Genetic and phenotypic landscape of pediatric-onset epilepsy in 142 Indian families: Counseling and therapeutic implications

The application of genomic technologies has led to unraveling of the complex genetic landscape of disorders of epilepsy, gaining insights into their underlying disease mechanisms, aiding precision medicine, and providing informed genetic counseling. We herein present the phenotypic and genotypic insights from 142 Indian families with epilepsy with or without comorbidities. Based on the electroclinical findings, epilepsy syndrome diagnosis could be made in 44% (63/142) of the families adopting the latest proposal for the classification by the ILAE task force (2022). Of these, 95% (60/63) of the families exhibited syndromes with developmental epileptic encephalopathy or progressive neurological deterioration. A definitive molecular diagnosis was achieved in 74 of 142 (52%) families. Infantile-onset epilepsy was noted in 81% of these families (61/74). Fifty-five monogenic, four chromosomal, and one imprinting disorder were identified in 74 families. The genetic variants included 65 (96%) single-nucleotide variants/small insertion-deletions, 1 (2%) copy-number variant, and 1 (2%) triplet-repeat expansion in 53 epilepsy-associated genes causing monogenic disorders. Of these, 35 (52%) variants were novel. Therapeutic implications were noted in 51% of families (38/74) with definitive diagnosis. Forty-one out of 66 families with monogenic disorders exhibited autosomal recessive and inherited autosomal dominant disorders with high risk of recurrence.

Acute and sub-acute toxicity study of anti-obesity herbal granules in Sprague Dawley rats

Abstract Toxicological studies are essential for developing novel medications in pharmaceutical industries including ayurvedic preparation. Hence, the present study is aimed to evaluate acute and 28-days repeated dose oral toxicity of anti-obesity polyherbal granules (PHG) in Sprague Dawley rats by OECD guidelines No 425 and 407, respectively. In an acute oral toxicity study, a single dose of 2 g/kg PHG was administered to rats and mortality, body weight, and clinical observations were noted for fourteen days. However, in the subacute oral toxicity study, the PHG was administered orally at doses of 0.3, 0.5 and 1 g/kg daily for 28 days to rats. Food intake and body weight were recorded weekly. On the 29th day, rats were sacrificed and subjected to haematological, biochemical, urine, necropsy, and histopathological analysis. In an acute oral toxicity study, no treatment-related, mortality, behavioral changes, and toxicity were found throughout fourteen days. Likewise, in the sub-acute toxicity study, no mortality and toxic effects were found in haematology, biochemical, urine, necropsy and histopathological analysis in rats for 28 days of treatment with PHG. Based on these results, the LD50 of PHG was found to be greater than 2 g/kg and the no-observed-adverse-effect level (NOAEL) of PHG for rats was found to be 0.5 g/kg/day. Thus, anti-obesity polyherbal granules showed a good safety profile in animal studies and can be considered an important agent for the clinical management of obesity.

De novo variants underlying monogenic syndromes with intellectual disability in a neurodevelopmental cohort from India

The contribution of de novo variants as a cause of intellectual disability (ID) is well established in several cohorts reported from the developed world. However, the genetic landscape as well as the appropriate testing strategies for identification of de novo variants of these disorders remain largely unknown in low-and middle-income countries like India. In this study, we delineate the clinical and genotypic spectrum of 54 families (55 individuals) with syndromic ID harboring rare de novo variants. We also emphasize on the effectiveness of singleton exome sequencing as a valuable tool for diagnosing these disorders in resource limited settings. Overall, 46 distinct disorders were identified encompassing 46 genes with 51 single-nucleotide variants and/or indels and two copy-number variants. Pathogenic variants were identified in CREBBP, TSC2, KMT2D, MECP2, IDS, NIPBL, NSD1, RIT1, SOX10, BRWD3, FOXG1, BCL11A, KDM6B, KDM5C, SETD5, QRICH1, DCX, SMARCD1, ASXL1, ASXL3, AKT3, FBN2, TCF12, WASF1, BRAF, SMARCA4, SMARCA2, TUBG1, KMT2A, CTNNB1, DLG4, MEIS2, GATAD2B, FBXW7, ANKRD11, ARID1B, DYNC1H1, HIVEP2, NEXMIF, ZBTB18, SETD1B, DYRK1A, SRCAP, CASK, L1CAM, and KRAS. Twenty-four of these monogenic disorders have not been previously reported in the Indian population. Notably, 39 out of 53 (74%) disease-causing variants are novel. These variants were identified in the genes mainly encoding transcriptional and chromatin regulators, serine threonine kinases, lysosomal enzymes, molecular motors, synaptic proteins, neuronal migration machinery, adhesion molecules, structural proteins and signaling molecules.

Nuclear proteostasis imbalance in laminopathy-associated premature aging diseases

Laminopathies are a group of rare genetic disorders with heterogeneous clinical phenotypes such as premature aging, cardiomyopathy, lipodystrophy, muscular dystrophy, microcephaly, epilepsy, and so on. The cellular phenomena associated with laminopathy invariably show disruption of nucleoskeleton of lamina due to deregulated expression, localization, function, and interaction of mutant lamin proteins. Impaired spatial and temporal tethering of lamin proteins to the lamina or nucleoplasmic aggregation of lamins are the primary molecular events that can trigger nuclear proteotoxicity by modulating differential protein-protein interactions, sequestering quality control proteins, and initiating a cascade of abnormal post-translational modifications. Clearly, laminopathic cells exhibit moderate to high nuclear proteotoxicity, raising the question of whether an imbalance in nuclear proteostasis is involved in laminopathic diseases, particularly in diseases of early aging such as HGPS and laminopathy-associated premature aging. Here, we review nuclear proteostasis and its deregulation in the context of lamin proteins and laminopathies.

Further validation of craniosynostosis as a part of phenotypic spectrum of BCL11B-related BAFopathy

Heterozygous disease-causing variants in BCL11B are the basis of a rare neurodevelopmental syndrome with craniofacial and immunological involvement. Isolated craniosynostosis, without systemic or immunological findings, has been reported in one of the 17 individuals reported with this disorder till date. We report three additional individuals harboring de novo heterozygous frameshift variants, all lying in the exon 4 of BCL11B. All three individuals presented with the common findings of this disorder i.e. developmental delay, recurrent infections with immunologic abnormalities and facial dysmorphism. Notably, craniosynostosis of variable degree was seen in all three individuals. We, thus add to the evolving genotypes and phenotypes of BCL11B-related BAFopathy and also review the clinical, genomic spectrum along with the underlying disease mechanisms of this disorder.

The E262K mutation in Lamin A links nuclear proteostasis imbalance to laminopathy-associated premature aging

Deleterious, mostly de novo, mutations in the lamin A (LMNA) gene cause spatio-functional nuclear abnormalities that result in several laminopathy-associated progeroid conditions. In this study, exome sequencing in a sixteen-year-old male with manifestations of premature aging led to the identification of a mutation, c.784G>A, in LMNA, resulting in a missense protein variant, p.Glu262Lys (E262K), that aggregates in nucleoplasm. While bioinformatic analyses reveal the instability and pathogenicity of LMNAE262K , local unfolding of the mutation-harboring helical region drives the structural collapse of LMNAE262K into aggregates. The E262K mutation also disrupts SUMOylation of lysine residues by preventing UBE2I binding to LMNAE262K , thereby reducing LMNAE262K degradation, aggregated LMNAE262K sequesters nuclear chaperones, proteasomal proteins, and DNA repair proteins. Consequently, aggregates of LMNAE262K disrupt nuclear proteostasis and DNA repair response. Thus, we report a structure-function association of mutant LMNAE262K with toxicity, which is consistent with the concept that loss of nuclear proteostasis causes early aging in laminopathies.

Multilocus disease-causing genomic variations for Mendelian disorders: role of systematic phenotyping and implications on genetic counselling

Multilocus disease-causing genomic variations (MGVs) and multiple genetic diagnoses (MGDs) are increasingly being recognised in individuals and families with Mendelian disorders. This can be mainly attributed to the widespread use of genomic tests for the evaluation of these disorders. We conducted a retrospective study of families evaluated over the last 6 years at our centre to identify families with MGVs and MGDs. MGVs were observed in fourteen families. We observed five different consequences: (i) individuals with MGVs presenting as blended phenotypes (ii) individuals with MGVs presenting with distinct phenotypes (iii) individuals with MGVs with age-dependent penetrance (iv) individuals with MGVs with one phenotype obscured by another more predominant phenotype (v) two distinct phenotypes in different individuals in families with MGVs. Consanguinity was present in eight (8/14, 57.1%) of them. Thirteen families had two Mendelian disorders and one had three Mendelian disorders. The risk of recurrence of one or more conditions in these families ranged from 25% to 75%. Our findings underline the importance of the role of a clinical geneticist in systematic phenotyping, challenges in genetic counselling and risk estimation in families with MGVs and MGDs, especially in highly inbred populations.

Transcriptome Sequence Reveals Candidate Genes Involving in the Post-Harvest Hardening of Trifoliate Yam Dioscorea dumetorum

Storage ability of trifoliate yam (Dioscorea dumetorum) is restricted by a severe post-harvest hardening (PHH) phenomenon, which starts within the first 24 h after harvest and renders tubers inedible. Previous work has only focused on the biochemical changes affecting PHH in D. dumetorum. To the best of our knowledge, the candidate genes responsible for the hardening of D. dumetorum have not been identified. Here, transcriptome analyses of D. dumetorum tubers were performed in yam tubers of four developmental stages: 4 months after emergence (4MAE), immediately after harvest (AH), 3 days after harvest (3DAH) and 14 days after harvest (14DAH) of four accessions (Bangou 1, Bayangam 2, Fonkouankem 1, and Ibo sweet 3) using RNA-Seq. In total, between AH and 3DAH, 165, 199, 128 and 61 differentially expressed genes (DEGs) were detected in Bayangam 2, Fonkouankem 1, Bangou 1 and Ibo sweet 3, respectively. Functional analysis of DEGs revealed that genes encoding for CELLULOSE SYNTHASE A (CESA), XYLAN O-ACETYLTRANSFERASE (XOAT), CHLOROPHYLL A/B BINDING PROTEIN1, 2, 3, 4 (LHCB1, LHCB2, LHCB3, and LCH4) and an MYB transcription factor were predominantly and significantly up-regulated 3DAH, implying that these genes were potentially involved in the PHH as confirmed by qRT-PCR. A hypothetical mechanism of this phenomenon and its regulation has been proposed. These findings provide the first comprehensive insights into gene expression in yam tubers after harvest and valuable information for molecular breeding against the PHH.

Hedgehog acyl-transferase-related multiple congenital anomalies: Report of an additional family and delineation of the syndrome

This study includes previous reports of four affected individuals from two unrelated families with hedgehog acyl-transferase (HHAT)-related multiple congenital anomaly syndrome. Microcephaly, small cerebellar vermis, holoprosencephaly, agenesis of corpus callosum, intellectual disability, short stature, skeletal dysplasia, microphthalmia-anophthalmia, and sex reversal constitute the phenotypic spectrum of this condition with variable expression. We report an additional family with three affected conceptuses: two abortuses and one living proband. We did proband-parents trio exome sequencing and identified a biallelic in-frame deletion c.365_367del; (p.Thr122del) in exon 5 of HHAT. With this report, we delineate the phenotype and allelic heterogeneity of the HHAT-related multiple congenital anomaly syndrome.

Biallelic mutations in the death domain of PIDD1 impair caspase-2 activation and are associated with intellectual disability

PIDD1 encodes p53-Induced Death Domain protein 1, which acts as a sensor surveilling centrosome numbers and p53 activity in mammalian cells. Early results also suggest a role in DNA damage response where PIDD1 may act as a cell-fate switch, through interaction with RIP1 and NEMO/IKKg, activating NF-κB signaling for survival, or as an apoptosis-inducing protein by activating caspase-2. Biallelic truncating mutations in CRADD—the protein bridging PIDD1 and caspase-2—have been reported in intellectual disability (ID), and in a form of lissencephaly. Here, we identified five families with ID from Iran, Pakistan, and India, with four different biallelic mutations in PIDD1, all disrupting the Death Domain (DD), through which PIDD1 interacts with CRADD or RIP1. Nonsense mutations Gln863* and Arg637* directly disrupt the DD, as does a missense mutation, Arg815Trp. A homozygous splice mutation in the fifth family is predicted to disrupt splicing upstream of the DD, as confirmed using an exon trap. In HEK293 cells, we show that both Gln863* and Arg815Trp mutants fail to co-localize with CRADD, leading to its aggregation and mis-localization, and fail to co-precipitate CRADD. Using genome-edited cell lines, we show that these three PIDD1 mutations all cause loss of PIDDosome function. Pidd1 null mice show decreased anxiety, but no motor abnormalities. Together this indicates that PIDD1 mutations in humans may cause ID (and possibly lissencephaly) either through gain of function or secondarily, due to altered scaffolding properties, while complete loss of PIDD1, as modeled in mice, may be well tolerated or is compensated for.

Biallelic mutations in the death domain of PIDD1 impair caspase-2 activation and are associated with intellectual disability

PIDD1 encodes p53-Induced Death Domain protein 1, which acts as a sensor surveilling centrosome numbers and p53 activity in mammalian cells. Early results also suggest a role in DNA damage response where PIDD1 may act as a cell-fate switch, through interaction with RIP1 and NEMO/IKKg, activating NF-κB signaling for survival, or as an apoptosis-inducing protein by activating caspase-2. Biallelic truncating mutations in CRADD-the protein bridging PIDD1 and caspase-2-have been reported in intellectual disability (ID), and in a form of lissencephaly. Here, we identified five families with ID from Iran, Pakistan, and India, with four different biallelic mutations in PIDD1, all disrupting the Death Domain (DD), through which PIDD1 interacts with CRADD or RIP1. Nonsense mutations Gln863* and Arg637* directly disrupt the DD, as does a missense mutation, Arg815Trp. A homozygous splice mutation in the fifth family is predicted to disrupt splicing upstream of the DD, as confirmed using an exon trap. In HEK293 cells, we show that both Gln863* and Arg815Trp mutants fail to co-localize with CRADD, leading to its aggregation and mis-localization, and fail to co-precipitate CRADD. Using genome-edited cell lines, we show that these three PIDD1 mutations all cause loss of PIDDosome function. Pidd1 null mice show decreased anxiety, but no motor abnormalities. Together this indicates that PIDD1 mutations in humans may cause ID (and possibly lissencephaly) either through gain of function or secondarily, due to altered scaffolding properties, while complete loss of PIDD1, as modeled in mice, may be well tolerated or is compensated for.

Knobloch Syndrome in Siblings with Posterior Fossa Malformations Along with Cerebellar Midline Cleft Abnormality Caused by Biallelic COL18A1 Mutation: Case-Based Review

Knobloch syndrome (KS) is an autosomal recessive disorder caused by biallelic pathogenic variants in COL18A1 . KS clinically manifests with the typical eye findings (high myopia, vitreoretinal degeneration, retinal detachment, and lens subluxation), variable neurological findings (occipital encephalocele, polymicrogyria, cerebellar malformations, epilepsy, and intellectual disability), and the other uncommon clinical manifestations. Literature review of all KS patients (source PubMed) was done with special reference to cerebellar abnormalities. Here, we report two siblings with typical KS with posterior fossa malformations and novel cerebellar midline cleft abnormality analyzed by whole exome sequencing. Known pathogenic homozygous variant c.2908C > T; (p.Arg970Ter) in exon 26 of COL18A1 was found as a cause for KS. These two siblings presented with early-onset severe ocular manifestations, facial dysmorphism, and variable central nervous system manifestations along with novel cerebellar midline cleft abnormality. The presence or absence of structural brain malformations and genotypes does not absolutely predict cognitive functions in KS patients. However, the presence of posterior fossa abnormality may be predictive for the development of ataxia in later life and needs further studies.

Trichothiodystrophy type 4 in an Indian family

Trichothiodystrophy, non-photosensitive type 4 (TTD4), is a rare genetic disorder with an autosomal recessive mode of inheritance. It is characterized by coarse and brittle hair, anomalies of the tissues derived from the neuro-ectoderm (skin, hair, and nails) and intellectual disability. We herein report two male siblings aged 13 and 16 years with TTD4 and a known homozygous pathogenic variant, c.229del [p.(Arg77Glyfs*76)] in exon 1 of MPLKIP (NM_138701.3). We herein highlight the clinical and molecular findings of the first reported case of TTD4 in probands of Indian ethnicity.

Primary Ewing sarcoma of the coronoid process of mandible

Ewing sarcoma (ES) is a rare, primary malignancy of the bone that occurs mainly in childhood and early adolescence. ES usually occurs in long bones of the axial skeleton. Although uncommon in the jaws, ES at this site is most likely to occur in the posterior mandible. The outcome for patients with localised disease has improved over the decades, due to better combination chemotherapies and better methods of local control. We present the clinicopathologic features and management of a case of ES that developed in the left coronoid process of the mandible of a 31-year-old male. Chemotherapy and, later, a segmental mandibulectomy were used to achieve local control. A fibula-free flap repair was performed with good aesthetic results. This case elucidates the importance of the interdisciplinary approach required for the evaluation and treatment of this aggressive neoplasm.

First Report of Fusarium acuminatum on Pigeonpea in India

Pigeonpea (Cajanus cajan (L.) Millsp.) is the most important protein rich grain legume crop being cultivated worldwide. During surveys (2010 through 2012) conducted in major pigeonpea growing states in southern and central India (Andhra Pradesh, Karnataka, and Maharashtra), rapid mortality of pigeonpea plants was observed. This occurred in all of the surveyed areas with disease incidence of 20 to 60% irrespective of cultivar and crop growth stage. Symptoms included chlorosis, drooping and rolling of the leaves followed by rapid mortality of whole plant. Pinkish growth on infected stems and branches was observed and the inner layer of the infected stem had brown discoloration. Xylem vessels of the infected plants were healthy and did not show any blackening. Isolations from infected stem tissues consistently yielded cultures of Fusarium sp. on potato dextrose agar (PDA) medium. Monoconidial isolation from three separate isolates was used to establish pure cultures. The morphological characters of the fungus were consistent with descriptions in Fusarium keys (1) for Fusarium acuminatum (Ellis & Everhart). The mean colony growth was 86 mm after 7 days, with white aerial mycelium developing brownish pigmentation in the center on PDA. The dorsal side of the colony had rose to burgundy pigmentation. Macroconidia were broadly falcate with 3 to 5 septa, and were 3 to 8 × 39 to 64 μm. Microconidia were absent and chlamydospores formed in chains of 20 to 50 μm. Koch's postulates were established on seedlings of pigeonpea (cv. ICP 7119) using root dip inoculation of 10-day-old seedlings. The roots were immersed in a conidial suspension (6 × 10⁶ conidia/ml) for 2 to 3 min; the control plants' roots were immersed in sterilized distilled water in a beaker. Inoculated seedlings were transplanted into pre-irrigated pots (12 cm) containing sterilized vertisol and sand (3:1). Five seedlings were used for each of three replications. Inoculated plants were kept in the greenhouse at 28 ± 2°C and irrigated with sterilized water. Inoculated plants developed symptoms identical to those observed in the field and disease incidence reached 100% within 96 h after inoculation. The experiment was conducted twice with two independent sets of plants. No symptoms were observed in water-inoculated control plants. The rDNA internal transcribed spacer (ITS sequence) was amplified with ITS1 and ITS4 primers (4). The amplicons of both forward and reverse (438 bp) were sequenced and submitted to GenBank (Accession No. JX177431). A BLASTn search revealed 100% sequence similarity to the nucleotide sequence of F. acuminatum (Ellis & Everhart) (GenBank Accession No. HQ443205). To our knowledge, this is the first report with confirmed molecular identification of F. acuminatum on pigeonpea. Occurrence of F. acuminatum on various plant species have been reported by Summerell et al. (3). Presence of F. acuminatum from soils of pigeonpea fields have been reported; however, no information on location, symptoms, plant mortality, and identification of pathogen has been provided (2). References: (1) J. F. Leslie and B. A. Summerell. Pages 122-123 in: The Fusarium Laboratory Manual. Blackwell Publishing Professional, Hoboken, NJ, 2006. (2) A. P. Singh and S. N. Bhargava. Phytopathol. Z. 100:300, 1981. (3) B. A. Summerell et al. Fungal Diversity 46:1, 2011. (4) T. J. White et al. Pages 315-322 in: PCR protocols: Guide to Methods and Applications, San Diego, Academic Press, 1990.

Alternaria tenuissima Causing Alternaria Blight on Pigeonpea in India

Pigeonpea (Cajanus cajan (L.) Millsp.) is a major grain legume of the tropics and subtropics worldwide. In India, pigeonpea is the third most important food legume after chickpea and field pea. Blight symptoms on pigeonpea were observed in alarming proportion during the 2009 through 2011 crop seasons in Andhra Pradesh state in India. Disease incidence ranged from 20 to 80% irrespective of cultivars sown. Infected plants in the field showed symptoms on all aerial parts of the plant (leaves, stems, buds, and pods) irrespective of age of the plant and leaves. Symptoms on leaves were small, circular, necrotic spots that developed quickly forming typical concentric rings (1). Later, these spots coalesced and caused blighting of leaves. Spots were initially light brown and later turned dark brown. On stems, spots were sunken with concentric rings. In severe infection, defoliation and drying of infected leaves, branches, and flower buds was observed. The fungus was successfully isolated from all the infected plant parts (leaves, stem, buds, and pods) on potato dextrose agar (PDA) medium. After 4 to 5 days of incubation at 28 ± 1°C with a 12-h photoperiod, the fungus produced colonies that were regular and flat. The periphery of the colony was olive green with a black center. Monoconidial isolations were used to establish a pure culture of the fungus. Conidiophores were short, arising singly, and were 8.86 mm long and 2.97 mm thick. Conidia varied from 15.78 to 28.70 mm long and 8.03 to 13.47 mm wide. Very small beak (1.6 to 3.2 mm) or no beak was observed. Horizontal and vertical septations of conidia varied from four to six and two to four, respectively. The pathogenicity test was conducted on 8- to 10-day-old pigeonpea plants of cultivar ICPL 87119 by spraying with a conidial suspension (5 × 10⁵ conidia/ml). Inoculated plants were covered with polythene bags and kept in a greenhouse at 28 ± 1°C with a 12-h photoperiod. After 48 h, the polythene bags were removed. Ten days after inoculation, symptoms were similar to those observed in fields. This experiment was conducted twice with two independent sets of plants. No symptoms were observed in water-inoculated control plants. The fungus was reisolated from the inoculated plants. On the basis of the morphological characteristics, the pathogen was tentatively identified as Alternaria tenuissima. The identification was further confirmed by the rDNA and internal transcribed spacer (ITS) primer. The ITS region of rDNA was amplified with ITS 1 and ITS 4 primers. Both orientation sequenced amplicons (481 bp) were submitted to GenBank (Accession No. JQ074094). A BLASTn search revealed 99% similarity to A. tenuissima (Accession No. HQ343444). To our knowledge, this is the first report of molecular identification of A. tenuissima causing Alternaria blight in pigeonpea in India. Reference: (1) Kannaiyan, J. and Nene, Y. L. 1977. Trop. Grain Legume Bull. 9:34.

Antihypercholesterolaemic influence of dietary tender cluster beans (Cyamopsis tetragonoloba) in cholesterol fed rats

BACKGROUND & OBJECTIVES

Cluster beans (Cyamopsis tetragonoloba) are rich source of soluble fibre content and are known for their cholesterol lowering effect. The beneficial anti-hypercholesterolaemic effect of whole dietary cluster beans as a source of dietary fibre was evaluated in high cholesterol diet induced hypercholesterolaemia in experimental rats.

METHODS

Male Wistar rats (90-95 g) divided in six groups of 10 rats each were used. Freeze dried tender cluster beans were included at 12.5 and 25 per cent levels in the diet of animals maintained for 8 wk either on high (0.5%) cholesterol diet or basal control diet.

RESULTS

Significant anti-hypercholesterolaemic effect was seen in cluster bean fed animals, the decrease in serum cholesterol being particularly in the LDL associated fraction. There was also a beneficial increase in HDL associated cholesterol fraction. Hepatic lipid profile showed a significant decrease in both cholesterol and triglycerides as a result of feeding tender cluster beans along with high cholesterol diet.

INTERPRETATION & CONCLUSIONS

The present experimental results showed the beneficial hypocholesterolaemic and hypolipidimic influences dietary tender cluster beans in atherogenic situation. Studies in human need to be done to confirm the results.

Keller's arthroplasty in adults with hallux valgus and hallux rigidus

BACKGROUND

The role of Keller's resection arthroplasty in the management of adult hallux valgus with hallux rigidus is debatable. There are no studies addressing this particular problem.

METHODS

This study is a retrospective review of 32 patients (49 feet), conducted by an independent assessor. Subjective and objective criteria were used to assess the results of surgery. There were 30 women and 2 men with an average age at surgery of 62.5years.

RESULTS

The results of surgery in terms of relief of pain, cosmesis and use of regular footwear were satisfactory. Excellent and good subjective results were obtained in 39% and 37% of cases respectively. Radiological analysis revealed decrease in the intermetatarsal and first metatarsophalangeal angle in a significant number of cases. Final results assessed by Vallier's modification of Bonney and MacNab criteria, revealed excellent to good results in 87% of feet. A significant number of complications were noted but there was no association between the occurrence of complications and the final result or the subjective functional grade. There was no association between the amount of resection of proximal phalanx and occurrence of metatarsalgia or the final outcome.

CONCLUSION

The results of this study suggest that Keller's arthroplasty has a role in patients with adult hallux valgus associated with degenerative changes in the first metatarsophalangeal joint.

Low bone mineral density in Indian patients with fragility fractures

OBJECTIVE

Low bone mineral density (BMD) is a major risk factor for fragility fractures in osteoporosis. In recent studies, its use with clinical risk factors has been shown to enhance prediction of fragility fractures. The present study was done to assess BMD in Indian patients with fragility fractures using digital X-ray radiogrammetry (DXR-BMD).

METHODS

A total of 228 patients (64 male and 164 female) admitted to an Orthopedic Hospital for management of fragility fracture were recruited. For each patient, DXR-BMD was obtained from an anteroposterior radiograph of the non-dominant hand.

RESULTS

The number of subjects with hip fracture was 104 (40 male, 64 female). Vertebral fractures were seen in 67 patients (11 male, 56 female) and distal radial fracture in 57 patients (13 male, 44 female). The DXR-BMD (g/cm(2)) was significantly lower in subjects with any fragility fracture (0.51 vs. 0.58 in men and 0.41 vs. 0.54 in women). When compared to the age-matched normative reference data by decade, all subjects with fragility fracture had significantly lower DXR-BMD except male subjects in the age decade of 40-49 years.

CONCLUSION

This study confirms lower DXR-BMD in Indian subjects with fragility fractures. This may have a potential role in fracture prediction when used with clinical risk factors in the Indian population.

The impact of VKORC1-1639 G>A polymorphism on the maintenance dose of oral anticoagulants for thromboembolic prophylaxis in North India: A pilot study

BACKGROUND

The dose requirements for oral anticoagulants in thromboembolic events are influenced by promoter polymorphism in the VKORC1 gene. However, limited data are available on the influence of the polymorphism in various Indian populations. The present study aimed at determining the relationship between the VKORC1-1639 G>A genotypes and maintenance doses of oral anticoagulants for therapeutically stable INR values in patients taking Acitrom after valve replacement surgery.

MATERIALS AND METHODS

Fifty patients from the northern Indian region were genotyped for VKORC1-1639 G>A by polymerase chain reaction and restriction fragment length polymorphism. Means of the weight-normalized daily Acitrom dose were calculated for every patient.

RESULTS AND DISCUSSION

The VKORC1 1639G>A minor allele frequency in the study population (n = 50) was found to be 22%. The patients with a wild type genotype required the maximum drug dose as suggested for full functionality of the enzyme. Heterozygous patients were found to have an intermediate drug dose and the patients with a variant homozygous genotype had the minimum maintenance drug dose requirement. These findings are in concurrence with the effect of the promoter polymorphism on vitamin K epoxide reductase activity.1639G>A minor allele frequency in the study population (n = 50) was found to be 22%. The patients with a wild type genotype required the maximum drug dose as suggested for full functionality of the enzyme. Heterozygous patients were found to have an intermediate drug dose and the patients with a variant homozygous genotype had the minimum maintenance drug dose requirement. These findings are in concurrence with the effect of the promoter polymorphism on vitamin K epoxide reductase activity.

CONCLUSION

The VKORC1-1639 G>A status can be indicative of establishing the therapeutic dose of oral anticoagulants in Indian patients.

Essential thrombocythemia in a young man treated for myocardial infarction

Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm which can cause thrombohaemorrhagic complications usually involving microvasculature. Medium-sized arterial thrombosis has been reported, but coronary occlusion usually occurs with additional risk factors, for example, smoking, hyperlipidaemia and so on. We present a case of acute myocardial infarction (AMI) in a young man (29 years) with ET but without any coronary artery associated risk factors. He was successfully treated for his AMI and ET with cytoreductive treatment and has recovered well. Due to automated platelet counting, ET is being increasingly identified; early detection can prevent long-term complications, and patients can have normal life span.

Evaluation of Essential Oils and Their Components for Broad-Spectrum Antifungal Activity and Control of Late Leaf Spot and Crown Rot Diseases in Peanut

Clove oil, cinnamon oil, and five essential oil components (citral, eugenol, geraniol, limonene, and linalool) were tested for growth inhibition of 14 phytopathogenic fungi. Citral completely inhibited the growth of Alternaria alternata, Aspergillus flavus, Curvularia lunata, Fusarium moniliforme, F. pallidoroseum, and Phoma sorghina in paper disc agar diffusion assays. Cinnamon oil, citral, and clove oil as low as 0.01% (vol/vol) inhibited the spore germination of Cercospora arachidicola, Phaeoisariopsis personata, and Puccinia arachidis by >90% in vitro. Limonene and linalool were observed to be the least antifungal against the test fungi and were not used in further studies. Clove oil (1% vol/vol) applied as a foliar spray 10 min before Phaeoisariopsis personata inoculation reduced the severity of late leaf spot of peanut up to 58% when challenge inoculated with 10⁴ conidia ml^-1. This treatment was more effective (P = 0.01) than 0.5% (vol/vol) citral, cinnamon oil, or clove oil and 1% (vol/vol) eugenol or geraniol. Seed treatment with the test compounds had no effect on the incidence of crown rot in peanut in Aspergillus niger-infested soil. However, soil amendment with 0.25% (vol/wt) clove oil and cinnamon oil reduced the preemergence rotting by 71 and 67% and postemergence wilting by 58 and 55%, respectively, compared with the nontreated control. These two treatments were more effective (P < 0.01) than geraniol on preemergence rotting, and more effective than citral, eugenol, and geraniol on postemergence wilting. All treatments significantly outperformed the nontreated control but none were as effective as thiram treatment.

Chitin-supplemented foliar application of chitinolytic Bacillus cereus reduces severity of Botrytis gray mold disease in chickpea under controlled conditions

AIM

To identify and evaluate chitinolytic bacteria for control of Botrytis gray mold (BGM), a devastating disease in chickpea.

METHODS AND RESULTS

Two antifungal bacterial isolates, chitinolytic Bacillus cereus CRS 7 and nonchitinolytic Pseudomonas fluorescens CRS 31, from the rhizosphere of chickpea, were applied as a prophylactic foliar spray and evaluated for control of BGM. In a controlled environment, the two isolates reduced the severity of BGM on the susceptible cv. JG 62 to 6.0 and 5.6, respectively, compared with 9.0 in the control, measured on a 1-9 rating scale. Supplementation of the foliar application of CRS 7 with 0.5% and 1.0% colloidal chitin reduced BGM severity to 4.4 and 4.1 respectively, while chitin-supplemented application of CRS 31 was similar to CRS 31 applied alone. Partially purified 47-kDa chitinase from the cell-free culture filtrate of CRS 7 at 20 and 40 mug protein ml(-1) (enzyme activity 3.1 units ml(-1)) inhibited the germination and lysed the conidia of Botrytis cinerea, and as a prophylactic foliar spray reduced BGM severity to 5.4 and 4.8, respectively.

CONCLUSION

Chitin supplementation improved the biocontrol of the foliar disease BGM by chitinolytic bacterium. Disease control with partially purified chitinase of CRS 7 supported the major role of chitinolysis in improved control of BGM.

SIGNIFICANCE AND IMPACT OF THE STUDY

Enhanced control of BGM by chitin-supplemented application of CRS 7 is of significant in view of the frequent inconsistency in biocontrol of foliar diseases. This study supports further attempts on chitinolysis-based biocontrol methods for foliar disease biocontrol.

Identification of Sources of Multiple Disease Resistance in Mini-core Collection of Chickpea

Host plant resistance is the major component in the management of fungal diseases in chickpea (Cicer arietinum). We screened a chickpea mini-core collection composed of 211 germ plasm accessions representing the diversity of the global chickpea germ plasm collection of 16,991, maintained at the International Crops Research Institute for the Semi-Arid Tropics to identify sources of multiple disease resistance. The accessions were screened for resistance against As-cochyta blight (Ascochyta rabiei), Botrytis gray mold (Botrytis cinerea), Fusarium wilt (Fusarium oxysporum f. sp. ciceris), and dry root rot (Rhizoctonia bataticola) under a controlled environment. High levels of resistance were observed to Fusarium wilt (FW), where 21 accessions were asymptomatic and 25 resistant. In all, 3, 55, and 6 accessions were moderately resistant to Ascochyta blight (AB), Botrytis gray mold (BGM), and dry root rot (DRR) respectively. ICC 11284 was the only accession moderately resistant to both AB and BGM. Combined resistance also was identified for DRR and FW in 4 accessions, and for BGM and FW in 11 accessions. Through this study, chickpea germ plasm accessions were identified that possess high levels of resistance to more than one fungal disease and would be useful in chickpea multiple disease resistance breeding programs.

Survival rates in dysvascular lower limb amputees

BACKGROUND

To assess the 5-year and 10-year survival rates of major (above ankle disarticulation level) dysvascular lower limb amputees attending a sub-regional Disablement Services Centre (DSC) specialising in amputee rehabilitation. Also to investigate the association between survival rates, cause of dysvascularity, level of amputation, smoking status and occupational status.

SETTING

The study was undertaken in sub-regional DSC for amputee rehabilitation covering a base population of about 3.5million people. Over 80% of lower limb amputations were done for dysvascularity (peripheral vascular disease, diabetic or combination). All these patients were followed up in the DSC for their prosthetic/amputee rehabilitation. Modular case records of 201 consecutive patients from 1994 to 1995 who had diagnosis of dysvascularity as the cause of major lower limb amputations, were scrutinised regarding their 10-year survival; demographic details, level of lower limb amputations, Above Knee (AK=Transfemoral), Below Knee (BK=Transtibial), smoking status, occupational status, healing of the stump at first assessment, cause of amputation and association of these factors with survival rates.

RESULTS

Of 201 individuals with either AK or BK amputations, 60% (121) had AK amputations and 67% (134) were males, the mean age was 69years of age. Sixty-seven percent (97) had history of smoking, either current 43% (62) or prior 24% (35) smoking, and 59% (68) were skilled or non-skilled manual workers. Fifty-one percent (99) had diagnosis of peripheral vascular disease, whilst 34% (65) had combination of peripheral vascular disease and diabetes, diabetes on its own in 4% (7). In 12% (23) other causes were noted such as embolism, acute ischaemia, venous ulcers, etc. Regarding stumps healing at first assessment, healing was noted in 54% (109) whilst stump was unhealed in 46% (92). The median survival was 48months. Using Cox proportional hazards regression to identify association with survival, the hazard ratio (HR) was significant regarding level of amputation: HR 2.34; 95% confidence interval (CI) (1.58, 3.47), P<0.001 (a recent BK amputation increases the risk by 2.3 compared to a recent AK amputation in diabetic cohort and also in the peripheral vascular disease/diabetes cohort). Hazard ratio was less than 1.0 in bilateral amputees: HR 0.35, 95% CI (0.21, 0.60), P<0.001 (bilateral amputation decreases risk by 0.35).

CONCLUSION

Our study indicates that the median survival remains at 4years, which is similar to the previously published evidence in the Finish study of 1998 and the earlier study from Scotland in 1992. Unlike the previous data, our study indicates that patients with BK amputations have a higher hazard ratio than the AK amputees, and an association with diabetes has poorer prognosis regarding survival.

Botrytis grey mould of chickpea: a review of biology, epidemiology, and disease management

Botrytis grey mould (BGM), caused by Botrytis cinerea Pers. ex. Fr., is an economically important disease of chickpea (Cicer arietinum L.), especially in areas where cool, cloudy, and humid weather persists. Several epidemics of BGM causing complete crop loss in the major chickpea-producing countries have been reported. The pathogen B. cinerea mainly survives between seasons on infected crop debris and seeds. Despite extensive investigations on pathological, physiological, and molecular characteristics of B. cinerea causing grey mould type diseases on chickpea and several other hosts, the nature of infection processes and genetic basis of pathogen variability have not been clearly established. This lack of information coupled with the need for repeated application of chemical fungicides forced the deployment of host plant resistance (HPR) as a major option for BGM management. Effective and repeatable controlled-environment and field-screening techniques have been developed for identification of HPR. Of the selected portion of chickpea germplasm evaluated for BGM resistance, only few accessions belonging to both cultivated and wild Cicer spp. were tolerant to BGM, and the search for higher levels of disease resistance continues. Fungicide application based on disease predictive models is helpful in precision-based fungicide application. Integrated disease management (IDM) of BGM has proved more effective than any of the individual disease management components in large-scale, on-farm studies conducted in India, Nepal, and Bangladesh. Further information on the biology of B. cinerea and epidemiology of the disease is needed to strengthen the IDM programs. In this paper the biology of B. cinerea including its variability, epidemiology of BGM, identified sources of resistance, and other management options, and available information on biochemical and genetic basis of disease resistance have been reviewed with a mention of future research priorities.

The challenge of grandmultiparity in obstetric practice

INTRODUCTION

Traditionally grandmultiparity has been considered to be an obstetric hazard both to the mother and foetus. Compounding factors are low socioeconomic status, poor female literacy and social deprivation. In developed populations with improved and optimal obstetric services, parity per se is no longer considered a significant risk for adverse obstetric and perinatal outcome.

OBJECTIVES

To compare the obstetric and perinatal outcome between grandmultiparas and second gravidas with previous one delivery as well as analyse certain socio demographic features in the two groups.

METHODOLOGY

Case records from Maternity Hospital, Kathmandu, an inner city tertiary care centre were retrospectively studied. 106 cases of grandmultiparous patients were compared with 110 cases of second gravidas who had previously delivered once which was taken as the control group. Biosocial features as well as obstetric and perinatal outcome were analyzed.

RESULTS

Rural residents comprised 60.4% of the grandmultiparous group versus 27.7% of the control group. A predominance of early marriage as well as an older age profile was noted in the grandmultipara. ANC attendance was documented to be much lower among grandmultipara with 26.4% having absolutely no antenatal care. A higher frequency of hypertensive disorders in pregnancy, preterm birth, anaemia, malpresentations, multiple pregnancy and premature rupture of membranes, postpartum haemorrhage and retained placenta was noted in the grandmultipara which also had a slightly higher caesarean delivery rate. The salient adverse perinatal outcome was found to be intrauterine foetal death, preterm birth and neonatal sepsis.

CONCLUSION

In our set up, grandmultiparity continues to challenge our obstetric practice with its associated increased likelihood of maternal and perinatal complications. Concerted effort should be directed to reducing high parity in the community through effective family planning initiatives and specialized antepartum and intrapartum supervision of this group should be available.

B-Lynch brace suture simple surgical technique for managing post-partum haemorrhage - report of three cases

Post-partum haemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used but none has been uniformly successful. Three cases which were managed successfully with brace suture following failure of medical management for post-partum haemorrhage are being presented. The ease and usefulness of this procedure as a life saving measure, its relative safety and its capacity for preserving the uterus and thus fertility is high lighted.

Biological control of collar rot disease with broad-spectrum antifungal bacteria associated with groundnut

Bacteria associated with 6 habitats of groundnut were evaluated for their broad-spectrum antifungal activity and suppression of collar rot (Aspergillus niger) of groundnut. Three hundred and ninety-three strains were tested against 8 fungal pathogens of groundnut including 5 necrotrophic fungi, Aspergillus flavus, A. niger, Rhizoctonia bataticola, Rhizoctonia solani, and Sclerotium rolfsii, and 3 biotrophic fungi, Cercospora arachidicola, Phaeoisariopsis personata, and Puccinia arachidis. Pseudomonas sp. GRS 175, Pseudomonas aeruginosa GPS 21, GSE 18, GSE 19, and GSE 30, and their cell-free culture filtrates were highly antagonistic to all the test fungi. The cell-free culture filtrates of these bacteria were fungicidal and induced mycelial deformations including hyphal bulging and vacuolization in necrotrophic fungi. The cell-free culture filtrates at 10% (v/v) concentration significantly inhibited the spore germination of biotrophic fungi. In the greenhouse, P. aeruginosa GSE 18 emerged as an effective biocontrol agent of collar rot closely followed by P. aeruginosa GSE 19. The bacterium applied as a seed treatment reduced the pre-emergence rotting and postemergence wilting by > 60%. Pseudomonas aeruginosa GSE 18 effectively colonized the groundnut rhizosphere, both in native and in A. niger infested potting mixtures. Ninety-day-old peat formulation of P. aeruginosa GSE 18 had biocontrol ability comparable with the midlog-phase cells. Pseudomonas aeruginosa GSE 18, tolerant to thiram, in combination with the fungicide had an improved collar rot control. The present study was a successful attempt in selection of broad-spectrum and fungicide tolerant biocontrol agents that can be a useful component of integrated management of collar rot.

Phylloplane bacteria increase seedling emergence, growth and yield of field-grown groundnut (Arachis hypogaea L.)

AIM

To isolate and characterize groundnut-associated bacterial isolates for growth promotion of groundnut in field.

METHODS AND RESULTS

Three hundred and ninety-three groundnut-associated bacteria, representing the geocarposphere, phylloplane and rhizosphere, and endophytes were applied as seed treatment in greenhouse. Maximum increase in plant biomass (up to 26%) was observed following treatment with a rhizosphere isolate identified as Bacillus firmis GRS 123, and two phylloplane isolates Bacillus megaterium GPS 55 and Pseudomonas aeruginosa GPS 21. There was no correlation between the production of L-tryptophan-derived auxins and growth promotion by the test isolates. Actively growing cells and peat formulations of GRS 123 and GPS 55, and actively growing cells of GPS 21, significantly increased the plant growth and pod yield (up to 19%) in field. Rifampicin-resistant mutants of GRS 123 and GPS 21 colonized the ecto- and endorhizospheres of groundnut, respectively, up to 100 days after sowing (DAS), whereas GPS 55 was recovered from both the habitats at 100 DAS.

CONCLUSION

Seed bacterization with phylloplane isolates promoted groundnut growth indicating the possibility of isolating rhizosphere beneficial bacteria from different habitats.

SIGNIFICANCE AND IMPACT OF THE STUDY

Identification of phylloplane bacteria as effective plant growth-promoting rhizobacteria (PGPR) broadens the spectrum of PGPR available for field application.

Comprehensive abortion care service at Kathmandu Medical College--an experience

INTRODUCTION

His Majesty's Government amended the Nepal Criminal Code (Muluki Ain)--for Liberalising abortion law in the month of Chaitra 2058 (March 2002) and Royal Assent was given on 10th Asoj 2059 (27th September 2002). Accordingly Comprehensive Abortion Care (CAC) Services was initiated in the country. Kathmandu Medical College after enlisting with Ministry of Health started this service from June 2004.

OBJECTIVE

This study was carried out to know--1. Reasons for undergoing CAC service. 2. The complications after the CAC services. 3. The various contraceptive methods adopted by the client following CAC.

METHODOLOGY

Hospital based prospective study was carried out in Department of Obstetrics & Gynaecology at KMCTH from the period July 2004 to April 2005. Total 160 patients who asked for CAC were enrolled in the study. Counselling, history taking and general examination and per vaginal examination was carried out at the visit. CAC was performed with premedication with Doxycycline 100 mg and Ibuprofen 400 mg half an hour before the procedure. Paracervical block was also given with 1% xylocaine. MVA was performed as described in standard techniques. Patient was discharged after 1-2 hours of observation and with contraception opted by the clients.

RESULTS

Main reason for performing CAC was unwanted pregnancy in 66.75%. Complication following CAC was 1.25%. Post CAC contraception was adopted by 93%. Most preferred method was Inj. Depoprovera

CONCLUSION

The reason for CAC service asked by the patients was unwanted pregnancy. CAC service performed had minimal complication and also gave the opportunity for contraception.

Ascochyta blight of chickpea (Cicer arietinum L.): a review of biology, pathogenicity, and disease management

Ascochyta blight (AB), caused by Ascochyta rabiei is a major disease of chickpea (Cicer arietinum L.), especially in areas where cool, cloudy, and humid weather persists during the crop season. Several epidemics of AB causing complete yield loss have been reported. The fungus mainly survives between seasons through infected seed and in infected crop debris. Despite extensive pathological and molecular studies, the nature and extent of pathogenic variability in A. rabiei have not been clearly established. Accumulation of phenols, phytoalexins (medicarpin and maackiain), and hydrolytic enzymes has been associated with host-plant resistance (HPR). Seed treatment and foliar application of fungicides are commonly recommended for AB management, but further information on biology and survival of A. rabiei is needed to devise more effective management strategies. Recent studies on inheritance of AB resistance indicate that several quantitative trait loci (QTLs) control resistance. In this paper we review the biology of A. rabiei, HPR, and management options, with an emphasis on future research priorities.

Pattern of dermatoses in diabetics

Two hundred diabetics comprising of 125 males and 75 females were studied for the presence of cutaneous lesions and type of infective organism, if any, in them. 70.2% of patients with uncontrolled diabetes mellitus showed some form of cutaneous involvement while only 51% of the patients with controlled diabetes had it. Infections with bacterial (16%) and fungal (10.5%) agents were the most common manifestation. Among bacterial infections, Staph. aureus was the most frequent causative agent in 65.6% cases. Pruritus was present in 4.5% of cases only.

Successful perinatal management of hydrops fetalis due to hemolytic disease associated with D-- maternal phenotype

We report the successful management of a case of hemolytic disease and hydrops fetalis secondary to anti Rh 17 antibodies in a woman with the rare D-- phenotype. We discuss the efficacy of intravenous immunoglobulins in treating hemolytic disease of the newborn infant.

Do triglycerides modulate the effectiveness of clozapine?

We describe a case in which a patient's clinical response to clozapine appears to correlate positively with his serum triglyceride concentrations. We propose that the observed clinical response may partly be the result of the physical interaction of clozapine with the very low-density lipoproteins. We base this supposition on our previous in-vitro study showing that the plasma distribution of clozapine is significantly altered by increases in plasma triglyceride concentrations. Although this case only represents one patient, it highlights the possibility that serum lipids may be potential contributors to the clinical effectiveness of clozapine.

The osseofasciocutaneous flap: a new method to transfer fibula along with a sufficient amount of skin

We describe a new technique of bone transfer, using a deep fascial blood supply to transfer bone together with a large area of skin. The viability of this flap and further confirmation by isotope scanning have established that the bone transfer is vascularised. This provides a simple solution to the complex problem of leg trauma with massive skin and bone loss.

Resistance of Wild Arachis Species to Late Leaf Spot and Rust in Greenhouse Trials

Seventy-four accessions of wild Arachis species along with a susceptible line TMV 2 belonging to A. hypogaea were evaluated for resistance to late leaf spot and rust under greenhouse environment. The experiment was conducted twice to confirm the resistance of the accessions. Percentage of leaf area damaged and disease score on a 1 to 9 scale for late leaf spot and rust were recorded for all accessions in both experiments. Additionally, percentage of defoliation was recorded for late leaf spot. One accession, ICG 8190, of A. hoehnei and one accession, ICG 13199, of A. duranensis were asymptomatic to late leaf spot in both experiments. In addition, 26 accessions were classified as resistant, 10 accessions were moderately resistant, and the remaining 36 accessions exhibited a susceptible reaction to late leaf spot. Only one accession, ICG 8954 of A. kuhlmannii, remained asymptomatic to rust in both experiments. All other accessions, except ICG 8206 of A. ipaensis, ICG 8197, ICG 8198, ICG 11549, and ICG 13178 of A. monticola, and ICG 13171 of A. stenosperma were classified as highly resistant to rust. Four accessions of A. monticola were susceptible to late leaf spot and rust.