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Objective: To find the relationship between human leukocyte antigens (HLA) and cryoglobulin positivity in hepatitis C virus (HCV) infected individuals., Methods: Eligible individuals selected from pre and post renal transplant settings were divided into three groups. Group A (n = 301) consisted of normal controls, while group B (n = 200) comprised of pathological controls that were HCV antibody (anti-HCV) positive but negative for cryoglobulins. Group C comprised of 56 anti-HCV positive, cryoglobulin positive patients. HLA-A, -B and -DRB1 loci were typed by polymerase chain reaction (PCR) method and relationship between HLA antigens, anti-HCV status and cryoglobulinaemia was analyzed., Results: HLA-A*02, -B*57 and -DRB1*03 were more frequently found among group C members as compared to groups A and B. Only HLA-B* 57 occurrence reached statistical significance (14.3% versus 6% and 4%, corrected P-value = 0.045 and 0.012 and OR = 2.6 and 4 respectively) No differences in the distribution of HLA antigens were seen among healthy and pathological controls., Conclusion: The presence of HLA-B*57 confers susceptibility to cryoglobulinaemia in HCV infected patients in our population. HCV positive renal transplant recipients with these alleles should be monitored for cryoglobulin formation).

In the present study biosorption technique, the accumulation of metals by biomass was used for the removal of nickel from aqueous medium. The rice bran in its acid treated (H(3)PO(4)) form was used as a low cost sorbent. The adsorption characteristics of nickel on protonated rice bran were evaluated as a function of pH, biosorbent size, biosorbent dosage, initial concentration of nickel and time. Within the tested pH range (pH 1-7), the protonated rice bran displayed more resistance to pH variation, retaining up to 102 mg/g of the nickel binding capacity at pH 6. Meanwhile, at lower pH values the uptake capacity decreased. The % age removal of nickel was maximum at 0.25 g of biosorbent dose and 0.25 mm biosorbent size. At the optimal conditions, metal ion uptake was increased as the initial metal ion concentration increased up to 100mg/L. Kinetic and isotherm experiments were carried out at the optimal pH 6.0 for nickel. The metal removal rate was rapid, with 57% of the total adsorption taking place within 15-30 min. The Freundlich and Langmuir models were used to describe the uptake of nickel on protonated rice bran. The Langmuir and Freundlich model parameters were evaluated. The equilibrium adsorption data was better fitted to Langmuir adsorption isotherm model. The adsorption followed pseudo second-order kinetic model. The thermodynamic assessment of the metal ion-rice bran biomass system indicated the feasibility and spontaneous nature of the process and DeltaG degrees values were evaluated as ranging from -22.82 to -24.04 kJ/mol for nickel sorption. The order of magnitude of the DeltaG degrees values indicated an ion-exchange physiochemical sorption process.

Objective: To document the prevalence of Helicobacter pylori (H. pylori), Hepatitis A virus (HAV), Hepatitis C virus (HCV), Hepatitis E virus (HEV) antibodies and Hepatitis B virus surface antigen (HBsAg), in the pediatric age group of low socioeconomic urban communities of Karachi and to identify risk factors associated with these infections., Design: Cross-sectional survey., Place and Duration of Study: Three selected squatter settlements of Karachi during April 2002 to December 2004., Patients and Methods: Three hundred and eighty children, ages 5 months to 15 years were investigated. Venous blood samples were collected and questionnaire filled on sociodemographic characteristics (family income, number of dependents in the family, area of living, number of people per room per house, and number of children sharing bed with parents and siblings). Gastrointestinal symptoms were recorded. Anti-HAV IgG (Hepatitis A virus IgG antibody), anti-HCV (Hepatitis C virus antibody), anti-HEV (Hepatitis E antibodies) and HBsAg, were analyzed by enzyme immunoassays (EIAs). Samples were also screened for anti-HIV1/2 (human immunodeficiency virus 1 and 2 antibodies by EIA. IgG antibodies against H. pylori were detected by immunochromatography., Results: A correlation between increasing age and seroconversion was seen for hepatotropic viruses. At 14 years and above,100% of the children were found to be positive for anti-HAV, 26% for anti-HEV, and 1.4%, for anti-HCV while HBsAg was positive in 1.9%. H. pylori infection did not show a significant increase with age. Both anti-HAV and anti-H. pylori were present simultaneously in 30% of the population investigated., Conclusion: With age, increasing number of children acquired antibodies against hepatotropic viruses and H. pylori. Occurrence of HBsAg and anti-HEV at a later age suggests horizontal, rather than vertical transmission.

Background: Post-transplantation lymphoproliferative disorder (PTLD) after heart transplantation is a fatal complication, and standard treatment is either ineffective or too toxic. We have studied the incidence, clinical course, prognostic factors, and different treatment regimens pertaining to PTLD in 110 heart and 80 kidney transplant recipients., Methods: Information was abstracted from chart review of 110 heart transplant recipients and 80 kidney transplant recipients between January 1989 and October 2002. We report 15 patients with PTLD, 6 patients received a heart transplant and 9 patients received a renal transplant., Results: The overall incidence of PTLD was 8.9% (5.4% in heart and 13.7% in kidney transplant recipients). The average interval between transplantation and the diagnosis of PTLD in heart transplantation patients was 5.5 years, and their overall mean age was 44 years. The indications for transplantation were ischemic cardiomyopathy in 5 patients (1 patient received both heart and kidney transplants), glomerulonephritis in 6 patients, diabetes nephropathy in 2 patients, and polycystic disease in 2 patients. Six patients were diagnosed with early disease (<12 months), 7 with late onset (1 to 10 years), and 2 with very late onset (>10 years). Five patients had PTLD grade 2 (2 heart and 3 kidney transplants) and 10 patients had PTLD grade 3 (4 heart and 6 kidney transplants). Immunosuppressive treatment for PTLD patients consisted of cyclosporine, 73% (11/15); tacrolimus, 6.6% (1/15); prednisone, 100% (15/15); azathioprine, 80% (12/15); mycophenolate mofetil, 20% (3/15); murine monoclonal anti-human CD3 (OKT3), 7% (1/15); and anti-thymocyte globulin, 13% (2/15). PTLD developed in 11.5% of patients with primary Epstein-Barr virus infection and in 28.9% of patients with primary cytomegalovirus infection. Five patients received rituximab therapy, 5 had conventional chemotherapy, 3 had radiotherapy, 3 had reduction in immunosuppression, 2 had ganciclovir, 1 underwent surgery, and 1 patient died before receiving treatment. The mortality rate was 26.6%. The average interval between transplantation and the diagnosis of PTLD in heart transplant recipients was 5.5 years. The mortality rate was significantly higher in the control group than in the rituximab group., Conclusions: Caucasian race and male gender were independent risk factors for developing PTLD. Pretransplant cytomegalovirus seropositive status is a strong predictor of developing PTLD. Management of PTLD requires randomized controlled trials of various chemotherapeutic and antiviral drugs regimens. Treatment of PTLD with rituximab is a beneficial alternative with a favorable outcome. Patients in whom primary Epstein-Barr virus, cytomegalovirus, or hepatitis C infection develop after transplantation should be managed with heightened surveillance for the development of PTLD. Further randomized trials are needed to evaluate the efficacy of antiviral drugs, intravenous immunoglobulin, interferon, and prophylactic Epstein-Barr virus immunization strategies.

1. Non-HLA antibodies reactive against CLL and lymphoblast lines were detected by cytotoxicity in sera from 22 patients who had been transplanted with kidneys from HLA identical donors. 2. Whether these antibodies had been responsible for the rejection of the HLA identical grafts remain to be determined. 3. Among 71 patients who received HLA mismatched transplants, and had rejected their grafts, 65 (93%), formed antibodies to HLA or MICA antigens. The 5 patients who did not develop antibodies were shown to have antibodies against CLL and lymphoblast lines, suggesting that these grafts may have been rejected by non-HLA antibodies.

Background: Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal and cardiovascular consequences of living-related kidney donation., Methods: Data of living-related kidney donors who were regularly followed up in a dedicated clinic at the Sindh Institute of Urology and Transplantation between July 2000 and January 2004 was retrieved. They had donated their kidneys from 1986 onward. Data on weight, blood pressure, creatinine clearance, level of proteinuria, and new onset diabetes mellitus were analyzed., Results: Seven hundred and thirty-six donors with a mean age of 36+/-10.9 years (M:F 1.1:1) were evaluated. With a mean postnephrectomy duration of 3+/-3.2 years (range 6 months-18 years), the creatinine clearance fell to 87% of prenephrectomy values, and 49 (6.7%) had a creatinine clearance of less than 60 mL/ min. Hypertension developed in 76 (10.3%) donors, and 179 (24.3%) had proteinuria exceeding 150 mg/24 hr. Overweight (27.8%) and obese subjects (11.5%) had a higher prevalence of hypertension and new onset diabetes mellitus. One donor developed end-stage renal failure., Conclusion: Donor nephrectomy has minimal adverse effects on overall health status. Regular donor follow-up identifies at-risk populations and potentially modifiable factors.

Objective: Evaluation of fractional excretion of Sodium, Potassium and Magnesium as indicators of cyclosporine (CsA) toxicity in de-novo renal transplant recipients., Methods: A prospective study was conducted on 59 live related renal allograft recipients. Fractional excretion(FE) of sodium (Na+), potassium (K+) and magnesium (Mg2+) were calculated on day 1, 3, 5 and 10 post transplant. Graft dysfunctions were evaluated by colour-Doppler, CsA levels and renal biopsy. Normal ranges were determined on 30 healthy subjects., Results: The mean creatinine on day 1 was 3.1 +/- 1.3 mg/dl and declined to 1.6 +/- 1.2 on day 10. FE of Na+, K+ and Mg2+ were 12 +/- 9%, 34 +/- 20% and 13 +/- 10% respectively on day 1 and reduced to 2.2 +/- 2%, 11 +/- 14% and 11 +/- 14% on day 10. Of the 59 recipients, 38 (64%) had uneventful recovery (group A), 21(36%) had graft dysfunction [6 acute rejection (group B) and 15 either acute tubular necrosis or high CsA(group C)]. In group A, on day 1, FENa+, FEK+ and FEMg2+ were 5 +/- 4%, 24 +/- 12% and 6.6 +/- 3% respectively and these declined to 1.2 +/- 0.6%, 4.6 +/- 0.7% and 6 +/- 3% respectively on day 10. Compared to group A, group C had significantly high values on day 1, FENa+ 15 +/- 8%, FEK+ 36 +/- 24% and FEMg2+ 21 +/- 10% (p < 0.0001) and on day 10, FENa+ 3.7 +/- 2.7%, FEK+ 20 +/- 15% and FEMg2+ 15 +/- 8% (p < 0.05). In the group B, day 1 and day 10 levels were FENa+ 6 +/- 3%, FEK+ 26 +/- 13% and FEMg2+ 7 +/- 2.8% and FENa+ 1.2 +/- 0.7%, FEK+ 4.2 +/- 0.5%, FEMg2+ 7 +/- 4% respectively. CsA levels and AUC did not correlate with CsA toxicity., Conclusion: FE of magnesium is a useful marker of CsA toxicity independent of CsA blood levels. FE studies can supplement renal biopsy findings.

Objective: To evaluate the effect of cyclosporine (CSA) on serum magnesium and its fractional excretion in renal transplant recipients., Methods: A cross sectional comparative study on 50 live related renal transplant recipients on CSA therapy with serum creatinine < 2.0 mg/dl and 30 healthy controls. Serum creatinine, magnesium and its fractional excretion and CSA levels were monitored. Patients were followed at 6 months., Results: The mean serum creatinine in patients was 1.41 +/- 0.42 mg/dl, cyclosporine 210 +/- 66 ng/ml at a dose of 4.8 +/- 1.4 mg/kg/day. The serum magnesium was 1.77 +/- 0.32 mg/dl vs 1.98 +/- 0.17 mg/dl in healthy controls (p < 0.05). Fractional excretion was 5.05 +/- 2.53% in patients vs 2.8 +/- 1.05% in controls (p < 0.05). No correlation was found between CSA levels (100-400 ng/ml) and serum magnesium (r = 0.053) or FEMg% (r = 0.215). Of the 50 recipients 27 (54%) had FEMg% in the control range. At 6 months follow up no difference in CSA levels was found between recipients with FEMg% in the normal range vs those with FEMg > 5%. However, serum creatinine increased from 1.42 +/- 0.30 mg/dl to 1.68 +/- 0.82 mg/dl (p < 0.05)., Conclusion: CSA therapy lowers serum magnesium as compared to healthy controls and there is marked increase in FEMg% in 50% of the patients. Patients with FEMg > 5% developed renal function deterioration. FEMg percent can thus be a good follow up marker of CSA chronic toxicity in stable transplant recipients.

Organ transplantation started with organs donated by living subjects. Increasing demands brought cadaveric organ donation. The brain-death law, mandatory for this procedure, is prevalent in all countries involved in organ transplantation except Pakistan. Spain is the leading country in cadaveric organ donation (32.5 pmp). Despite the sources of living and cadaveric organs, both heart-beating and non-heart-beating, the gap between the demand and supply has widened. An example is the United States, where the numbers of patients on the waiting list for kidney transplantation have risen from 30,000 in 1988 to more than 116,000 in 2001. This has caused a resurgence in living donors all over the world. These can be related, unrelated, spousal, marginal, or ABO-incompatible donors. Family apprehensions, medical care costs, and nonexistent social security can be barriers to this form of organ donation. Unrelated organ donation can open the doors to commercialism. To make this process more successful, transplantation should be made reachable by all sectors of the population. This is possible when transplantation is taken to the public sector institutions and financed jointly by the government and community. To increase living organ donation especially in Asian countries, which face barriers of low literacy rates, ignorance, and cultural and religious beliefs, more efforts are needed. Public awareness and education play an important role. Appreciation and supporting the donors is necessary and justified. It is a noble act and should be recognized by offering job security, health insurance, and free education for the donor's children.

DNA methods have resulted in improved renal allograft survival rates in cadaveric renal transplantation. This paper describes the impact of DNA typing by PCRSSP on a living related renal transplant (LRRT) programme. It evaluates error rates in serology, acute rejections, graft function and survival rates between the two typing methods. Serological typing was done on CTS 120 antisera Class 1 and 60 antisera Class 2 and 72 antisera Terasaki Class1 and 72 antisera Class2 Antigens. Low resolution PCR-SSP typing was done by 24 primers for HLA A , 48 for HLA B and 24 for HLA DR. Of the 585 transplants, 159 (Group I) were serology based, 172 serology and PCR-SSP for HLA DR (Group II) and 254 on serology and PCR-SSP for HLA A and B and only PCR-SSP for HLA DR (Group III). Error rates in serology as compared to PCR-SSP were 24% for HLA A, 16% for HLA B and 35% for HLA DR. Acute rejection in Group I were 39% Group II 30% and Group III 26% (p 0.02). Graft function of serum creatinine<1.5 mg/dl at 1 year was found in 26% of Group I patients as compared to 48% of Group III (p<0.0001). One and three year graft survival was 93% and 87% for Group II as compared to 81% and 69% for Group I respectively (p 0.0001). Matching by this combination of serology and PCR-SSP is not only economical for a developing country but also improves graft survival by 12% at 1 and 18% at 3 years.

Purpose: We evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery., Materials and Methods: We retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively., Results: Of the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively., Conclusions: The use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex stones.

Healthcare in developing countries less funded than developed nations (0.8 to 4% vs. 10 to 15%, respectively), and must contend against approximately 1/3 of the population living below the poverty line ($1US/day), poor literacy (58% males/29% females), and less access to potable water and basic sanitation. Cultural and societal constraints combine with these economic obstacles to translate into poor transplantation activity. Donor shortage is a universal problem. Paid donation comprises 50% of all transplants in Pakistan. Post-transplant infections are a major problem in developing countries, with 15% developing tuberculosis, 30% cytomegalovirus, and nearly 50% bacterial infections. The solutions to these problems may seem simplistic: alleviate poverty, educate the general population, and expand the transplant programs in public sector hospitals where commerce is less likely to play a major role. The SIUT model of funding in a community-government partnership has increased the number of transplantations and patient and organ survival substantially. Over the last 15 years, it has operated by complete financial transparency, public audit and accountability. The scheme has proven effective and currently 110 transplants/year are performed, with free after care and immunosuppressive drugs. Confidence has been built in the community, with strong donations of money, equipment and medicines. We believe this model could be sustained in other developing nations.

Purpose: We evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan., Materials and Methods: This retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy., Results: There were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%)., Conclusions: The pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

We retrospectively analyzed the results of 75 living-related pediatric renal transplants performed at our center between January 1986 and December 1999. The major causes of end-stage renal disease (ESRD) were glomerulonephritis (26%) and nephrolithiasis (16%), while the etiology was unknown in 50%. The mean age of the recipients was 12 yr (range 6-17 yr) and that of the donors was 39 yr (range 20-65 yr). The majority (73%) of donors were parents. Eighty five per cent of donors were one-haplotype matched and the rest identical. Immunosuppression was based on a triple drug regimen. Thirty per cent of recipients were rapid metabolizers of cyclosporin A (CsA) (area under the curve [AUC]: < 6,000 ng/mL/h), while 16% were slow metabolizers (AUC: > 8,000 ng/mL/h). Forty three (57%) children encountered 59 rejection episodes, the majority of which (59%) were recorded in the first month post-transplant. Seventy-four per cent of the rejection episodes were steroid sensitive and the rest, except two, were resolved by therapy with antithymocyte globulin (ATG) or orthoclone thymocyte 3 (OKT3). After a mean follow-up of 37 months, 17 (22%) grafts had chronic rejection and 76% of these recipients had previously experienced acute rejection episodes. The overall infection rate was high, necessitating two hospital admissions/patient/year. The majority (53%) of the infections were bacterial. Urinary tract infections (UTIs) were seen in 17 (23%) recipients. Twelve of these had ESRD as a result of stone disease and eight grafts were lost because of UTIs. Eight per cent of recipients developed tuberculosis (TB), and extra-pulmonary lesions were seen in 50%. Surgical complications were encountered in eight patients. Free medication to all recipients and parental support ensured a compliance rate of 93%. Baseline growth deficit was seen in children of the two groups studied (the 6-12 yr and 13-17 yr age-groups), with Z-scores of - 2.39 and - 2.12, respectively. No growth catch-up was observed at 12 and 24 months in either group. Post-donation complications were seen most commonly in donors > 50 yr of age and included: proteinuria (> 300 mg/24 h, four patients), hypertension (three patients), and diabetes (one patient). Twenty-four grafts were lost, 54% as a result of immunological and the rest as a result of non-immunological causes, and 17 recipients died during the follow-up period. Infections were the main cause of patient and graft loss. Overall 1- and 5-yr graft and patient survival rates were 88% and 65%, and 90% and 75%, respectively.

The economic indicators of Pakistan show that the GNP is dollar 70 billion and foreign exchange reserves stand at dollar 8.0 billion and foreign debt at more than dollar 36 billion. Against this backdrop, the government is unlikely to provide state-of-the-art facilities for management of end-stage organ failure. The unequal distribution of wealth leaves more than 40% below the poverty line. Economic solutions are based on temporary fixes where foreign aid and loans keeps the government machinery operational. Many of the basic health measures such as immunization are also foreign funded. Under such a scenario, local philanthropy has come to play a vital role. SIUT developed a model based on self-help--a model based on a community-government partnership, where the doctor plays the pivotal role and the beneficiary is the patient. SIUT acquired funds by developing a community-government partnership. The government fulfills about 40% of the total budget and the rest comes from the community as donations. The scheme has been extremely successful in providing free medical care and renal support to thousands of patients. It has been sustained over the past 15 years through complete transparency, public audit and accountability. These confidence-building means stimulate the community to come forward and donate money, equipment and medicines. The goal of transplantation is to provide organs to all with long-term survival of the graft. The emerging challenges to achieve this goal and efforts that can be made to increase and sustain transplant activity in Pakistan require a concerted effort on the part of the government, society and the medical profession.

Two hundred and twenty ureteric stones in 214 patients were fragmented intracorporeally by pneumatic lithotripsy under general/regional anaesthesia in a day care set-up. Patients were followed-up weekly and retreatment was done at 4 weeks where necessary. Majority (77%) of patients were in the age group 21-40 years with a male to female ratio of 2:1. Stone location was 86% in the lower third, 11% in the middle and 3% in the upper third ureter. Size of stones was less than 6 mm in 14%, 7-12 mm in 67% and more than 20 mm in 4% cases. All 81% stones of < 12 mm were fragmented in one treatment session while single treatment rate for stones 13-18 mm was 85% and 44% for more than 20 mm size. Overall non-fragmentation rate was 0.9%. Stone free state at four weeks was 95%. Complications were observed in 8.6% cases which included urosepsis, haematuria and perforations. Infrared spectroscopy (IR) in 45 stones showed majority (64%) to be composed of calcium oxalate. Our experience shows that PL is a safe and effective means of performing intracorporeal lithotripsy for both large and hard ureteric stones.

Objectives: To study the treatment of ureteric stones by laser lithotripsy (LL) and pneumatic lithotripsy (PL), and to evaluate the results of the two treatment modalities to assess effectiveness, complications and cost benefits., Patients and Methods: Between January 1993 and February 1994 200 ureteric stones in 194 patients were fragmented intracorporeally, 48 by LL and 152 by PL. The ages of the patients ranged from 31 to 40 years with a male to female ratio of 2:1. All procedures were performed under general/regional anaesthetic in a day-care set-up. Patients were followed at weekly intervals. Re-treatment was carried out at 4 weeks where necessary., Results: The majority of the stones treated (84%) were in the lower third of the ureter, 69% measured 7-12 mm in diameter, and 61% were composed of calcium oxalate. Ninety-three per cent of the stones were fragmented in one treatment session. The overall stone-free status at 4 weeks was 95% for PL and 84% for LL. The non-fragmentation rate was 10% for LL and 1% for PL. Post-treatment complications were encountered in 8% of the patients treated by LL and 7% by PL., Conclusions: Our experience shows that PL and LL both provide a safe and effective means of performing intracorporeal lithotripsy for smaller ureteric stones. However, PL is more effective in fragmenting larger and harder stones. Moreover, PL is more user-friendly and highly cost-effective compared with LL.

Acid phosphatase (AP) reaction is a specific cytochemical marker for T-cell lymphoblastic leukaemia (T-ALL). Twenty six cases of ALL were diagnosed as T-ALL employing cytochemical profiles including AP and sheep red blood cell rosettes. Three district patterns of AP reaction were observed. On one end of the spectrum, 100% of the positive blasts showed the classical dot-like reaction while on the other 100% showed a scattered reaction. Between the two a mixed pattern was observed with 30-80% of the positive blasts showing the dot-like reaction while the rest showed scattered pattern. Dot-like pattern showed L1 morphology, high counts and low SRBC rosettes while scattered showed L2 morphology, low counts and high SRBC rosettes. The pattern observed in our series differs from the dot-like reaction observed in T-ALL in the western series. We recommend that this pattern must be borne in mind when employing AP reaction for T-ALL diagnosis (JPMA 42: 151, 1992).

Most laboratories in Pakistan use expensive imported clinical chemistry reagent kits resulting in high cost/test to the patients. To reduce these costs, reagents were prepared from basic chemicals, substrates and enzymes imported from Sigma Chemical Company U.K. This reduced the cost/test by up to 500% in some reagents. The quality of these reagents was tested by Wellcome External, Q.C. Locally prepared reagents were comparable to or better than commercial reagents systems in terms of accuracy and precision. This paper describes the preparations according to I.F.C.C., costs and quality control of some of the reagents i.e., glucose, calcium, bilirubin, albumin, total protein, urea, ALT, AST and LDH and their comparisons with equivalent commercial kits.

Thyroid hormone levels were estimated in fifty patients with hepatitis B. In acute phase, T3 was raised in 10% and T4 in 60%. This rise was directly proportional to the transaminases levels. Twenty cases were also studied in the recovery phase where thyroid hormones returned to within normal limits. This rise of T3 and T4 in acute phase is attributed to increased thyroxin binding capacity due to release of thyroid binding globulin into circulation from necrosing hepatocytes.

To determine the frequency of giardiasis in patients undergoing upper G.I. endoscopy for dyspepsia and other upper G.I. disorders, duodenal aspirates were collected in 200 patients and simultaneous duodenal biopsies in 163 patients. Nine percent aspirates and 1.8% duodenal biopsies showed Giardia lamblia trophozoites. Giardia as a cause of dyspepsia should be considered in patients with negative endoscopy and in those who remain symptomatic inspite of adequate treatment for known upper G.I. disorders.

A double layer technique which requires an underlayer of peripheral blood leucocytes, in addition to phytohaemmagglutinin (PHA) in the overlayer, to obtain good T-lymphocyte colony formation, was used to assess the effect of two inhibitors of mitochondrial protein synthesis, chloramphenicol and ethidium bromide. A significant inhibition of the colony growth of peripheral blood T lymphocytes was observed when either of the drugs was incorporated in the underlayer. The inhibitory effect was always smaller (c. 50%) when the drugs were added to the overlayer. These findings point to the existence of a T-lymphocyte colony stimulating factor(s), released mainly by the leucocyte-rich underlayer and essential for T-colony formation, the production of which is inhibited by these mitochonrial inhibitors.