Landscape of genetic infantile epileptic spasms syndrome-A multicenter cohort of 124 children from India

OBJECTIVE

Literature on the genotypic spectrum of Infantile Epileptic Spasms Syndrome (IESS) in children is scarce in developing countries. This multicentre collaboration evaluated the genotypic and phenotypic landscape of genetic IESS in Indian children.

METHODS

Between January 2021 and June 2022, this cross-sectional study was conducted at six centers in India. Children with genetically confirmed IESS, without definite structural-genetic and structural-metabolic etiology, were recruited and underwent detailed in-person assessment for phenotypic characterization. The multicentric data on the genotypic and phenotypic characteristics of genetic IESS were collated and analyzed.

RESULTS

Of 124 probands (60% boys, history of consanguinity in 15%) with genetic IESS, 105 had single gene disorders (104 nuclear and one mitochondrial), including one with concurrent triple repeat disorder (fragile X syndrome), and 19 had chromosomal disorders. Of 105 single gene disorders, 51 individual genes (92 variants including 25 novel) were identified. Nearly 85% of children with monogenic nuclear disorders had autosomal inheritance (dominant-55.2%, recessive-14.2%), while the rest had X-linked inheritance. Underlying chromosomal disorders included trisomy 21 (n = 14), Xq28 duplication (n = 2), and others (n = 3). Trisomy 21 (n = 14), ALDH7A1 (n = 10), SCN2A (n = 7), CDKL5 (n = 6), ALG13 (n = 5), KCNQ2 (n = 4), STXBP1 (n = 4), SCN1A (n = 4), NTRK2 (n = 4), and WWOX (n = 4) were the dominant single gene causes of genetic IESS. The median age at the onset of epileptic spasms (ES) and establishment of genetic diagnosis was 5 and 12 months, respectively. Pre-existing developmental delay (94.3%), early age at onset of ES (<6 months; 86.2%), central hypotonia (81.4%), facial dysmorphism (70.1%), microcephaly (77.4%), movement disorders (45.9%) and autistic features (42.7%) were remarkable clinical findings. Seizures other than epileptic spasms were observed in 83 children (66.9%). Pre-existing epilepsy syndrome was identified in 21 (16.9%). Nearly 60% had an initial response to hormonal therapy.

SIGNIFICANCE

Our study highlights a heterogenous genetic landscape and phenotypic pleiotropy in children with genetic IESS.

S100PBP is regulated by mutated KRAS and plays a tumour suppressor role in pancreatic cancer

We have previously shown that expression of S100PBP, an S100P binding partner, gradually decreases during progression of pancreatic ductal adenocarcinomas (PDAC). Here, we show that loss of S100PBP leads to oncogenic transformation of pancreatic cells; after deregulation of S100PBP expression, both in silico and in vitro analyses highlighted alterations of genes known to modulate cytoskeleton, cell motility and survival. Overexpression of S100P reduced S100PBP expression, while co-immunoprecipitation indicated the interaction of S100P with S100PBP-p53-ubiquitin protein complex, likely causing S100PBP degradation. The doxycycline-induced KrasG12D activation resulted in decreased S100PBP levels, while low-dose treatment with HDAC inhibitor MS-275 rescued its expression in both human and mouse PDAC cell lines. This indicates KrasG12D as an upstream epigenetic regulator of S100PBP. Finally, analysis of TCGA PanCancer Atlas PDAC datasets demonstrated poor prognosis in patients with high S100P and low S100PBP expression, suggesting that S100PBP is a novel tumour suppressor gene with potential clinical utility.

In situ spatiotemporal characterization and analysis of chemical reactions using an ATR-integrated microfluidic reactor

Determining kinetic reaction parameters with great detail has been of utmost importance in the field of chemical reaction engineering. However, commonly used experimental and computational methods however are unable to provide sufficiently resolved spatiotemporal information that can aid in the process of understanding these chemical reactions. With our work, we demonstrate the use of a custom designed single-bounce ATR-integrated microfluidic reactor to obtain spatiotemporal resolution for in situ monitoring of chemical reactions. Having a single-bounce ATR accessory allows us to individually address different sensing areas, thereby providing the ability to obtain spatially and temporally resolved information. To further enhance the spatial resolution, we utilize the benefits of synchrotron IR radiation with the smallest beam spot-size ∼150 μm. An on-flow modular microreactor additionally allows us to monitor the chemical reaction in situ, where the temporal characterization can be controlled with the operational flowrate. With a unique combination of experimental measurements and numerical simulations, we characterize and analyse a model SN2 reaction. For a chemical reaction between benzyl bromide (BB) and sodium azide (SA) to produce benzyl azide (BA), we successfully show the capability of our device to determine the diffusion coefficients of BB and SA as 0.367 ± 0.115 10-9 m2 s-1 and 1.17 ± 0.723 10-9 m2 s-1, respectively. Finally, with the above characteristics of our device, we also calculate a reaction rate of k = 0.0005 (m3s-1mol-1) for the given chemical reaction.

Melatonin and Triclofos Sodium to Execute Sleep Electroencephalography in Pediatric Patients: A Cost-Effectiveness Analysis Alongside a Randomized Controlled Trial

OBJECTIVES

To evaluate cost-effectiveness between oral sedatives melatonin and triclofos sodium used to perform sleep electroencephalography (EEG) in pediatric patients and develop a criterion for resource allocation by the institution.

METHODS

This prospective study was conducted alongside the randomized controlled trial conducted at a tertiary care hospital, wherein pediatric patients arriving for sleep EEG were randomized to receive melatonin dosed at 0.3 mg/kg (< 10 kg), 3 mg (10-15 kg), and 6 mg (> 15 kg) and triclofos at 50 mg/kg (maximum dose 1 g, 6 mo to 11 y; 2 g, 11 to 18 y) after due consent. The cost-effectiveness analysis was performed from the healthcare institution's perspective. Successful EEG and abnormal EEG were the effectiveness parameters.

RESULTS

Two hundred twenty-eight patients were divided equally between two groups. Melatonin (N = 114) and triclofos (N = 114) recorded successful EEG in 89.4% and 91.2% patients and abnormal EEG in 49% and 42.3% patients, respectively (p > 0.05). The total direct cost incurred was INR 1881.75 (USD 26.6) and INR 2772.5 (USD 39.2) for melatonin and triclofos, respectively (p < 0.05). The cost-effectiveness ratio-1 (CER-1) for melatonin and triclofos per successful EEG recorded was INR 18.45 (USD 0.39) and INR 26.66 (USD 0.58), respectively. The CER-2 for melatonin and triclofos per abnormal EEG detected was INR 37.64 (USD 0.53) and INR 63.01 (USD 0.89), respectively.

CONCLUSIONS

Melatonin is more cost-effective than triclofos when charged based on individual dose requirements. Hospitals, diagnostic centers, healthcare institutions may consider resource-utilization-based costing system for cost-effective allocation of resources.

Compliance with status epilepticus management protocol and effect on clinical outcomes in children with status epilepticus

BACKGROUND

Guidelines for the management of status epilepticus (SE) aid in rationalising the treatment for a better clinical outcome; however, published literature regarding the use of antiepileptics and compliance is limited, even after the availability of a consensus guideline.

OBJECTIVES

To evaluate the use of antiepileptics in children with SE and to analyse the effect of compliance with the Status Epilepticus Management Protocol on clinical outcomes.

METHODS

An open-label non-randomised prospective observational study was conducted in children with SE aged 1 month to 14 years for 8 months in a tertiary care teaching hospital. The recommended antiepileptics, sequence of drug administration and time frames of management offered to paediatric patients were assessed for compliance with the Status Epilepticus Management Protocol adopted in our hospital. Comparison of clinical outcomes (hospital stay, intubation, refractory and super-refractory SE, duration of SE cessation, functional motor deficits and cognitive decline) between compliant and non-compliant patients was assessed.

RESULTS

A total of 40 patients were included in the study, of which 28 (70%) were boys. All the patients received midazolam nasal spray in the triage area. Only 18% of the patients received rescue benzodiazepine (BZD) antiepileptic drug (AED) therapy in pre-hospital settings. Median time (p25-p75) of administration of first-line AED (BZD) and second-line AED (non-BZD) was 11 (8-15) min and 30 (22-35) min, respectively. Administration of continuous infusion (IV midazolam) was delayed at 57 (45-69) min. Compliance with the Status Epilepticus Management Protocol was seen in 24 (60%) patients. Non-compliance with the treatment protocol in relation to the time frame significantly prolonged the length of hospital stay (9 vs 4 days, p=0.0008) and SE duration from first assessment (115 vs 50 min; p=0.005). At discharge, the proportion of patients returning to their functional baseline was significantly different in the compliant and non-compliant patient groups (79% vs 44%). There were no deaths.

CONCLUSION

Rescue therapy in the pre-hospital setting needs attention. There was full compliance with the Status Epilepticus Management Protocol for choice of AED and sequence of AED therapy. Non-compliance in treatment management within time frames significantly affected the length of hospital stay, duration of SE and clinical outcome.

Clinical Profile and Treatment Outcomes of Hypermanganesemia with Dystonia 1 and 2 among 27 Indian Children

Background

Hypermanganesemia with dystonia 1 and 2 (HMNDYT1 and 2) are rare, inherited disorders of manganese transport.

Objectives

We aimed to describe clinical, laboratory features, and outcomes among children with HMNDYT.

Methods

We conducted a retrospective multicenter study involving tertiary centers across India. We enrolled children between 1 month to 18 years of age with genetically confirmed/clinically probable HMNDYT. Clinical, laboratory profile, genetic testing, treatment details, and outcomes scored by treating physicians on a Likert scale were recorded.

Results

We enrolled 27 children (19 girls). Fourteen harbored SLC30A10 mutations; nine had SLC39A14 mutations. The SLC39A14 cohort had lower median age at onset (1.3 [interquartile range (IQR), 0.7-5.5] years) versus SLC30A10 cohort (2.0 [IQR, 1.5-5.1] years). The most frequent neurological features were dystonia (100%; n = 27), gait abnormality (77.7%; n = 21), falls (66.7%; n = 18), and parkinsonism (59.3%; n = 16). Median serum manganese (Mn) levels among SLC39A14 (44.9 [IQR, 27.3-147.7] mcg/L) cohort were higher than SLC30A10 (29.4 [17.1-42.0] mcg/L); median hemoglobin was higher in SLC30A10 (16.3 [IQR, 15.2-17.5] g/dL) versus SLC39A14 cohort (12.5 [8.8-13.2] g/dL). Hepatic involvement and polycythaemia were observed exclusively in SLC30A10 variants. A total of 26/27 children underwent chelation with disodium calcium edetate. Nine demonstrated some improvement, three stabilized, two had marked improvement, and one had normalization. Children with SLC39A14 mutations had poorer response. Two children died and nine were lost to follow-up.

Conclusions

We found female predominance. Children with SLC39A14 mutations presented at younger age and responded less favorably to chelation compared to SLC30A10 mutations. There is emerging need to better define management strategies, especially in low resource settings.

Clinical and Electrophysiological Factors Predicting Prolonged Recovery in Children with Guillain-Barré Syndrome

OBJECTIVE

To compare clinical and nerve conduction studies (NCS) parameters predictive of outcome in children with acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN).

METHODS

In this prospective observational study, NCS was done on all children at admission and repeated before discharge. Functional status of patients was graded as per Hughes Disability score. These children were followed up till they achieved independent walking. Clinical and NCS criteria were compared between (a) AMAN and AIDP and (b) two subgroups of children with AMAN-those who achieved early (within 60 d) versus delayed (i.e., after 60 d) walking.

RESULTS

Fifty-seven children were initially enrolled, first NCS showed inexcitable nerves in 10, AMAN in 29, acute motor-sensory axonal neuropathy (AMSAN) in 3, AIDP in 13, and 2 were normal. Subsequent NCS showed AMAN in 37, AIDP in 15, AMSAN in 3 patients. There were no deaths, 16 required ventilation. Follow-up till independent walking, was available for 40 patients. AMAN was associated with faster progression, greater peak disability, prolonged hospital stay, and delayed walking (p < 0.05). Asymmetrical nerve involvement predicted prolonged hospital stay as well as delayed walking. In the AMAN group, prolonged ulnar F-wave latencies were significantly associated with delayed walking (p = 0.02).

CONCLUSION

Long term prognosis of pediatric GBS is generally satisfactory. AMAN, asymmetric involvement and prolonged ulnar F-wave latencies in children with AMAN were associated with delayed walking.

Time Elapsed from Onset of Pediatric Convulsive Status Epilepticus to Antiepileptic Administration-An Experience of Single Institute

Data regarding time elapsed from the onset of pediatric convulsive status epilepticus (CSE) to antiepileptic (AED) administration remains scarce after the adoption of standard treatment-guidelines in Indian healthcare settings. A prospective observational analysis was performed on 52 children presenting to an urban, academic tertiary care teaching hospital diagnosed with CSE and evolving to refractory CSE (RCSE). Time frames of AED administration were compared to the adopted 'Status Epilepticus Management Protocol'. Fifty-two patients [36 (69.2%) male] were enrolled, with a median age of 4.1 y. After CSE onset, the median (p25-p75) time until the administration of the first-line, second-line, and third-line therapy phases of AED doses were 30 (25-37) min, 68 (48-79) min, and 105 (100-135) min, respectively. The second dose of non-BZD AED was administered at a median (p25-p75) of 90 (71-95) min. Twenty-six (50%) patients received at least one continuous infusion. The time elapsed from CSE onset to AED administration and escalation from one class to another was delayed.

Transfusion support for a woman with RHD*09.01.02 and the novel RHD*01W.161 allele in trans

According to recent work group recommendations, individuals with the serologic weak D phenotypes should be RHD genotyped and individuals with molecular weak D types 1, 2, 3, 4.0, or 4.1 should be treated as D+. We report an African American woman with a long-standing history of metrorrhagia, who presented for infertility evaluation. Blood grouping showed AB with a possible subgroup of A, based on mixed-field agglutination, and a serologic weak D phenotype. Results from routine red cell genotyping for the RHD gene was incongruent with the serologic RhCE phenotype. For the surgical procedure, the patient was hence scheduled to receive group AB, D- RBC transfusions. Subsequent molecular analysis identified the ABO*A2.01 and ABO*B.01 alleles for the ABO genotype and the novel RHD allele [NG_007494.1(RHD):c.611T>A] along with an RHD*09.01.02 allele for the RHD genotype. Using a panel of monoclonal anti-D reagents, we showed the novel RHD(I204K) allele to represent a serologic weak D phenotype, despite occurring as a compound heterozygote, designated RHD*weak D type 161 (RHD*01W.161). Individuals with a weak D type 4.2 allele are prone to anti-D immunization, while the immunization potential of novel RHD alleles is difficult to predict. For now, patients should be treated as D- in transfusion and pregnancy management, when they harbor a novel RHD allele along with any weak D allele other than weak D types 1, 2, 3, 4.0, or 4.1. This study exemplifies strategies for how and when a laboratory should proceed from routine genotyping to nucleotide sequencing before any decisions on transfusion practice is made.

Efficacy and tolerability of Melatonin vs Triclofos to achieve sleep for pediatric electroencephalography: A single blinded randomized controlled trial

PURPOSE

To compare Melatonin with Triclofos for efficacy (proportion of successful EEG, need of augmentation, sleep onset latency (SOL), yield of discharges, duration of sleep, presence and grade of artifacts) and tolerability (adverse effect profile).

METHODS

A randomized trial was performed (block randomization). All children were advised regarding sleep deprivation, EEG technician administered the drug. EEG was labelled successful if at least 30 min of record could be obtained (sleep with or without awake state). Pediatric neurologist reported the EEG findings-sleep onset latency, epileptiform abnormalities and graded the artifacts (excess beta activity and movement artifacts if present). The parents were interviewed telephonically next day by a pediatric resident for any adverse effects. The parents, pediatric neurologist and pediatric resident were blinded for the drug given.

RESULTS

228 children were randomized (114 each received Melatonin and Triclofos). Both the groups were comparable at baseline for age group and demographic data. The proportion of successful EEG was 89.4% in Melatonin and 91.2% in Triclofos. First dose was effective in 64% in Melatonin and 63.15% in Triclofos group. Augmentation dose was needed in 25.4% in Melatonin and 28% in Triclofos group. Mean total sleep duration was 80 min after Melatonin and 82.39 after Triclofos administration. Adverse effects were observed in 6.14% of Melatonin and 8.65% of Triclofos group. None of the results were statistically significant.

CONCLUSION

There was no significant difference between efficacy and tolerability of Melatonin and Triclofos. Melatonin can be safely used to achieve sleep for EEG in children.

Significant treatment gap and co-morbidities identified in an epidemiological survey of pediatric epilepsy in rural suburbs of India

PURPOSE

A cross-sectional epidemiological survey of children was conducted in two rural clusters to estimate the point prevalence and study various aspects of childhood epilepsy.

MATERIAL AND METHODS

In the first stage, a house-to-house survey was conducted by health workers using a screening questionnaire, which was pre-validated in a pilot study. All screen positive houses were visited by pediatric neurologist for detailed evaluation. Children with a clinical diagnosis of epilepsy underwent EEG and were evaluated for type of seizure, epilepsy syndrome, etiology, co-morbidities and treatment gap. Knowledge, attitude and practice regarding epilepsy was assessed amongst caregivers of the affected children.

RESULTS

A total population of 75,455 population was screened, 19,181 children aged 2 months to 18 years were identified. Out of 355 screen positive children, 66 were diagnosed with epilepsy. The point prevalence of pediatric epilepsy was 3.44 per 1000 children. 53% had focal epilepsy, 31.8% had an identifiable epilepsy syndrome, 44% had at least one comorbidity. The etiology was identified in 68%, the commonest being perinatal brain insult. The magnitude of treatment gap was 45.45%, with significant deficits in knowledge.

CONCLUSION

There are significant deficits in diagnosis and treatment of pediatric epilepsy among the rural population of India. The existing rural health care facilities need to be augmented to facilitate the timely diagnosis and optimum care of these children, including care of associated co-morbidities.

First-episode psychosis: How long does it last? A review of evolution and trajectory

Study of first-episode psychosis (FEP), an episode of psychotic nature which manifests for the first time in an individual in the longitudinal continuum of his/her illness, has been study matter of research interest in recent years. A comprehensive review of the literature will help us understand the evolution and trajectory of this concept better. A literature review of available articles addressing the concept, phenomenology, evolution, identification, course, and outcome of FEP was done; the same was subsequently divided into broad topics for better clarity and analyzed. FEP constituted a clinical psychotic phenomenon with underlying significant heterogeneity in diagnosis, stability, course, and outcome. The study has attempted to view FEP both as horizontal spectrum across various diagnoses and longitudinally ranging from asymptomatic individual with unknown risk status to attenuated psychosis to multiple relapses/unremitting illness. Many risk and protective factors have been brought out with varying certainty ranging bio-psycho-social spectrum. Efforts have been made to calculate polygenic risk score based on genes involvement/sharing between various psychotic spectrum disorders; as well as biomarker panels to identify people at risk. FEP may prove to be an important concept to understand psychosis in general; without putting things into the diagnostic rubric. It may help understand multiple risk and protective factors for the course and outcome of psychotic illness and may clear the cloud to sharpen the evidence toward commonality and distinctiveness between various psychotic diagnoses in vogue for more comprehensive concept.

Resurgence of Subacute Sclerosing Panencephalitis: Case Series and Global Epidemiological Trends

Resurgence of subacute sclerosing panencephalitis (SSPE)—case series and global epidemiological trends. We noted a recent increase in cases of SSPE admitted in our institute, even though they had received measles vaccination. We did a detailed study of our cases and compared with global epidemiological trends of SSPE in preimmunization and era of developed immunity. Out of total 23 cases of SSPE, 12 presented in the year 2017 alone, reflecting a steep rise in incidence. Sixteen patients had received measles vaccine and never had prior measles infection. Mean age of onset was 8.2 years and average time of progression to advanced stage of disease was 65 days. Global data showed similar trends, that is, earlier age of onset with a faster rate of progression in the postvaccination era as compared with prevaccine era. Possible mechanisms to account for this trend include an early wild measles infection in the critical age of 6 to 9 months, before vaccination. There is a changing epidemiological trend of SSPE in terms of lower age of onset and faster rate of progression, also reflected in global data. There is a need for multicenter studies to verify the findings and explore possible measures like lowering the age of measles vaccination to halt this alarming trend.

Transfusion support during childbirth for a woman with anti-U and the RHD*weak D type 4.0 allele

D- red blood cells (RBCs), always in short supply, and Rh immune globulin (RhIG) are not needed for patient care if D+ RBCs can safely be transfused. According to a recent work group recommendation, patients with the RHD*weak D type 4.0 allele can be considered D+. We report an African American woman who presented for delivery at the end of the third trimester, at which time anti-U and a serologic weak D phenotype were recognized, requiring U-, D- RBC units. We obtained 3 U- RBC units, including 1 D- unit. Later, the RHD*weak D type 4.0 allele was determined by RHD genotyping, only 6 days before delivery. The patient had an uneventful vaginal delivery of a D+ baby. No transfusion was needed for mother or baby. In this case, a pregnant woman with the RHD*weak D type 4.0 allele can safely be managed as D+, relaxing the unnecessary D- restriction for the limited U- RBC supply. The procured U-, D- RBC unit was frozen with 14 days of shelf-life remaining. To conserve D- RBC units, not limited to U-, for patients with a definite need, we recommend molecular analysis of a serologic weak D phenotype before a transfusion becomes imminent. The best time to resolve a serologic weak D phenotype with RHD genotyping is early in a pregnancy. Immunohematology 2021;37:1-4 .

D– red blood cells (RBCs), always in short supply, and Rh immune globulin (RhIG) are not needed for patient care if D+ RBCs can safely be transfused. According to a recent work group recommendation, patients with the RHD*weak D type 4.0 allele can be considered D+. We report an African American woman who presented for delivery at the end of the third trimester, at which time anti-U and a serologic weak D phenotype were recognized, requiring U–, D– RBC units. We obtained 3 U– RBC units, including 1 D– unit. Later, the RHD*weak D type 4.0 allele was determined by RHD genotyping, only 6 days before delivery. The patient had an uneventful vaginal delivery of a D+ baby. No transfusion was needed for mother or baby. In this case, a pregnant woman with the RHD*weak D type 4.0 allele can safely be managed as D+, relaxing the unnecessary D– restriction for the limited U– RBC supply. The procured U–, D– RBC unit was frozen with 14 days of shelf-life remaining. To conserve D– RBC units, not limited to U–, for patients with a definite need, we recommend molecular analysis of a serologic weak D phenotype before a transfusion becomes imminent. The best time to resolve a serologic weak D phenotype with RHD genotyping is early in a pregnancy. Immunohematology 2021;37:1–4 .

Thinking beyond infections in children with recurrent/persistent pneumonia

Children with recurrent or persistent pneumonia often have underlying chronic cardiopulmonary disease, but few reports on this subject have been published. Children with isolated common cardiac diseases, uncomplicated bronchial asthma or with incomplete records were excluded. Of 4361 children followed during a five-year period, 107 were included in our study. Underlying causes were identified in 99.0%: immunodeficiency disorders (20.2%), cardiothoracic malformations (18.3%), syndromic conditions (14.4%), infections (10.6%) bronchiectasis (10.6%), gastro-oesophageal reflux disease (6.6%), interstitial lung disease (3.8%) and other miscellaneous conditions (15.4%). Thus, children with recurrent or persistent pneumonia should be carefully evaluated for an underlying aetiology, as early diagnosis and appropriate management will decrease morbidity and mortality in most of these children.

Short-course radiotherapy with consolidation chemotherapy versus conventionally fractionated long-course chemoradiotherapy for locally advanced rectal cancer: randomized clinical trial

BACKGROUND

The trial hypothesis was that, in a resource-constrained situation, short-course radiotherapy would improve treatment compliance compared with conventional chemoradiotherapy for locally advanced rectal cancer, without compromising oncological outcomes.

METHODS

In this open-label RCT, patients with cT3, cT4 or node-positive non-metastatic rectal cancer were allocated randomly to 5 × 5 Gy radiotherapy and two cycles of XELOX (arm A) or chemoradiotherapy with concurrent capecitabine (arm B), followed by total mesorectal excision in both arms. All patients received a further six cycles of adjuvant chemotherapy with the XELOX regimen. The primary endpoint was treatment compliance, defined as the ability to complete planned treatment, including neoadjuvant radiochemotherapy, surgery, and adjuvant chemotherapy to a dose of six cycles.

RESULTS

Of 162 allocated patients, 140 were eligible for analysis: 69 in arm A and 71 in arm B. Compliance with planned treatment (primary endpoint) was greater in arm A (63 versus 41 per cent; P = 0.005). The incidence of acute toxicities of neoadjuvant therapy was similar (haematological: 28 versus 32 per cent, P = 0.533; gastrointestinal: 14 versus 21 per cent, P = 0.305; grade III-IV: 2 versus 4 per cent, P = 1.000). Delays in radiotherapy were less common in arm A (9 versus 45 per cent; P < 0.001), and overall times for completion of neoadjuvant treatment were shorter (P < 0.001). The rates of R0 resection (87 versus 90 per cent; P = 0.554), sphincter preservation (32 versus 35 per cent; P = 0.708), pathological complete response (12 versus 10 per cent; P = 0.740), and overall tumour downstaging (75 versus 75 per cent; P = 0.920) were similar. Downstaging of the primary tumour (ypT) was more common in arm A (P = 0.044). There was no difference in postoperative complications between trial arms (P = 0.838).

CONCLUSION

Reduced treatment delays and a higher rate of compliance were observed with treatment for short-course radiotherapy with consolidation chemotherapy, with no difference in early oncological surgical outcomes. In time- and resource-constrained rectal cancer units in developing countries, short-course radiotherapy should be the standard of care.

Association of Child Neurology (AOCN) - Indian Epilepsy Society (IES) Consensus Guidelines for the Diagnosis and Management of West Syndrome

JUSTIFICATION

West syndrome is one of the commonest causes of epilepsy in infants and young children and is a significant contributor to neurodevelopmental morbidity. Multiple regimens for treatment are in use.

PROCESS

An expert group consisting of pediatric neurologists and epileptologists was constituted. Experts were divided into focus groups and had interacted on telephone and e-mail regarding their group recommendations, and developed a consensus. The evidence was reviewed, and for areas where the evidence was not certain, the Delphi consensus method was adopted. The final guidelines were circulated to all experts for approval.

RECOMMENDATIONS

Diagnosis should be based on clinical recognition (history/home video recordings) of spasms and presence of hypsarrhythmia or its variants on electroencephalography. A magnetic resonance imaging of the brain is the preferred neuroimaging modality. Other investigations such as genetic and metabolic testing should be planned as per clinico-radiological findings. Hormonal therapy (adrenocorticotropic hormone or oral steroids) should be preferred for cases other than tuberous sclerosis complex and vigabatrin should be the first choice for tuberous sclerosis complex. Both ACTH and high dose prednisolone have reasonably similar efficacy and adverse effect profile for West syndrome. The choice depends on the preference of the treating physician and the family, based on factors of cost, availability of infrastructure and personnel for daily intramuscular injections, and monitoring side effects. Second line treatment options include anti-epileptic drugs (vigabatrin, sodium valproate, topiramate, zonisamide, nitrazepam and clobazam), ketogenic diet and epilepsy surgery.

Adult attention-deficit Hyperactivity disorder: From clinical reality toward conceptual clarity

There is ambiguity about the clinical picture and concept of attention-deficit hyperactivity disorder (ADHD) in adults. Relevant literature was extracted from various search engines, analyzed, and interpreted. Available literature suggests a significant prevalence of ADHD in the adult population affecting the quality of socio-occupational functioning. Inattentiveness was more commonly present than hyperactivity-impulsivity. Frequent comorbidities with other psychiatric disorders like anxiety disorders and substance use disorders were noted. Pharmacological management and psychotherapy have been found effective in its management. ADHD is a disorder across the lifespan and fairly prevalent among adults. Greater awareness and more research are required for a better understanding of Adult ADHD and its effective management.

Circulating miR-133b and miR-21: potential non-invasive diagnostic biomarkers of coronary artery disease

Background

While coronary artery disease (CAD) has become a major threat worldwide, the timely biomarker-based early diagnosis of CAD remains a major unmet clinical challenge.

Purpose

We aimed towards assessing the level of circulatory microRNAs as candidates of novel biomarkers in early diagnosis of CAD.

Methods

A total of 147 subjects were recruited from Delhi and surrounding regions which includes 78 subjects with angiographically proven CAD, 15 pre-atherosclerotic normal coronary artery (NCA) subjects and 54 healthy individuals. Quantitative real-time PCR assays were performed using total RNA isolated from plasma of CAD patients and healthy individuals in order to measure the relative expression profiles of circulating miR-133b and miR-21. The severity level of the disease in each individual was assessed on the basis of number of diseased vessels involved and extent of stenosis.

Results

MiR-133b was found to be significantly downregulated (p&lt;0.05) by 4.6 fold whereas miR-21 was significantly upregulated (p&lt;0.05) by ∼2 fold in plasma samples of CAD patients as compared to healthy individuals. Importantly, both the miRNAs showed an association with disease severity as miR-133b was downregulated by 8.45 fold in acute coronary syndrome (ACS), 3.38 fold in Stable angina (SA) and 2.08 fold in NCA. MiR-21 was upregulated by 2.46 fold in ACS, 1.90 fold in SA and 1.12 fold in NCA. Moreover, miR-133b could significantly differentiate subjects with ST-elevation myocardial infarction (STEMI) from Non-STEMI. Both the miRNAs exhibited a noteworthy diagnostic potential as translated through an upstanding sensitivity and specificity. MiR-133b showed an area under the curve (AUC): 0.80 with 75.6% sensitivity and 76% specificity at recommended optimal cut-off point of 14.0 whereas, miR-21 showed and AUC value of 0.79 with 72.2% sensitivity and 69.4% specificity at optimal cut-off point of 5.59 as assessed by receiver operating characteristics (ROC) curve analysis.

Conclusions

The reduced expression of miR-133b and elevated expression level of miR-21 in plasma suggest their significant role in the pathophysiology as well as their implication towards the individual's susceptibility in developing CAD. Thus, we conclude that these two circulating miRNAs could be possible candidates of non-invasive biomarkers in the early prediction and diagnosis of CAD.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Department of Science and Technology, New Delhi, India; University Grant Commission (JRF/SRF Fellowship: Ref no. 22/12/2013(ii)EU-V

Role of various lifestyle and behavioral strategies in positive mental health across a preventive to therapeutic continuum

There is growing interest in lifestyle and behavioral strategies not only in prevention but also in the management of psychiatric morbidity. Available literature in this direction was accessed, and the role of various lifestyle and behavioral factors was explored. There is strong evidence of the role of good sleep, nutritious diet, exercise, social connectedness, enhanced self-esteem, sense of purpose in life, resilience, mindfulness, and environmental mastery in the promotion of mental well-being and prevention and management of psychiatric disorders. There is a significant scope of lifestyle and behavioral intervention in ensuring positive mental health spanning from preventive to therapeutic dimension.

Workplace based assessment: A review of available tools and their relevance

Workplace-based assessment (WPBA) appears to be a promising tool for more comprehensive assessment of the learners. Relevant literature in this direction was collated and analyzed for its relevance, salience, and merit. Many WPBA tools are being used by various educational institutions which spans across multiple domains and over the entire duration of the workplace learning. It caters to holistic assessment with structured measures, real-time feedback, and continuous professional development. It is being used more for formative assessment and has limited utility in summative assessment as on date. WPBA tools have promising prospect in bringing novelty, objectivity, and holistic approach in assessment.

Efficacy, Tolerability and Serum Phenytoin Levels after Intravenous Fosphenytoin Loading Dose in Children with Status Epilepticus

OBJECTIVE

To evaluate the efficacy and tolerability of intravenous fosphenytoin in children with status epilepticus, and resulting serum total phenytoin levels.

METHODS

In this prospective study, 51 children aged less than 18 years received intravenous loading dose of fosphenytoin (18-20 mg/kg). Serum total phenytoin levels were estimated at 90 -100 minutes. Outcomes studied were (i) seizure control and local and/or systemic adverse effects in next 24 hours and (ii) phenytoin levels and its correlation with dose received, seizure control and adverse effects.

RESULTS

The actual dose of fosphenytoin received varied from 15.1 to 25 mg/kg. Seizures were controlled in 45 (88%) children and, two required additional dose of 10 mg/kg. None of the children showed any local or systemic adverse effects. Serum total phenytoin levels were in the therapeutic range (10-20 µg/mL) in 12 (23.5%), sub-therapeutic in 16 (31.3%) and supra-therapeutic in 25 (49%) children. There was weak correlation of the phenytoin levels with dose of fosphenytoin received, seizure control, or adverse effects.

CONCLUSIONS

Intravenous fosphenytoin loading dose of 20 mg/kg is effective in controlling seizures in 88% of children with status epilepticus, with a good safety profile. Seizure control and adverse effects appear to be independent of serum total phenytoin levels achieved.

Evaluation of Volumetric Doses of Organs at Risk in Carcinoma Cervix Patients with HDR Intracavitary Brachytherapy and Comparison of CT-based and Conventional Plans

Background:

Brachytherapy treatment planning in cervix carcinoma patients using two dimensional (2D) orthogonal images provides only point dose estimates while CT-based planning provides volumetric dose assessment helping in understanding the correlation between morbidity and the dose to organs at risk (OARs) and treatment volume.

Objective:

Aim of present study is to compare International Commission on Radiation Units and Measurements Report 38 (ICRU 38) reference point doses to OARs with volumetric doses using 2D images and CT images in patients with cervical cancer.

Material and Methods:

In this prospective study, 20 patients with cervical cancer stages (IIB-IIIB) were planned for a brachytherapy dose of 7Gy per fraction for three fractions using 2D image-based treatment plan and CT-based plan. ICRU 38 points for bladder and rectum were identified on both 2D image-based plan and CT-based plan and doses (D_ICRU) at these points were compared to the minimum dose to 2cc volume (D_2cc) of bladder and rectum receiving the highest dose.

Results:

D_2cc bladder dose was 1.60 (±0.67) times more than D_ICRUb bladder dose whereas D_2cc rectum dose was 1.13±0.40 times D_ICRUr. Significant difference was found between D_ICRUb and D_2cc dose for bladder (p=.0.016) while no significant difference was seen between D_ICRUr and D_2cc dose for rectum (p=0.964).

Conclusion:

The study suggests that ICRU 38 point doses are not the true representation of maximum doses to OARs. CT-based treatment planning is more a reliable tool for OAR dose assessment than the conventional 2D radiograph-based plan.

Genetic polymorphisms in DNA repair genes and their association with cervical cancer

Background and objective: Carcinoma of cervix is the second most common cancer among women worldwide. The DNA repair network plays an important role in the maintenance of genetic stability, protection against DNA damage and carcinogenesis. Alterations in repair genes XRCC1, XRCC2 and XRCC3 and been reported in certain cancers. We hypothesised an association between XRCC1+399A/G, XRCC2+31467G/A and XRCC3+18067C/T polymorphisms and the risk of cervical cancer. Subjects and methods: This study included 525 subjects (265 controls and 260 cervical cancer cases). Genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Results: Women with GA and AA genotypes of XRCC1+399A/G showed 2.4-3.8 fold higher risk of cervical cancer (P = 0.001). The +399A* allele was significantly linked with cervical cancer (P = 0.002). However, XRCC2+31479G/A and XRCC3+18067C/T polymorphisms did not show any statistically significant associations. Conclusion: The XRCC1+399A/G SNP is linked with cervical cancer. We suggest that this variant can be utilized as a prognostic marker for determination of cervical cancer susceptibility.

Impact of GSTM1, GSTT1 and GSTP1 genes polymorphisms on clinical toxicities and response to concomitant chemoradiotherapy in cervical cancer

BACKGROUND

Certain forms of chemoradiotherapy generate toxic reactive oxygen species, which may be ameliorated by antioxidant enzymes such as glutathione S-transferase (GST). Genetic polymorphisms of GST may predict treatment outcomes and can be used as genetic marker to screen patients before treatment. We hypothesised an effect of GST polymorphisms on the response and toxicities produced by chemoradiation therapy.

MATERIALS AND METHODS

GST polymorphisms were determined by multiplex polymerase chain reaction and PCR-restriction fragment length polymorphism (PCR-RFLP) in 227 women with cervical cancer receiving cisplatin based chemoradiotherapy. Treatment response and toxicities were evaluated by standard internationally recognised criteria (RECIST and RTOG).

RESULTS

Severe (grade 3-4) gastrointestinal and haematological toxicities were present in 22 (9.4%) and 16 (7.0%) patients, respectively. GSTM1 null, GSTT1 null and GSTP1 AG genotypes brought marginally better non-significant associations. In single locus analysis GSTP1 AG and GG was linked to greatest risk of severe (grade 3-4) gastrointestinal toxicity (OR = 3.12, P = 0.035 and OR = 6.99, P = 0.01, respectively). In gene-gene interaction analysis, GSTM1 null-GSTP1 GG showed 4.2-fold higher risk of severe gastrointestinal toxicity (P = 0.014). GSTT1 null-GSTP1 AG reached statistical significance with a 3.9-fold higher risk of high grade gastrointestinal toxicity (P = 0.038).

CONCLUSIONS

Although no significant links were found between GST polymorphism and treatment response, null genotypes of GSTM1, GSTT1 and 'G' allele of GSTP1 bring a higher risk of severe gastrointestinal toxicity due to chemoradiation therapy in cervical cancer.

Short-term carbon dynamics in a temperate grassland and heathland ecosystem exposed to 104 days of drought followed by irrigation

Temperate ecosystems are susceptible to drought events. The effect of a severe drought (104 days) followed by irrigation on the plant C uptake, its assimilation and input of C in soil were examined using a triple ¹³CO₂ pulse-chase labelling experiment in model grassland and heathland ecosystems. First ¹³CO₂ pulse at day 0 of the experiment revealed much higher ¹³C tracer uptake for shoots, roots and soil compared to the second pulse (day 44), where all plants showed significantly lower ¹³C tracer uptake. After the third ¹³CO₂ pulse (day 70), very low ¹³C uptake in shoots led to a negligible allocation of ¹³C into roots and soil. During irrigation after the severe drought, the ¹³C tracer that was allocated in plant tissues during the second and third pulse labelling was re-allocated in roots and soil, as soon as the irrigation started. This re-allocation was higher and longer lasting in heathland compared to grassland ecosystems.

Achieving selectivity for copper over zinc with luminescent terbium probes bearing phenanthridine antennas

A family of terbium probes was synthesized and evaluated for the luminescence detection of copper and zinc in water at neutral pH. Each probe incorporates a terbium ion chelated by a macrocyclic polyaminocarboxylate and conjugated to either one, two, or three phenanthridine antennas via a diamine linker. All three probes, Tb-1Phen, Tb-2Phen, and Tb-3Phen, exhibit similar responses toward copper and zinc. In each case, the terbium-centered time-gated phosphorescence decreases upon binding either Cu^I or Cu^II but not upon addition of Zn^II. The phosphorescence of Tb-2Phen is also not significantly affected by other metal ions including Mg^II, Ca^II, Mn^II, Fe^II, Ni^II, Cd^II, and Hg^II. Tb-1Phen, on the other hand, responds weakly to Mn^II, Fe^II and Ni^II. The lack of affinity of each probe for Zn^II was further confirmed by competition experiments with Cu^I and Cu^II. Notably, whereas the terbium-centered emission of each probe is quenched upon copper coordination, the phenanthridine-centered luminescence emission is not. As such, each probe functions as a ratiometric probe for the selective detection of copper over zinc. Theoretical calculations further demonstrate that the turn off response of the probe is due to an increase in the distance separating the lanthanide ion from its phenanthridine antennas upon coordination of copper, which in turn decreases the efficiency of terbium sensitization by the phenanthridines.

Studies on the structural changes during curing of epoxy and its blend with CTBN

Cashew nut shell liquid (CNSL), an agricultural renewable resource material, produces natural phenolic distillates such as cardanol. Cardanol condenses with formaldehyde at the ortho- and para-position of the phenolic ring under acidic or alkaline condition to yield a series of polymers of novolac- or resol-type phenolic resins. These phenolic resins may further be modified by epoxidation with epichlorohydrin to duplicate the performance of such phenolic-type novolacs (CFN). The structural changes during curing of blend samples of epoxy and carboxyl terminated poly (butadiene-co-acrylonitrile) (CTBN) were studies by Fourier-transform infrared (FTIR) spectrophotometer. The epoxy samples were synthesized by biomass material, cardanol. Blend sample was prepared by physical mixing of CTBN ranging between 0 and 20weightpercent CTBN liquid rubber into cardanol-based epoxidized novolac (CEN) resin. The FTIR spectrum of uncured blend sample clearly indicated that there appeared a band in the region of 3200-3500cm^-1 which might be due to the presence of phenolic hydroxyl group and OH group of the opened epoxide. Pure epoxy resin showed peaks near 856cm^-1 which might be due to oxirane functionality of the epoxidized novolac resin. Both epoxy and its blend sample was cured with polyamine. The cure temperature of CEN resin was found to be decreased by the incorporation of CTBN. The decomposition behavior was also studied by thermogravimetric analyzer (TGA). Two-step decomposition behavior was observed in both epoxy and its blend samples.

Complete on/off responsive ParaCEST MRI contrast agents for copper and zinc

Two thulium-based paraCEST contrast agents enable detection and imaging of copper and zinc by MRI with a complete on/off response.

A cohort study of vulvar cancer over a period of 10 years and review of literature

OBJECTIVE

The objective of this study was to study the risk factors, management protocols, and the outcome of vulvar cancer cases over a period of 10 years in a tertiary care hospital.

METHODOLOGY

It is a retrospective cohort study. The hospital records of 41 patients with histologically proven vulvar cancer were studied from the Department of Obstetrics and Gynaecology and the Department of Radiotherapy (RT). The presence of risk factors, stage of disease, treatment modalities used, and disease outcomes in terms of survival were studied. The data collected were analyzed and compared with the published literature.

RESULTS

The mean age for the diagnosis of vulvar cancer was 52 years and the peak incidence was seen in the age group of 50-70 years. Incidence was significantly more in multiparous (P = 0.001) and postmenopausal women (P = 0.007). An average of 4.1 cases were seen per year. Nearly, 97.56% of the cases were squamous cell carcinomas. Twenty cases belonged to the early stage of the disease (Stage I and II) whereas 21 cases had advanced disease (Stage III and IV). Nearly, 48.78% of the cases were primarily treated with surgery, 26.83% with RT, 7.3% with chemotherapy, and 17.07% with combined chemoradiation. Seventy-eight percent of the surgically treated cases had a mean survival of 5 years. Mean survival of 1 year was recorded in advanced disease cases. Limitation of the study was poor follow-up after treatment.

CONCLUSION

Incidence of vulvar cancer is significantly high in multiparous and postmenopausal women. Conservative surgical treatment is the best option in the early stage of the disease (Stage I and II) and gives high survival rates whereas advanced disease treated with chemoradiation has a poor survival.

Post-translationally modified human lens crystallin fragments show aggregation in vitro

BACKGROUND

Crystallin fragments are known to aggregate and cross-link that lead to cataract development. This study has been focused on determination of post-translational modifications (PTMs) of human lens crystallin fragments, and their aggregation properties.

METHODS

Four crystallin fragments-containing fractions (Fraction I [∼3.5 kDa species], Fraction II [∼3.5-7 kDa species], Fraction III [∼7-10 kDa species] and Fraction IV [>10-18 kDa species]), and water soluble high molecular weight (WS-HMW) protein fraction were isolated from water soluble (WS) protein fraction of human lenses of 50-70 year old-donors. The crystallin fragments of the Fractions I-IV were separated by two-dimensional (2D)-gel electrophoresis followed by analysis of their gel-spots by mass spectrometry. The Fractions I-IV were examined for their molecular mass, particle-diameters, amyloid fibril formation, and for their aggregation by themselves and with WS-HMW proteins.

RESULTS

Crystallin fragments in Fractions I-IV were derived from α-, β- and γ-crystallins, and their 2D-gel separated spots contained multiple crystallins with PTMs such as oxidation, deamidation, methylation and acetylation. Crystallin fragments from all the four fractions exhibited self-aggregated complexes ranging in M_r from 5.5×10⁵ to 1.0×10⁸ Da, with diameters of 10-28 nm, and amyloid fibril-like formation, and aggregation with WS-HMW proteins.

CONCLUSION

The crystallin fragments exhibited several PTMs, and were capable of forming aggregated species by themselves and with WS-HMW proteins, suggesting their potential role in aggregation process during cataract development.

GENERAL SIGNIFICANCE

Crystallin fragments play a major role in human cataract development.

EpiNet as a way of involving more physicians and patients in epilepsy research: Validation study and accreditation process

Objective

EpiNet was established to encourage epilepsy research. EpiNet is used for multicenter cohort studies and investigator‐led trials. Physicians must be accredited to recruit patients into trials. Here, we describe the accreditation process for the EpiNet‐First trials.

Methods

Physicians with an interest in epilepsy were invited to assess 30 case scenarios to determine the following: whether patients have epilepsy; the nature of the seizures (generalized, focal); and the etiology. Information was presented in two steps for 23 cases. The EpiNet steering committee determined that 21 cases had epilepsy. The steering committee determined by consensus which responses were acceptable for each case. We chose a subset of 18 cases to accredit investigators for the EpiNet‐First trials. We initially focused on 12 cases; to be accredited, investigators could not diagnose epilepsy in any case that the steering committee determined did not have epilepsy. If investigators were not accredited after assessing 12 cases, 6 further cases were considered. When assessing the 18 cases, investigators could be accredited if they diagnosed one of six nonepilepsy patients as having possible epilepsy but could make no other false‐positive errors and could make only one error regarding seizure classification.

Results

Between December 2013 and December 2014, 189 physicians assessed the 30 cases. Agreement with the steering committee regarding the diagnosis at step 1 ranged from 47% to 100%, and improved when information regarding tests was provided at step 2. One hundred five of the 189 physicians (55%) were accredited for the EpiNet‐First trials. The kappa value for diagnosis of epilepsy across all 30 cases for accredited physicians was 0.70.

Significance

We have established criteria for accrediting physicians using EpiNet. New investigators can be accredited by assessing 18 case scenarios. We encourage physicians with an interest in epilepsy to become EpiNet‐accredited and to participate in these investigator‐led clinical trials.