Wegener's granulomatosis in India: clinical features, treatment and outcome of twenty-five patients

OBJECTIVE

To report our clinical experience on Wegener's granulomatosis (WG).

METHODS

A retrospective review of case records of all patients with WG in our Rheumatology Clinic during the period July 1988 to June 2000 was carried out and the details of demography, clinical and laboratory data, treatment and outcome were obtained and analysed.

RESULTS

Twenty-five patients (16 females and 9 males) were found eligible for inclusion in the study. The mean age and duration of symptoms at presentation were 33.5 years and 5.5 months, respectively. Two patients had limited WG. Twenty-two patients with generalized WG were treated with standard regimen comprising oral prednisolone (1 mg/kg/day) and oral cyclophosphamide (2 mg/kg/day). Cyclophosphamide was continued for at least one year after the patient attained remission. One patient was treated with intravenous cyclophosphamide regimen. The two patients with limited WG were treated with oral prednisolone and methotrexate (10-12.5 mg as a single dose per week). Remission was achieved in 24 patients after a median time of six months. The median follow-up of patients was five years (range 4 months-11 years). Five patients were lost to follow-up. Eight patients suffered a relapse. The mean time for relapse was 34 months after the initial remission. Seven out of eight patients remitted again after reinstitution of the initial induction regimen. One patient died of diffuse pulmonary haemorrhage despite early institution of therapy.

CONCLUSION

WG is being increasingly diagnosed in India now because of greater awareness and diagnostic aids. Although remissions are easy to achieve, relapses continue to pose a challenge to the treating physician.

Clinical applications of phage-derived sFvs and sFv fusion proteins

Single chain Fv antibodies (sFvs) have been produced from filamentous bacteriophage libraries obtained from immunised mice. MFE-23, the most characterised of these sFvs, is reactive with carcinoembryonic antigen (CEA), a glycoprotein that is highly expressed in colorectal adenocarcinomas. MFE-23 has been expressed in bacteria and purified in our laboratory for two clinical trials; a gamma camera imaging trial using ¹²³I-MFE-23 and a radioimmunoguided surgery trial using ¹²⁵I-MFE-23, where tumour deposits are detected by a hand-held probe during surgery. Both these trials show MFE-23 is safe and effective in localising tumour deposits in patients with cancer. We are now developing fusion proteins which use MFE-23 to deliver a therapeutic moiety; MFE-23::CPG2 targets the enzyme carboxypeptidase G2 (CPG2) for use in the ADEPT (antibody directed enzyme prodrug therapy) system and MFE::TNFα aims to reduce sequestration and increase tumor concentrations of systemically administered TNFα.

Identification of E2F-1/Cyclin A antagonists

A simple method for the synthesis of a rationally designed (S,S)-[Pro-Leu]-spirolactam scaffold is described. This was expanded to a small biased library of compounds mimicking the 'ZRXL' motif in order to identify E2F-1/Cyclin A antagonists. The synthesized compounds were evaluated in an E2F-1/Cyclin A binding assay and moderately active analogues were identified. In addition, the critical roles of Phe, Leu, Lys, and Arg residues of the identified motif were determined.

Studies on toxicity, anti-stress and hepato-protective properties of Kombucha tea

OBJECTIVE

The objective of the study was to evaluate toxicity, anti-stress activity and hepato-protective properties of Kombucha tea.

METHOD

Kombucha tea was fed orally for 15 days using three different doses i.e. normal dose, five and ten times the dose. Rats were then sacrificed and various biochemical, and histological parameters were estimated. Anti-stress activity was evaluated either by 1) by exposing animals to cold and hypoxia and estimating the levels of malondialdehyde and reduced glutathione in plasma/blood or 2) by subjecting the animals to restraint stress and recording faecal output. Hepato-toxicity was induced by challenging the animals to an acute dose of paracetamol (1 gm/kg) orally and determining the plasma levels of SGPT, SGOT and MDA.

RESULTS

The effect of oral administration of different doses of K-tea to albino rats was examined and the results indicate that K-tea has no significant toxicity as revealed by various biochemical and histopathological parameters. K-tea has been found to prevent lipid peroxidation and fall in reduced glutathione level when rats were exposed to cold and hypoxia in simulated chamber. Further, K-tea has also been found to decrease the Wrap-restraint faecal pellet output in rats. K-tea has also been found to decrease paracetamol induced hepatotoxicity significantly.

CONCLUSION

The study shows that K-tea has anti-stress and hepato-protective activities.

Serological appraisal of malaria status in tribal area of Orissa, India

A cross-sectional seroepidemiological study conducted in 173 tribal residents (including all age groups) from three villages of Sundergarh district of Orissa using ELISA as a tool revealed high levels of antibody titres against both AR1 and Pf antigens. The mean +/- S.D. ELISA O.D. obtained for AR1 were 0.73 +/- 0.2, 1.037 +/- 0.196, 1.05 +/- 0.42 and for Pf, 0.70 +/- 0.2, 1.0 +/- 0.28, 0.94 +/- 0.4 respectively for Badramoli, Jharbeda and Boneikela population. Parasitological results showed high incidence of malaria in < 5 years age group in Badramoli and Boneikela villages when compared to other age groups. An. fluviatilis was found to be the principle malaria vector as found in the HBI results. High ELISA O.D. and high equivalent transmission index (ETI) indicate a high malaria transmission in the area. Seroepidemiological studies could be used for effective surveillance and stratification of endemicity in a given area which can help in executing intervention strategy for malaria control.

Significance of haematological manifestations in patients with tuberculosis

OBJECTIVE

Tuberculosis is a major public health problem in India. Haematological changes associated with tuberculosis have been incompletely investigated. To the best of our knowledge, there is no comprehensive study assessing the haematological abnormalities in these patients from the Indian subcontinent. In the present study, we have compared peripheral blood and bone marrow findings in patients with disseminated/miliary tuberculosis (DTB/MTB) as well as pulmonary tuberculosis (PTB). An attempt has also been made to assess the effect of antituberculosis therapy on the haematologic abnormalities.

MATERIAL AND METHODS

Thirty two patients with disseminated/miliary tuberculosis and 23 patients with pulmonary tuberculosis were prospectively studied to determine the various haematological manifestations in tuberculosis and the effect of antituberculosis therapy. All patients received standard antituberculosis treatment. They were subjected to a detailed haemogram including peripheral blood examination, which was repeated on completion of antituberculosis therapy. Bone marrow aspiration and biopsy was also done in all patients before starting antituberculosis treatment.

RESULTS

Normocytic normochromic anaemia was the most common abnormality observed in all the groups and subgroups (DTB/MTB 84%, PTB 86%). Other haematological abnormalities of the white blood cells include leucopenia (DTB/MTB 25%, PTB 0%; p < 0.02), neutropenia (DTB/MTB 22%, PTB 0%; p < 0.04), lymphocytopenia, monocytopenia, leukocytosis, neutrophilia, lymphocytosis and monocytosis. Pancytopenia was observed only in patients with disseminated/miliary tuberculosis (p < 0.05). Thrombocytopenia was more common in patients with disseminated/miliary tuberculosis (p < 0.007), whereas thrombocytosis was more common in patients with pulmonary tuberculosis (p < 0.04). The patients of disseminated/miliary tuberculosis with granulomas in the bone marrow had certain significant differences as compared to patients without granulomas. These patients showed severe anaemia, peripheral monocytopenia and bone marrow histiomonocytosis. The haemogram reverted to normal with antituberculosis therapy in these patients.

CONCLUSIONS

In view of the varied haematological abnormalities observed in patients with tuberculosis in this part of the world, it is concluded that the differential diagnosis of tuberculosis should be entertained in patients with varied haematological disorders.

Repetitive genetic inversion of optical extinction data

We describe a genetic method of deriving aerosol size distributions from multiwavelength extinction measurements. The genetic inversion searches for log-normal size distribution parameters whose calculated extinctions best fit the data. By repetitively applying the genetic inversion using different random number seeds, we are able to generate multiple solutions that fit the data equally well. When these solutions are similar, they lend confidence to an interpretation, whereas when they vary widely, they demonstrate nonuniqueness. In this way we show that, even in the case of a single log-normal distribution, many different distributions can fit the same set of extinction data unless the misfit is reduced below typical measurement error levels. In the case of a bimodal distribution, we find many dissimilar size distributions that fit the data to within 1% at six wavelengths. To recover the original bimodal distribution satisfactorily, we found that extinctions at ten wavelengths must be fitted to within 0.5%. Our results imply that many size distributions recovered from existing extinction measurements can be highly nonunique and should be treated with caution.

Role of cysteine-291 and cysteine-322 in the polymerization of human tau into Alzheimer-like filaments

Filamentous tau pathology is central to a large number of dementing disorders, including Alzheimer's disease in which polymerized tau is hyperphosphorylated. Previous studies on heparin-dependent tau polymerization, using recombinant tau isoforms lacking Cys-291, suggest that tau dimerization via Cys-322 is critical for initiation of assembly of soluble tau into filaments. We report heparin-dependent in vitro polymerization of human recombinant tau (1-383 isoform), containing both Cys-291 and Cys-322, into paired helical filaments as characterized by electron microscopy. Tau polymerization, under physiological tau concentrations in the presence of dithiothreitol (DTT), was followed by a Thioflavine S fluorescence assay. To understand the molecular basis for heparin-induced tau polymerization, we expressed and purified C291A, C322A, and C291A/C322A tau mutants. The DTT requirement for tau polymerization was abolished using either the C291A or C322A tau mutant and polymerization was not observed with the C291A/C322A tau double mutant. Analysis by sodium dodecyl sulfate gel electrophoresis showed that, unlike wild type tau, a significant amount of the C291A mutant and the C322A mutant is present as a disulfide bonded dimer. Taken together these results suggest that, in isoforms containing both Cys-291 and Cys-322, a dimeric tau with an intermolecular disulfide bond through either Cys-291 or Cys-322 is presumably acting as a seed for initiation of tau polymerization.

Enhanced protection against fatal mycobacterial infection in SCID beige mice by reshaping innate immunity with IFN-gamma transgene

Humans with immune-compromised conditions such as SCID are unable to control infection caused by normally nonpathogenic intracellular pathogens such as Mycobacterium bovis bacillus Calmette-Guérin. We found that SCID beige mice lacking both lymphocytes and NK cells had functionally normal lung macrophages and yet a selectively impaired response of type 1 cytokines IFN-gamma and IL-12, but not TNF-alpha, during M. bovis bacillus Calmette-Guérin infection. These mice succumbed to such infection. A repeated lung gene transfer strategy was designed to reconstitute IFN-gamma in the lung, which allowed investigation of whether adequate activation of innate macrophages could enhance host defense in the complete absence of lymphocytes. IFN-gamma transgene-based treatment was initiated 10 days after the establishment of mycobacterial infection and led to increased levels of both IFN-gamma and IL-12, but not TNF-alpha, in the lung. Lung macrophages were activated to express increased MHC molecules, type 1 cytokines and NO, and increased phagocytic and mycobactericidal activities. Activation of innate immunity markedly inhibited otherwise uncontrollable growth of mycobacteria and prolonged the survival of infected SCID hosts. Thus, our study proposes a cytokine transgene-based therapeutic modality to enhance host defense in immune-compromised hosts against intracellular bacterial infection, and suggests a central effector activity played by IFN-gamma-activated macrophages in antimycobacterial cell-mediated immunity.

A prospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculosis pleural effusion

We prospectively evaluated the usefulness of adenosine deaminase [ADA] estimation in the diagnosis of tuberculosis [TB] pleural effusion. Seventy five subjects with pleural effusion were studied. Forty eight of them had TB pleural effusion [M:F: 37:11; mean age 33 +/- 14.4 years range 17-76] and the remaining 27 had pleural effusion due to causes other than TB [non-TB group] [M:F: 19:8; mean age 47.3 +/- 16.5 years; range 17-75]. Pleural fluid [PF] ADA levels were significantly higher in TB (n=48; mean 95.8 +/- 57.5 IU/L) compared with non-TB group (n=27; mean 30.7 +/- 27.2 IU/L) [p<0.001]. Serum ADA [S-ADA] levels were also significantly higher in TB (n=45; mean 39.6 +/- 18.3 IU/L) compared with non-TB group (n=26; mean 18.0 +/- 13.7 IU/L) [p<0.001]. PF-ADA levels were higher compared to S-SDA in TB (p <0.001) and non-TB groups [p<0.01]. Using a cut off of 35 IU/L, the sensitivity and specificity of PF-ADA in the diagnosis of TB was computed to be 83.3% and 66.6% respectively. At a cut-off level of 100 IU/L, PF-ADA was found to have a sensitivity 40% and specificity 100%. From this study it is concluded that, using 100 IU/L as the cut-off, it is possible to avoid pleural biopsy to ascertain the diagnosis of TB in as much as 40% of the patients.

Socio-economic factors associated with malaria in a tribal area of Orissa, India

Study on the socio-economic factors and human behaviour in a cross-section of tribal communities in Sundargarh district, Orissa revealed that poor socioeconomic status and socio-cultural factors play important role in maintaining high degree of malaria transmission. Human behaviour such as location of hamlets, type of housing, sleeping habits, outdoor activities after dusk, poor knowledge about the disease and treatment seeking behaviour are of great significance as determinants of malaria transmission. All these factors need to be considered before planning community health programme. Estimation of economic loss due to malaria showed an average loss of 8.96 mandays per malaria patient with an average loss of 3.84 mandays to other family members. Mean total loss per malaria episode comes to Rs.334.91. The study showed that malaria is one of the major disease affecting the tribals to the greatest extent and putting a lot of burden on the economic upliftment of these communities.

[W206R]-procaspase 3: an inactivatable substrate for caspase 8

We report here the cloning and high-level expression of a soluble proform of human caspase 3 (Ser(24)-H(277)) engineered to contain a short stretch of N-terminal sequence (MTISDSPREQD) from the prosegment of procaspase 8 and a C-terminal heptahistidine tag. The precursor protein isolated from extracts of recombinant Escherichia coli by immobilized metal-ion affinity chromatography was predominantly unprocessed and migrated as a 32-kDa polypeptide on sodium dodecyl sulfate-polyacrylamide gels. Incubation of this protein with recombinant human caspase 8 produced fragments characteristic of the properly processed caspase 3, but the product was inactive. Amino-terminal sequence analysis of the caspase 3 polypeptides proved that caspase 8 had specifically cleaved the Asp(175)-Ser(176) bond to yield the expected p18 and p12 subunits, with partial cleavage at the Asp(28)-Ser(29) bond to release the prosegment. The lack of caspase 3 activity was found to be the result of a fortuitous mutation in which Trp(206) in the S4 subsite was replaced by arginine (W206R). This mutant procaspase 3, which we call m-pro3, serves as a useful reagent with which to test the efficacy of caspase 8 inhibitors in blocking processing of the natural polypeptide substrate of this enzyme and may be valuable as a source of "proenzyme" for crystallographic analysis.

Clinical characteristics, pulmonary function abnormalities and outcome of prednisolone treatment in 106 patients with sarcoidosis

The clinical profile of one hundred and six biopsy proved patients with sarcoidosis is reported from New Delhi. The disease occurred more frequently in males (68 of the 106; 64%) in their fifth decade. Dry cough (83%), exertional dyspnoea (61%), fever (56%) and joint pains (44%) were frequent symptoms. Hepatomegaly (45%), peripheral lymphadenopathy (45%), cutaneous involvement (42%), presence of crepitations (36%) were frequent signs. In addition, ocular symptoms (18%), parotid gland enlargement (12%), facial nerve palsy (8%) were observed. Audible wheeze was present in nine patients. Radiologically, 25 (24%), 67 (63%) and 14 (13%) of patients belonged to stage I, II and III respectively at presentation. More than one sibling was involved in six families. Pulmonary functions revealed mixed obstructive and restrictive ventilatory defect. However, obstructive ventilatory defect was predominant. Systemic steroids were used in 81 patients who regularly followed up. Frequent relapses occurred on tapering off or stopping the corticosteroids in 21 patients. History of malaise (p < 0.05), presence of crepitations (p < 0.05), wheezing (p < 0.05), peripheral blood eosinophilia (p < 0.05) and FEV1/FVC (%) < 65% of the predicted value (p < 0.05), were independent predictors of relapse. Hyperuricaemia, hitherto unreported in patients with sarcoidosis was observed in 41% of patients for whom values were available. Two patients died; one from cardiomyopathy and another from stroke. In summary, constitutional symptoms such as fever, weight loss and pulmonary infiltrates, were more frequently encountered in Indian patients with sarcoidosis as compared to western studies. A high index of clinical suspicion and histopathological confirmation early in the illness are required to ascertain the diagnosis lest these patients will get treated as tuberculosis with potentially hepatotoxic drugs.

Cerebral venous thrombosis in a patient of paroxysmal nocturnal haemoglobinuria following aplastic anaemia

A young lady who had aplastic anaemia presented for cerebral venous thrombosis after five years of follow up. She was diagnosed to have paroxysmal nocturnal haemoglobinuria. She had received immunosuppressive therapy with methylprednisolone, cyclosporine-A, anti-lymphocyte globulin, danazol and pregnenolone. The relation between aplastic anaemia, paroxysmal nocturnal haemoglobinuria and cerebral venous thrombosis is discussed. The role of immunosuppressive therapy for aplastic anaemia in causation of paroxysmal nocturnal haemoglobinuria is reviewed.

Transformation of a kappa-opioid receptor antagonist to a kappa-agonist by transfer of a guanidinium group from the 5'- to 6'-position of naltrindole

The importance of the indole scaffold of GNTI 3 in directing its address (5'-guanidinium group) to associate with the Glu297 residue of the kappa-opioid receptor was investigated by the synthesis and biological evaluation of its 4'- (4a), 6'- (4b), and 7'- (4c) regioisomers. The finding that only the 5'-regioisomer (GNTI) possessed potent kappa-opioid antagonist activity and high affinity at kappa-receptors illustrates the importance of the 5'-position in orienting the guanidinium group to the proper recognition locus (Glu 297) for potent kappa-antagonist activity. The discovery that the 6'-regioisomer of GNTI was a potent kappa-agonist, together with the results of site-directed mutagenesis studies that are consistent with association between the 6'-guanidinium group and Glu297, suggest that the transition from an inactive to an active state of the kappa-receptor involves a conformational change of TM6. We propose that association of the 6'-guanidinium group of 4b with Glu297 promotes axial rotational motion of transmembrane helix VI which leads to receptor activation via a conformational change of inner loop 3.

Intensity of Labor Pain and Cesarean Delivery

Some authors have suggested that the intensity of labor pain may be related to labor dystocia. We performed a secondary analysis of a previously published randomized investigation of the effects of epidural analgesia during labor compared with patient-controlled IV meperidine on cesarean delivery. Two-hundred-fifty-nine women who received patient-controlled IV meperidine were identified for analysis. All women were in spontaneous labor with a singleton, term gestation. Women requiring 50 mg or more of meperidine per hour during labor were compared with those who required <50 mg/h. In addition, their pain scores (visual analog scale) were compared before and after analgesia administration. Pain scores were significantly higher in women requiring 50 mg/h of meperidine (8.7 vs 8.0, P = 0.05), and their labors tended to be longer (9 vs 5 h, P = 0.09). More cesarean deliveries for obstructed labor were performed in women requiring >50 mg/h of meperidine (14% vs 1.4%, P = 0.001). Neonatal outcomes were similar in the two groups.

A new Antennapedia-derived vector for intracellular delivery of exogenous compounds

We describe the design, synthesis and cell translocation capacity of a peptide derived from the third alpha-helix of the homeodomain of Antennapedia. The new sequence appears to be an efficient and nontoxic means to deliver a covalently linked peptide cargo into cells.

Sarpogrelate inhibits serotonin-induced proliferation of porcine coronary artery smooth muscle cells: implications for long-term graft patency

BACKGROUND

Serotonin can induce proliferation of vascular smooth muscle cells. We assessed the ability of a specific serotonin receptor antagonist, sarpogrelate, to inhibit proliferation of cultured porcine coronary artery smooth muscle cells.

METHODS

Cell proliferation and mitotic activity were measured using 3-(4,5-dimethyl-thiazol-2-yl)-2,5-diphenyltetrazolium bromide. To determine the effect of sarpogrelate on DNA (deoxyribonucleic acid), RNA (ribonucleic acid), and protein synthesis, radioactive incorporation of 3H-thymidine, 3H-uridine, and 3H-phenylalanine, respectively, was used. Synthesis of DNA was also assessed by flow cytometry with propidium iodide as a fluorochrome.

RESULTS

Serotonin, platelet-derived growth factor, endothelin, and angiotensin II all induced proliferation of porcine coronary artery smooth muscle cells. Sarpogrelate specifically inhibited the serotonin-induced cytokine trigger but did not influence platelet-derived growth factor-, endothelin-, or angiotensin II-induced cell proliferation. Sarpogrelate inhibited the serotonin-induced increase in intracellular free ionized calcium concentration, prevented mitogen-activated protein kinase activation, and down-regulated expression of the protooncogenes c-fos and c-jun. Sarpogrelate acted at the G1 phase of the cell cycle.

CONCLUSIONS

These data suggest that sarpogrelate could be used as a therapeutic agent to inhibit serotonin-induced neointimal hyperplasia and improve patency of coronary artery bypass grafts.

Measurement of the critical DNA lesions produced by antibody-directed enzyme prodrug therapy (ADEPT) in vitro, in vivo and in clinical material

An antibody-directed enzyme prodrug therapy (ADEPT) system against CEA-positive tumours is currently in phase I clinical trials. It consists of a prodrug, 4-[N,N-bis(2-iodoethyl) amino] phenoxycarbonyl L -glutamic acid (ZD2767P) and a conjugate of the F(ab')(2) anti-CEA antibody A5B7 and the bacterial enzyme carboxypeptidase G2 (CPG2). ZD2767P is converted by antibody-targeted CPG2 into an active bifunctional alkylating drug (ZD2767) at the tumour site. The IC(50) value of the prodrug against the human colorectal tumour LS174T cell line was 55 +/- 9 microM following a 1 h exposure. In contrast, co-incubation of ZD2767P with CPG2 resulted in 229-fold increase in activity. Using a modified comet assay, DNA interstrand cross links (ISC) were detected within 1 h of ZD2767P + CPG2 treatment and were repaired by 24 h. A clear dose-response was seen between the level of ISC, growth inhibition and ZD2767 concentration. Administration of a therapeutic dose of ZD2767P 72 h after the F(ab')(2) A5B7 conjugate to mice bearing LS147T xenografts resulted in extensive ISC in the tumour after 1 h; repair was seen at 24 h. Tumour biopsies and peripheral lymphocytes were studied in 5 patients on the ADEPT phase I clinical trial. In 4 patients no ISC were detected. These patients also demonstrated poor localization of conjugate and no tumour response was seen. However a significant level of ISC was detected in one tumour biopsy, which also showed evidence of conjugate localization and clinical response. These studies demonstrate the application of the comet assay in the measurement of ISC in vitro and in clinical material and confirm that activation of ZD2767P results in the formation of DNA crosslinks.

Lipase catalysed synthesis of optically enriched α-haloamides

An efficient lipase catalysed synthesis of optically enriched alpha-halogenated amides with concomitant optical enrichment of the starting alpha-haloesters is described. Candida antarctica lipase (CAL) was found to be a better catalyst over porcine pancreatic lipase (PPL) and Candida cylindracea lipase (CCL). The effect of different organic solvents was also studied.

Novel cyclopropylindole conjugates and dimers: synthesis and anti-cancer evaluation

There is a considerable interest currently in the development of DNA sequence specific or selective agents for genetic targeting for the control of gene expression, for application in diagnosis or ultimately in therapy. In this context CC-1065 is one of the most impressive lead compounds isolated in trace quantities from the culture of Streptomyces zelensis at Upjohn in 1978. The unique structure was confirmed by single X-ray in 1981. However CC-1065 cannot be used in humans because it was found that it caused delayed deaths in experimental animals. In the search for compounds with better antitumor selectivity and DNA sequence specificity many CC-1065 analogs have been synthesized in an attempt to avoid the undesired side effects while retaining its potency against tumor cells. Two successful attempts in the modification in the active moiety of the parent natural product 1,2,8,8a-tetrahydro-7-methylcyclopropa[3,2-e]indole-4-one (CPI) and 1,2,9,9a-tetrahydrocyclopropa[c]benz[e]indole-4-one (CBI) have been made. We review here recent progress with the analogs of CPI and CBI and their conjugates both by solution and solid phase, also the progress and development of CPI and CBI conjugates with polyamides (information reading molecules in the minor groove of DNA). Since CPI-CPI dimers are significantly more potent than CC-1065 in vitro and in vivo, a large number of CBI-CBI dimers with varying linkers lengths and positions synthesized in our group and their pharmacological properties have been reviewed.