. Biomarkers identified by TLI have been incorporated in developing algorithms to be used in selecting “the embryo” with the best potential for a live birth. However, the few randomized control studies (RCT) have not shown convincingly that TLI significantly improves live birth rate.

Study design, size, duration

Analyses of TLI data from transferred embryos, cultured in the EmbryoScope TM between June 2012 and August 2018, in a single IVF clinical setting were included. 2082 treatment cycles with Known Implantation Data (KID) for implantation and live birth were included in the analyses. Nucleation errors such as micronucleation, binucleation, and multinucleation were systematically annotated. Cleavage abnormalities such as direct cleavages, rapid and reverse cleavages were annotated for a minimum of 44 hours post insemination.

Participants/materials, setting, methods

Annotations for cleavage abnormalities, morphokinetic variables and nucleation errors, during a minimum of 44 hours, for 2959 transferred embryos were obtained from the EmbryoScope. The potential negative association between day 2 KID embryo biomarkers and implantation as well as live birth was assessed. The analyses controlled for potential confounding by adjusting for maternal age, infertility diagnosis, BMI, hormonal stimulation regime and insemination method.

Main results and the role of chance

Preliminary results were obtained regarding biomarkers in the form of nucleation errors, cleavage abnormalities and early embryo morphological attributes. Several of these biomarkers were significantly associated with implantation and live birth. Nucleation errors were associated with substantial decrease in implantation and live birth, but contrary to findings from other studies, none of the recorded nucleation error types precluded live birth. Many morphokinetically defined cleavage abnormalities were also shown to be significantly associated with implantation and live birth, with timings to 2-cells (t2) and second cell cycle (cc2) displaying the most prominent predictions for live birth probability.

Within each of the three biomarker groups, logistic regression models with implantation and live birth probability predictions displayed reasonable explanatory power regarding implantation and live birth. Combining all types of biomarkers lead to logistic regression models with substantially higher explanatory power than when the regression models only comprised a single biomarker group.

With a study of this size and P values for the basic findings predominantly being highly significant, the role of chance is likely to be limited. The statistical uncertainty may therefore be subordinated to the confounding caused by embryo transfer selection and further by exclusive use of embryos with known implantation

Limitations, reasons for caution

Only transferred embryos with KID data were analysed and hence the outcome of other embryos is unknown. Our study used mostly day 2 embryos, therefore generalisation up to blastocyst stage is not possible. Our findings apply to our study cohort and may differ from findings in another clinical setting.

Wider implications of the findings: Our study provides knowledge about the role of TLI biomarkers and their potential for deselecting embryos for transfer. This will avoid transfer of lower quality embryos with lower chances of live birth. Incorporating such non-invasive de-selection strategies, alongside morphology may contribute to improving IVF outcome.

Trial registration number

NA

Locally advanced tongue squamous cell carcinoma in epidermolysis simplex bullosa patient: a therapeutic conundrum

Epidermolysis bullosa simplex (EBS) is a debilitating condition affecting the skin and mucous membranes that is characterised by frequent ulceration and blistering on trivial trauma. In EBS, oral cavity mucosal injuries lead to a high propensity for developing squamous cell carcinomas. Locally advanced tongue carcinoma arising in this background presents a challenging therapeutic conundrum. To our knowledge, this is the first case of aggressive locally advanced tongue carcinoma that has developed sporadically in a patient with EBS and no family history. Routine screening of oral mucosal lesions will lead to early detection and timely management of this debilitating condition.

The anti-aging protein alpha-Klotho in systemic sclerosis patients: does a relationship to telangiectasia exist?

OBJECTIVE

The anti-aging protein alpha-Klotho has been reported to have an emerging role in the pathogenesis of systemic sclerosis (SSc). More studies are needed to approach this issue. This study aimed to assess the serum levels of α‑Klotho in SSc patients compared to healthy controls, and to correlate them with the disease parameters.

METHODS

Forty-two SSc patients were included in this study. History taking, clinical examination, and related investigations were performed. The modified Rodnan skin score (mRss) was used to assess skin tightness in SSc patients. Twenty-seven age- and sex-matched healthy participants served as controls. Serum α‑Klotho was assessed in the two groups.

RESULTS

SSc patients comprised 39 females and 3 males; mean age was 42.2 ± 12.1 years and mean disease duration 8.5 ± 6.3 years. Serum α‑Klotho levels were decreased in scleroderma patients in comparison to healthy controls (p < 0.001). Scleroderma patients who had higher frequencies of telangiectasias and digital ischemic lesions had higher serum α‑Klotho levels (p = 0.01 and p = 0.04, respectively). By simple regression, only telangiectasias were significantly associated with higher α‑Klotho levels (p = 0.01). No other significant relationships were found between serum α‑Klotho and SSc disease parameters.

CONCLUSION

Scleroderma patients had significantly lower serum α‑Klotho levels than healthy controls. Higher α‑Klotho levels were significantly associated with telangiectasias. An imbalance in serum α‑Klotho levels may be involved in systemic sclerosis. Further longitudinal studies in a larger population of systemic sclerosis patients may provide a clearer clue for its role.

Improving Metastatic Breast Cancer Care in Kenya Using Information Technology

Background and context: In Africa, up to two thirds of breast cancer patients have been reported to present with an advanced stage of III or IV at diagnosis leading to a disproportionately higher mortality. In Kenya, breast cancer is the most common cancer in females in terms of diagnosis and mortality. Metastatic breast cancer (MBC) patients are an ignored part of the breast cancer community as they are marginalized in many of the breast cancer related initiatives. MBC suffer from clinical depression, anxiety and four out of five of these women do not receive any services, referral or guidance to help them with their emotional distress. Preferred evidence based methods of support desired by women with MBC, include online support. International resources are not always applicable to the local context thus making them unattractive for people from diverse cultures and background, such as those from Africa. Kenya has a high percentage of literate females and highest Internet usage in the area. This provides a unique opportunity in an otherwise limited resource country to reach out to a significant population of MBC patients. The patients voices are a valuable and trustworthy assessment of their actual needs. They have been used frequently in the area of cancer as a first step in designing needs-tailored interventions. We propose to develop a virtual online forum with the aim of providing patients with MBC, and their caregivers an interactive forum for psycho social support, addressing stigmas, seek relevant clinical advice, find links to the nearest healthcare facilities, download helpful information, participate in support group activities and receive links to other important helpful sites that are locally relevant. We also propose that such forum should also reflect the needs of our patients as described by themselves. Aim: Primary aim of this project is developing a virtual online interactive support forum where MBC patients and their caregivers can access information on social, psychological, spiritual, religious and clinical needs. The purpose is to be partly achieved by assessing the patient needs by needs assessment survey and to evaluate the impact of such intervention on patient knowledge and satisfaction with care. Strategy/Tactics: Web site development is the key component of the project. Patients would be asked to fill out the Supportive Care Needs Survey/The Knowledge Assessment Tool. The surveys will take place at four major cancer treatment hospitals in Kenya. Postlaunch promotion and awareness about Web site will be made and, usage data and knowledge tool to be used to assess the impact and acceptability. Web site updated regularly to address issues identified. Program/Policy process: Information gathered would be made part of policy on national cancer strategy, recommendations to factor in identified patient needs in policy. What was learned: Ongoing process.

The Kenya cancer research and control stakeholder program: Evaluating a bilateral partnership to strengthen national cancer efforts

Background

In response to a growing cancer burden and need for improved coordination among stakeholders in Kenya, the US National Cancer Institute and the Kenya Ministry of Health collaboratively hosted a stakeholder meeting in 2014 which identified four priority areas of need (research capacity building, pathology and cancer registries, cancer awareness and education, and health system strengthening) and developed corresponding action plans.

Methods

Surveys were conducted with participants to collect input on the progress and impact of the 2014 stakeholder meeting.

Findings

Of 69 eligible participants, 45 responded from academia, healthcare institutions, civil society, government, and international agencies. Of the four technical focus areas, three have continued to conduct working group meetings and two have conducted in-person meetings to review and update their respective action plans. Accomplishments linked to or enhanced by t meeting include: Kenyan and international support for expansion of population-based cancer registries, increased availability of prioritized diagnostic tests in selected regional referral hospitals, a greater focus on development of a national cancer research agenda, strategic planning for a community education strategy for cancer awareness, and improved coordination of partners through in-country technical assistance.

Interpretation

The Stakeholder Program has successfully united individuals and organizations to improve cancer control planning in Kenya, and has enhanced existing efforts and programs across the country. This model of partners working in parallel on prioritized track activities has supported development of long term coordination of cancer research and control activities sustainable by the Kenyan government and Kenyan institutions.

Cutaneous vasculitis in systemic lupus erythematosus patients: potential key players and implications

Objectives

The aim of the present work was to study the clinical characteristics of cutaneous vasculitis (CV) in systemic lupus erythematosus (SLE) patients and find possible potential key players in its development and implicated associations with the disease manifestations.

Patients and methods

Fifty adult female SLE patients underwent full history taking, thorough clinical examination and laboratory investigations. The SLE Disease Activity Index (SLEDAI) and accumulated damage using the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI) were assessed.

Results

The mean age of the patients was 29.1 ± 6.1 years and was significantly lower in those with CV ( p = 0.018). The disease duration was 4.9 ± 3.7 years. CV was present in 30% of the patients. Musculoskeletal manifestations and hypocomplementemia were present in all patients with CV. The SLEDAI and SLICC/ACR DI tended to be higher in those with CV. Complement (C3 and C4) was significantly consumed in CV patients ( p < 0.0001). Antiphospholipids were comparable between those with and without CV. Lupus nephritis, cardiovascular manifestations and Sjögren syndrome were significantly linked to the development of CV ( p = 0.025, p = 0.023 and p < 0.0001, respectively). Both C3 and C4 showed a high sensitivity (93.3% and 86.7%) to detect CV in SLE at cut-off values below 81.4 mg/dl and 16.8 mg/dl, respectively.

Conclusion

CV is closely related to hypocomplementemia but not to antiphospholipids and is associated with lupus nephritis, musculoskeletal manifestations and Sjögren syndrome.

Subclinical sacroiliitis in brucellosis. Clinical presentation and MRI findings

PURPOSE

The aim of this work was to detect subclinical sacroiliac joint involvement in patients with brucellosis and study their clinical and laboratory features.

PATIENTS AND METHODS

The study included 100 brucellosis patients being followed-up in the Gastroenterology and Hepatology Unit, Theodor Bilharz Research Institute and Cairo University outpatient clinics. A thorough history, physical examination, routine laboratory tests, and abdominal ultrasound were obtained for all patients. Extended rheumatological examination was performed including clinical testing for sacroiliitis and enthesitis. None of the patients reported a history of back pain or any symptoms suggestive of sacroiliitis during the course of the infection. Plain x-ray and MRI scan of the sacroiliac joints were performed for all patients.

RESULTS

Asymptomatic sacroiliitis was present in 24 % of the brucellosis patients; none of the patients had tenderness over their spine with preserved lumbar spine mobility. Sacroiliitis was mainly unilateral being bilateral in 20.83 %. There was an obvious relationship with animal contact and occupation of the patients. Osteoarticular involvement was common (67 %) including arthralgias, arthritis, myalgias, spondylitis, enthesitis and bursitis, being clearly higher in those with sacroiliitis. The MRI scan showed blurring of the margins in 66.67 %, widening in 25 %, narrowing in 54.17 %, erosions in 20.83 %, and sclerosis in 12.5 %.

CONCLUSION

Osteoarticular manifestations of brucellosis are prevalent and subclinical sacroiliitis is evident, a finding that may classify these patients as having brucellar spondyloarthropathy (BSA). Referring brucellosis patients for rheumatological assessment has the advantage of early assessment of asymptomatic cases with sacroiliitis which is commonly overlooked.

Association of 25-hydroxyvitamin D with areal and volumetric measures of bone mineral density and parathyroid hormone: impact of vitamin D-binding protein and its assays

A comparison of the association of different forms of 25-hydroxyvitamin D [25(OH)D] with parathyroid hormone (PTH) and with areal and volumetric bone mineral density (BMD) demonstrated that bioavailable and free 25(OH)D do not provide a better index of vitamin D status in terms of bone health compared to total 25(OH)D.

INTRODUCTION

This study aims to compare measures of vitamin D-binding protein (DBP) using a monoclonal versus polyclonal ELISA and assess correlations of total versus estimated free and bioavailable 25(OH)D with BMD and PTH concentrations.

METHODS

DXA and peripheral quantitative CT (pQCT) scans were obtained in 304 adults (158 black, 146 white), ages 21-80 years. Free and bioavailable 25(OH)D were calculated from total 25(OH)D, DBP, and albumin concentrations. Multivariable linear regression with standardized beta coefficients was used to evaluate associations of bone measures and PTH with total, free, and bioavailable 25(OH)D.

RESULTS

Measures of DBP obtained using a monoclonal versus polyclonal ELISA were not correlated (r s = 0.02, p = 0.76). Free and bioavailable 25(OH)D based on the polyclonal assay were lower in black versus white participants (p < 0.0001); this race difference was not evident using the monoclonal assay. Adjusted for age, sex, calcium intake, and race, all forms of 25(OH)D were negatively associated with PTH, but the absolute coefficient was greatest for total 25(OH)D (-0.34, p < 0.001) versus free/bioavailable 25(OH)D (-0.18/-0.24 depending on DBP assay, p ≤ 0.003). In analyses stratified on race, none of the measures of 25(OH)D were associated with BMD across DXA and pQCT sites.

CONCLUSIONS

The monoclonal versus polyclonal ELISA yielded highly discrepant measures of DBP, particularly among black individuals, likely related to established race differences in DBP polymorphisms. Contrary to prior studies, our findings indicate that using DBP to estimate bioavailable and free 25(OH)D does not provide a better index of vitamin D status in terms of bone health.

Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period

INTRODUCTION

The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled.

OBJECTIVE

To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias.

METHODS

Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later.

RESULTS

A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR.

CONCLUSIONS

Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes.

Effects of propofol and isoflurane on haemodynamics and the inflammatory response in cardiopulmonary bypass surgery

Cardiopulmonary bypass (CPB) causes reperfusion injury that when most severe is clinically manifested as a systemic inflammatory response syndrome. The anaesthetic propofol may have anti-inflammatory properties that may reduce such a response. We hypothesised differing effects of propofol and isoflurane on inflammatory markers in patients having CBR Forty patients undergoing elective CPB were randomised to receive either propofol or isoflurane for maintenance of anaesthesia. CRP, IL-6, IL-8, HIF-1α (ELISA), CD11 and CD18 expression (flow cytometry), and haemoxygenase (HO-1) promoter polymorphisms (PCR/electrophoresis) were measured before anaesthetic induction, 4 hours post-CPB, and 24 hours later. There were no differences in the 4 hours changes in CRP, IL-6, IL-8 or CD18 between the two groups, but those in the propofol group had higher HIF-1α (P = 0.016) and lower CD11 expression (P = 0.026). After 24 hours, compared to the isoflurane group, the propofol group had significantly lower levels of CRP (P < 0.001), IL-6 (P < 0.001) and IL-8 (P < 0.001), with higher levels CD11 (P = 0.009) and CD18 (P = 0.002) expression. After 24 hours, patients on propofol had increased expression of shorter HO-1 GT(n) repeats than patients on isoflurane (P = 0.001). Use of propofol in CPB is associated with a less adverse inflammatory profile than is isofluorane, and an increased up-regulation of HO-1. This supports the hypothesis that propofol has anti-inflammatory activity.

Effect of major burns on early and late activating markers of peripheral blood T lymphocytes

It is known that lymphocytes immunophenotype is a reflection of the functional level of the immune system. The immunosuppressive effect of major burns is also known for many years. T lymphocytes of 50 major burn patients were analyzed in base line (BL) samples at 24 hours and at 1 week and 2 weeks after burn, using monoclonal antibodies of CD3, CD4, CD8, CD25 (IL2R) and HLA-DR by flow cytometry and β2-microglobulin (β2-m) by ELISA. Recorded values were compared with those of 50 healthy donors. There was statistically significant reduction in absolute number of CD3 positive cells (CD3+) (p<0.000) and CD4/CD8 ratio (p=0.01) in the first 24 hours in comparison with controls. CD25 (IL-2R) shows insignificant upregulation on T lymphocytes after burn with significant upregulation of HLA-DR. The absolute number of CD3+ cells began to increase after 2 weeks (p=0.03) but remained less than controls (p=0.08). CD4/CD8 ratio was more or less same as healthy controls after 2 weeks. Upregulation of CD25 was insignificantly increased and that of HLA-DR was markedly increased after 2 weeks (p=0.001). Significant negative correlations were detected between mean values of β2-m and both absolute numbers of CD3 and CD4 positive cells in BL and one week samples. In addition there was significant correlation between mean values of β2-m and values of CD25 expression in the BL samples. The obtained data is suggestive of persistent activation of T lymphocytes two weeks after major burns whereas early shedding of β2-m is related to activation of lymphocytes increasing their susceptibility to apoptosis, both indicative of altered immune response. Burn intensivists and surgeons should be keen to support the patients' immune system in the first hours following major burns. This support will ensure free-bacteremic blood with a consequent better prognosis.

Pathologic characteristics of breast cancer with special emphasis on prevalence of triple-negative breast cancer from Kenya: A 4-year experience

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Background: Previous sub classification of breast cancer in Kenya has been fraught by small sample size, non uniform staining methodology and lack of independent review. Triple Negative Breast Cancer (TNBC) is a “special interest” cancer since it represents a significant proportion of breast cancer patients and is associated with a poorer prognosis. We aimed to determine the estrogen receptor (ER), progesterone receptor (PR) and Her2/neu receptor characteristics of breast cancers and the prevalence of TNBC diagnosed at Aga Khan University Hospital, Nairobi (AKUHN) between 2007 to date.

Methods: Slides and blocks of archived invasive breast cancers diagnosed at AKUHN were identified, retrieved and reviewed by two independent pathologists. Histological type, grade and pathological stage were documented. Representative sections from available blocks were stained for ER, PR, Her2 with appropriate internal controls. Scores for ER/PR were interpreted based on the ALLRED system, Her2 /neu scoring followed CAP guidelines. The initial 111 cases were validated and confirmed at Sunnybrook Health Sciences Centre, Toronto.

Results: 456 cases of invasive breast cancers were diagnosed at AKUHN during the study period. 91% of cases were invasive ductal carcinomas (NOS).The rest were special types. 37% of the tumors were grade 3 and 63% were grade 2. Blocks for 318 of 456 cases were available for receptor analysis. 54% were ER and/or PR positive, with 52% of these in women < 50 yrs. 86% of the ER and/or PR positive tumors were grade 2. Only 12% were Her2/neu positive. Of the 318 cases studied, 111 (32%) were identified as TNBC. Median age was 53 yrs. 88% were grade 3.

Conclusions: Invasive ductal carcinoma (NOS) was the most common breast cancer in our study. Nearly half of our cases were ER and/or PR positive and a third were TNBC. Both occurred predominantly in women less than 50 yrs. This represents the largest validated pathologic sub classification of breast cancer from a tertiary academic hospital in Kenya. Expansion of this study to encompass all breast cancers diagnosed in Kenya is underway.

In vitro characterization and release study of Ambroxol hydrochloride matrix tablets prepared by direct compression

A series of either hydrophilic or hydrophobic polymers were used to prepare controlled release Ambroxol hydrochloride (AMX) matrix tablets by direct compression. Both the compatibility and flow properties of AMX/polymer mixtures were investigated. The effect of the amount and type of polymer on the physical properties and in vitro drug release was studied and compared to commercially available Ambroxol(®) SR capsules. A kinetic study of the release profile of AMX from the prepared matrix tablets was performed. All excipients used in the study were compatible with the model drug. AMX/drug mixtures containing sodium alginate (NA) and hydroxypropylmethyl cellulose (HPMC) showed better flow properties than other polymers used in the study. The in vitro drug release studies showed that matrix tablets formulae containing 10% HPMC (S7) or a combination of 30% NA and 5% HPMC (Ah) exhibited a higher ability to control the release of AMX. The kinetic study revealed that a diffusion controlled mechanism prevailed except when carbopol was used. Formula Ah followed a non-fickian diffusion mechanism similar to Ambroxol(®) SR capsules. Both formulae S7 and Ah could be considered as potential candidates for formulation of AMX controlled release matrix tablets.

Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions

Cytology is able to deliver rapid accurate diagnoses with minimal equipment and laboratory infrastructure at minimal cost, and this is especially so for fine needle biopsy (FNB), which is a powerful diagnostic tool in medically resource-poor environments, where histopathology laboratories are small in number and poorly supported financially. The crucial element in the development of cytology services is to train a sufficient number of well trained cytopathologists and cytotechnologists to create a 'critical mass' of personnel who not only provide routine diagnostic services, but also can train an ever expanding number of pathologists, cytotechnologists, and health workers. A review of practical programs to train cytopathologists and cytotechnologists in their own countries will be presented, including a recent series of FNB and cytology tutorials run in sub Saharan Africa. The need for local cytopathology programs and the potential for both local and visiting cytopathologists to provide a faculty will be discussed, as well as a range of possible programs which can bring African pathologists and trainee pathologists to Western institutions for periods of their training. Ideally, the regional Societies of Cytology, including the recently formed West African Society of Cytology, will establish their own diagnostic protocols, training programs, syllabuses, examinations and accreditation and career pathways for both cytopathologists and cytotechnologists, and organize tutorials where they will invite overseas faculty to contribute. Crucially, these new societies will empower cytopathologists and cytotechnologists to approach health services and governments to state the need for cytology services as a cost-effective accurate diagnostic service that enhances patient care.

IL-17A and IL-17F gene expression is strongly induced in the mucosa of H. pylori-infected subjects from Kenya and Germany

Helicobacter pylori infection is the major cause of gastritis. Immunologically, H. pylori gastritis is associated with an infiltration of immune cells into gastric mucosa and the upregulation of various cytokines. Here, we analysed the gene expression of IL-1- and IL-17-related cytokines in regard to H. pylori infection in 85 German and 51 Kenyan patients with reflux-related or dyspeptic symptoms, respectively. Degree of gastritis and density of colonization were assessed histologically in accordance with the updated Sydney classification. Gene expression levels of cytokines IL-1β, IL-8, IL-18, IL-33, IL-17A, IL-17F and IL-23 as well as IL-23R were analysed by real-time RT-PCR. In both populations, H. pylori-infected individuals had significant higher inflammatory scores for activity and chronicity than H. pylori-negative subjects (P values between 0.006 and <0.0001). IL-8 mRNA was induced up to 6-fold in H. pylori-infected patients (P < 0.05), while the expression levels of IL-1β, IL-18, IL-23, IL-33 and IL-23R did not differ with respect to the H. pylori status in both groups. Most strikingly, a significant induction of both IL-17A and IL-17F was noted in H. pylori-infected individuals of both ethnic groups. Almost all IL-17F-positive samples revealed co-expression of IL-17A (40/42, 95.2%). Analysing IL-17A and IL-17F transcript levels of these 40 'double-positive' samples, a highly significant positive correlation between both genes was identified (P < 0.001). Taken together, H. pylori infection leads to a strong upregulation of both IL-17A and IL-17F in the gastric mucosa suggesting a regulatory link between both genes.

Exploring the role of Chlamydia pneumoniae in cardiovascular disease: a narrative review

An overwhelming number of studies have suggested that Chlamydia pneumoniae infections play a role in the development of atherosclerosis. Several, but not all, seroepidemiological studies have shown that C. pneumoniae antibodies may be related to the development of atherosclerotic disease. Additionally, C. pneumoniae seems to be present in atherosclerotic but not in healthy vascular tissue. Experimental studies have suggested a number of molecular mechanisms by which vascular C. pneumoniae infection might stimulate atherosclerosis development. Alternatively, nonvascular C. pneumoniae infection may cause clinically relevant atherosclerosis-related cardiovascular events through the systemic effects of chronic infection. Genetic variation may account for individual differences in susceptibility to the proatherogenic effects of C. pneumoniae infection. Despite the suggested role of infection in atherosclerosis, antibiotics seem to have no place in the secondary prevention of atherosclerosis-related cardiovascular events. The present narrative review evaluates the role of C. pneumoniae infections in the development of cardiovascular disease.

External quality assurance of breast cancer pathologic reporting in Kenya

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Background: Eighty percent of women diagnosed with breast cancer (BC) in East Africa present with advanced disease; current literature suggests a preponderance of triple negative/basal like breast cancer in this subset of African women. These studies are limited by their retrospective nature, small numbers, and unclear quality of pathologic specimen reporting. The objective of this study is to provide external quality assurance (EQA), quality control, and validation of hormone receptor and Her2 status of breast cancer specimens from Kenya. Methods: 108 retrospectively identified BC tumour blocks from the Aga Khan University Hospital (Nairobi, Kenya) during 2006–2008 will undergo repeat pathologic assessment for estrogen receptor (ER), progesterone receptor (PR), and Her2 status at Sunnybrook Health Sciences Center (Toronto, Canada).Currently at the Aga Khan University Pathology Lab, ER,PR and Her2 testing is performed manually once every two weeks using Heat Induced Antigen Retrieval and Dako reagents including the ENVISION detection system. Parallel controls of known tissue reactivity are also run; however there is currently no formal EQA. Results: Results will be used to identify areas of improvement in specimen handling and pathology reporting. Conclusions: Standardized and accurate pathologic assessment of BC specimens in East Africa is essential for establishing centres of excellence in Kenya and the wider East African region for hormone receptor and Her2 neu analysis. Results would contribute to understanding the prevalence of triple negative disease in East Africa, lead to improved treatment recommendations and patient outcomes, and serve as a foundation for prospective studies in East Africa.

No significant financial relationships to disclose.

Elevated tissue expression of thrombomodulatory factors correlates with acute symptomatic carotid plaque phenotype

OBJECTIVES

Thrombomodulatory factors have been implicated in plaque instability. The aim was to examine the relationship between thrombomodulatory gene expression, timing of clinical events and plaque histology.

DESIGN OF STUDY

Plaques were obtained from 40 consecutive patients undergoing carotid endarterectomy and divided into three groups (group 1, early symptomatic, within 1 month; group 2, late symptomatic, 1-6 months and group 3, asymptomatic). Total RNA was isolated to determine the expression of tissue plasminogen activator (t-PA), urokinase plasminogen activator (u-PA), plasminogen activator inhibitor-1 (PAI-1), tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombomodulin (TM), CD68 and vascular endothelial-cadherin (VE-Cadherin).

RESULTS

Expression of t-PA, PAI-1, TF, TFPI, TM, CD68 and VE-cadherin were significantly increased in the early symptomatic group (p=0.019, 0.028, 0.018, 0.025, 0.038, 0.016 and 0.027 respectively), but the level of gene expression in the late symptomatic group was indistinguishable from the asymptomatic group. The incidence of plaque rupture and intraplaque haemorrhage was significantly increased in the early symptomatic groups (58% versus 18%/18% group 2/3, and 55% versus 6%/9% respectively, p<0.05 for both).

CONCLUSIONS

Expression of thrombomodulatory genes is increased in unstable plaques, though levels after 1 month are comparable to asymptomatic plaques. This transient rise may influence plaque instability, and rapid resolution mirrors the clinical reduction in risk of further thrombo-embolic events.

Pediatric urolithiasis in Tunisia: a multi-centric study of 525 patients

PURPOSE

To investigate retrospectively the clinical and epidemiological characteristics, and method of treatment of childhood urolithiasis, a major urological problem in Tunisia.

MATERIALS AND METHODS

The records of 525 children with urolithiasis treated in Tunisia between 1990 and 2004 were reviewed in a multi-centric study with regard to age at diagnosis, sex, history, and physical, laboratory, and radiologic findings. Metabolic evaluation when performed included serum electrolytes, calcium, phosphorus, uric acid, 24-h urine collection for calcium and creatinine, and a sodium nitroprusside test for cystine. In all cases urine specimens were sent for culture.

RESULTS

The stone was located in the upper tract in 420 (80%) and lower tract in 105 children. Of the urine cultures, 40% were positive. Metabolic investigation was performed in 201 patients and was normal in 170 (84%). Urinary stasis secondary to a urinary tract anomaly that led to the formation of stones was found in 77 patients. Stones were treated by surgery (80%), extracorporeal shock wave lithotripsy (ESWL) (5%) and ureteroscopic extraction (4%), and percutaneous nephrolithotomy was performed in 10 patients (2%). The stone passed spontaneously in 9% of cases.

CONCLUSION

The use of ESWL and endourological methods of treatment for childhood urolithiasis must be generalized, with open surgery being reserved for particular and complex cases.

Abdominal Aortic Aneurysm Rupture Is Associated With Increased Medial Neovascularization and Overexpression of Proangiogenic Cytokines

Objective— Matrix metalloproteinase (MMP) activity has been linked to abdominal aortic aneurysm (AAA) rupture. Medial neovascularization (MNV), a histopathologic characteristic of AAAs, involves proteolytic degradation of extracellular matrix by MMPs to facilitate endothelial cell migration. The role of MNV in aneurysm rupture is unknown. This study investigated whether MNV is increased in aneurysm rupture.

Methods and Results— Biopsy samples from aneurysm rupture edge were compared with control biopsy samples from aneurysm wall at the level of rupture and from anterior sac in 12 ruptured AAAs. Further controls were obtained from anterior sac of 10 nonruptured AAAs. MNV, microvessel diameter, maturity index, and inflammatory infiltrate were quantified using morphometric analyses following immunohistochemistry. Expression of proangiogenic mediators was quantified using quantitative real-time-polymerase chain reaction. Compared with anterior sac and aneurysm wall at level of rupture, MNV was increased ( P <0.001) in rupture edge biopsy samples and consisted of smaller diameter ( P <0.001) and more immature microvessels ( P <0.001). mRNA expression of α v -integrin, vascular endothelial growth factor, vascular endothelial-cadherin, monocyte chemoattractant protein-1, and vimentin was increased ( P <0.05) in rupture edge biopsy samples.

Conclusions— This study demonstrated increased medial neovascularization and overexpression of proangiogenic cytokines at aneurysm rupture edge. Further investigations into whether this angiogenic response was a causative factor of aneurysm rupture are needed.

Embryonal rhabdomyosarcoma with uterine inversion: case report

Presented here is a 16-year-old nulliparous girl who had embryonal rhabdomyosarcoma causing uterine inversion. She had been referred with a one year history of continuous vaginal bleeding and vaginal swelling. Histology had shown sarcoma botyroides and had received five courses of chemotherapy at the referring hospital. At surgery she was found to have uterine inversion and extended hysterectomy was carried out to be followed by radiotherapy.