Analysis of renal function in patients entered onto CTEP-sponsored phase I studies since 1979

2519

Background: The NCI and FDA utilize different criteria for classifying renal dysfunction. We analyzed renal function in all patients entered onto CTEP-sponsored phase I clinical trials since 1979 to evaluate the percentage of patients with acceptable renal function according to criteria utilized by the National Cancer Institute, as compared with those advocated by the Food and Drug Administration. Methods: Data from 12575 patients entered onto CTEP-sponsored phase I studies since 1979 were evaluated. Renal function was characterized by calculating creatinine clearance (CrCl) by three different formulae (Cockroft-Gault, Jelliffe, and Levey), as well as GFR according to MDRD. Results: Of the 12,575 patients, data were available to calculate renal function with all the 4 formulae in 5,177. Distributions of CrCl and GFR were defined, and patients were classified as having normal renal function or severe, moderate, or mild renal dysfunction according to FDA or NCI criteria. The resulting distributions are indicated in the table below. Conclusions: Approximately 40% of patients entered into CTEP-sponsored phase I trials have mild renal dysfunction according to FDA criteria and approximately 95% have CrCls > 50 ml/min. These data imply that moderate and severe are the only renal dysfunction categories that need to be evaluated in renal dysfunction studies of novel antineoplastic agents and that FDA guidelines should be applicable. Whether patients in the NCI database with CrCls of 50–80 ml/min experience more toxicities than those with creatinine clearances > 80 ml/min is undergoing evaluation.

[Table: see text]

[Table: see text]

Angiogenesis index (AI) as a predictor of tumor burden in lymph nodes in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

14509

Background: Lymph Node (LN) status is the most important prognostic factor in colon cancer (Cca). Angiogenesis Index (AI) has been studied as a prognostic marker in various solid tumors with conflicting results. Hence, a retrospective analysis was done to evaluate the role of AI as a prognostic marker in Cca. Methods: Pts with Cca who underwent SLNM to determine LN status were included. A portion of tumor was sent for tumor marker analysis including p53, Thrombospondin-1 and CD31 by IHC. AI was derived for each specimen by summing the biomarker specific score for the three tumor markers. AI of -ve 6 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and non-SLNs were measured in greatest diameter by ocular micrometer; and were added for each pt to estimate overall tumor burden in SLNs and non-SLNs. Results: A total of 111 consecutive pts with Cca were included in the study. SLNM was successful in 100% pts. Pts with distant metastasis (mets) (n=18), Tis (n=1) and skip mets (n=9) were excluded from final analysis. Out of the remaining 83 pts, an AI of -6 or less was found in 22 pts (26.5%) while 61 pts (73.5%) had AI of more than (>) -6. Of the 61 pts with AI > -6, 37.7% pts were SLN +ve while 62.3% pts were SLN -ve (p=0.05)( Table 1A ). Of the 22 pts with AI less than or -6, 45.5% pts were SLN +ve and 54.5% pts were SLN -ve (p=0.65). Size of the metastatic tumor burden in lymph nodes was available in 69.7% of SLN +ve pts. Total average tumor burden for pts with AI > -6 (n=15) was 2.04cm as compared to 1.48cm in pts with AI of -6 or less (n=8)(p=0.66). Average SLN met size was 0.73cm in pts with AI > -6 and 0.63cm in pts with AI of -6 or less (p=0.66)( Table 1B ). Conclusions: AI did not correlate with nodal positivity or tumor burden in LNs in pts with Cca. LN status remains the most important prognostic marker in Cca. Further larger trials are required to determine the role of AI as a prognostic marker in Cca.

[Table: see text] [Table: see text]

No significant financial relationships to disclose.

Evaluation of liver function impairment and lipid peroxidation induced by lantana camara leaf powder administration in adult rat serum and liver

Lantana camara is a common weed and certain medicinal properties have been attributed to this plant, but most varieties of this plant are reported to be highly toxic to animals. The plant is a native of America but a few varieties are indigenous to tropical Asia and Africa. The present investigation was done to study the hepatotoxic and lipid peroxidative effects of this noxious weed on female Wistar rats. Eighty four percent (84%) increase was observed in the activity of AST in group B and 120% increase was noted in group C in serum. In, liver tissue this increase was 66% and 258%. In the case of ALT, 165% increase was observed in group B and 219% increase was observed in group C in serum. In, liver there was 46% increase in group B and 216% increase in group C in the ALT activity. Similarly, 30% and 50% increase in group B and 120% and 300% increase in group C in the activity of ALP was observed with respect to control group. The overall protein concentration was increased in serum and decreased in liver tissue. Lipid peroxidation in liver tissue was inhibited by 22% in group B and 55% in group C. Thus Lantana camara is a toxic plant which produces severe hepatotoxicity in rats, but it also prevented lipid peroxidation that may suggest that Lantana camara may be acting as antioxidant but, exactly which of its component is responsible for this activity is not known and needs future investigations.

Development of passive haemagglutination (PHA) and haemagglutination inhibition (HAI) technique for potency estimation of Cobra Antisnake Venom Serum (ASVS)

Antibodies against snake venom or antivenom potency are assayed quantitatively by in-vivo neutralization test in mice, which requires large number of laboratory animals. In potency assays of biological substances such as antivenoms, it is highly desirable to avoid suffering and death of animals by substituting in-vivo method with in-vitro methods, provided such methods measure life-saving capability with precision similar to that of in-vivo method. The in-vitro tests determine the neutralizing power of antivenom by permitting the evaluation of a particular biological activity of the venom and its neutralization after mixing the venom with the antivenom [Theakston RDG, Reid HA. Development of simple standard assay procedures for the characterization of snake venom. Bull WHO 1983;61:949-956; Gutierrez JM, Rojas G, Lomonte B, Gene JA, Chaves F, Alvarado J, et al. Standardizing of assays for testing the neutralizing ability of antivenoms. Toxicon 1990;28:1127-1129; Theakston R.D.G. Comments on letter of Gutierrez et al. on standardization of assays for testing the neutralizing ability of antivenoms. Toxicon 1990;28:1131-1132; Harvey AL, Barfaraz A, Thomson E, Faiz A, Preston S, Harris JB. Screening of snake venom for neurotoxic and myotoxic effects using simple in-vitro preparation from rodents and chicks. Toxicon 1994;32:257-265; World Health Organization Progress in characterization of venom and standardization of anti-venoms. Geneva: WHO offset publication; 1981. p. 58.]. Hence, the ideal requirements for an assay in detecting venom and venom antibody include high level of sensitivity, specificity (ability to differentiate between venom and venom antibody produced by closely related species of snakes), reproducibility and simplicity. A new in-vitro procedure for quantitative analysis of potency of ASVS by passive haemagglutination (PHA) and haemagglutination inhibition (HAI) has been explored. The methods described are simple, rapid, economical, reproducible and useful in replacing the more expensive in-vivo neutralization assays. Moreover, it also eliminates the use of laboratory animals.

Role of Bupivacaine in reducing post tonsillectomy pain

Pain following tonsilleclomy is of major concern to both the surgeons and the Anesthesiologists. Pre-incisional Bupivacaine infiltration into the tonsillar fossa has been used as a method of relieving post-operative pain in children. In this study pre-incisional Bupivacaine infiltration into the tonsillar fossa resulted in immediate post-operative pain lasting four to six hours.

A comparative study on the efficacy of rofecoxib in monoarticular arthritis induced by latex of Calotropis procera and Freund's complete adjuvant

The role of prostaglandins in Calotropis procera latex induced inflammation and hyperalgesia has been well established. The acute inflammation induced by the dried latex (DL) of this plant could be effectively ameliorated by standard anti-inflammatory drugs. In present study we have evaluated the efficacy of rofecoxib, a COX-2 inhibitor in monoarthritis induced by intra-articular injection of DL and compared it with that against Freund's Complete Adjuvant (FCA). DL and FCA were injected into the right ankle joint of the rat and the joint diameter was measured by a micrometer screw gauge on day 0, 4, 8, 12, 20 and 28. Concomitantly the hyperalgesic response was also evaluated by motility test, stair climbing ability test, dorsal flexion pain test and compression test. The effect of rofecoxib was evaluated on these parameters in both the models. Both DL and FCA produced peak inflammation on day 4 that was associated with decreased pain threshold and functional impairment. Although rofecoxib was more effective in improving motility in the DL model, its effect on joint inflammation, hyperalgesia and stair climbing ability was comparable in both the models. Thus, our study indicates that DL induced monoarthritis could be used as a model for the screening and evaluation of anti-inflammatory and anti-arthritic drugs.

Benefits, limitations and pitfalls of sentinel lymph node (SLN) mapping (M) for colorectal carcinoma (CRCa): A multicenter trial

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Background: Clinical application of SLNM in CRCa patients (pts) is controversial due to the variable results in the literature for its success, skip metastases (mets) and accuracy. Hence prospective data from 5 institutions were analyzed to identify the factors associated with failure and skip mets in CRCa pts undergoing SLNM. Methods: SLNM was performed by peri-tumoral injections of 1–3 ml of 1% lymphazurin subserosally. First 1–4 blue nodes marked as SLNs were examined by 4 sections with H & E and 1 for cytokeratin. Rate of failure and skip mets rate along with age, sex, tumor site, size, grade, T & N stages were analyzed. Results: 549 consecutive CRCa pts underwent SLNM; 453 colon (C) and 96 rectal (R) pts. M: F ratio was 48%: 52% and median age of 72 years. The average no. of LNs was 14.5. SLNM failed in 1% of C and 8% of R pts ( Table ). Of the 8 R failures, 7 had neoadjuvant therapy. No correlation was found between failure, size or T-stage. Overall nodal positivity (+ve) rate was 48%. Of the 466 invasive CRCa pts with successful SLNM, rate of skip mets was 7% in C and 4% in R. Age, sex, grade and neoadjuvant therapy had no correlation with skip mets. Of 28 skip mets pts, 79% had tumors >3cm and 93% had advanced (T3, T4) tumors. Higher skip mets also was found in the transverse colon tumor. The success, accuracy, and sensitivity rates were 98%, 95%, and 88% respectively. Of node +ve pts, 47% had mets found only in the SLNs. SLNM upstaged 35% of C and 36% of R pts with micromets. Conclusions: In CRCa, SLNM is highly successful and accurate in predicting the presence or absence of nodal mets. Submucosal fibrosis of the lymphatics due to neoadjuvant therapy may result in higher failure rates for R pts. Skip mets are higher in transverse C tumors and increase in frequency as the T-stage increases. Pts upstaged by SLNM may benefit from adjuvant chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

P53 as a predictor of tumor burden in lymph nodes (LN) in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

3617

Background: p53 and LN status(S) are important prognostic markers in Cca. Our study was done to evaluate whether p53 S could predict tumor burden in LNs in Cca undergoing SLNM. Methods: Pts with Cca underwent SLNM to determine the LN S. A portion of tumor was used for detection of p53 S by IHC.p53 Histo Score (HS) was defined as (Intensity of stain in cells from 0–4 +1) × (% cells staining). HS of 180 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and nonSLNs were measured in greatest diameter by ocular micrometer. For overall tumor burden in SLNs and nonSLNs,all metastatic foci were added for each pt. Results: SLNM was successful in 100% of the 117 consecutive pts with Cca. Pts with distant metastasis (mets) (18) and skip mets (9) were excluded. Of the remaining 90 pts,39% were SLN positive (+ve) and 61% were SLN negative (-ve). HS of ≤ 180 was found in 66% and HS >180 was found in 34% of the pts. In 55 SLN -ve pts 76% had HS ≤ 180 while 24% had HS >180. In 35 SLN +ve pts, 49% had HS of ≤ 180 and 51% had HS >180. ( Table ) Of SLN +ve pts, size of metastatic tumor in LNs was available in 86% of pts. Average (av.) non SLN met size was 0.95 cms in pts with HS ≤ 180 and 3.4 cms in pts with HS > 180. Av. SLN met size was 0.63 cms in pts with HS ≤ 180 and 0.9 cms in pts with HS>180 ( Table ). No statistical significance was found among T stage of pts with HS >180 vs ≤ 180. Conclusion: Pts with p53 HS >180 showed significantly greater tumor burden in both SLNs and non SLNs as compared to pts with HS ≤ 180. Also probability of having SLN -ve disease is higher in pts with HS ≤ 180 as compared to pts with HS >180 in Cca. Thus,even in SLN -ve pts, high HS may indicate a worse prognosis. Hence,a high p53 HS might predict pts with Cca having higher tumor burden in LNs and thus identify an aggressive subgroup of pts.

[Table: see text]

No significant financial relationships to disclose.

Comparative analysis of CT-scan and PET-scan with intraoperative ultrasound (IOUS) in detecting liver metastases

3632

Background: Open, laparoscopic or percutaneous radiofrequency ablation (RFA) has been used for the surgical treatment of liver metastases (mets). However, it requires accurate preoperative (preop) localization of liver mets. CT scan and PET scan have been widely used for such preop evaluation. However, intraoperative ultrasound (IOUS) remains the gold standard. Very little data is available comparing IOUS with preop CT and/or PET scan. Thus, a retrospective study was done to compare the efficacy of IOUS with preop CT and/or PET scan in detecting the number of liver mets. Methods: A retrospective chart review was done that included all patients (pts) who underwent surgical treatment for liver mets. Data was obtained from medical records, radiology, intraop reports. Results: 53 pts including 57% men and 43% women with a median age of 62years (age range 35–80 years) were included in the study. Imaging data was available for CT, PET and IOUS in 53, 24 and 39 pts respectively. CT, PET, and IOUS detected 2.4, 1.7 and 2.6 lesions/ pt respectively. In 24 patients, both CT and PET scan report was available. Of these, the imaging study detecting the maximum number of lesions was selected for comparison of preop evaluation with IOUS. A comparison between preop imaging (CT/PET scan) vs. IOUS in these 24 pts revealed an average of 2.3 vs. 2.8 lesions/pt respectively ( Table ). When compared with preop imaging (CT/PET scan), IOUS detected additional lesions in 33% pts; fewer lesions in 17% pts and similar number of lesions in 50% pts. Comparison between CT and IOUS in 39 patients revealed 1.9 vs. 2.6 lesions/pt respectively and that between PET and IOUS in 24 patients revealed 1.7 vs. 2.8 lesions/pt respectively. Conclusions: Although CT scan and PET scan remains effective modalities for preop evaluation of liver mets, IOUS is found to be superior for planning accurate surgical treatment. Thus, the efficacy of percutaneous RFA may be limited due to inability to perform IOUS.

[Table: see text]

No significant financial relationships to disclose.

Comparative analysis of MRI vs mammography in evaluation of size, number of lesions and nodal status of breast cancer

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Background: Breast MRI is thought to be better in evaluating patients (pts) with BrCa. Our study was to compare MRI vs mam to predict leisons and LNS in BrCa. Methods: A retrospective study of 100 consecutive pts with pathologically proven BrCa was done. All had preoperative MRI and mam. Findings were compared to the final pathologic size, used as gold standard. MRI and was done at same center and single surgeon did all surgeries. Results: Of 100 pts,MRI reported 124 lesions. MRI reported size in 107 and mam reported size in 63 lesions. In MRI detected sizes 8% had same size as pathological size, 66% were overestimated by a mean of 0.64cm and 26% were underestimated by a mean of 0.48cm. For mam lesions, 10% had same size, 34% were overestimated by a mean of 1.10cm, 57% were underestimated by a mean of 0.78 cm. Total of 25 additional lesions were found in 23 pts in same and 6 leisons in 6 pts in contralateral breast by MRI. MRI also detected enlarged axillary and intramammary LN in 15% pts, 40% were true positives(+ve) and 60% were false +ve. One pt had metastatic LN in the contralateral axilla detected by MRI and confirmed by lymphoscintogram and pathology. 3% pts had neo-adjuvant chemotherapy Conclusion: In our study mam underestimated the breast lesion size in pts significantly more than MRI, but MRI overestimated BrCa lesion size in more number of pts. The mean difference in size on MRI when compared to the pathological size is less than 1 cm, while mam overestimated by a mean of greater than 1cm. This might be particularly important for T1 and T2 lesions, where size is the most important criterion for the T-stage classification. The identification of additional lesions and enlarged LN on MRI further validates the utility of MRI.

[Table: see text]

No significant financial relationships to disclose.

Evaluation of cytotoxic potential of latex of Calotropis procera and podophyllotoxin in Allium cepa root model

In the present study we have utilized the Allium cepa root tip meristem model to evaluate the cytotoxic and anti-mitotic activities of latex of Calotropis procera (DL) and podophyllotoxin. Standard cytotoxic drug cyclophosphamide and non-cytotoxic drugs cyprohcptadine and aspirin served as controls. Like cyclophosphamide, both DL and podophyllotoxin significantly inhibited the growth of roots and mitotic activity in a dose-dependent manner. However, podophyllotoxin was more potent in this regard and produced root decay. Cyproheptadine and aspirin, on the other hand, showed a marginal effect on the root growth and mitotic activity at much higher concentrations.

Antioxidant and protective effect of latex of Calotropis procera against alloxan-induced diabetes in rats

In the present study, dry latex (DL) of Calotropis procera possessing potent anti-inflammatory activity was evaluated for its antioxidant and anti-hyperglycemic effects against alloxan-induced diabetes in rats. Daily oral administration of DL at 100 and 400 mg/kg doses produced a dose-dependent decrease in the blood glucose and increase in the hepatic glycogen content. DL also prevented the loss of body weight in diabetic rats and brought down the daily water consumption to values comparable to normal rats. DL also produced an increase in the hepatic levels of the endogenous antioxidants, namely superoxide dismutase (SOD), catalase and glutathione, while it brought down the levels of thiobarbituric acid-reactive substances (TBARS) in alloxan-induced diabetic rats. The efficacy of DL as an antioxidant and as an anti-diabetic agent was comparable to the standard anti-diabetic drug, glibenclamide.

Pediatric HIV infection

OBJECTIVE

The present cross sectional study was undertaken to study clinical profile of HIV infection in children in Northern India.

METHODS

64 children from newborn to eighteen years, presenting for confirmation of diagnosis of HIV infection or monitoring of CD4-CD8 counts in confirmed cases, were evaluated. Children were categorized as per CDC classification of Pediatric HIV. The diagnosis was confirmed by serological tests or PCR assay. CD4-CD8 counts were done by FACS Count.

RESULTS

Majority of the children were between 18 months to 5 years. Adolescents comprised 24% of the case. 51.5% children were infected through the mode of mother to child transmission. 39% of the case was transfusion-mediated. Unsafe medical injections probably contributed to 6.2% and heterosexual promiscuity led to 3.1% cases. Clubbing, not described in Indian studies so far, was seen in 9.3% cases.

CONCLUSIONS

HIV infection is a chronic childhood disease extending into adolescence, and contaminated blood and unsafe medical injections are still important routes of HIV transmission in India.

Altered lipid parameters in patients infected with Entamoeba histolytica, Entamoeba dispar and Giardia lamblia

Information on the effect of parasitic infections on lipid parameters is scarce. Certain parasites induce significant changes in lipid parameters, as demonstrated by the fact that substitution of lipid/cholesterol for serum in axenic culture medium (in vitro) and in experimental models (in vivo) supports vigorous growth of Entamoeba histolytica. Thus, significant changes in lipid parameters may be induced in an infected host. Blood samples are obtained from intestinal amoebiasis patients passing E. histolytica (n=8), E. dispar (n=15) or Giardia lamblia (n=9) cysts, or diagnosed with amoebic liver abscess (ALA; n=50) and from apparently normal healthy individuals (control group; n=30). Levels of total serum cholesterol, high-density lipoprotein and low-density lipoprotein are assessed using commercial kits. E. histolytica and E. dispar isolates are differentiated by hexokinase isoenzyme electrophoresis and by enzyme-linked immunosorbent assay (ELISA; Techlab) tests. Results show that E. histolytica, E. dispar and G. lamblia cyst passers had significantly lower levels of total serum cholesterol (73.42 +/- 2.24 mg/dL), compared to levels in ALA cases (101 +/- 2.85 mg/dL) and in controls (166.26 +/- 2.02 mg/dL). Further study of a greater number of cases is needed to explore the relevance of this finding.

Prevalence of parenterally transmitted hepatitis viruses in clinically diagnosed cases of hepatitis

Hepatitis B virus (HBV) is the most important causative agent of blood borne hepatitis in humans. Hepatitis D Virus (HDV) infection occurs either as a coinfection or superinfection in HBV carriers. Hepatitis C virus (HCV) is the major cause of transfusion non-A, non-B hepatitis and continues to be a major cause of human liver disease throughout the world. The present study was conducted on 70 clinically diagnosed cases of viral hepatitis to study the prevalence of parenterally transmitted viral hepatitis. The serum samples were tested for HBsAg, HBeAg, IgM anti-HBc, anti-HBe, anti-HCV and anti-HDV using separate ELISA kits. Of the 70 serum samples tested, 28 (40%) were positive for HBsAg out of which 3 (4.28%) were positive for HBeAg also. Five (7.1%) of the HBsAg positive cases tested positive for IgM anti-HBc also. HBsAg alone was found in 17 (24.28%) cases. The prevalence of anti-HCV was 3 (4.28%) in 70 cases. Thus early screening of clinically diagnosed cases of viral hepatitis is essential for establishing diagnosis and treatment to prevent long term sequelae.

Laparoscopic-assisted ileo-colectomy for tuberculosis

BACKGROUND

Laparoscopic-assisted colon resection (LACR) for benign disease has gained acceptance and has a lower morbidity than open surgery. Reports in Western literature have outlined the use of LACR for diverticulosis, ulcerative colitis, and Crohn's disease. We evaluated the use of LACR in patients with ileo-cecal tuberculosis (IC-TB) and describe our technique and results.

METHODS

Twenty-six patients (20 F) between 16 and 45 years of age underwent a LACR for IC-TB over a 4-year period. Three access ports were used in 22 patients, four patients needed four ports. The cecum, ascending colon, proximal transverse colon, and terminal ileum were mobilized completely. The right colic vessels were divided intracorporeally. The specimen was delivered using a 5- to 6-cm incision. The ileo-colic pedicle and bowel were divided outside and an ileocolic anastomosis performed. After placing the bowel within the abdomen the pneumoperitoneum was recreated, saline irrigation done, and hemostasis achieved.

RESULTS

No patient needed a formal laparotomy. Peristalsis returned within 48 h in 19 patients and after 72 h in the remaining seven. Oral liquids were started on all patients by the 3rd postoperative day (POD) and a soft diet by the 5th POD. Twenty patients had a bowel movement by the 4th POD and the rest by the 5th POD. Eighteen patients were discharged by the 5th day and the remaining by the 7th day. Three patients developed wound sepsis. Twenty-one patients could resume normal activity within 2 weeks, the rest within a month.

CONCLUSION

Laparoscopic-assisted colon resection seems to be an ideal operation for patients with ileo-cecal tuberculosis. It has minimal morbidity and allows a quick return to normal activity.

Cytokine mRNA expressions in symptomatic vs. asymptomatic amoebiasis patients

Infection with Entamoeba histolytica results in high mortality worldwide. Studies on the cytokine response in symptomatic and asymptomatic amoebiasis (caused by E. histolytica, the pathogenic species and E. dispar, the non-pathogenic species) subjects and their correlation with symptomatology are lacking. The present study reports the cytokine response (TNF-alpha, IFN-gamma, IL-4, IL-10 and TGF-beta) in such subjects as measured by RT-PCR. The results showed significantly (< 0.05) higher expressions of IL-10 and TGF-beta in the symptomatic group as compared to the asymptomatic and healthy controls. The cytokine profile indicated the role of suppressive immune response in symptomatic amoebiasis patients.

SEN virus infection--a new hepatitis virus: a review

Approximately 10% of transfusion associated hepatitis and 20% of community acquired hepatitis cases do not have a defined etiology, suggesting the existence of an additional causative agent. The recent agents which have been detected in blood were Hepatitis G virus (HGV) and TT virus (TTV), members of the family Circoviridae. These viruses were initially thought to be associated with post-transfusion hepatitis but later studies negated this causal effect. Recently, a novel DNA virus at the moment designated as SEN virus (SEN-V) was discovered and is thought to be associated with post-transfusion hepatitis. This virus is related to the above two agents and belongs to the same family. Whether, like HGV and TTV causal relationship with hepatitis is finally confirmed only time will tell, but, at the moment the association appears to present. The present review summarizes the present available data on this new agent of hepatitis.

Screening by VDRL test to detect hidden cases of syphilis

A total of 59,450 sera from January 1996 to December 2000 were subjected to VDRL testing. Overall VDRL positivity rate was 3.2% and downward trend was observed in the recent years, 1999 and 2000. Majority of the samples were from Gynaecology department, out of which 1.57% were VDRL positive. Out of 30,045 samples from antenatal females, 517(1.47%) were positive, while 304(1.8%) were positive out of 16,980 samples obtained from couples. Out of 304 samples from couples found positive, 17.4% wives had titre >R16; 27.9% wives had titre R1 to R8, out of which 15.3% husbands had titre of >R16. Also, 166 wives with nonreactive VDRL had 19.3% husbands with titre > R16. Thus, couple VDRL test plays an important role in detection of hidden cases of syphilis in the community and early detection and treatment of such cases will further reduce the perinatal morbidity and mortality.

RATIONAL OF COMBINATION ANTIMICROBIAL THERAPY FOR BACTERIAL INFECTIONS

ABSTRACT

Naegleria meningitis: a rare survival

Acute amebic meningoencephalitis caused by free-living amebae naegleria fowleri is extremely rare and uniformly fatal with only seven survivals reported till date. An interesting case of naegleria meningitis diagnosed by wet mount cytology of cerebrospinal fluid (CSF) and treated with amphoterecin B, rifampicin and ornidazole with complete recovery is presented. In cases of suspected pyogenic meningitis, if CSF staining, antigen detection or culture is negative for bacteria, a wet mount cytology of CSF for naegleria is suggested. Early treatment with amphoterecin B and rifampicin may improve survival.

Hepatitis G virus (HGV): current perspectives

Five viruses are usually associated with hepatitis in humans: A-E. In addition to these viruses as aetiological agents of hepatitis, there remain a number of patients with hepatitis in whom no virus could be identified. It was therefore postulated that there may be other agents which may be causing hepatitis. Recently, two viruses have been associated with hepatitis: hepatitis G virus (HGV), and transfusion transmissible virus (TTV). Hepatitis G virus (HGV) is a single stranded RNA virus which represents a newly discovered virus belonging to the flavivirus family. HGV is distinct from hepatitis C virus (HCV) and the newly discovered GBV-A and GBV-B agents, while GBV-C represents an isolate of HGV. The structure of the HGV genome resembles that of HCV. HGV replicates in peripheral blood cells, while replication in liver cells has not been observed till date. Diagnosis of HGV infection is mainly by use of polymerase chain reaction (PCR), as serological techniques are still being developed. Epidemiological data indicate that the virus is prevalent throughout the world, including India and is transmitted via blood/blood products, sexually and vertically from infected mothers to children. The relationship between infection with the virus and presence of liver pathology is controversial and has not been proven beyond doubt, as majority of patients with HGV have no detectable evidence of disease.

Acanthamoeba adherence to soft contact lens and human corneal stroma

In the present study, the adhesibility of Acanthamoeba castellani trophozoites and cysts to hydrogel contact lenses and to human cornea was investigated. Segments of unworn contact lenses were prepared (120 segments in total). In addition, 8 corneal buttons were obtained from 8 enucleated eyes. And each cornea cut into 8 radial segments. To these lens and corneal segments, 1.2 x 106/ml and 1.3 x 106/ml of cysts and trophozoites respectively were added under varying conditions. The adhesion was checked at 0, 3 and 24 hours after the exposure. Adhesion analysis showed that the trophozoites adhered equally well to lens or cornea. There is an increase in the number of trophozoites adhering to contact lenses as well as cornea. This difference is more significant for contact lenses. Washing of contact lenses significantly decreased the adherence of the trophozoites after 3 hours of incubation. When the comparison of adhesion was done between the unwashed worn and unwashed unworn contact lenses, it was observed that there was a significant difference in adherence to new lenses where the adherence was much lower. The study shows that washing of contact lenses does decrease the chances of colonization by Acantamoeba catellani and also that older lenses have higher chances of getting colonized probably due to the occurrence of scratches et. on the surface which may help in colonization.

Receptor-Ck regulates giardia encystation process

The study addressed to resolve the mechanism involved in cholesterol-dependent regulation of giardia encystation process, revealed that (a) the trophozoites have the ability to express genes coding for receptor-Ck and sterol element binding protein (SREBP); (b) inhibition of cholesterol dependent activation of receptor-Ck results in the upregulation of CWP-1 gene expression leading to encystation process. Based upon these findings, we propose that receptor-Ck dependent signalling is responsible for the regulation of giardia encystation process by cholesterol.

Structural evaluation of porcine heart valve prostheses with radiofrequency ultrasound

BACKGROUND

Bioprosthetic heart valve use is limited by progressive degeneration. Early degenerative changes are often occult, making assessment of tissue integrity difficult. Ultrasound tissue characterization may detect alterations in tissue structure and allow early detection of leaflet degeneration.

METHODS

Using a modified echocardiographic unit (Acuson), radiofrequency (RF) integrated backscatter amplitude (IBA) (integral/RF/dt) was measured in 38 leaflets from nine explanted and six control porcine valves. Regions of interest in each leaflet were studied using four ultrasound frequencies. Radiographic gray scale mean and leaflet thickness were measured at each region of interest. Percent collagen and mineral were calculated for each region of interest using color-image processing of histologic sections and compared to IBA.

RESULTS

IBA values for control vs. explanted leaflets were (mean value+/-standard deviation): 8.2+/-4.69 dB vs. -4.7+/-4.64 dB at 7.0 MHz; -5.8+/-4.34 dB vs. -3.1+/-5.34 dB at 5.0 MHz; -3.8+/-3.38 dB vs. -2.1+/-3.18 dB at 3.5 MHz; and -9.0+/-4.58 dB vs. -7.1+/-4.25 dB at 2.5 MHz. Collagen content was 27.7+/-8.50% vs. 33.2+/-10.90%, mineral content was 0.1+/-0.10% vs. 2.1+/-4.30%, and radiographic gray scale mean was 150.6+/-1.96 vs. 145.3+/-5.14 for control vs. explanted leaflets, respectively. For control and explanted leaflets IBA, collagen content, mineral content, and radiographic gray scale mean were different (control vs. explanted P<0.05). Leaflet thickness was also noted to be different between the two groups. IBA was different among explanted leaflets with low, medium, and high mineral content.

CONCLUSION

IBA was found to be a useful technique to differentiate normal from explanted porcine prosthetic valves in vitro. This method may be useful in the serial assessment of bioprosthetic leaflet degenerative properties in vivo.

Early abortion by mifepristone (RU 486) followed by vaginal gel (meteneprost) versus oral (misoprostol) prostaglandin

The present study was conducted to compare the therapeutic regimens of low-dose mifepristone (200 mg) plus vaginal meteneprost versus oral misoprostol in terms of efficacy and safety for medical termination of early pregnancy. A randomized clinical trial was conducted by the Department of Obstetrics and Gynecology at the All India Institute of Medical Sciences, New Delhi. A total of 101 subjects were enrolled within 56 days of amenorrhea. A single dose of 200 mg of mifepristone (RU 486) was given and, 48 hr later, prostaglandin was administered as either 5 mg of 9 methylene PGE2 vaginal gel, meteneprost (classified as group I) or 600 microg of oral PGE1 derivative misoprostol (classified as group II). In group I, 50 subjects and in group II, 51 subjects were treated with the respective schedule. The success rate with mifepristone + misoprostol (group II) was 88.63% which was significantly higher than that with mifepristone + meteneprost (group I) which was 82% (p < 0.05). The average duration of bleeding in cases with complete abortion was 8.95+/-5.67 and 9.77+/-6.51 in group I and II, respectively. There were no serious side-effects. Only one subject in group I (2%) required blood transfusion for heavy bleeding. This study indicated that oral prostaglandin after a low dose of mifepristone (200 mg) could be developed into an effective method to terminate early pregnancy. Oral administration of both drugs would be a more convenient, feasible, private and acceptable regimen.

Routine vaginal cuff smear testing in post-hysterectomy patients with benign uterine conditions: when is it indicated?

BACKGROUND

By the age of 60 years, an estimated 33% of women will have undergone a hysterectomy. Approximately 85% of these hysterectomies are performed for benign disease. The object of this study was to evaluate cytologic findings from vaginal cuff smears in patients who have undergone hysterectomy for benign uterine conditions.

METHODS

We conducted a community-based retrospective study and follow-up of women with vaginal cuff cytologic smears who had had a hysterectomy for benign uterine conditions. A total of 220 women were randomly selected who had one or more vaginal cuff smears. The main outcomes measures were invasive carcinoma, dysplastic lesions, and infections detected by vaginal cuff smear testing. The setting was a large inner-city hospital.

RESULTS

Ninety-seven percent of 220 women who underwent hysterectomy for benign uterine conditions and who were observed for an average of 89 months had no cytologic abnormalities on vaginal cuff smears. Cytologic evaluation found no invasive carcinomas. Dysplastic lesions were detected in 7 patients (3%). Seventy percent of patients (n = 154) had one or more infections; these infections included bacterial vaginosis (106), trichomoniasis (95), candidiasis (40), koilocytosis suggestive of human papilloma virus (HPV) infection (3), and cytopathic effect of herpes (4). The prevalence of koilocytosis was much higher in the patients with dysplasia (P = .0003).

CONCLUSIONS

Most routine vaginal cuff cytology screening tests need not be performed in women who have had a hysterectomy for benign uterine conditions.

Isolation of emetine resistant clones of Entamoeba histolytica by petri dish agar method

Emetine resistant clones of Entamoeba histolytica strain HM1:IMSS were isolated by using petri dish agar method after mutation with ethyl-methanesulphonate. Two emetine resistant clones were obtained and both were resistant to emetine at a concentration of 24 micrograms/ml of emetine. The 50 per cent inhibitory concentration (IC50) for both emetine sensitive and resistant clones was 5 and 14 micrograms/ml respectively. The colony forming efficiency of E. histolytica strain HM1:IMSS varied from 44 to 54 per cent. This method is useful for isolating clones from different strains of the parasite for molecular and immunological studies.

Fasciolopslasis--a re-emerging infection in Azamgarh (Uttar Pradesh)

Fasciolopsiasis is endemic in the far east. In India, there have been a few reports of the infection, prior to the 1990's. We report two cases from Azamgarh district of Uttar Pradesh. Both the cases were from nearby villages where water chestnuts are cultivated. These may be a source of infection. Pigs are commonly observed in these areas and and may be the source of ova. The only missing link is the finding of infected snails. Presence of at least three cases (one reported earlier) in the area indicates the potential for the infection to re-emerge. Further epidemiological studies are needed to analyse the various ecological factors of transmission. Fasciolopsiasis is endemic in China, Taiwan, Vietnam and Thailand. In India, (Fascilopsis buski) infections in man have been reported earlier from Assam, Maharashtra, Tamil Nadu and parts of Uttar Pradesh. However, to the best of our knowledge, no such reports have been made since 1990's. We herewith report two recent cases from district Azamgarh, Uttar Pradesh (U.P.), India. Factors, such as cultivation of water chestnuts, presence of snails as intermediate hosts and pigs as definitive host in this geographical area seem to be suggestive of an endemic focus and thus needs further epidemiological survey for preventive and control measures, at the earliest.

Antibiotic prophylaxis in elective cholecystectomy: a randomized, double blinded study comparing ciprofloxacin and cefuroxime

A prospective, randomised and double blind study was undertaken to compare the prophylactic efficacy of ciprofloxacin and cefuroxime in 155 patients undergoing elective cholecystectomy. Patients with past history of jaundice or presence of jaundice, diabetes mellitus, common bile duct stones and previous biliary tract surgery were excluded. Patients were allocated to the following groups: group A-no antibiotic (n = 30); group B-ciprofloxacin (200 mg i/v before surgical incision and a second dose after 12 hrs) (n + 45); group C-ciprofloxacin given only post operatively (200 mg i/v, 12 hourly X 2 days followed by oral 500 mg twice daily X 3 days) (n = 35); group D-cefuroxime (750 mg i/v before surgical incision and a second dose after 12 hrs) (n = 45). Efficacy of the antibiotic was defined as a patient being free of post operative wound infection. Maximum numbers of infection occurred in group A (26.67%) and group C (25.71%). The incidence of wound infection was significantly lower when ciprofloxacin was used as prophylaxis (group B) than when used post operatively (group C) only (P < 0.05). Patients who received ciprofloxacin (group B) and cefuroxime (group D) as prophylaxis had significantly reduced incidence of infection (4.44% and 6/67% respectively); no statistically significant difference was found between these groups. Ciprofloxacin could be used as prophylactic antimicrobial in elective cholecystectomy in developing countries because of its effectiveness, economy and ready availability.

Cryptosporidiosis in a tertiary care hospital

BACKGROUND

Cryptosporidium, an important cause of diarrhoea, has been reported worldwide both in immunocompetent and immunocompromised individuals and has emerged as a serious public health problem. This study was undertaken to assess the present status of cryptosporidiosis in children and adults with diarrhoea who attended the Nehru Hospital, Chandigarh which is a tertiary care hospital.

METHODS

Routine stool examination was done using saline and iodine stained preparations for various parasites. Modified Ziehl-Neelsen and rapid safranin-methylene blue techniques were used to detect Cryptosporidium in 2000 stool samples (1645 adults, 355 children) from March to November 1998.

RESULTS

Of the 2000 samples, 205 (10.2%) were positive for various parasites. Five (1.4%) children were positive for Cryptosporidium and one child was positive for human immunodeficiency virus. In adults, Cryptosporidium was found in only one patient (0.06%). Giardia lamblia was the commonest parasite detected both in adults (4%) and children (15.2%).

CONCLUSION

The present study highlights the importance of Cryptosporidium as a cause of diarrhoea, especially in children. Thus, there is a need for specific staining techniques to detect Cryptosporidium in routine diagnostic laboratories.

Characterization of Giardia lamblia groups A and B from North India by isoenzyme and random amplified polymorphic DNA analysis

Giardia lamblia (syn. G. intestinalis) infection in young adults leads to acute/chronic diarrhea in some individuals and is asymptomatic in others. Recently, G. lamblia strains have been characterized as group A (symptomatic) and group B (asymptomatic or control) by advanced isoenzyme and molecular biology studies. In the present brief pilot study, ten G. lamblia isolates obtained from five symptomatic (group A) and five asymptomatic (group B) persons were characterized by isoenzyme and random amplified polymorphic DNA (RAPD) analysis. Isoenzyme analysis demonstrated remarkable homogeneity in seven enzyme patterns, the exception, being that of phosphoglucomutase, for which two zymodemes (I and III) were observed. In contrast, RAPD analysis showed homogeneity for eight primers; exceptions were two primers, A02 and B05, which separated group A G. lamblia isolates into two rapdemes (A(R1) and A(R2)) and group B G. lamblia isolates into four rapdemes (B(R1), B(R2), B(R3) and B(R4)). Further phenetic analysis showed average genetic distances of 0.105 within group A and 0.121 within group B G. lamblia isolates according to Jaccord's distance scale, which suggests that both lineages appear to consist of a range of variants with no significant (P < 0.05) genetic diversity. The two techniques demonstrated a positive association with regard to differentiation between group A and group B G. lamblia isolates. These very preliminary results indicate that RAPD analysis could be a potentially useful substitute for isoenzyme analysis.

A high incidence of ciprofloxacin resistance in urinary isolates in eastern Nepal

A study was conducted to examine the incidence of ciprofloxacin resistance in the strains of bacteria isolated from patients with suspected urinary tract infection (UTI) and to analyse the level of resistance. A total of 63 bacterial isolates were grown from quantitative urine culture and were in significant count. Antibiotic susceptibility tests were done by using disc diffusion method of Kirby-Bauer and the level of resistance was analyzed by break point minimum inhibitory concentration (MIC). Majority of bacteria isolated and tested were Gram negative with Escherichia coli as the commonest isolate. Antibiotic susceptibility testing revealed a high prevalence of resistance to nalidixic acid, ampicillin and norfloxacin.