Etiology and Impact of Hepatic Steatosis in Pakistan: Role of Hepatitis C Virus Genotype 3 Infection

Introduction: Hepatic steatosis has emerged as an important histological finding in patients with deranged liver function. It may be an important factor for the progression of hepatitis C virus-associated liver disease, particularly in genotype 3 infections. Aims: To determine the etiology and impact of hepatic steatosis in our patients presenting with chronic hepatitis. Methods: All liver biopsies performed at our hospital during 2010-2014 were analyzed by a single pathologist using histological activity index (HAI) scores and Brunt’s classification for steatosis. Patients were evaluated for factors reported to be associated with steatosis, including the prevalence of HCV. Results: Biopsies of 439 patients (284 male, mean ages 38.5 ± 11.2 years) were studied. Hepatic steatosis was present in 324 (73.8%) biopsies. It was mild in 190/439 (43.3%), moderate in 88/439 (20%) and severe in 46/439 (10.5%) cases. On univariate analysis, steatosis was associated with HCV infection (p=0.023), BMI >25 (p=0.008) and raised ALT (p=0.003), but not with diabetes, hypertriglyceridemia, HBV infection or alcohol intake. On multiple logistic regression HCV and BMI >25 were independent risk factors for steatosis. There was a linear ascending association of hepatic steatosis with grade and stage of liver disease (p ≤ 0.001). Among 369 HCV patients, 280 (76%) had steatosis. It was mild in 159/369 (43%), moderate in 82/369 (22.2%) and severe in 39/369 (10.6%) cases. There were only 32 non-alcoholic, non-viral hepatitis patients and 8/32 (25%) had moderate or severe steatosis. Conclusions: Significant hepatic steatosis is present in 30.5% of our patients with chronic hepatitis. HCV genotype 3 infection is the predominant factor for hepatic steatosis in Pakistan. Steatosis has a linear ascending correlation with hepatic inflammation and fibrosis.

Clinicohematological parameters and outcomes in a cohort of chronic lymphocytic leukemia patients with Deletion 17p from Pakistan

BACKGROUND: Chronic lymphocytic leukemia (CLL) exhibits profound heterogeneity in its clinical course. Its clinicohematological and cytogenetic features play a significant role in determining the clinical course and in predicting the treatment response and prognosis. In this context, 17p deletion is known to predict a poor prognosis, as these cases are refractory to conventional therapy. This study aimed to evaluate the clinicohematological characteristics, outcomes, and prognostic factors among CLL patients with and without del 17p in Pakistan. METHODS: This prospective observational study was conducted at the Department of Haematology, Armed Forces Institute of Pathology (Rawalpindi, Pakistan) between January 2013 and December 2017. Patients were diagnosed based on the International Workshop on Chronic Lymphocytic Leukaemia IWCLL criteria, their clinicohematological parameters were recorded, and cytogenetic analyses were performed. The time from diagnosis to treatment and the 2-year overall survival rate were also evaluated. RESULTS: We evaluated 130 CLL cases, including 24 patients (18.5%) with del 17p, who included 18 men (75%) and 6 women (25%). The median age was 68 years. Binet stage C was detected at the presentation in 16 patients (67%). Treatment was administered to 14 patients (70%) at a median interval of 11 months (range, 0–28 mo) after diagnosis. The overall response rate was 64.3%, the median event-free survival was 9 months (range, 1–23 mo), and the 2-year overall survival rate was 65%. CONCLUSION: Del 17p is relatively common in Pakistan, and patients harboring this deletion had poor treatment response and survival outcomes.

Impairment of liver synthetic function and the production of plasma proteins in primary breast cancer patients on doxorubicincyclophosphamide [AC] protocol

Doxorubicin and Cyclophosphamide [AC protocol] combination is usually considered as a first line therapy in newly diagnosed breast cancer patients. Thus, a retrospective observational study was conducted to monitor the effect of AC protocol on liver synthetic functions and production of plasma proteins in breast cancer patients, reporting to specialized cancer care hospital of Lahore, Pakistan. A total of 75 patients [n=75] on AC protocol with breast cancer were observed in this study. The patient data including age, gender, body surface area, dosage, disease status and laboratory biochemical values were recorded by reviewing historical treatment records. Pre-treatment values were taken as baseline values for albumin, globulin, blood urea nitrogen [BUN], albumin/globulin [A/G] ratio and total proteins. The baseline values were compared after each cycle of by applying ANOVA using statistical tool SPSS[Registered sign] version 21. The plasma levels of blood urea nitrogen [BUN], total protein and globulin dropped significantly [p<0.05] in patients of all age groups. However, the albumin levels were not significantly changed [p>0.05]. The A/G ratio level increased [p<0.05] as a result of reduction in globulin levels. Significant changes in plasma protein levels were observed in the elderly patients [50 to 65 years] than patients between 20 to 50 years of age. AC protocol impairs liver synthetic functions as observed by decreased blood urea nitrogen [BUN] and plasma protein levels

Frequency of thrombocytopenia in plasmodium vivax malaria

To determine the frequency of thrombocytopenia in Plasmodium vivax [P.vivax] malaria cases at two hospitals. Cross-sectional descriptive study. The study was conducted at the departments of Pathology, Combined Military Hospitals Malir and Sibi, Pakistan from Jul 2011 to Mar 2012. A total of 2709 samples were collected from febrile patients for detection of malaria parasite [944 from CMH Malir and 1765 from CMH Sibi]. Cases having infection with P. falciparum alone or having mixed infection with P. vivax and P. falciparum were excluded from the study. Both thick and thin film microscopy and immunochromatographic method [OptiMAL-IT] were used for detection of malarial parasite. Platelet counts were done using automated haematology analyser [Sysmex KX 21] with re-evaluation of low counts with manual methods. Total of 170 patients were found positive for P. vivax malaria [44 from CMH Malir and 126 from CMH Sibi]. Platelet counts ranged from 21 - 457 x loyi with a mean of 134 x loyi. Ninety five [2.1%] from CMH Malir and 4.2% from CMH Sibi out of 170 patients had thrombocytopenia, and the difference in thrombocytopenia at the two hospitals was insignificant [0.017]. Thrombocytopenia in patients with P. vivax infection is equally prevalent in the two hospitals, representing a widely different geographical area and should prompt a more thorough search for malarial parasite

Bone marrow stromal cell [BMSC] and skeletal aging: role of telomerase enzyme

Telomere shortening and telomerase deficiency have been linked with several age related degenerative diseases. Moreover, degenerative changes in various tissues/organs have been attributed to derangement of stem cell functions causing regenerative tragedy. Bone marrow stromal cells [BMSCs] are considered the ideal candidates for regenerative approaches owing to their beneficial effects in numerous clinical applications. Thus, the effect of telomerase deficiency in perpetrating age related changes in BMSC functions during in vitro culture; their morphology, proliferation and differentiation, that can be extrapolated and reasoned for skeletal aging is conversed in this review. Besides, information regarding pertinent molecular and biochemical markers that can be employed to examine the earliest events, during the course of BMSC aging, is also provided. Additionally, impact of telomerase deficiency in enacting skeletal aging phenotype and its associated microenvironment is also discussed. In the end, further studies, using tissue specific models of telomerase deficiency, are recommended as a future research strategy to advance our understanding of tissue specific telomerase regulation

Impact of a bleeding care pathway in the management of acute upper gastrointestinal bleeding.

Objectives Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies. Methods A BCP for patients with UGI bleed with admission in a bleeding care unit (BCU) has been in use at our hospital since 2005. Prior to this, a high dependency unit was used for management of all emergencies including UGI bleeding. We compared the length of stay in the bleeding care/high dependency unit, total hospital stay, time to UGI endoscopy after admission, and survival between pre-2005 and post-2005 patients. Results Five hundred and fifty-one patients were admitted with acute UGI bleed in the last 5 years; 121 belonged to pre- BCP (2004) period and 430 after implementation of the pathway (2005–2008). The mean (SD) time to UGI endoscopy improved from 21.3 (7.4) hours in the pre-BCU era to 9.4 (9.9) hours in BCU, p<0.001. BCU stay was shorter from 2.41 (1.4) days pre-BCP to 1.93 (1.32) days post-BCP, (p<0.001). The total hospital stay in pre-BCU (4.0 [2.08] days) as compared to BCU (4.13 [2.62] days; p=0.58) was similar; there was no impact of BCU on survival. Conclusion A BCU implementation showed improvement in time to UGI endoscopy, and did not reduce BCU stay or impact survival.

Eisenmenger syndrome: a silent killer in adults born with heart septal defect: experience from cardiac centre at Faisalabad

Eisenmenger syndrome is a term used to any large shunt between systemic and pulmonary circulation which results in high pulmonary arterial pressure and irreversible changes in pulmonary vascular bed with bidirectional shunt with physical limitation and shortness of breath. Eisenmenger syndrome particularly creates problems to fetus and mother in pregnancy and there is a particularly risk during aneasthesia while performing general surgery. We collected all consecutive patients above age 12 with atrial septal defect [ASD], ventricular septal defect [VSD] and patent ductus arteriosus [PDA] who attended echocardiography department between June 2008 to October 2010. We also analysed all pregnant females with Eisenmenger complex during this period. Out of 309 patients diagnosis of one of three shunts was confirmed either by transthorasic echocardiography with intravenous saline infusion or transesophageal echocardiography Eisenmenger syndrome was diagnosed in 39 patients [19 patients with ASD, 11 patients with VSD and 09 patients with PDA]. All 39 patients were followed till October 2010 and were alive. Among 03 pregnant females, 02 completed pregnancy without any hazard to child and mother. However tubal ligation was opted at time of delivery. One lady opted abortion and ligation to prevent further pregnancy. 05 patients underwent non cardiac surgery under general anesthesia without any complication. Eisenmenger syndrome a silent killer in a congenital treatable disease which is being neglected and diagnosis is being delayed. It seems Eisenmenger syndrome is on rise in Pakistan. We need to establish adult congenital heart disease department in each cardiac centre where trained persons should be appointed who had experience of congenital heart disease. Screening clinics need to be established at school and community level to diagnose this silent killer at a stage when pulmonary artery pressure is still reversible

Epidural anaesthesia; single-shot for day-case knee arthroscopy using a 50-50 mixture of lignocaine and bupivacaine

To compare the benefits and adverse effects of three different drug combinations when used for single-shot epidural anaesthesia for day-case arthroscopy. Prospective, random, double-blind study. A 250 bedded secondary care hospital. From October 2005 to Feb 2007. We studied 75 adult male patients, aged between 23 to 63 years, weight <100 kg, ASA physical status I or II undergoing elective knee arthroscopy as day-case procedure/Patients were randomly divided into three groups [25 patients in each group] and single-shot epidural anaesthesia was performed using a total of 20 ml epidural lignocaine 2% [Group 1] bupivacaine 0.5% [Group 2] or a mixture containing lignocaine 2% and bupivacaine 0.5%, 10 ml each [Group 3]. Time to achieve maximum height [in minutes] was similar in group-1 and group-3 [10 +/- 4 and 11 +/- 2], but it was significantly longer in group-2 [20 +/- 3]. Block time was comparable in group-2 and 3 [130 +/- 25 and 118 +/- 37] but it was significantly shorter in group-1 [60 +/- 20]. Post-operative discharge time was longest in the group-2, and comparable in group-1 and S.The incidence of complications like bradycardia, hypotension, nausea and vomiting were more in group-2 and less in group-1 and group-3. Inadequate anaesthesia was more in group-1 and least in other two groups. Four patients of group-1 needed rescue analgesia and two from same group needed general anaesthesia as compared to none in group-2 and group-3. In 4-point patient satisfaction scale, maximum patients from Group-3 rated it perfect while most patients from group-1 were not satisfied with the quality of anaesthesia. The results of our study show that a 50-50 mixture of lignocaine and bupivacaine with fentanyl 50 pg when used for single-shot epidural anaesthesia for day case knee arthroscopy, provides better quality of analgesia, with fewerincidences of side effects and more patient satisfaction as compared to lignocaine or bupivacaine alone

Sustained virological response to pegylatedinterferon and ribavirin in patients with genotype3 HCV cirrhosis.

Background: Chronic hepatitis C (CHC) virus infection in patients with cirrhosis is difficult to treat. There is limited data on the outcome of treatment for genotype 3 HCV infection with cirrhosis. Aims: To determine sustained virological response (SVR) and its predictive factors in patients with cirrhosis due to genotype 3 HCV infection treated with pegylated interferon and ribavirin (RBV). Methods: Consecutive patients with compensated cirrhosis due to HCV genotype 3 with positive HCV RNA treated with peg-IFN and RBV in our Gastroenterology Clinics during November 2005 to December 2006 were included in this study. Cirrhosis was diagnosed on the basis of liver biopsy and/or biochemical testing and ultrasound of abdomen. Primary end point of treatment was SVR. Results: Of 66 patients, 32 (48.5%) were male. The mean age was 46.2±10.1 years; there were 61 (92.4%) patients with Child’s A cirrhosis followed by 5 (7.6%) with Child’s B type. 33 (50%) patients received pegylated interferon alfa-2a (180 μg/wk) with ribavirin and 33 (50%) received pegylated interferon alfa 2b (1 μg /kg/week) with ribavirin. EVR was achieved in 44 (66.7%), and ETR in 46 (69.7%); overall SVR was achieved in 38 (57.6%) patients. Factors predictive of SVR were age (p value = 0.03), treatment naïve status (p value = 0.04) and EVR (p value<0.001). Five patients were unable to complete the treatment due to side effects or cytopenias. Conclusions: Treatment of patients with HCV genotype 3, compensated cirrhosis, with pegylated interferon and ribavirin is effective and well tolerated.

Factors determining the clinical outcome of acute variceal bleed in cirrhotic patients.

Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis.

Anaesthetic risks in children with obstructive sleep apnea syndrome undergoing adenotonsillectomy

To determine the frequency of anaesthetic risks in children having Obstructive Sleep Apnea Syndrome [OSAS], undergoing adenotonsillectomy. A case-control study. Department of Anaesthesiology, Armed Forces Hospital, Najran, Saudi Arabia from November 2006 to January 2008. The study was carried out in 60 children scheduled to undergo adenotonsillectomy and divided into two equal groups of 30 each. Group-1 had obstructive sleep apnoea syndrome and group-2 had children without it. Both groups were given a standard general anaesthesia and frequency and rate of complications and medical interventions taken in such children were studied. P-value and odds ratio were determined. The age ranged from 3 to 10 years. The frequency of difficult intubation was higher in the group-1 than in the control group [16.6 vs. 3.3%, odds ratio 5.8]. At the time of induction of anaesthesia desaturation was higher in group-1 [33.3 vs. 6.6%, p=0.021, odds ratio 7]. At the time of extubation, desaturation was significantly higher in group-1 [43.3 vs. 6.6%, p=0.002, odds ratio 10.70]. The complications at extubation, for example cough, laryngospasm and postoperative nausea and vomiting were higher in group-1 but not statistically significant. In the postanaesthesia care unit, the frequency of complications and medical interventions were also higher in group-1. More patients of group-1 required oxygen [63.3 vs. 10%, p < 0.001, odds ratio 15.54] and insertion of an oropharyngeal airway [20% vs. nil, p=0.023] respectively. Children with OSAS, operated for adenotonsillectomy, are at significant risk of certain life-threatening perioperative anaesthetic complications. These results may be used as a guideline for safe and successful anaesthetic management of these children

Factors predicting in-hospital mortality in patients with cirrhosis hospitalized with gastro-esophageal variceal hemorrhage.

AIM : To identify factors at the time of admission that predict in-hospital mortality in patients with gastro-esophageal variceal hemorrhage. METHODS : Case records of patients admitted with gastro-esophageal variceal hemorrhage between January 1998 and October 2003 were retrospectively analyzed. Relevant clinical and laboratory parameters and their relationship to mortality, were studied. Clinical parameters assessed included Child-Pugh class, ascites, portosystemic encephalopathy (PSE) and occurrence of rebleed within 24 hours of esophago-gastroduodenoscopy. The laboratory parameters assessed were: hemoglobin, prothrombin time, serum bilirubin, creatinine and albumin. RESULTS : Of the 343 patients admitted during the study period, 30 (8.7%) died in hospital. Serum bilirubin (2.4 versus 1.6 mg/dL) and serum creatinine (2.1 vs 1.1 mg/dL) levels were higher among non-survivors than among survivors. Non-survivors were also more likely to suffer from PSE (53%) than survivors (17%), while re-bleeding within 24 hours of endoscopy occurred in 40% and 5% of these groups, respectively. On multivariate analysis, serum creatinine > 1.5 mg/dL at the time of admission (p < 0.001), serum bilirubin > 3 mg/dL (p < 0.001), presence of PSE (p = 0.003) and rebleed within 24 hours of endoscopy (p < 0.001) were significant predictors of mortality. CONCLUSION : Serum creatinine and bilirubin levels, presence of PSE and re-bleeding within 24 hours of initial endoscopy are independent predictors of mortality in patients with gastro-esophageal variceal bleeding.

Graft versus host disease in allogeneic stem cell transplantation - 3 l/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22] ALL [n=3], AML [n=l] Fanconi's anaemia [n=2], and Gaucher's disease [n=l], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in B-Thalassaemia, 50% [n=ll/22] in CML, 50% [n=2/4] in Acute Leukaemias and 25% [n=8/32] in Aplastic Anaemia. Chronic GvHD was 25% [n=l/4] in Acute Leukaemias, 18.8% [n=6/32] in Aplastic Anaemia, 18.2% [n=4/22] in CML and 4% [n=l/25] in B-Thalassaemia. The overall survival in acute GvHD was 84.2% [n=32] where as the overall survival in chronic GvHD was 50% [n=6]. The overall mortality in acute GvHD was 15.8% [n=6] and 50% in chronic GvHD [n=6]. The morbidity and mortality due to severe acute and chronic GvHD remains high despite standard prophylaxis against GvHD. New strategies are needed to prevent and treat GvHD

Posttransplant Guillain Barre Syndrome

This case report describes a patient with severe aplastic anaemia, who developed Guillain Barre Syndrome [GBS] 10 weeks after allogeneic haematopoietic stem cell transplantation [HSCT] from HLA-matched siblingíyounger sister. GBS was preceded by pneumonia, herpes labialis and oral candidiasis a week earlier. Treatment with ventilatory management, intravenous human immunoglobulin [IVIg] and antimicrobials resulted in smooth recovery in thirty-one days

Graft versus host disease in allogeneic stem cell transplantation - 3 1/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22], ALL [n=3], AML [n=1] Fanconi's anaemia [n=2], and Gaucher's disease [n=1], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in

Allogeneic stem cell transplantation in chronic myeloid leukaemia 2 1/2 year experience

To evaluate out come of allogeneic Stem Cell Transplantation [SCT] in chronic myeloid leukaemia [CMC] at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from April 2002 to October 2004. Twenty-two patients with CML underwent allogeneic SCT from HLA matched siblings. Patients were divided into standard [n=14] and high-risk [n=8] groups. Patients were subjected to conditioning regimens consisting of Busulphan and Cyclophosphamide. Cyclosporin, Prednisolone and Methotrexate were given for GvHD prophylaxis. All donors were subjected to PBSC harvest after G-CSF therapy for five days. All received G-CSF from Day+5 until ANC >0.5 x 109/l. The median age of the patients was 29 years [range 7-53 years] with a male to female ratio of 6.3:1. Engraftment was achieved in all patients. Median time to achieve neutrophil [ANC 0.5x109/l] and platelet [20x109/l] recovery was 13 days and 12 days respectively. Median stay in hospital was 18 days. Acute GvHD [Grade-II-IV] was observed in eleven patients [50%] while chronic GvHD was seen in four patients [18%]. One patient relapsed 8 months post transplant. Two patients [9%] developed Veno-occlusive disease [VOD] liver. One patient had haemorrhagic cystitis. Four patients [18%] had post transplant infectious complications, which included pseudomonas septicemia, aspergillosis, tuberculous pleural effusion and herpes zoster. Overall mortality was 22.7% [n=5]. The major causes of mortality were VOD liver, GvHD grade IV, Pseudomonas septicaemia and aspergillosis. Overall survival was 77.2% [n=17] and disease free survival was [n=16] 72.7%. Follow up ranges were from 23 to 828 days [median 212 days]. The preliminary results of SCT in this small series of patients with CML are very encouraging. To improve the long-term survival it is imperative that patients are transplanted early after diagnosis and conditioning regimens are selected carefully

FLAG-IDA in the treatment of refractory/ relapsed acute leukaemias: Single center study

To evaluate the efficacy and toxicity profile of the combination of fludarabine, high dose cytarabine, idarubicin, and granulocyte colony stimulating factor in refractory relapsed cases of acute leukaemia, a study is being conducted at Armed Forces Bone Marrow Transplant Centre [AFBMTC] Rawalpindi since January 2003. Data up to June 2004 [early report] is being presented. Twelve Patients with refractory/relapsed [Ref/Rel] acute leukaemia [AL] were treated with fludarabine 30mg/m2 and cytosine arabinoside [AraC] Arac 2 g/m2 for 5 days, idarubicin 10mg/m2 for 3 days, and granulocyte colony stimulating factor G-CSF 5 micro g/kg from day 0 till neutrophil recovery [ANC >1.0 x 109/l]. Response was evaluated by bone marrow examination on day 20-post chemotherapy. Patients included were refractory acute lymphoblastic leukaemia [ALL] [n=2], relapsed ALL [n=3], refractory acute myeloid leukaemia [AML] [n=3], secondary AML [n=2] relapsed AML [n=1] and acute undifferentiated leukaemia [AUL] [n=1]. Complete remission [CR] was achieved in 8 [66.6%] patients. Three [25%] patients died of post chemotherapy complications and one patient failed to achieve remission. Out of 8 patients who achieved CR, 4 underwent allogeneic bone marrow transfusion [BMT], 1 is being evaluated for the same, 1 received idorubicin, AraC and etopuside [ICE] and high dose AraC, 1 did not receive further chemotherapy and 1 relapsed two months after remission. Seven patients are still in CR after a median follow up of 8 months [range 3-18]. Major complications encountered were diarrhoea, mucositis, toxic ileus, transient hepatic toxicity, fungal and bacterial infections. In our experience, FLAG-IDA is well tolerated and effective regimen in relapsed / refractory acute leukaemias. The toxicity is acceptable, enabling most patients to receive further treatment, including transplantation procedures

Genus and species-specific IgG and IgM antibodies for pulmonary tuberculosis

To evaluate three different enzyme immunoassays for serological diagnosis of pulmonary tuberculosis and to compare their diagnostic accuracy in different combinations. Design: A non-interventional comparative study. Place and Duration of Study: The study was carried out at the Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi between April and September 2001. Subjects and Sera from patients suffering from pulmonary tuberculosis [n=94] with sputum positive for acid fast bacilli [AFB] and sera from control group of healthy individuals [n=90] with sputum negative for AFB were tested by Pathozyme-Myco G EIA, Pathozyme-TB Complex Plus EIA and Pathozyme Myco M EIA kits for the genus-specific IgG and IgM, and the species-specific IgG antibodies against antigens of Mycobacterium tuberculosis. The detection of IgG against genus-specific antigens by Pathozyme-Myco G had a sensitivity of 46% and a specificity of 93%, of IgG against species-specific antigens by Pathozyme-TB Complex Plus had a sensitivity of 64% and specificity of 97% and of IgM against genus-specific antigens by Pathozyme Myco M had a sensitivity of 67% and specificity of 98%. When the results of these immunoassays were evaluated in combination, their sensitivity improved. Combination of genus-specific IgM and species-specific IgG yielded best results with a sensitivity of 87% and specificity of 93%. The sensitivity of serological diagnosis of tuberculosis is low, but it can be increased by utilizing a combination of several antigens