Role of meteorological parameters with the spread of Covid-19 in Pakistan: application of autoregressive distributed lag approach

This research focuses on the impacts of different meteorological parameters (temperature, humidity, rainfall, and evapotranspiration) on the transmission of Covid-19 in the administrative regions and provinces of Pakistan, i.e., Azad Jammu and Kashmir, Gilgit Baltistan, Khyber Pakhtunkhwa, Islamabad, Punjab, Sindh, and Balochistan from June 10, 2020, to August 31, 2021. This study analyzes the relation between Covid-19-confirmed cases and the meteorological parameters with the help of the autoregressive distributed lag model. In this research, additional tools (t-statistics, f-statistics, and time series analysis) are used for the motive of examining the linear relationship, the productivity of the model, and for the significant association between dependent and independent variables, lnccc and lnevp, lnhum, lnrain, lntemp, respectively. Values of t-statistics and f-statistics reveal that variables have a connection and individual significance for the model exist. Time series display that the Covid-19 spread increased from June 10, 2020, to August 31, 2021, in Pakistan. Temperature positively influenced the Covid-19-confirmed cases in all provinces of Pakistan in the long run. Evapotranspiration and rainfall influenced positively, while specific humidity influenced negatively on the confirmed Covid-19 cases in Azad Jammu Kashmir, Khyber Pakhtunkhwa, and Punjab. Specific humidity had a positive impact, while evapotranspiration and rainfall had the negative impact on the Covid-19-confirmed cases in Sindh and Balochistan. Evapotranspiration and specific humidity influenced positively, while rainfall influenced the Covid-19-confirmed cases negatively in Gilgit Baltistan. Evapotranspiration influenced positively, while specific humidity and rainfall influenced negatively on the Covid-19-confirmed cases in Islamabad.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13762-023-04997-4.

Role of PGPR and silver nanoparticles on the physiology of Momordica charantia L. irrigated with polluted water comprising high Fe and Mn

The current investigation designed to estimate the bioremediation potential of plant growth-promoting rhizobacteria (PGPR) and Ag-nanoparticles. Tube well and HIT water comprising Mn and Fe above recommended values were used as treatments while tap water irrigation was treated as control. The HIT water showed 24, 200, and 64.11% higher content of Na, K Ca over control. Seeds were sterilized in 95% ethanol and soaked for 3 h before sowing in 73 h old culture of Pseudomonas stutzeri (Kx574858) @ 108 cells/ml. Phytotoxic effect of Fe and Mn reduce plant biomass and suppress photosynthetic activity indicates. The carotenoids, proline, and proline activity were 366, 450, and 678% higher in tube well water with combined PGPR and Ag-nanoparticles treatments. Pseudomonas stutzeri was more effective than Ag-nanoparticles to reduce oxidative stress with higher production of carotenoids, flavonoids, proline content, and enzyme SOD and CAT activities in HIT water. It is contingent that the high Mn and Fe bearing waste water enhance PGPR bioremediation potential to reduce metal stress in plants with synergistic action of PGPR and organic matter to alleviate oxidative stresses under metal stress. The residual effect of P. stutzeri on organic matter content of the rhizosphere soil and germination rate was higher for Momordica charantia L.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

POS0661 MAJOR COST SAVINGS ASSOCIATED WITH BIOLOGIC DOSE REDUCTION IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background

Anti-TNF drugs have dramatically improved the management of inflammatory arthritis (IA).

Although the introduction of biosimilars have reduced the cost, chronic use of biologic agents

has a high impact on healthcare expenditure. This study evaluated the cost effectiveness of a

dose reduction strategy for the most commonly used anti- TNF drugs over a period of 10 years

in patients with IA in remission.

Objectives

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS) would remain in remission after 10 year period, following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction.

Methods

This prospective, non-blinded, non-randomised study was commenced in 2010. Patients

with IA, Rheumatoid arthritis (RA),ankylosing spondylitis (AS) and Psoriatic arthritis (PsA)

who were in remission as defined by disease activity indices (DAS28<2.6, BASDAI<4), and

were offered Anti TNF dose reduction. Patients on etanercept were reduced from 50mg

weekly to fortnightly, adalimumab 40mg once monthly instead of fortnightly. Patients were

assessed for disease activity at 1, 4 and 10 years following reduction in dosing

frequency.Cost saving was calculated by deducting the total annual cost of the biologic

agent used over 10 years compared with the cost if the dosing interval had not changed.

Results

Seventy nine patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n=45), 13% psoriatic arthritis (n=10) and 30% ankylosing spondylitis (n=24). 57% (n=45) were taking etanercept and 43% (n=34) adalimumab. The percentage of patients who maintained dose reduction at 10 years was 9% (n=7). Of the total 48 patients who were successfully dose reduced at year 1 (n=42), (69%, n=29) were able to maintain the dose reduction up to 4 years and 9% (n=7) maintained this dose reduction up to year 10. The estimated cost saving was €4,928 per patient per year. Estimated cost savings for 7 patients on reduced dose was €344,952.88 over 10 years.

Conclusion

Anti TNF dose reduction strategy in patients with IA results in substantial cost savings. Implementation of a dose reduction strategy while monitoring of disease activity reduces the financial impact of the use of biologic therapies. Further studies should be done to identify which patients are more likely to remain in remission while on dose reduction.

References

[1]Bonafede MM, Gandra SR, Watson C, Princic N, Fox KM. Cost per treated patient for etanercept, adalimumab, and infliximab across adult indications: a claims analysis. Adv Ther. 2012 Mar;29(3):234-48. doi: 10.1007/s12325-012-0007-y. Epub 2012 Mar 9. PMID: 22411424.

[2]Joaquín Borrás-Blasco, Antonio Gracia-Pérez, J Dolores Rosique-Robles, MD Elvira Casterá & F Javier Abad (2014) Clinical and economic impact of the use of etanercept 25 mg once weekly in rheumatoid arthritis, psoriatic arthropathy and ankylosing spondylitis patients, Expert Opinion on Biological Therapy, 14:2, 145-150, DOI: 10.1517/14712598.2014.868433

[3]Carter CT, Changolkar AK, Scott McKenzie R. Adalimumab, etanercept, and infliximab utilization patterns and drug costs among rheumatoid arthritis patients. J Med Econ. 2012;15(2):332-9. doi: 10.3111/13696998.2011.649325. Epub 2012 Jan 6. PMID: 22168788.

Disclosure of Interests

None declared

The Prevalence and Patterns of Menopausal Symptoms in Women Living with HIV

Increasing numbers of women with HIV are experiencing menopause. We use data from a large, representative sample of women with HIV to describe the prevalence and clustering of menopausal symptoms amongst pre-, peri- and post-menopausal women using hierarchical agglomerative cluster analysis. Of the 709 women included, 21.6%, 44.9% and 33.6% were pre-, peri- and post-menopausal, respectively. Joint pain (66.4%) was the most commonly reported symptom, followed by hot flashes (63.0%), exhaustion (61.6%) and sleep problems (61.4%). All symptoms were reported more commonly by peri- and post-menopausal women compared to pre-menopausal women. Psychological symptoms and sleep problems clustered together at all menopausal stages. Somatic and urogenital symptom clusters emerged more distinctly at peri- and post-menopause. We recommend regular and proactive assessment of menopausal symptoms in midlife women with HIV, with an awareness of how particular patterns of symptoms may evolve over the menopausal transition.

Protection of bone mineral density in heart failure patients:audit on current clinical practice in a busy tertiary care hospital cardiology department in Ireland

Background

The strong association between heart failure (HF) and osteoporosis is well recognised. Heart failure, due to its multiple risk factors and common pathogenesis with osteoporosis can lead to low bone mineral density (BMD) and increase the risk of fragility fractures. The mortality of HF patients following these fractures is high. Current National Osteoporosis Foundation Guidelines recommend that pharmacological therapy should be reserved for postmenopausal women and men aged 50 years or older who present with a hip or vertebral fracture, where the vertebral fractures may be clinical or identified on a radiograph alone.

Methods

Most HF patients have frequent chest radiographs over their course years. We aimed to audit the prevalence of osteoporosis and current practice of prescribing BMD-protection in patients attending the HF clinic in a busy tertiary care hospital in Ireland. 100 patients attending the clinic in the last one year were randomly selected and clinical, medication and chest radiograph information on this cohort was collected via the hospital electronic information system. All those patients with Radiologist confirmed vertebral compression fractures (VCF) on their plain chest radiographs were audited regarding osteoporosis screening and bone protection prescription.

Results

Due to limited penetration,18 out of 100 chest radiographs were inconclusive,reducing the sample size to 82. 9 out of the remaining 82 patients had radiologist confirmed VCF on their plain chest radiographs whereas 2 patients had VCF incidentally picked up on their lumbar spine x-rays. All patients were aged more than 50. 4 were female and 7 male. Median ejection fraction calculated was 35%. 3 out of 11 were smokers,8 had atrial fibrillation and were on anticoagulation,4 had DM-II and 2 had CKD. 10 were on loop diuretics. Of note,4 patients were on calcium and vitamin D supplements but only 1 patient was on antiresorptive therapy for osteoporosis.

Conclusion

Despite its strong association with heart failure,Osteoporosis remains undertreated in this patient cohort.Due to the significant mortality and morbidity associated with major osteoporotic fractures, doctors should carefully assess and screen heart failure patients for osteoporosis and initiate specific therapy where indicated.

Funding Acknowledgement

Type of funding sources: None.

Lotus seeds (Nelumbinis semen) as an emerging therapeutic seed: A comprehensive review

Nelumbinis semen is commonly known as lotus seeds that have been used as a vegetable, functional food, and medicine for 7,000 years. These are low caloric, a rich source of multiple nutrients and bioactive constituents, which make it a unique therapeutic food. N. semen plays an important part in the physiological functions of the body. Nowadays, people are more conscious about their health and desire to treat disease naturally with minimal side effects. So, functional foods are getting popularity due to a wide range of essential constituents, which are associated to decrease the risk of chronic diseases. These bioactive compounds from seeds are involved in anti-adipogenic, antioxidant, antitumor, cardiovascular, hepato-protective, anti-inflammatory, anti-fertility, anti-microbial, anti-viral, hypoglycemic, etc. Moreover, the relationship between functional compounds along with their mechanism of action in the body, their extraction from the seeds for further research would be of great interest.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

The association between severe menopausal symptoms and engagement with HIV care and treatment in women living with HIV

Using data from the PRIME Study, an observational study of the menopause in women living with HIV in England, we explored the association between menopausal symptoms and: (i) antiretroviral therapy (ART) adherence and (ii) HIV clinic attendance. We measured menopausal symptom severity with the Menopause Rating Scale (MRS, score ≥17 indicating severe symptoms), adherence with the CPCRA Antiretroviral Medication Adherence Self-Report Form, and ascertained HIV clinic attendance via self-report. Odds ratios were obtained using logistic regression. Women who reported severe menopausal symptoms had greater odds of suboptimal ART adherence (adjusted odds ratio (AOR) 2.22; 95% CI 1.13, 4.35) and suboptimal clinic attendance (AOR 1.52; 95% CI 1.01, 2.29). When psychological, somatic and urogenital domains of the MRS were analysed individually there was no association between adherence and severe symptoms (all p > 0.1), however there was an association between suboptimal HIV clinic attendance and severe somatic (AOR 1.98; 95% CI 1.24, 3.16) and psychological (AOR 1.76; 95% CI 1.17, 2.65) symptoms. Severe menopausal symptoms were significantly associated with sub-optimal ART adherence and HIV clinic attendance, however we cannot infer causality, highlighting the need for longitudinal data.

"Support for the supporters": a qualitative study of the use of WhatsApp by and for mentor mothers with HIV in the UK

Third-sector organizations, an important support for people living with HIV, increasingly use digital technology to improve service efficiency and reach. However, there is limited empirical evidence on this use by women living with HIV. The 4M Network (4MNet) is a peer-run UK-wide network of trained Mentor Mothers (MMs) living with HIV; it uses the WhatsApp platform as its primary digital communication tool. We report on a qualitative study about 4MNet MMs' experiences of using WhatsApp, to inform the design of future digital support services. Seven telephone interviews were conducted with five MMs and two project management team (PMT) members in February 2019. Interviews were analyzed using Interpretive Phenomenological Analysis (IPA). WhatsApp was found to have several key features that provided both positive and negative use considerations. WhatsApp eased communication among MMs and supported participation in group activities despite differing schedules and geographic locations. Challenges encountered with WhatsApp included: financial restrictions to data storage and continual access; self-confidence using technology; and security and privacy concerns. Peer-led digital communication is found to be acceptable and effective for women living with HIV. Understanding barriers and valued features of existing digital platforms increasingly used among potentially marginalized groups is vital for informing inclusive innovation.

Thermal, electro-magnetic and thermoelectric investigation of CoNb1-x Ti x Sn (x = 0, 0.75, 0.5, 1) half-Heusler alloy

In this work, structural, thermal, electro-magnetic and thermoelectric attributes of CoNb_1-x Ti _x Sn (x  =  0, 0.75, 0.5, 0.25, 0) alloys have been investigated using density functional theory (DFT). The structural reforms, brought to CoNbSn, portray the increase in its rigidity when increasing the Ti content substituted at the Nb site. They also remodel the character of the alloy from semiconducting paramagnetic to half-metallic ferromagnetic nature. By investigating elastic properties that are interlinked with structural optimizations and enthalpy of formation, studied alloys displayed stable structure. Thermoelectric properties such as Seebeck coefficient (S), electrical conductivity (σ/τ) and power factor (S ² σ/τ), are calculated based on the Boltzmann transport theory. Results revealed that for x  =  0.75 in CoNb_1-x Ti _x Sn, a temperature dependent switch from n-type to p-type is observed. According to the results obtained, CoNb_1-x Ti _x Sn alloys could have potential thermoelectric applications.

Role of water chemistry and stabilizers on the Vero-cells-based infectivity of Newcastle disease virus live vaccine

Newcastle disease virus (NDV) live vaccines are supplied in lyophilized form and usually administered through conventional routes (drinking water, spray, or eye drop) following reconstitution in a diluent. Virus inactivation due to physico-chemical properties of the diluent at the time of administration may lead to vaccine failure. The present study aimed to evaluate the survival of NDV live vaccine strain immersed in 5 pH-amended water samples (pH 5.00, pH 6.00, pH 7.00, pH 8.00, and pH 9.00) by sequential determination of virus infectivity on Vero cells for 3 hours. Minimum reduction in virus infectivity was recorded in the water with neutral or slightly alkaline pH, while the virus was relatively less stable at extreme pH conditions. Maximum reduction of infectivity was observed in the water with pH 9.00 in which the virus was completely inactivated within 3 hours. Addition of stabilizers (Cevamune^® or skimmed milk) slightly altered the pH and total dissolved solids (TDS) values of the virus-charged water samples. In the stabilizer-added water samples, minimum reduction in infectivity was observed in the water with neutral pH, followed by the ones with a pH of 8.00, 6.00, 5.00, and 9.00. In all types of water samples, T-90 values (time required for 90% reduction in virus infectivity) were highest (485 minutes) at neutral pH (pH 7.00) and lowest (102 to 134 min) at an extreme alkaline condition (pH 9.00). Results of the present study indicate that water with a pH range of 7.00 to 8.00 is suitable for administration of NDV live vaccines. However, the addition of Cevamune^® or skimmed milk may have beneficial effects on preserving the infectivity of the virus, even at extreme pH conditions.

Evolution of pH buffers and water homeostasis in eukaryotes: homology between humans and Acanthamoeba proteins

Aim: This study intended to trace the evolution of acid–base buffers and water homeostasis in eukaryotes. Acanthamoeba castellanii  was selected as a model unicellular eukaryote for this purpose. Homologies of proteins involved in pH and water regulatory mechanisms at cellular levels were compared between humans and A. castellanii. Materials & methods: Amino acid sequence homology, structural homology, 3D modeling and docking prediction were done to show the extent of similarities between carbonic anhydrase 1 (CA1), aquaporin (AQP), band-3 protein and H+ pump. Experimental assays were done with acetazolamide (AZM), brinzolamide and mannitol to observe their effects on the trophozoites of  A. castellanii. Results: The human CA1, AQP, band-3 protein and H+-transport proteins revealed similar proteins in Acanthamoeba. Docking showed the binding of AZM on amoebal AQP-like proteins.  Acanthamoeba showed transient shape changes and encystation at differential doses of brinzolamide, mannitol and AZM.  Conclusion: Water and pH regulating adapter proteins in Acanthamoeba and humans show significant homology, these mechanisms evolved early in the primitive unicellular eukaryotes and have remained conserved in multicellular eukaryotes.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Successful fertility treatment with gonadotrophin therapy for male hypogonadotrophic hypogonadism

Gonadotrophin therapy with human chorionic gonadotrophin and recombinant FSH is indicated for use in men with reduced spermatogenesis due to hypogonadotrophic hypogonadism (HH). Patients require regular monitoring for side effects and desired response to treatment. We present a man with HH, azoospermia and a history of previous anabolic steroid usage who had undergone gonadotrophin therapy, had subsequently achieved conception and has now fathered a child.

Effect of ibandronate therapy on serum homocysteine and leptin in postmenopausal osteoporotic females

A significant change in serum leptin level and no change in homocysteine were observed with ibandronate treatment. No correlation of homocysteine and leptin was found with bone mass density (BMD). Results indicate that ibandronate reduces serum leptin levels but how does it help in reducing the osteoporosis. It needs to be explored.

INTRODUCTION

The current study was planned to determine the effects of ibandronate on serum homocysteine and leptin levels in postmenopausal osteoporotic females and to correlate these with BMD.

METHODS

Forty-two newly diagnosed and untreated postmenopausal osteoporotic females were selected on the basis of their BMD (BMD < -2.5) from Orthopaedic Out Patient Department of Shaikh Zayed Hospital, Lahore, Pakistan, and 36, age and BMI matched non-osteoporotic postmenopausal females, were also selected as a control group. Baseline physical and biochemical parameters were compared. In osteoporotic patients, changes in circulating leptin and homocysteine levels were studied after 6 months of therapy with ibandronate (150 mg). The collected data were analyzed on SPSS 16.

RESULTS

There was no significant difference observed in the mean value of all baseline parameters except BMD in both groups. After 6 months of treatment with ibandronate (150 mg), a significant change was observed in serum leptin levels (19.48 ± 1.60 ng/ml vs. 14.09 ± 0.85 ng/ml, p < 0.002), while no considerable change observed in serum homocysteine levels (16.22 ± 0.95 μmol/l vs. 16.80 ± 1.03 μmol/l, p < 0.63). Serum leptin was found significantly correlated with anthropometric parameters. No correlation of serum leptin and homocysteine was found with BMD (r = 0.09, p value = 0.54; r = -0.17, p value = 0.27).

CONCLUSION

Our results show that ibandronate reduces serum leptin levels while it has no effect on serum homocysteine levels. Further studies are needed to explain how the decrease in serum leptin level may help in reducing the progression of osteoporosis.

Open conformation tissue transglutaminase testing for celiac dietary assessment

OBJECTIVES

Anti tissue-transglutaminase antibody is the mainstay of celiac disease serologic testing. Whilst it has high sensitivity in patients on an unrestricted diet, sensitivity is poor for evaluation of gluten free diet adherence.

AIM

To assess the utility of a novel assay measuring Immunoglobulin-A antibodies to catalytically active open conformation tissue-transglutaminase in assessment of ongoing gluten exposure in celiac disease patients on an alleged gluten free diet.

METHODS

Through prospective assessment, 147 patients with celiac disease were divided into good and poor adherence. Open and closed (conventional) tissue-transglutaminase titres were measured using standard enzyme linked immunosorbent assay. 50 patients with inflammatory bowel disease served as disease controls.

RESULTS

Overall 128 patients had been on gluten free diet for more than six months and 19 were found to be poorly adherent on dietary review. Within this group 13 (68.4%) and 10 (52.6%) patients respectively were positive for the open conformation and conventional assay (p=0.51). Two and one control patients tested positive for closed and open assays respectively.

CONCLUSIONS

Compared to native assays open conformation tissue-transglutaminase may have higher sensitivity in the poor gluten free diet adherence group and higher specificity in the control population. Larger population studies are warranted to assess whether the open conformation tissue-transglutaminase assay may be superior to the conventional assay.

Body mass index and the risk of obesity in coeliac disease treated with the gluten-free diet

BACKGROUND

Coeliac disease is increasingly diagnosed and weight changes are common after adoption of a gluten-free diet (GFD), however data on body mass index (BMI) changes are limited.

AIM

To assess changes in BMI after diagnosis in a large coeliac population.

METHODS

A total of 1018 patients with biopsy confirmed coeliac disease seen at our centre were studied retrospectively. Initial and follow-up BMIs were recorded, as was GFD adherence as assessed by an expert dietitian.

RESULTS

A total of 679 patients with at least two recorded BMIs and GFD adherence data were included in the study. Mean follow-up was 39.5 months. Compared to regional population data, the coeliac cohort was significantly less likely to be overweight or obese (32% vs. 59%, P < 0.0001). Mean BMI increased significantly after GFD initiation (24.0 to 24.6; P < 0.001). 21.8% of patients with normal or high BMI at study entry increased their BMI by more than two points.

CONCLUSIONS

Individuals with coeliac disease have lower BMI than the regional population at diagnosis. BMI increases on the GFD, especially in those that adhere closely to the GFD. On the GFD, 15.8% of patients move from a normal or low BMI class into an overweight BMI class, and 22% of patients overweight at diagnosis gain weight. These results indicate that weight maintenance counselling should be an integral part of coeliac dietary education.

Noncoeliac enteropathy: the differential diagnosis of villous atrophy in contemporary clinical practice

BACKGROUND

Duodenal villous atrophy (DVA) is a key diagnostic finding in coeliac disease (CD). However, the differential diagnosis for this finding is broad.

AIM

To identify conditions causing noncoeliac enteropathy (NCE) with villous atrophy and methods to differentiate between CD and NCE in clinical practice.

METHODS

Through record review we identified patients with DVA due to conditions other than CD. Patient demographics, clinical features and relevant investigations were compared with CD patients. Rates of CD misdiagnosis, and response to treatments were recorded.

RESULTS

Thirty cases of NCE were identified with ten different aetiologies. Unspecified immune-mediated enteropathy was the most common aetiology; affecting 10 patients. Gastrointestinal symptoms were more common in NCE than those in CD patients (P < 0.01). Twenty of the 24 NCE patients tested were HLA-DQ2/DQ8 negative. Twenty-six NCE patients were negative for IgA tissue transglutaminase (tTG) (P = 0.0001). Intraepithelial lymphocytosis was absent in 10 (33.3%) patients. Twenty-one NCE patients initially misdiagnosed with CD and one with gluten intolerance were prescribed a gluten free diet (GFD). Fifteen of 22 had repeat biopsy and none showed histological improvement.

CONCLUSIONS

Although coeliac disease is the most common cause of DVA, noncoeliac enteropathy is not rare and may easily be mistaken for coeliac disease. Noncoeliac enteropathy is suggested by a normal initial tTG (87%), lack of intraepithelial lymphocytosis on biopsy, and lack of histological response to a gluten free diet. Subjective response to gluten free diet has poor predictive value for coeliac disease. Noncoeliac enteropathy can often be confirmed by negative HLA-DQ2/DQ8 testing and targeted investigations can ascertain a definitive aetiology in most cases.

Pregnancy in HIV-infected teenagers in London

OBJECTIVE

The aim of the study was to describe pregnancies in HIV-infected teenagers.

METHODS

A review of the case notes of HIV-infected pregnant teenagers aged 13-19 years from 12 London hospitals was carried out for the period 2000-2007.

RESULTS

There were 67 pregnancies in 58 young women, of whom one was known to have acquired HIV vertically. The overall mother-to-child transmission (MTCT) rate of HIV was 1.5% (one of 66). There were 66 live births. Median ages at HIV diagnosis and conception were 17 and 18 years, respectively. Sixty-three per cent of women were diagnosed with HIV infection through routine antenatal screening. Eighty-two per cent of pregnancies (41 of 50) were unplanned, with 65% of women (26 of 40) using no contraception. Forty-three per cent of the women (20 of 46) had a past history of a sexually transmitted infection (STI). In 63 pregnancies, antiretroviral therapy was started post-conception, with prevention of HIV MTCT the only indication in 81% of cases. Fifty-eight per cent of those on highly active antiretroviral therapy (HAART) had an undetectable HIV viral load by delivery. Eighty-seven per cent were uncomplicated pregnancies. Seventy-one per cent delivered by Caesarean section and 21% (14 of 64) had a preterm delivery (<37 weeks). In the 12 months after delivery, 45% of women received contraceptive advice and 25% of women became pregnant again.

CONCLUSION

Obstetric and virological outcomes were favourable in this group of HIV-infected young women. However, the majority of pregnancies were unplanned with poor documentation of contraception use and advice and low rates of STI screening. A quarter of women conceived again within 12 months of delivery. Effective measures to reduce STIs, unplanned pregnancies and onward HIV transmission in HIV-infected teenagers are needed.

Streptozotocin causes pancreatic beta cell failure via early and sustained biochemical and cellular alterations

The morphological and biochemical changes that occur in the early phase of streptozotocin (STZ)-induced beta cell failure have not been characterized. The pancreas and plasma of rats treated with STZ were processed for morphological and biochemical parameters 1-24 h and 4 weeks after STZ treatment. Marked reduction in body weight was observed as early as 3 h post STZ treatment and hyperglycemia coupled with hypoinsulinaemia appeared in rats 1 h after treatment with STZ. Hyperglycemia, hyperglucagonemia and hypoinsulinemia became permanent 24 h after STZ treatment. The number of insulin-positive cells decreased significantly (p<0.05) at 24 h after STZ treatment with a concomitant increase in the number of glucagon-immunoreactive cells. Electron microscopy showed coalescing of beta cell granules 18 h after STZ treatment. A near to complete degranulation of beta cells settled at 21 h after STZ administration. The pancreatic tissue and plasma levels of adrenaline and noradrenaline increased significantly (p<0.004: pancreatic tissue; p<0.04: plasma) 3 h after STZ treatment and remained high after a reduction at 6 h post STZ treatment. The pancreatic tissue and plasma levels of 5-HIAA decreased significantly (p<0.002 pancreatic tissue; p<0.04: plasma) 1 h after STZ treatment and remained low after a reduction at 6-9 h post STZ treatment. STZ elicited significant dose-dependent increases in insulin secretion from the isolated pancreas. The early changes in catecholamine level may be used in screening and follow-up studies on diabetes mellitus.

The peripheral nervous system and the perception of verticality

Orientation of the body with respect to gravity is based on integration of visual, vestibular and somatosensory signals. Here, we investigated the subjective postural vertical (SPV) and visual vertical (SVV) in three patients with bilateral somatosensory deafferentation and a group of age-matched normal subjects. Our hypothesis was that the patients with bilateral somatosensory deafferentation may show tilt induced bias in the construction of their SPV, with a normal SVV. Patient 1 had a severe Guillain Barré syndrome and almost complete absence of peripheral sensation, the two other patients had a thoracic spinal injury with a sensory loss from T6-7 down. On initial testing, compared with normal subjects and the patients with spinal injury, Patient 1 had a significant bias in SPV towards the side of a preceding tilt in both directions. Several months later, after significant improvement of sensation, this tilt-induced bias in SPV had resolved completely. In addition, Patient 1 had a significantly enlarged "cone of verticality", which did not change following improvement in peripheral sensation, reflecting persisting disturbance in the perception of body verticality. In the two patients with spinal injury, bias towards the side of a preceding tilt was not significant. These findings confirm the importance of somatosensory input from the trunk to the perception of SPV in the seated position.

Sexual health services for South Asians in London, UK: a case-control study

National guidance on sexual health in England recommends service development to meet the specific needs of ethnic minority populations. Our aim was to evaluate mode of referral, number of sexually transmitted infections (STIs) diagnosed, and the offering and uptake of HIV testing in patients of South Asian ethnicity. A retrospective case-control study was undertaken in two London genito-urinary (GU) medicine clinics. There were 250 case-control pairs with approximately equal numbers of men and women. South Asians were less likely to have an STI (Odds ratio [OR] 0.66, 95% confidence interval [CI] 0.45, 0.97) or to report risk factors for HIV (OR 0.45, 95% CI 0.28, 0.71). Offering and uptake of HIV antibody testing were high in both South Asian and non-South Asian groups (OR 0.62, 95% CI 0.27, 1.51). South Asians were significantly more likely than controls to have been referred by other medical services rather than self-referred (OR 2.00, 95% CI 1.32, 3.01), which is in keeping with poorer access to GU medicine services in London.

Sexually transmitted infections among UK street-based sex workers

BACKGROUND

Female sex workers are a heterogeneous group and recent reports of declining incidence of sexually transmitted infections (STIs) do not apply to all populations. This is an observational study of street-based sex workers attending an inner-London genitourinary (GU) clinic between 1 July 2006 and 31 January 2007.

METHODS

In July 2006 the local sex worker outreach project developed a weekly drop-in for street-based sex workers. From the drop-in, sex workers were fast tracked to attend a range of dedicated health services, including the GUM clinic.

RESULTS

The outreach team made contact with 120 street-based sex workers in the borough. 40 of these attended the drop-in and 25 attended the GU clinic. 8 had tuberculosis. There were frequent reports of recent recreational drug use, unprotected sex with clients and no reliable contraception. 7 were pregnant, 6 were HIV positive and 12 had positive syphilis serology. A further 17 STIs were identified.

CONCLUSIONS

There was a high frequency of HIV, syphilis, other bacterial STIs and unwanted pregnancy among sex workers attending this clinic. There were considerable amounts of other physical ill health in this group, with frequently reported risky sexual behaviour. This study demonstrates the need for targeted development work to meet the multifactorial needs of these women.

The progressive effects of a fat enriched diet on ventricular myocyte contraction and intracellular Ca2+ in the C57BL/6J mouse

The C57BL/6J mouse has a genetic susceptibility to develop diabetes when fed with a high-fat, high-sucrose diet. The general characteristics of diet-induced diabetes in this model include progressive development of hyperinsulinaemia, hyperglycaemia, insulin resistance and obesity, features that are frequently observed in the clinical setting. This study investigated the progressive effects of a fat enriched (FE) diet on contraction and intracellular Ca2+ in ventricular myocytes from the C57BL/6J mouse. The characteristics of the mice fed with the FE diet compared to mice receiving control diet included progressive increase in the rate of body weight gain, increased fasting blood glucose and time-dependent differences in the disposal of blood glucose after a glucose challenge. The ultrastructure of cardiac myocytes and associated capillaries did not show any gross morphological alteration after 27 weeks of FE diet compared to controls. At 5 months the resting cell length (RCL) and the kinetics of shortening were not significantly altered in ventricular myocytes from mice receiving the FE diet compared to age-matched controls. At 5 and at 7 months the amplitude of shortening was increased in myocytes receiving the FED diet compared to controls. At 7 months the time to half (THALF) relaxation of myocyte contraction was shortened in myocytes from mice receiving the FE diet compared to controls. Mean THALF relaxation in myocytes from mice fed the FE diet was 32.0 +/- 1.4 ms (n = 23) compared to 40.2 +/- 2.0 ms (n = 27) in controls. Neither resting intracellular Ca+ nor the kinetics or amplitude of the Ca2+ transient were altered by FE diet. Differences in myofilament sensitivity to Ca2+ might underlie the changes in contractility.

Impact of ivermectin on the ultrastructure of the testis of Argas (Persicargas) persicus (Ixodoidea: Argasidae)

Mated male Argas persicus were dissected 1 and 2 weeks after feeding on untreated and ivermectin (IVM)-treated pigeons. One week after feeding, testes of untreated ticks were filled with rounded spermatids with subplasmalemmal vesicles and cytoplasmic organelles, but lacking in treated ticks. Two weeks after feeding, testes were crowded with elongated spermatozoa supported by double-walled cisternal tubes. The tubes consisted of two opposite walls, each with outer-fringed processes and inner elongated cisternae. Both were supported with electron dense striated plates in the middle of the spermatozoon. Internally, the cisternal tubes contained mitochondria and vacuoles. The nuclei were elongated dense masses between the tubes and the cell membranes. Subcutaneous inoculation of IVM at the dose 400 microg/kg pigeon resulted in extensive alterations in the testis of A. persicus. IVM prevented the development of new spermatids. There was a break down of cell membranes and cytoplasmic organelles of spermatozoa. Multivesicular bodies and numerous vacuoles were noticed in their cytoplasm. Double membranes of elongated cisternae and striation of electron dense plates became indistinct. IVM caused granulation and vacuolization of the nucleus as well as injury of mitochondrial cristae. The results suggest that IVM may bind to the neurotransmitter or the hormone involved in the process of sperm development or may be toxic to the germinal cells of A. persicus testis.

Empirical treatment for tuberculosis: survey of cases treated over 2 years in a London area

OBJECTIVE

To determine factors influencing the decision to treat tuberculosis empirically and its outcome.

METHODS

A retrospective survey was done to assess the factors influencing the decision to treat tuberculosis empirically and the effectiveness of such treatment, within a London area. Data on tuberculosis cases treated during 1995-96 (n = 218) was collected and analysed.

RESULTS

One hundred and fifty-eight (72.5%) cases of tuberculosis were treated empirically, that is, in the absence of positive smear or histology. Factors suggesting tuberculosis were clinical suspicion, abnormal radiology, elevated Erythrocyte Sedimentation Rate (ESR) and/or C-reactive Protein (CRP), grade 3 or 4 Heaf test, contact or family history, and Heaf conversion. Significantly more Asian [79 of 105 (75.2%); p < 0.02] and African patients [61 of 81 (75.3%); p < 0.05] were treated empirically as compared to West European patients [14 of 28 (50%)]. Based on logistic regression, any non-European ethnicity carried a significant risk for being treated empirically [OR: 2.7, CI: 1.7-20.8; p < 0.05]. Patients requiring revision of diagnosis (n = 9) were older [55.7 +/- 10.1 vs 32.8 +/- 16.0 years; p < 0.001]; 6 of them had neoplastic conditions.

CONCLUSION

In this survey, frequent use of empirical treatment for tuberculosis in non-European patients reflects the physicians' high index of suspicion. Although such therapy is justifiable in selected cases, the proportion requiring revision of diagnosis may be reduced by more thorough investigation, especially in older patients.

Allergen avoidance in infancy and allergy at 4 years of age

In an attempt to prevent or reduce the manifestations of atopic disease, a group of infants considered to be genetically at high risk of atopy was entered in a prenatally randomized, controlled study. A prophylactic group (n = 58) was either breast-fed with their mothers excluding foods regarded as highly antigenic from their diets, or given an extensively hydrolysed formula. In addition, strenuous efforts were made to reduce exposure to the house-dust mite by application of acaricide to the bedroom and living room carpets and upholstered furniture. A control group (n = 62) was fed conventionally by breast or on formula, and no specific environmental measures were taken. The results (previously reported) after 1 year showed significantly less total allergy, asthma, and eczema in the prophylactic group. Similar results were obtained at 2 years although the reduction in asthma no longer achieved statistical significance. However, there was significantly less sensitization, as shown by a battery of skin prick tests (SPTs), to both dietary allergens and aeroallergens in the prophylactic group. All the children have now been reviewed at the age of 4 years, and SPTs to a wide range of dietary allergens and aeroallergens have been performed. The control group continues to show more total allergy (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.21-6.13, P < 0.02), definite allergy (allergic symptoms plus positive SPT) (OR 5.6, CI 1.8-17.9, P < 0.005), and eczema (OR 3.4, CI 1.2-10.1, P < 0.05). More control children have positive SPTs (OR 3.7, CI 1.3-10.0, P < 0.02). A dual approach to the prevention of allergic disease, avoiding as far as possible sensitization to food and aeroallergens, significantly reduces the risk of atopic disease. This should be reserved for infants considered at very high risk of atopy, and close medical and dietetic supervision must be available.

Silent sarcoidosis and clubbing

We report a case of sarcoidosis which was not diagnosed in life for a variety of reasons. In particular the chest was silent despite extensive pulmonary damage, and florid finger clubbing developed within a very short time.