Performance of serum adenosine deaminase in measuring disease activity in rheumatoid arthritis patients

Background

Numerous tools to assess activity of rheumatoid arthritis (RA) are available to use. For any marker to be a more appropriate indicator of disease activity, it should be more authentic to the patho-physiologic basis of the disease.

Significant elevations of serum lipase not caused by pancreatitis: a systematic review

Background

Many authors advocate lipase as the preferred serological test for the diagnosis of pancreatitis and a cut-off level of three or more times the upper limit of normal (ULN) is often quoted. The literature contains no systematic review that explores alternative causes of a lipase level over three times as high as the ULN. Such a review was therefore the objective of this study.

Methods

The EMBASE and MEDLINE databases (1985 to August 2013) were searched for all eligible articles. Predetermined data were extracted and independently analysed by two reviewers.

Results

In total, data from 58 studies were included in the final analysis. The following causes other than pancreatitis of lipase levels exceeding three times the ULN were found: reduced clearance of lipase caused by renal impairment or macrolipase formation; other hepatobiliary, gastroduodenal, intestinal and neoplastic causes; critical illness, including neurosurgical pathology; alternative pancreatic diagnoses, such as non-pathological pancreatic hyperenzymaemia, and miscellaneous causes such as diabetes, drugs and infections.

Conclusions

A series of differential diagnoses for significant serum lipase elevations (i.e. exceeding three times the ULN) has been provided by this study. Clinicians should utilize this knowledge in the interpretation and management of patients who have lipase levels over three times as high as the ULN, remaining vigilant for an alternative diagnosis to pancreatitis. The medical officer should be aware of the possibility of incorrect diagnosis in the asymptomatic patient.     

Therapeutic effect of mesenchymal stem cells on experimentally induced hypertensive cardiomyopathy in adult albino rats

Hypertensive heart diseases affect millions of people worldwide. We aimed to investigate the hypertensive left ventricular histological changes and assess the effectiveness of bone marrow derived mesenchymal stem cells (MSCs) therapy in the treatment of hypertensive cardiomyopathy. Adult male albino rats were assigned into two groups: group I (control), group II (Experimental) subdivided into subgroup IIa (hypertensive) and subgroup IIb (stem cell therapy). Left ventricles (LVs) were processed for light and electron microscope. Mallory’s trichrome and immunostaining for caspase-3 and desmin were carried out. Hypertension caused left ventricular histological and immunohistochemical changes that had been effectively improved by MSCs therapy.     

Accuracy of diagnosis and relationship with quality of emergency medicine training program

An indicator for emergency room performance is the ability to establish the correct diagnosis within the emergency room over the years. The authors chose to examine the non-congruence of Emergency Room diagnoses to that established after hospital stay for three selected years. A total of 8488 records were reviewed and all disparate diagnosis were recorded and categorized. Retrospective chart reviews were done from July 2008 to February 2009 at the Aga Khan University Hospital, Karachi. A substantial reduction in the percentage of disparate diagnoses was seen over the years from 41% in the initial year to 14% in the last year evaluated. It was concluded that over the years there has been an improvement in the reliability of Emergency Room diagnoses at the Aga Khan University Hospital, Karachi.     

A comparison of the presence of Theileria ovis by PCR amplification of their SSU rRNA gene in small ruminants from two provinces of Pakistan

ObjectiveTo compare the presence of Theileria ovis in small ruminants from two provinces of Pakistan and to determine the risk factors associated with the spread of theileriosis.MethodsIn present study, a total of 210 blood samples were collected from sheep (n=99) and goats (n=111) from 5 sampling sites in Punjab (Dera Ghazi Khan, Layyah, Multan and Rahim Yar Khan districts) and Khyber Pukhtoon Khwa (district Kohat) provinces, in Pakistan, from randomly selected herds. Data on the characteristics of the animals (species, gender, age, tick presence or absence, prior treatment for babesiosis) and the herd (location, size, species of animals, dogs associated with the herds, tick burden of dogs associated with the herds) was collected through questionnaires.ResultsTwelve blood samples (6% of total), 11 from district Kohat, produced the 520 base pairs DNA fragment specific for small subunit ribosomal RNA (ssu rRNA) gene of Theileria ovis, by PCR amplification, of which 11 were sheep and 1 was goat indicating that sheep are more significantly (P=0.001) prone to this parasite. On the other hand parasite was detected only in 2 out of 210 samples (1%) by blood smear screening confirming PCR as the reliable detection tool.ConclusionsPCR is more sensitive and reliable diagnostic tool for detection of Theileria sp. as compared to blood smear screening. Incidence of Theileria ovis is very high in Khyber Pukhtoon Khwa as compared to Punjab province. It was also observed that presence of ticks on animals was the only significant risk factor associated with the theileriosis in small ruminants.     

The possible role of the age of the human host in determining the localization of hydatid cysts

Cystic hydatid disease or cystic echinococcosis (CE) is a cyclozoonotic infection distributed world-wide. The morbidity attributable to the infection depends on the size of the cyst(s) and the organ(s) involved. The cysts are most commonly found in the liver and lungs but certain locations have been reported to be more prevalent in children and/or young adults than in older subjects. In order to identify the relationship, if any, between the age of the patient and the site of involvement, the age and cyst distribution of 92 cases of CE were analysed. Lung, brain, spinal and orbital hydatid cysts were more commonly seen in younger patients whereas other sites were preferentially involved in older patients. The factors that determine the final localization of the cysts are discussed. It is concluded that age somehow alters the host-parasite relationship and thus affects the organ distribution of the cysts.     

Review of the use of cephalosporins in children with anaphylactic reactions from penicillins

OBJECTIVE:

It is a widely accepted practice that children with anaphylaxis from penicillins should avoid cephalosporins. The purpose of the present study was to determine whether there is evidence in the literature to support this practice.

DATA SOURCES:

MEDLINE, EMBASE, Toxline, International Pharmaceutical Abstracts and PubMed were used to search the literature published from 1966 to 2001. The Canadian Medical Protective Association, Health Canada and the Boston Collaborative Drug Surveillance Program were also contacted to determine whether there were any unpublished cases of cross-reactivity between penicillins and cephalosporins.

DATA EXTRACTION:

Cases describing the use of cephalosporins in adults and children with positive penicillin skin tests or anaphylaxis from penicillin were evaluated. Case reports of anaphylaxis from cephalosporins in paediatric patients were identified.

DATA SYNTHESIS:

There have been five reported cases of serious reactions from cephalosporins in patients with a history of anaphylaxis from penicillins. All cases occurred in adults; three developed anaphylaxis from the older, first-generation cephalosporins, cephalothin and cephaloridine; one developed anaphylaxis from cefamandole; and one developed anaphylaxis from cefaclor. There have been 12 other published reports of anaphylaxis from cephalosporins in adults with a history of penicillin allergy or a positive penicillin skin test, but with no history of anaphylaxis from penicillin. In seven studies, in which a total of 158 patients with positive penicillin skin tests were administered cephalosporins, seven had apparent immunoglobulin E-mediated reactions when they were given a cephalosporin. When the class of cephalosporin was able to be determined, none of the reports of reactions from cephalosporins in patients with allergies to penicillin involved third-generation cephalosporins. There have been 13 case reports of anaphylaxis from cephalosporins in paediatric patients.

CONCLUSION:

There are no published case reports of anaphylaxis from cephalosporins in children with anaphylaxis from penicillin, and there are only a small number of such reports in adults. Anaphylaxis from cephalosporins appears to be incredibly rare in children. There is minimal evidence in the literature to support the avoidance of cephalosporins in children with anaphylaxis from penicillins.Key Words: Anaphylaxis, Antibiotic allergy, Antibiotic hypersensitivity, Cephalosporins, Cross-reactivity, Drug allergy, Drug hypersensitivity, PenicillinA common problem in paediatrics is determining whether a cephalosporin can be used in a child with a history of a serious reaction from a penicillin, and whether a penicillin can be administered to a child with a history of a serious reaction from a cephalosporin. In many cases, such patients are prescribed antibiotics that are less effective, more toxic, have a broader spectrum or are more expensive than the drug of choice for their condition.Diagnostic tests for antibiotic allergies are limited and are standardized only for penicillin.When penicillin is metabolized, the beta-lactam ring opens to form a penicilloyl derivative that, when bound to serum and tissue proteins, accounts for more than 90% of immunologically active penicillin metabolites (the major determinants). However, about 16% of allergic reactions to penicillin involve multiple, different antigens that result from further penicillin metabolism. These antigens are referred to as minor determinants (1). In patients who have a history of penicillin allergy but negative skin test results using major and minor determinants, studies have shown that the chance of a serious allergic reaction to penicillin is negligible (1). Skin testing for cephalosporin allergy is sometimes performed, but is not standardized because the antigenic determinants of a serious allergic reaction have not been established. Standard teaching is that patients who have had possible anaphylaxis from penicillin should be given cephalosporins only with extreme caution, because their risk of developing anaphylaxis from cephalosporins is increased (2). Penicillins have a beta-lactam ring attached to a thialazolidine ring with one side chain, while cephalosporins have a beta-lactam ring attached to a dihydrothiazine ring with two side chains (1) (Figure ​(Figure1).1). Because of the similar structures, there is a theoretical risk of cross-reactivity between penicillins and cephalosporins.Open in a separate windowFigure 1Comparison of chemical structure of penicillins and cephalosporins. R Side chainSoon after cephalosporins were introduced, there were reports of anaphylaxis in patients who were given cephalosporins and who had also experienced anaphylaxis from penicillin. Furthermore, during the initial clinical trials with first-generation cephalosporins and cefamandole, 8.1% of patients with a history of allergy to a penicillin had a possible allergy to a cephalosporin, compared with 4.5% of patients with no such history (3). However, in those initial trials, no attempt was made to ensure that the reaction to the penicillin or to the cephalosporin was truly allergic. The purpose of the present study was to determine whether there is further evidence in the literature to support the avoidance of cephalosporins in children with suspected penicillin allergies. If the risk of cross-reactivity between penicillins and cephalosporins is low in the adult population, the same is probably true for the paediatric population. Therefore, the incidence of case reports of anaphylaxis from cephalosporins in adults or children with anaphylaxis from penicillin or a positive penicillin skin test was studied. The results of cephalosporin challenge in patients with positive penicillin skin tests were also reviewed. If it is exceedingly rare for children to develop anaphylaxis from cephalosporins, it may not be necessary to avoid their use in children who are allergic to penicillins. Therefore, the total number of published case reports of anaphylaxis from cephalosporins in all children was also researched.