Multiple sclerosis and lung cancer: an unexpected inverse association

Multiple sclerosis is associated with a decreased risk of cancer. Smoking is a risk factor both for multiple sclerosis and lung cancer. We performed a meta-analysis on studies of cancer frequency in multiple sclerosis. Surprisingly, we found that the risk of lung cancer is reduced in multiple sclerosis [odds ratio 0.67 (95% confidence interval 0.59-0.76) P < 0.00001]. Since this does not appear to be secondary to altered smoking behaviour, we hypothesise that this may be secondary to altered immune surveillance.

Effects of 2-Deoxy-d-Glucose on Proliferation of Vascular Smooth Muscle Cells and Endothelial Cells

2-Deoxy-d-glucose (2-DG) is a glucose analogue that has been proposed for cancer therapy due to its cytostatic properties. Its effect on the proliferation of smooth muscle cells and endothelial cells has not been fully clarified. The aims of this study were to investigate the effects of 2-DG on the proliferation of porcine aortic endothelial cells (PAEC) and porcine smooth muscle cells (PSMC), to establish an overview of its dose-dependent inhibitory capacity and to examine whether the short-term incubation of cells with 2-DG has an impact on cell proliferation in culture. Our results showed a dose-dependent significant inhibitory effect on proliferation, which was more pronounced in PSMC than in PAEC. Even after short-term incubation of cells with 2-DG, relevant inhibition of proliferation was documented. The clinical application of 2-DG might be a promising concept by inhibiting cells that show a potentially rapid proliferation in response to non-malignant stimuli, such as smooth muscle cells after intracoronary stenting.

All that is swollen and red is not infection!

Unilateral upper limb extremity swelling and pain are common presentations in clinical practice whose differential diagnoses include cellulitis, abscess, lymphoedema, and venous thrombosis. We report here the case of a renal transplant recipient with an unusual cause of upper extremity swelling and pain. His condition of native radiocephalic, arteriovenous (AV), fistula-related, venous hypertension was misdiagnosed and managed as cellulitis. This case illustrates the importance of an index of suspicion and careful clinical examination for diagnosis and thus, avoid potentially dangerous and distressing symptoms. The patient improved with a surgical AV fistula ligation.

Incidence of Haemophilus influenzae type b meningitis in India

BACKGROUND & OBJECTIVE

Vaccine policy depends on locally relevant disease burden estimates. The incidence of Haemophilus influenzae type b (Hib) disease is not well characterized in the South Asian region, home to 30 per cent of the world's children. There are limited data from prospective population incidence studies of Hib in Asia, and no data available from India. We therefore carried out this study to assess the burden of Hib meningitis in India.

METHODS

A prospective surveillance study was carried out during 1997 and 1999 in hospitals for cases of Hib meningitis from 5 administrative areas of an Indian district (Vellore, Tamil Nadu) with 56,153 children under 5 yr of age, over a 24 month period

RESULTS

Ninety seven cases of possible meningitis (> 10 WBC/microl in CSF) were reported, an annual incidence of 86 per 100,000 (95%CI 69 to 109) in 0-4 yr old children, and 357 per 100,000 in 0-11 month infants. Eighteen had proven bacterial meningitis, an annual incidence of 15.9 per 100,000. Eight CSF had Hib by culture or antigen testing, an annual incidence of 7.1 per 100,000 (95%CI 3.1 to 14.0) in children 0-59 months. In infants 0-11 months of age, the incidence of Hib meningitis was 32 per 100,000 (95%CI 16 to 67) and in the 0-23 month group it was 19 (95%CI 8 to 37).

INTERPRETATION & CONCLUSION

Our data are the first minimal estimate of the incidence of Hib meningitis for Indian children. The observed incidence data are similar to European reports before Hib vaccine use, suggest substantial disease before 24 months of age, and provide data useful for policy regarding Hib immunization.

Immune tolerance induction to enzyme-replacement therapy by co-administration of short-term, low-dose methotrexate in a murine Pompe disease model

Clinical investigations of recombinant human acid alpha-glucosidase for the treatment of Pompe disease often reveal the appearance of therapy-specific antibodies. These antibodies could potentially interfere with recombinant human acid alpha-glucosidase efficacy and induce immunological consequences. Several immunosuppressive agents, including methotrexate, mycophenolate mofetil and cyclosporin A with azathioprine, were evaluated for their potential to induce immune tolerance to recombinant human acid alpha-glucosidase. Methotrexate was the only agent that reduced recombinant human acid alpha-glucosidase-specific antibody responses in acid alpha-glucosidase knock-out mice. A 3-week, low-dose methotrexate regimen controlled recombinant human acid alpha-glucosidase-specific antibody levels throughout 8 months of weekly recombinant human acid alpha-glucosidase treatment. The success of this methotrexate regimen appears to require methotrexate administration within the first 24 h of recombinant human acid alpha-glucosidase treatment. In an attempt to understand the benefit of methotrexate within the first day of recombinant human acid alpha-glucosidase administration, the immune response 24 h following intravenous recombinant human acid alpha-glucosidase treatment was investigated. A consistent expansion of peritoneal B1 B cells was observed. Control over this B1 B cell response may be part of the complex mechanism of action of methotrexate-induced immune tolerance.

Simultaneous Estimation of Esomeprazole and Domperidone by UV Spectrophotometric Method

A novel, simple, sensitive and rapid spectrophotometric method has been developed for simultaneous estimation of esomeprazole and domperidone. The method involved solving simultaneous equations based on measurement of absorbance at two wavelengths, 301 nm and 284 nm, lambda max of esomeprazole and domperidone respectively. Beer's law was obeyed in the concentration range of 5-20 mug/ml and 8-30 mug/ml for esomeprazole and domperidone respectively. The method was found to be precise, accurate, and specific. The proposed method was successfully applied to estimation of esomeprazole and domperidone in combined solid dosage form.

Newborn hearing screening in a South African private health care hospital

OBJECTIVE

Early Hearing Detection and Intervention (EHDI) programs are being established as part of the public health systems in increasing numbers of countries. In developing countries, however, little progress has been made towards implementing NHS programs and South Africa's public and private health care sectors is no exception. The current study presents the first report on a hospital-based UNHS program conducted in the South African private health care sector to provide preliminary results towards advocating for and guiding future programs.

METHODS

A retrospective study of a UNHS program at a private hospital in urban Gauteng, South Africa over a 4 year period of time was performed. Screening was conducted with Transient Evoked Otoacoustic Emissions (TEOAE) with a rescreen recommended within 6 weeks if referred. Diagnostic audiological assessments were performed on those infants referring the rescreen. The discharge screening costs were subsidized through the hospital birthing package for the first 22 months of the program.

RESULTS

Six thousand two hundred and forty-one newborns were screened from 13,799 hospital births during the first 4 years. Ninety-four percent of these infants were from the well-baby nurseries. During the initial 22 months, whilst the service was subsidized as part of the hospital birthing package, coverage of 75% was attained compared to 20% during the subsequent 26 months. The overall referral rate for the screening program across the 4 years was 11.1% but referral rates decreased by between 2 and 4% for each year of program existence with a 5% rate in year 4. Only 32% of the rescreens were completed at the hospital and no data was available for the remaining infants because parents were provided a choice of follow up centers. Referral for a diagnostic assessment after the rescreens at the hospital was predictive of sensorineural hearing loss in one-third of cases and the estimated prevalence was 3 in every 1000.

CONCLUSIONS

Screening coverage in the current study was not adequately high and can be attributed to insufficient parental knowledge to make an informed decision. Improvements in program efficiency over time also suggest that pilot programs must be monitored over sufficiently long periods of time to allow observations of optimal efficiency. Initial referral rates and prevalence data indicate a large hearing loss burden and the capacity to implement increasingly efficient programs in South Africa.

Characterization and in vivo performance of dextran-spermine polyplexes and DOTAP/cholesterol lipoplexes administered locally and systemically

In this study, we compared two systems which can be applied for transfection in vitro and in vivo: polyplexes based on the polymer dextran-spermine (D-SPM) and lipoplexes based on 1,2-dioleoyl-3-trimethylammonium-propane (DOTAP)/cholesterol. The carriers differ in (1) solubility in aqueous media, (2) source of the positive charges (quaternary amines for DOTAP and primary plus secondary amines for D-SPM), (3) electrostatics, i.e., for lipid and polymer, respectively: zeta-potential (81.0 and 48.1 mV), surface potential (180 and 92 mV), and surface pH (10.47 and 8.97), and (4) charge distribution (ordered versus non-ordered). The stability of the complex upon interaction with serum proteins was studied by means of fluorescence resonance energy transfer (FRET) between rhodamine-labeled cationic carriers and fluorescein-labeled DNA. Addition of serum increases the lipid-DNA average distance and decreases the polymer-DNA distance. However, FRET efficiency indicates that serum proteins do not induce a major DNA dissociation for either polyplexes or lipoplexes. Comparing the biodistribution of rhodamine-labeled complexes and the transgene expression after intravenous (i.v.), intramuscular (i.m.), and intranasal (i.n.) administration, we found that local administration of lipoplexes resulted in the lipoplexes remaining at the site of injection, whereas the polyplexes showed systemic distribution, accompanied by transgene expression in lungs and liver. It is suggested that the high water-solubility of the polymer combined with its lower positive charge (compared to DOTAP), which makes its association with the cells at the site of injection weaker, enables the polymer to reach and transfect distant organs through the blood stream. Using chemically modified D-SPM, we demonstrated the importance of high density of positive charges and a sufficient level of secondary amines for achieving efficient transgene expression in vivo.

Syphilitic acute posterior placoid chorioretinitis in nonimmuno-compromised patients

PURPOSE

To describe the clinical and angiographic features of three cases of secondary syphilis in immunocompetent patients, which presented as acute posterior placoid chorioretinitis (APPC) to the ophthalmologist.

METHODS

Interventional case series. The aetiology of the APPC was confirmed by serology to be secondary syphilis. Optical coherence tomography, electrophysiology, fundus fluorescein, and indocyanine green (ICG) angiography were performed at presentation and after resolution. Appropriate treatment for secondary syphilis was instituted in each patient.

RESULTS

The clinical features, fundus fluorescein and ICG angiography, multifocal electroretinography (mfERG), and optical coherence tomography findings of APPC are described. All three patients had a satisfactory resolution of the APPC with improvement in visual acuity.

CONCLUSIONS

APPC in secondary syphilis can occur even in immunocompetent patients. A high index of suspicion is required for early diagnosis of this condition resulting in a good visual outcome with adequate treatment. mfERG and optical coherence tomography are useful in the diagnosis and follow-up of these patients.

Tacrolimus immunosuppression in high-risk corneal grafts

BACKGROUND

Unlike the immune privilege enjoyed by low-risk corneal grafts, high-risk corneal grafts experience rejection rates comparable to liver and kidney transplants. Systemic immunosuppression reduces the risk of rejection in high-risk corneal grafts.

METHODS

Systemic tacrolimus, a specific T cell inhibitor, was used at a mean daily dose of 2.5 mg to immunosuppress 43 patients undergoing high-risk corneal transplantation. Immunosuppression was continued for a period of 18-24 months after the high-risk corneal graft.

RESULTS

During a mean follow-up period of 33.7 months, clarity of the graft was maintained in 65% of patients. Eight patients experienced rejection episodes while on tacrolimus, and this led to graft failure in five patients.

CONCLUSION

Tacrolimus is relatively safe and effective in reducing rejection and prolonging graft survival in patients with high-risk keratoplasty compared with other series where similar immunosuppression was not used.

Impression cytology of the ocular surface

Impression cytology refers to the application of a cellulose acetate filter to the ocular surface to remove the superficial layers of the ocular surface epithelium. These cells can then be subjected to histological, immunohistological, or molecular analysis. Proper technique is essential as the number of cells sampled can vary considerably. Generally two to three layers of cells are removed in one application but deeper cells can be accessed by repeat application over the same site. Applications for impression cytology include diagnosing a wide range of ocular surface disorders, documenting sequential changes in the conjunctival and corneal surface over time, staging conjunctival squamous metaplasia, and monitoring effects of treatment. It is also a useful investigational tool for analysing ocular surface disease with immunostaining and DNA analysis. It is non-invasive, relatively easy to perform, and yields reliable information about the area sampled with minimal discomfort to the patient. Major ophthalmic centres should develop and introduce this technique into routine clinical practice. This is best achieved with a team approach including the ophthalmologist, pathologist, microbiologist, and the immunologist.

Solar disinfection of water for diarrhoeal prevention in southern India

AIMS

To evaluate the efficacy and acceptability of solar irradiation in the prevention of diarrhoeal morbidity in children under 5 years of age, in an urban slum in Vellore, Tamil Nadu.

METHODS

A total of 100 children were assigned to receive drinking water that had been subjected to solar disinfection in polyethylene terephthalate bottles. One hundred age and sex matched controls were also selected. Both groups were followed by weekly home visits for a period of six months for any diarrhoeal morbidity. At the end of the follow up period, the acceptability of the intervention was assessed by interviews, questionnaires, and focus group discussions.

RESULTS

There was significant reduction in the incidence, duration, and severity of diarrhoea in children receiving solar disinfected water, despite 86% of the children drinking water other than that treated by the intervention. The incidence of diarrhoea in the intervention group was 1.7 per child-year, and among controls 2.7 per child-year, with an incidence rate ratio of 0.64 (95% CI -0.48 to 0.86). The risk of diarrhoea was reduced by 40% by using solar disinfection. In qualitative evaluation of acceptability, most women felt that solar disinfection was a feasible and sustainable method of disinfecting water.

CONCLUSIONS

Solar disinfection of water is an inexpensive, effective, and acceptable method of increasing water safety in a resource limited environment, and can significantly decrease diarrhoeal morbidity in children.

Epithelial proliferative potential of organ cultured corneoscleral rims; implications for allo-limbal transplantation and eye banking

AIMS

To determine the epithelial proliferative capacity of organ cultured limbal tissue and correlate this with various donor and eye banking factors.

METHODS

24 corneoscleral limbal (CSL) rims left over from penetrating keratoplasty were split in half and set up as in vitro explant cultures. Corneal epithelial proliferative potential (CEPP) was assessed by the number of "cycles" of growth achieved before explants underwent exhaustion and failure to generate an epithelium to subconfluence. The dependence of CEPP on the age of the donor, time of death to enucleation, time of enucleation to organ culture, and time in organ culture in the eye bank was determined.

RESULTS

CSL rims were capable of up to four cycles of culture with a wide variation between tissue samples. Of the various factors examined, death to enucleation time was the only statistically significant factor affecting the CEPP (regression coefficient: -0.062 (cycles/hour), CI -0.119 to -0.004, p = 0.037). Time in organ culture had little effect on CEPP.

CONCLUSIONS

Preselected organ cultured CSL rims from eye banks may offer a viable alternative tissue source for use in allo-limbal transplantation.

Rates and factors associated with suicide in Kaniyambadi Block, Tamil Nadu, South India, 2000-2002

BACKGROUND

Inefficient civil registration systems, non-report of deaths, variable standards in certifying death and the legal and social consequences of suicide are major obstacles to investigating suicide in the developing world.

OBJECTIVE

The aim of this study was to prospectively determine the suicide rate in Kaniyambadi Block, Tamil Nadu, South India, for the years 2000-2002 using verbal autopsies.

METHOD

The setting for the study was a comprehensive community health programme in a development block in rural South India. The main outcome measure was death by suicide, diagnosed by a detailed verbal autopsy and census, and birth and death data to identify the population base.

RESULTS

The average suicide rate was 92.1 per 100,000. The ratio of male to female suicides was 1:0.66. The age-specific suicide rate for men increased with age while that for women showed two peaks: 15-24 years and over 65 years of age. Hanging (49%) and poisoning with organo-phosphorus compounds (40.5%) were the commonest methods of committing suicide. Acute and/or chronic stress was elicited for nearly all subjects. More men suffered from chronic stress while more women had acute precipitating events (chi2 = 4.58; p < 0.04). People less than 44 years of age had more acute precipitating events before death while older subjects reported more chronic stress (chi2 = 17.38; p < 0.001).

CONCLUSION

The study replicates findings of an earlier study from the area. The suicide rate documented in this study is very high and is a major public health concern. There is a need for sentinel centres in India and in developing countries to monitor trends and to develop innovative strategies to reduce deaths by suicide.

Laparoscopic colorectal surgery: learning curve and training implications

AIMS

This paper is a review of experience of laparoscopic colorectal surgery at a district general hospital with particular emphasis on the learning curve and training implications.

METHODS

All patients undergoing colorectal surgery where laparoscopy was attempted between March 1998 and October 2003 were included in this study.

RESULTS

There were 80 patients of which 49 had malignancy. Twenty eight stomas and 52 bowel resections were performed laparoscopically. The conversion rate for bowel resection was 32% (decreasing from 38% to 44% to 22%). This was significant (p = 0.001) when compared with stoma formation (7%). The firm has support from a specialist registrar and staff grade surgeon. In 22% of cases, one of the middle grades was the principal operating surgeon, mainly laparoscopic mobilisation and stoma formation. Only 6% of resections were performed by the middle grades. Conversely, a middle grade was the main operating surgeon in 66% of open resections and 61% of stoma formations during the same period. There were in all two deaths and 14 postoperative complications. All patients who had laparoscopic resections for malignancy had clear resection margins.

CONCLUSION

This audit highlights that there is a long learning curve in laparoscopic colorectal surgery with decrease in conversion rates with increasing experience. There is also a reduction in training opportunities in open surgery during the learning phase of the consultant, although this may be counterbalanced by the exposure to laparoscopic techniques. Laparoscopic colonic mobilisation, as a part of stoma formation, is a good starting point for specialist registrar training.