Presentation and clinical course of Wolfram (DIDMOAD) syndrome from North India

AIMS

Wolfram syndrome, also known as DIDMOAD, is a relatively rare inherited neurodegenerative disorder, first evident in childhood as an association of juvenile-onset diabetes mellitus and optic atrophy, followed by diabetes insipidus and deafness. The aim of the study was to examine the clinical profile of patients with DIDMOAD syndrome presenting to a tertiary care hospital in north India.

METHODS

Clinical presentation of juvenile-onset diabetes mellitus fulfilling the diagnosis of Wolfram syndrome was studied using a prepared standardized form.

RESULTS

Subjects with juvenile-onset non-autoimmune diabetes mellitus attending the diabetic clinic at a tertiary care centre in north India were followed for 10 years and a diagnosis of fully developed Wolfram syndrome was confirmed in seven individuals. The series consisted of five male and two female patients with a mean age of 17.5 ±7.34 years. Two subjects had consanguinity and none had any other family member affected. Optic atrophy was present in all, sensorineural hearing loss in 4/7, central diabetes insipidus in 4/7 and nephrogenic diabetes insipidus in 2/7 subjects. The new associations found were: spastic myoclonus, short stature with pancreatic malabsorption, nephrogenic diabetes insipidus, cyanotic heart disease and choledocholithiasis with cholangitis. Genetic analysis revealed mutation in exon 8 of the WFS1 gene in all the cases studied.

CONCLUSIONS

The present clinical series of Wolfram syndrome reveals a varied clinical presentation of the syndrome and some new associations.

Applying patient centered approach in management of pulmonary tuberculosis: A case report from Malaysia

A 24 year university student with history of productive cough was registered as sputum smear confirmed case of pulmonary tuberculosis. During treatment, patient suffered from itchiness associated with anti tuberculosis drugs and was treated with chlorpheniramine (4mg) tablet. Patient missed twenty eight doses of anti tuberculosis drugs in continuation phase claiming that he was very busy in his studies and assignments. Upon questioning he further explained that he was quite healthy after five months and unable to concentrate on his studies after taking prescribed medicines. His treatment was stopped based on clinical improvement, although he did not complete six months therapy. Two major reasons; false perception of being completely cured and side effects associated with anti TB drugs might be responsible for non adherence. Non sedative anti histamines like fexofenadine, citrizine or loratidine should be preferred over first generation anti histamines (chlorpheniramine) in patients with such lifestyle. Patient had not completed full course of chemotherapy, which is preliminary requirement for a case to be classified as "cure" and "treatment completed". Moreover, patient had not defaulted for two consecutive months. Therefore, according to WHO treatment outcome categories, this patient can neither be classified as "cure" or "treatment completed" nor as "defaulter". Further elaboration of WHO treatment outcome categories is required for adequate classification of patients with similar characteristics. Likelihood of non adherence can be significantly reduced by applying the WHO recommended "Patient Centered Approach" strategy. Close friend, class mate or family member can be selected as treatment supporter to ensure adherence to treatment.

Degeneration of the extensor muscle group in a surgical low back and leg pain population

The spinal muscles have received great attention in low back pain (LBP) with suggestions of a de-conditioning syndrome. It is not known whether it is a long or short term consequence of LBP. This study explored the cross section area (CSA) and muscle quality of the spinal extensor group in LBP patients referred to a spinal clinic. MRI scans of 100 annoymised patients were retrospectively reviewed; sagittal and transverse (from levels L3-5) images were archived and analysed to determine CSA and levels of fat infiltration of the extensor muscle groups. Forty six patients had spinal stenosis (28 males, 18 females, mean age 66 ± 14.2 years) and 54 had a disc prolapse (28 males, 26 females, mean age 50 ± 12.9 years). CSA was significantly smaller in the stenotics at both L3/4 and L4/5. Patients presenting with leg pain and a disc herniation had a significantly smaller CSA (p < 0.01) at L3/4 and L4/5 levels. Fat infiltration was present in both groups but was significantly greater in the stenotic group (p < 0.01) and was present at a similar degree at all spinal levels. Multiple regression analysis confirmed that reduced CSA was linked to leg pain (p < 0.01) and age was linked with fat infiltration (p < 0.01). Future work should explore the extent of such changes in an age and sex matched control population with no current back pain or sciatica.

Physiological changes in scalp, facial and body hair after the menopause: a cross-sectional population-based study of subjective changes

BACKGROUND

Significant changes in scalp, facial and body hair occur after the menopause. These can have a significant negative impact on self-esteem and are also potential markers of endocrine or metabolic diseases. Knowledge of postmenopausal hair changes is important for clinicians to distinguish between normal physiological change and those that require further medical investigation.

OBJECTIVES

To assess the subjective experience of scalp, facial and body hair change in a large cohort of normal postmenopausal females.

METHODS

Postmenopausal females aged 45 years or over of northern European origin completed a questionnaire detailing scalp, facial and body hair changes following the menopause. Women with a history of thyroid disease, oophorectomy or premature menopause were excluded from the study. The Mann-Whitney U-test and the χ(2) test were used to assess the correlation between scalp, facial and body hair changes with age.

RESULTS

Diffuse generalized hair loss was the most common form of scalp hair loss, reported by 26% of women. Frontal hair loss was reported by 9% of women. Facial hair gain was cited by 39% of females with the chin being the most frequent site for new growth (32% of women). Body hair loss was significantly correlated with older age (P < 0·001) and was most frequent at androgen-sensitive sites. We noted two patterns: (i) diffuse hair loss in which diffuse generalized scalp hair loss was significantly correlated with body hair loss and increasing age (P < 0·05); and (ii) frontal hair loss which was associated with higher facial hair scores and relatively younger age (P < 0·05) compared with women with diffuse hair loss.

CONCLUSIONS

This is the first comprehensive study of the subjective hair changes in postmenopausal women. This study demonstrates two distinct patterns of hair change relating to age, which may reflect different underlying pathophysiological mechanisms and are of relevance to the medical management of these women as well as being possible predictors of health outcomes.

First Report of Tomato leaf curl Palampur virus on Bitter Gourd in Pakistan

Bitter gourd (Momordica charantia L.) is widely grown and consumed as a vegetable in Pakistan and other countries in the region. In 2007, a severe disease appeared on bitter gourd that reduced yield significantly. Symptoms of the disease included chlorosis, leaf crumpling, vein thickening, and stunting of plants that were suggestive of a virus infection. Symptomatic leaf samples were collected from fields in the vicinity of Faisalabad, Pakistan (Thikriwala, 12 km from Faisalabad, 31°22'0″N, 72°53'0″E). Seven infected samples were tested for the presence of Zucchini yellow mosaic virus (ZYMV), Cucumber mosaic virus, Papaya ringspot virus, Melon necrotic spot virus, and Squash mosaic virus by double-antibody sandwich-ELISA according to the manufacturer's instructions (Bio-Rad, Hercules, CA). All samples of bitter gourd were found to be negative for all five RNA viruses, whereas melon samples collected from the same area (Thikriwala) were infected by ZYMV as reported earlier (3). Samples were also screened for begomoviruses by molecular tests. Total DNA was extracted with the cetyltrimethylammoniumbromide method (4). All seven symptomatic samples were positive for a begomovirus when DNA A of Tomato leaf curl New Delhi virus (ToLCNDV) was used as a general probe by Southern hybridization. A probe of the movement protein (MP) gene of ToLCNDV was also positive by Southern hybridization, suggesting the infection of a bipartite begomovirus. The presence of a begomovirus was confirmed by PCR with universal primers designed for amplification of begomoviruses (BegomoRe F 5'ACGCGT GCCGTGCTGCTGCCCCCATTGTCC3' and BegomoRe R 5'ACGCGT ATGGGCTGYCGAAGTTSAGACG3'). A fragment of the expected length (approximately 2.8 kb) was cloned in a T/A cloning vector (ptz57R/t; Fermentas, Burlington, Ontario, Canada) and partially sequenced. Sequence analysis of partial sequences (925 bp, GenBank Accession No. FN555137; 719 bp, GenBank Accession No. FN555138) showed maximum identity (97%) with Tomato leaf curl Palampur virus (ToLCPaV) recently reported from India and Iran (1,2). To our knowledge, this is the first report of ToLCPaV in Pakistan and the first report of the virus on bitter gourd. References: (1) J. Heydarnejad et al. Arch. Virol. 154:1015, 2009. (2) Y. Kumar et al. Virus Genes 38:193, 2009. (3) A. H. Malik et al. Plant Pathol. 55:285, 2006. (4) M. G. Murray and W. F. Thompson. Nucleic Acids Res.8:4321, 1980.

Defining the gap between electrographic seizure burden, clinical expression and staff recognition of neonatal seizures

BACKGROUND

Neonatal seizures are often subclinical, making accurate diagnosis difficult.

OBJECTIVE

To describe the clinical manifestations of electrographic seizures recorded on continuous video-EEG, and to compare this description with the recognition of clinical seizures by experienced neonatal staff.

METHODS

Term infants, at risk of seizures, were monitored by continuous 12-channel video-EEG from <6 hours of birth for up to 72 hours. All clinical seizures were recorded by experienced neonatal staff on individual seizure charts. Video-EEG recordings were subsequently analysed. The number, duration and clinical expression of electrographic seizures were calculated (in seconds), and compared with the seizures clinically suspected by the neonatal staff.

RESULTS

Of 51 infants enrolled, nine had electrographic seizures. A further three had clinically suspected seizures, without associated electrographic abnormality. Of the total 526 electrographic seizures, 179 (34%) had clinical manifestations evident on the simultaneous video recording. The clinical seizure activity corresponded to 18.8% of the total electrographic seizure burden. Overdiagnosis also occurred frequently. Of the 177 clinically suspected seizure episodes documented by staff, 48 (27%) had corresponding electrographic evidence of seizure activity Thus, only 9% (48/526) of electrographic seizures were accompanied by clinical manifestations, which were identified and documented by neonatal staff.

CONCLUSION

Only one-third of neonatal EEG seizures displays clinical signs on simultaneous video recordings. Moreover, two-thirds of these clinical manifestations are unrecognised, or misinterpreted by experienced neonatal staff. In the recognition and management of neonatal seizures clinical diagnosis alone is not enough.

Dynamics of polymer packaging

We use the stochastic rotation dynamics algorithm to investigate the packaging of flexible and semiflexible polymers into a capsid that is permeable to solvent molecules. The model takes into account hydrodynamic interactions arising due to local flow. The flexible chain maintains a random configuration as it is being fed into the capsid, in contrast to the semiflexible chain, whose configuration is initially spool-like, becoming more random at high packing. We measure the packing rate, which is found to decrease with the percentage of the chain packed and highlight the difference between the flexible and semiflexible chains. Reflecting experiments, we find pauses in the packing process for individual chains as the motor loses grip of the fluctuating beads. We also find that hydrodynamics is important, in that the packaging rate is faster when flow is included.

Polymer packaging and ejection in viral capsids: shape matters

We use a mesoscale simulation approach to explore the impact of different capsid geometries on the packaging and ejection dynamics of polymers of different flexibility. We find that both packing and ejection times are faster for flexible polymers. For such polymers a sphere packs more quickly and ejects more slowly than an ellipsoid. For semiflexible polymers, however, the case relevant to DNA, a sphere both packs and ejects more easily. We interpret our results by considering both the thermodynamics and the relaxational dynamics of the polymers. The predictions could be tested with biomimetic experiments with synthetic polymers inside artificial vesicles. Our results suggest that phages may have evolved to be roughly spherical in shape to optimize the speed of genome ejection, which is the first stage in infection.

Hemolysis of human red blood cells by riboflavin-Cu(II) system: enhancement by azide

Photoactivated riboflavin in the presence of Cu(II) generates reactive oxygen species (ROS) which can hemolyze human red blood cells (RBC). In the present work we examined the effect of sodium azide (NaN3) on RBC in the presence of riboflavin and Cu(II). The addition of NaN3 to the riboflavin-Cu(II) system enhanced K+ loss and hemolysis. The extent of K+ loss and hemolysis were time and concentration dependent. Bathocuproine, a Cu(I)-sequestering agent, inhibited the hemolysis completely. Among various free radical scavengers used to identify the major ROS involved in the reaction, thiourea was found to be the most effective scavenger. Thiourea caused almost 85% inhibition of hemolysis suggesting that *OH is the major ROS involved in the reaction. Using spectral studies and other observations, we propose that when NaN3 is added to the riboflavin-Cu(II) system, it inhibits the photodegradation of riboflavin resulting in increased *OH generation. Also, the possibility of azide radical formation and its involvement in the reaction could not be ruled out.

Polymer translocation: The effect of backflow

We investigate the effect of backflow on the translocation dynamics of short, flexible polymer chains threading through a small hole in a wall. We find that hydrodynamic interactions between polymer beads play an important role in determining the translocation time distribution: as a monomer moves through the hole it sets up a flow field which transfers momentum to neighboring monomers, thus helping them to move in the same direction. Translocation times are calculated by using the velocity-Verlet algorithm to solve the equations of motion of a polymer which moves in a fluid described by the stochastic rotation algorithm, a particle-based Navier-Stokes solver.

Decreased antioxidant enzyme expression and increased oxidative damage in erosive lichen planus of the vulva

The aim of this study was to investigate whether increased oxidative stress occurs in erosive lichen planus of the vulva. Skin biopsies from six patients with untreated, histologically confirmed erosive lichen planus of the vulva were examined immunohistochemically using antibodies against antioxidant enzymes. The protein-bound lipid peroxidation products malondialdehyde (MDA) and 4-hydroxynonenale (4-HNE) and the oxidative DNA damage marker 8-hydroxy-2'-deoxyguanosine (8-OHdG) were investigated. Protein carbonyls as markers of protein oxidation were visualised using the dinitrophenylhydrazone (DNPH) method. Normal vulval tissues from 12 subjects served as controls. In vulval lichen planus tissue the enzymatic antioxidant defence was found to be significantly decreased in the epidermal layers. Furthermore, a significant increase of lipid peroxidation products and oxidative DNA damage was found within the epidermis. Protein oxidation occurred predominantly in the papillary dermis. This is the first study to demonstrate a decreased antioxidant defence and increased oxidative damage to lipids, DNA and proteins in lichen planus. These oxidative modifications point to pathophysiological alterations mainly within the basal cell layers of the epidermis and at the dermoepidermal junction. Further studies are warranted to investigate the potential role of oxidative stress in the development of autoimmunity in this disease.