Surveillance and impact of occult hepatitis B virus, SEN virus, and torque teno virus in Egyptian hemodialysis patients with chronic hepatitis C virus infection.

OBJECTIVES: Egypt ranks first regarding the prevalence of hepatitis C virus (HCV) infection. Many patients have concomitant diseases like kidney disorders requiring hemodialysis, a procedure carrying the hazard of transmitting other hepatitis viruses. The purpose of this study was to investigate for occult hepatitis B virus (HBV), SEN virus (SENV), and torque teno virus (TTV) among chronic HCV patients on maintenance hemodialysis to identify their impacts. METHODS: A total of 325 hemodialysis patients were enrolled and divided into two groups based on HCV RNA testing results. Blood samples were collected before hemodialysis. Sera were tested for hepatitis B core antibodies (anti-HBc) and hepatitis B surface antibodies (anti-HBs) using ELISA. HBV, SENV, and TTV DNA were detected by PCR. The serum alanine aminotransferase (ALT) level was measured. RESULTS: Anti-HBc and HBV DNA were detected in 73.1% and 50.8% of group 1 versus 36.4% and 22.6% of group 2. The serum ALT level was higher in group 1 than group 2. SENV was detected in 11.5% of group 1 versus 8.2% of group 2. TTV was detected in 29% of group 1 versus 27% of group 2. CONCLUSIONS: There is an increased prevalence of occult HBV in our locality among chronic HCV patients undergoing hemodialysis. The existence of SENV and TTV viremia has no clinical impact.

HLA-DQB1*05:144, a novel allele, discovered in a Southeast Asian donor for stem cell transplantation.

HLA-DQB1*05:144 differs from HLA-DQB1*05:01:01 by a single substitution in exon 3.

Factors responsible for increased percent recirculation in arterio-venous fistula among the haemodialysis patients.

Recirculation is an important issue in haemodialysis (HD) patients as increased percent recirculation causes decreased dialysis delivery of the patients. The purpose of the study was to determine the amount and factors of recirculation in those patients. The study was a cross sectional one carried in the Department of Nephrology, Dhaka Medical College and Hospital during October 2010 to September 2011. A total of 118 end stage renal disease patients with arterio-venous fistula who were on HD for more than 3 months were purposively selected. The degree of recirculation was measured with urea based two needle technique method. For each patient distances between arterial and venous and distances of needles from fistula and its directions were recorded. Echocardiography and A-V fistula Colour Doppler Ultrasound were also performed. The mean A-V fistula recirculation was 8.1 +/- 5.5% with a range 0-66%. The most common factors were close proximity and improper arterial and venous needles placement. No difference was observed between diabetic and non diabetic also between hypertensive and normotensive. A-V fistula recirculation is common occurrence in HD patients and the most common factors of recirculation are misplacement and close proximity of needles therefore emphasis should be given on education and training of HD staffs.

IL15 levels on day 7 after hematopoietic cell transplantation predict chronic GVHD.

Chronic GVHD (cGVHD) is an important complication of allogeneic hematopoietic cell transplantation (HCT). As preemptive therapy might be efficacious if administered early post transplant, we set out to determine whether cGVHD can be predicted from the serum level of a biomarker on day 7 or 28. In a discovery cohort of 153 HCT recipients conditioned with BU, fludarabine and rabbit antithymocyte globulin (ATG), we determined serum levels of B-cell-activating factor, vascular endothelial growth factor, soluble TNF-α receptor 1, soluble IL2 receptor α, IL5, IL6, IL7, IL15, γ-glutamyl transpeptidase, cholinesterase, total protein, urea and ATG. Patients with low levels of IL15 (<30.6 ng/L) on day 7 had 2.7-fold higher likelihood of developing significant cGVHD (needing systemic immunosuppressive therapy) than patients with higher IL15 levels (P<0.001). This was validated in a validation cohort of 105 similarly-treated patients; those with low IL15 levels had 3.7-fold higher likelihood of developing significant cGVHD (P=0.001). Low IL15 was not associated with relapse; it trended to be associated with acute GVHD and was associated with low infection rates. In conclusion, low IL15 levels on day 7 are predictive of cGVHD, and thus could be useful in guiding preemptive therapy.

Management of differentiated thyroid carcinoma.

The study was done to determine the clinical, radiological and histopathological characteristics along with the management outcome of differentiated thyroid carcinoma. This Retrospective study included sixty patients with differentiated thyroid carcinoma presented to Department of Otolaryngology and Head-Neck Surgery at Dhaka Medical College Hospital and Apollo Hospitals Dhaka from June 2006 to December 2008. The data of each patient included age, sex, presenting symptoms and signs, provisional diagnosis, preoperative investigations, operation notes, histopathological examination and state at follow up. This study included 28 males and 32 females. The mean age was 42.7 years. Maximum patients presented at 4th decade. The commonest presentation was thyroid swelling followed by lateral neck swelling. Detailed clinical assessment before operative treatment has been done for all patients. Fifty five patients (91.66%) presented with single nodule. Distant metastasis was found in 2 cases. All patients underwent fine needle aspiration cytology which was conclusive in 38 patients (63.33%). All the sixty patients underwent surgical excision; either total thyroidectomy or completion thyroidectomy. Neck dissection was performed in 8 patients. All patients received postoperative radio-iodine. Fifty one cases were papillary carcinoma and 9 cases were follicular carcinoma. Except for one case with local recurrence the remaining cases were disease free on follow up (up to 10-40 months). One patient died with bone metastasis 2 years after operation. Of all thyroid cancers, majority cases are papillary cancer (85%). In contrast to other cancers, thyroid cancer is almost always curable. Most thyroid cancers grow slowly and are associated with a very favorable prognosis. Early diagnosis and treatment of the same is strongly advisable.

Prostate biopsies from black men express higher levels of aggressive disease biomarkers than prostate biopsies from white men.

A wide array of biomarkers is being investigated as predictors of prostate cancer (PCa) diagnosis and recurrence. We compared the expression of a small panel of these biomarkers as a function of race among men undergoing radical prostatectomy (RP). Prostate needle biopsy specimens from 131 patients treated with RP at the Durham Veterans Affairs Medical Center were hematoxylin and eosin stained and immunofluorescent assayed for α-methylacyl CoA racemase (AMACR), androgen receptor (AR) and Ki67. Proprietary image analysis was used to identify six biometric feature combinations that were significantly associated with progression in a previous study. Analysis of population characteristics, stratified by race, was performed using rank-sum and χ(2)-test. The effect of race on expression of these biomarker profiles was analyzed using multivariate linear regression. All six biomarker features were expressed at higher levels in black men than white men, with Norm AR (P=0.006) and Ki67 (P=0.02) attaining statistical significance. On multivariate analysis, all markers were expressed at higher levels in black men, with Norm AR (P=0.001), Ki67 (P=0.007) and Ki67/lum (P=0.022) reaching significance. These data support the hypothesis that PCa may be biologically more aggressive among black men.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan.

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers (22.0% male and 3.8% females) and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers (96%) believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers [22.0% male and 3.8% females] and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers [96%] believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools

Implications for the practice of a patient expectation and satisfaction survey, at a teaching hospital in Karachi, Pakistan.

OBJECTIVE: To study the expectations and satisfaction of patients visiting Family Practice Clinics, at the Aga Khan University Hospital, in Karachi, Pakistan. METHODOLOGY: A cross sectional survey of 316 patients was carried out. A questionnaire, based on the study objectives was developed and administered. The participating patient signed a consent form, after assurance of confidentiality was provided. Data on the demographic profile of the patients was collected. RESULTS: The mean age was 33.81 years, with 105 (33.2%) women, and 211 (66.8%) men. The majority were married, with education above intermediate level and were in private or government service or were housewives. The median for the patient waiting time was 30 minutes, against an expectation of 12.69 minutes. Reading newspaper, watching television, reading magazine, reading Quran and listening to music were quoted as ways to lessen the burden of waiting to see a physician. The average consultation time with the physician was 13.89 minutes, against an expectation of 16.37 minutes. Patient expectation in terms of listening by the doctor with patience, explanation of the diagnosis and treatment, prescription of medicines, ordering of investigations and specialist referral has been documented. Objections to the presence of medical student, nursing student, resident doctor, nurse and an observer, in the consultation room have also been documented. Reasons quoted for the objection include issues of privacy/confidentiality, lack of justification, discomfort, and interference with the consultation process. The expected average cost for doctor's consultation was Pakistani Rs. 124, while 196 (61.8%) of the respondents were satisfied with the consultation based on Rs. 70. CONCLUSION: We have collected important information to improve the services offered at our Family Practice clinics.

The rush to judgment: Does the evidence support the enthusiasm over three-dimensional conformal radiation therapy and dose escalation in the treatment of prostate cancer?.

PURPOSE: To discuss the assumptions behind and current clinical evidence on three-dimensional conformal radiation therapy (3D-CRT) and dose escalation in the treatment of prostate cancer. METHODS: We first define 3D-CRT in comparison to standard radiation therapy and discuss the assumptions on which the technology of 3D-CRT and dose escalation are based. We then examine the evidence on the benefits and limitations from the current most commonly cited studies on dose-escalation trials to treat prostate cancer. RESULTS: The assumption that 3D-CRT can provide a tighter margin around the tumor area to allow for dose escalation is not yet proven by studies that show continual difficulty in defining the planning treatment volume because of extrinsic and intrinsic difficulties, such as imaging variabilities and patient and organ movement. Current short-term dose-escalation studies on the use of 3D-CRT to treat prostate cancer are limited in their ability to prove that increasing dose improves survival and does not incur potential long-term complications to normal tissue. CONCLUSION: Although 3D-CRT is a promising technology that many radiation oncologists and clinics are quickly adopting to treat such tumors as prostate cancer, the long-term evidence on the benefits and limitations of this technology is still lacking. Until we have solid long-term evidence on the true clinical potential of this new technology, let us not rush to judgment, but exercise caution, diligence, and thoughtfulness in using this new technology to treat our patients.

Field equivalence for clinical electron beams.

The concept of field equivalence for electron beams is examined using a pencil beam theory applied to circular fields. It is shown that a circular field can be found for a field of any size, shape and energy for which the depth dose distribution is approximately equivalent. The usefulness of the concept in clinical dosimetry is discussed.

Calculation of depth dose and dose per monitor unit for irregularly shaped electron fields: an addendum.

Electron beam output (dose/MU) is generally specified at the depth of maximum dose (zmax). The location of this point depends on beam energy, field size and field shape. Useful relationships have been developed to estimate zmax as a function of field size and beam energy. The formalism uses a pencil beam theory applied to circular fields.

Cost-benefit analysis of 3D conformal radiation therapy--treatment of prostate cancer as a model.

Three-dimensional conformal radiation therapy (3D-CRT) is a promising new treatment technique based on the principle that improved precision in both tumor definition and dose delivery will enhance outcomes by maximizing dose to the tumor area while minimizing dose to normal tissue. Using a cost-benefit analysis, in terms of outcomes, we first examined the overall risks and benefits of 3D-CRT. We then used the treatment of prostate cancer as a model to compare actual clinical outcomes reported between 3D-CRT and standard radiation therapy (SRT). Our analysis shows that application of 3D-CRT to the clinical setting remains difficult because of the continual difficulties of target definition, and that dose escalation cannot yet be justified on the basis of the lack of benefit found, and suggested increased late toxicity, in most of the dose escalation series compared with SRT.

Pedestrian environment and behavior in Karachi, Pakistan.

Pedestrian road traffic accidents (RTAs) are responsible for a substantial number of injuries and deaths in Karachi. To better understand the situations facing pedestrians we selected ten of Karachi's highest risk locations for pedestrian RTAs and observed 250 pedestrians for each of three activities--crossing the street, walking on the street, and walking on the sidewalk. We also observed the extent and effect of street and sidewalk encroachments. A total of 35% of the pedestrians crossing the street caused traffic to swerve to avoid them. Pedestrians crossing one lane at a time were 2.9 times more likely to cause the traffic to swerve than pedestrians who crossed the whole street at once (53 vs. 18%, RR = 2.9, 95% CI = 1.9-4.3). Pedestrians crossing in a group were 1.8 times more likely to cause traffic to swerve compared to those crossing singly (49 vs. 28%, RR = 1.8, 95% CI = 1.3-2.5, P = 0.001). A total of 36% ran while crossing and were 1.8 times more likely to cause traffic to swerve than those who walked (48 vs. 27%, RR = 1.8, 95% CI = 1.3-2.5). An average of 77% of the sidewalk width was blocked by encroachments which forced pedestrians to step on the road resulting in vehicles swerving. An average 33% of the street width was blocked by illegally parked vehicles. Pedestrians in Karachi indulge in risky behaviors. Encroachments on streets and sidewalks compound the problem. Piloting efforts to modify pedestrian behavior and the environment they negotiate should be considered to reduce pedestrian deaths.

Calculation of depth dose and dose per monitor unit for irregularly shaped electron fields.

A new dosimetric quantity, the lateral build-up ratio (LBR), has been introduced to calculate depth dose distribution for any shaped field. Factors to account for change in incident fluence with collimation are applied separately. The LBR data for a small circular field are used to extract radial spread of the pencil beam, sigma(r), as a function of depth and energy. By using the relationship between LBR, sigma(r), energy and depth, a formalism is developed to calculate dose per monitor unit for any shaped field. Criteria for lateral scatter equilibrium are also developed which are useful in clinical dosimetry.

A comparison of severe pre-eclampsia/eclampsia in patients with and without HELLP syndrome.

BACKGROUND: The relationship of Haemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) syndrome with maternal and perinatal health and its presentation in Pakistani population is not known. PURPOSE: To determine the mode of presentation along with maternal and perinatal outcome of patients with HELLP syndrome. METHODS: Case records of patients with severe hypertension in pregnancy who delivered between January 1, 1989 and December 31, 1994 at The Aga Khan University Hospital, Karachi. Out of 120 cases of severe pre-eclampsia/eclampsia, there were 36 cases of HELLP syndrome (Group-A). These were then compared with cases without HELLP syndrome (Group B) for their mode of presentation along with maternal and perinatal morbidity and mortality. RESULTS: The overall incidence of HELLP syndrome was 0.4%. In the antepartum factors; unbooked status (66% vs 30%; p < 0.05), diastolic B.P. > 120 mmHg (61% vs 16%; p < 0.05) DIC (13% vs 2%; p = 0.03), seizures (40% vs 16%, p = 0.01) and ARF (11% vs 1%, p = 0.07) were significantly raised. In the intrapartum factors there were no significant differences between the two groups in mode of delivery and complications of delivery. Neonatal outcomes did not differ significantly in the two groups. CONCLUSIONS: Women with severe hypertension in pregnancy manifesting with HELLP syndrome show a significantly greater frequency of developing DIC, seizures and acute renal failure. Therefore, their care necessitates intensive monitoring to preclude development of these complications.

Cost-benefit analysis of 3D conformal radiation therapy.

BACKGROUND: The potential of 3D conformal radiation therapy to improve the efficacy of radiotherapy is one of the most important technical advances in recent years. The potential benefit of improved local control from dose escalation must be weighed against the potential cost of increased complications to normal tissue. METHOD AND RESULTS: We evaluated the cost-benefit of 3D conformal radiation therapy in terms of the benefit to tumor cure weighed against the cost of complications to normal tissue. Assessment of current data shows that problems remain in adequately defining variables that contribute to both the tumor cure probability (benefit) and normal tissue complication probability (cost). For tumor cure probability, identifying the dose escalation needed for cure for the most tumor sites as well as precisely defining tumor volume remain problematic. For normal tissue complication probability, inadequate clinical data on toxicity to normal tissue for different tumor sites continue to make it difficult to use methods that estimate complications, such as dose-volume histograms as proposed by Lyman, to the clinical setting. CONCLUSION: 3D conformal radiation therapy is a promising new technology that may substantially improve the efficacy of radiation therapy. More clinical research, however, is needed to recognize the costs and benefits of this new technology: 1. Tumor control probability: More information is needed on the accurate definition of the target volume as well as on the amount of radiation necessary to cure different tumor sites. 2. Normal tissue complication probability: Methods for determining toxicity to normal tissue are needed. Current calculations based on various models are insufficient.