344 A Rare Case of Meckel's Diverticulitis With a 3 Cm Enterolith

Meckel's diverticulum (MD) is a rare condition that affects only 2% of general population. Only 4 to 6% of those Meckel's diverticulea are symptomatic. Furthermore, having a MD containing enterolith is extremely rare, and herein we present a case of 55-year-old lady with Meckle's diverticulitis containing a 3 cm enterolith. The patient presented with symptoms mimic appendicitis; however, upon further evaluation with an enhanced abdomino-pelvic CT an MD containing enterolith was confirmed. An interval laparoscopically assisted diverticulectomy was performed and the patient recovery was un-eventful.

Activation of Functional Somatic Stem Cells Promotes Endogenous Tissue Regeneration

Periodontal ligament derived stem cells (PDLSCs) are capable of differentiating into multiple cell types and inducing a promising immunomodulation for tissue regeneration and disease treatment. However, it is still challenging to develop a practical approach to activate endogenous stem cells for tissue self-healing and regeneration. In this study, transcriptome analysis reveals that resveratrol promotes PDLSC stemness through activation of stem cell, osteoprogenitor, and chondroprogenitor markers. Self-renewal and multipotent differentiation abilities are also improved in resveratrol-treated PDLSCs. In addition, immunomodulation of PDLSCs is dramatically increased after resveratrol treatment. Mechanistically, we show that resveratrol activates ERK/WNT crosstalk through elevation of olfactory and growth factor signaling pathways to upregulate the expression levels of RUNX2 and FASL for osteogenesis and immunomodulation, respectively. By using a periodontitis animal model, administration of resveratrol partially rescues bone loss through activation of endogenous somatic stem cells and inhibition of inflammatory T-cell infiltration. Taken together, our findings identify a novel pharmacological approach to achieve autotherapies for endogenous tissue regeneration.

AB0854 A CASE REPORT OF BROWN SYNDROME COMPLICATING THE MANAGEMENT OF SCLEROMYOSITIS

Background:

Brown syndrome is a rare ocular motility disorder which has been reported in JRA, RA and SLE but never in a patient with scleromyositis.

Objectives:

To report the first case of Brown syndrome in a patient with scleromyositis and increase awareness of this condition.

Methods:

A case report and discussion.

Results:

The patient was diagnosed with scleromyositis, at the age of 34, after presenting with arthralgia, sclerodactyly, skin pigmentation, Raynaud’s phenomenon, mild muscle weakness and dyspnoea. His labs were CRP 47 mg/L, CK 868 IU/L, ANA strongly positive; anticentromere Ab negative and Anti-PM/Scl-75 and Anti- PM/Scl-100 Ab positive. HRCT chest showed extensive pulmonary fibrosis with lower lobe honeycombing. TLCO was 3.98 (33% of predicted).

He was initially managed with high dose steroids and pulsed IV cyclophosphamide with azathioprine for maintenance therapy. His lung disease stabilised and myositis resolved but he continued to develop calcinosis cutis so was switched to 6 monthly IV rituximab.

6 years later, he developed morning headaches with intermittent diplopia, described as double vision in vertical gaze with one image being above the other. Episodes lasting 10 minutes to 2 hours. Examination showed normal visual acuity and fundoscopy, no peripheral or eye muscle weakness.

Investigations to exclude myasthenia gravis, cerebral vasculitis and atypical infection were organised (MRI, AChR antibody, lumbar puncture, MRA) and were normal.

Because of intermittent nature of his episodes, his eye examination was always normal but he captured images in disconjugate gaze with right eye looking upwards and outwards when trying to look straight (Figure 1). Occasionally this was associated with orbital pain and an audible click. These features are suggestive of Brown syndrome.

He continues to have recurrent episodes despite immunosuppression but prednisolone 20mg daily for 1-2 days at onset of each attack causes rapid resolution of symptoms.

Figure 1.

Right eye looking upwards and outwards when trying to look straight

Conclusion:

Scleromyositis is an overlap syndrome of scleroderma and dermatomyositis. Muscle involvement is mild and clinical presentation can be variable. The PM/Scl antibodies are highly characteristic of the syndrome. (1)

Brown syndrome is an ocular motility disorder, first described in 1950, characterized by the inability to fully elevate the affected eye in adduction due to pathology of the superior oblique tendon sheath. (2)

It can be congenital or acquired, viz, trauma, surgery or sinusitis and also been described in RA, JIA and SLE. (3)

If superior oblique tendon cannot relax or slide freely through the trochlea then the affected eye cannot depress completely, leading to diplopia on upward gaze. (4) In inflammatory disease it is thought that swelling of the posterior part of the superior oblique tendon or tenosynovitis are likely causes of the tendon sheath abnormality. (4) This is likely to be the case in this patient because his symptoms are recurrent, respond to steroids and tend to occur more towards the end of rituximab cycles.

Recognition of this syndrome is important because invasive investigations can be avoided. Also, intermittent diplopia in a patient with autoimmune disease is suggestive of myasthenia gravis which maybe incorrectly diagnosed.

Finally, this case demonstrates the syndrome can be easily managed with short courses of oral steroids, although patients who are already on immunosuppressant treatment may need this in addition.

References:

[1]Török L, Dankó K, Cserni G, Szûcs G. PM-SCL autoantibody positive scleroderma with polymyositis (mechanic’s hand: clinical aid in the diagnosis). JEADV 2004; 18: 356–359

[2]Brown H W. Congenital structural muscle anomalies. In:Alien J H, ed. Strabismus ophthalmic symposium I. St Louis:CV Mosby, 1950: 205-6.

[3]Cooper C, Kirwan JR, McGill NW, Dieppe PA. Brown’s syndrome: an unusual ocular complication of rheumatoid arthritis. Ann Rheum Dis 1990; 49:188-9.

[4]Sandford-Smith JH. Superior oblique tendon syndrome and its relationship to stenosing tenosynovitis. Br JOphthalmol 1973; 57:859-65.

Disclosure of Interests:

None declared

AB0756 IMMUNE-MEDIATED BASIS FOR A PHASE 2A CLINICAL STUDY COMPARING RILZABRUTINIB VS GLUCOCORTICOIDS IN RITUXIMAB-REFRACTORY PATIENTS WITH IGG4-RELATED DISEASE

Background:

IgG4-related disease (IgG4-RD) is an immune-mediated disorder causing fibro-inflammatory lesions. Although the cause remains unknown, it may be driven by interactions between B lymphocytes and CD4+ cytotoxic and regulatory T cells and is characterized by an increase in short-lived plasmablasts, circulating antibodies, and macrophages. Standard therapy mainly includes glucocorticoids (GC), limited by toxicity with long-term use (> 6 mo), and to a lesser extent, immunosuppressives (eg, rituximab). Bruton tyrosine kinase (BTK) plays an important role in the activation of multiple immune effector cells such as B cells, mast cells, eosinophils, basophils, monocytes/macrophages, and neutrophils. Dysregulation of the activation of these immune cells results in autoimmune inflammation, tissue damage, and development of fibrosis. Rilzabrutinib is a highly selective oral BTK inhibitor that targets multiple pathways of innate and adaptive immunity (with direct effects on B-cell and FcR pathways) and has the potential to inhibit antigen presentation to autoreactive T cells.

Objectives:

To provide the biological rationale for rilzabrutinib in IgG4-RD.

Methods:

Rilzabrutinib has been evaluated in biochemical, in vitro studies, and in vivo models of inflammatory diseases. Additional support is provided by the phase 2 trial for oral rilzabrutinib in patients with pemphigus vulgaris and the phase 2 trial for oral rilzabrutinib in patients with immune thrombocytopenia (ITP).

Results:

Rilzabrutinib inhibited the activity of BTK and B-cell receptor in B cells (IC50 5-123 nM) and Fc gamma receptor in IgG/Fc gamma receptor-stimulated monocytes (IC50 56 nM) and blocked IgG- and IgM-mediated antibody production in enriched B cells when stimulated in T-cell dependent (anti-CD40+IL-21) and T-cell independent (TLR-9/CpG and TNP-LPS) pathways. The impact of rilzabrutinib on innate cell pathways was further confirmed by significant dose-dependent inhibition of macrophage and neutrophil-driven passive rat Arthus reaction (P < 0.01 vs vehicle) and antibody-induced murine ITP (P < 0.05 vs vehicle). In a 12-week phase 2 pemphigus vulgaris trial, 54% of patients achieved the primary endpoint, control of disease activity (CDA) on low-dose corticosteroids by week 4, and 73% achieved it by week 12. In the phase 2 trial of ITP patients (median 6 prior therapies), rilzabrutinib 400 mg bid showed rapid and sustained improvement in platelet counts and only grade 1/2-related adverse events1. In responders, platelet counts increased as early as day 8, potentially due to innate immune mechanisms. Collectively, results in both B and innate immune cells provide an initial basis for evaluating rilzabrutinib in IgG4-RD. The ongoing phase 2a study (NCT04520451) is investigating rilzabrutinib 400 mg bid (+tapered GC) vs GC control (3:1) for 12 weeks in IgG4-RD patients refractory to rituximab. The primary objective is to evaluate the safety and ability of rilzabrutinib to induce GC-free remission at week 12. Coupled with known preclinical/clinical findings, mechanistic analyses in this ongoing IgG4-RD study will profile B and other immune cell effects pre-/post-rilzabrutinib dosing to enhance the clinical understanding of rilzabrutinib in IgG4-RD.

Conclusion:

Studies of rilzabrutinib that show beneficial effects on both B-cell and innate cell pathways provide support for its therapeutic role in immune-mediated diseases and for targeting the underlying pathophysiological effects of IgG4-RD. Effective and safe therapies that rapidly induce and maintain clinical responses, while minimizing the need for continuous GC treatment, remain an unmet need for patients with IgG4-RD.

References:

[1]Kuter et al. Res Pract Thromb Haemost. 2020;4(suppl 1): PB1318.

Disclosure of Interests:

Li Long Employee of: Principia Biopharma, a Sanofi Company, Matthew Baker: None declared, Mollie Carruthers: None declared, Alireza Meysami: None declared, Robert Spiera Consultant of: research funding and personal fees for consulting from Chemocentryx, Formation Biologics, Roche-Genentech, and Sanofi, Grant/research support from: research funding fees from BMS, Boehringer Ingelheim, Corbus, GSK, and Inflarx; personal fees from AbbVie, CSL Behring, GSK, and Janssen, Mamatha Reddy Employee of: Principia Biopharma, a Sanofi Company, Marianne Kavanagh Employee of: Principia Biopharma, a Sanofi Company, Michelle Francesco Employee of: Principia Biopharma, a Sanofi Company, Claire Langrish Employee of: Principia Biopharma, a Sanofi Company, Ann Neale Employee of: Principia Biopharma, a Sanofi Company, Puneet Arora Employee of: Principia Biopharma, a Sanofi Company, John H. Stone Consultant of: research funding and personal fees for consulting from Principia and Sanofi

Proof of concept for the clinical effects of oral rilzabrutinib, the first Bruton tyrosine kinase inhibitor for pemphigus vulgaris: the phase II BELIEVE study

Background

Bruton tyrosine kinase (BTK) inhibition targets B‐cell and other non‐T‐cell immune cells implicated in the pathophysiology of pemphigus, an autoimmune disease driven by anti‐desmoglein autoantibodies. Rilzabrutinib is a new reversible, covalent BTK inhibitor demonstrating preclinical efficacy as monotherapy in canine pemphigus foliaceus.

Objectives

To evaluate the efficacy and safety of oral rilzabrutinib in patients with pemphigus vulgaris in a multicentre, proof‐of‐concept, phase II trial.

Methods

Patients with Pemphigus Disease Area Index severity scores 8–45 received 12 weeks of oral rilzabrutinib 400–600 mg twice daily and 12 weeks of follow‐up. Patients initially received between 0 and ≤ 0·5 mg kg⁻¹ prednisone‐equivalent corticosteroid (CS; i.e. ‘low dose’), tapered after control of disease activity (CDA; no new lesions, existing lesions healing). The primary endpoints were CDA within 4 weeks on zero‐to‐low‐dose CS and safety.

Results

In total, 27 patients with pemphigus vulgaris were included: nine newly diagnosed (33%) and 18 relapsing (67%); 11 had moderate disease (41%) and 16 moderate to severe (59%). The primary endpoint, CDA, was achieved in 14 patients (52%, 95% confidence interval 32–71): 11 using low‐dose CS and three using no CS. Over 12 weeks of treatment, mean CS doses reduced from 20·0 to 11·8 mg per day for newly diagnosed patients and from 10·3 to 7·8 mg per day for relapsing patients. Six patients (22%) achieved complete response by week 24, including four (15%) by week 12. Treatment‐related adverse events were mostly mild (grade 1 or 2); one patient experienced grade 3 cellulitis.

Conclusions

Rilzabrutinib alone, or with much lower CS doses than usual, was safe, with rapid clinical activity in pemphigus vulgaris. These data suggest that BTK inhibition may be a promising treatment strategy and support further investigation of rilzabrutinib for the treatment of pemphigus.

What is already known about this topic?

Standard pemphigus treatment relies on systemic high‐dose corticosteroids (CS), rituximab and/or immunosuppressives, which are limited by delayed onset of action and potential toxicities.

Immune‐mediated mechanisms that are fast acting on both the innate and adaptive immune systems, are steroid sparing, and have safety profiles well suited for chronic administration are greatly needed for patients with pemphigus.

What does this study add?

Rilzabrutinib is an oral Bruton tyrosine kinase (BTK) inhibitor targeting B‐cell and other non‐T‐cell immune cells implicated in pemphigus pathophysiology.

Treatment with rilzabrutinib (with or without low‐dose CS) demonstrated rapid disease control and a well‐tolerated safety profile in patients with newly diagnosed and relapsing pemphigus vulgaris.

BELIEVE provides evidence for a promising treatment strategy via BTK inhibition, supporting further investigation of rilzabrutinib in other immune‐mediated diseases.

Linked Comment: A.M. Drucker and N.H. Shear. Br J Dermatol 2021; 185:691–692.

Plain language summary available online

Global publication productivity in dermatology: a bibliometric description of the past and estimation of the future

BACKGROUND

In the past two centuries, generations of dermatologists around the world have created an enormous number of publications. To our knowledge, no bibliometric analysis of these publications has been performed so far, nor have registered trials been analysed to anticipate future publication trends.

OBJECTIVES

To determine the global distribution of national publication productivity, most published topics, institutions and funding sources contributing most to publications and to anticipate future trends based on registered clinical trials.

METHODS

Following pre-assessment on PubMed, Embase, Web of Science and Scopus, the number of publications for 'dermatology' was determined for each of 195 countries, normalized per 1 Mio inhabitants and bibliometrically analysed. Dermatology-related trials registered at clinicaltrials.gov were specified by the top-10 diagnoses for the top-10 countries.

RESULTS

The search yielded 1 071 518 publications between 1832 and 2019 with the top-5 diagnoses being melanoma, basal cell carcinoma, psoriasis, pruritus/itch and atopic dermatitis. The top-3 countries with highest absolute numbers of publications were the USA (30.6%), Germany (8.1%) and the UK (8.1%), whereas Switzerland, Denmark and Sweden had the highest publication rates when normalized by inhabitants. The most productive affiliation was the Harvard Medical School, the leading funding source the National Institutes of Health. Currently, maximum number of trials are registered in the USA (8111), France (1543) and Canada (1368). The highest percentage of all dermatology-related trials in a specific country were as follows: Melanoma in the Netherlands (24.8%), psoriasis in Germany (21.7%) and atopic dermatitis in Japan (15.9%).

CONCLUSION

The top-10 countries including the USA, Canada, a few European and Asian countries contributed more than 3/4 of all publications. The USA hold the dominant leader position both in past publication productivity and currently registered trials. While most Western countries continue to focus their research on the top-10 topics, China and India appear to prioritize their scope towards other topics.

AB1266 JOINTS STILL PLEADING FOR ATTENTION

Background:

Despite the prevalence of musculoskeletal diseases in an increasingly elderly patient population, musculoskeletal (MSK) examination remains frequently overlooked and poorly completed in medical clerking. Indeed, studies over the years have emphatically demonstrated the widespread omission of MSK examination. (1,2)

Objectives:

The aim of this study was to evaluate the documentation of MSK examination in medical clerking on the acute medical take. Furthermore, we sought to assess doctors’ perception of MSK examination and to evaluate the effect of GALS teaching.

Methods:

Medical clerkings of 50 patients in the medical assessment unit (MAU) were reviewed on a single day irrespective of the pathology. Case notes were assessed for presenting complaints and documentation of clinical examination findings. Results of the baseline study along with GALS examination techniques were presented at the departmental meeting. Case notes review was subsequently repeated with the same sample size.

Results:

Baseline study showed that MSK exam was recorded in only 10% of patients despite 20% of patients presenting with fall/collapse. In contrast, 100% of medical clerkings had respiratory examination, 94% had cardiovascular examination while 94% had abdominal examination documented. Although confidence in performing MSK examination was not felt to be a problem, perceived time constraints was a major barrier.

Repeat study with another 50 set of clerkings demonstrated a significant improvement, with 22% of clerkings having MSK examination recorded. However, the quality of documentation of MSK examination remained sketchy.

Conclusion:

Our study reaffirms the fact that MSK examination remains broadly neglected despite the high proportion of patients admitted with fall or collapse. Although the completion of MSK examination improved following GALS screen teaching, the quality of clinical examination documentation remained inadequate. Evidently, the indifference towards MSK examination warrants prompt attention and action by medical educators and rheumatologists.

References:

[1]Kwok F, Lee L, Gupta A. THU0598 Can you hear the joints crying? musculoskeletal examination in junior doctors’ medical admission clerkings.Annals of the Rheumatic Diseases2017;76:432.

[2]Lillicrap MS, Byrne E, Speed CA. Musculoskeletal assessment of general medical in-patients--joints still crying out for attention. Rheumatology (Oxford). 2003 Aug;42(8):951-954.

Disclosure of Interests:

None declared

Mass deworming for soil-transmitted helminths and schistosomiasis among pregnant women: A systematic review and individual participant data meta-analysis

The objective of the review is to use individual participant data (IPD) meta-analysis to explore the effect of mass deworming during pregnancy. We developed a search strategy and searched the databases till March 2018. We included individually randomised controlled trials; cluster randomised controlled trials and quasi randomised studies providing preventive or therapeutic deworming drugs for soil transmitted helminthiases and schistosomiasis during pregnancy. All IPD were assessed for completeness, compared to published reports and entered into a common data spreadsheet. Out of the seven trials elgible for IPD, we received data from three trials; out of 8,515 potential IPD participants; data were captured for 5,957 participants. Findings from this IPD suggest that mass deworming during pregnancy reduces maternal anaemia by 23% (Risk ratio [RR]: 0.77, 95% confidence intreval [CI]: 0.73-0.81; three trials; 5,216 participants; moderate quality evidence). We did not find any evidence of an effect of mass deworming during pregnancy on any of the other outcomes. There was no evidence of effect modification; however these findings should be interpreted with caution due to small sample sizes. The quality of evidence was rated as moderate for our findings. Our analyses suggest that mass deworming during pregnancy is associated with reducing anaemia with no evidence of impact on any other maternal or pregnancy outcomes. Our analyses were limited by the availability of data for the impact by subgroups and effect modification. There is also a need to support and promote open data for future IPDs.

Feasibility and acceptability of a proposed pharmacy-based harm reduction intervention to reduce opioid overdose, HIV and hepatitis C

BACKGROUND

Evidence-based harm reduction intervention components which might benefit pharmacy patients have not been integrated and studied.

OBJECTIVE

To investigate the feasibility and acceptability of a proposed pharmacy-based harm reduction intervention to reduce opioid overdose, HIV and hepatitis C called PharmNet.

METHODS

Indiana managing pharmacists were surveyed in 2018 to assess the feasibility and acceptability of an intervention for opioid misuse screening, brief intervention, syringe and naloxone dispensing, and referrals provision. The Consolidated Framework for Implementation Research informed the survey development and analysis.

RESULTS

The sample included 303 (30.8%) pharmacists; 215 (70.9%) provided detailed written comments. Intervention Characteristics: 83.3% believed PharmNet would benefit patients, and that staff could deliver the intervention with adequate training (70.0%). Inner Setting: While 77.2% believed their pharmacy culture supported practice change, 57.5% of chain pharmacists believed their pharmacies would not have time for PharmNet. Outer Setting: 73.3% believed additional addiction and overdose screening is needed in their community, and pharmacies should offer new services to help reduce opioid overdose and addiction among their patients (79.5%). A vast majority (97.7%) were asked by patients in the past 2 years about syringe related issues; 67.7% were asked about syringes for non-prescription injection drug use. Individuals Involved: While 62.4% believed PharmNet was within pharmacy scope of practice and 90.1% were comfortable consulting about syringe use, pharmacists reported that they had limited control over the implementation environment.

PROCESS

38.0% of pharmacists indicated interest in advising the development of PharmNet.

CONCLUSIONS

An implementation trial of a modified version of PharmNet is likely feasible; yet will be challenged by structural pressures particularly in chain pharmacies. Successful implementation will involve the development of resources and policy components to manage outer and inner setting characteristics and align the intervention to the implementation environment.

Tele-evidence: A videoconferencing tool as a viable alternative to physical appearance of doctors for the judicial summons

Introduction:

The role of physicians often extends beyond provision of direct patient care and includes appearance in courts as professional or expert witnesses to give their testimony in various legal cases. This often consumes precious time and resources of the doctors and the hospitals. This study was taken up to evaluate the present system of the physical appearance of the doctors to various courts and compare it with the videoconferencing mode of giving testimony (tele-evidence).

Materials and Methods:

Available records of summons and vehicles used were analyzed to calculate the cost involved and man-hours consumed in honoring the court summons. Telemedicine facility, available in our institute, was used for conducting tele-evidence with selected courts of the two states as a pilot, which was later expanded. A survey was also done to assess the experience of the physicians with physical appearance and videoconferencing using structured questionnaire after approval from the Institute's Ethics Committee. Likert scale of 0–10 points was used to measure satisfaction.

Results:

There was 43% drop in the monthly mileage of vehicles, 49% reduction in the fuel cost per month, and 28% savings in terms of time consumed for court duties. Satisfaction score for parameters of time consumed, physical strain, mental strain, communication with Honorable Judges, and overall experience was 87% through tele-evidence as compared to 31% with physical appearance.

Conclusion:

Tele-evidence is an acceptable and implementable mode of testifying and has led to tremendous resource savings in our tertiary care setting. The model needs to be replicated for deliverance of justice and is in consonance with Government's push toward Digital India.

Galectin-3: an emerging biomarker in stroke and cerebrovascular diseases

The carbohydrate-binding molecule galectin-3 has garnered significant attention recently as a biomarker for various conditions ranging from cardiac disease to obesity. Although there have been several recent studies investigating its role in stroke and other cerebrovascular diseases, awareness of this emerging biomarker in the wider neurology community is limited. We performed a systematic search in PubMed, Embase, Scopus, CINAHL, Clinicaltrials.gov and the Cochrane library in November and December 2016 for articles related to galectin-3 and cerebrovascular disease. We included both human and pre-clinical studies in order to provide a comprehensive view of the state of the literature on this topic. The majority of the relevant literature focuses on stroke, cerebral ischemia and atherosclerosis, but some recent attention has also been devoted to intracranial and subarachnoid hemorrhage. Higher blood levels of galectin-3 correlate with worse outcomes in atherosclerotic disease as well as in intracranial and subarachnoid hemorrhage in human studies. However, experimental evidence supporting the role of galectin-3 in these phenotypes is not as robust. It is likely that the role of galectin-3 in the inflammatory cascade within the central nervous system following injury is responsible for many of its effects, but its varied physiological functions and multiple sites of expression mean that it may have different effects depending on the nature of the disease condition and the time since injury. In summary, experimental and human research raises the possibility that galectin-3, which is closely linked to the inflammatory cascade, could be of value as a prognostic marker and therapeutic target in cerebrovascular disease.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Galectin-3 and risk of ischaemic stroke: Reasons for Geographic and Racial Differences in Stroke cohort

BACKGROUND AND PURPOSE

Galectin-3 is a biomarker of atherosclerotic and cardiovascular disease, and may be a useful marker for ischaemic stroke risk.

METHODS

The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled and examined 30 239 US participants between 2003 and 2007 (41% black, 59% white and 55% in the southeastern stroke belt). Baseline galectin-3 was measured in 526 subjects with incident ischaemic stroke over 5.4 years and in a cohort random sample (CRS) of 947 participants. Cox proportional hazards models were used to calculate hazard ratios (HRs) of ischaemic stroke by quartiles of galectin-3.

RESULTS

In the CRS, galectin-3 was significantly higher with older age, black race, female sex, body mass index, hypertension, diabetes mellitus and kidney disease, and also in those who developed incident stroke. Participants with galectin-3 levels in the fourth versus first quartile had a 2.3-fold increased stroke risk [95% confidence interval (CI) 1.6, 3.4] in an unadjusted model. An interaction with age was found (P = 0.06), and therefore age-stratified analyses were performed. Amongst those younger than age 64, baseline galectin-3 in the second-fourth quartiles was associated with increased stroke risk (HR 3.0, 95% CI 1.6, 5.5) compared to the first quartile in an age-, race- and sex-adjusted model. The HR was 2.0 (95% CI 1.0, 4.0) with multivariable adjustment. There was no association amongst older participants.

CONCLUSIONS

Galectin-3 was associated with incident ischaemic stroke in younger but not older individuals. Confirmation of this finding, and elucidation of its implications for stroke pathophysiology and prevention, is needed.

Effect of Microbial inoculation in combating the aluminium toxicity effect on growth of Zea mays

The present study is aimed at improving the aluminium tolerance in maize crop employing the potential of microbial inoculants in conferring resistance to these toxicities via production of certain chelating compounds like siderophores, exopolysachharides and organic acids. Acid soils have now-a-days become one of the key factors for limiting growth of many agriculturally important crops. Aluminium  is one of the major elements present in acid soils and is mainly responsible for toxicity in the soil. This aluminium is rapidly soluble in soil water and hence absorbed by plant roots under conditions where soil pH is below 5. This toxicity leads to severe root growth inhibition, thereby limiting the production of maize crops. It was observed that use of microbial inoculums can be helpful in elimination of these toxic compounds and prevent the inhibition of root growth . It was found that the soils contaminated with aluminium toxicity decreased the root length of maize plant significantly by 65% but Bacillus and Burkholderia inoculation increased this root length significantly by 1.4- folds and 2- folds respectively thereby combating the effect of aluminium toxicity. Aluminium concentration was found maximum in roots of plants which were grown under aluminium stress condition. But this aluminium accumulation decreased ̴ 2-folds when Burkholderia was used as seed inoculants under aluminium stress conditions. Also, at 60mM aluminium accumulation, phosphorus solubilisation in roots was found to be increased upto 30% on Burkholderia inoculation. However, Bacillus inoculation didn't show any significant difference in either of the case. Thus, the inoculation of seeds with Burkholderia isolates could prove to be a boon in sequestering aluminium toxicity in Zea mays.

Innate and humoral recognition of the products of cell death: differential antigenicity and immunogenicity in lupus

While apoptotic debris is believed to constitute the original antigenic insult in lupus (which is characterized by a time-dependent diversification of autoreactivity), whether such debris and autoantibodies specifically recognizing its constituents mediate differential effects on innate and humoral responses in lupus-prone mice is currently unknown. Apoptotic blebs (as opposed to cellular lysate) enhanced preferentially the maturation of dendritic cells (DCs) from bone marrow precursors drawn from lupus-prone mice. Murine, somatically mutated, apoptotic cell-reactive immunoglobulin (Ig)G monoclonal antibodies demonstrated enhanced recognition of DCs and also displayed a prominent lupus strain-specific bias in mediating DC maturation. Further, immunization of such antibodies specifically in lupus-prone mice resulted in widespread humoral autoreactivity; hypergammaglobulinaemia (a hallmark of systemic autoimmunity) was observed, accompanied by enhanced antibody titres to cellular moieties. Induced antibodies recognized antigens distinct from those recognized by the antibodies employed for immunization; in particular, nephritis-associated anti-double stranded (ds) DNA antibodies and neonatal lupus-associated anti-Ro60 antibodies were elicited by a non-dsDNA, non-Ro60 reactive antibody, and Sm was a favoured target. Further, only in lupus-prone mice did such immunization enhance the kinetics of humoral anti-self responses, resulting in the advanced onset of glomerulosclerosis. These studies reveal that preferential innate and humoral recognition of the products of cell death in a lupus milieu influence the indices associated with autoimmune pathology.

Effect of narrow band ultraviolet B phototherapy on T helper 17 cell specific cytokines (interleukins-17, 22 and 23) in psoriasis vulgaris

BACKGROUND

Psoriasis is mediated by a T helper 17 (Th17) cell inflammatory process. This study describes the changes in serum levels of IL-17, 22 and 23 in patients of psoriasis vulgaris treated with narrow band ultraviolet B (NBUVB).

METHODS

The serum levels of IL-17, 22 and 23 were compared with a control group (n = 30) before and after NBUVB. In addition, post-NBUVB levels were compared with healthy controls. Psoriasis Area Severity Score (PASI) and Body Surface Area scoring were used to evaluate severity of disease.

RESULTS

When compared with the non-psoriasis control group, IL-17, 22 and 23 were higher in psoriasis patients (p < 0.05, p < 0.001, p < 0.001, respectively). The serum levels of all three interleukins strongly correlated with severity of disease. Although IL-17, 22 and 23 decreased after NBUVB, decline in IL-17 was not significant after phototherapy as compared to controls (p = 0.634). IL-22 and 23 continued to remain elevated post-phototherapy when compared with control group (p < 0.05, p < 0.0001, respectively).

CONCLUSIONS

The serum levels of IL-17, 22 and 23 decrease after phototherapy in psoriasis. Post-phototherapy only the IL-17 levels decrease to that of non-psoriasis controls. Our study supports the role of T helper 17 cell specific cytokines in psoriasis and a possible mechanism of action of NBUVB via inhibition of these cytokines.

Free living amoebae in water sources of critical units in a tertiary care hospital in India

BACKGROUND

Isolation of free-living amoebae (FLA) is reported sparsely from water taps, ventilators, air conditioners, haemodialysis units and dental irrigation systems of hospitals worldwide. Their prevalence in hospital environment especially in wards having immunocompromised patients may pose a risk to this group of susceptible population as they may cause disease themselves or may carry pathogens inside them. No study from India has performed such surveillance.

OBJECTIVE

To evaluate extent of FLA contamination in water sources of bone marrow transplant (BMT) intensive care unit (ICU), transplant ICU, haemodialysis unit and high dependency unit in a tertiary care hospital in India.

MATERIALS AND METHODS

A total of hundred samples including fifty each of tap water samples and swabs from mouth of taps used for drinking, bathing and hand washing purposes in these units were collected according to standard procedure. Samples were inoculated onto non-nutrient agar plates at room temperature followed by morphological confirmation. Molecular identification including polymerase chain reaction (PCR) and sequencing was performed in culture positive samples.

RESULTS

Four tap water samples and ten swab samples showed growth of trophozoites and cyst formation. Morphologically, four amoebae resembled Acanthamoeba spp. which was further confirmed by PCR and sequencing showed them to be of T3 and T4 genotypes.

CONCLUSION

The presence of these FLA in hospital water sources emphasises the urgent need of implementing effective preventive measures. Further studies are required to estimate the true prevalence of FLA in Indian hospitals by taking larger number of samples.

Greenhouse gases emission from soils under major crops in Northwest India

Quantification of greenhouse gases (GHGs) emissions from agriculture is necessary to prepare the national inventories and to develop the mitigation strategies. Field experiments were conducted during 2008-2010 at the experimental farm of the Indian Agricultural Research Institute, New Delhi, India to quantify nitrous oxide (N2O), methane (CH4), and carbon dioxide (CO2) emissions from soils under cereals, pulses, millets, and oilseed crops. Total cumulative N2O emissions were significantly different (P>0.05) among the crop types. Emission of N2O as percentage of applied N was the highest in pulses (0.67%) followed by oilseeds (0.55%), millets (0.43%) and cereals (0.40%). The emission increased with increasing rate of N application (r(2)=0.74, P<0.05). The cumulative flux of CH4 from the rice crop was 28.64±4.40 kg ha(-1), while the mean seasonal integrated flux of CO2 from soils ranged from 3058±236 to 3616±157 kg CO2 ha(-1) under different crops. The global warming potential (GWP) of crops varied between 3053 kg CO2 eq. ha(-1) (pigeon pea) and 3968 kg CO2 eq. ha(-1) (wheat). The carbon equivalent emission (CEE) was least in pigeon pea (833 kg C ha(-1)) and largest in wheat (1042 kg C ha(-1)). The GWP per unit of economic yield was the highest in pulses and the lowest in cereal crops. The uncertainties in emission values varied from 4.6 to 22.0%. These emission values will be useful in updating the GHGs emission inventory of Indian agriculture.

Elucidation of the potential disease-promoting influence of IgM apoptotic cell-reactive antibodies in lupus

The undigested remnants of apoptosis are believed to stimulate the generation of autoantibodies in lupus. The biological properties of initiator, disease-specific IgM antibodies that specifically recognize apoptotic cells, readily detected in the sera of lupus patients, remain unclear. Apoptotic cell-reactive IgM monoclonal antibodies (generated from lupus-prone mice), as opposed to control IgM, preferentially stimulated maturation of bone marrow-derived dendritic cells (BMDCs) derived from such mice, relative to BMDCs derived from healthy mice. An influence of both antibody specificity and cell genotype was also apparent in the secretion of signature inflammatory cytokines. Immunization of such antibodies in lupus-prone animals induced increases in total serum IgG levels, with the elicited antibodies also preferentially recognizing moieties on dying cells. An expanded specificity was apparent both upon Western blot on cellular lysate and from the enhanced recognition of dsDNA, Ro60, RNP68 and Sm; the antibody most efficient in mediating autoreactive diversity, while being germline encoded, also induced the highest degree of phenotypic changes on BMDCs. Apoptotic cell-reactive IgM antibodies may therefore be potentially capable of influencing the course of systemic autoimmune disease by affecting both innate and adaptive immunity.

Forensic Application of Palatal Rugae in Dental Identification

INTRODUCTION

The palatal rugae are anatomical folds or wrinkles located on the anterior third of the palate behind the incisive papilla on each side of the palatal raphe. The rugae patterns have been studied for various purposes mainly in the field of anthropology, comparative anatomy, genetics, prosthodontics, orthodontics and forensic odontology. This study is aimed to determine the difference in number and pattern of palatal rugae in males and females.

METHODS

This is a prospective study in which maxillary impressions of 50 volunteers, 25 males and 25 females were taken and the casts prepared. The boundaries of the rugae were marked with a HB pencil and were observed with a magnifying glass following the classification used by Kapali, et al, (1997). Association between rugae number and sex and rugae shape and sex were tested using two sample unpaired t test.

RESULTS

The study revealed significant difference in the pattern of converge rugae which were found to be higher in females than males, however, no statistical significant difference was found in the number of rugae between the two sexes.

CONCLUSIONS

The rugae pattern can be an additional method of differentiation between the males and females in conjunction with the other methods used in forensic sciences.

Mean gestation at delivery and histological chorioamnionitis correlates with early-onset neonatal sepsis following expectant management in pPROM

This prospective observational study was carried out in India among 100 women with preterm pre-labour rupture of membranes (pPROM) between 26(0/7)-33(0/7) weeks on expectant management in order to correlate early-onset neonatal sepsis (EONS) with various features of chorioamnionitis. The incidence of pPROM during the study period of 1.5 years was 7%. The mean gestation at pPROM was 30(6/7) ± 1.8 weeks and at delivery was 32(1/7) ± 1 weeks. Features of chorioamnionitis in the form of clinical, microbiological, histological or a combination of these were observed in 70/100 women. Clinical chorioamnionitis was seen in 16%, bacterial isolates were present in 30% on cervical swab and in 39% on placental membrane culture and 19% had histological chorioamnionitis. EONS was present in 23/97 (24%). Clinical chorioamnionitis (p = 0.069), bacterial isolates on cervical swab (p = 0.56) or placental membranes (p = 0.39) were not found to predict EONS; whereas histological chorioamnionitis (p = 0.002) and lower gestation at delivery (p = 0.013) were significantly associated with EONS.

Adenosine induced coronary spasm – A rare presentation

Adenosine is commonly used as a pharmacological agent in myocardial perfusion imaging, as an antiarrhythmic agent, and in Cath Lab. during PCI for treating no reflow phenomenon. Coronary spasm has been reported following adenosine injection during stress imaging. We report a rare complication with ST segment elevation, following adenosine injection, given for treatment of supraventricular tachycardia.

Post LASIK progressive astigmatism in a child with partially accommodative esotropia

INTRODUCTION

Refractive surgery is considered a safe and effective method for correction of refractive errors in adults.

OBJECTIVE

To report an unusual case of a young child with partially accommodative esotropia presenting with deterioration of vision and worsening of esotropia following refractive surgery.

CASE REPORT

Unanticipated and progressive irregular corneal astigmatism along with deterioration of visual acuity and loss of stereopsis developed post- LASIK in a seven-year-old Indian child with partially accommodative esotropia.

CONCLUSION

Keratorefractive surgery in young children has to be undertaken with caution, especially in such cases where there is no medical indication for refractive surgery and waiting beyond teenage years is a viable option.

Development and Validation of an RP-HPLC Method for Quantitative Estimation of Eslicarbazepine Acetate in Bulk Drug and Tablets

A convenient, simple, accurate, precise and reproducible RP-HPLC method was developed and validated for the estimation of eslicarbazepine acetate in bulk drug and tablet dosage form. Objective was achieved under optimised chromatographic conditions on Dionex RP-HPLC system with Dionex C18 column (250×4.6 mm, 5 μm particle size) using mobile phase composed of methanol and ammonium acetate (0.005 M) in the ratio of 70:30 v/v. The separation was achieved using an isocratic elution method with a flow rate of 1.0 ml/ min at room temperature. The effluent was monitored at 230 nm using diode array detector. The retention time of eslicarbazepine acetate is found to be 4.9 min and the standard calibration plot was linear over a concentration range of 10-90 μg/ml with r(2)=0.9995. The limit of detection and quantification were found to be 3.144 and 9.52 μg/ml, respectively. The amount of eslicarbazepine acetate in bulk and tablet dosage form was found to be 99.19 and 97.88%, respectively. The method was validated statistically using the percent relative standard deviation and the values are found to be within the limits. The recovery studies were performed and the percentage recoveries were found to be 98.33± 0.5%.

Cold abscess of the thigh in an infant

Local and minor adverse reactions to diphtheria-pertussis-tetanus (DPT) vaccination are usually mild and appear within 48 hours of vaccination. We herein report a rare association with intramuscular DPT injection and discuss pertinent issues. Primary tuberculous abscess was the final diagnosis.

Note: reliable and reusable ultrahigh vacuum optical viewports

We report a simple technique for the realization of ultrahigh vacuum optical viewports. The technique relies on using specially designed thin copper knife-edges and using a thin layer of Vacseal(®) on tip of the knife-edges between the optical flat and the ConFlat(®) (CF) flange. The design of the windows is such that it gives uniform pressure on the flat without breaking it. The assembled window is a complete unit, which can be mounted directly onto a CF flange of the vacuum chamber. It can be removed and reused without breaking the window seal. The design is reliable as more than a dozen such windows have survived several bake out and cooling cycles and have been leak tested up to 10(-11) Torr l/s level with a commercial Helium leak detector. The advantages of this technique are ease of assembly and leak proof sealing that survives multiple temperature cycling making the windows reliable and reusable.

Simple alignment technique for polarisation maintaining fibres

We describe a simple technique for rapid alignment of input state of polarisation with respect to the preferred axis of polarisation maintaining fibres. In this technique a combination of a half-wave and a quarter-wave plate is used to turn the polarisation of incoming beam and to compensate for stress-induced perturbation of polarisation states in a laid-out fibre, respectively. The angular alignment technique is tested with temperature excursion on the fibre. The technique is easy to implement, affordable, and gives quick and accurate alignment.

Prevalence of vitamin D deficiency in a North London antenatal population

OBJECTIVE

We evaluated the prevalence of vitamin D deficiency in the antenatal patients attending North Middlesex University Hospital between March 2008 and March 2009.

STUDY DESIGN

A prospective study of maternal levels of vitamin D at booking.

RESULTS

The prevalence of both deficient and insufficient levels of 25[OH]D was 87.6% across all included patients.

CONCLUSION

There is a high prevalence of asymptomatic vitamin D deficiency in the antenatal booking population.

Rapid cell-surface prion protein conversion revealed using a novel cell system

Prion diseases are fatal neurodegenerative disorders with unique transmissible properties. The infectious and pathological agent is thought to be a misfolded conformer of the prion protein. Little is known about the initial events in prion infection because the infecting prion source has been immunologically indistinguishable from normal cellular prion protein (PrP(C)). Here we develop a unique cell system in which epitope-tagged PrP(C) is expressed in a PrP knockdown (KD) neuroblastoma cell line. The tagged PrP(C), when expressed in our PrP-KD cells, supports prion replication with the production of bona fide epitope-tagged infectious misfolded PrP (PrP(Sc)). Using this epitope-tagged PrP(Sc), we study the earliest events in cellular prion infection and PrP misfolding. We show that prion infection of cells is extremely rapid occurring within 1 min of prion exposure, and we demonstrate that the plasma membrane is the primary site of prion conversion.