Antibodies to serotonin attenuate closed head injury induced blood brain barrier disruption and brain pathology

Closed head injury (CHI) often results in profound brain swelling and instant death of the victims due to compression of the vital centers. However, the neurochemical basis of edema formation in CHI is still obscure. Previous studies from our laboratory show that blockade of serotonin synthesis prior to CHI in a rat model attenuates brain edema, indicating a prominent role for serotonin in head injury. Thus, neutralization of endogenous serotonin activity and/or blocking of its receptors will induce neuroprotection in CHI. Since serotonin has more than 14 receptors and selective serotonin antagonists are still not available, we used serotonin antiserum to neutralize its in vivo effects before or after CHI in a rat model. CHI was produced by an impact of 0.224 N on the right parietal skull bone under Equithesin anesthesia by dropping a weight of 114.6 g from a height of 20 cm through a guide tube. This concussive brain injury resulted in blood-brain barrier (BBB) disruption, brain edema formation, and volume swelling at 5 h that were most pronounced in the contralateral cerebral hemisphere. The plasma and brain serotonin levels were increased several-fold at this time. Intracerebroventricular administration of serotonin antiserum (1:20, monoclonal) into the left lateral cerebral ventricle (30 microL in PBS) 30 min before or 30 min (but not 60 min) after CHI significantly attenuated BBB disruption, brain edema formation, volume swelling, and brain pathology. The plasma and brain serotonin levels continued to remain high. These observations are the first to suggest that antiserum to serotonin when administered into the CSF during the early phase of CHI are capable of inducing neuroprotection.

Validation of accuracy and community acceptance of the BIRTHweigh III scale for categorizing newborn weight in rural India

OBJECTIVE

To determine the accuracy and acceptability of a handheld scale prototype designed for nonliterate users to classify newborns into three weight categories (>or=2,500 g; 2,000 to 2,499 g; and <2,000 g).

STUDY DESIGN

Weights of 1,100 newborns in Uttar Pradesh, India, were measured on the test scale and validated against a gold standard. Mothers, family members and community health stakeholders were interviewed to assess the acceptability of the test scale.

RESULT

The test scale was highly sensitive and specific at classifying newborn weight (normal weight: 95.3 and 96.3%, respectively; low birth weight: 90.4 and 99.2%, respectively; very low birth weight: 91.7 and 98.4%, respectively). It was the overall agreement of the community that the test scale was more practical and easier to interpret than the gold standard.

CONCLUSION

The BIRTHweigh III scale accurately identifies low birth weight and very low birth weight newborns to target weight-specific interventions. The scale is extremely practical and useful for resource-poor settings, especially those with low levels of literacy.

Cerebral malaria in adults -- a description of 526 cases admitted to Ispat General Hospital in Rourkela, India

Although the clinical picture of cerebral malaria in children has been reported extensively, scant information is available about cerebral malaria in adults. This report relates to one of the largest series of adult cases of cerebral malaria patients ever described. At Rourkela, in eastern India, 526 adults (aged >12 years) who each satisfied the World Health Organization's criteria for cerebral malaria were admitted to Ispat General Hospital between 1995 and 2001. These cases represented 18% of the 2994 adult patients who were admitted with Plasmodium falciparum malaria over the same period. Most (76%) of the adult cases of cerebral malaria were male, 48% were aged 21-40 years, and only 4% were older than 60 years. The most common presenting symptoms were fever (97.7%), vomiting (54.6%), headache (30.8%) and seizures (17.1%). Most (62.4%) of the cases had associated severe complications: jaundice (47.5%), acute renal failure (28.9%), and/or severe anaemia (9.7%). Overall, 175 (23%) of the cases were fatal, mortality being particularly high (59%) among those with multi-organ failure. Of the fatal cases, 107 (61%) died within the first 24 h of hospitalization, presumably indicative of late presentation. As the management of multiple complications may be inadequate at primary centres, early referral to higher centres is recommended.

Are therapeutic stem cells justified in bilateral multicystic kidney disease? A review of literature with insights into the embryology

Aim was to describe the challenges faced in the management of bilateral multicystic kidney disease (MCKD). A case of antenatally detected bilateral polycystic disease was referred at 28 weeks of gestation. The patient was advised to continue pregnancy till term and be in regular follow-up. Postnatally, the male baby passed urine in normal stream and was diagnosed as bilateral multicystic kidney disease on ultrasonography. He developed symptoms of renal failure. The baby was operated with right pyeloplasty and left pyelostomy, as the left ureter was atretic. The histopathology was consistent with bilateral multicystic kidney disease. Postoperatively, the baby was stable with intermittent episodes of metabolic acidosis that were managed medically and with peritoneal dialysis. Autologous stem cells were injected at the age of 1 year into the aorta at the level of the renal arteries clamping the aorta below. Repeat biopsy at time of stem cell injection showed 5/10 glomeruli showing global sclerosis on right side and 5/15 glomeruli showing global sclerosis on left side. The only improvement seen was in decreased doses of medicines to keep the child metabolically stable. The baby kept struggling but succumbed at the age of 17 months and 15 days. Post mortem bilateral renal biopsies demonstrated presence of primitive renal tubules and blastemal cells that were not demonstrated earlier. Survival for few months in bilateral multicystic kidney disease is thus possible with adequate treatment, the novel use of stem cells in these cases may prove beneficial in future though it is too early to comment further.

In vivo humoral and cellular reactions, and fate of injected bacteria Aeromonas hydrophila in freshwater prawn Macrobrachium rosenbergii

Live non-opsonized and opsonized Aeromonas hydrophila were injected into juveniles of freshwater prawn Macrobrachium rosenbergii to study the cells involved in phagocytosis, distribution of bacteria, cellular reactions and clearance of both forms of bacteria from the system. The bacteria were rapidly distributed to various tissues viz., gills, heart, hepatopancreas within 1h, and the tissues revealed haemocytic nodule formation after 3 h of injection. There was rapid clearance of both the forms of bacteria from the circulation. However, clearance efficiency was significantly (P < 0.05) faster in the case of opsonized bacteria at 12 h after injection. Similarly, the nodule formation, that was prominent in cardiac musculature, was rapidly eliminated from the tissues of the group injected with opsonized bacteria as compared to non-opsonized bacteria injected group, thus confirming the existence of opsonic factors in haemolymph of this prawn. In another experiment, various dose levels of bacteria were injected intramuscularly into prawns and haemolymph was collected after 1, 6, 24, 72 h and 7 days of injection to study various immune parameters. Although, no major alterations in the total and differential haemocyte counts were observed in bacteria injected prawns compared to control, there was a significant decline in phenoloxidase activity in the highest dose bacteria injected group at the earlier phase and a rise in agglutinin levels at the later phase of the experimental period in the higher dose groups.

Randomized trial of toremifene to reduce high grade prostatic intraepithelial neoplasia (HGPIN) prior to radical prostatectomy (RP)

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Background HGPIN may be a precursor lesion for prostate cancer (PCA). The selective estrogen-receptor modulator toremifene (TOR) has shown chemopreventive activity in preclinical models of PCA. The effect of TOR on HGPIN was studied in men with PCA prior to RP. Methods Men with biopsy-proven PCA, scheduled for RP were randomized (2:1) either to TOR 40 mg po qd for 3 to 6 weeks prior to RP or to no therapy. The primary endpoint was the proportion of HGPIN in the RP specimen. Planned sample sizes were 35 and 17 per arm respectively, providing 93% power if treatment increased the proportion of patients with no RP HGPIN from 15% to 35% and decreased the mean log nonzero HGPIN values from 1 to ¼ standard deviation. Expression of bcl2, ki67, and CD31 were determined on biopsy (BX), and RP tissues, separately for normal adjacent to tumor (NAT), HGPIN, and PCA tissues. Serum hormone levels and toxicity were also assessed. Results The treatment arm accrued 31 patients, the control arm 13 patients. RP HGPIN ranged from 0.5% to 12%. There was no difference in HGPIN means between treatment (3.8%) and control (3.3%) (P=0.77 one-sided Wilcoxon) HGPIN at baseline predicted HGPIN at RP (Spearman correlation=0.64, P=0.0005) but 66% of patients had no detected HGPIN at baseline. Bcl2, ki67, and CD31 were mutually positively correlated in all 3 tissues, in both BX and RP specimens. In both BX and RP specimens, bcl2 was highest by far in HGPIN, and lowest in PCA. Ki67 was lowest in NAT, elevated in HGPIN and highest in PCA. CD31 showed no differences. In treated patients but not in controls, dihydrotestosterone, testosterone, androstenedion, and estradiol increased significantly between baseline, day 14 and final. TOR was well tolerated. Conclusions These data do not support an effect of TOR on HGPIN over 3 to 6 weeks at 40 mg po qd.

No significant financial relationships to disclose.

Does BCR-ABL transcript type predict cytogenetic response to imatinib mesylate in chronic phase, chronic myeloid leukemia patients?

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Background: We prospectively studied BCR-ABL transcript type (b2a2, b3a2, e1a2 and e19a2 in 100 CML-CP patients treated with Imatinib mesylate therapy and studied their correlation with the cytogenetics responses. Methods: Between Aug, 2004 and Sep, 2006, 100 CML –CP patients (median age was 32 years, range, 11 to 62 years, M: F: 2.5: 1) were treated prospectively with imatinib mesylate 400 mg daily on outpatients. 70 patients were pre-treated with interferon Alfa. The mean duration of Gleevec treatment was 24 months (range 3 to 38 months). Patients were monitored closely for clinical, hematological, cytogenetic & molecular response as per standard guidelines. Bone marrow was studied at 3, 6, 9 then 4–6 months interval for cytogenetic response (CGR) and also for the presence of BCR-ABL transcript types by multiplex and nested RT-PCR technique. Results: 96% of patients achieved complete hematological remission (CHR); median time being 21 days, ranging from 7 to 110 days. 60% of patients achieved Major CGR (complete 32, partial CGR-28); median time 8 months, ranging from 6 to 22 months. Previously untreated patients had higher major (70% vs 55.7%) and complete (46.6% vs 25.7%) CGR compared to patients previously treated with interferon alfa. Analysis for BCR-ABL transcript type revealed - b2a2 in 38%, b3a2 -54% and both in 8% of patients. 28 of 38(74%) patients with b2a2 type acieved Major CGR compared to 24 of 54 (44%) patients with b3a2 transcript, p<0.002. Of remaining 40 patients with minor or no CGR, 10(25%) had b2a2 compared to 30 (75 %) b3a2 type, p<.002. However, there was no significant correlation between transcript type and pre-treatment characteristics e.g. spleen size (in cm), Hb (G/dl), WBC & platelets counts. Conclusions: Present study suggests that site of breakpoint in major breakpoint cluster region might be predictive of cytogenetic responses to Imatinib Mesylate in CML patients.

No significant financial relationships to disclose.

Stem Cells as a Therapeutic Modality in Pediatric Malformations

AIM

The aim of this study was to explore stem cell use in congenital anomalies.

PATIENTS AND METHODS

During July 2005 through July 2006, autologous stem cells were used in 29 patients: 12 with liver cirrhosis and 17 with meningomyelocele. Stem cells were injected into the hepatic artery and the portal vein or into the hepatobiliary radicals for liver cirrhosis, or into the spinal cord and caudal space for meningomyelocele. Preoperative status served as the control condition.

OBSERVATIONS AND RESULTS

The ages of patients with liver cirrhosis ranged between 1.5 and 9 months (mean, 4.12 months). The etiology was extra hepatic biliary atresia (EHBA) versus neonatal cholestasis and choledochal cyst in 8; 2 and 2 patients, respectively. Five patients died due to ongoing cirrhosis. Follow-up at 3 to 12 months (N = 7) showed absence of cholangitis (4/7), yellow stools (5/7), decreased liver firmness (3/7), improved liver function (6/7), and better appetite (6/7). Hepatobiliary scan was excretory in 6 of 7 with improved uptake in 4 of 7. Histopathology demonstrated comparative improvement in fibrosis among 3 patients. Meningomyelocele patients were between 0 and 1 month, 1-5 months, and 1-4 years in 5, 8, and 2 cases respectively. Five had a history of rupture. Three had undergone meningocele repair in the past with neurological deficits. Redo surgery for a tethered cord was performed in 1 patient. Follow-up at 3 to 11 months in 14 cases showed improved power in 7 with dramatic recovery in 3 (22%) and status quo in 7 (50%).

CONCLUSION

Initial stem cell use in liver cirrhosis and meningomyelocele has suggested beneficial results. However, long-term evaluation in randomized controlled trials is essential to draw further conclusions.

Difficult laryngoscopy made easy with the use of left-hand laryngoscope blade

In scenarios where difficult airway is anticipated as a result of a mass or any pathology in the right side of the upper airway, the plan of approach depends on the extent of difficulty assessed by various airway assessment tests/methods. If significant difficulty is suspected some of the available options include either an awake/sedated fibreoptic or blind nasal intubations. When the airway pathology involves part of the right side or exclusively the whole of the right side compressing the airway towards the left, there is no room to position a normal right or straight blade. A left-hand laryngoscope can be used in these types of cases where anatomy and contour of the blade manoeuvres the tongue and the right-sided lesion, thereby providing an unobstructed left-sided view of the larynx. The left-hand laryngoscope blade has been useful in converting the Cormack and Lehane grade III/IV laryngoscopies to grade II in our cases where the pathology was located exclusively on the right side of the airway. These cases suggest that there may be a role of left-hand laryngoscope in the management of difficult airway, particularly, in cases where there are right-sided mass lesions obstructing the airway.

Genotyping of Edwardsiella tarda isolated from freshwater fish culture system

The applicability of PCR-RFLP of 16S rDNA and conventional phenotypic methods for differentiation of Edwardsiella tarda associated in freshwater fish culture system was studied. In this study, by conventional biochemical tests and antibiotic resistant patterns 2 and 14 groups were obtained. But these methods failed to discriminate the isolates habitat wise. However, PCR-RFLP of 16S rDNA was found to be specific to detect habitat-specific isolates. All the fish isolates belonging to particular genotypes were found only in fish, not in water or sediment. Some of the genotypes were exclusively present in water and sediment. This study indicates the prevalence of site-specific genotypes in freshwater ecosystems. Molecular method is found to be superior to discriminate the E. tarda habitat wise to conventional typing methods.

Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India

OBJECTIVE

Two-thirds of women globally give birth at home, yet little data are available on use of skin-to-skin care (STSC) in the community. We describe the acceptability of STSC in rural Uttar Pradesh, India, and measured maternal, newborn, and ambient temperature in the home in order to inform strategies for introduction of STSC in the community.

STUDY DESIGN

Community-based workers in intervention clusters implemented a community mobilization and behavior change communication program that promoted birth preparedness and essential newborn care, including adoption of STSC, with pregnant mothers, their families, and key influential community members. Acceptance of STSC was assessed through in-depth interviews and focus groups, and temperature was measured during home visits on day of life 0 or 1.

RESULTS

Incidence of hypothermia (<36.5 degrees C) was high in both low birth weight (LBW) and normal birth weight (NBW) infants (49.2%, (361/733) and 43% (418/971), respectively). Mean body temperature of newborns was lower (P<0.01) in ambient temperatures <20 degrees C (35.9+/-1.4 degrees C, n=225) compared to > or =20 degrees C (36.5+/-0.9 degrees C, n=1450). Among hypothermic newborns, 42% (331/787) of their mothers had a lower temperature (range -6.7 to 0.1 degrees C, mean difference 0.4+/-1.2 degrees C). Acceptance of STSC was nearly universal. No adverse events from STSC were reported. STSC was perceived to prevent newborn hypothermia, enhance mother's capability to protect her baby from evil spirits, and make the baby more content.

CONCLUSION

STSC was highly acceptable in rural India when introduced through appropriate cultural paradigms. STSC may be of benefit for all newborns and for many mothers as well. New approaches are needed for introduction of STSC in the community compared to the hospital.

Management of severe and complicated malaria

Severe malaria is invariably caused by Plasmodium falciparum. In India, both adults and children are affected by severe malaria. However, children are more prone for developing anemia and convulsions as manifestations of severe malaria, while acute renal failure and jaundice are more common among adults. Pregnant women are vulnerable to hypoglycemia, anemia and pulmonary complications. The case-fatality rate due to severe malaria is 10-15% in spite of therapy but it increases in the presence of renal failure or respiratory distress (pulmonary edema or ARDS). Of late, multi-organ failure and high mortality figures are being reported increasingly from different parts of India. Early diagnosis and prompt treatment will reduce the mortality due to malaria. Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area. However, other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded. Parenteral quinine is the mainstay of therapy. A recent multi-centric study has demonstrated the efficacy of intravenous artesunate in reducing the mortality by 30%. The usefulness of adjunct therapy is still controversial.

Characterisation of Pseudomonas aeruginosa isolated from freshwater culture systems

Members of the genus Pseudomonas are important phytopathogens and agents of human infections, while other strains and species exhibit bioremediation and biocontrol activities. Species-specific detection of Pseudomonas species in the environment may help to gain a more complete understanding of the ecological significance of these microorganisms. The objective of present study was comparative analysis of biochemically and PCR based confirmed 10 isolates of Pseudomonas aeruginosa (6 from fish intestine and 4 from pond sediment). PCR-ribotyping and PAGE revealed that there was extensive heterogeneity at the genetic and protein levels. Both genetic and phenotypic heterogeneity were more in the sediment isolates compared to the fish isolates. SDS-PAGE clearly demonstrated the differences between fish and sediment isolates as evident from the higher range of protein profiling. In antibiotic sensitivity test no habitat specific antibiogram was obtained. Zinc adversely affected the DNA of all the isolates to be amplified by PCR as DNA banding pattern was different from normal DNA in stressed DNA. Thus stress, particularly, zinc may interfere monitoring of Pseudomonas by PCR.

Spinal cord injury induced heat shock protein expression is reduced by an antioxidant compound H-290/51. An experimental study using light and electron microscopy in the rat

The possibility that oxidative stress participates in heat shock protein 72 kD (HSP 72) expression following a focal trauma to the spinal cord was examined using a potent antioxidant compound H-290/51 in a rat model. A focal spinal cord injury (SCI) inflicted by making a longitudinal incision on the right dorsal horn of the T10-T11 segment under equithesin anaesthesia resulted in profound upregulation of HSP 72 expression in the adjacent spinal cord segments T9 and T12. This expression of HSP was most marked in the ipsilateral cord at 5 h after SCI. Pretreatment with H-290/51 (50 mg/kg, p.o.) 30 min before SCI markedly attenuated HSP expression in the spinal cord seen at 5 h. The motor functions of traumatized rats were also improved in the drug treated group. At this time, structural changes in the spinal cord and edema formation were considerable reduced compared to the untreated traumatized rats. Taken together, these observations suggest that (i) oxidative stress participates in HSP response following trauma, and (ii) the antioxidant compound H-290/51 attenuates cellularstress, improves motor functions and induces considerable neuroprotection in the early phase of SCI. Further studies using post-injury treatment with H-290/51 is needed to explore its therapeutic potentials in clinical settings.

Intracerebral administration of neuronal nitric oxide synthase antiserum attenuates traumatic brain injury-induced blood-brain barrier permeability, brain edema formation, and sensory motor disturbances in the rat

The role of nitric oxide (NO) in traumatic brain injury (TBI)-induced sensory motor function and brain pathology was examined using intracerebral administration of neuronal nitric oxide synthase (nNOS) antiserum in a rat model. TBI was produced by a making a longitudinal incision into the right parietal cerebral cortex limited to the dorsal surface of the hippocampus. Focal TBI induces profound edematous swelling, extravasation of Evans blue dye, and up-regulation of nNOS in the injured cerebral cortex and the underlying subcortical areas at 5 hours. The traumatized animals exhibited pronounced sensory motor deficit, as seen using Rota-Rod and grid-walking tests. Intracerebral administration of nNOS antiserum (1 : 20) 5 minutes and 1 hour after TBI significantly attenuated brain edema formation, Evans blue leakage, and nNOS expression in the injured cortex and the underlying subcortical regions. The nNOS antiserum-treated rats showed improved sensory motor functions. However, administration of nNOS antiserum 2 hours after TBI did not influence these parameters significantly. These novel observations suggest that NO participates in blood-brain barrier disruption, edema formation, and sensory motor disturbances in the early phase of TBI, and that nNOS antiserum has some potential therapeutic value requiring additional investigation.