Age-related proximal femur bone mineral loss in South Indian women: a dual energy X-ray absorptiometry study

OBJECTIVES

i) To collect normative data for proximal femur bone mineral density (BMD) in South Indian women using dual energy X-ray absorptiometry (DXA) and ii) to study the rate and significance of hip bone mineral loss with advancing age in this population.

MATERIAL AND METHODS

Forty five women, whose age ranged from 16 to 84 years were studied. This sample was drawn randomly from general medical practice at KJ Hospital, Chennai, South India during November, 1997 to April, 1998. Of these 45 cases, 21 were pre-menopausal (mean +/- SD age = 30.9+/-8.8 years) and 24 post-menopausal (mean +/- SD age = 62.1+/-11.0 years). Subjects with secondary bone diseases were excluded. Also excluded were those taking any drugs known to affect calcium metabolism e.g., thiazide diuretics, oestrogen and calcium. Subjects were divided into seven decadal age groups from 15-24 years to 75-84 years. BMD of the right proximal femur was evaluated using a QDR-1000 DXA bone densitometer (Hologic Inc., Waltham, Massachusetts, USA). Data analysis was done with SPSS/PC statistical software package.

RESULTS

Linear regression analysis showed significant (p < 0.001) negative correlations between all hip BMD variables at different regions of interest and patient's age. Relative to that at 30 years of age, rates of BMD loss in the neck of femur, trochanter, intertrochanter, total hip and Ward's triangle were 0.68%, 0.65%, 0.58%, 0.61% and 1.05% per annum respectively. Over the age of 65 years, the above mentioned regions BMD decreased by 0.91%, 0.84%, 0.72%, 0.78% and 1.66% per annum respectively.

CONCLUSION

Normative data for proximal femur BMD in South India women have been evaluated and it may prove useful for diagnosing osteoporosis in the women of South India.

Spontaneous fungal peritonitis (Candida glabrata) in a patient with cirrhosis

We report a case of spontaneous fungal peritonitis in a patient with cirrhosis. A 70-year-old woman with cirrhosis secondary to autoimmune hepatitis was admitted with fever and abdominal distention. Paracentesis revealed neutrocytosis, and despite appropriate antibacterial coverage, no clinical improvement was noted and the ascitic fluid white cell count increased on repeat paracentesis. Two consecutive ascitic fluid cultures grew Candida glabrata, and antifungal therapy with amphotericin was initiated, pending sensitivity of the isolate. Because of worsening renal function, amphotericin was discontinued and itraconazole was started, as sensitivity of the isolate was then available. Antifungal therapy resulted in resolution of ascitic fluid neutrocytosis and culture negativity. However, the patient's renal function continued to deteriorate, necessitating hemodialysis. Despite multiple courses of antibiotics, she died of fulminant sepsis and multiorgan failure.

Syntheses of immunodominant peptide regions of hepatitis C viral pathogens using PS-BDODMA resin: a single peptide derived from the conserved domain (E2/NS1) was highly effective in detecting anti-HCV antibodies

Peptides were synthesized with very high purity and yield on a highly solvating copolymer of 1,4-butanediol dimethacrylate cross-linked polystyrene support (PS-BDODMA). The polymer was synthesized by radical aqueous suspension polymerization using toluene as the diluent and 1% polyvinyl alcohol as the suspension stabilizer. The supports were highly resistant to various chemical reagents and solvents that are frequently used in polypeptide synthesis. The peptides synthesized on this support were designed from the core (C), envelope (E1 and E2) and nonstructural protein (NS1-NS5) regions of the prototype hepatitis C viral (HCV) polyprotein, and were used to develop a peptide-based immunoassay (PBEIA) for the detection of HCV antibodies. The purity of these peptides was tested by HPLC. Peptide identity was confirmed by amino acid analysis and MALDI-TOF-MS. A single peptide chosen from a conserved area (E2/NS1) at the C-terminus of the hypervariable region (HVRI) was found to be sufficient for effective and reliable diagnosis of HCV infection in infected individuals, as well as also apparently healthy individuals. The CD spectrum of the peptide shows no preference for any ordered secondary structure. When used, peptide mixtures from various protein regions of HCV reduced the sensitivity and reliability of the diagnosis partly because of epitope masking.

Predominance of antibodies to hepatitis C virus envelope proteins in various disease statuses of hepatitis C

The antibody profile to various proteins of hepatitis C virus (HCV) was studied in 113 patients positive for HCV RNA in various disease statuses of hepatitis C (HC). A single peptide (E2/NS1, aa 413-436 of HCV polyprotein) chosen from a conserved region at the C-terminus of the hypervariable region (HVR) HVR1 of HCV was found to be sufficient for reliable diagnosis of the infection, even in the acute phase. Six hundred and one suspected HC cases and 200 voluntary blood donors were tested by this peptide. The sensitivity of detection of HCV antibodies by this peptide did not increase with addition of peptides from other HCV proteins. Our results clearly demonstrate that antibodies to HCV envelope proteins occur in a higher percentage of the infected population than those to other proteins. This emphasizes the necessity of using representative sequences from HCV envelope proteins in diagnostic immunoassays of this viral infection.

Avulsion fractures of the anterior inferior iliac spine: the case for surgical intervention

Two cases of avulsion fracture of the anterior inferior iliac spine are reported. One was a missed diagnosis that resulted in exostosis formation needing excision. The second case was an adolescent with significant displacement of the fragment and a primary open reduction and internal fixation was done. A high index of suspicion is necessary to diagnose this relatively rare injury and surgery has a role in carefully selected cases.

Isolated intrahepatic biliary dilatation in a patient with acquired immune deficiency syndrome (AIDS): AIDS cholangiopathy versus incidental unilobar Caroli's disease

We describe a case of possible monolobar Caroli's disease in a patient with acquired immune deficiency syndrome (AIDS) who presented with features of cholangitis. Diagnostic workup, which included endoscopic retrograde cholangiography, revealed focal intrahepatic biliary dilatation confined to the right lobe. The patient subsequently underwent right hepatic lobectomy. Pathology revealed multiple cysts filled with calculi and inflammation in the cyst walls. Special stain results for fungi and acid-fast organisms were negative. The presence of advanced AIDS in this patient raised the possibility of this being a possible manifestation of AIDS cholangiopathy.

Synthesis of esculentin-1 antibacterial peptide fragments on 1,4-butanediol dimethacrylate cross-linked polystyrene support

Peptide segments corresponding to antibacterial esculentin-1 (1-15), (3344), (9-27), and their modified forms were synthesized on 1,4-butanediol dimethacrylate cross-linked polystyrene (PS-BDODMA) support. Hydroxymethyl and aminomethyl 2% PS-BDODMA supports were used for the synthesis. The HMPB linker was appended to the aminomethyl resin using HBTU in presence of HOBt and the first amino acid was incorporated using MSNT. The conventional Fmoc synthetic protocol was used for the synthesis of peptides. The peptides were cleaved from the support using TFA. The peptides were purified by HPLC, and characterized by amino acid analysis and MALDI TOF MS. The secondary structures of the peptides were revealed by CD measurements. The synthesis of these peptides illustrates the utility of the new support for the synthesis of long-chain bioactive peptides. The synthetic peptides were tested for antimicrobial activity against Escherichia coli Mos blue, E. coli 2, Bacillus brevis, B. megaterium, Pseudomonas HTL, and Vibrio mimicus. The antibacterial activity of the peptides was explained on the basis of the helicity and charged nature of the sequences.

Syntheses of four peptides from the immunodominant region of hepatitis C viral pathogens using PS-TTEGDA support for the investigation of HCV infection in human blood

Four peptides were designed and synthesized on a highly solvating copolymer of tetraethyleneglycol diacrylate cross-linked polystyrene (PS-TTEGDA) support with very high purity and yield. The polymer was synthesized in various cross-linking densities (1, 2, 3, 4, 5 and 10%) using radical aqueous suspension polymerization. Four per cent PS-TTEGDA resin showed rigidity and mechanical characteristics comparable with those of divinylbenzene cross-linked polystyrene (PS-DVB) support. Swelling and solvation characteristics of PS-TTEGDA were much higher than PS-DVB support in all solvents used in solid-phase peptide synthesis. Forty-eight hour treatment of the support with neat trifluoroacetic acid did not show any change in its infrared spectra. PS-TTEGDA could be functionalized with chloromethyl, aminomethyl and hydroxymethyl functional groups under various controlled conditions. Synthetic utility of the support was demonstrated by the synthesis of four peptides selected from the envelope and nonstructural protein region of the prototype hepatitis C virus (HCV). These peptides were later used successfully to develop a peptide-based immunoassay (PBEIA) for the detection of HCV immunity. Peptides designed from the NS1 and NS4 protein regions were found to be very promising for the development of a new diagnostic kit to detect HCV infection in human blood. Peptide purity was tested by RP-FPLC and the peptide identity was confirmed by amino acid analysis.

Production & characterization of monoclonal antibodies to Mycobacterium tuberculosis

BACKGROUND & OBJECTIVES

Monoclonal antibodies (MAbs) against Mycobacterium tuberculosis H37Rv culture filtrate (CF) were raised by immunizing BALB/c mice and characterization was done. Attempts have been directed towards identifying mycobacterial antigens in biological fluids by employing polyclonal and monoclonal antibodies specific for M. tuberculosis. Immunohistologic studies, using MAbs for the localization of whole or fragmented bacilli in the biopsy specimens were also carried out.

METHODS

Intrasplenic IS and intraperitoneal i.p. routes of immunization, were compared. The MAbs were characterized for their isotype, binding specificity, nature of binding epitope, reactivity in immunoassays etc.

RESULTS

IS and i.p. routes of immunization, were compared and i.p. was found superior. Ten MAbs designated TRC 1-10 were produced. Of these, 7 MAbs, TRC 1-7 reacted with the 30/31 kDa doublet (antigen 85 complex), TRC 8 with 12 kDa in addition to 30/31 kDa and TRC 9 and 10 with the 24 and 12 kDa antigens respectively. Six MAbs were classified as broadly cross reactive and 2 showed limited cross reactivity. TRC 8 and 10 showed species specificity. Employing TRC 8 in sandwich ELISA, antigen was detected in sera from 17 of 25 pulmonary tuberculosis patients and 3 of 20 controls. TRC 8 was found to be useful in detecting antigens specifically in M. tuberculosis and M. leprae infected tissues, by immunoperoxidase staining.

INTERPRETATION & CONCLUSION

TRC 8 was found to be restricted in its reactivity to M. tuberculosis complex and M. leprae. TRC 8 may prove useful in immuno-diagnosis of tuberculosis.

Systemic lupus erythematosus in males: a retrospective study with a review of the literature

OBJECTIVE

To delineate the clinical pattern of a cohort of male patients with systemic lupus erythematosus (SLE) and compare it with previously reported data.

DESIGN

Retrospective review of hospital records.

SUBJECTS

Male patients (n = 11) who were diagnosed with SLE and admitted to a 500-bed university hospital between 1990 and 1998. Eight of the men were African-American and three were Latino. The mean age was 36 years (range, 29-46).

METHODS

Clinical and laboratory data were collected according to a well-established protocol. Imaging and invasive studies (including aspirations and biopsies) were also recorded.

RESULTS

Nine of the patients (82%) had renal involvement, with five needing dialysis within a year of presentation. Five patients had neurologic involvement: two presented with psychosis and three with seizures. Eight patients had hematologic involvement, and seven had serosal and articular involvement. Cutaneous lesions (discoid lupus) were noted in only one patient. A majority of the patients were noncompliant and were lost to follow-up; therefore, ultimate outcome could not be clearly delineated.

CONCLUSION

Renal, serosal, neurologic, articular, and hematologic involvement occurred frequently in our sample of male patients with SLE. The most striking finding was the high frequency of renal involvement with poor prognosis. A high index of suspicion for SLE in males may permit earlier diagnosis and may dictate the need for more aggressive therapy.

Nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis (NASH) is a liver disease that, until recently, has been underrecognized as a common cause of elevated liver enzymes. This distinct clinical entity is characterized by liver biopsy findings similar to those seen in alcoholic hepatitis but in the absence of alcohol consumption sufficient to cause such changes. Patients with NASH are often middle-aged and obese, with coexisting diabetes or hyperlipidemia, but NASH also occurs in younger lean, otherwise healthy individuals and even in children. Although NASH is generally a benign disorder, it may be progressive, leading to cirrhosis and complications of portal hypertension. Liver biopsy remains the gold standard for diagnosis. Therapy for NASH remains poorly defined, although weight reduction and ursodeoxycholic acid may have a beneficial effect.

Intravenous morphine for emergency treatment of cancer pain

Despite the wide use of the World Health Organization (WHO) analgesic ladder for the relief of cancer pain, it is not uncommon to find patients presenting with severe pain to palliative care centres. This is more so in the developing world, where facilities for pain relief are few and the health care system is not well organized. It has been the practice in a pain and palliative care clinic in south India to give repeated boluses of 1.5 mg of morphine intravenously every 10 min to patients presenting with severe pain. An audit of the procedure was undertaken by a retrospective study of 793 case notes. Seventy-nine per cent of patients had total relief of their pain with intravenous morphine. Three per cent of patients experienced side-effects during the procedure. These included nausea and vomiting, itching, giddiness, restlessness, dyspnoea, chest pain, disorientation and a feeling of uneasiness. Thirty-two per cent of patients had drowsiness, which was one of the end-points of the procedure. It is concluded that intravenous morphine in repeated boluses of 1.5 mg every 10 min is a safe and effective method of managing cancer pain emergencies in a clinical setting in a developing country.

Cytogenetic studies of 1001 Down syndrome cases from Andhra Pradesh, India

Cytogenetic data obtained from investigating 1001 patients of Down syndrome (DS) and their parents over a period of 20 years (January 1979-January 1999) are presented. The frequency of pure trisomy, mosaicism and translocation was 87.92, 7.69 and 4.39 per cent respectively. The origin of the extra chromosome 21 due to meiotic non-disjunction was 79.24 per cent maternal and 20.76 per cent paternal. A high frequency of acrocentric chromosome associations was also observed in mothers of children of Down syndrome, this might have predisposed to an enhanced risk for non-disjunction. Birth order of DS showed a higher number of first and second borns. Reproductive performances of the parents indicated a high rate of abortions, compared to controls. Cytogenetic investigations carried out over these years greatly helped in the management of these children and for counseling the affected families.

Retinoblastoma in adults. Report of three cases and review of the literature

Retinoblastoma usually presents in children younger than 5 years. To our knowledge, 20 cases of retinoblastoma in adults (older than 20 years) have been reported in the literature. Of 173 patients with histopathologically proven retinoblastoma seen in our institute, three were adults. All the patients had endophytic tumors with vitreous seeds. Ultrasonography did not reveal calcification in two cases. Immunohistochemistry with neuron-specific enolase was used to confirm the diagnosis in two cases. All three patients ultimately required enucleation. None of the patients had been referred with a diagnosis of retinoblastoma. The diagnosis of retinoblastoma should be considered in cases of whitish mass lesion in the fundus of an adult.

Modulation of barrier function of small intestinal epithelial cells by lamina propria fibroblasts in response to lipopolysaccharide: possible role in TNFalpha in inducing barrier dysfunction

Recent evidence suggests an interaction between immune, enteric neural and fibroblasts in the regulation of intestinal function. Earlier, we have reported that lipopolysaccharide (LPS) induced cell proliferation, collagen synthesis and production of proinflammatory mediators in lamina propria fibroblasts. In this report, we investigated the change in transepithelial resistance (TER) as a marker of epithelial barrier function by lipopolysaccharide (LPS) and its modulation by human small intestinal lamina propria fibroblasts (HSILPF). Epithelial cells incubated with LPS alone did not show any change in the TER at any concentration or prolonged exposure. However, co-cultivation of epithelial cells with lamina propria fibroblasts which had been exposed to LPS resulted in a rapid decrease in TER by 2 hr. The decrease in the TER was continued till 8 hr followed by returning to the basal level by 24 hr. The supernatant of LPS-treated HSILPF was less effective in causing a fall in the TER than HSILPF itself. The fall in TER was accompanied by loosening of tight junctions as depicted by increased penetration of horse radish peroxidase (HRP) across the epithelial cells from the apical to the basal side. Increased incorporation of 3[H]thymidine (tritiated thymidine) in epithelial cells was observed at 48 hr in the presence of LPS-treated HSILPF. The decrease in TER during the early time period in epithelial cells was abrogated to 70% by incubating the LPS-treated HSILPF and the conditioned medium of LPS-treated HSILPF with anti-TNFalpha antibody, and not with antibody to other cytokines like IL1alpha, IL1beta, IL6 and IL8. Overall, these results suggest that TNFalpha produced by HSILPF in response to LPS as a soluble form cause a decrease in the TER and loosening of tight junctions, and such early changes in the epithelial barrier may contribute to local inflammation in the gut.

Primary choriocarcinoma of the ovary. Report of two cases

Primary choriocarcinoma of the ovary (PCO) is rare. This can be gestational (GCO) or nongestational (NGCO) in origin. It is difficult to differentiate between CGO and NGCO. NGCO carries a worse prognosis than GCO. We present two cases of metastatic GCO who were treated successfully with combination chemotherapy and are alive and disease free at the time of reporting.

Melatonin and protection from whole-body irradiation: survival studies in mice

The radioprotective ability of melatonin was investigated in mice exposed to an acute whole-body gamma radiation dose of 815 cGy (estimated LD50/30 dose). The animals were observed for mortality over a period of 30 days following irradiation. The results indicated 100% survival for unirradiated and untreated control mice, and for mice treated with melatonin or solvent alone. Forty-five percent of mice exposed to 815 cGy radiation alone, and 50% of mice pretreated with solvent and irradiated with 815 cGy were alive at the end of 30 days. Irradiated mice which were pretreated with 125 mg/kg melatonin exhibited a slight increase in their survival (60%) (p=0.3421). In contrast, 85% of irradiated mice which were pretreated with 250 mg/kg melatonin were alive at the end of 30 days (p=0.0080). These results indicate that melatonin (at a dose as high as 250 mg/kg) is non-toxic, and that high doses of melatonin are effective in protecting mice from lethal effects of acute whole-body irradiation.

Interaction of lipopolysaccharide with human small intestinal lamina propria fibroblasts favors neutrophil migration and peripheral blood mononuclear cell adhesion by the production of proinflammatory mediators and adhesion molecules

Fibroblasts are important effector cells having a potential role in augmenting the inflammatory responses in various diseases. In infantile diarrhea caused by enteropathogenic Escherichia coli (EPEC), the mechanism of inflammatory reactions at the mucosal site remains unknown. Although the potential involvement of fibroblasts in the pathogenesis of cryptococcus-induced diarrhea in pigs has been suggested, the precise role of lamina propria fibroblasts in the cellular pathogenesis of intestinal infection and inflammation caused by EPEC requires elucidation. Earlier we reported the lipopolysaccharide (LPS)-induced cell proliferation, and collagen synthesis and downregulation of nitric oxide in lamina propria fibroblasts. In this report, we present the profile of cytokines and adhesion molecules in the cultured and characterized human small intestinal lamina propria fibroblasts in relation to neutrophil migration and adhesion in response to lipopolysaccharide (LPS) extracted from EPEC 055:B5. Upon interaction with LPS (1-10 micrograms/ml), lamina propria fibroblasts produced a high level of proinflammatory mediators, interleukin (IL)-1alpha, IL-1beta, IL-6, IL-8, tumor necrosis factor (TNF)-alpha and cell adhesion molecules (CAM) such as intercellular cell adhesion molecule (ICAM), A-CAM, N-CAM and vitronectin in a time-dependent manner. LPS induced cell-associated IL-1alpha and IL-1beta, and IL-6, IL-8 and TNF-alpha as soluble form in the supernatant. Apart from ICAM, vitronectin, A-CAM, and N-CAM proteins were strongly induced in lamina propria fibroblasts by LPS. Adhesion of PBMC to LPS-treated lamina propria fibroblasts was ICAM-dependent. LPS-induced ICAM expression in lamina propria fibroblasts was modulated by whole blood, PBMC and neutrophils. Conditioned medium of LPS-treated lamina propria fibroblasts remarkably enhanced the neutrophil migration. The migration of neutrophils was inhibited by anti-IL-8 antibody. Co-culture of fibroblasts with neutrophils using polycarbonate membrane filters exhibited time-dependent migration of neutrophils. These findings indicate that the coordinate production of proinflammatory cytokines and adhesion molecules in lamina propria fibroblasts which do not classically belong to the immune system can influence the local inflammatory reactions at the intestinal mucosal site during bacterial infections and can influence the immune cell population residing in the lamina propria.

Spontaneous oesophageal perforation due to mediastinal tuberculous lymphadenitis - atypical presentation of tuberculosis

Spontaneous non-traumatic oesophageal perforation secondary to bursting of a mediastinal tuberculous abscess into the oesophagus is rare. The diagnosis is delayed, as perforation remains localised due to mediastinal lymph nodes. Patient can be effectively managed by paraoesophageal drainage of the mediastinal abscess and oesophageal diversion.

Managing morphine-induced constipation: a controlled comparison of an Ayurvedic formulation and senna

Constipation is a frequent cause of distress in advanced cancer. A palliative care unit in Kerala, a southern state of India, conducted a controlled trial comparing a liquid Ayurvedic (herbal) preparation (Misrakasneham) with a conventional laxative tablet (Sofsena) in the management of opioid-induced constipation in patients with advanced cancer. Although there was no statistically significant difference in the apparent degree of laxative action between the two, the results indicate that the small volume of the drug required for effective laxative action, the tolerable taste, the once-daily dose, the acceptable side effect profile, and the low cost make Misrakasneham a good choice for prophylaxis in opioid-induced constipation. There is a need for further studies of Ayurvedic medicines in palliative care.

Selective musculocutaneous fasciculotomy for spastic elbow in cerebral palsy: a preliminary study

Three hundred and ten people with cerebral palsy who had spasticity in one or more limbs underwent selective motor fasciculotomy (SMF) of the nerves supplying the harmful spastic muscles with the aim of achieving useful tone and to improve voluntary movements. Among them, 52 people (average age 9.5 years) had 75 spastic elbows who were considered fit cases to undergo SMF of the musulocutaneous nerve (MCN). The nerve was dissected in the upper 1/3rd of the arm. Bipolar current was used to stimulate the component fascicles and to detect those carrying excessive impulses. Some of the hyperactive fascicles were ablated according to preoperative grading of the spasticity, etc. Total relief in spasticity was achieved in 47 (62.66%) elbows. Whereas, in the remaining 28 (37.33%) elbows some degree of spasticity persisted. There were overall beneficial effects of SMF on the motor functions and the flexed elbow posture. There were no side effects and recurrence of spasticity. The results were observed for an average period of 17 months. It must be noted that, 5 people who had involuntary elbow flexion on activity, like walking, also developed normal posture and the to & fro swinging movements following surgery. In conclusion, SMF of MCN is an effective and safe procedure for achieving longlasting useful tone and voluntary movements in the harmful spastic elbow of people with cerebral palsy. The present report is an account of the largest number of cerebral palsy people in the world literature to date.