Correction: Exome sequencing of Pakistani consanguineous families identifies 30 novel candidate genes for recessive intellectual disability.

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Circumcision Rates after the Release of Preputial Adhesions

Aim We aim to determine if the release of preputial adhesions (RPA) successfully managed symptoms related to physiological phimosis and prevented the need for circumcision. Methods We performed a retrospective review and analysed data on RPA procedures performed between January 2005 and December 2017. Results 534 RPA's were performed. Median age at RPA was 52.7 months (range: 3-197 months). Mean follow-up was 108 months (range: 4.7 to 152.4 months). 44 children and 1 child subsequently required a circumcision or preputioplasty respectively (8.4% incidence). There was no statistical difference in the circumcision rates in children who had RPA over 5 years vs those that had RPA under 5 years old (6.6% vs 9.8%; p = 0.21). The histology of the 44 excised foreskins showed BXO in 2 (4.5%) and chronic inflammation in 11 (25%). Conclusion RPA is an effective alternative to circumcision where either reassurance on the benign and self-limiting nature of physiologic phimosis or steroid treatment are unsuccessful in managing symptoms.

Exome sequencing of Pakistani consanguineous families identifies 30 novel candidate genes for recessive intellectual disability.

Intellectual disability (ID) is a clinically and genetically heterogeneous disorder, affecting 1-3% of the general population. Although research into the genetic causes of ID has recently gained momentum, identification of pathogenic mutations that cause autosomal recessive ID (ARID) has lagged behind, predominantly due to non-availability of sizeable families. Here we present the results of exome sequencing in 121 large consanguineous Pakistani ID families. In 60 families, we identified homozygous or compound heterozygous DNA variants in a single gene, 30 affecting reported ID genes and 30 affecting novel candidate ID genes. Potential pathogenicity of these alleles was supported by co-segregation with the phenotype, low frequency in control populations and the application of stringent bioinformatics analyses. In another eight families segregation of multiple pathogenic variants was observed, affecting 19 genes that were either known or are novel candidates for ID. Transcriptome profiles of normal human brain tissues showed that the novel candidate ID genes formed a network significantly enriched for transcriptional co-expression (P<0.0001) in the frontal cortex during fetal development and in the temporal-parietal and sub-cortex during infancy through adulthood. In addition, proteins encoded by 12 novel ID genes directly interact with previously reported ID proteins in six known pathways essential for cognitive function (P<0.0001). These results suggest that disruptions of temporal parietal and sub-cortical neurogenesis during infancy are critical to the pathophysiology of ID. These findings further expand the existing repertoire of genes involved in ARID, and provide new insights into the molecular mechanisms and the transcriptome map of ID.

Rate of active Helicobacter pylori infection among symptomatic patients of Pakistan.

Only few epidemiological studies have examined the rate of active H. pylori infection in the symptomatic population in Pakistan. This retrospective study presents the laboratory data collected during the past 13 years (2002 to 2015) from 2315 symptomatic patients referred to the BreathMAT Lab, Nuclear Medicine, Oncology and Radiotherapy Institute, Islamabad for the diagnosis of active H. pylori infection using the 13C Urea Breath Test. Rate of infection and its association with gender and age were evaluated. The overall rate of active H. pylori infection was 49.5% and there was no association of this rate of infection with gender. An increase in rate of infection was observed with increasing age with significant difference (p < 0.05). The patients that tested negative for this infection might be having symptoms due to stress and indiscriminate use of non-steroidal antiinflammatory drugs (NSAIDs) in this community. The fact that half of the symptomatic patients were negative needs to be highlighted and further suggests that symptomatic patients should be tested by the 13C UBT before prescribing antibiotic treatment for H. pylori eradication. In addition, there is a need to educate this community about the harmful and side effects of self medication and overuse of NSAIDs.

Effects of acacia honey on wound healing in various rat models.

Honey is a traditional remedy for the treatment of infected wounds, and is becoming more important as microbial resistance to conventional therapeutic agents increases. A study was conducted to assess the wound-healing activity of Acacia honey using incision, excision, burn and dead-space wound models in rats. Different formulations of honey were used and rats were treated topically as well as orally. Both the higher and lower doses of honey produced a significant effect on healing (p < 0.05). The area of epithelization was found to increase, followed by an increase in wound contraction, skin-breaking strength, tissue granulation. The hydroxyproline content also increased in the rats treated with higher doses of honey compared to control, indicating an increase in collagen formation.

Wife abuse: a hidden problem. A study among Saudi women attending PHC centres.

The aim of this cross-sectional study was to measure the prevalence, severity and type of wife abuse experienced by ever-married women attending primary health centres in Medina, Saudi Arabia. Women were interviewed in private at health centres using a questionnaire which included items from the Modified Conflict Tactic Scale, Kansas Marital Scale and the lie scale of the Minnesota Multiphase Personality Inventory. Of 689 eligible women, 25.7% reported physical abuse and 32.8% emotional abuse without physical violence. Of those physically abused, 36.7% suffered minor and 63.3% severe incidents. The lifetime prevalence of abuse among the women was 57.7%. Only 36.7% of 109 abused women had informed and discussed the issue with their primary care physician.

Exploring pharmacists' opinions regarding PHARMAC's interventions in promoting brand changes.

BACKGROUND: In New Zealand, the use of generic medicines is advocated by the Pharmaceutical Management Agency of New Zealand (PHARMAC). Among other interventions, PHARMAC uses educational awareness campaigns to educate pharmacists to promote the uptake of generic medicines. However, the opinion of pharmacists regarding these interventions has not yet been evaluated. OBJECTIVES: The objective of this study was to explore pharmacists' opinions regarding PHARMAC's interventions in promoting medicine brand changes. METHOD: A cross-sectional study design was employed to explore pharmacists' opinions regarding brand changes. A questionnaire was sent to 500 randomly selected pharmacists in New Zealand. In second component of the study, five community pharmacies in the Auckland region were selected through convenience sampling, and a semi-structured interview was conducted with a pharmacist in each site. RESULTS: One-hundred and eighty seven questionnaires were returned and analyzed (response rate of 37.4%). Sixty-eight percent of pharmacists supported brand changes and 98.4% mentioned that PHARMAC is responsible for informing them of brand changes. Over half (51.3%) of pharmacists found the current interventions effective, and 39.6% were satisfied with the current brand change information provided by PHARMAC. The majority (94.7%) of pharmacists currently receive faxed information but many indicated (70.8%) that they prefer email notifications. Cilazapril was considered the least difficult medicine to substitute in the past 10 years and omeprazole the most difficult. Patient acceptance and claims about effectiveness were the main factors in determining the difficulty of brand substitution. Fewer than half of the respondents felt that interventions were implemented with enough preparation time for a brand change. The ideal lead-in time was in the range of three to six months. Pharmacists expressed a number of concerns about brand changes such as the frequency at which they occur and the lack of generic stock availability when a brand change occurs. CONCLUSION: Over one-third of respondents were satisfied with brand change information provided by PHARMAC. Cilazapril was the least difficult medicine to substitute, while omeprazole and salbutamol changes were the most difficult. Claims about effectiveness, quality and side effects were the main factors identified as barriers to generic substitution.

Isolation of maternal mononuclear cells from placentas for use in in vitro functional assays.

Interest in immunoregulatory mechanisms within uteroplacental tissues, particularly in malarial infection during pregnancy, prompted us to develop a technique to extract maternal mononuclear cells from human term placentas. This method is described. The phenotypes of isolated cells were characterised for expression of CD45, CD3, CD4, CD8, CD14, CD15, CD68, CD22, CAM 5.2 and class II MHC antigens and compared with those in situ in frozen sections of the same placentas. Isolated mononuclear cell preparations were examined for contamination by fetal trophoblasts. Fetal leukocyte contamination appeared unlikely since histological sections of placental tissue, after the extraction of maternal leukocytes, showed intact chorionic villi with no disruption of fetal stem vessels. This technique produces preparations of maternal placental mononuclear cells which are representative of cells in situ, show minimal fetal cell contamination and are suitable for functional studies.

Suppressed peripheral and placental blood lymphoproliferative responses in first pregnancies: relevance to malaria.

An understanding of processes that predispose pregnant women, and in particular primigravidae, to malaria infection is essential to improve malaria management in pregnancy. Lymphoproliferative responses to malaria-specific (F32, 190L, and 190N) as well as other antigens (Candida and purified protein derivative [PPD]) were examined in the peripheral and placental blood of 102 Gambian women at the time of delivery. The lymphoproliferative responses of placental cells were poor to all antigens compared with those of peripheral blood (Candida P < 0.001, PPD P < 0.001, F32 P = 0.008, 190L P = 0.003, and 190N P = 0.10). Reduced proliferative capacity of placental mononuclear cells may contribute to heavy parasite colonization of this organ. Proliferation to malarial and PPD but not Candida antigens was selectively suppressed in peripheral and placental blood of primiparae relative to multiparae (F32 P = 0.07, 190L P = 0.09, 190N P = 0.007, PPD P = 0.09). Autologous plasma contained factors that suppressed lymphoproliferative responses to the same series of antigens to which the primiparae responded poorly (F32 P < 0.001, 190L P < 0.001, 190N P < 0.001, PPD P = 0.03). Malarial antibody levels were comparable among women of different parities and between peripheral and placental blood. Primigravidae may be more susceptible to malaria because of unique physiologic factors, such as higher levels of circulating immunosuppressive corticosteroids (P < 0.001), rather than differences in levels of acquired immunity.

A commercial pregnancy test modified for field studies of fetal loss.

We describe simple modifications to the ICON II hCG (URINE) pregnancy test to provide a sensitive and specific urinary assay for hCG in field studies of fetal loss. The modified assay had a qualitative lower limit of detection of 0.30 IU/l, a 50% qualitative limit of 0.61 IU/l, a 100% qualitative limit of 1.16 IU/l, and a quantitative limit of 0.80 IU/l. Coefficients of variation ranged from 9.9% to 21.1%. Parallelism was observed among serially diluted subject samples. We used the assay in an 11-month prospective study of fetal loss in rural Bangladesh in which urine samples were collected twice-weekly from 494 women; 330 pregnancies and 93 fetal losses were detected. The median time to a positive pregnancy diagnosis was day 26 from last menses. The modified assay provided qualitative detection of early pregnancy comparable to laboratory assays, and appears to be well suited for use in epidemiologic or rural-population fetal loss studies.

Evidence for involvement of amino acid neurotransmitters in anesthesia and naloxone induced reversal of respiratory paralysis.

General anesthetics render a person unconscious and may produce respiratory paralysis at therapeutic doses. No pharmacological agent is available to restore respiration and the mechanism/s of anesthesia or apnea is not clearly understood. In this report, we present evidence to show that naloxone reversed respiratory failure induced by thiopental, ketamine, halothane but not that induced by phenobarbital. Furthermore, 25 mg/kg, i.v. thiopental, 140 mg/kg, i.v. ketamine, and 3% halothane produced anesthesia without significantly altering respiratory rate, increased GABA and decreased glutamate (except ketamine and phenobarbital) levels in rat brain stem and cortex, but not in caudate and cerebellum. Aspartate, glycine and alanine levels were not affected in four brain regions studied. Pretreatment with TSC for 30 minutes did not change GABA or glutamate contents, but abolished the anesthetic as well as the respiratory depressant actions of the anesthetics. Increasing the doses of anesthetics produced respiratory failure with further rise in GABA and fall in glutamate in brain stem and cortex. Naloxone reversed respiratory paralysis and restored GABA close to control values in rat brain stem and cortex with no changes in caudate or cerebellum. Data presented here suggest that GABA may be necessary to produce loss of consciousness and naloxone reverses anesthetic induced respiratory failure.

Specificity of lymphocytotoxic autoantibodies (LCAbs) found in the serum of leprosy patients: class I MHC antigens.

Lymphocytotoxic autoantibodies (LCAbs) of the IgM class have been identified in patients with borderline tuberculoid (BT) and borderline lepromatous (BL) leprosy with Type I reactions (I) as well as lepromatous leprosy (LL) patients with erythema nodosum leprosum reactions (ENL). The observation that lymphocytotoxic activity (LCA) was reduced in the presence of platelets led us to determine whether LCAbs had specificities for Class I Major Histocompatibility Complex (MHC) determinants. Absorption of LCA positive sera with platelets, classically used to deplete Class I specific lymphocytotoxic antibodies, reduced LCA towards autologous as well as allogeneic target cells. This was true for LCA positive sera from all patient classifications (group BT in the autologous system, p less than 0.01; in all other patient groups, p less than 0.001). Introducing B-2m to cytotoxicity assays only marginally reduced LCA when added at high concentrations (5 mg/ml). An anti-Class I MHC antiserum which blocked the lytic activity. The data indicate that LCAbs while absorbed by platelets, are not specific for the Class I MHC antigens. The autoantigen recognized by these autoantibodies therefore remains to be identified.

Maternal infections influence infection susceptibility in childhood.

The proposed hypothesis suggests that the types of infections commonly experienced in pregnancy and in childhood are linked. The suggestion is made that maternal infections leave an impression on the developing fetal immune system and modulate future responsiveness to infection and/or vaccination challenge. A number of factors are explored which may influence this process, namely immunoregulation in pregnancy and infection type, gestation, maturity of the fetal immune system, and parity.

Placental malaria. I. Pathological classification.

Pregnant women are more likely to contract malaria than their non-pregnant counterparts. The aim of this study was to develop a simple classification system for the histopathological diagnosis of placental malaria infection applicable to placentas collected in field conditions. The placentas were classified into four groups depending on the presence and distribution of parasites and malaria pigment: active infection, active-chronic infection, past-chronic infection, not infected. The frequency of parasitized placentas (26.4%) was in keeping with the prevalence of placental parasitaemia documented in epidemiological studies. An additional 29.8% placentas showed pigment in fibrin only, indicating past-chronic infection. Chronic placental malaria infection was most common in primigravidae, possibly reflecting ineffective clearance of parasites from the placenta. Seasonal fluctuations between infection categories support progression of placental infection with delayed clearance of pigment from fibrin. The proposed classification system has allowed diagnosis of different categories of placental malaria infection by two independent observers. A standardized method of diagnosis may enhance understanding of placental pathology and reduced birth weight in malaria infection during pregnancy.

Placental malaria. II. A semi-quantitative investigation of the pathological features.

Malaria in pregnancy is associated with reduced birth weight. Most pathological studies of placental malaria infection have focused on severe Plasmodium falciparum infection. In the present study of 121 placentas delivered in a rural area of The Gambia, malaria infection was diagnosed in tissue sections using a simple classification system and severity of pathology was ranked semiquantitatively. Deposition of malaria pigment in circulating cells was associated with active infections whereas pigment in fibrin was a feature of active-chronic infections. Primigravidae had higher levels of pigment at all sites, although these observations were not always significant. Thickening of the trophoblast basement membrane occurred in all infection categories but fibrinoid necrosis of chorionic villi was a feature of active and active-chronic infection. Both birth weight and placental weight were increased in infected placentas but widespread trophoblast basement membrane thickening was associated with decreased birth weight. Both birth weight and placental weight decreased with increased fibrinoid necrosis and cytotrophoblast prominence but the results were not significant. By this approach it has been possible to correlate placental pathology with different infection categories and to analyse the pathological features associated with decreased birth weight.

Inflammatory reactions in placental blood of Plasmodium falciparum-infected women and high concentrations of soluble E-selectin and a circulating P. falciparum protein in the cord sera.

To better understand reasons for increased susceptibility to malaria in pregnancy; and the interrelationships between maternal malaria, local immune reactions and the development of the fetus, concentrations of soluble interleukin-10 (IL-10), cytokine receptors, adhesion molecules, a Plasmodium falciparum protein, glutamate-rich protein (GLURP) and antibodies to P. falciparum rhoptry-associated protein-1 were measured among 105 Gambian women and their neonates. Peripheral blood concentrations of IL-10, soluble cytokine receptors and soluble adhesion molecules were found to be different from those concentrations measured in the placenta. Markers of inflammatory reactions: IL-10, sIL-2R, sIL-4R, and soluble tumour necrosis factor receptor I (sTNF-RI) were found in high concentrations in the placenta, indicating that inflammatory reactions take place in the placenta which has been regarded as an immunoprivileged site. Concentrations of soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble intracellular adhesion molecule-1 (sICAM-1), potential adhesion receptors for malaria parasites, were associated with an active P. falciparum infection in the placenta although the associations did not reach significance. P. falciparum exoantigen, GLURP, was detected in cord blood indicating transplacental passage of malarial antigens. Concentrations of E-selectin were higher in cord blood samples compared with peripheral blood samples. This appeared to be associated with development of cord endothelial cells and not with P. falciparum infection.

Relationships between maternal malaria and malarial immune responses in mothers and neonates.

Immune responses of 97 Gambian women and their neonates were studied. New methods distinguished between active and previous placental malaria, were used to examine relationships between maternal malaria and neonatal immune responses. Many placentas (61%) had active or previous malarial infection. Maternal and cord malarial IgG levels correlated (P < 0.001). Malarial IgG was raised in cord blood in active placental malaria; IgM was not detected. Mean lymphoproliferation and the proportion of responders to soluble P. falciparum antigens (F32) and conserved regions of p190 expressed on trophozoites and schizonts (190L and 190N) were higher in neonates than mothers. There was no clear relationship between maternal malaria and neonatal mean lymphoproliferation to malarial antigens, although fewer neonates responded when mothers were actively infected. Matched maternal and neonatal lymphoproliferation responses did not correlate. However, first born neonatal lymphoproliferation to PPD and malarial antigens appeared lower than other neonates, in agreement with lower lymphoproliferation in primigravidae compared with multigravidae. Also in common with mothers, autologous plasma suppressed neonatal lymphoproliferation to PPD and malarial antigens, suggesting common immunoregulation. Higher cortisol or other circulating factors in first pregnancies may be implicated. The relevance of cell-mediated malarial immune responses detected at birth remains to be established.

Serum lymphocytotoxic activity in leprosy.

Sera from 167 patients across the spectrum of leprosy and 46 endemic controls were screened for lymphocytotoxic activity (LCA). The Terasaki microdroplet lymphocytotoxicity assay was performed at 37 degrees C and 15 degrees C to test sera for LCA against a panel of lymphocytes from 50 donors which represented most known HLA-ABC antigens. Raised complement-dependent LCA at 15 degrees C was seen in leprosy patients with histories of erythema nodosum leprosum (ENL) or reversal/Type I (I) reactions. Eighty-six per cent of lepromatous (LL) patients with a history of ENL (n = 21, P less than 0.001), 83% of borderline lepromatous (BL) and 88% of borderline tuberculoid patients (BT) with a history of Type I reactions (n = 12, P less than 0.01 and n = 24, P less than 0.001 respectively) had LCA compared to 39% of endemic controls (n = 46). LCA was attributed to IgM on the basis of reduced activity when serum was treated with both dithiothreitol or absorbed with antiserum for IgM. Removal of immune complexes and rheumatoid factor did not influence LCA. LCA-positive sera reacted similarly with allogeneic lymphocytes from either healthy donors or leprosy patients. Moreover LCA-positive sera reacted with autologous lymphocytes. Specificities for HLA-ABC antigens were not identified. The potential role of these autoantibodies, manifested in leprosy patients with hypersensitivity reactions remains speculative.