A pseudo-outbreak of disseminated cryptococcal disease after orthotopic heart transplantation.

Cryptococcal infection is the third most common invasive fungal infection (IFI) among solid-organ transplant (SOT) recipients and is considered an important opportunistic infection due to its significant morbidity and mortality. To determine whether a cluster of cryptococcosis in heart transplant patients was of nosocomial nature, three cases of orthotopic heart transplant recipients with postoperative disseminated cryptococcal infection were investigated and paired with an environmental survey in a tertiary care hospital. The infection prevention department conducted a multidisciplinary investigation, which did not demonstrate any evidence of health care-associated environmental exposure. Moreover, multilocus sequence typing showed that one isolate was unique and the two others, although identical, were not temporally related and belong to the most common type seen in the Southern US. Additionally, all three patients had preexisting abnormalities of the CT chest scan and various degrees of acute and chronic rejection. Reactivation was suggested in all three patients. Screening methods may be useful to identify at risk patients and trigger a prophylactic or preemptive approach. However, more data is needed.

Intramyocardial implantation of CD133+ stem cells improved cardiac function without bypass surgery.

INTRODUCTION: Cell transplantation for myocardial regeneration has been shown to have beneficial effects on cardiac function after myocardial infarction. Most clinical studies of intramyocardial cell transplantation were performed in combination with coronary artery bypass grafting (CABG). The contribution of implanted stem cells could yet not be clearly distinguished from the effect of the CABG surgery. Our current phase 1 clinical study has focused on the safety and feasibility of CD133+-enriched stem cell transplantation without CABG and its potential beneficial effect on cardiac function. METHOD AND RESULTS: Ten patients with end-stage chronic ischemic cardiomyopathy (ejection fraction <22%) were enrolled in the study. Bone marrow (up to 380 mL) was harvested from the iliac crest. CD133+ cells were purified from bone marrow cells using the CliniMACS device with purities up to 99%. Autologous bone marrow CD133+ cells (1.5-9.7 X 106 cells) were injected into predefined regions. Cardiac functions prior to and 3, 6, and 9 months after cell transplantation were assessed by cardiac magnetic resonance imaging. Stem cell transplantation typically improved the heart function stage from New York Heart Association/Canadian Cardiovascular Society class III-IV to I-II. The mean preoperative and postoperative ventricular ejection fractions were 15.8 +/- 5% and 24.8 +/- 5%, respectively. CONCLUSION: CD133+ injection into ischemic myocardium was feasible and safe. Stem cell transplantation alone improved cardiac function in all patients. This technique might hold promise as an alternative to medical management in patients with severe ischemic heart failure who are ineligible for conventional revascularization.

Hypertension in pregnancy: hospital based study.

Eighteen hundred two pregnant women consisting of 750 primigravida and 1,052 multigravida were screened for hypertension between July 2000 to June 2002. Hypertension was noted in 97 (5.38%) patients. Twenty five patients were lost to follow up and only 72 patients were included in the final study. The age of the patients ranged between 19 to 32 (mean +/- SD = 24.75 +/- 3.36) years. The majority of patients 41 (57%) were primigravida and 31 (43%) were multigravida. Of 31 multigravida, vast majority (84%) of patients were found to be hypertensive in the third trimester. Only 5 (16%) patient had hypertension in the first trimester. Stage I, II and III hypertension were noted in 18%, 50% and 32% of patients respectively as per JNC-VI criteria. Preeclampsia (PE) was seen in 44.44% (n=32), eclampsia in 40.28% (n=29), HELLP syndrome in 6.94% (n=5), chronic hypertension (HTN) with superimposed PE in 6.94% (n=5) and chronic HTN in 1.38% (n=1). Of the 6 patients with chronic hypertension 50% (3) had essential HTN. Acute renal failure (S. creat > 3 mg/dl) was seen in 7 patients and 4 required dialytic support. Maternal mortality was 5.55% (4) and perinatal death occurred in 37.5% (27) of deliveries. Low birth weight was seen in 66.66% (48) of births. Hypertension complicated 5.38% of all pregnancies in our study. Preeclampsia-eclampsia and its variants remain the major cause of hypertension in pregnant women. Hypertension during pregnancy is responsible for high fetal mortality and low birth weight.

[Resident psychiatrists in Amsterdam recognize the value of personal therapy]. / De waardering van leertherapie door psychiaters in opleiding in Amsterdam.

BACKGROUND: Resident psychiatrists in the Netherlands, unlike their counterparts in other countries, are obliged to undergo 50 hours of personal psychotherapy. In 1994 Trijsburg et al. published the results of a questionnaire that had been completed by psychiatrists, psychologists and other persons training to become psychotherapists. AIM: To fnd out how resident psychiatrists in Amsterdam in 2003 characterised and rated the therapy module in their course. METHOD: Resident psychiatrists in Amsterdam were asked to complete a shortened version of the 1994 questionnaire. The Utrecht Burn-out Scale was added. RESULTS: Personal therapy was greatly appreciated, but the psychotherapists were more convinced of the positive effects than were the residents. Hardly anyone referred to any negative aspects. The residents did not consider personal therapy to be an essential element in their course. Two-thirds of the residents in Amsterdam were female, a large increase compared to the male-female ratio in 1994. The workload of the residents was in accordance with that of other workers in the health care sector. CONCLUSION: Since resident psychiatrists in Amsterdam have a positive attitude to compulsory personal therapy, there seems to be no compelling reasonfor abolishing this module--even though the beneficial effects of this therapy have never been demonstrated.

Clinical Factors Implicated in Primary Graft Dysfunction After Heart Transplantation: A Single-center Experience.

BACKGROUND: Primary graft dysfunction (PGD) is a frequent complication after cardiac transplantation and remains one of the leading causes of mortality in these patients. The objective of this case-control study is to identify donor and surgical procedure's factors associated with PGD, and further guide possible strategies to prevent PGD. METHODS: Retrospective analysis of the medical records of patients who underwent cardiac transplantation at Memorial Hermann Hospital at Texas Medical Center between October 2012 and February 2015. RESULTS: The study population included 99 patients, of which 18 developed PGD. Univariate analysis of donor characteristics revealed opioid use (P = .049) and death owing to anoxia (P = .021) were associated with PGD. The recipient/donor blood type match AB/A was significantly associated with PGD (P = .031). Time from brain death to aortic cross clamp (TBDACC) of ≥3 and ≥5 days were also found to be associated with PGD (P = .0011 and .0003, respectively). Multivariate analysis confirmed that patients with a time from brain death to aortic cross clamp ≥3 and ≥5 days had lesser odds of developing PGD (odds ratio, 0.098 [P = .0026] and OR, 0.092 [P = .0017], respectively]. CONCLUSIONS: Our study showed that a longer time from brain death to aortic cross clamp was associated with lower odds of developing PGD. Therefore, postponing heart procurement for a few days after brain death seems to be beneficial in preventing PGD.

A novel tetratricopeptide repeat (TPR) containing PP5 serine/threonine protein phosphatase in the malaria parasite, Plasmodium falciparum.

BACKGROUND: The malarial parasite, Plasmodium falciparum (Pf), is responsible for nearly 2 million deaths worldwide. However, the mechanisms of cellular signaling in the parasite remain largely unknown. Recent discovery of a few protein kinases and phosphatases point to a thriving reversible phosphorylation system in the parasite, although their function and regulation need to be determined. RESULTS: We provide biochemical and sequence evidence for a protein serine/threonine phosphatase type PP5 in Plasmodium falciparum, and named it PfPP5. The 594-amino acid polypeptide was encoded by a 1785 nucleotide long intronless gene in the parasite. The recombinant protein, expressed in bacteria, was indistinguishable from native PfPP5. Sequencing comparison indicated that the extra-long N-terminus of PfPP5 outside the catalytic core contained four tetratricopeptide repeats (TPRs), compared to three such repeats in other PP5 phosphatases. The PfPP5 N-terminus was required for stimulation of the phosphatase activity by polyunsaturated fatty acids. Co-immunoprecipitation demonstrated an interaction between native PfPP5 and Pf heat shock protein 90 (hsp90). PfPP5 was expressed in all the asexual erythrocytic stages of the parasite, and was moderately sensitive to okadaic acid. CONCLUSIONS: This is the first example of a TPR-domain protein in the Apicomplexa family of parasites. Since TPR domains play important roles in protein-protein interaction, especially relevant to the regulation of PP5 phosphatases, PfPP5 is destined to have a definitive role in parasitic growth and signaling pathways. This is exemplified by the interaction between PfPP5 and the cognate chaperone hsp90.

Model building and quantitative analysis of a tandem immuno-capturing assay as a screening tool for breast cancer.

The onset of breast cancer appears to occur, on average, a decade earlier in Mexican women in comparison to American or European women. Early detection and prevention of breast cancer are of crucial importance to increase survival and improve quality of life. Based on the molecular elucidation of critical events leading to breast carcinogenesis, a tandem immuno-capturing blood test was developed as a quantitative population screening assay in view of providing a cost-effective and non-invasive alternative to population screening. Clinical analysis of 63 Mexican women within an age group of 35-70, revealed that Interstron activity increases from 800+/-65 IUJPA (Interstron Units) in the asymptomatic normal women to 994+/-100 IUJPA in the symptomatic/benign group, reaching 1289+/-81 IUJPA in the cancerous group. Accordingly, activity thresholds were established at 800 and 1200 IUJPA respectively, encompassing three risk groups: (i) Healthy Otherwise Normal (<800 IUJPA); (ii) Grey Risk Area (>800 and <1200 IUJPA), and (iii) At Risk group (>1200 IUJPA). Taking into account both baseline and clinical case reports, the Healthy Otherwise Normal group and the At Risk group were mostly homogeneous in nature, comprising a population of normal and cancer patients respectively. The Grey Risk group is heterogeneous, likely reflecting a transitional nature towards a potential early stage of breast disease development. Based on these results, a screening algorithm was developed as the underlining principle for population surveillance encompassing over 30,000 Mexican women. The current screening results have enabled us to objectively prioritize medical attention to approximately 1 in 8 women out of the general population mapped within the At Risk group. Overall, our findings suggest that monitoring Interstron activity units provides a valuable quantitative screening analysis as to selectively streamline the population of women in need of early medical counseling and/or mammography, thereby enhancing both the quality and cost-effectiveness of preventative population surveillance programs targeting breast cancer.

Human progesterone receptor A and B isoforms in CHO cells. I. Stable transfection of receptor and receptor-responsive reporter genes: transcription modulation by (anti)progestagens.

A hormone-dependent transcription modulation system was established on the basis of a two-step transfection procedure of the human progesterone receptor isoforms (hPR-A and hPR-B, respectively) and a progesterone receptor-responsive reporter (MMTV-Luc). In the first step, stable transfection of the hPR-A and hPR-B isoform-encoding cDNAs was performed in the steroid receptor-negative CHO K1 cell line. Individual clones were characterized for hPR-isoform expression with respect to Western immuno-blotting, transcriptional activation and hormone binding. With respect to the latter characteristic, individual hPR-isoforms demonstrated similar dissociation constants (Kd for hPR-A: 0.5 +/- 0.3 and hPR-B: 0.8 +/- 0.3 nM, respectively) irrespective of the amount of receptor isoform expressed (Bmax varying from 4.1 to 33.2 nM). The Kd values observed for individual hPR-isoforms were comparable to those found for human breast tumor MCF-7 cells (Kd for hPR-A + hPR-B: 0.6 +/- 0.3 nM). In the second step, hPR-isoform expressing CHO clones were supertransfected with a MMTV-Luc reporter construct resulting in permanent cell lines useful for testing the activity of natural and synthetic steroids in their ability to modulate gene transcription. Both isoform-specific reporter cell lines responded in a similar ranking order towards different progesterone reference compounds such as Org 2058, progesterone (Prog), R5020, norethisterone (NE), and medroxy progesterone acetate (MPA). Moreover, a good correlation was observed between the relative binding affinity (RBA) and the transcriptional activation potency of these compounds towards the individual hPR-isoforms. The latter correlation could not only be demonstrated for the progestagenic agonist reference compounds but was also observed for the progestagenic antagonist reference compounds like Org 33628, Org 31710, RU 38486 and ZK 98299. The major difference observed between the individual PR-isoforms was related to the degree of stimulation of the reporter gene (MMTV-based) within the cellular CHO context. Therefore, these cell lines can be used for the determination and quantitation of the activity of (anti)progestagenic compounds in vitro but may also be useful to predict the activity of compounds in vivo (see also II Comparison of binding, transactivation and ED50 values of several synthetic (anti) progestagens in vitro in CHO and MCF-7 cells and in vivo in rabbits and rats).

The sickle cell gene is widespread in India.

The sickle cell gene was first described in India in a tribal population in the south, leading to the belief that it was confined to tribal groups. The present study confirms that it is widespread in the state of Orissa and spreads throughout Hindu society, being more common in upper and scheduled castes than in tribal groups.

Comparative evaluation of indirect and sandwich ELISA for the detection of antibodies to bovine respiratory syncytial virus (BRSV) in dairy cattle.

Seroprevalence of bovine respiratory syncytial virus (BRSV) infection in both exotic and crossbred cattle were described. A baculovirus expressed recombinant purified nucleocapsid (N) protein was used in indirect and sandwich ELISA for screening of 499 bovine sera samples from all over the state for the presence of BRSV antibodies. The seroprevalence rate of BRSV was found to be 46.09% through indirect ELISA while it would found to be 65.33% by sandwich ELISA. The result also indicated that exotic breeds were more susceptible to BRSV infection compared to crossbred cattle. A comprehensive analysis on susceptibility to BRSV as regards to various factors like age and sex was also summarized.

Mucocutaneous lesions in transplant recipient in a tropical country.

Dermatological manifestations are common in renal transplant patients, but differ markedly with ethnic group and geographical location. We studied mucocutaneous lesions in 54 renal allograft recipients (related donors = 30; unrelated donors = 24) living in tropical atmospheres. Their gender was 50 males, and 4 females ranging in age between 15 and 63 years (mean = 37.84 years). The mean duration of follow-up was 124 months (range = 4 to 173 months). All patients received kidneys from living donors and were kept on immunosupression with mean daily doses of prednisolone, azathioprine, and cyclosporine of 10.2 mg, 68.6 mg, and 252 mg, respectively. The mean trough concentration of cyclosporine was 185 ng/mL. The mucocutaneous lesions were divided into four groups: drug-induced (n = 24, 44.4%), fungal (n = 18, 33.3%), viral (n = 9, 16.6%), and bacterial (n = 10, 18.5%). Cushingoid features, gum hypertrophy, and hypertrichosis were seen in 7 (12.9%) patients. Steroid acne was seen in three cases. Pityriasis versicolor was the most common (20.3%) fungal infection of the skin. In addition, Tinea unguium and mucocutaneous candidiasis were noted in four and three cases respectively. Herpes virus infection (Herpes zoster 5; Herpes simplex 2) was noted in 7 (12.9%) cases. Chicken pox at 5 years posttransplant and cutaneous vasculitis associated with cytomegalovirus disease at 6 months posttransplant were seen in one case each. We have not seen warts in our patients. Pyogenic bacterial infection of skin in the form of abscess (n = 6), cellulitis (n = 3), and pyoderma (n = 1) were observed in 10 (18.5%) patients. Thus, drug-induced mucocutaneous side effects and skin fungal infections are the most common dermatological manifestations among renal transplant recipients living in a tropical country.

Momentum integral method for studying flow characteristics of blood through a stenosed vessel.

Taking into consideration the slip velocity at the wall of a blood vessel, a mathematical model is developed in the paper for the study of blood flow through a mammalian blood vessel in the presence of a stenosis. By employing the momentum integral technique, analytical expressions for the velocity profile, pressure gradient and skin-friction are derived. The condition for an adverse pressure gradient is also deduced. It is observed that the slip velocity bears the potential to influence the velocity distribution of blood to a remarkable extent and to reduce considerably the pressure-gradient as well as the skin-friction.

Familial nanophthalmos: management and complications.

Nanophthalmos is a rare form of congenital hypermetropia, in which, the individual is at a high risk of developing angle-closure glaucoma. We report a family of nanophthalmos affecting a brother and sister, as confirmed by biometry. Genetic analysis revealed an autosomal recessive mode of inheritance. The sister developed angle-closure glaucoma, which was refractory to medical and laser therapy. She underwent surgical interventions which resulted in complications. The clinical presentation, management, and complications encountered are discussed.

Sickle cell disease in India.

A screening programme involving 9,822 hospitalised patients revealed the frequency of individuals with S gene to be 11.1 per cent. A population survey of 1,000 randomised subjects from amongst about 70,000 people in one block of the area showed the frequency to be 15.1%. The gene is not confined to tribal peoples, but is prevalent throughout the society, being more frequent in scheduled castes and some caste Hindus. With the available Indian data a sickle cell belt can be mapped out in the country. Analysis of clinical data on the first 700 cases of sickle cell disease seen in the Sickle Cell Research Centre (ICMR) at Burla shows patients of all ages, even beyond 40 years, though many patients tend to die by 20 years of age. Genetically, while most patients are SS and 8.1% are S-beta thalassaemia, cases of SD disease and SE disease were also encountered. A frequency of 0.32% of alpha thalassaemia gene was noted in SS patients against 0.28% in sickle cell trait and 0.12% in AA controls. The disease was found to manifest as early as 3 months or may remain asymptomatic till adult life. Though generally running a milder course, moderate to severe anaemia, vaso-occlusive attacks (86.5-89.36%), splenic sequestration (8.43%-12.76%), crippling avascular bone necrosis (5.7%-35.08%), osteomyelitis (5/700), and epistaxis (28.92%-35.08%) remain a few clinical events deserving competent and urgent medical management.(ABSTRACT TRUNCATED AT 250 WORDS)

Splenectomy in sickle cell disease.

INTRODUCTION: Since role of splenectomy in sickle cell disease still remains controversial, this paper evaluates the same in 32 cases of splenectomy in sickle disease patients observed by the author. MATERIAL AND METHODS: After proper diagnosis by standard methods the cases were observed for 2-3 years before deciding on splenectomy. Though acute splenic sequestration (53%) and chronic hypersplenism (21.8%) were the main indication. Two cases of splenic abscess and one case with frequent pain attacks were also subjected to splenectomy. There was one immediate post-operative death. RESULTS: The cases were followed up for 1 to > 8 years. While Acute splenic sequestration disappeared, in chronic hypersplenism cases as well as others besides a sense of general well being, steady state hemoglobin rose by > 2G/dl in 81% and significant increase in height and weight was seen in 90% and 61% cases respectively. Frequency of pain attack, fever, anaemia and need for blood transfusion improved in 79% patients. CONCLUSION: Splenectomy in selected cases appears to be an acceptable procedure in sickle disease.

Clinical profile of sickle cell trait.

OBJECTIVES: Although sickle cell trait is considered a harmless condition in ordinary circumstances, a large number of pathological conditions have been attributed to it often without a scientific basis. Many patients visit this centre with various complaints and on testing are found to be sickle cell trait. Hence it was thought necessary to analyse these cases to find out the nature of their ailments. METHODS: Two hundred cases of sickle cell trait diagnosed by sickling test and hemoglobin electrophoresis on CAM, and 150 age and sex matched control cases with normal hemoglobin phenotype from a survey were studied. Hemoglobin estimation was done in all by cyanmethemoglobin method. Besides history and clinical examination other relevant investigations were done as necessary to arrive at the diagnosis. Seven cases of sickle cell trait were asymptomatic while the rest were suffering from different conditions. 51% of sickle cell trait and 86% of control cases had mild to severe anaemia which improved with iron therapy in trait cases. Hepatomegaly (11% vs 4.6%), epistaxis (5% vs 0.66%) and cholelithiasis (3% vs 0%) was seen in significantly more number in sickle cell traits than the control cases. Splenomegaly and midsystolic murmurs were present in higher percent of cases but was not statistically significant. There was one case of epilepsy with multiple small infarcts in the brain and another with focal fits with epileptogenic focus in the left cerebral hemisphere where no other cause could be found except sickle cell trait. CONCLUSION: The ailments of sickle cell trait cases are like persons with normal hemoglobin. Anaemia is not more frequent and can improve with iron therapy. However, hepatomegaly, epistaxis, cholelythiasis are seen more frequently and minor cerebral infarcts probably can occur in sickle cell trait. These require more elaborate studies to decide their pathogensis.

Sickle haemoglobin, G-6PD deficiency and malaria in western Orissa.

Sixty cases of malaria were screened for sickle haemoglobin and G-6PD deficiency. Plasmodium vivax was detected in 40 (66%) and Plasmodium falciparum in 21 (35%) cases, with six of the latter having cerebral manifestation. Sickle Hb was found in 7 (11.5%) patients and G-6PD deficiency in 3 (5%) cases. Both patients with SS disease had vivax malaria, while of 5 with sickle cell trait 3 had only vivax, one only falciparum and one mixed infection. Amongst G-6PD deficient patients one had vivax and two falciparum malaria. One of the latter had both SC trait and G-6PD deficiency. Thus, adult persons with SS disease or SC trait were not found to be resistant to either vivax or falciparum malaria. A high frequency (5%) of G-6PD deficiency amongst malaria patients warrants a caution against indiscriminate use of 8-aminoquinoline drugs.

Serum immunoglobulins in sickle cell disease.

Immunoglobulins IgG, IgA and IgM were estimated in 20 cases of sickle cell disease in steady state, eleven cases of sickle cell disease in crisis and/or infection, 20 cases of sickle cell trait and 14 normal healthy controls. Immunoglobulin deficiency has not been observed in sickle cell disease. Significantly raised IgG but normal IgA and IgM found in sickle cell disease cases was probably due to chronic stimulation of reticuloendothelial cells secondary to chronic hemolysis. IgM levels were significantly higher in patients with splenic enlargement > 3 cm. There was no alteration in immunoglobulin levels in sickle cell trait.