Interpretation of HbA1c : association with mean cell volume and haemoglobin concentration.

AIM: The utility of HbA1c in diabetes diagnosis is reduced in settings associated with altered haemoglobin glycation. We have studied whether HbA1c varies with mean cell volume and mean cell haemoglobin concentration as measures of haemoglobin metabolism. METHODS: Randomly selected adults from rural Victoria, Australia, were invited for biomedical assessment. After excluding patients with known diabetes and/or serum creatinine ≥ 0.12 mmol/l, 1315 adults were included. Demography, arthropometric measurements, oral glucose tolerance test, analyses of full blood count and HbA1c were undertaken. RESULTS: After adjusting for age, sex, ethnicity, BMI, town and socio-economic status, there were no significant differences in haemoglobin, mean cell volume or mean cell haemoglobin concentration by glycaemic status (defined by oral glucose tolerance test). HbA1c was significantly and independently associated with fasting glucose, town, mean cell haemoglobin concentration, ethnicity, age and BMI among men < 50 years (R² = 33.8%); fasting glucose, 2-h glucose, mean cell haemoglobin concentration and town among men ≥ 50 years (R² = 47.9%); fasting glucose, mean cell volume, mean cell haemoglobin concentration, town, 2-h glucose and age among women < 50 years (R² = 46.3%); fasting glucose, mean cell haemoglobin concentration, mean cell volume and 2-h glucose among women ≥ 50 years (R² = 51.6%). A generalized linear model showed a gradient from an adjusted mean HbA1c of 36 (95% CI 34-38) mmol/mol with a mean cell haemoglobin concentration of ≤ 320 g/l to 30 (95% CI 29-31) mmol/mol with a mean cell haemoglobin concentration of > 370 g/l. The gradient across mean cell volume was negative, but only by 1 mmol/mol (0.1%) HbA1c . CONCLUSION: A mean HbA1c difference of 5 mmol/mol (0.5%) across the mean cell haemoglobin concentration reference range suggests that an accompanying full blood count examination may be required for its use in the diagnosis of diabetes. Further studies are required to confirm this.

Skeletal fluorosis due to excessive tea and toothpaste consumption.

We describe the case of a 53-year-old woman who presented with a metatarsal fracture and was found to have a bone mineral density (BMD) T-score of +11 in the lumbar spine and +7.6 in the hip. Subsequent investigation revealed very high serum, urine and tissue fluoride levels, associated with excessive tea and toothpaste consumption. The case emphasises the need to exclude fluorosis in individuals with unexpectedly high BMD levels.

The reliability of nonreconstructed computerized tomographic scans of the abdomen and pelvis in detecting thoracolumbar spine injuries in blunt trauma patients with altered mental status.

BACKGROUND: Computerized tomography, traditionally utilized to evaluate and detect visceral abdominal and pelvic injuries in multiply injured patients with altered mental status, also has been useful for detecting thoracolumbar spine fractures and dislocations. The purpose of the present study was to test the reliability of nonreconstructed computerized tomography of the abdomen and pelvis as a screening tool for thoracolumbar spine injuries in blunt trauma patients with altered mental status. METHODS: The study consisted of fifty-nine consecutive patients with altered mental status who were admitted to a Level-II trauma center. Each patient had a nonreconstructed computerized tomographic scan of the abdomen and pelvis (5-mm slices), and of the chest when indicated, as well as anteroposterior and lateral radiographs of the thoracolumbar spine. Reconstructed computerized tomographic scans dedicated to the spine (< or =2-mm slices) were completed. With use of the reconstructions as the gold standard, sensitivity and specificity with 95% confidence intervals were calculated to assess the diagnostic accuracy of using the nonreconstructed computerized tomographic scans and the radiographs. RESULTS: Reconstructions of the spine detected seventy-two thoracolumbar spine fractures, whereas nonreconstructed computerized tomographic scans of the abdomen and pelvis detected fifty-eight and those of the chest detected sixteen. With use of the reconstructions as the standard, computerized tomography of the chest, abdomen, and pelvis had a sensitivity of 89% (95% confidence interval, 65% to 96%) and a specificity of 85% (95% confidence interval, 65% to 96%) for the detection of all fractures, compared with 37% and 76% for plain radiographs, respectively. Computerized tomography of the chest, abdomen, and pelvis was 100% sensitive and specific for the detection of whether a patient had any fracture at all, whereas radiographs were 54% sensitive and 86% specific. No fractures that were missed on nonreconstructed computerized tomography required surgery or other interventions. CONCLUSIONS: Nonreconstructed computerized tomography detected fractures of the thoracolumbar spine more accurately than plain radiographs did and is recommended for the diagnosis of thoracolumbar spine fractures in acute trauma patients with altered mental status. Reconstructions do not need to be ordered unless an abnormality that is found on the nonreconstructed computerized tomographic scan needs additional elucidation.

Gold finger: metal jewellery as a disease modifying antirheumatic therapy!

Polyarticular psoriatic arthritis is a chronic, progressive and disabling auto-immune disease often affecting the small joints of the hands in a symmetrical fashion. The disease can progress rapidly causing joint swelling and damaging cartilage and bone around the joints resulting in severe deformities. We report a very unusual case of a 49-year-old woman who presented with polyarticular psoriatic arthritis affecting all proximal interphalangeal (PIP) joints of both hands except the left ring finger PIP joint. On clinical examination there was no evidence of arthritis in the left ring finger PIP joint. We confirmed the paucity of joint damage in the PIP joint of the left ring finger using more modern imaging modalities such as musculoskeletal ultrasound and MRI scan of the small joints of the hands. All other PIP joints in both hands demonstrated advanced degrees of joint damage secondary to chronic psoriatic inflammatory arthritis. We postulated that wearing a gold wedding ring has helped protecting the PIP joint of the left ring finger from the damaging effect of inflammatory arthritis. The possible mechanisms by which metal jewellery (gold ring) confer protection to adjacent joints was discussed.

A20 inhibits NF-kappa B activation downstream of multiple Map3 kinases and interacts with the I kappa B signalosome.

A20, a TNF inducible gene, inhibits TNF-mediated apoptosis as well as NF-kappa B induced by this cytokine. Reporter assay experiments revealed that A20 is a very effective inhibitor of NF-kappa B signaling induced by TRAFs and several Map3 kinases, including NIK, MEKK1, COT, and TAK1. Similarly, the NF-kappa B inducing activity of TAX, an activator of the I kappa B kinase complex, is also abrogated by A20. Inhibition of NF-kappa B is specific as A20 has no effect on TNF-alpha-induced JNK activation. These results suggest that the molecular target of A20 is more distal to the receptor than TRAFs as previously proposed. A20 inhibits NF-kappa B-dependent transcription without a concomitant decrease in nuclear NF-kappa B DNA binding activity or nuclear translocation of p65. This apparent discrepancy between transcriptional readout and gel shift experiments is observed with a variety of stimuli, including expression of IKK beta. Therefore, in addition to the phosphorylation of I kappa B, another signal is needed for transcriptional activation of NF-kappa B. A20 inhibits this non-redundant signal. The observation that A20 associates with IKK alpha and is phosphorylated upon IKK beta co-expression may suggest that A20 interferes with some aspects of signalosome function.

Regulatory effects of eotaxin on acute lung inflammatory injury.

Eotaxin, which is a major mediator for eosinophil recruitment into lung, has regulatory effects on neutrophil-dependent acute inflammatory injury triggered by intrapulmonary deposition of IgG immune complexes in rats. In this model, eotaxin mRNA and protein were up-regulated during the inflammatory response, resulting in eotaxin protein expression in alveolar macrophages and in alveolar epithelial cells. Ab-induced blockade of eotaxin in vivo caused enhanced NF-kappaB activation in lung, substantial increases in bronchoalveolar lavage levels of macrophage inflammatory protein (MIP)-2 and cytokine-induced neutrophil chemoattractant (CINC), and increased MIP-2 and CINC mRNA expression in alveolar macrophages. In contrast, TNF-alpha levels were unaffected, and IL-10 levels fell. Under these experimental conditions, lung neutrophil accumulation was significantly increased, and vascular injury, as reflected by extravascular leak of (125)I-albumin, was enhanced. Conversely, when recombinant eotaxin was administered in the same inflammatory model of lung injury, bronchoalveolar lavage levels of MIP-2 were reduced, as was neutrophil accumulation and the intensity of lung injury. In vitro stimulation of rat alveolar macrophages with IgG immune complexes greatly increased expression of mRNA and protein for MIP-2, CINC, MIP-1alpha, MIP-1beta, TNF-alpha, and IL-1beta. In the copresence of eotaxin, the increased levels of MIP-2 and CINC mRNAs were markedly diminished, whereas MIP-1alpha, MIP-1beta, TNF-alpha, and IL-1beta expression of mRNA and protein was not affected. These data suggest that endogenous eotaxin, which is expressed during the acute lung inflammatory response, plays a regulatory role in neutrophil recruitment into lung and the ensuing inflammatory damage.

Molecular cloning and characterization of DEFCAP-L and -S, two isoforms of a novel member of the mammalian Ced-4 family of apoptosis proteins.

We report the deduced amino acid sequences of two alternately spliced isoforms, designated DEFCAP-L and -S, that differ in 44 amino acids and encode a novel member of the mammalian Ced-4 family of apoptosis proteins. Similar to the other mammalian Ced-4 proteins (Apaf-1 and Nod1), DEFCAP contains a caspase recruitment domain (CARD) and a putative nucleotide binding domain, signified by a consensus Walker's A box (P-loop) and B box (Mg(2+)-binding site). Like Nod1, but different from Apaf-1, DEFCAP contains a putative regulatory domain containing multiple leucine-rich repeats (LRR). However, a distinguishing feature of the primary sequence of DEFCAP is that DEFCAP contains at its NH(2) terminus a pyrin-like motif and a proline-rich sequence, possibly involved in protein-protein interactions with Src homology domain 3-containing proteins. By using in vitro coimmunoprecipitation experiments, both long and short isoforms were capable of strongly interacting with caspase-2 and exhibited a weaker interaction with caspase-9. Transient overexpression of full-length DEFCAP-L, but not DEFCAP-S, in breast adenocarcinoma cells MCF7 resulted in significant levels of apoptosis. In vitro death assays with transient overexpression of deletion constructs of both isoforms using beta-galactosidase as a reporter gene in MCF7 cells suggest the following: 1) the nucleotide binding domain may act as a negative regulator of the killing activity of DEFCAP; 2) the LRR/CARD represents a putative constitutively active inducer of apoptosis; 3) the killing activity of LRR/CARD is inhibitable by benzyloxycarbonyl-Val-Ala-Asp (OMe)-fluoromethyl ketone and to a lesser extent by Asp-Glu-Val-Asp (OMe)-fluoromethyl ketone; and 4) the CARD is critical for killing activity of DEFCAP. These results suggest that DEFCAP is a novel member of the mammalian Ced-4 family of proteins capable of inducing apoptosis, and understanding its regulation may elucidate the complex nature of the mammalian apoptosis-promoting machinery.

Protective effects of anti-C5a in sepsis-induced thymocyte apoptosis.

Multiorgan apoptosis occurs during sepsis. Following cecal ligation and puncture (CLP) in rats, thymocytes underwent apoptosis in a time-dependent manner. C5a blockade dramatically reduced thymocyte apoptosis as measured by thymic weight, binding of annexin V to thymocytes, and laddering of thymocyte DNA. When C5a was generated in vivo by infusion of purified cobra venom factor (CVF), thymocyte apoptosis was significantly increased. Similar results were found when CVF was injected in vivo during the early stages of CLP. In animals 12 hours after induction of CLP, there was an increase in the activities of caspase-3, -6, and -9, but not caspase-1 and -8. Cytosolic cytochrome c levels increased by twofold, whereas mitochondrial levels showed a 50% decrease. Western blot analysis revealed that the content of Bcl-X(L) (but not of Bcl-2, BAX, Bad, and Bim) significantly decreased in thymocytes after CLP. C5a blockade in the sepsis model almost completely inhibited caspase-3, -6, and -9 activation, significantly preserved cytochrome c in the mitochondrial fraction, and restored Bcl-X(L) expression. These data suggest that systemic activation of complement induces C5a-dependent apoptosis of thymocytes and that the blockade of C5a during sepsis rescues thymocytes from apoptosis.

Insertional mutation of the collagen genes Col4a3 and Col4a4 in a mouse model of Alport syndrome.

Mice homozygous for the transgenic insertion in line OVE250 exhibit severe progressive glomerulonephritis. Ultrastructural changes in the glomerular basement membrane (GBM) at 2 weeks of age resemble those in Alport syndrome. The transgenic insertion site was mapped by FISH to mouse chromosome 1 close to Pax3. Genetic and molecular analyses identified a deletion of genomic DNA at the transgene insertion site. Exons 1 through 12 of the collagen IV gene Col4a4, exons 1 and 2 of the adjacent Col4a3 gene, and the intergenic promoter region are deleted. Transcripts of Col4a3 and Col4a4 are undetectable in mutant kidney, and both proteins are missing from the GBM. Persistent cellular proliferation in mutant kidneys suggests that interaction with the extracellular matrix may be important for cell maturation. Evolutionarily conserved sequence elements in the promoter regions of human and mouse Col4a3 and Col4a4 include a 19-bp element that was tandemly duplicated in the human lineage and a CTC box element common to several genes encoding extracellular matrix proteins. This new animal model of Alport syndrome, Col4Delta3-4, lacks both alpha3 and alpha4 chains of collagen IV and exhibits an earlier disease onset than mice lacking alpha3 only.

Alternate splicing in human Na+-MI cotransporter gene yields differentially regulated transport isoforms.

myo-Inositol is a ubiquitous intracellular organic osmolyte and phosphoinositide precursor maintained at millimolar intracellular concentrations through the action of membrane-associated Na+-myo-inositol cotransporters (SMIT). Functional cloning and expression of a canine SMIT cDNA, which conferred SMIT activity in Xenopus oocytes, predicted a 718-amino acid peptide homologous to the Na+-glucose cotransporter with a potential protein kinase A phosphorylation site and multiple protein kinase C phosphorylation sites. A consistent approximately 1.0- to 13.5-kb array of transcripts hybridizing with this cDNA are osmotically induced in a variety of mammalian cells and species, yet SMIT activity appears to vary among different tissues and species. An open reading frame on human chromosome 21 (SLC5A3) homologous to that of the canine cDNA (96.5%) is thought to comprise an intronless human SMIT gene. Recently, this laboratory ascribed multiply sized, osmotically induced SMIT transcripts in human retinal pigment epithelial cells to the alternate utilization of several 3'-untranslated SMIT exons. This article describes an alternate splice donor site within the coding region that extends the open reading frame into the otherwise untranslated 3' exons, potentially generating novel SMIT isoforms. In these isoforms, the last putative transmembrane domain is replaced with intracellular carboxy termini containing a novel potential protein kinase A phosphorylation site and multiple protein kinase C phosphorylation sites, and this could explain the heterogeneity in the regulation and structure of the SMIT.

Well-breeding Anopheles dirus and their role in malaria transmission in Myanmar.

Mosquitos were collected with human and animal baits from March 1996 to January 1998 in four villages located along the Yadana gas pipe line in Yepyu township, Dawae district, Tanintharyi Division, southern Myanmar. A total of 23 anopheline species were collected. Anopheles dirus were abundant in pre-monsoon (May/June) an post-monsoon (October) months. All An. dirus caught both humans and cattle were assayed with specific, sporozoite enzyme-linked immunosorbent assays (ELISAs). A total of 5/250 (2%) caught with human bait was found positive with Plasmodium vivax from Eindayaza, Ohnbinkwin and Thaechaung during rainy and cool-dry months. Larval surveys also showed An. dirus larvae/pupae were caught from domestic wells (6 to 46% found positive). Clinical surveys indicated that transmission is hyperendemic and occur all year round in all four villages.

Human Na(+)-myo-inositol cotransporter gene: alternate splicing generates diverse transcripts.

Na(+)-myo-inositol cotransport activity generally maintains millimolar intracellular concentrations of myo-inositol and specifically promotes transepithelial myo-inositol transport in kidney, intestine, retina, and choroid plexus. Glucose-induced, tissue-specific myo-inositol depletion and impaired Na(+)-myo-inositol cotransport activity are implicated in the pathogenesis of diabetic complications, a process modeled in vitro in cultured human retinal pigment epithelium (RPE) cells. To explore this process at the molecular level, a human RPE cDNA library was screened with a canine Na(+)-dependent myo-inositol cotransporter (SMIT) cDNA. Overlapping cDNAs spanning 3569 nt were cloned. The resulting cDNA sequence contained a 2154-nt open reading frame, 97% identical to the canine SMIT amino acid sequence. Genomic clones containing SMIT exons suggested that the cDNA is derived from at least five exons. Hypertonic stress induced a time-dependent increase, initially in a 16-kb transcript and subsequently in 11.5-, 9.8-, 8.5-, 3.8-, and approximately 1.2-kb SMIT transcripts, that was ascribed to alternate exon splicing using exon-specific probes and direct cDNA sequencing. The human SMIT gene is a complex multiexon transcriptional unit that by alternate exon splicing generates multiple SMIT transcripts that accumulate differentially in response to hypertonic stress.

Ascariasis and childhood malnutrition.

The present review will examine epidemiological perspectives and be confined mainly to the results of those field studies published since 1975 in order to provide concrete scientific evidence of the effect of ascariasis on childhood malnutrition, particularly on growth. The field studies were done in many developing countries from Africa, Asia and Latin America, using cross-sectional and intervention studies in which anthelmintics were employed, with different dosing frequency and follow-up periods ranging from 33 days to 2 years. In general, a better nutritional status in terms of growth, lactose tolerance, vitamins A and C, and albumin levels were observed among Ascaris-free or treated than among Ascaris-infected or untreated children even in cross-sectional or non-randomized studies. More importantly, the improvement in weight or height after chemotherapeutic treatment was found to be significant particularly in those randomized controlled studies with an initially high prevalence of ascariasis and malnutrition, a low prevalence of other intestinal parasites, repetitive and regular treatments of children with tetramisole, levamisole or pyrantel, within a period of 12 or 24 months. Reasons for failures to detect improved growth in some studies are provided. This review strongly indicates that A. lumbricoides infection definitely retards childhood growth.

Bacteriologic studies of food and water consumed by children in Myanmar: 1. The nature of contamination.

To isolate major bacterial pathogens from children's food and drinking water, a 3-month study was conducted in a suburban community in Yangon, Myanmar. From the morning meals and stored drinking water of 208 randomly selected children, 775 food and 113 water samples were collected and were cultured using standard methods. Escherichia coli, Vibrio cholerae non-01, and Salmonella were isolated from 505, 28 and 6 food samples respectively, and E. coli and V. cholerae non-01 were isolated from 29 and 5 water samples respectively. Among the E. coli isolates, 8 produced heat-stable toxin (ST) and 3 were enteroinvasive. Nine V. cholerae non-01 produced cholera-like toxin. Of the 29 E. coli isolates from the samples of drinking water, 3 produced ST. All water samples were negative for Salmonella. The study underscores the importance of bacterial contamination of children's food and drinking water and stresses the need to improve environmental sanitation.

Bacteriologic studies of food and water consumed by children in Myanmar: 2 Lack of association between diarrhoea and contamination of food and water.

The association between contamination of morning samples of food and water of 208 children aged 6-29 months and the incidence of diarrhoea was investigated for 3 months in Yangon, Myanmar. Contamination of the samples was determined by isolation of faecal coliforms (FC) by standard methods. The children were divided into three groups, high, medium and low, according to the proportion of food and water samples found to be contaminated. The incidence of diarrhoea was recorded by weekly recall. Of the 779 food samples, 504 (65%), and of the 860 drinking water samples, 187 (22%) were positive for FC. The association between food and water contamination and the incidence of diarrhoea was assessed by comparing the cumulative incidences in the high and medium groups with that in the low group which served as reference. Diarrhoea risk ratios (RR) for children in the medium and high contamination groups (food, RR = 1.04 in medium and 0.78 in high vs 1 in low; water, RR = 0.73 and 0.73 vs 1) were not significantly different from those who were in the low-contamination group even after controlling for the confounding variables.

Measles-associated diarrhoea in the Infectious Diseases Hospital, Rangoon.

A study was conducted in the Infectious Diseases Hospital in Rangoon (Burma) to determine the magnitude of measles-associated diarrhoea morbidity and mortality in children under 6 years of age contributing to the overall diarrhoeal morbidity and mortality, and to determine the bacterial pathogens of measles-associated diarrhoea cases. Measles-associated diarrhoea cases occur most frequently in younger age groups (12-23 and 0-11 months). Although not directly comparable, their contribution to the total diarrhoeal cases (8%) was high but the proportion of measles-associated diarrhoeal deaths contributing to total diarrhoeal deaths was lower than the theoretical estimates. A low fatality rate (2%) among the measles-associated diarrhoea cases was found and this suggests a much lower rate in the community. This implies that measles-associated diarrhoeal mortality is probably not a major public health problem in Burma. Chest infection was the most common complication (32%) and was found in the majority of deaths resulting from complicated measles. A definite seasonal distribution of measles and measles-associated diarrhoea cases was found. Only 10% of the stool samples examined were positive for bacterial pathogens and all were shigellae. We found that a significant number of measles-associated diarrhoeal cases were malnourished.