Efficacy of GM-CSF as an adjuvant to hepatitis B vaccination in patients with chronic renal failure--results of a prospective, randomized trial

BACKGROUND

Chronic renal failure patients on hemodialysis are at an increased risk of acquiring hepatitis B infection. Hence vaccination against hepatitis B assumes great importance in these patients. However, the response to hepatitis B vaccination is poor, even when 4 double doses (40 microg) of the vaccine are given. This study was conducted to determine the efficacy of GM-CSF as an adjuvant to hepatitis B vaccine in CRF patients.

METHODS

CRF patients including both hemodialysis (HD) and non-dialysis (ND) patients were randomized to receive either placebo or a single injection of GM-CSF (in varying doses of 50 microg, 100 microg, 150 microg) a day prior to the 1st dose of recombinant hepatitis B vaccine (40 microg). Three more doses of the vaccine were given at 1, 2, and 6 months. The anti-HBs antibody titres were measured by ELISA at 3 and 7 months. Patients having antibody titres less than 10 IU/L were considered non-responders. The response rate and mean antibody titers were compared between the control (I) and GM-CSF (II) groups.

RESULTS

In group I, 31 and 27 patients were available for evaluation at 3 and 7 months respectively. In group II, 33 and 28 patients could be evaluated at the same time points. Within the control group (group I), the response rate in hemodialysis patients (63.6%) was lower as compared to non-dialysis patients (81.2%). The response rate in group II was higher than that in group I at both 3 months as well as 7 months (78.1% vs. 62.3% and 89.3% vs. 74.1%, p = ns). The best response rates in group II were observed when GM-CSF was used in a dose of 150 microg (90.9% at 3 months and 100% at 7 months). The mean antibody titers were also found to be higher in the group II as compared to group I (409.6 vs. 243.9 IU/L, p = 0.01).

CONCLUSION

The results of this randomized, prospective study suggest that: 1. Patients with chronic renal failure should be vaccinated for hepatitis B as chronic renal insufficiency is established. 2. GM-CSF is an effective adjuvant to hepatitis B vaccine in these patients especially when a priming dose of 150 microg is used prior to 1st dose of hepatitis B vaccination.

Effect of gamma irradiation on Listeria monocytogenes in frozen, artificially contaminated sandwiches

Gamma irradiation has been shown to effectively control L monocytogenes in uncooked meats but has not been extensively studied in ready-to-eat foods. The presence of Listeria in ready-to-eat foods is often due to postprocess contamination by organisms in the food-manufacturing environment. Because gamma irradiation is applied after products are packaged, the treated foods are protected from environmental recontamination. Currently, a petition to allow gamma irradiation of ready-to-eat foods is under review by the Food and Drug Administration. This study was conducted to determine if gamma irradiation could be used to control L. monocytogenes in ready-to-eat sandwiches. Ham and cheese sandwiches were contaminated with L. monocytogenes, frozen at -40 degrees C, and exposed to gamma irradiation. Following irradiation, sandwiches were assayed for L. monocytogenes. A triangle test was performed to determine if irradiated and nonirradiated sandwiches differed in sensory quality. We found that the D10-values ranged from 0.71 to 0.81 kGy and that a 5-log reduction would require irradiation with 3.5 to 4.0 kGy. The results of a 39-day storage study of sandwiches inoculated with 10(7) CFU of L monocytogenes per g indicated that counts for nonirradiated sandwiches remained fairly constant. Counts for sandwiches treated with 3.9 kGy decreased by 5 log units initially and then decreased further during storage at 4 degrees C. Sensory panelists could distinguish between irradiated and nonirradiated sandwiches but were divided on whether irradiation adversely affected sandwich quality. Our results suggest that manufacturers of ready-to-eat foods could use gamma irradiation to control L. monocytogenes and improve the safety of their products.

Genes encoding chimeras of Neurospora crassa erg-3 and human TM7SF2 proteins fail to complement Neurospora and yeast sterol C-14 reductase mutants

The human gene TM7SF2 encodes a polypeptide (SR-1) with high sequence similarity to sterol C-14 reductase, a key sterol biosynthetic enzyme in fungi, plants and mammals. In Neurospora and yeast this enzyme is encoded by the erg-3 and erg24 genes respectively. In an effort to demonstrate sterol C-14 reductase activity for SR-1 we constructed six recombinant genes coding for chimeras of the Neurospora erg-3 and SR-1 protein sequences and tested them for complementation of the Neurospora erg-3 mutant. To our surprise, all the chimeras failed to complement erg-3. A few of the chimeric proteins were also tested against the yeast erg24 mutant, but again there was no complementation. We discuss some reasons that might account for these unexpected findings.

The sterol C-14 reductase encoded by the Neurospora crassa erg-3 gene: essential charged and polar residues identified by site-specific mutagenesis

Sterol C-14 reductase catalyses the reduction of the Delta(14,15) bond in intermediates in the sterol biosynthesis pathway using NADPH as a cofactor. We have undertaken a systematic site-directed mutational analysis of all the conserved charged and potentially proton-donating residues of the sterol C-14 reductase from Neurospora crassa. The effect of each mutation was determined using an in vivo assay based on the complementation of the corresponding N. crassa mutant ( erg-3). The non-complementing mutations were also tested in the erg24 mutant of Saccharomyces cervisiae. The results are discussed with reference to the predicted topology of the enzyme and to its proposed catalytic mechanism, which involves addition of a proton from an appropriately positioned charged or polar residue to the substrate double bond, followed by addition of hydride ion from NADPH.

Lens regeneration in mice under the influence of vitamin A

The effect of vitamin A has been studied on lens regeneration in young (7 days old) as well as adult mice. A longitudinal slit was made under local anesthesia in the cornea over the lens. The lens was extracted intact through the incision. Intraperitonial injection of vitamin A (0.05 ml of 30 IU/ml in young and 0.05 ml of 50 IU/ml in adult) was given to the operated animals. Vitamin A was found to induce lens regeneration in not only young but also in adult mice. Regenerated lenses were similar in shape, size, transparency and histological features to normal intact lenses.

Homeotic regeneration of eye in amphibian tadpoles and its enhancement by vitamin A

After removal of both the lateral eyes of external gill stage tadpoles of the toad Bufo melanostictus, the pineal organ gets transformed into a median eye. This type of transformation occurs in tadpoles of both control and vitamin A treated groups. However, vitamin A increases the likelihood of homeotic regeneration (57% in the control group and 71% in the vitamin A treated group). Histological studies showed that the newly transformed median eye developed from the pineal organ. The pineal eye so developed possessed all components of a normal eye such as a retina, sensory cells and lens.

Adenosquamous carcinoma of colon

Primary adenosquamous carcinoma of the colon is an aggressive entity. We report a 41-year-old man with a combination of adenocarcinoma and squamous cell carcinoma of the cecum, treated by right hemicolectomy and ileo-transverse anastomosis. Postoperatively he received adjuvant chemotherapy. However, the tumor recurred at the original site within two months and thereafter the patient was lost to follow up.

Effect of prophylactic ondansetron on postoperative nausea and vomiting after elective craniotomy

This prospective, randomized, placebo-controlled, double-blind study was designed to evaluate the efficacy of ondansetron, a 5-HT3 antagonist, in preventing postoperative nausea and vomiting (PONV) after elective craniotomy in adult patients. The authors also tried to discover certain predictors for postcraniotomy nausea and vomiting. We studied 170 ASA physical status I and II patients, aged 15 to 70 years, undergoing elective craniotomy for resecting various intracranial tumors and vascular lesions. A standardized anesthesia technique and postoperative analgesia were used for all patients. Patients were divided into two groups and received either saline placebo (Group 1) or ondansetron 4 mg (Group 2) intravenously at the time of dural closure. Patients were extubated at the end of surgery and episodes of nausea and vomiting were noted for 24 hours postoperatively in the neurosurgical intensive care unit. Demographic data, duration of surgery, and anesthesia and analgesic requirements were comparable in both groups. Overall, a 24-hour incidence of postoperative emesis was significantly reduced in patients who received ondansetron compared with those who received a saline placebo (39% in Group 1 and 11% in Group 2, P = .001). There was a significant reduction in the frequency of emetic episodes and rescue antiemetic requirement in patients treated with ondansetron; however, ondansetron did not significantly reduce the incidence of nausea alone (14% in Group 2 vs 5% in Group 1, P = .065). Prophylactic ondansetron had a favorable influence on PONV outcome measures such as patient satisfaction and number needed to prevent emesis (3.5). Side effects were similar in both groups. We conclude that ondansetron 4 mg given at the time of dural closure is safe and effective in preventing emetic episodes after elective craniotomy in adult patients.

Right and left atrial activation during external direct-current cardioversion shocks delivered for termination of atrial fibrillation in humans

We examined the regional electrophysiologic effects of successful and unsuccessful direct-current cardioversion shocks on different right and left atrial regions in patients with sustained atrial fibrillation (AF). Patients with sustained AF undergoing external cardioversion underwent simultaneous mapping of the right and left atria. Electrogram changes after shock delivery, regional atrial activation, and effects of shock intensity were analyzed. Twenty-two patients with sustained AF received 52 shocks (mean 2.4/patient, 22 successful and 30 unsuccessful). The efficacy of 50, 100, 200, and 300 J was 18%, 39%, 100%, and 100%, respectively. In all 22 successful shocks, there was virtually simultaneous termination of electrical activity in all right and left atrial regions mapped. Unsuccessful shocks resulted in a significant increase in mean atrial cycle length at lateral right atrium, superior left atrium, and proximal, mid, and distal coronary sinus (p = 0.01), but not at the interatrial septum (p >0.2), which often disappeared before the next shock. This cycle length prolongation was accompanied by reduction in fragmented and chaotic electrograms (p <0.03) and emergence of discrete electrograms at all right and left atrial regions that persisted until the next shock. The changes in electrogram morphology failed to alter the surface electrocardiographic appearance of AF. There was no correlation between the shock intensity and the magnitude of these effects. We conclude that termination of AF with external cardioversion shocks is associated with the widespread extinction of regional atrial wave fronts. Unsuccessful shocks are associated with a temporary slowing of atrial activation at all regions except at the interatrial septum and emergence of organized and/or rapidly propagating wave fronts.

Risk factors of malaria in the fringes of an evergreen monsoon forest of Arunachal Pradesh

BACKGROUND

The forested hilly and foothill regions of north-east India are highly endemic for malaria and have a distinct epidemiological pattern. Nearly half the reported cases of malaria are from these areas. A knowledge of the risk factors in this eco-geographic entity may be helpful in formulating a specific control strategy. Hence, we conducted a community-based epidemiological study in a hilly, forested terrain of Arunachal Pradesh and examined different socio-demographic factors to identify those predisposing to the occurrence of malaria, especially Plasmodium falciparum infection, in such areas.

METHODS

Four epidemiological surveys were carried out during 1997 in 7 villages located at the fringes of a forest (total population: 1177) under Nompong Primary Health Centre of Changlang district, Arunachal Pradesh. Blood slides were collected randomly from the inhabitants, irrespective of their fever status, ensuring at least 50% coverage. One hundred and thirty-four microscopically confirmed Plasmodium falciparum cases were identified and 536 controls were randomly selected from the list of uninfected inhabitants. Relevant socio-demographic information was obtained from both cases and controls. The data were analysed by simple and multiple logistic regression using the unconditional maximum likelihood method.

RESULTS

Factors which were found to be strongly associated with Plasmodium falciparum malaria on univariate analysis were age, ethnicity, village of residence and accessibility to the nearest health care facility. However, in multiple regression analysis, after controlling for the effects of confounding variables, the only risk factor identified was accessibility to the nearest health care facility (adjusted odds ratio: 4.5; 95% CI: 1.8-11.3; p < 0.0001 for those at a distance of 2-8 km and adjusted odds ratio: 11.1; 95% CI: 4.1-30.0; p < 0.0001 for those > 8 km away).

CONCLUSION

Distance, particularly non-motorable distance, from the place of residence to the nearest health care facility was a major risk factor for malaria in this hilly forested terrain. This indicates the need for special efforts to detect cases early and institute treatment promptly in such areas of the north-eastern region, so as to reduce the morbidity and mortality of malaria.

IRF3 and IRF7 phosphorylation in virus-infected cells does not require double-stranded RNA-dependent protein kinase R or Ikappa B kinase but is blocked by Vaccinia virus E3L protein

Induction of interferon-alpha (IFNalpha) gene expression in virus-infected cells requires phosphorylation-induced activation of the transcription factors IRF3 and IRF7. However, the kinase(s) that targets these proteins has not been identified. Using a combined pharmacological and genetic approach, we found that none of the kinases tested was responsible for IRF phosphorylation in cells infected with Newcastle disease virus (NDV). Although the broad-spectrum kinase inhibitor staurosporine potently blocked IRF3 and -7 phosphorylation, inhibitors for protein kinase C, protein kinase A, MEK, SAPK, IKK, and protein kinase R (PKR) were without effect. Both IkappaB kinase and PKR have been implicated in IFN induction, but cells genetically deficient in IkappaB kinase, PKR, or the PKR-related genes PERK, IRE1, or GCN2 retained the ability to phosphorylate IRF7 and induce IFNalpha. Interestingly, PKR mutant cells were defective for response to double-stranded (ds) RNA but not to virus infection, suggesting that dsRNA is not the only activating viral component. Consistent with this notion, protein synthesis was required for IRF7 phosphorylation in virus-infected cells, and the kinetics of phosphorylation and viral protein production were similar. Despite evidence for a lack of involvement of dsRNA and PKR, vaccinia virus E3L protein, a dsRNA-binding protein capable of inhibiting PKR, was an effective IRF3 and -7 phosphorylation inhibitor. These results suggest that a novel cellular protein that is activated by viral products in addition to dsRNA and is sensitive to E3L inhibition is responsible for IRF activation and reveal a novel mechanism for the anti-IFN effect of E3L distinct from its inhibition of PKR.

Phosphorylation-induced dimerization of interferon regulatory factor 7 unmasks DNA binding and a bipartite transactivation domain

Interferon regulatory factor 7 (IRF7) is an interferon (IFN)-inducible transcription factor required for activation of a subset of IFN-alpha genes that are expressed with delayed kinetics following viral infection. IRF7 is synthesized as a latent protein and is posttranslationally modified by protein phosphorylation in infected cells. Phosphorylation required a carboxyl-terminal regulatory domain that controlled the retention of the active protein exclusively in the nucleus, as well as its binding to specific DNA target sequences, multimerization, and ability to induce target gene expression. Transcriptional activation by IRF7 mapped to two distinct regions, both of which were required for full activity, while all functions were masked in latent IRF7 by an autoinhibitory domain mapping to an internal region. A conditionally active form of IRF7 was constructed by fusing IRF7 with the ligand-binding and dimerization domain of estrogen receptor (ER). Hormone-dependent dimerization of chimeric IRF7-ER stimulated DNA binding and transcriptional transactivation of endogenous target genes. These studies demonstrate the regulation of IRF7 activity by phosphorylation-dependent allosteric changes that result in dimerization and that facilitate nuclear retention, derepress transactivation, and allow specific DNA binding.

The anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria

IMPLICATIONS

This case report describes the anesthetic considerations for a patient with paroxysmal nocturnal hemoglobinuria. Specific strategies to be applied in the perioperative period to prevent hemolytic episodes and venous thrombosis are also discussed.

Epidemic dropsy--a clinical study of the Delhi outbreak

BACKGROUND

A major outbreak of epidemic dropsy occurred in Delhi, India, in August-September 1998, due to the consumption of contaminated mustard oil.

METHODS

The clinical data of 212 adult patients of epidemic dropsy who presented to our hospital is analysed.

RESULTS

Pitting pedal oedema (100%), skin erythema (75%), limb tenderness (63%), diarrhea (51%) and hepatomegaly (34%) were the prominent clinical manifestations observed in the patients. Superficial retinal haemorrhages and retinal venous dilatation was observed on fundus examination and 9% of patients developed an open angle glaucoma over a three month follow up period. Cardiac failure was present in 14% of patients. Most patients had mild disease which responded to cessation of mustard oil consumption, bed rest, diuretics and antioxidants. There were six deaths, all of whom had intractable cardiac failure. A unique feature of this outbreak was the documentation of acute renal failure in three patients, a phenomenon never described previously.

CONCLUSIONS

Strict law enforcement to prevent the contamination of edible oils is essential to avoid the occurrence of future similar outbreaks.

Metoprolol: a review of its use in chronic heart failure

Metoprolol, a relatively selective beta1-blocker, is devoid of intrinsic sympathomimetic activity and possesses weak membrane stabilising activity. The drug has an established role in the management of essential hypertension and angina pectoris, and more recently, in patients with chronic heart failure. The effects of metoprolol controlled-release/extended-release (CR/XL) in patients with stable, predominantly mild to moderate (NYHA functional class II to III) chronic heart failure have been evaluated in the large Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) trial and the much smaller Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) pilot study. Treatment with metoprolol CR/XL was initiated at a low dosage of 12.5 to 25 mg once daily and gradually increased at 2-weekly intervals until the target dosage (200 mg once daily) or maximal tolerated dosage had been attained in patients receiving standard therapy for heart failure. At 12 months, metoprolol CR/XL was associated with a 34% reduction in relative risk of all-cause mortality in patients with chronic heart failure due to ischaemic or dilated cardiomyopathy in the MERIT-HF trial. The incidence of sudden death and death due to progressive heart failure were both significantly decreased with metoprolol CR/XL. Similarly, a trend towards decreased mortality in the metoprolol CR/XL group compared with placebo was observed in the RESOLVD trial. Data from small numbers of patients with severe (NYHA functional class IV) heart failure indicate that metoprolol CR/XL is effective in this subset of patients. However, no firm conclusions can yet be drawn. Improvement from baseline values in NYHA functional class, exercise capacity and some measures of quality of life with metoprolol CR/XL or immediate-release metoprolol were significantly greater than those with placebo. The drug is well tolerated when treatment is initiated in low dosages and gradually increased at intervals of 1 to 2 weeks.

CONCLUSIONS

Metoprolol CR/XL effectively decreases mortality and improves clinical status in patients with stable mild to moderate (NYHA functional class II or III) chronic heart failure due to left ventricular systolic dysfunction, and the drug is effective in patients with ischaemic or dilated cardiomyopathy. Although limited data indicate that metoprolol CR/XL is effective in patients with severe (NYHA functional class IV) chronic heart failure, more data are needed to confirm these findings. Treatment with metoprolol CR/XL significantly reduced the incidence of sudden death and death due to progressive heart failure.

Mosquito fauna and malaria vectors in Jairampur, district Changlang, Arunachal Pradesh

In an entomological study, covering three biotopes like village, panikheti (wet rice cultivated land) and urban agglomeration, a total of 35 species of mosquitoes in eight genera were recorded in Jairampur area of Arunachal Pradesh. Two mosquito species--Orthopodomyia anopheloides and Tripteroides indicus were recorded for the first time in Arunachal Pradesh. Anopheles dirus and An. minimus, the two well-known malaria vectors were encountered in the study along with several potential vector species like An. annularis, An. culicifacies, An. maculatus group and An. philippinensis/nivipes. The diversity of mosquito species as well as the man-vector contact was maximum in the panikheti and minimum in the village biotope.

Entamoeba histolytica: rapid detection of indian isolates by cysteine proteinase gene-specific polymerase chain reaction

Amoebiasis, caused by Entamoeba histolytica, is still one of the major problems for developing countries like India. Early detection of the parasite is a must for its prevention and control. In this study, PCR analysis of the cysteine proteinase gene from clinical isolates of symptomatic intestinal and amoebic liver abscess (ALA) cases has been compared with the stool microscopy, serology, and ultrasonography methods. The clinical isolates negative for E. histolytica by stool microscopy demonstrated the presence of the cysteine proteinase gene by PCR amplification. Also the gene copy number was increased in ALA samples compared with intestinal cases. Hence an accurate, early, and easier detection was possible by cysteine proteinase gene amplification directly from the clinical samples.

Antioxidant content of whole grain breakfast cereals, fruits and vegetables

BACKGROUND

Considerable scientific evidence suggests that whole grains, as commonly consumed in the United States and Europe, reduce risk for chronic disease including cancer and heart disease. Whole grains provide a wide range of nutrients and phytochemicals that may work synergistically to optimize human health. Fruits and vegetables provide protection against age related diseases. It is believed their high content of antioxidant compounds is key to such protection.

OBJECTIVE

This research compares the antioxidant activity of whole grain, ready-to-eat (RTE) breakfast cereals to that of fruits and vegetables.

METHOD

Antioxidant activity was determined by dispersing finely ground samples in a 50% aqueous methanol solution of the stable free radical 2,2-diphenyl-1-picrylhydrazyl (DPPH). DPPH, which forms a deep purple solution, reacts with antioxidants and color loss at 515 nm correlates to antioxidant content, which is expressed as Trolox equivalents/100 grams (TE).

RESULTS

Whole grain breakfast cereals analyzed in this study contained from 2,200-3,500 TE. By comparison, fruits generally ranged from 600-1,700 TE, with a high of 2,200 TE for red plums. Berries averaged 3,700 TE and. vegetables averaged 450 TE with a high of 1,400 TE for red cabbage. A 41 gram average serving of RTE breakfast cereal provides 1,120 TE, while an average 85 gram serving of vegetables or fruits provides 380 and 1,020 TE, respectively.

CONCLUSION

Whole grain breakfast cereals, fruits and vegetables are all important dietary sources of antioxidants.