Decreased CD10 Expression in the Bone Marrow Neutrophils of HIV Positive Patients

Background: HIV-1 infection is associated with various quantitative and qualitative changes in haemopoietic cells. Clear distinction between primary myelodysplastic syndrome (MDS) and secondary dysplasia may not always be possible. Adjunctive analyses used in the diagnosis of MDS include cytogenetics and flow cytometry (FCM). Much focus has been placed on establishing FCM guidelines aiding in the diagnosis of MDS, and to distinguish this condition from secondary dysplastic changes. One of the parameters often cited is the CD10 expression on the granulocyte population, as this marker denotes granulocytic maturation.  Aims: To determine the expression level of CD10 on granulocytes in HIV positive patients.  Methods: In total, 117 HIV-1 positive and 29 HIV-1 negative patients were included in this study. Bone marrow aspirate samples were evaluated in terms of morphological abnormality as well as CD10 expression on the granulocytic population.  Results: The average CD10 expression among the HIV-1 positive patients were markedly reduced, at 18.4%, and 113 patients (96.6%) of these patients had expression levels below 50%. Discussion: Disease conditions causing secondary dysplasia, especially HIV-1 infection, is associated with a marked reduction in CD10 expression on the granulocyte population independent from the presence of myelodysplastic features. This marker is therefore of doubtful significance as a diagnostic tool in distinguishing between primary and secondary dysplasia

Fluid management in diabetic-acidosis — Ringer’s lactate versus normal saline : a randomized controlled trial

OBJECTIVE: To determine if Ringer’s lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA). DESIGN: Parallel double blind randomized controlled trial. METHODS: Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and 47.2, a blood glucose of >13 mmol/l and had urine ketones of 52+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment. RESULTS: Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer’s lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer’s lactate groups. The hazard ratio (Ringer’s compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937–3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378–988) (IQR: 435–1095 min) and for Ringer’s lactate solution 540 min (95% CI 184–896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer’s lactate solution group (410 min, IQR: 240–540) than the 0.9% sodium chloride solution group (300 min, IQR: 235–420, P = 0.044). No difference could be demonstrated between the Ringer’s lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758) CONCLUSION: This study failed to indicate benefit from using Ringer’s lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer’s lactate solution.University of Pretoria, Research Development Programmehttp://qjmed.oxfordjournals.org

A thyroid-related endocrine emergency in pregnancy

A 28-year-old woman presented with a thyroid storm while pregnant. Thyroid storm in pregnancy is a rare, life threatening endocrinological emergency. The diagnosis and management can be challenging. Even with early aggressive therapy the maternal mortality is still high and adverse effects on the pregnancy and fetus are common

Capillary β – Hydroxybuterate testing in patients with diabetic ketoacidosis

Introduction: Diabetic ketoacidosis (DKA) is a major life-threatening complication of both type 1 and type 2 diabetes. Insulin treatment for diabetic ketoacidosis is guided using the changes in blood glucose levels, blood gas analysis and urine ketone measurement. Evidence for the use of capillary β -Hydroxybuterate in the monitoring of therapy for diabetic ketoacidosis is not sufficient, and needs to be evaluated in adult patients. The present study was undertaken to determine if quantitative measurement of β- Hydroxybuterate can simplify the management of diabetic ketoacidosis, and if the correction of hyperketonaemia could predict resolution of diabetic ketoacidosis. Methods: A prospective, descriptive study, evaluating measurement of capillary β-Hydroxybuterate in patients with diabetic ketoacidosis was performed. The relationship between capillary β-Hydroxybuterate levels and values of pH was assessed during treatment and as a possible end point evaluation for intravenous insulin therapy. Patients were recruited at two hospitals over a 24 month period. All patients were treated according to a standard DKA management protocol. Data was collected until resolution of DKA and all patients were followed up until discharge. Results: 54 patients were included in the analysis. The mean age of included patients was 36.4 years (SD 10.32). The relationship between capillary ketones, (β - hydroxybuterate) and pH was explored using non- linear mixed models, fitted with restricted cubic splines. The results from this analysis suggest a complex, time dependant association between pH and measured β - Hydroxybuterate. Assessing if β-Hydroxybuterate could predict normalisation of pH, was done with logistic regression (with subject-specific intercept and slope) including restricted cubic splines. From this model it is evident that the cut-off values for resolution, using capillary ketones, is definitely time dependent. Conclusion: This study did not show to a clinically significant, applicable relationship between capillary β-Hydroxybuterate levels and values of pH during treatment of DKA. A single cut-off value for DKA resolution could not be determined, suggesting that β-Hydroxybuterate capillary measurement alone cannot be used as a possible end point evaluation for intravenous insulin therapy.Dissertation (MSc)--University of Pretoria, 2013.lk2014School of Health Systems and Public Health (SHSPH)MScUnrestricte

An unusual presentation of a catecholamine producing tumour

In patients with pheochromocytomas it is well known that different factors can precipitate an acute pheochromocytoma crisis. Our patient presented with a vesicular skin rash and respiratory distress suggestive of disseminated varicella zoster for which he was treated with steroids and acyclovir. Two days later hypertension was noted for the first time

The correlation between C-reactive protein and toxic granulation of neutrophils in the peripheral blood

BACKGROUND: During inflammation, the serum concentrations of granulocyte colony-stimulating factor (G-CSF), plasma interleukin-6 (IL-6), and C-reactive protein (CRP) increase. A positive correlation between CRP and the percentages of neutrophils exhibiting toxic granulation during inflammation has been demonstrated, and that the fluctuations of CRP and toxic granulation of neutrophils were similar. OBJECTIVES: We studied whether grading of toxic granulated neutrophils can be used as a surrogate marker for infection or inflammation, and also be an easier method than previously described methods. MATERIALS AND METHODS: We graded 357 consecutive peripheral blood slides from patients on whom a full blood count with differential count and CRP level was performed, according to intensity of toxic granulation in the neutrophil population, according to a newly proposed grading system. RESULTS: The CRP range was between 1 and 530.3 mg/l. The results confirm the association between a rise in CRP and progressive intensity of toxic granulation in neutrophils in peripheral blood. Kruskal-Wallis equality of populations rank test showed a statistically significant difference between the graded categories (p=0.0001). The Trend test was also statistically significant (p=0.000). CONCLUSION: The proposed system can be applied to patients with inflammatory or infectious conditions, where grading of toxic granulation of neutrophils can possibly be used as a surrogate marker to assess infection or inflammation and their response to treatment. It may be of particular use in cases where traditional infectious or inflammatory markers cannot be used, owing to inherent problems associated with the respective conditions

Rationale, design, and baseline characteristics in Evaluation of LIXisenatide in Acute Coronary Syndrome, a long-term cardiovascular end point trial of lixisenatide versus placebo

BACKGROUND: Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Furthermore, patients with T2DM and acute coronary syndrome (ACS) have a particularly high risk of CV events. The glucagon-like peptide 1 receptor agonist, lixisenatide, improves glycemia, but its effects on CV events have not been thoroughly evaluated. METHODS: ELIXA (www.clinicaltrials.gov no. NCT01147250) is a randomized, double-blind, placebo-controlled, parallel-group, multicenter study of lixisenatide in patients with T2DM and a recent ACS event. The primary aim is to evaluate the effects of lixisenatide on CV morbidity and mortality in a population at high CV risk. The primary efficacy end point is a composite of time to CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. Data are systematically collected for safety outcomes, including hypoglycemia, pancreatitis, and malignancy. RESULTS: Enrollment began in July 2010 and ended in August 2013; 6,068 patients from 49 countries were randomized. Of these, 69% are men and 75% are white; at baseline, the mean ± SD age was 60.3 ± 9.7 years, body mass index was 30.2 ± 5.7 kg/m(2), and duration of T2DM was 9.3 ± 8.2 years. The qualifying ACS was a myocardial infarction in 83% and unstable angina in 17%. The study will continue until the positive adjudication of the protocol-specified number of primary CV events. CONCLUSION: ELIXA will be the first trial to report the safety and efficacy of a glucagon-like peptide 1 receptor agonist in people with T2DM and high CV event risk