Establishing local reference intervals for full blood count and white blood cell differential counts in Cape Town, South Africa.

BACKGROUND: Accurate laboratory reference intervals (RIs) are essential to differentiate between health and disease. There are variations in haematological indices within populations relating to gender, age, ethnicity and environment. Iron deficiency is common, has a wide range of clinical morbidities and affects red cell indices. Locally derived RIs for full blood count (FBC) parameters are needed for the Western Cape region of South Africa, after the exclusion of iron deficiency. In addition, information regarding the prevalence of iron deficiency in first-time blood donors would inform blood transfusion services regarding policies to screen for and treat iron deficiency. OBJECTIVES: To establish locally derived RIs for FBC and white blood cell (WBC) differential count parameters in healthy adults in the Cape Town area, by including first-time blood donors and excluding those with iron deficiency and thalassaemic indices. These new locally established RIs could update those in use by the local National Health Laboratory Service. A secondary objective was to establish the prevalence of iron deficiency in first-time blood donors. This would inform blood donation policies regarding screening and appropriate iron supplementation in high-risk groups prior to blood donation. METHODS: This was a prospective, descriptive study with direct convenience sampling. Participants were prospective voluntary blood donors aged between 18 and 60 years, presenting for first-time blood donation. Ethnicity was self-identified. Participants who tested positive for HIV or hepatitis B and/or C viruses were excluded. Prospective participants with iron deficiency, defined by serum ferritin levels below the RI, and those with red cell indices suggestive of an underlying thalassaemia trait were excluded. FBC samples were analysed using a Sysmex XN-1000 cell counter. Statistical non-parametric methods were used to calculate the RIs, according to international guidelines. RESULTS: Of the 774 participants screened, 82 (11%) had iron deficiency and were excluded. Six hundred and sixty-two patients were included for analysis, 409 (62%) female and 253 (38%) male. The majority of the participants, 348 (53%), were between 20 and 29 years of age, with a mean age of 29 years for females and 28 years for males. Participants comprised a mix of the various ethnic groups residing in Western Cape Province. The mean haemoglobin concentration for females was lower than that for males (p<0.0001). There were significant gender differences for total WBC count, absolute neutrophil count and platelet count, with females having higher counts than males. CONCLUSIONS: Locally established, population-specific RIs are essential for the accurate interpretation of haematological indices. This study established locally derived gender-specific RIs for the Cape Town region, after exclusion of iron deficiency. These new RIs have implications for the accurate diagnoses of cytopenias, cytoses and other blood count abnormalities. Iron deficiency is common in first-time blood donors, and screening for iron deficiency using point-of-care testing should be considered.

Biochemical storage lesions occurring in nonirradiated and irradiated red blood cells: a brief review.

Red blood cells undergo a series of biochemical fluctuations during 35-42-day storage period at 1°C to 6°C. The sodium/potassium pump is immobilised causing a decrease in intracellular potassium with an increase in cytoplasmic sodium levels, glucose levels decline, and acidosis occurs as a result of low pH levels. The frailty of stored erythrocytes triggers the formation of haemoglobin-containing microparticles and the release of cell-free haemoglobin which may add to transfusion difficulties. Lipid peroxidation, oxidative stress to band 3 structures, and other morphological and structural molecular changes also occur leading to spheroechinocytes and osmotic fragility. These changes that transpire in the red cells during the storage period are referred to as "storage lesions." It is well documented that gamma irradiation exacerbates storage lesions and the reports of increased potassium levels leading to adverse reactions observed in neonates and infants have been of particular concern. There are, however, remarkably few systematic studies comparing the in vitro storage lesions of irradiated and nonirradiated red cell concentrates and it has been suggested that the impact of storage lesions on leucocyte reduced red blood cell concentrate (RBCC) is incomplete. The review examines storage lesions in red blood cells and their adverse effects in reference to blood transfusion.

The clinical and pathological features of gastric impaction in twelve horses.

REASONS FOR PERFORMING STUDY: Gastric impaction in the horse is poorly described in the veterinary literature. OBJECTIVES: To review the clinical and pathological features of gastric impaction. METHODS: The clinical details of horses presenting with colic over a 7-year period and cases in which gastric impaction was considered to determine the outcome were reviewed. Clinical and clinicopathological data were recorded. RESULTS: Twelve cases of gastric impaction were recorded (1.4% of 857 horses hospitalised for colic). Diagnosis was achieved by ultrasonographic examination, gastroscopy, exploratory celiotomy and/or post mortem examination. Five out of 12 horses were successfully treated, 5/12 were subjected to euthanasia (3 at celiotomy and 2 due to recurrence of impaction) and 2/12 died. Three out of 12 horses had spontaneous gastric rupture despite attempted treatment (one was subjected to euthanasia at celiotomy and 2 died). Post mortem examination (7 horses) revealed gross muscular thickening of the stomach wall in 6/7 horses. Histological examination revealed focal fibrosis of the stomach wall in 4/6 and focal myositis in 1/6 horses. CONCLUSIONS AND PRACTICAL SIGNIFICANCE: Gastric impaction is a rare cause of colic and affected horses can present with acute, chronic or recurrent colic in the presence or absence of other gastrointestinal disease. Spontaneous gastric rupture may occur. A proportion of affected horses have gross thickening of the muscular layers of the stomach wall.

Resistant starch, large bowel fermentation and a broader perspective of prebiotics and probiotics.

The metabolic end products of the large bowel microbiota contribute significantly to human health. After weaning to solid foods, some of the most important of these are the short chain fatty acids (SCFA) produced by the fermentation of undigested dietary components and endogenous secretions. The main SCFA are acetate, propionate and butyrate which have numerous documented effects promoting large bowel function. Of the major acids, butyrate seems especially important. It is a major metabolic fuel for colonocytes and promotes a normal phenotype in these cells, potentially lowering the risk of diseases such as colo-rectal cancer. Imbalances in the microbiota are thought to predispose to large bowel dysfunction and probiotics are being developed to correct this. However, most commercial products contain bacteria (lactobacilli and bifidobacteria) which are dominant species in milk-fed infants but have limited roles in adults. Prebiosis is defined usually by the specific stimulation of these bacteria. However, the end products of most probiotics do not include butyrate or propionate which raises questions about their effectiveness in promoting bowel health in adults. Resistant starch (RS) is a dietary fibre component and its fermentation generally favours butyrate production. Dietary RS intakes and faecal butyrate levels are high in populations at low risk of diet-related large bowel diseases. Conversely, RS intakes and faecal butyrate levels are very low in high risk groups. This raises the possibility that greater RS consumption could be of health benefit. RS is not regarded widely as a prebiotic but (according to the accepted definition) most forms show the requisite features in stimulating specific bacteria, giving raised total SCFA and butyrate levels and a consequent benefit to the host. Current efforts to improve public health through increasing RS consumption could be facilitated by greater recognition of its prebiotic role.

Gene expression in a starch synthase IIa mutant of barley: changes in the level of gene transcription and grain composition.

The barley shrunken grain mutant M292 has a novel high-amylose starch phenotype caused by a mutation in the starch synthase IIa gene (SsIIa) located at the starch excess-6 (sex6) locus on chromosome 7H of barley. The loss of SSIIa enzyme activity leads to a decrease in amylopectin synthesis to less than 20% of the levels found in wild-type grains. Detailed composition analysis indicates that the contents of protein, non-starch polysaccharides, lipid, sucrose and hexoses, and fructo-oligosaccharides are increased in mature M292 grain compared to wild type. Using a microarray analysis, we characterize the differences between the transcription profiles of wild-type and mutant barley endosperms at mid-grain fill. The expression changes include genes involved in carbon storage, stress-related genes, and a number of transcripts with unassigned function. The changes in gene expression are discussed in terms of the altered grain composition of the mutant seed.

Probiotic research in Australia, New Zealand and the Asia-Pacific region.

Although the epicentres of probiotic research in the past decade have been Japan and Europe, researchers in the Asia-Pacific region have actively contributed to the growing understanding of the intestinal microbial ecosystem, and interactions between gut bacteria, diet and health of the human host. A number of new probiotic strains have been developed in the region that have been demonstrated to have beneficial impacts on health in animal and human trials, including improved protection against intestinal pathogens and modulation of the immune system. Probiotics targeted to animals, including aquaculture, feature heavily in many Asian countries. Developments in probiotic technologies have included microencapsulation techniques, antimicrobial production in fermented meats, and synbiotic combinations. In particular, the impact of resistant starch on the intestinal environment and fermentation by intestinal bacteria has been intensively studied and new probiotic strains selected specifically for synbiotic combinations with resistant starch. This paper provides an overview of probiotic research within Australia, New Zealand and a number of Asian countries, and lists scientists in the Asia-Pacific region involved in various aspects of probiotic research and development.

Comparison of two selective media for the detection and enumeration of Lactobacilli in human faeces.

The enumeration of faecal bacteria is an important requirement for many studies of bowel health. One approach is the use of selective culture media for the culture and identification of genera or species from faeces. This study compares the culture of Lactobacilli from dilution series of faecal samples from six healthy human volunteers on two commonly used media, LAMVAB and Rogosa agar. Colonies were counted after a 72-h anaerobic incubation at 37 degrees C, and colony morphology recorded by a single observer. DNA was isolated from a representative number of colonies and genus-specific PCR, single-stranded conformation polymorphism (SSCP) and DNA sequencing performed. Total colony counts ranged from <3.00 to 7.48 log(10) cfu/g of faeces for LAMVAB and 5.09 to 7.66 log(10) cfu/g for Rogosa. For each subject, the total colony count was higher on Rogosa than that obtained with LAMVAB agar. SSCP analysis and DNA sequencing indicated that colony morphology was not an accurate predictor of genus identity. Growth of two species, Lactobacillus acidophilus and Lactobacillus gasseri, was not supported on LAMVAB medium. Rogosa agar was more likely to support growth of non-Lactobacillus species. Therefore, neither medium gave a fully accurate representation of the Lactobacilli species present in human faecal samples.

Focused gut-mucosal nutrition for diarrhoeal disease: improved nutrient therapy.

The main substrates fuelling ion absorption in the mucosa of the small intestine and large intestine are respectively glutamine and short-chain fatty acids. Measurements now reported showed that derivation of both glutamine and fibre for short-chain fatty acid production can be achieved from a single foodstuff--macerated groundnuts. Macerated groundnuts may be more suitable as an additive in oral rehydration solutions for promoting ion absorption than other agents that are low either in glutamine or fibre, such as rice water or resistant starch.

Colonic infection by Bilophila wadsworthia in pigs.

Bilophila wadsworthia is a common inhabitant of the human colon and has been associated with appendicitis and other local sites of inflammation in humans. Challenge-exposure or prevalence studies in laboratory and other animals have not been reported. B. wadsworthia is closely related phylogenetically to Desulfovibrio sp. and Lawsonia intracellularis, which are considered colon pathogens. We developed a PCR specific for B. wadsworthia DNA. Samples of bacterial DNA extracted from the feces of pigs on six farms in Australia and four farms in Venezuela were examined. Specific DNA of B. wadsworthia was detected in the feces of 58 of 161 Australian and 2 of 45 Venezuelan pigs, results comprising 100% of the neonatal pigs, 15% of the weaned grower pigs, and 27% of the adult sows tested. Single-stranded conformational polymorphism analysis of PCR product DNA derived from pigs or from known human strains showed an identical pattern. Histologic examination of the intestines of weaned B. wadsworthia-positive pigs found no or minor specific lesions in the small and large intestines, respectively. B. wadsworthia is apparently a common infection in neonatal pigs, but its prevalence decreases after weaning. The possible role of B. wadsworthia as an infection in animals and in human colons requires further study.

Coarse brown rice increases fecal and large bowel short-chain fatty acids and starch but lowers calcium in the large bowel of pigs.

Young male pigs were fed a diet formulated from human foods including either boiled white rice plus rice bran or heat-stabilized brown rice at equivalent levels of fiber for 3 wk. Stool and starch excretion were low in pigs fed white rice during the first 2 wk of the experiment. In pigs fed brown rice, their excretion was high during wk 1 but declined in wk 2 while short-chain fatty acid (SCFA) excretion was higher at both times. Large bowel digesta mass, measured during wk 3, was higher in pigs fed brown rice but only in the proximal colon. Large bowel and fecal starch concentrations were higher in pigs fed brown rice but the difference was insufficient to explain the increase in large bowel digesta mass. In pigs with a cecal cannula, digesta starch concentrations were equally higher when white or brown rice was fed compared with the corresponding rice which had been finely milled, indicating that particle size was a determinant of ileal digestibility. Concentrations and pools of total and individual SCFA were higher in all regions of the colon but not the cecum of pigs fed brown rice. Large bowel Ca(2+) concentrations were lower in pigs fed brown rice, suggesting greater absorption. The data confirm earlier findings that brown rice raises large bowel digesta mass and SCFA through greater fermentation of starch but show that starch itself makes a relatively small contribution to digesta and stool mass. Apparently, the rate of passage of digesta is a determinant of the concentrations and pools of SCFA in the distal colon and in feces.

Starches, resistant starches, the gut microflora and human health.

Starches are important as energy sources for humans and also for their interactions with the gut microflora throughout the digestive tact. Largely, those interactions promote human health. In the mouth, less gelatinised starches may lower risk of cariogensis. In the large bowel, starches which have escaped small intestinal digestion (resistant starch), together with proteins, other undigested carbohydrates and endogenous secretions are fermented by the resident microflora. The resulting short chain fatty acids contribute substantially to the normal physiological functions of the viscera. Specific types of resistant starch (e.g. the chemically modified starches used in the food industry) may be used to manipulate the gut bacteria and their products (including short chain fatty acids) so as to optimise health. In the upper gut, these starches may assist in the transport of probiotic organisms thus promoting the immune response and suppressing potential pathogens. However, it appears unlikely that current probiotic organisms can be used to modulate large bowel short chain fatty acids in adults although resistant starch and other prebiotics can do so. Suggestions that starch may exacerbate certain conditions (such as ulcerative colitis) through stimulating the growth of certain pathogenic organisms appear to be unfounded. Short chain fatty acids may modulate tissue levels and effects of growth factors in the gut and so modify gut development and risk of serious disease, including colo-rectal cancer. However, information on the relationship between starches and the microflora is relatively sparse and substantial opportunities exist both for basic research and food product development.

Teaching clinical biomechanics in the context of uncertainty.

Uncertainty in the theories that provide the underpinnings of the clinical practice of podiatric biomechanics creates a dilemma: How should educators prepare students to make clinical decisions in the context of this uncertainty? Students need to be exposed to all approaches and be given the tools to make their own clinical decisions. Critical thinking involves the ability to weigh evidence, examine arguments, and construct rational bases for decisions and beliefs. Perry's model of cognitive development provides educators with one model for fostering critical thinking skills in students to guide them through the uncertainty in clinical biomechanics. This article presents the teaching philosophy that is used to teach undergraduate clinical biomechanics in the Department of Podiatry at La Trobe University, Australia.

The effect of pregnancy on footprint parameters. A prospective investigation.

Pregnancy produces significant alterations in the posture of the pregnant woman; however, gait changes that occur during pregnancy have not been adequately evaluated in the literature. This prospective investigation of the footprints of 25 pregnant women from early pregnancy to just prior to parturition revealed a significant increase in the base of gait during walking. This change in gait function may be a compensatory mechanism to improve locomotor stability, and may have important implications for foot function and development of lower-extremity pathology in pregnant women.

Jejunal glucose uptake and oxygen consumption in turkey poults selected for rapid growth.

Two lines of turkey poults, one selected for rapid growth at 16 wk of age (F line) and the other a randombred control line (RBC2) were used to investigate the effect of selection for rapid growth on jejunal O2 consumption and glucose transport as well as whole-body O2 consumption. All trials used unsexed poults and were designed as a randomized complete block with day and line as independent variables. In Trial 1, 120 turkey poults, fed a standard starter ration (25.5% CP), were used to examine the effect of selection on feed intake, body weight gain, and efficiency from hatching (Day 0) to 13 d of age. At Day 14, 36 of 60 birds from each line were killed to measure intestinal length and weight and jejunal O2 consumption after 18 h of feed deprivation. Compared with the RBC2 line, the F line had relatively shorter but heavier small intestinal segments when adjusted by 18 h feed-deprived body weight (FBW; P < 0.001). The F line consumed more O2 over the entire jejunum adjusted to FBW than RBC2 line (43.8 vs 34.6 nmol O2/min.g FBW; P < 0.001). Jejunal ouabain- and cycloheximide-sensitive O2 consumption were greater (P < 0.05) in the F line. In Trial 2, 16 14-d-old poults from each line were used to measure in vitro jejunal glucose transport rate. There was no difference in glucose transport of the jejunum (nanomoles per minute per gram of FBW) between the lines. In Trial 3, 20 poults from each line were used to measure whole-body O2 consumption at 7 to 10 d of age. The F and RBC2 lines had similar whole-body O2 consumption rate per gram of FBW. These data suggest that selection of turkeys for rapid growth at 16 wk of age did not increase efficiency of jejunal glucose uptake in 14-d-old turkey poults.

Selection for body composition does not affect energetic efficiency of jejunal glucose uptake in mice.

Five-wk-old male mice from three lines were used to examine whether the apparent energetic efficiency of active jejunal glucose uptake in mouse jejunum is altered by genetic selection for different body composition. The mice lines were selected as follows: HE, high percentage of body fat with no change in body weight as a constraint; LF, low percentage of body fat; and RS, randomly bred control. Body weight was similar in all lines. Total jejunal O2 consumption and ouabain-sensitive O2 consumption were used to estimate the energy expenditure associated with glucose absorption and Na+/K(+)-ATPase activity. Tritiated 3-O-methyl-D-glucose was used to determine glucose uptake by mouse jejunum. Line LF, when compared with line HE, had lower body fat as indicated by epididymal fat pad weight (143 vs. 362 mg/mouse, P < 0.001). There were no significant differences in small intestinal weight, length and density (mg/cm) between LF and HE lines. Jejunal villus width was greater in line LF compared with line HE (115 vs. 92 microm, P < 0.002). Jejunal glucose transport and O2 consumption were not different between LF and HE lines. Ouabain-sensitive O2 consumption was not significantly different among the three lines. No differences were noted in the apparent energetic efficiency of active glucose uptake among lines.

Introduction of a donor exposure reduction programme for multiple-transfused very-low-birth-weight infants.

OBJECTIVE: To conduct an audit of the frequency of red cell concentrate transfusions (RCCTs) in infants of different weight categories, the donor exposure rate (DER), in these transfused infants and the volume of blood wasted during each transfusion, and to identify from this baseline information specific categories of infants who would benefit from the introduction of a limited donor exposure programme (LDEP). STUDY SETTING: Neonatal wards and neonatal intensive care unit (NICU), Tygerberg Hospital, Western Cape. STUDY DESIGN: A prospective descriptive study and comparison with a historic control group. SUBJECTS: Information on the birth weight, age at the time of each RCCT and number of blood donors to whom an infant was exposed were collected post factum for all infants admitted to the neonatal wards and NICU between May 1993 and May 1994. During this time, the red blood cell concentrate was supplied as single paediatric bags (180 ml) transfused within 14 days of donation. An LDEP was introduced in February 1995. With this system, red blood cells were supplied as triple packs: a main unit of 250 ml with three empty satellite packs allowing up to three separate transfusions. These were assigned to a specific infant and were to be transfused within 21 days of donation. A second system where one adult blood bag was divided into two 180 ml bags and assigned to one infant to be transfused within 35 days of donation was also assessed. RESULTS: Of the 7854 infants admitted during the first 12-month audit period, 387 (4.9%) received 977 RCCTs. Of these, 183 (47.3%) received one transfusion, 72 (18.6%) two transfusions, 51 (13.2%) three transfusions, 27 (7.0%) four transfusions and 54 (13.9%) five or more transfusions. Infants (N = 188) with a birth weight below 1500 g admitted to the NICU were identified as the group with the highest prevalence of RCCTs (68.6%), and it was therefore decided that in the prospective study such infants would qualify for the LDEP. A total of 81 infants was transfused with either the double (N = 47) or the triple bags (N = 34) over a 5-month period. The decrease in the mean DER (+/-SD) was clinically significant when the triple (1.9 +/- 0.8) (P = 0.0001) and the double bags (1.6 +/- 0.8) (P = 0.0001) were compared with the previous single-bag system (4.4 +/- 3.5). Of concern was the large mean volume of concentrated red cells (118.5 +/- 12.5 ml) wasted per transfusion with the single-bag system. CONCLUSIONS: This survey confirmed a high RCCT rate as well as a very high DER in very-low-birth-weight (VLBW) infants treated at a tertiary centre. By assigning a triple or double bag of red cells from one blood donor and extending the storage of blood for small-volume RCCTs in infants from 14 days to 35 days, donor exposure was reduced significantly. We urge the introduction of the multibag blood transfusion system and extended storage period of blood for small-volume RCCT for VLBW infants in South Africa.

Peptide regulation of intestinal glucose absorption.

Terminal hydrolysis of oligosaccharides at the small intestinal brush border yields monomeric glucose, most of which is then absorbed by the transepithelial route. This involves carrier-mediated processes requiring specialized functional proteins situated in the brush border (SGLT1) and basolateral (GLUT2) membranes. Glucose translocation at the enterocyte apical membrane is an active, Na(+)-dependent and saturable process, whereas exit from enterocytes is by facilitated diffusion and is energy-independent. Specific adaptation of glucose active transport occurs in response to changes in the proportion of glucose in the diet. The regulatory signals responsible for transport induction are imprecisely defined, although numerous protein hormones and gut regulatory proteins are implicated. Epidermal growth factor and peptide YY invoke up-regulation of jejunal active glucose transport in vivo. Recently, peptide YY has been shown to stimulate active glucose transport in mice without altering oxygen consumption of jejunal tissue. Several other peptides whose presence in tissues of the small bowel imply that they exert control over epithelial nutrient transport are considered, and the relevance of these physiological manipulations, with various regulatory peptides and hormones, to animal agriculture are discussed.

Von Willebrand's disease in the Western Cape.

OBJECTIVE: To establish the prevalence of the various subtypes of Von Willebrand's disease (VWD) among patients with bleeding disorders in the Western Cape and to review appropriate treatment strategies. DESIGN: A systematic clinical and laboratory study. SETTING: Haemophilia clinics at two tertiary referral hospitals (Groote Schuur Hospital and Red Cross War Memorial Children's Hospital) in the Western Cape. PATIENTS: Twenty-two patients (14 females, 8 males; ages 3 - 55 years) were studied. Those studied were selected for reasons of convenience, as they were compliant and regular attenders at the clinics. MAIN OUTCOME MEASURES: History of a bleeding tendency; bleeding time measurements; factor VIII assays, von Willebrand factor (VWF) antigen assays; ristocetin co-factor assays and VWF multimer analysis. RESULTS: Fourteen patients had typical type I VWD; 2 had type II and 5 had type III variants, and there was 1 unclassifiable variant. Analysis of local factor VIII concentrates showed the presence of high-molecular-weight VWF multimers. CONCLUSION: The results are similar to patterns reported elsewhere in the world. Locally produced factor VIII concentrates, unlike a number of commercially produced concentrates, contain sufficient multimers for use as appropriate replacement therapy.

Fe-52 imaging of intrathoracic extramedullary hematopoiesis in a patient with beta-thalassemia.

Fe-52 scintigraphy was used to confirm extramedullary hematopoiesis in a patient with beta-thalassemia and intrathoracic masses. Imaging was performed on a standard gamma camera with a high-energy collimator. Tc-99m labeled tin colloid and In-111 chloride scintigraphy failed to reveal uptake by the masses. The exclusion of malignancy obviated the need for invasive diagnostic measures.