Sparing the hippocampus and the hypothalamic- pituitary region during whole brain radiotherapy: a volumetric modulated arc therapy planning study

BACKGROUND

Feasibility testing of a simultaneous sparing approach of hippocampus, hypothalamus and pituitary gland in patients undergoing whole-brain radiotherapy (WBRT) with and without a concomitant boost to metastatic sites.

INTRODUCTION

Cognitive impairment and hormonal dysfunction are common side effects of cranial radiotherapy. A reduced dose application to the patho-physiologically involved functional brain areas, i.e. hippocampus, hypothalamus and pituitary gland, could reduce these common side effects. While hippocampal sparing is already a common practice to improve cognitive outcome, technical experience of additional combined sparing of the hypothalamus/pituitary gland (HT-P) is insufficient.

METHODS

Twenty patients were included in the planning study. In 11 patients, a total dose of 36 Gy of WBRT (2 Gy per fraction) plus a simultaneous integrated boost (SIB) of 9 Gy (0.5 Gy per fraction, total dose: 45 Gy) to the brain metastases was applied. In 9 patients, prophylactic cranial irradiation (PCI) was simulated with a total dose of 30 Gy (2 Gy per fraction). In both patient cohorts, a sparing approach of the hippocampus and the HT-P area was simulated during WBRT. For all treatment plans, volumetric modulated arc therapy (VMAT) was used. Quality assurance included assessment of homogeneity, conformality and target coverage.

RESULTS

The mean dose to the hippocampus and HT-P region was limited to less than 50% of the prescribed dose to the planning target volume (PTV) in all treatment plans. Dose homogeneity (HI) of the target volume was satisfying (median HI = 0.16 for WBRT+SIB and 0.1 for PCI) and target coverage (conformation number, CN) was not compromised (median CN = 0.82 for SIB and 0.86 for PCI).

CONCLUSION

Simultaneous dose reduction to the hippocampus and the HT-P area did not compromise the PTV coverage in patients undergoing WBRT+SIB or PCI using VMAT. While the feasibility of the presented approach is promising, prospective neurologic, endocrine outcome and safety studies are required.

FRI0252 HIGH EARLY MORTALITY IN IDIOPATHIC INFLAMMATORY MYOPATHIES: RESULTS FROM INCEPTION COHORT AT A TERTIARY CARE CENTER IN NORTHERN INDIA

Background:

The idiopathic inflammatory myopathies (IIM) lead to significant morbidity and mortality. Understanding short term outcomes is the 1st step towards addressing risk factors for poor prognosis.

Objectives:

To assess the response to therapy, disease and treatment related morbidity and mortality in an inception cohort of IIM and determine the predictors of early mortality.

Methods:

Sixty-nine patients with a physician diagnosis of IIM as per 2017 ACR/EULAR classification criteria were recruited into an inception cohort from Dec 2017 to Nov 2019. Their follow-up data was recorded from June 2019 to December 2019.

Clinical, laboratory and outcome variables were recorded as delineated in Figure 1A. Baseline characteristics were compared between deaths versus survivors, responders versus non-responders and those with and without major infections.

Results are expressed as median (IQR). SPSS, v23, IBM 2010 was used for statistical analysis.

Results:

Of the 69 (54 female and 15 male) patients of median age 40 (23-51) and disease duration 3 (IQR 1-6) months, Dermatomyositis (DM) was the most common subset 26 (37.6%) (Fig, 1B). Myositis Specific and Myositis Associated Antibody (MSA and MAA) were positive in 30 (43.4%) and 11 (17%) respectively (Fig. 1 C).

Forty-eight patients followed-up over 10 (IQR 4.5-13) months accounting for 473 patient years, of which 8 (16.6%) suffered mortality and three PM were reclassified (Fig, 1B). Four (10%) had minimal, 3 (7.5%) had moderate and 33 (82.5%) had a major clinical response (Fig. 2A) with treatment. Eight (20%) of the 40 who survived had a relapse and 13 (32.5%) had steroid related complications. Eleven (27.5%) had at least 1 infection and it correlated with duration of steroid use (p-0.009, RR 0.78, 0.6-0.9) but not the cumulative dose of steroid (p-0.147)

Duration of symptoms prior to treatment, subtype of myositis, MSA or presence of ILD did not predict the short-term response.

6-month survival was 83.3% (Figure 2B). Rapidly progressive ILD was the most common cause of death followed closely by malignancy and infection (n=3, 37.5%)(Table 1). Diagnosis of Cancer associated myositis (OR 6.1), positive anti-MDA5 (OR 5.8) and a negative ANA (OR 5.8) were predictors of early mortality.

Table 1.

Clinical details of the 8 patients who died on follow up.

Case No.Diagn-osisGen-derAge at disease onset (y)Duration of disease in monthsMSAMAACause of deathPlace of death1DMM574Anti-MDA 5Anti- Ro 52RP ILDHospital2DMM5312NegativeNegativeDisseminated TuberculosisHospital3DMF686Anti-TIF 1 yNegativeMalignancyHome4JDMF141NegativeNegativeRP ILDHospital5OMF431NegativeAnti-PM/SclUnclearHome6OMF456Anti-Jo 1Anti- Ro 52LRTIHome7DMM801NegativeAnti- Ro 52MalignancyHome8DMF313Anti-MDA 5NegativeRP ILDHospital

DM- Dermatomyositis, JM- Juvenile Dermatomyositis, OM- Overlap Myositis, M- Male, F- Female, MSA- Myositis Specific Autoantibodies, MAA- Myositis Associated Autoantibodies, RP ILD- Rapidly Progressive Interstitial Lung Disease, LRTI- Lower Respiratory Tract Infection

Conclusion:

Indian patients with IIM suffer high early mortality attributable to RP ILD, cancer and infections.

Positive anti-MDA 5 and a negative ANA predict poor survival.

Acknowledgments:

Muscle Autoantibody testing was funded by APLAR.

Disclosure of Interests:

None declared

SAT0515 COMPLEX HYPERMOBILITY EHLERS-DANLOS SYNDROME (HEDS): MAPPING THE PATIENT’S JOURNEY OVER 40 MONTHS IN A TERTIARY REFERRAL CENTRE

Background:

Ehlers-Danlos Syndromes are heritable connective tissue disorders.They are multisystemic and patients can present with several symptoms such as joint pain and instability, visceral and autonomic dysfunction, as well as significant psychosocial sequela. Managing this cohort of young patients is usually challenging as many patients present late due to delayed diagnosis, often with several complications, problems with mobility and opioid use. Furthermore, there is often a prolonged lack of coordinated healthcare and access to social care services. A recent parliamentary debate in the U.K. highlighted that hEDS services are excluded from specialist Rheumatology commissioning services. In order to ascertain the relevance and utility of specialist services in this population, we conducted this study.

Objectives:

The objective of this study was to map the patient experience following a referral to the specialist clinic in order to assess the need for an integrated, multidisciplinary approach to treating patients with hypermobility EDS.

Methods:

We retrospectively reviewed the records of 50 patients with the diagnosis of hypermobility EDS who were seen in a specialist hypermobility clinic at University College Hospital UCLH between January 2016 and March 2016. Relevant data was collected regarding their medical care in our hospital up to October 2019.

Results:

The median age was 37 (range 21-59). We had 10 males and 40 females. The diagnosis of hypermobility EDS was based on the 1997 criteria as these patients were seen prior to the 2017 classification. Overall, the study yielded 6 key themes: 1. All patients experienced chronic pain, with 36% reporting use of opioids for pain management. 2. Patients were referred to multiple medical specialities within the same hospital trust, (22% patients were referred to ≥5 specialities). 3. Patients required a high number of follow up appointments (28% of patients required ≥20 follow-up visits). 4. Failed discharges were common; patients were often referred back to the Rheumatology Clinic despite being discharged to primary care. 5. Patients had a significant number of comorbidities, reflected by polypharmacy. (36% of patients were prescribed ≥5 medications). 6. Disability was high (20% of patients reported severe mobility problems).

Conclusion:

This study shows that patients with hEDS referred to UCLH have significant levels of disability, opioids use and polypharmacy especially for a relatively young population of patients. They need a complex interdisciplinary approach in a timely manner. In order to minimise delays and allow earlier diagnosis and intervention, we have recently adopted a multidisciplinary team approach, including pain specialists, rheumatologists, psychologists, physiotherapists, nurse specialists, urogynaecologists and neurogastroenterologists. This allows more coordinated and efficient care and incorporates an EDS-specific pain management programme. Specialised services for complex hEDS cases should be established and adequately resourced. Moreover, it would be cost effective to commission a patient-centred “one-stop-shop” service, where patients, who often travel from long distances with severe disabilities, can be seen by multiple specialities in a single visit.

References:

[1]Bennett, S., Walsh, N., Moss, T. and Palmer, S. (2019). Understanding the psychosocial impact of joint hypermobility syndrome and Ehlers–Danlos syndrome hypermobility type: a qualitative interview study. Disability and Rehabilitation, pp.1-10. Healthwatch Calderdale. (2019). Hypermobility Syndromes Project - Healthwatch Calderdale.

[2]Tinkle, B., Castori, M., Berglund, B., Cohen, H., Grahame, R., Kazkaz, H. and Levy, H. (2017). Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), pp.48-69.

Disclosure of Interests:

None declared

OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Background:

A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.

Objectives:

This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.

Methods:

Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.

Results:

One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.

Conclusion:

Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.

References:

[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036

Disclosure of Interests:

None declared

OP0200 PATIENTS WITH HYPERMOBILITY RELATED DISORDERS HAVE A SIGNIFICANT NUMBER OF ORTHOPAEDIC INTERVENTIONS ON MULTIPLE SITES AND AT A YOUNG AGE: DATA FROM A TERTIARY REFERRAL CENTRE

Background:

Mechanisms of pain associated with joint hypermobility are poorly understood and include nociceptive pain from structural joint changes along with soft tissue injuries linked to impaired proprioception; central sensitisation associated with chronic pain and muscle weakness alongside deconditioning. Anxiety and depression are also thought to play a role in patients presenting with pain and hypermobility. We have observed an increase in the rate of orthopaedic surgical procedures undertaken in patients attending the hypermobility clinics compared to those attending the general rheumatology and chronic pain clinics. There is limited published data regarding orthopaedic interventions in patients with hypermobility related disorders especially those with confirmed genetic mutations.

Objectives:

We aimed to evaluate the characteristics of patients in our hypermobility cohort focusing on those who had received prior surgical intervention in order to understand the underlying mechanism behind their presentations.

Methods:

A retrospective review of medical records was conducted of patients attending a hypermobility clinic at our tertiary referral centre, University College London Hospital, between January 2018 and December 2018.

Results:

There were 350 patients (300 females, 50 males) with a mean age of 36 years (range 18-71 years). 63% had a diagnosis of Hypermobility Spectrum Disorder or Hypermobility Syndrome and 37% had a type of Ehlers-Danlos Syndromes (EDS) (hypermobile, classical, vascular or other rare type). 46 patients (13%) had documented genetic mutations. 83 patients (24%) had undergone orthopaedic interventions including 9 who had EDS with confirmed genetic mutations. 54% of patients who had surgical intervention were under the age of 40. The total number of surgical procedures in the cohort was 227 (equating to 0.6485 interventions per patient). Of those requiring operative intervention, the average number of interventions per patient was 2.73. One third of patients had surgery on two or more joint groups, including 8 patients (2%) who had surgery in four or more joint groups. Knees (24%) and hips (23%) were the most common sites for operative intervention with 9% having surgery on their shoulders. 29% of pts had significant hypermobility with a Beighton score of 7 and above but there was no correlation between Beighton score and number of surgical procedures. Only 2% of cases were referred from an orthopaedic team thereby excluding a referral bias.

Conclusion:

Patients with hypermobility related disorders have a significant number of orthopaedic surgical procedures on multiple sites and at a young age, with indication of mechanical pathology playing an important role in their symptoms. The Beighton score does not appear to be a reliable predictor of surgical intervention. This is not surprising given that the score only covers 5 joint areas and excludes common surgical sites such as the hips and shoulders. Early diagnosis and a holistic non-operative approach combining physiotherapy and chronic pain management is essential to reduce the need for multiple surgical procedures.

References:

[1]Chopra P, Tinkle B, Hamonet C, Brock I, Gompel A, Bulbena A, et al. Pain management in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet [Internet]. 2017 [cited 2020 Jan 27];175(1):212–9. Available from:http://www.ncbi.nlm.nih.gov/pubmed/28186390

[2]Shirley ED, Demaio M, Bodurtha J. Ehlers-danlos syndrome in orthopaedics: etiology, diagnosis, and treatment implications. Sports Health [Internet]. 2012 Sep [cited 2019 Jan 30];4(5):394–403. Available from:http://www.ncbi.nlm.nih.gov/pubmed/23016112

Disclosure of Interests:

None declared

Are hypothalamic- pituitary (HP) axis deficiencies after whole brain radiotherapy (WBRT) of relevance for adult cancer patients? - a systematic review of the literature

Background

Cranial radiotherapy (cRT) can induce hormonal deficiencies as a consequence of significant doses to the hypothalamic-pituitary (HP) axis. In contrast to profound endocrinological follow-up data from survivors of childhood cancer treated with cRT, little knowledge exists for adult cancer patients.

Methods

A systematic search of the literature was conducted using the PubMed database and the Cochrane library offering the basis for our debate of the relevance of HP axis impairment after cRT in adult cancer patients. Against the background of potential relevance for patients receiving whole brain radiotherapy (WBRT), a particular focus was set on the temporal onset of hypopituitarism and the radiation dose to the HP axis.

Results

Twenty-eight original papers with a total of 1728 patients met the inclusion criteria. Radiation doses to the HP area ranged from 4 to 97 Gray (Gy). Hypopituitarism incidences ranged from 20 to 93% for adult patients with nasopharyngeal cancer or non-pituitary brain tumors. No study focused particularly on hypopituitarism after WBRT. The onset of hypopituitarism occurred as early as within the first year following cRT (range: 3 months to 25.6 years). However, since most studies started follow-up evaluation only several years after cRT, early onset of hypopituitarism might have gone unnoticed.

Conclusion

Hypopituitarism occurs frequently after cRT in adult cancer patients. Despite the general conception that it develops only after several years, onset of endocrine sequelae can occur within the first year after cRT without a clear threshold. This finding is worth debating particularly in respect of treatment options for patients with brain metastases and favorable survival prognoses.

Transdermal Microneedles-A Materials Perspective

Transdermal drug delivery is an emerging field in the pharmaceutical remit compared with conventional methods (oral and parenteral). Microneedle (MN)-based devices have gained significant interest as a strategy to overcome the skin's formidable barrier: the stratum corneum. This approach provides a less invasive, more efficient, patient friendly method of drug delivery with the ability to incorporate various therapeutic agents including macromolecules (proteins and peptides), anti-cancer agents and other hydrophilic and hydrophobic compounds. This short review attempts to assess the various materials involved in the fabrication of MNs as well as incorporation of other excipients to improve drug delivery for novel medical devices. The focus will be on polymers, metals and other inorganic materials utilised for MN drug delivery, as well as their application, limitations and future work to be carried out.

Successful transplantation of transfected enriched buffalo (Bubalus bubalis) spermatogonial stem cells to homologous recipients

Genetic modification of spermatogonial stem cells (SSCs) is an alternative method to pronuclear microinjection and somatic cell nuclear transfer for transgenesis in large animals. In the present study, we optimized the process of homologous SSC transplantation in the water buffalo (Bubalus bubalis) using transfected enriched SSCs generated by a non-viral transfection approach. Firstly, the SSC enrichment efficiencies of extracellular matrix components viz. collagen, gelatin, and Datura stramonium agglutinin (DSA) lectin were determined either individually or in combination with Percoll density gradient centrifugation. The highest enrichment was achieved after differential plating with DSA lectin followed by Percoll density gradient centrifugation. Nucleofection showed greater transfection efficiency (68.55 ± 4.56%, P < 0.05) for enriched SSCs in comparison to fugene HD (6.7 ± 0.25%) and lipofectamine 3000 (15.57 ± 0.74%). The transfected enriched SSCs were transplanted into buffalo males under the ultrasound guidance and testis was removed by castration after 7-8 weeks of transplantation. Persistence and localization of donor cells within recipient seminiferous tubules was confirmed using fluorescent microscopy. Further confirmation was done by flow cytometric evaluation of GFP expressing cells among those isolated from two-step enzymatic digestion of recipient testicular parenchyma. In conclusion, we demonstrated for the first time, generation of buffalo transfected enriched SSCs and their successful homologous transplantation in buffaloes. This study represents the first step towards genetic modifications in buffaloes using SSC transplantation technique.

Comparative analysis of buffalo (Bubalus bubalis) non-transgenic and transgenic embryos containing human insulin gene, produced by SCNT

Somatic cell nuclear transfer (SCNT), using transgenic donor cells, is a highly efficient method for producing transgenic embryos. We compared the developmental competence, quality and gene expression of transgenic embryos produced by Hand-made cloning from buffalo fetal fibroblasts (BFFs) containing human insulin gene, with non-transgenic embryos produced from BFFs (Controls). The expression vector (pAcISUBC), constructed by inserting human insulin gene between DNA fragments containing mammary gland-specific buffalo β-lactoglobulin (buBLG) promoter and terminator buBLG 3'UTR regions into pAcGFP-N1 vector, was used for obtaining the 11 kb insert for transfection of BFFs by nucleofection. Presence of the transgene in embryos was confirmed by examining GFP expression by RT-PCR and immunofluorescence. The blastocyst rate was lower (P < 0.05) for transgenic embryos than for controls (35.7 ± 1.8% vs 48.7 ± 2.4%). The apoptotic index was higher (P < 0.05) for transgenic than for control blastocysts which, in turn, was higher (P < 0.05) than for IVF counterparts (6.9 ± 0.9, 3.8 ± 0.5 and 1.8 ± 0.3, respectively). The total cell number was similar for transgenic and non-transgenic blastocysts (143.2 ± 17.0 and 137.2 ± 7.6, respectively). The expression level of pro-apoptotic genes BAX and BID but not that of CASP3 and CASP9, and cell cycle check point control-related gene P53 was higher (P < 0.05), and that of development- (IGF-1R and G6PD) and pluripotency-related gene NANOG was lower (P < 0.05) in transgenic than in control embryos. The expression level of epigenetic-related genes DNMT1, DNMT3a and HDAC1 and pluripotency-related gene OCT4 was similar in the two groups. The expression level of BAX, BID, CASP9, P53, DNMT1 and DNMT3a was higher (P < 0.05) and that of OCT4, NANOG IGF-1R and G6PD was lower (P < 0.05) in cloned transgenic than in IVF blastocysts whereas, that of CASP3 and HDAC1 was similar between the two groups. In conclusion, these results suggest that transgenic embryos produced by SCNT have lower developmental competence and quality, and altered gene expression compared to non-transgenic embryos.

Electrodiagnostic evidence of suprascapular nerve recovery after decompression

INTRODUCTION

The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing.

METHODS

Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration.

RESULTS

Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression.

DISCUSSION

Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.

Resident Accuracy of Musculoskeletal Palpation With Ultrasound Verification

OBJECTIVES

The purpose of this observational study was to determine the accuracy of musculoskeletal palpation of the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon verified by ultrasound imaging among physical medicine and rehabilitation residents.

METHODS

Eighteen physical medicine and rehabilitation resident physicians at a single specialized institution were asked to identify the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon on 2 separate standardized patient models during a single data collection. They were asked to place a paper clip flat on the surface of the skin parallel to the specified anatomic structure. A high-frequency linear array transducer was used to identify whether the paper clip was correctly placed over the structures and to measure the distance from the intended structure.

RESULTS

The accuracy rates for palpation of the medial joint line, medial patellar tendon, and posterior tibialis tendon in both models were 14%, 36%, and 28%, respectively, for all levels of residents. Accuracy rates for all of the structures by level of education were 19%, 29%, and 31% for postgraduate years 2, 3, and 4. Median confidence scores were 3.75, 3.5, and 2 for the medial joint line, medial patellar tendon, and posterior tibialis tendon.

CONCLUSIONS

This study highlights the level of inaccuracy of musculoskeletal palpation skills and draws further attention to an area of much-needed improvement in our musculoskeletal residency training programs. Ultrasound imaging is an effective noninvasive method for providing swift feedback to medical students and residents and thereby reduce the instances of inaccurate musculoskeletal palpation.

Practical consensus recommendation on when to do BRCA testing

BRCA-mutation associated breast cancer and to future cancer risks and sensitivity to systemic therapies. Now that rapid genetic testing for BRCA1 and BRCA2 mutations is available, BRCA mutation status can be considered when making treatment and prevention decisions for BRCA testing, BRCA mutation carriers with breast cancer. Expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

Xpert(®) MTB/RIF for improved case detection of extra-pulmonary TB in a tertiary care setting in urban India

SETTING

Department of microbiology at a tertiary care hospital, Mumbai, India.

OBJECTIVE

To determine 1) the sensitivity and specificity of the Xpert(®) MTB/RIF assay in comparison with microscopy and culture in extra-pulmonary tuberculosis (EPTB), and 2) the number of additional cases of EPTB and rifampicin (RMP) resistance detected using this assay.

DESIGN

The study was conducted from July 2013 to April 2015. All consecutive patients with clinically suspected EPTB referred for microscopic examination to the Department of Microbiology that were sufficient in specimen volume were included in the study.

RESULTS

Of the 728 specimens included in the study, respectively 5.5%, 23.5% and 20.9% were positive on smear, culture and Xpert. Compared to culture, Xpert had a sensitivity of 84.2% (95%CI 81.4-86.6) and specificity of 98.2% (95%CI 90-104). All specimens with high and medium load on assay were positive on culture; 28 (18.4%) specimens were RMP-resistant and 124 (81.6%) were Xpert-susceptible. No additional RMP-resistant cases were detected using Xpert as compared to phenotypic drug susceptibility testing.

CONCLUSION

The ability of the Xpert assay to rapidly detect a significantly greater number of bacteriologically confirmed EPTB cases, including RMP-resistant cases, makes it an important diagnostic tool in a TB-endemic country.

209 PRODUCTION OF BUFFALO (BUBALUS BUBALIS) EMBRYOS CONTAINING HUMAN LYSOZYME GENE

Lysozyme is a ubiquitous enzyme found in all major taxa of living organisms with a diverse role in human and animal health. It plays an important role as a nonspecific immune factor and anti-inflammatory factor and is a part of the innate immune system. Research on the expression of recombinant human lysozyme is, thus, potentially valuable to the dairy industry. Therefore, the present study was carried out to observe the developmental competence and quality of cloned embryos containing the human lysozyme gene. Primary fetal fibroblast cells were obtained from a slaughterhouse-derived fetus. The initial passage cells were transfected with pAchLYZ vector containing human lysozyme gene and green fluorescence protein (GFP) via nucleofection, lipofectamine, and FuGene (Roche Diagnostics, Indianapolis, IN, USA). Transfected cells were selected by adding G418 (400–800 µg µL−1), which selectively killed the nontransfected cells in culture. The presence of hLYZ gene in transfected cells was confirmed by PCR amplification of this gene. For cloned embryo production, reconstructs were formed with 2 enucleated demi oocyte fused with 1 donor cell of hLYZ transfected cells or nontransfected fibroblast cells. Gene expression in the resulting embryos was assessed for apoptosis (BID, BAX, and BCL-XL) and development- (G6PD, IGF1R, and FGF) and pluripotency-related (OCT4, SOX2, and NANOG) genes. The transfection efficiency of the cells by nucleofection methods was the highest and toxicity to the cells was minimum as compared with chemical methods. Transfected cells expressed GFP within 48 to 72 h of transfection. When these cells were passaged the intensity of GFP expression was reduced and the reduced level was maintained in subsequent passages. A total of 114 and 60 reconstructed embryos were produced using transfected and nontransfected cells, respectively. When transfected cells were used, the cleavage, 4 cell, 8 to 16 cell, morula, and blastocyst rate was 62.01 ± 4.78, 43.54 ± 3.93, 27.69 ± 4.44, 24.55 ± 5.12, and 22.87 ± 5.39%, respectively, whereas rates were 73.34 ± 2.36, 68.34 ± 4.82, 59.89 ± 2.39, 46.44 ± 2.64, and 36.36 ± 2.53% for nontransfected cells, respectively. The cleavage rate had no significant (P < 0.05, Student’s t-test) difference in both type of donor cells but all other stages [i.e. 4 cell, 8 to 16 cell, morula, and blastocyst rate was significantly (P < 0.05) lower with transfected cells]. Most of the transgenic cloned embryos expressed GFP and integrated with hLYZ gene. We found that proapoptotic gene (BID and BAX) expression did not differ, whereas BCL-XL expression was significantly low (P < 0.05) in transgenic embryos. The development- (G6PD, IGF1R, and FGF) and pluripotency-related (OCT4, SOX2, and NANOG) gene expression was significantly (P < 0.05) lower in transgenic embryos. In conclusion, transgenic cloned embryo successfully developed up to the blastocyst stage in the preliminary study for producing genetically modified animal with human milk components having antimicrobial activity, which would be potentially valuable for human as well as animal health.

208 PRODUCTION OF TRANSGENIC CLONED BUFFALO (BUBALUS BUBALIS) EMBRYOS CONTAINING HUMAN INSULIN GENE THROUGH HAND-GUIDED CLONING

Diabetes is a growing disease worldwide and has emerged as a major healthcare problem in India. Insulin is an essential medicine for the treatment of diabetes. Large dairy animals, such as buffaloes and cows, may be used as bioreactors for cost-effective production of human insulin. The present study was aimed to produce transgenic buffalo embryos containing the human insulin gene through hand-guided cloning for production of transgenic animals. Buffalo female fetal fibroblast cells at passage number 3 were transfected using mammary gland- specific expression vector containing the human insulin gene under buffalo β-lactoglobulin promoter by nucleofection method and cultured with G418 drug for 3 weeks to obtain positive transgenic cell clones. Transgene integration into buffalo female fetal fibroblast genome was confirmed by PCR and Southern blotting. Nontransfected and transgene integrated cells were used as nuclear donors to produce embryos by the hand-guided cloning technique. The developmental competence and quality of embryos as judged by total cell number and TUNEL assay were compared among transgenic and nontransgenic (control) embryos. The blastocyst rate was lower (P < 0.05) for transgenic embryos than that of nontransgenic cloned embryos (35.97 ± 2.16 v. 45.80 ± 4.11, respectively). The apoptotic index was found to be lower (P < 0.05) for control blastocysts than that for transgenic blastocysts. However, the total cell number was similar (P < 0.05) among transgenic and control cloned blastocysts. Thus, transgenic cells, and subsequently transgenic embryos containing the human insulin gene, were successfully produced and transferred in recipients. In the future, these may be used for production of transgenic buffalo expressing human insulin in its milk and thus can be further utilised in large-scale production of human insulin.