Autoimmune hemolytic anemia in India: clinico-hematological spectrum of 79 cases

The clinico-hematological profile and treatment outcome of patients with autoimmune hemolytic anemia (AIHA) were assessed using a retrospective case record analysis. There were 79 (52 primary; 27 secondary) consecutive patients identified with a median age of 30.5 years. The main presenting complaints were pallor (94%), fever (46%), jaundice (51%), bleeding manifestations (10%) and splenomegaly (68%). Jaundice was much more common in primary (63%) as opposed to secondary (26%) disease. The direct antiglobulin test was negative in six patients. Oral prednisolone produced remission in 87.5% patients. Six patients (three children, three adults) relapsed after a median period of 2 months after response. All of these responded to a second course of steroids, in a median period of 14 days. No correlation was found between response and the parameters of age, sex, jaundice, low pretreatment hemoglobin, reticulocyte count, total leucocyte count (TLC), platelet count, subtype of AIHA and hepatosplenomegaly. Relapse correlated with increased duration between the onset of symptoms and treatment (r = 0.996; p = 0.0001).

Trichrome staining for detection of intestinal protozoa a better screening method

Intestinal protozoal infections are common in our country because of poor hygiene and tropical conditions. The efficacy of trichrome staining to screen stool smear was compared with commonly used methods i.e. concentrated iodine mount and direct wet mount to test its better effectiveness. All Stool samples were first examined by routine methods i.e. direct wet mount and iodine staining. A portion of stool sample was also inoculated in vial containing polyvinyl alcohol (PVA) fixative. From PVA preserved samples, slides were prepared and stained by modified wheately's trichrome method. The results of both methods were compared and relative accuracy was calculated. 1054 stool specimens were examined and 259 parasites detected, of which 20.7% were protozoa and 3.7% helminthde. Trichrome staining detected 19.1% protozoa while routine methods detected 12.9% protozoa. For identification of protozoa, accuracy was 91.8% in favor trichrome staining and 61.8% by wet mount and iodine staining. Trichrome stained smear alone can be used as screening method in those geographic areas where protozoa infections are common.

Laparoscopic feeding jejunostomy in esophagogastric cancer

BACKGROUND

Patients with esophagogastric malignancies often require nutritional supplementation in the perioperative period, especially in the setting where neoadjuvant therapy may delay tumor resection. A simple technique is described here that can be performed at the time of staging laparoscopy and that has not been described before.

RESULTS

Forty-three patients treated over a 4-year period who had a laparoscopic feeding jejunostomy placed at the time of staging laparoscopy were reviewed. Of these, 35 had preoperative chemotherapy according to a modified MRC OEO2 protocol. In the period between staging and eventual resection, 32% required immediate feeding, and in 14% of those who were thought not to need feeding it later became necessary. More patients gained weight or had a rise in albumin in the group that had jejunal feeding (p < 0.05). The mean time to surgery was 10 weeks. There were no conversions to an open procedure, nor were there any laparotomies for tube-related complications. Dislodgement was recorded in 6 patients; blockage, in 4. In most of these cases a simple bedside replacement of the tube was all that was required. Mean time in the operating room for each procedure was 44 minutes.

CONCLUSIONS

Laparoscopic percutaneous feeding jejunostomy is a safe and simple technique that adds little to the morbidity and cost of managing patients with esophagogastric cancers. It facilitates optimization of nutrition in the perioperative period for these patients, especially in those receiving preoperative chemotherapy.

Comparison of two dosages of thymoglobulin used as a short-course for induction in kidney transplantation

Thymoglobulin is used effectively as an induction agent in kidney transplantation, but the optimal dose is not well established. We evaluated the degree and durability of T-cell clearances with two different thymoglobulin regimens in adult kidney transplant recipients (KTR). Seven KTR received a 3-day thymoglobulin-based induction of 1.0 mg/kg/day while nine received 1.5 mg/kg/day, in addition to maintenance immunosuppression. Lymphocyte subsets were monitored for 6 months. Renal function, infections and malignancies were monitored for 24 months. T-cell subsets were significantly lower by day 30 with the thymoglobulin 1.5 mg/kg/day regimen when compared with the 1.0 mg/kg/day regimen; this trend was sustained at 6-month (CD3(+): 438 +/- 254 vs. 1001 +/- 532 cells/mm(3), P = 0.016). Renal function between the two groups was not significantly different at 6- and 24-months post-transplant. One case of BK Virus viremia in the 1.5 mg/kg/day thymoglobulin group was detected. No acute rejection episodes, cytomegalovirus infections, or malignancies were noted in either group. Thymoglobulin induction was efficacious in both groups, but with a significantly sustained T-cell clearance in the 1.5 mg/kg/day regimen. A more profound T-cell clearance within the first 6 months postinduction therapy may translate into a decreased risk of immunological injury and improved long-term outcome after kidney transplantation.

Laryngeal cancer after topical mitomycin C application

Mitomycin C is part of the mitomycin group of antibiotics and has found use in medicine in the treatment of various cancers, including those of the head and neck. In recent years, it has gained popularity as a topical treatment to prevent scar formation in the larynx and choanae in paediatric and adult inflammatory processes. Also, this alkylating agent is potentially a potent carcinogen. We report the first case in the world literature of laryngeal carcinoma in a non-smoking adult, which may have been induced by topical mitomycin C application to a glottic web. We discuss the mechanism of action of this drug, and we advise caution on its use for benign laryngeal pathologies.

Endosulfan degradation by a Rhodococcus strain isolated from earthworm gut

A Rhodococcus MTCC 6716 bacterial strain was isolated apparently for the first time from the gut microflora of an Indian earthworm (Metaphire posthuma). Endosulfan was used as a carbon source by the strain and degraded it up to 92.58% within 15 days. Furthermore, the isolated strain of the bacterium did not produce the persistent form of the toxic metabolite endosulfan sulfate. This strain exhibits luxury growth in minimal medium with high concentrations of endosulfan (80 microg mL(-1)). Degradation of the endosulfan occurred simultaneously with bacterial growth and an increase in chloride ion (87.1%) in the growth medium, suggesting nearly complete degradation of the insecticide. This strain is able to tolerate 45 degrees C and retain its degradation potential even under sunlight exposure. Since endosulfan is used worldwide for pest control and its residues have been retained for long periods in soil, water, and agricultural products, the strain isolated by us is valuable for bioremediation of endosulfan-contaminated soil and water.

Diplectanids infesting the gills of the barramundi Lates calcarifer (Bloch) (Perciformes: Centropomidae), with the proposal of Laticola n. g. (Monogenoidea: Diplectanidae)

Four species of the Monogenoidea, Laticola lingaoensis n. sp., L. latesi (Tripathi, 1957) n. comb. [previously Pseudorhabdosynochus latesi (Tripathi, 1957) Kritsky & Beverley-Burton, 1986], L. paralatesi (Nagibina, 1976) n. comb. [previously Diplectanum paralatesi Nagibina, 1976] and Diplectanum penangi Liang & Leong, 1991, are reported from the gills of Lates calcarifer (Centropomidae) from the South China Sea (new geographical records for L. latesi and D. penangi). Collections from off Bathurst Island, Northern Territory, Australia, represent a new geographic record for L. paralatesi; Chilka Lake, Orissa, India, is established as the type-locality for L. latesi. Laticola n. g. (Diplectanidae) is proposed for species with a spoon-shaped copulatory organ with two to four concentric incomplete ridges in the base. Laticola lingaoensis, the type-species of Laticola, is described, and L. latesi and L. paralatesi are redescribed based on specimens from the South China Sea. Pseudorhabdosynochus monosquamodiscusi Balasuriya & Leong, 1995 and Pseudorhabdosynochus yangjiangenesis Wu & Li, 2005 are considered junior subjective synonyms of L. latesi and L. paralatesi, respectively.

Disseminated Langerhans cell histiocytosis-an interesting case report with concise review of literature

A 2-year-old boy presented with fever, recurrent infections and multiple skin lesions. He had anemia, eczematous skin lesions, cervical lymph node enlargement, hepatomegaly and lytic lesions on skull x-ray. The skin infiltrates were CD 68, CD 1a positive and S100 positive. He was diagnosed as disseminated langerhans cell histiocytosis. The occurrence of histiocytosis is reviewed and possible treatment is discussed.

The routine use of intra-operative ultrasound in patients with colorectal cancer improves the detection of hepatic metastases

INTRODUCTION

Up to one fifth of patients with carcinoma of the colon have occult liver metastases at the time of presentation. Intra-operative hepatic ultrasonography might improve disease staging. We report the use of intra-operative ultrasonography (IOUS) in routine clinical practice over a five-year period.

METHOD

Seventy-six patients with colorectal carcinoma (F 21, M 55) of median age 67 years (range 43-89 years) for whom full data were available had IOUS at the time of colonic resection. All patients had had a computerized tomography (CT), magnetic resonance imaging (MRI) or ultrasonography (USS).

RESULTS

Of 76 patients, 10 had a Dukes A, 32 had a Dukes B and 34 a Dukes C carcinoma. In 20 patients IOUS detected lesions not seen on pre-operative scanning including 11 metastases (one suitable for resection), seven benign hepatic cysts and two were benign hepatic nodules. Forty-nine patients have remained free of disease and 25 have died with systemic disease (mean survival 10 months, range 2-24 months). In the seven patients diagnosed as having hepatic cysts at IOUS two have died of systemic disease. The remaining patients (n=12) who died with systemic disease had a negative IOUS.

CONCLUSION

IOUS increases diagnostic yield but a significant proportion of patients with occult hepatic metastases are not detected. IOUS improves disease staging in some patients refining the indications for adjuvant therapy and enhancing the estimate of prognosis and improving decision-making.

Lupus Nephritis

Lupus nephritis is one of the more serious manifestations of the systemic autoimmune disease, systemic lupus erythematosus, and is associated with considerable morbidity and even mortality. Treatment remains problematic, particularly in terms of controlling the underlying disease process while at the same time preventing unacceptable side effects of therapy. In recent years, clinical trials have started to define optimum regimens of the immunosuppressive agents presently in use. The etiology and pathogenesis of systemic lupus erythematosus and lupus nephritis still are understood incompletely. Nevertheless, insights gained from basic science research in both animals and human beings now are being translated into newer therapies that have the potential to be safer and more specific than those currently available.

Morphological and metabolic alterations in duckweed (Spirodela polyrhiza) on long-term low-level chronic UV-B exposure

Laboratory grown duckweed (Spirodela polyrhiza) plants were exposed to 0.72 and 1.44J of UV-B radiation daily for 7 days at 0.4mW/cm(2) intensity. Chlorosis and necrosis were observed along with depletion in protein, pigments (chlorophyll, pheophytin, carotenoids, phycoerythrin, phycocyanin, and flavoxanthin), biomass, root length, and frond size in UV-B-exposed plants. The study confirms morphological and metabolic alterations leading to reduction in the productivity of duckweed following long-term exposure to UV-B radiation.

Reduced incidence of upper gastrointestinal ulcer complications with the COX-2 selective inhibitor, valdecoxib

AIM

In a predefined analysis, data were pooled from eight blinded, randomized, controlled trials, and separately from three long-term, open-label trials to determine the rate of upper gastrointestinal ulcer complications with the cyclo-oxygenase-2 selective inhibitor, valdecoxib, vs. non-selective non-steroidal anti-inflammatory drugs.

METHODS

In randomized, controlled trials, 7434 osteoarthritis and rheumatoid arthritis patients received placebo (n = 973), valdecoxib 5-80 mg daily (n = 4362), or a non-selective non-steroidal anti-inflammatory drug (naproxen, ibuprofen or diclofenac; n = 2099) for 12-26 weeks. In long-term, open-label trials, 2871 patients received valdecoxib 10-80 mg daily for up to 1 year. All potential events were reviewed by a blinded, independent review committee based on a priori definitions of ulcer complications (perforations, obstructions, bleeds).

RESULTS

In randomized, controlled trials, 19 of 955 potential events were adjudicated to be ulcer complications. Valdecoxib was associated with a significantly lower ulcer complication rate than non-selective non-steroidal anti-inflammatory drugs (0.68% vs. 1.96%, all patients; 0.29% vs. 2.08%, non-aspirin users; P < 0.05). In long-term, open-label trials, seven of 310 potential events were adjudicated to be ulcer complications; the annualized incidence for valdecoxib was 0.39% (seven of 1791 patient-years) for all patients and 0.2% (three of 1472 patient-years) for non-aspirin users.

CONCLUSIONS

Valdecoxib, including above recommended doses, is associated with a significantly lower rate of upper gastrointestinal ulcer complications than therapeutic doses of non-selective non-steroidal anti-inflammatory drugs.

Role of multidetector CT virtual bronchoscopy in the evaluation of post-tracheostomy tracheal stenosis--a preliminary study

AIM

To study the technique and utility of virtual bronchoscopy (virtual reality endobronchial simulation, VRES) as a tool to evaluate post-tracheostomy tracheal stenoses and to correlate the findings of virtual and invasive bronchoscopy and to follow-up treated lesions or those currently under treatment that were initially diagnosed with VRES.

METHODOLOGY

This prospective study comprised nine patients in the age group 13 to 65 years presenting with breathlessness and stridor following one or multiple tracheostomies. They underwent plain CT using a multidetector CT (MDCT) scanner (Siemens Volume Zoom) using narrow (1 mm) collimation. These thin slice images were post-processed using an Irix-based workstation with a 'Fly-Through' endoscopy application. These patients also underwent a rigid (three patients) or fiberoptic (six patients) bronchoscopy.

RESULTS

Of the nine patients that underwent VRES, five were found to have stenoses, three had obstructing granulation tissue, one had an obstructing membrane and one had synechiae. The invasive bronchoscopic findings supported the VRES diagnosis in all but one case of stenosis, one of granulation tissue and the case with synechiae. Membranes and synechiae were relatively difficult to diagnose without the corresponding axial and multiplanar images. VRES achieved a higher sensitivity, while invasive bronchoscopy a higher specificity.

CONCLUSIONS

VRES proved to be comparable to invasive bronchoscopy in the depiction of post-tracheostomy tracheal stenoses, with a notable advantage in critical stenoses in that the airway distal to the stenosis could be assessed with VRES but not with invasive bronchoscopy. A preliminary VRES was found to be of assistance in the selection of patients for the more invasive therapeutic procedures such as laser ablation of granulation tissue and its follow-up.

Tobacco and alcohol consumption in relation to oral cancer

The present case control study was done on 50 cases of oral cancer and 50 controls These two groups are compared after taking the history in detail with special emphasis on the tobacco and alcohol intake. My various statistical tests, we correlated the strength of association between tobacco/alcohol intake and development of oral cancer. Tobacco only and combined exposure to tobacco and alcohol was found to be strongly related to the development of oral cancer but alcohol alone does not have significant role in causation of oral cancer.

Simultaneous determination of unlabeled and carbon-13-labeled etoricoxib, a new cyclooxygenase-2 inhibitor, in human plasma using HPLC-MS/MS

A method for the simultaneous determination of etoricoxib and its carbon-13 analog ((13)C(6)-etoricoxib) from human plasma has been developed and used to support bioavailability studies. Plasma samples (0.5 mL) were extracted by using a 3M Empore 96-well plate (C(8)) and the resulting extracts were analyzed by using a PE-Sciex API-3000 HPLC-MS/MS with a heated nebulizer interface (500 degrees C). The method was validated with two different calibration curve ranges, one for etoricoxib (5 to 2500 ng/mL) determined in the presence of lower concentrations of (13)C(6)-etoricoxib (0.5 to 250 ng/mL), and a second curve for the quantitation of similar concentrations of both etoricoxib and (13)C(6)-etoricoxib (0.5 to 250 ng/mL). Extraction recoveries of etoricoxib, (13)C(6)-etoricoxib, and a methylated internal standard were >70% over the range of concentrations included in both calibration curves. Intraday precision and accuracy for the quantitation of etoricoxib were 7.8% relative standard deviation (RSD) or less and within 3.4% respectively over the range of 5 to 2500 ng/mL, and 10.8% RSD or less and within 4 % respectively over the range of 0.5 to 250 ng/mL. Within-batch precision and accuracy for the quantitation of (13)C(6)-etoricoxib over the range of 0.5 to 250 ng/mL were 8.3% RSD or less and within 2.3%, respectively. The validated assay was used in support of human clinical trials.

Spatial regulation of DELTA expression mediates NOTCH signalling for segmentation of Drosophila legs

The Notch (N) signalling pathway is recruited for segregation of cell fates in a number of Drosophila tissue types. We show here that N dependent segmentation of Drosophila legs is regulated by a dynamic pattern of expression of its ligand, DELTA (DL). During third larval instar and early stages of pupation, high levels of DL expression is seen in stripes of cells in the leg imaginal discs which later form the proximal borders of leg joints. These domains also displayed heightened Dl enhancer activity. During subsequent stages of pupation, following segmentation of the leg primordium, DL expression becomes uniform throughout these segments barring the joints. We further show that regulatory Dl mutations or mis-expression of DL abolish leg segmentation. Domains of N signalling for segmentation of legs of flies are thus set up by a stringent spatial regulation of expression of its ligand at the segment border. Further, a comparable role of DL in antennal development reveals a common paradigm of DL-N signalling for segmentation of appendages in flies.

Role of human liver cytochrome P4503A in the metabolism of etoricoxib, a novel cyclooxygenase-2 selective inhibitor

Etoricoxib, a potent and selective cyclooxygenase-2 inhibitor, was shown to be metabolized via 6'-methylhydroxylation (M2 formation) when incubated with NADPH-fortified human liver microsomes. In agreement with in vivo data, 1'-N'-oxidation was a relatively minor pathway. Over the etoricoxib concentration range studied (1-1300 microM), the rate of hydroxylation conformed to saturable Michaelis-Menten kinetics (apparent K(m) = 186 +/- 84.3 microM; V(max) = 0.76 +/- 0.45 nmol/min/mg of protein; mean +/- S.D., n = 3 livers) and yielded a V(max)/K(m) ratio of 2.4 to 7.3 microl/min/mg. This in vitro V(max)/K(m) ratio was scaled, with respect to yield of liver microsomal protein and liver weight, to obtain estimates of M2 formation clearance (3.1-9.7 ml/min/kg of b.wt.) that agreed favorably with in vivo results (8.3 ml/min/kg of b.wt.) following i.v. administration of [(14)C]etoricoxib to healthy male subjects. Cytochrome P450 (P450) reaction phenotyping studies-using P450 form selective chemical inhibitors, immunoinhibitory antibodies, recombinant P450s, and correlation analysis with microsomes prepared from a bank of human livers-revealed that the 6'-methyl hydroxylation of etoricoxib was catalyzed largely (approximately 60%) by member(s) of the CYP3A subfamily. By comparison, CYP2C9 (approximately 10%), CYP2D6 (approximately 10%), CYP1A2 (approximately 10%), and possibly CYP2C19 played an ancillary role. Moreover, etoricoxib (0.1-100 microM) was found to be a relatively weak inhibitor (IC(50) > 100 microM) of multiple P450s (CYP1A2, CYP2D6, CYP3A, CYP2E1, CYP2C9, and CYP2C19) in human liver microsomes.