The effects of anti-TNF-α treatment with adalimumab on growth in children with Crohn's disease (CD)

INTRODUCTION

Adalimumab is used to treat children with Crohn's disease (CD), but the effects of adalimumab on growth in CD have not been studied.

AIM

To study growth and disease activity over 12 months (6 months prior to (T-6), baseline (T0) and for 6 months following (T+6) adalimumab).

SUBJECTS AND METHODS

Growth and treatment details of 36 children (M: 22) who started adalimumab at a median (10th, 90th) age of 14.7 years (11.3, 16.8) were reviewed.

RESULTS

Of 36 cases, 28 (78%) went into remission. Overall 42% of children showed catch up growth, which was more likely in: (i) those who achieved remission (median change in height SDS (ΔHtSDS) increased from -0.2 (-0.9, 1.0) at T0 to 0.2 (-0.6, 1.6) at T+6, (p=0.007)), (ii) in those who were on immunosuppression ΔHtSDS increased from -0.2 (-0.9, 1.0) at T0 to 0.1 (-0.8, 1.3) at T+6, (p=0.03) and (iii) in those whose indication for using adalimumab therapy was an allergic reaction to infliximab, median ΔHtSDS increased significantly from -0.3 (-0.9, 1.0) at T0 to 0.3 (-0.5, 1.6) at T+6, (p=0.02). Median ΔHtSDS also increased from -0.4 (-0.8, 0.7) at T0 to 0.0 (-0.6, 1.6) at T+6, (p=0.04) in 15 children who were on prednisolone therapy when starting adalimumab.

CONCLUSION

Clinical response to adalimumab therapy is associated with an improvement in linear growth in a proportion of children with CD. Improved growth is more likely in patients entering remission and on immunosuppression but is not solely due to a steroid sparing effect.

Curative one-shot systemic virotherapy in murine myeloma

Current therapy for multiple myeloma is complex and prolonged. Antimyeloma drugs are combined in induction, consolidation and/or maintenance protocols to destroy bulky disease, then suppress or eradicate residual disease. Oncolytic viruses have the potential to mediate both tumor debulking and residual disease elimination, but this curative paradigm remains unproven. Here we engineered an oncolytic vesicular stomatitis virus to minimize its neurotoxicity, enhance induction of antimyeloma immunity, and facilitate noninvasive monitoring of its intratumoral spread. Using high resolution imaging, autoradiography and immunohistochemistry, we demonstrate that the intravenously administered virus extravasates from tumor blood vessels in immunocompetent myeloma-bearing mice, nucleating multiple intratumoral infectious centers which expand rapidly and necrose at their centers, ultimately coalescing to cause extensive tumor destruction. This oncolytic tumor debulking phase lasts only for 72 hours after virus administration, and is completed before antiviral antibodies become detectable in the bloodstream. Anti-myeloma T cells, cross-primed as the virus-infected cells provoke an antiviral immune response, then eliminate residual uninfected myeloma cells. The study establishes a curative oncolytic paradigm for multiple myeloma where direct tumor debulking and immune eradication of minimal disease are mediated by a single intravenous dose of a single therapeutic agent. Clinical translation is underway.

Novel Tandem Duplication in Exon 1 of the SNURF/SNRPN Gene in a Child with Transient Excessive Eating Behaviour and Weight Gain

A deletion in 15q11.2 involving the SNURF/SNRPN gene is the typical finding in patients with Prader-Willi syndrome. Apart from translocations disrupting this gene, no other mutation types have been described so far. We report a patient in whom a small duplication in exon 1 of the SNURF/SNRPN gene was diagnosed which is predicted to interrupt only SNURF expression. The patient was investigated due to overgrowth, increased appetite and developmental delay in childhood. This duplication was inherited from her father who carries the duplication on his paternal chromosome 15 and also had transient excessive eating behaviour as an adolescent. RNA studies showed that the duplication introduces a premature stop codon in SNURF.

Valsartan Loaded Solid Lipid Nanoparticles: Development, Characterization, and In vitro and Ex vivo Evaluation

Qualitative analysis of a mucoadhesive polymeric (hydroxypropyl methylcellulose, HPMC) suspension of norfloxacin was carried out with the aim of developing an oral controlled release gastro-retentive dosage form. The characterization of ultrasonicated formulation was performed by Fourier Transform Infrared Spectroscopy (FTIR), Raman spectroscopy, X-ray powder diffraction (XRD) and Scanning electron microscopy (SEM) analyses. For interpretation, FTIR (400-4000 cm-1 region) and Raman (140-2400 cm-1 region) spectra were used. XRD data of pure drug, polymer and the mucoadhesive polymeric suspension were obtained using a powder diffractometer, scanned from a Bragg’s angle (2θ) of 10˚ to 70˚. In addition, dispersion of particle was studied using SEM techniques. The results from FTIR and Raman spectroscopic analyses of the mucoadhesive suspension suggested that carboxylic groups of norfloxacin and hydroxyl groups of HPMC undergo chemical interaction leading to esterification and hydrogen bonding. The XRD data indicated the retention of crystalline nature of norfloxacin in the mucoadhesive suspension. Moreover, the SEM image analysis suggested that in the formulation, maximum particles exhibited network like structure to produce pseudoplastic flow. From our analysis, it may be concluded that it is feasible to prepare a homogeneous, uniformly dispersed, pharmaceutically stable controlled release norfloxacin suspension that has better bioavailability and penetration capacity.

Genome-wide association study identifies multiple novel loci associated with disease progression in subjects with mild cognitive impairment

Alzheimer's disease (AD) is the leading cause of dementia among the elderly population; however, knowledge about genetic risk factors involved in disease progression is limited. We conducted a genome-wide association study (GWAS) using clinical decline as measured by changes in the Clinical Dementia Rating-sum of boxes as a quantitative trait to test for single-nucleotide polymorphisms (SNPs) that were associated with the rate of progression in 822 Caucasian subjects of amnestic mild cognitive impairment (MCI). There was no significant association with disease progress for any of the recently identified disease susceptibility variants in CLU, CR1, PICALM, BIN1, EPHA1, MS4A6A, MS4A4E or CD33 following multiple testing correction. We did, however, identify multiple novel loci that reached genome-wide significance at the 0.01 level. These top variants (rs7840202 at chr8 in UBR5: P=4.27 × 10(-14); rs11637611 with a cluster of SNPs at chr15q23 close to the Tay-Sachs disease locus: P=1.07 × 10(-15); and rs12752888 at chr1: P=3.08 × 10(-11)) were also associated with a significant decline in cognition as well as the conversion of subjects with MCI to a diagnosis of AD. Taken together, these variants define approximately 16.6% of the MCI sub-population with a faster rate of decline independent of the other known disease risk factors. In addition to providing new insights into protein pathways that may be involved with the progress to AD in MCI subjects, these variants if further validated may enable the identification of a more homogeneous population of subjects at an earlier stage of disease for testing novel hypotheses and/or therapies in the clinical setting.

Effector T cells immune reactivity among patients with acute hepatitis E

Hepatitis E virus (HEV) is a leading cause of acute viral hepatitis in several developing countries. Information on cellular immune responses during acute hepatitis E is limited. We therefore studied peripheral blood mononuclear cells (PBMCs) from patients with acute hepatitis E and healthy adult subjects who lacked anti-HEV antibodies for enumeration of various T-cell subsets using flow cytometry and to assess HEV-specific T effector cell responses using interferon-gamma ELISPOT assays. The patients showed increased numbers of CD8(+) cells and CD4(+) CD8(+) cells compared with healthy controls. In addition, the proportion of PBMCs that produced interferon-gamma in response to recombinant HEV open reading frame (ORF) 2 and ORF 3 proteins were found to be higher in patients than in healthy controls. Using pools of 15-mer overlapping peptides corresponding to these recombinant proteins, the immunodominant regions in these proteins for interferon-gamma-producing cells were mapped to regions corresponding to amino acids 181-249 and 301-489 of HEV ORF2 protein. These data provide evidence for the activation of effector T cells during acute hepatitis E. These responses may play a role in viral clearance from the host in patients with HEV infection.

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease

BACKGROUND

Adalimumab is efficacious therapy for adults with Crohn's disease (CD).

AIM

To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience.

METHODS

British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA).

RESULTS

Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate).

CONCLUSIONS

Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.

Oral calcium supplementation reverses the biochemical pattern of parathyroid hormone resistance in underprivileged Indian toddlers

BACKGROUND

Toddlers in Pune, India, accustomed to low dietary calcium intake but vitamin D replete have low serum ionised calcium and inappropriately raised serum inorganic phosphorus concentrations together with elevated serum parathyroid hormone (PTH) concentrations. We hypothesised that dietary calcium deficiency leads to end organ resistance to PTH, thus resulting in mild hypocalcaemia and hyperphosphataemia, and that this would be reversed by oral calcium supplementation.

METHODS

51 subjects (25 male; mean (SD) age 2.4 (0.8) years) from an urban slum in Pune were randomised to 500 mg of oral calcium supplement or placebo, daily, for 8 weeks. All subjects received 20 mg of oral elemental iron, daily, as 90% had a serum ferritin concentration <12 microg/l. All subjects were examined for clinical stigmata of rickets and had a wrist radiograph performed. Serum concentrations of ionised calcium, phosphorus, PTH and fibroblast growth factor-23 (FGF-23) were measured at the start and end of the trial.

RESULTS

No subject had clinical or radiological evidence of rickets. There was a significant increase in mean serum ionised calcium concentration (p<0.001) in the supplemented but not the placebo group (p = 0.32). The decrease in mean serum phosphorus concentration in the supplemented group was greater (p<0.001) than in the placebo group (p = 0.003). Mean serum PTH fell in the calcium supplemented (p = 0.001) but not in the placebo (p = 0.303) group. The mean serum FGF-23 concentration did not change in response to calcium supplementation.

CONCLUSIONS

From these data the authors conclude that low dietary calcium intake is associated with resistance to PTH.

Increased T-lymphocyte apoptosis in lupus correlates with disease activity and may be responsible for reduced T-cell frequency: a cross-sectional and longitudinal study

Apoptosis of lymphocytes is increased in patients with lupus. This may be pathogenic leading to increased load of autoantigens or may be a bystander effect of immune activation. A major unresolved issue is whether apoptosis is related to disease activity. Also its association with lymphocyte frequencies, anti-nucleosomal antibodies and serum IL 10 levels needs to be explored further. The aims of this study are to measure T- and B-lymphocyte apoptosis in patients with lupus and look at the effect of disease activity in a cross-sectional and longitudinal design and to determine frequency of T and B cells, level of anti-nucleosomal antibodies and serum IL 10 and assess their relationship with apoptosis. This study included 41 patients with SLE and 20 controls. A cutoff value of 4 in systemic lupus erythematosus disease activity index (SLEDAI) was used to separate active from inactive SLE. The frequency and degree of apoptosis of T and B lymphocyte were enumerated by flow cytometry using peripheral blood mononuclear cells (PBMCs) stained with CD3/CD19 and annexin V/PI. The data for T/B cell frequency are represented as % of these cells in the PBMC population, whereas percentage of apoptotic cells is out of total T or B cells. Serum anti-nucleosomal antibodies and IL 10 were assayed using ELISA. A repeat assessment of these parameters was carried out in 11 active patients when they became inactive. We found higher T-lymphocyte apoptosis in patients with SLE versus controls (14.8 +/- 9.2, 7.2 +/- 3.0; P < 0.05) and a lower frequency of T cells (72.7 +/- 12.6, 79.9 +/- 5.8; P < 0.05). T-lymphocyte apoptosis was higher in patients with active disease compared with inactive (18.5 +/- 11.3, 11.6 +/- 5.4; P = 0.05). Further, T-lymphocyte apoptosis directly correlated with SLEDAI (r = 0.37, P < 0.05) and inversely with T-cell frequency (r = -0.29, P < 0.05). Anti-nucleosomal antibodies correlated with SLEDAI but not apoptosis. On longitudinal follow-up, a decline in T-cell apoptosis was seen in patients with SLE, however this was not statistically significant. We confirmed a higher degree of apoptosis in T-lymphocytes in patients with SLE and found a direct correlation of T-cell apoptosis with disease activity. Patients had reduced T-cell frequency, which inversely correlated with T-cell apoptosis and may suggest a cause-effect relationship.

Q-switched Nd:YAG Laser to Treat Nevomelanocytic Nevi

Background:

Q-switched Nd:YAG laser, a melanin pigment-specific laser was used to treat melanocytic nevi in Indian patients.

Objective:

To assess the clinical response of nevi to Q-switched Nd:YAG laser of 1064 nm wavelength.

Materials and Methods:

Nineteen patients received an average of 2.57 treatments with Q-switched Nd:YAG laser of 1064 nm wavelength, repetition rate of 10 Hz, 10 nanoseconds pulse width, and spot size of 4 mm to 6 mm with a fluence ranging from 4 to 9.7 joules/cm². The clinical end point of the laser treatment was brisk whitening. The response was assessed by using a global assessment score.

Results:

The clinical global assessment score showed excellent response in 8/19 patients and good response in 6/19 patients.

Conclusion:

The Q-switched Nd:YAG laser of 1064 nm wavelength resulted in significant improvement (lightening) of nevi.

Severe tissue trauma triggers the autoimmune state systemic lupus erythematosus in the MRL/++ lupus-prone mouse

Tissue damage associated with a severe injury can result in profound inflammatory responses that may trigger autoimmune development in lupus-prone individuals. In this study, we investigated the role of a large full-thickness cutaneous burn injury on the early onset of autoimmune disease in lupus-prone MRL/++ mice. MRL/++ mice (chronic model) exhibit autoimmune symptoms at >70 weeks of age, whereas MRL/-Faslpr mice (acute model) develop autoimmune disease in 17–22 weeks due to a lymphoproliferative mutation. Autoimmune disease developed in MRL/++ mice (4–15 weeks post injury) is manifested by skin lesions, vasculitis, epidermal ulcers, cellular infiltration, splenomegaly, lymphadenopathy, hypergammaglobulinemia, elevated autoantibodies and renal pathologies including proteinuria, glomerulonephritis and immune complex deposition; complications that contribute to reduced survival. Transcription studies of wound margin tissue show a correlation between the pathogenic effects of dysregulated IL-1β, IL-6, TNF-α and PGE2 synthesis during early wound healing and early onset of autoimmune disease. Interestingly, MRL/++ mice with healed wounds (30–40 days post burn) strongly rejected skin isografts. Conversely, skin isografts transplanted onto naive age-matched MRL/++ littermates achieved long-term survival. Collectively, these findings suggest that traumatic injury exacerbates inflammatory skin disease and severe multi-organ pathogenesis in lupus-prone mice.

Alterations in natural killer cells and natural killer T cells during acute viral hepatitis E

The mechanism of liver damage in acute hepatitis E is poorly understood. In this study, we assessed the frequency and activation status of natural killer (NK) and natural killer T (NKT) cells and cytotoxic activity of NK cells in the peripheral blood mononuclear cells (PBMCs) obtained from patients with hepatitis E (n = 41) and healthy controls (n = 61). Flow cytometry was used to assess NK (CD3(-)/CD56(+)) and NKT cell (CD3(+)/CD56(+)) fractions (% of PBMCs) and activation status (CD69(+); % of NK, NKT cells). NK cell cytotoxicity was assessed using major histocompatibilities complex-deficient K562 cells as target cells. In 14 patients, the studies were repeated during the convalescence period. Patients had fewer median (range) NK cells [8.9% (2.4-47.0) vs 11.2% (2.6-35.4)] and NKT cells [8.7% (2.8-34.1) vs 13.6% (2.3-36.9)] than controls (P < 0.05 each). Activation markers were present on large proportion of NK cells [43.5% (11.2-58.6) vs 15.5% (3.0-55.8)] and NKT cells [41.5% (17.4-71.1) vs 12.8% (3.3-63.2); P < 0.05 each] from patients. NK cell cytotoxicity was similar in patients and controls. During convalescence, all the parameters normalized. In conclusion, reversible alterations in NK and NKT cell number and activation status during acute hepatitis E suggest a role of these cells in the pathogenesis of this disease.

Prophylactic efficacy of high-molecular-weight antigenic fractions of a recent clinical isolate of Leishmania donovani against visceral leishmaniasis

T-cell mediated immune responses are key determinants to the natural course of infection caused by intracellular parasites such as Leishmania. Thus, T-cell activating proteins of these microbes continue to generate active interest particularly in view of their possible role in the design and development of newer and more effective vaccines. We have recently reported the presence of T-cell immunostimulatory antigens with the high-molecular-weight (MW) fractions (134-64.2 kDa) of whole Leishmania donovani antigen (strain 2001), which stimulated variable amounts of IFN-gamma, IL-12 and IL-10 in exposed immune individuals. The present study was undertaken to further evaluate these high-MW antigenic fractions (MW range >100-60 kDa) for potential protective efficacy. The high-MW region of the parasite was resolved into five antigenic fractions (Prep A-E) using continuous elution gel electrophoresis. Prior to in vivo protection studies in hamsters, these fractions were used to evaluate in vitro cellular responses in eight Leishmania-exposed individuals and treated cured hamsters. The protective efficacy of prep (A + B), C, D and E in combination with BCG was evaluated in inbred hamsters using standard immunization protocol. Proliferative responses were seen in all eight of eight exposed individuals to prep D [median stimulation index (SI): 5.2 (range 3.9-7.1)] and E [median SI: 5.6 (range 4.4-8.2)], five of eight individuals to prep B and prep C and three of eight to prep A [median SI: 0.2 (range 0.1-7.2)]. The median proliferative responses to prep D and prep E were significantly higher than to fraction prep A; (P < 0.05) but not to prep B and prep C. However, prep A-E induced equivalent levels of IFN-gamma, IL-10 and IL-12 cytokines. Fractions D and E also exhibited marked parasite inhibition in spleen (52.5% and 73.7%) and liver (65% and 80.2%) as compared with prep (A + B) (23% in spleen and 24% in liver) and prep C (38% in spleen and 24% in liver). Prep D and prep E vaccinated animals showed higher in vitro stimulatory responses (mean SI: 6.6 and 8.8) and nitric oxide (NO) induction (mean NO levels: 6.4 and 10.7 mug/ml) against whole cell extract as compared with other groups. The protection also correlated with presence of suppressed Leishmania-specific IgG levels in prep D and prep E immunized hamsters. These studies indicate the presence of immunostimulatory and protective molecules in 60-80 kDa region of L. donovani, which may be further exploited for developing a subunit vaccine.

Oesophageal and tracheal perforation in thyroid B-cell lymphoma

We report an unusual case of spontaneous oesophageal and tracheal perforation secondary to thyroid B-cell lymphoma in a previously healthy 76-year-old woman. Findings on chest radiography, CT and oesophagram are correlated to endoscopy, surgery and pathology. Such perforation is a rare and serious complication that should be specifically considered when a patient with a neck neoplasm develops acute respiratory or gastrointestinal symptoms.

Successful treatment of Nocardia nova bacteremia and multilobar pneumonia with clarithromycin in a heart transplant patient

Nocardia is an opportunistic pathogen in solid organ transplantation for which long-term sulfonamide therapy is considered the treatment of choice. We report a patient 7 months status post-orthotopic heart transplantation with Nocardia nova bacteremia and pneumonia. Initial treatment consisted of intravenous trimethoprim-sulfamethoxazole, which cleared blood cultures, but the patient subsequently went into renal failure and required alternative therapy. This report describes the first case of N nova bacteremia after orthotopic heart transplantation successfully treated with clarithromycin. All therapy should be guided by antibiotic sensitivity, and combination therapy should be considered in acutely ill patients and cases where in vitro synergy has been documented. This case suggests that clarithromycin can be an alternative treatment in cases of sulfonamide resistance, intolerance, or allergy.

Hepatitis E virus infection among animals in northern India: an unlikely source of human disease

Hepatitis E virus (HEV) is a major cause of acute hepatitis in many developing countries. Based on data from nonendemic regions, an animal reservoir of HEV has been proposed; however, data from HEV-endemic regions are limited. We tested sera from 200 pigs, 98 chickens, 86 goats, 58 sheep and 30 buffaloes for anti-HEV IgG using two different enzyme immunoassays. Specificity of the detected antibodies was confirmed using inhibition assays. Stool specimens from 210 pigs, 94 piglets and 37 sheep were tested for HEV-RNA using nested amplification methods; the polymerase chain reaction products were sequenced and compared with known human and swine HEV sequences. Of the 200 swine sera, 193 and 195, respectively, tested positive in the two assays. All goat sera showed anti-HEV reactivity in both the assays. Inhibition studies confirmed the HEV specificity of antibodies detected in swine and goat sera using both the assays. Sera from sheep, buffalo and chickens also showed high rates of apparent reactivity, but inhibition studies were unable to confirm the specificity of reactions in these species. One faecal specimen showed amplification using Indian swine HEV-specific primers. The genomic sequence of the amplicon from this isolate had only 76-79% nucleotide and 93% amino acid homology with human HEV isolates reported from India and other parts of the world, and most closely resembled swine HEV isolates from other parts of India. Infection with HEV or a related agent is widespread among animals in northern India. However, the swine HEV in India differs genetically from human HEV isolates, indicating that pigs may not play an important role in the spread of human hepatitis E in endemic regions.

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.

Comparison of generalized autocalibrating partially parallel acquisitions and modified sensitivity encoding for diffusion tensor imaging

BACKGROUND AND PURPOSE

Diffusion tensor magnetic resonance imaging (DTI) of the brain is usually acquired with single-shot echo-planar imaging, which is associated with localized signal loss, geometric distortions, and blurring. Parallel imaging can lessen these artifacts by shortening the length of the echo-train acquisition. The self-calibrating parallel acquisition techniques, image domain-based modified sensitivity encoding (mSENSE) and k-space-based generalized autocalibrating partially parallel acquisitions (GRAPPA), were evaluated with DTI of the brain in 5 healthy subjects.

METHODS

GRAPPA and mSENSE with higher acceleration factors (R) up to 4 were compared with conventional DTI (with and without phase partial Fourier, another method of reducing the echo-train length) on a 1.5T Sonata scanner (Siemens, Erlangen, Germany). The resulting images and diffusion maps were evaluated qualitatively and quantitatively. Qualitative analysis was performed by 3 reviewers blinded to the technique using image sharpness and the level of artifacts as characteristics for scoring each set of images. Quantitative comparisons encompassed measuring signal-to-noise ratio, Trace/3 apparent diffusion coefficient (ADC), and fractional anisotropy (FA) in 6 white-matter (WM) and gray-matter (GM) regions.

RESULTS

Reviewers scored the GRAPPA and mSENSE R = 2 images better than images acquired with conventional techniques. FA contrast was improved at the GM/WM junction in peripheral brain areas. Trace/3 ADC and FA measurements were consistent for all methods. However, R = 3,4 images suffered from reconstruction-related artifacts.

CONCLUSIONS

GRAPPA and mSENSE (R = 2) minimized the susceptibility and off-resonance effects associated with conventional DTI methods, yielding high-quality images and reproducible quantitative diffusion measurements.

A potential role for interleukin-18 in inhibition of the development of Cryptosporidium parvum

Accumulating evidence suggests that intestinal epithelial cells (IECs) constitutively express the immunoregulatory cytokine interleukin (IL)-18. IECs also serve as the host cell for the intracellular parasitic protozoan Cryptosporidium parvum. In the present study, C. parvum infection of a human enterocyte cell-line HCT-8 resulted in increased expression of IL-18 mRNA as measured by quantitative reverse transcription-polymerase chain reaction (RT-PCR). IL-18 protein was detected in control uninfected cells and following infection there was increased expression as measured by enzyme-linked immunosorbent assay (ELISA). Gene expression revealed the presence of the IL-18 receptor subunits not only in cell-lines but also in freshly isolated IECs, suggesting that IL-18-mediated signalling events may contribute to epithelial host defence during infection. Recombinant IL-18 inhibited intracellular development of the parasite in HCT-8 and HT-29 cells. Increased expression of bactericidal antibiotic peptides LL-37 and alpha-defensin 2 by IL-18 in HCT-8 and HT-29 cells may represent one mode of action by which this pluripotent cytokine aids in limiting the development of intracellular pathogens such as C. parvum in the gastrointestinal tract.

Incarcerated inguinal hernia presenting as spontaneous scrotal fecal fistula

We report a case of neglected, strangulated, inguinal hernia in a middle-aged male, which presented as a scrotal fecal fistula. This is the first such case reported in an adult. The patient was treated by resection and anastamosis of the ileum, local debridement of the scrotum and Shouldice repair for the inguinal defect.

Bone mass in Indian children--relationships to maternal nutritional status and diet during pregnancy: the Pune Maternal Nutrition Study

CONTEXT/OBJECTIVE

Bone mass is influenced by genetic and environmental factors. Recent studies have highlighted associations between maternal nutritional status during pregnancy and bone mass in the offspring. We hypothesized that maternal calcium intakes and circulating micronutrients during pregnancy are related to bone mass in Indian children. DESIGN/SETTING/PARTICIPANTS/MAIN OUTCOME MEASURES: Nutritional status was measured at 18 and 28 wk gestation in 797 pregnant rural Indian women. Measurements included anthropometry, dietary intakes (24-h recall and food frequency questionnaire), physical workload (questionnaire), and circulating micronutrients (red cell folate and plasma ferritin, vitamin B12, and vitamin C). Six years postnatally, total body and total spine bone mineral content and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA) in the children (n = 698 of 762 live births) and both parents.

RESULTS

Both parents' DXA measurements were positively correlated with the equivalent measurements in the children (P < 0.001 for all). The strength of these correlations was similar for fathers and mothers. Children of mothers who had a higher frequency of intake of calcium-rich foods during pregnancy (milk, milk products, pulses, non-vegetarian foods, green leafy vegetables, fruit) had higher total and spine bone mineral content and BMD, and children of mothers with higher folate status at 28 wk gestation had higher total and spine BMD, independent of parental size and DXA measurements.

CONCLUSIONS

Modifiable maternal nutritional factors may influence bone health in the offspring. Fathers play a role in determining their child's bone mass, possibly through genetic mechanisms or through shared environment.

Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues

Hydrogen peroxide in the form of carbamide peroxide is widely used for tooth whitening (bleaching), both in professionally- and in self-administered products. Adverse effects have become evident. Cervical root resorption is a possible consequence of internal bleaching and is more frequently observed in teeth treated with the thermo-catalytic procedure. Tooth sensitivity is experienced in 15-78% of patients undergoing external tooth bleaching. However, clinical studies addressing other adverse effects are lacking. Direct contact with hydrogen peroxide induces genotoxic effects in bacteria and cultured epithelial cells, but the effect is reduced or totally abolished in the presence of metabolising enzymes. Several carcinogenesis studies, including the hamster cheek pouch model, indicate that hydrogen peroxide (H(2)O(2)) might possibly act as a promoter. Until further clinical research is concluded to address the question of possible carcinogenicity, it is recommended that: tooth-bleaching products using concentrated H(2)O(2) should not be used without gingival protection; that H(2)O(2) containing products should be avoided in patients with damaged or diseased soft tissues. For nightguard vital bleaching, minimal amounts of low dose H(2)O(2) (including in the form of carbamide peroxide) are preferred, thereby avoiding prolonged and concentrated exposures.

Benign esophageal stricture following aluminium phosphide poisoning

Aluminium phosphide is often implicated in accidental and suicidal poisoning in India. Ingestion of even half a fresh tablet invariably results in death, whereas exposed tablets are usually considered harmless. We report two cases of short-segment esophageal strictures that occurred following ingestion of exposed tablet of aluminium phosphide. Both cases could be successfully managed by endoscopic dilatation.

Leishmania donovani: Identification of stimulatory soluble antigenic proteins using cured human and hamster lymphocytes for their prophylactic potential against visceral leishmaniasis

Most of the studies for the identification of prophylactic antigens that elicit T cell responses were concentrated on membrane proteins of Leishmania donovani. This study was taken up to assess L. donovani soluble promastigote antigens for their ability to stimulate proliferation of peripheral blood mononuclear cells (PBMCs) from cured visceral leishmaniasis (VL) patients, endemic and non-endemic controls and lymphocytes/peritoneal macrophages of cured hamsters. The soluble protein was subjected to sequential precipitation with saturated ammonium sulphate (20%, 40%, 60% and 80%), of which largely 80% fractioned protein showed significant cellular responses in cured patients and hamsters. This fraction was further fractionated into five sub fractions by preparative SDS-PAGE and subjected to re-evaluation for their ability to induce cellular responses. Out of these, only F2 sub fraction belonging to the MW of 97.4-68 kDa stimulated remarkable lymphoproliferative and IFN-gamma responses in cured VL patients and in endemic controls. Similarly, significant lymphoproliferative responses and nitric oxide production were also noticed in cured Leishmania infected animals indicating an element of uniformity in responses between hamster and human. F2 sub fraction, when evaluated for its prophylactic efficacy with BCG against L. donovani challenge in hamster exhibited significant parasite inhibition in spleen (71.1%; p<0.001) and liver (68.2%; p<0.001) as compared to their unvaccinated counterpart. The vaccinated animals showed significant lymphoproliferative response and nitric oxide production but leishmania specific IgG level were suppressed. The results indicate the presence of immunostimulatory and protective molecules in F2 sub fraction which may further be exploited for the development of a vaccine against VL, hitherto an unrealized goal.

HLA-E and immunobiology of pregnancy

Recently, it has been suggested that non-classical antigens such as human leukocyte antigen (HLA)-G and HLA-E may interact with KIR receptors of NK cells which results into downregulation of immune response and helps in the maintenance of pregnancy. In the present study, we have investigated HLA-E polymorphism in normal fertile women and recurrent spontaneous aborters to assess the effect of HLA-E alleles on the success of pregnancy. Allele E*0101 was found to be significantly higher in patients with recurrent spontaneous abortion (chi(2) = 4.097 and P = 0.0430). Differential expression, peptide affinity, and stability of E*0101 may be one of the reasons.

Identification of Leishmania donovani antigens stimulating cellular immune responses in exposed immune individuals

Human visceral leishmaniasis (VL), also known as kala azar (KA) in India, is a systemic progressive disease caused by Leishmania donovani. In VL, Th1 responses correlate with recovery from and resistance to disease and resolution of infection results in lifelong immunity against the disease. However, recent data suggest an important role for interleukin (IL)-10 in maintaining the resistant state. We evaluated whole cell extract (WE) and 11 antigenic fractions [F1-F11, molecular weight (MW) range of 139-24.2 kDa] from L. donovani (2001 strain, a fresh field isolate from Bihar), for their ability to induce in vitro T cell proliferation and production of interferon (IFN)-gamma, interleukin (IL)-12, IL-10 and IL-4 by peripheral blood mononuclear cells (PBMCs) of exposed immune individuals (14 patients with history of VL, 10 household endemic contacts) and 20 non-endemic healthy controls. Twenty-one of 24 exposed individuals and no healthy controls showed proliferative response to WE. Whole-extract activated IFN-gamma, IL-12, IL-10 levels were higher in the exposed group than in controls; IL-4 was not detectable in any of the samples. Among 21 responders to WE, frequent proliferative responses were seen to fractions F1-F4 (MW > 64.2 kDa) and none to fractions F5-F11; fractions F1-F11 stimulated comparable levels of IFN-gamma and IL-12 while IL-10 levels were higher in response to F5-F11 compared to F1-F4. These data demonstrate the presence of immunostimulatory antigens in the high MW fractions of whole L. donovani antigen. However, these fractions do not stimulate a Th1 response and produce variable amounts of IFN-gamma and the regulatory cytokine, IL-10. Hence, these high MW immunostimulatory fractions need to be evaluated in greater depth for their possible role as protective antigens.

External cervical resorption of a primary canine

The authors describe the case of a 3-year-old boy who presented with a mobile right maxillary primary canine. Clinical examination revealed this tooth to have an abnormally large crown, which appeared to have sustained a crown-root fracture. Periodontal probing depths of 5 mm were detected around the tooth. Radiographically, there was a marked constriction at the cementoenamel junction with associated alveolar rarefaction. Both upper primary canines were subsequently removed under general anaesthetic and the right canine was subject to histopathological investigation. A diagnosis of external cervical resorption was made. A review of the literature confirmed this to be a very unusual case presentation.

Immunostimulatory cellular responses of cured Leishmania-infected patients and hamsters against the integral membrane proteins and non-membranous soluble proteins of a recent clinical isolate of Leishmania donovani

Development of an effective immunoprophylactic agent for visceral leishmaniasis (VL) has become imperative due to the increasing number of cases of drug resistance and relapse. Live and killed whole parasites as well as fractionated and recombinant preparations have been evaluated for vaccine potential. However, a successful vaccine against the disease has been elusive. Because protective immunity in human and experimental leishmaniasis is predominantly of the Th1 type, immunogens with Th1 stimulatory potential would make good vaccine candidates. In the present study, the integral membrane proteins (IMPs) and non-membranous soluble proteins (NSPs), purified from promastigotes of a recent field isolate, Leishmania donovani stain 2001, were evaluated for their ability to induce cellular responses in cured patients (n = 9), endemic controls (n = 5) of visceral leishmaniasis (VL) and treated hamsters (n = 10). IMPs and NSPs induced significant proliferative responses (SI 6.3 +/- 4.1 and 5.6 +/- 2.3, respectively; P < 0.01) and IFN-gamma production (356.3 +/- 213.4 and 294.29 +/- 107.6 pg/ml, respectively) in lymphocytes isolated from cured VL patients. Significant lymphoproliferative responses against IMPs and NSPs were also noticed in cured Leishmania animals (SI 7.2 +/- 4.7 & 6.4 +/- 4.1, respectively; P < 0.01). In addition, significant NO production in response both IMPs and NSPs was also noticed in macrophages of hamsters and different cell lines (J774A-1 and THP1). These results suggest that protective, immunostimulatory molecules are present in the IMP and NSP fractions, which may be exploited for development of a subunit vaccine for VL.

Analysis of human leukocyte antigen (HLA)-G polymorphism in normal women and in women with recurrent spontaneous abortions

Human leukocyte antigen (HLA)-G is a non-classical class I antigen. It has limited expression, but is high at the foetomaternal interface. This unique expression pattern of HLA-G suggests that it might be important for survival of the foetus during pregnancy. In the present study, 120 women with recurrent spontaneous abortions (RSA) and 120 fertile control women were genotyped for the HLA-G locus. This is the first report describing HLA-G polymorphism in normal fertile and RSA women from India. The allele HLA-G*010103 was higher in women with recurrent foetal losses. Interestingly, the HLA-G*010105 and G*010108 alleles were totally absent in normal fertile women but present in RSA women with frequencies of 1.7% and 0.4%, respectively. Allele G*010107 was absent in both the groups. The frequency of the null allele G*0105N was high (13.8%) in our population as compared to other world populations. Our data support the hypothesis that HLA-G polymorphism may contribute to recurrent foetal loss.

Mineral trioxide aggregate as a pulpotomy agent in primary molars: an in vivo study

The retention of pulpally involved deciduous tooth in a healthy state until the time of normal exfoliation remains to be one of the challenges for Pedodontists. A scientific noise has been generated about several materials some of which have been popular pulpotomy medicaments. Concerns have been raised about the toxicity and potential carcinogenicity of these materials, and alternatives have been proposed to maintain the partial pulp vitality, however to date no material has been accepted as an ideal pulpotomy agent. Mineral trioxide aggregate (MTA) is a biocompatible material which provides a biological seal. MTA has been proposed as a potential medicament for various pulpal procedures like pulp capping with reversible pulpitis, apexification, repair of root perforations, etc. Hence the present study was done to evaluate the efficacy of MTA as a pulpotomy medicament. A clinical and radiographic evaluation was done on children where MTA was used as pulpotomy medicament in primary molars for a period of 6 months and it was found to be a successful material.

Isolation of integral membrane proteins of Leishmania promastigotes and evaluation of their prophylactic potential in hamsters against experimental visceral leishmaniasis

The integral membrane proteins (IMP's) of promastigotes of two virulent strain of Leishmania (L.) donovani Dd8 and Leishmania (L.) infantum LV9 and one avirulent viscerotropic strain Leishmania tropica UR6 were extracted by phase separation technique using a non-ionic detergent "Triton X-114". This detergent is homogeneous at 0 degrees C but divides in an aqueous phase and a detergent phase at above 20 degrees C. The phase partition resulted in solubilisation of hydrophilic proteins in aqueous phase, and IMP's with an amphiphilic nature were recovered in the detergent phase. The strain wise quantitative recovery rates of IMP's were estimated. These proteins were purified by chill methanol centrifugation and used as vaccinogen, alone or in combination with adjuvant against L. donovani challenge in hamster model. Among all the combinations, hamsters immunised with IMP of L. donovani (Dd8) in combination with CFA resulted in 75% parasite inhibition in spleen (P <0.001), however, 61.14% (P <0.001) and 77.60% (P <0.001) parasitic inhibition was achieved in liver and bone marrow respectively as compared to their unvaccinated counter part. Similar combinations with UR6 and LV9 strain inhibited the parasite establishment up to 65.12% (P <0.001) and 66.87% (P <0.001), respectively on splenic site. The specific IgG level against (Dd8 strain) soluble leishmania promastigote antigen was monitored at different stages by enzyme linked immunosorbent assay (ELISA) corresponds to the level of parasitic establishment. Similar observations were made in cases of LV9 and UR6 strains. However, significant lymphoproliferative response to IMPs of Dd8 strain (SI 3.5-4.9, P <0.001) was noticed in all IMP + CFA vaccinated animals. Thus, this study will provide a lead for more manipulative trials to develop a subunit vaccine against the fatal disease.

Role of 14-bp deletion in theHLA-Ggene in the maintenance of pregnancy

Differential expression of human leukocyte antigens (HLAs) on trophoblast has been the focus of many studies, specially on extravillous cytotrophoblast cells, which migrates into the maternal uterine tissues. These invading cells do not express classical major histocompatibility complex class I (-A and -B) and class II molecules, along with low expression of HLA-C. HLA-G is the predominantly expressed antigen along with HLA-E. Hence, it is believed that expressed antigens may be involved in materno-fetal tolerance. In the present study, we have studied 14-bp deletion polymorphism in the exon-8 of the non-classical HLA-G antigen. There was no difference in the frequency of deletion/insertion polymorphism in fertile normal women and recurrent spontaneous abortion (RSA) women. However, the number of heterozygotes (-14b/+14b) were increased in RSA women. The probable mechanism for the increase of heterozygotes in recurrent fetal loss is discussed in light of soluble HLA-G.

Role of cysteine proteinase of Entamoeba histolytica in target cell death

The bacterial flora of the intestine plays an important role in the virulence caused by Entamoeba histolytica. Cysteine proteinase (CP), an amoebic virulence factor, plays a major role in host cell destruction. The mechanism of increased virulence following bacterial co-association is not understood. We studied CP of E. histolytica HM1:IMSS which was co-associated with Escherichia coli K12 strain pre-incubated with GalNAc or CP specific inhibitor E 64. Co-association of E. histolytica with bacteria enhanced CP activity 3-6-fold as assessed by azocasein assay and substrate gel electrophoresis showed bands at molecular weights of 28, 35 and 56 kDa. Northern and Western blot analysis showed increase in ehcp2 and ehcp5 gene expression. Trophozoites co-associated with E. coli showed greater cytotoxicity of BHK cells by a 51Cr release assay than trophozoites that had not been co-associated; this enhancement was abolished by E-64 treatment. The killing of BHK 21 targets by E. histolytica was characterized by DNA laddering which was not inhibited with E-64. GalNAc pre-incubation of trophozoites reduced cytotoxicity and DNA laddering, while E. coli co-associated E. histolytica showed smearing with faint laddering of BHK implicating both necrosis and apoptosis. Hence, bacterial co-association increases CP activity and CP gene expression and contributes to the necrosis of the target cell.