Screening for diabetic retinopathy in primary care with a mobile fundal camera--evaluation of a South African pilot project.

BACKGROUND AND AIMS: In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. METHODS: The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. RESULTS: Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe nonproliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. CONCLUSION: Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10,000 patients a year.     

Modulation of severity of reperfusion stunning in the isolated rat heart by agents altering calcium flux at onset of reperfusion.

The present study tested the hypothesis that a reduction in calcium flux across the sarcolemma or the sarcoplasmic reticulum at the onset of reperfusion could attenuate subsequent mechanical "stunning" (postischemic myocardial dysfunction). The isolated working rat heart was subjected to 20 minutes of total global ischemia, reperfused in the Langendorff mode for 5 minutes, and then made to work again for 10 minutes. During the early reperfusion period (first 2 minutes), the effects of agents thought to increase cytosolic calcium (high external calcium [modified Tyrode's solution replaced Krebs-Henseleit buffer as the perfusate], isoproterenol, forskolin, and Bay K 8644) were tested. All these interventions worsened stunning. The cardiac output (CO) of control hearts recovered to 74.7 +/- 3.4%, whereas recovery was 56.3 +/- 3.7% (p less than 0.05) for high calcium (10 mM), 53.4 +/- 3.6% (p less than 0.05) for isoproterenol, 43.4 +/- 4.1% (p less than 0.05) for Bay K 8644, and 62.7 +/- 2.4% (p less than 0.002) for forskolin. Interventions aimed at limiting calcium flux during early reperfusion, such as reperfusion with a low extracellular calcium or the addition of ryanodine (3 x 10(-9) M), nisoldipine (10(-8) M), or the inorganic blockers Mn2+ (2 mM) or Mg2+ (16 mM), were also tested. Low extracellular calcium (0.75 mM) improved CO to 91.8 +/- 0.8% (p less than 0.05). Reperfusion with ryanodine and nisoldipine gave CO recoveries of 103.6 +/- 1.8% (p less than 0.002) and 99.0 +/- 2.8% (p less than 0.002), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Implementation of a Tc-99m and Ce-139 scanning line source for attenuation correction in SPECT using a dual opposing detector scintillation camera

Image degradation during single photon emission computed tomography (SPECT) due to attenuation and Compton scatter of photons can cause clinical image artifacts and will also result in inaccurate quantitative data. Therefore attenuation correction methods recently received wide interest. Transmission imaging can be performed to obtain the attenuation coefficients of a nonhomogeneous attenuating medium accurately. The aim of this study was firstly to evaluate the imaging characteristics of the scanning line source assembly. The results obtained with Tc-99m and Ce-139 were compared. Secondly the calculated attenuation coefficients were compared with known values from literature, using Tc-99m and Ce-139 as transmission sources. Lastly the method of acquiring simultaneous transmission and emission data was investigated. This study shows that an attenuation coefficient map can be obtained using a scanning line source for transmission imaging with a dual opposing detector camera. The imaging characteristics of Tc-99m and Ce-139 as transmission sources are similar. The resolution obtained with the Ce-139 line source was poorer than that obtained with the Tc-99m line source. A linear relationship was found between CT numbers and attenuation coefficients for transmission images using both Tc-99m and Ce-139 line sources. The attenuation coefficient value for water was underestimated by 1% using the Tc-99m transmission source and underestimated by 10% using Ce-139 as transmission source. This underestimation of attenuation coefficient values was also obtained in the human study. A myocardial perfusion study processed without and with attenuation correction clearly demonstrated the effect of the attenuation correction in the inferior myocardial region. The potential of using a scanning line source as transmission source with a dual opposing detector camera has been demonstrated in this study. The transmission source, Ce-139 was successfully introduced in this investigation for simultaneous acquisition of transmission and emission data.     

Vasopressin release and firing of supraoptic neurosecretory neurones during drinking in the dehydrated monkey

A close relationship exists between drinking and the release of vasopressin, the two main factors responsible for the maintenance of body water content. Whereas the participation of peripheral factors, such as oropharyngeal stimulation, seems obvious in the metering of fluid intake and in thirst satiation, very little is known about their influence on vasopressin release. In the present experiments, the influence of drinking on vasopressin release was studied using both biochemical and electrophysiological approaches.In one group of monkeys made thirsty by water deprivation, the subsequent drinking of water during a 5–8 min induced: i) a short-term response, consisting of an abrupt fall in plasma vasopressin concentration which was independent of osmolality, occurred at the time of drinking and was partly reversed after the cessation of drinking, and ii) a longer lasting response, consisting of a slow diminution of plasma vasopressin concentration as the intestinal absorption of water progressed. In another group of thirsty monkeys, extracellular recordings were made during drinking from cells which were identified as neurosecretory neurones of the supraoptic nucleus, a number of them being considered vasopressin secreting on the basis of their phasic pattern of firing. Their firing decreased considerably during the periods of water intake and recovered to control levels immediately after-wards.The decrease in vasopressin release at the onset of water intake, the diminution in the firing rate of the neurones, the short latency and the reversibility of these events after cessation of drinking, suggest that a reflex inhibition of vasopressin-secreting neurones occurs which is probably induced by peripheral stimuli and most likely via oropharyngeal or other visceral receptors. It is postulated that this reflex inhibition of vasopressin release may participate in some active manner in the anticipatory mechanisms of thirst satiation.     

Sequence diversity of the nucleoprotein gene of iris yellow spot virus (genus Tospovirus, family Bunyaviridae) isolates from the western region of the United States

Summary. Iris yellow spot virus (IYSV), a tentative virus species in the genus Tospovirus and family Bunyaviridae, is considered a rapidly emerging threat to onion production in the western United States (US). The present study was undertaken to determine the sequence diversity of IYSV isolates from infected onion plants grown in California, Colorado, Idaho, Oregon, Utah and Washington. Using primers derived from the small RNA of IYSV, the complete sequence of the nucleoprotein (NP) gene of each isolate was determined and the sequences compared. In addition, a shallot isolate of IYSV from Washington was included in the study. The US isolates of IYSV shared a high degree of sequence identity (95 to 99%) with one another and to previously reported isolates. Phylogenetic analyses showed that with the exception of one isolate from central Oregon and one isolate from California, all the onion and shallot isolates from the western US clustered together. This cluster also included onion and lisianthus isolates from Japan. A second distinct cluster consisted of isolates from Australia (onion), Brazil (onion), Israel (lisianthus), Japan (alstroemeria), the Netherlands (iris) and Slovenia (leek). The IYSV isolates evaluated in this study appear to represent two distinct groups, one of which largely represents isolates from the western US. Understanding of the population structure of IYSV would potentially provide insights into the molecular epidemiology of this virus.     

Quantitative Analysis of Mycobacterial and Propionibacterial DNA in Lymph Nodes of Japanese and European Patients with Sarcoidosis

The cause(s) of sarcoidosis is unknown. Mycobacterium spp. are suspected in Europe and Propionibacterium spp. are suspected in Japan. The present international collaboration evaluated the possible etiological links between sarcoidosis and the suspected bacterial species. Formalin-fixed and paraffin-embedded sections of biopsy samples of lymph nodes, one from each of 108 patients with sarcoidosis and 65 patients with tuberculosis, together with 86 control samples, were collected from two institutes in Japan and three institutes in Italy, Germany, and England. Genomes of Propionibacterium acnes, Propionibacterium granulosum, Mycobacterium tuberculosis, Mycobacterium avium subsp. paratuberculosis, and Escherichia coli (as the control) were counted by quantitative real-time PCR. Either P. acnes or P. granulosum was found in all but two of the sarcoid samples. M. avium subsp. paratuberculosis was found in no sarcoid sample. M. tuberculosis was found in 0 to 9% of the sarcoid samples but in 65 to 100% of the tuberculosis samples. In sarcoid lymph nodes, the total numbers of genomes of P. acnes or P. granulosum were far more than those of M. tuberculosis. P. acnes or P. granulosum was found in 0 to 60% of the tuberculosis and control samples, but the total numbers of genomes of P. acnes or P. granulosum in such samples were less than those in sarcoid samples. Propionibacterium spp. are more likely than Mycobacteria spp. to be involved in the etiology of sarcoidosis, not only in Japanese but also in European patients with sarcoidosis.     

The HLA genetic constitution of the Bushmen (San)

The HLA-A, -B, and -C antigens of 290 and the DR antigens of 212 !Kung San individuals were characterized. The most frequent antigens were HLA-A30 gene frequency (gf) = 0.193, Bw58 (gf = 0.303), Cw6 (gf = 0.327), DR4 (gf = 0.273), and DQw3 (gf = 0.553). An unexpected finding was the low frequency of the classic African black antigen Bw42 (gf = 0.004). Marked differences as well as similarities in HLA gene frequencies were observed between the San and the South African Negroes, supporting the view that they had a common origin and were then separated for a very long time. During this period differences developed as a result of selective advantage in the Negroes following the pastoralist-agriculturalist way of life as opposed to the hunter-gatherer way of life. The picture is further complicated by the fact that gene flow, mostly from the San to the southern African Negroes, took place when they met again a few hundred years ago. The data also illustrate HLA haplotypes, linkage disequilibria, and four-locus haplotypes not previously seen in other human populations. The most frequent four-locus haplotype in the San, HLA-Aw43, Cw7, B7, DRw6 was also different from A30, Cw2, Bw42, DR3, the most common among the South African Negroes.     

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Implementation of HaemScreen, a workplace-based genetic screening program for hemochromatosis

There is debate as to whether community genetic screening for the mutation(s) causing hereditary hemochromatosis (HH) should be implemented, due to issues including disease penetrance, health economic outcomes, and concerns about community acceptance. Hemochromatosis is a common preventable iron overload disease, due in over 90% of cases to C282Y homozygosity in the HFE gene. We are, therefore, piloting C282Y screening to assess understanding of genetic information and screening acceptability in the workplace setting. In this program, HaemScreen, education was by oral or video presentation in a group setting. C282Y status was assessed by polymerase chain reaction (PCR) and melt-curve analysis on DNA obtained by cheek-brush sampling. Of eligible participants, 5.8% (1.5-15.8%) attended information and screening sessions, of whom 97.7% (5571 individuals) chose to be tested. Twenty-two C282Y (1 : 253) homozygotes were identified and offered clinical follow-up. There were 638 heterozygotes (1 : 8.7). The determinants for participation have been analyzed in terms of the principles outlined in the Health Belief Model. Widespread screening for HH is readily accepted in a workplace setting, and a one-to-many education program is effective. The level of participation varies greatly and the advertizing and session logistics should be adapted to the specific features of each workplace.