Human genetic variation studies and HLA class II loci

Human leucocyte antigen (HLA) loci widely known for their role in generation of immune responses by encoding cell-surface heterodimers are often considered to be effective for the purpose of reconstructing human phylogenies due to high degree of polymorphism and less recombination. In the present study, we have made an attempt to study HLA class II loci (DRB1, DQA1 and DQB1) in inferring phylogenetic relationship based on both phylogenetic and haplotype approach. In the phylogenetic approach, the compiled database of 19 populations got segregated and finely resolved in three basal clusters with very high bootstrap values corresponding to four geo-ethnic groups of Africans, Orientals, Americans and Caucasians. Maximum- likelihood phylogram has placed North Indian Hindus alongside other Caucasian populations. Haplotype analysis revealed high range of haplotype diversity with nearly 144 observed haplotypes. The haplotype distribution suggested that numbers of Caucasian-specific haplotypes are frequently found among north Indian Hindus. Our results indicate that if the property of less recombination is explored to assign extended haplotypes, followed by strong interpretation based on more logistic statistical model, then there is a high possibility that HLA class II loci can infer exact and accurate phylogenetic assessments as revealed by mtDNA and Y-chromosome markers.

Use of rK39 for diagnosis of post kala-azar dermal leishmaniasis in Nepal

A recently developed nitrocellulose-based dipstick test, rK39, has been widely used for the diagnosis of kala-azar. In this study, we evaluated its use for the diagnosis of post kala-azar dermal leishmaniasis (PKDL). We also investigated the time taken by patients to develop PKDL after apparent cure of kala-azar (visceral leishmaniasis, VL) and the time taken by patients to come to the hospital after the appearance of symptoms of PKDL. A majority of patients developed the disease within three years after the apparent cure of kala-azar (KA). A majority of patients sought treatment within five years after the onset of PKDL. The amastigotes of Leishmania donovani bodies (LDBs) were demonstrated in 70, 20, and 20% of slit-skin smears (SSS) prepared, respectively, from nodular, papular, and macular forms. The presence of highest density (6+) LDBs in the SSS of 20% of nodular PKDL patients indicated that they may have acted as reservoir in the community. Other reservoirs are not known in Nepal. Only 8% cases were detected by aldehyde test. Although this test is obsolete it is still used in rural parts of Nepal. The dipstick (rK39) was 96% sensitive and 100% specific to diagnose PKDL. Its positive predictive value, negative predictive value, and diagnostic efficacy were 100, 91, and 97% respectively. Due to the advantage of cost compared with the direct agglutination test (DAT), and being easy to use and store in field conditions, rK39 is a good tool to diagnose PKDL in rural situations. All the PKDL patients were cured of the disease after treatment by SAG.

Survival and treatment morbidity with therapeutic lymphadenectomy for regional nodal metastases from melanoma

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Background: Therapeutic lymphadenectomy (TL) is potentially curative therapy for clinically palpable nodal metastatic melanoma. However, TL is associated with significant morbidity and a dismal prognosis. Methods: Review of the melanoma database identified 275 patients who underwent TL. Patient, tumor, and treatment-related variables associated with recurrence and overall survival were analyzed. Results: The study group comprised of 63% males with a nodal basin distribution of 47% axilla, 35% groin and 18% neck. Median age, number of positive lymph nodes and size of the largest lymph node were 51 years 2 nodes and 2.5 cm respectively. Median survival was 27.4 months (77%, 55% and 34% at 1, 2 and 5-years respectively). Regional recurrence at the lymphadenectomy site occurred in 76 (28%) patients. Distant metastases developed in 67 (88%) patients with and 126 (63%) without regional recurrence. On multivariate analysis, the most powerful predictor of both survival and regional recurrence was lymph node ratio (LNR- number of positive nodes/total dissected nodes). Median survival for LNR <0.13 was 39 months versus 19 months for ≥0.13 (p = 0.005). Older age and male sex were also predictive of a decreased survival. Treatment-related morbidity was rare and included lymphedema (12%), wound complications (3%) and nerve injury (1%). Conclusion: The overall survival and acceptable morbidity justifies TL for clinically positive nodal metastatic melanoma. LNR is predictive of survival and regional recurrence following TL. Due to significant distant and regional failure rates, in addition to systemic adjuvant therapy these patients may benefit from radiation therapy.

No significant financial relationships to disclose.

T-cell epitope mapping of ORF2 and ORF3 proteins of human hepatitis E virus

Little data are available on cellular immune responses during infection with hepatitis E virus (HEV). We therefore mapped CD4 T-cell epitopes in open reading frame (ORF)2 and ORF3 proteins of HEV using lymphocyte proliferation assays and overlapping peptide libraries. Proliferation of peripheral blood mononuclear cells from 40 patients with acute hepatitis E and 21 healthy controls with recombinant HEV ORF2 protein or pools of overlapping HEV ORF2/ORF3 peptides was measured. HLA-DQB1 and HLA-DRB1 alleles were also determined. Mononuclear cells from patients with hepatitis E more often showed significant proliferation on stimulation with recombinant ORF2 protein than controls (32/40 vs 7/21), and had higher median (range) stimulation indices [2.6 (0.9-15.2) vs 1.3 (0.6-12.9)]. Peptide pools corresponding to amino acids 73-156, 289-372, 361-444 and 505-588 of HEV ORF2 protein were associated with significant proliferation. Individual peptides in these pools did not show a clear pattern of stimulation. HEV ORF3 peptide pools did not induce proliferative responses. Lymphocyte proliferation in response to the peptide pool corresponding to amino acids 289-372 of HEV ORF2 protein was associated with presence of HLA-DRB1 allele 010X. These data on mapping of T-cell epitopes in HEV proteins may prove useful for designing HEV vaccines and for studying the immunopathogenesis of hepatitis E.

Meningomylocele: An update

Therapy-resistant overactivity of detrusor or small capacity and poor compliance, will usually need to be treated by bladder augmentation. Ileal or colonic patches are used frequently for augmenting the bladder, with either intestinal segment appearing to be equally useful. Stomach is rarely used because of the associated complications, but it is the only available intestinal segment for patients with impaired renal function. Concerns regarding long-term effects of associated metabolic acidosis, including abnormalities in linear growth and bone metabolism are misplaced. Ureterocystoplasty offers an attractive urothelium-preserving alternative, avoiding the metabolic complications, mucus production and cancer risk of heterotopic epithelium associated with enterocystoplasty. Though ideal for patients with dilated ureter and nonfunctioning kidney, in patients with functioning kidney it carries added risks associated with transuretero-ureterostomy, mainly obstruction. Ureteral dilatation in meningomyelocele patients is avoidable with proper follow-up and treatment. Therefore they rarely should be candidates for this operation. Alternative urothelium-preserving techniques, such as auto augmentation and seromuscular cystoplasty, have not proven to be as successful as standard augmentation with intestinal segment. Work is in progress on various bioengineering techniques to culture and combine bladder cells in tissue culture for regeneration. Early efforts are exciting, but preliminary.

Chemokine receptor 5 (CCR5) deletion polymorphism in North Indian patients with coronary artery disease

BACKGROUND

Polymorphisms in genes coding for chemokine receptors, CCR2 and CCR5 have been studied as genetic markers of coronary artery disease (CAD). V64Ile polymorphism in CCR2 has been implicated in the manifestation of myocardial infarction in different populations, but data on association of the CCR5 deletion variant in etiology of CAD are conflicting. In the present study we tested genetic association between CCR5 Delta32 polymorphism and CAD among North Indians (Uttar Pradesh).

METHODS

Two hundred angiographically proven patients with coronary artery disease and two hundred age, sex and ethnically matched controls were genotyped for CCR5 Delta32 polymorphism by polymerase chain reaction. Genotype/allele frequencies were compared in patients and controls using the chi-square test.

RESULTS

The frequency of the heterozygote genotype in the population, including both patient and control group, was 3% and the frequency of the mutant allele Delta32 was 1.5%. CAD patients had a three times higher (4.6% vs. 1.5%) frequency of heterozygote genotype but the differences were statistically not significant. Association analysis did not achieve statistical significance, though odds ratio of 3.13 was observed for heterozygote genotype.

CONCLUSIONS

The allele frequency of the CCR5 Delta32 polymorphism in CAD patients is 2.25% and 0.75% among controls but the differences were not significant. Overall this fits well with the pattern of CCR5 Delta32 allele frequency in Indian subcontinent where it varies from 1 to 3%. The heterozygote (+/ Delta32) genotype does not seem to have any protective role against development of CAD in this population. In fact, North Indian CAD had a higher frequency of CCR5 Delta32 allele suggesting a possible susceptibility trend (odds ratio 3.08, CI 0.83-11.46, chi-square 2.167, NS).

Chimerism monitoring following allogeneic hematopoietic stem cell transplantation

Information regarding the chimeric status of hematopoietic stem cell transplantation (HSCT) recipients is of great significance when comparing different conditioning and prophylactic therapies. In recent years, short tandem repeats/variable number tandem repeats (STRs/VNTRs) have emerged as the best tool for chimerism monitoring. However, the polymorphisms of STR/VNTR markers vary within and between ethnic groups. The issue is further complicated in a heterogeneous population such as occurs in the Indian subcontinent. In the present study, we attempted to devise a robust scheme to identify a set of polymorphic STRs/VNTRs most suitable for chimerism evaluation in north Indian HCST recipients. At first, we did genotyping of 11 STR and one VNTR in 1000 randomly chosen north Indian individuals to quantify different diversity parameters. Resulting data indicated that ApoB3'HVR, FES, VWA, D3S1358 and D16S310 were most polymorphic loci with the average heterozygosity being 0.756+/-0.17. Furthermore, all markers were genotyped in 77 HLA-matched donor-recipient pairs to evaluate the informativeness in differentiating donor's and recipient's cells. A panel of seven markers (ApoB3HVR-D3S1358-HUM-THO1-VWF-1-D16S310-FES-VWA) differentiated 98.70% of donor-recipient pairs. This set of markers also successfully monitored the graft status in 14 HSCT cases during multiple time points following HSCT. The results were compared to the commercially available AmpF/STR SGM Plus multiplex PCR kit (Applied Biosystems, Foster City, CA, USA). Our findings established that the panel of seven markers we identified was more cost-effective and informative.

Association of carotid intima-media thickness with left main coronary artery disease

BACKGROUND

Previous studies have shown that carotid intima-media thickness correlates well with the presence and extent of coronary artery disease. This study was conducted to determine whether it could reliably predict the presence of left main coronary artery disease.

METHODS

Common carotid intima-media thickness was measured in 50 patients with angiographically proven significant (> or =50%stenosis) left main coronary artery disease and in another 50 age- and sex-matched patients with coronary artery disease without the involvement of the left main coronary artery. Measurements of the carotid intima-media thickness were made on the far wall 1 cm from the distal end of the common carotid artery bilaterally, and the average and the greater of the two values thus obtained for each patient were used for analysis. Plaques were not included in the measurement of carotid intima-media thickness.

RESULTS

The average and greater of the two values were significantly higher in patients with left main coronary artery disease as compared to those without it (average intima-media thickness: 0.926 +/- 0.12 vs. 0.78 9 +/- 0.16 mm; p< 0.001; greater intima-media thickness: 0.994 +/- 0.13 vs. 0.844 +/- 0.20 mm; p< 0.001). The cut-off values of 0.81 mm for the average carotid intima-media thickness and 0.87 mm for the greater carotid intima-media thickness were found to have optimum sensitivity (92% and 90%, respectively) and specificity (60% and 64%, respectively) for the detection of left main coronary artery disease. A higher cut-off value of 1.0 mm increased specificity to 92% and 84%, respectively, for the average and greater thicknesses, but sensitivity decreased markedly.

CONCLUSIONS

There is a significant association between increased carotid intima-media thickness and the presence of left main coronary artery disease. The measurement of carotid intima-media thickness can be used with reasonably good sensitivity and specificity for the detection of left main coronary artery disease in patients who are undergoing evaluation for suspectedcoronary artery disease.

Nephron sparing surgery: A single institution experience

Objective:

To report our experience in managing various benign and malignant renal tumors with nephron-sparing surgery.

Materials and Methods:

Records of patients who underwent nephron-sparing surgery (NSS) either through open or laparoscopic approach between May 1997 and June 2006 at our institution were reviewed. Patient and tumor-related characteristics, treatment modality and complications were noted.

Results:

There were 26 patients (29 renal units), including three with bilateral lesions who underwent nephron-sparing surgery. Mean age at surgery was 47.0 years (range 16-67 years). Mean tumor size was 4.7 cm (range 2-7.5 cm). Mean warm ischemia time was 41 min and 32.5 min, operative time 158 min and 186 min and blood loss 200ml and 85 ml in open (n=24) and laparoscopic approach (n=2) respectively. Complications were seen in five (19.2%) patients of whom two had postoperative bleeding requiring nephrectomy in one and angioembolization in another. One patient with persistent urinary leak required intervention. Local wound infection in one patient and incisional hernia in another were surgically managed. Histopathological profile revealed 13 (44.8%) benign lesions which included angiomyolipoma (eight), simple cyst (two), cortical adenoma (one), metanephric adenoma (one) and myelolipoma (one). The remaining 16 (55.2%) malignant lesions included renal cell carcinoma (15) and metastatic adenocarcinoma (one). At a mean follow-up of 38.6 months (range 1-91) no patient had local recurrence or distant metastasis. Cancer-specific survival was 100% and overall survival was 92.3%.

Conclusions:

Nephron-sparing surgery is a safe and effective alternative to nephrectomy in both benign and malignant lesions of the kidney.

Cortical localization of external urethral sphincter activation by transcranial electrical stimulation

PURPOSE

Repetitive transcranial electrical stimulation (rTES) was used to activate descending output to the external urethral sphincter muscle.

METHODS

Motor evoked potentials (MEPs) were recorded from external urethral sphincter (EUS), and anterior tibial (TA) muscles following high voltage rTES in 9 consecutive patients undergoing spine surgery. Anesthesia was achieved by continuous propofol/narcotic infusion without paralytic agents. Anodal cortical stimulation was delivered at C4/C3, C2/C1, and Cz/Fz locations in each patient. Latency and amplitude of the MEP was measured and compared for each bipolar stimulation montage.

RESULTS

The mean latency was 20.24 +/- 1.3 msec. for Cz/Fz; 20.19 +/- 1.1 msec. for C4/C3 and 20.19 +/- 1.1 msec. for C2/C1. Statistical analysis showed no significant difference in latency between the three sites (F(2,15) = 0.004; p > 0.05). The mean amplitude was 37.14 +/- 24.3 microV for Cz/Fz; 113.33 +/- 100.6 microV for C4/C3; and 85 +/- 73.9 microV for C2/C1. A significant difference between the amplitudes at three sites was observed (F(2,8) = 5.2; p < 0.05). The amplitude at C4/C3 was significantly greater than amplitude at CzlFz (t (8) = 3.08; p < 0.05), but data did not give enough evidence to believe that difference between amplitudes for site C4/C3 & C2/C1 was significant (p > 0.05).

CONCLUSIONS

This study shows that the intraoperative MEP monitoring of the EUS is a feasible method. Furthermore, activation of descending axonal outflow to the EUS muscle is best achieved by cortical stimulation directed from C4 to C3 or C2 to C1 points.

Does the evidence support the use of concurrent chemoradiotherapy as a standard in the management of locally advanced cancer of the cervix, especially in developing countries?

Locally advanced cancer of the cervix (FIGO stages III and IVA) is one of the most common malignancies in developing countries. Conventional treatment has been a judicious combination of external radiotherapy and intracavitary brachytherapy. However, prompted by the results of five randomised-controlled trials (RCTs) published in close succession, The National Cancer Institute (NCI) alert in 1999, and two meta-analyses, the management of cancer of the cervix has gradually changed. Concurrent chemoradiotherapy with cisplatin alone, or in combination, is gradually being favoured for the treatment of cancer of the cervix. This overview examines whether the published evidence is sufficiently adequate to justify the use of chemoradiotherapy using cisplatin as standard care in the management of cancer of the cervix, especially in developing countries, where most women present with locally advanced cancer of the cervix. A critical review of the various phase III randomised trials and meta-analyses indicates that, although chemoradiotherapy could be a standard form of treatment for early cancer of the cervix, its role in advanced stages needs further exploration before this could be incorporated into routine clinical care.

Primary bladder dermoid: a case report and review of the literature

Bladder dermoid is a rare presentation. Diagnosis of this case was made cystoscopically and confirmed histopathologically. Complete excision was possible endoscopically. This is the 3rd case report from the Indian and Asian subcontinent.

Dissolution testing of marketed rifampicin containing fixed dose combination formulations using a new discriminative media: a post marketing retrospective study

Currently recommended compendial dissolution methods for quality control of orally administered solid dosage forms of rifampicin containing formulations are not found to be able to forecast the in vivo performance. A recently proposed dissolution method of 0.01 N HCl at 50 rpm using paddle apparatus for screening was found to be more appropriate and able to predict the in vivo performance of those formulations. The objective of this investigation was to validate the new method of dissolution testing for solid dosage forms of rifampicin containing formulations using a basket apparatus and to compare it with the frequently recommended pharmacopeial method. In the present study the newly proposed dissolution condition (0.01 N HCl) was validated using six formulations of two, three and four drug combinations from two different manufacturers by basket method and compared with the widely recommended compendial medium. In this investigation, the appropriateness of the proposed methodology was confirmed by the dissolution results of the two FDC formulations (a two-drug and a four-drug combinations) that had previously passed the bioequivalence tests. It was found that the recommended dissolution medium of 0.01 N HCl can be used for screening of rifampicin containing formulations using both paddle and basket dissolution apparatus at 50 rpm and 100 rpm, respectively.

Effect of placental-extract gel and cream on non-healing wounds

OBJECTIVE

To compare the effects of topical placental-extract gel and cream in the treatment of chronic non-healing wounds with regard to wound healing and discomfort during dressing change.

METHODS

A sample of 120 patients attending the wound clinic at University Hospital, Varanasi, India, with wounds of more than six weeks' duration were enrolled into the study. They were alternately allocated to group A (topical application of placental-extract gel) or group B (placental-extract cream). Wound biopsy was performed, and swab culture and sensitivity were taken. Wound size was measured, and visual analogue scale (VAS) scores for pain and discomfort at dressing change were recorded at weekly follow-up in both groups. Biopsy was repeated after two weeks of treatment and sent for histopathological examination for assessment of angiogenesis in 25 cases from each group.

RESULTS

One hundred patients completed the study. More than 50% wound healing was observed after eight weeks in 72% of group A patients and 74% of group B patients (p = 0.75). Microscopic angiogenesis grading system (MAGS) scores were similar in both groups (not statistically significant, p = 0.92). The VAS scores for pain and discomfort were lower in group B (statistically significant, p < 0.02).

CONCLUSION

Placental-extract gel and cream are both effective topical agents for chronic non-healing wounds. However, there is less pain and discomfort during dressing change with the placental-extract cream, which we thus recommend for topical application in chronic non-healing wounds.

Antitumor activity of a synthetic agonist of TLR9 in preclinical lung cancer models

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Background: Synthetic agonists of TLR9 induce potent Th1-type innate and adaptive immune responses. In the present study, we have studied antitumor activity of a synthetic agonist of TLR9 referred to as immune modulatory oligonucleotide (IMO) in lung cancer models either alone or in combination with chemotherapeutic agents. Methods: Two different models are evaluated. In one model, mice implanted peritoneally with 3LL-C75 lung carcinoma cells were administered with IMO or PBS once in every two days for six times for evaluating antitumor activity of IMO alone. In a second model, to evaluate combination treatment of IMO with Gemcitabine or cyclophosphamide, mice bearing subcutaneously implanted 3LL tumor were administered with peritumoral injections of IMO and i.p. injections of Gemcitabine or cyclophosphamide. Results and Conclusions: Administration of IMO to mice bearing 3LL-C75 lung carcinoma inhibited tumor growth. Tumor free mice from this study failed to grow tumor when rechallenged with 3LL-C75 lung carcinoma cells, suggesting tumor bearing mice administered with IMO developed memory responses for the same tumor. Further more, naïve mice adoptively transferred with splenocytes obtained from mice that remained tumor free from the above treatment group failed to grow tumor to a rechallenge with 3LL-C75 tumor cells. The co-administration of IMO with chemotherapeutic agents, Gemcitabine and cyclophosphamide resulted in enhanced antitumor effects in 3LL lung cancer model. The present studies show potent antitumor activity of IMO when administered alone and in combination with Gemcitabine and cyclophosphamide in preclinical lung cancer models.

[Table: see text]