Nivolumab with or without ipilimumab in patients with recurrent or metastatic cervical cancer (CheckMate 358): a phase 1-2, open-label, multicohort trial

BACKGROUND

In preliminary findings from the recurrent or metastatic cervical cancer cohort of CheckMate 358, nivolumab showed durable anti-tumour responses, and the combination of nivolumab plus ipilimumab showed promising clinical activity. Here, we report long-term outcomes from this cohort.

METHODS

CheckMate 358 was a phase 1-2, open-label, multicohort trial. The metastatic cervical cancer cohort enrolled patients from 30 hospitals and cancer centres across ten countries. Female patients aged 18 years or older with a histologically confirmed diagnosis of squamous cell carcinoma of the cervix with recurrent or metastatic disease, an Eastern Cooperative Oncology Group performance status of 0 or 1, and up to two previous systemic therapies were enrolled into the nivolumab 240 mg every 2 weeks group, the randomised groups (nivolumab 3 mg/kg every 2 weeks plus ipilimumab 1 mg/kg every 6 weeks [NIVO3 plus IPI1] or nivolumab 1 mg/kg every 3 weeks plus ipilimumab 3 mg/kg every 3 weeks for four cycles then nivolumab 240 mg every 2 weeks [NIVO1 plus IPI3]), or the NIVO1 plus IPI3 expansion group. All doses were given intravenously. Patients were randomly assigned (1:1) to NIVO3 plus IPI1 or NIVO1 plus IPI3 via an interactive voice response system. Treatment continued until disease progression, unacceptable toxicity, or consent withdrawal, or for up to 24 months. The primary endpoint was investigator-assessed objective response rate. Anti-tumour activity and safety were analysed in all treated patients. This study is registered with ClinicalTrials.gov (NCT02488759) and is now completed.

FINDINGS

Between October, 2015, and March, 2020, 193 patients were recruited in the recurrent or metastatic cervical cancer cohort of CheckMate 358, of whom 176 were treated. 19 patients received nivolumab monotherapy, 45 received NIVO3 plus IPI1, and 112 received NIVO1 plus IPI3 (45 in the randomised group and 67 in the expansion group). Median follow-up times were 19·9 months (IQR 8·2-44·8) with nivolumab, 12·6 months (7·8-37·1) with NIVO3 plus IPI1, and 16·7 months (7·2-27·5) with pooled NIVO1 plus IPI3. Objective response rates were 26% (95% CI 9-51; five of 19 patients) with nivolumab, 31% (18-47; 14 of 45 patients) with NIVO3 plus IPI1, 40% (26-56; 18 of 45 patients) with randomised NIVO1 plus IPI3, and 38% (29-48; 43 of 112 patients) with pooled NIVO1 plus IPI3. The most common grade 3-4 treatment-related adverse events were diarrhoea, hepatic cytolysis, hyponatraemia, pneumonitis, and syncope (one [5%] patient each; nivolumab group), diarrhoea, increased gamma-glutamyl transferase, increased lipase, and vomiting (two [4%] patients each; NIVO3 plus IPI1 group), and increased lipase (nine [8%] patients) and anaemia (seven [6%] patients; pooled NIVO1 plus IPI3 group). Serious treatment-related adverse events were reported in three (16%) patients in the nivolumab group, 12 (27%) patients in the NIVO3 plus IPI1 group, and 47 (42%) patients in the pooled NIVO1 plus IPI3 group. There was one treatment-related death due to immune-mediated colitis in the NIVO1 plus IPI3 group.

INTERPRETATION

Nivolumab monotherapy and nivolumab plus ipilimumab combination therapy showed promise in the CheckMate 358 study as potential treatment options for recurrent or metastatic cervical cancer. Future randomised controlled trials of nivolumab plus ipilimumab or other dual immunotherapy regimens are warranted to confirm treatment benefit in this patient population.

FUNDING

Bristol Myers Squibb and Ono Pharmaceutical.

Structural vaccinology, molecular simulation and immune simulation approaches to design multi-epitopes vaccine against John Cunningham virus

The JCV (John Cunningham Virus) is known to cause progressive multifocal leukoencephalopathy, a condition that results in the formation of tumors. Symptoms of this condition such as sensory defects, cognitive dysfunction, muscle weakness, homonosapobia, difficulties with coordination, and aphasia. To date, there is no specific and effective treatment to completely cure or prevent John Cunningham polyomavirus infections. Since the best way to control the disease is vaccination. In this study, the immunoinformatic tools were used to predict the high immunogenic and non-allergenic B cells, helper T cells (HTL), and cytotoxic T cells (CTL) epitopes from capsid, major capsid, and T antigen proteins of JC virus to design the highly efficient subunit vaccines. The specific immunogenic linkers were used to link together the predicted epitopes and subjected to 3D modeling by using the Robetta server. MD simulation was used to confirm that the newly constructed vaccines are stable and properly fold. Additionally, the molecular docking approach revealed that the vaccines have a strong binding affinity with human TLR-7. The codon adaptation index (CAI) and GC content values verified that the constructed vaccines would be highly expressed in E. coli pET28a (+) plasmid. The immune simulation analysis indicated that the human immune system would have a strong response to the vaccines, with a high titer of IgM and IgG antibodies being produced. In conclusion, this study will provide a pre-clinical concept to construct an effective, highly antigenic, non-allergenic, and thermostable vaccine to combat the infection of the John Cunningham virus.

Efficacy and Safety of Nivolumab Plus Ipilimumab vs Nivolumab Alone for Treatment of Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck: The Phase 2 CheckMate 714 Randomized Clinical Trial

Importance

There remains an unmet need to improve clinical outcomes in patients with recurrent or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN).

Objective

To evaluate clinical benefit of first-line nivolumab plus ipilimumab vs nivolumab alone in patients with R/M SCCHN.

Design, Setting, and Participants

The CheckMate 714, double-blind, phase 2 randomized clinical trial was conducted at 83 sites in 21 countries between October 20, 2016, and January 23, 2019. Eligible participants were aged 18 years or older and had platinum-refractory or platinum-eligible R/M SCCHN and no prior systemic therapy for R/M disease. Data were analyzed from October 20, 2016 (first patient, first visit), to March 8, 2019 (primary database lock), and April 6, 2020 (overall survival database lock).

Interventions

Patients were randomized 2:1 to receive nivolumab (3 mg/kg intravenously [IV] every 2 weeks) plus ipilimumab (1 mg/kg IV every 6 weeks) or nivolumab (3 mg/kg IV every 2 weeks) plus placebo for up to 2 years or until disease progression, unacceptable toxic effects, or consent withdrawal.

Main Outcomes and Measures

The primary end points were objective response rate (ORR) and duration of response between treatment arms by blinded independent central review in the population with platinum-refractory R/M SCCHN. Exploratory end points included safety.

Results

Of 425 included patients, 241 (56.7%; median age, 59 [range, 24-82] years; 194 males [80.5%]) had platinum-refractory disease (nivolumab plus ipilimumab, n = 159; nivolumab, n = 82) and 184 (43.3%; median age, 62 [range, 33-88] years; 152 males [82.6%]) had platinum-eligible disease (nivolumab plus ipilimumab, n = 123; nivolumab, n = 61). At primary database lock, the ORR in the population with platinum-refractory disease was 13.2% (95% CI, 8.4%-19.5%) with nivolumab plus ipilimumab vs 18.3% (95% CI, 10.6%-28.4%) with nivolumab (odds ratio [OR], 0.68; 95.5% CI, 0.33-1.43; P = .29). Median duration of response for nivolumab plus ipilimumab was not reached (NR) (95% CI, 11.0 months to NR) vs 11.1 months (95% CI, 4.1 months to NR) for nivolumab. In the population with platinum-eligible disease, the ORR was 20.3% (95% CI, 13.6%-28.5%) with nivolumab plus ipilimumab vs 29.5% (95% CI, 18.5%-42.6%) with nivolumab. The rates of grade 3 or 4 treatment-related adverse events with nivolumab plus ipilimumab vs nivolumab were 15.8% (25 of 158) vs 14.6% (12 of 82) in the population with platinum-refractory disease and 24.6% (30 of 122) vs 13.1% (8 of 61) in the population with platinum-eligible disease.

Conclusions and Relevance

The CheckMate 714 randomized clinical trial did not meet its primary end point of ORR benefit with first-line nivolumab plus ipilimumab vs nivolumab alone in platinum-refractory R/M SCCHN. Nivolumab plus ipilimumab was associated with an acceptable safety profile. Research to identify patient subpopulations in R/M SCCHN that would benefit from nivolumab plus ipilimumab over nivolumab monotherapy is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT02823574.

Effect of Nystatin with and without DMAHDM on Antifungal and Mechanical Properties of Acrylic Resins

PURPOSE

To investigate antifungal and mechanical properties after the impregnation of Dimethyl Amino-ethyl Hexa-decyl Di-methacrylate (DMAHDM) alone or in combination with Nystatin in polymethylmethacrylate.

METHODOLOGY

The control group was fabricated by mixing powder and liquid of PMMA at the ratio of 2.5:1 g/mL. The DMAHDM was added to PMMA liquid and were mixed with PMMA powder. The Nystatin (500,000 International Units (IU)) was mixed with PMMA powder, whereby the composite powder was mixed with the DMAHDM-based liquid. The prepared specimens were tested for fungal adhesion testing (at days 1 and 30), impact strength and flexural strength. Oneway ANOVA post-hoc Tukey's test were used for statistical analysis.

RESULTS

Statistical analysis for the adhesion assay revealed that the antifungal activities of unaged and aged specimens in experimental groups were statistically significant as compared to control group A. The groups containing DMAHDM with Nystatin have shown statistically reduced flexural strength. The impact strength test revealed that groups containing 20% DMAHDM alone and DMAHDM with Nystatin showed statistically reduced impact strength compared to the control group.

CONCLUSION

Antifungal activities of experimental PMMA resin was increased. The addition of DMAHDM alone in PMMA resin has no deleterious effects on impact and flexural strength, however, at higher concentration values were reduced.

Nivolumab Plus Ipilimumab Versus EXTREME Regimen as First-Line Treatment for Recurrent/Metastatic Squamous Cell Carcinoma of the Head and Neck: The Final Results of CheckMate 651

PURPOSE

CheckMate 651 (ClinicalTrials.gov identifier: NCT02741570) evaluated first-line nivolumab plus ipilimumab versus EXTREME (cetuximab plus cisplatin/carboplatin plus fluorouracil ≤ six cycles, then cetuximab maintenance) in recurrent/metastatic squamous cell carcinoma of the head and neck (R/M SCCHN).

METHODS

Patients without prior systemic therapy for R/M SCCHN were randomly assigned 1:1 to nivolumab plus ipilimumab or EXTREME. Primary end points were overall survival (OS) in the all randomly assigned and programmed death-ligand 1 combined positive score (CPS) ≥ 20 populations. Secondary end points included OS in the programmed death-ligand 1 CPS ≥ 1 population, and progression-free survival, objective response rate, and duration of response in the all randomly assigned and CPS ≥ 20 populations.

RESULTS

Among 947 patients randomly assigned, 38.3% had CPS ≥ 20. There were no statistically significant differences in OS with nivolumab plus ipilimumab versus EXTREME in the all randomly assigned (median: 13.9 v 13.5 months; hazard ratio [HR], 0.95; 97.9% CI, 0.80 to 1.13; P = .4951) and CPS ≥ 20 (median: 17.6 v 14.6 months; HR, 0.78; 97.51% CI, 0.59 to 1.03; P = .0469) populations. In patients with CPS ≥ 1, the median OS was 15.7 versus 13.2 months (HR, 0.82; 95% CI, 0.69 to 0.97). Among patients with CPS ≥ 20, the median progression-free survival was 5.4 months (nivolumab plus ipilimumab) versus 7.0 months (EXTREME), objective response rate was 34.1% versus 36.0%, and median duration of response was 32.6 versus 7.0 months. Grade 3/4 treatment-related adverse events occurred in 28.2% of patients treated with nivolumab plus ipilimumab versus 70.7% treated with EXTREME.

CONCLUSION

CheckMate 651 did not meet its primary end points of OS in the all randomly assigned or CPS ≥ 20 populations. Nivolumab plus ipilimumab showed a favorable safety profile compared with EXTREME. There continues to be a need for new therapies in patients with R/M SCCHN.

Evaluation of Early Renal Involvement in Essential Hypertension by Measuring Urinary Biomarkers

Hypertensive kidney damage results in glomerular as well as tubular dysfunction. Albuminuria is a well-known marker of glomerular damage. On the other hand, urinary uromodulin is increasingly considered as a potential biomarker of early tubular dysfunction. The aim of the study was to assess glomerular and tubular function of the kidney by measuring urinary albumin and uromodulin excretion in hypertensive subjects. This cross-sectional study was conducted from July 2018 to June 2019 in Hypertension Clinic of Dhaka Medical College Hospital, Dhaka and Kidney Care and Research Centre, Sonargaon, Narayanganj, Bangladesh. In this study 122 hypertensive subjects with age >30 years, duration of hypertension <5 years, without accelerated or malignant BP, absence of dipstick proteinuria and eGFR >60ml/min were included. There were also 33 normotensive individuals included as healthy controls. Albumin-creatinine ratio (uACR mg/g), urine uromodulin-creatinine ratio (uUMODμg/g), urinary sodium-creatinine ratio (mEq/g) and potassium-creatinine ratio (mEq/g) were measured from single morning spot urine sample. Urinary uromodulin levels were measured by ELISA method. The hypertensive and normotensive subjects were age matched 49.0±12.0 vs. 48.0±11.0, years (p=NS). The mean uACR was 29.0±65.0 versus 5.6±2.7mg/g, (p<0.001) respectively. The median uUMOD in hypertensive subjects was 3.38 (1.73-9.06) and in normotensives 3.85(2.28-5.69) μg/g (p=non significant). Multivariate analysis showed significant inverse association between diastolic blood pressure and urinary uromodulin excretion. A uUMOD cut-off of 2.9 (25th percentile) showed eGFR, urinary sodium and potassium excretions were significantly lower at low uromodulin group. The glomerular involvement was found in 21.0% of hypertensive subjects as evidenced by albuminuria. No difference was observed in urinary uromodulin level between hypertensive and normotensive subjects. Low urinary uromodulin level was associated with lower eGFR, Na+ and K+ excretion which indicate simultaneous tubular and glomerular involvement.

The effect of selected commercially available mouth-rinses vs. curcumin photosensitizers in an artificial mouth model mimicking their use before meals on early colonizers single species biofilm

OBJECTIVE

The aim of the study was to determine the bacterial-adherence to the experimental pellicle pretreated with commercially available oral-rinse/ photosensitizer (mimicking use of oral-rinse/ photosensitizer before meals).

MATERIALS AND METHODS

An artificial mouth (NAM) system was used for the development of single-species biofilm (Actinomyces viscosus, Streptococcus mitis and Streptococcus sanguinis respectively). Two commercially available oral-rinses containing active ingredients [Essential oils (EO) and Chlorhexidine gluconate (CHX) were used. Curcumin photosensitizer (PS) was used as a photosensitizer against the microbes. For the adherence study, the experimental pellicle on the beads (in the capillary tubes of the NAM system) was pretreated with the oral-rinse and photosensitizer before the inoculation of bacteria; this would resemble the use of rinse/ photosensitizer before meal. The bacterial population of the biofilm was determined using serial dilution assay and expressed as colony forming unit per ml. Deionized distilled water was used in place of oral-rinse/photosensitizer and served as a negative-control. For the qualitative study, bacterial population viewing was carried out using Scanning Electron Microscope (SEM).

RESULTS

It was observed that on treatment with the oral-rinses the bacterial population of S.mitis, S.sanguinis and A.viscosus (adherence) was significantly reduced where the reduction was less for EO-based oral-rinse compared with that of CHX and curcumin PS in the following sequence EO<CHX<PS (p<0.05).

CONCLUSIONS

From the results, it appears that curcumin photosensitizer and oral-rinses contain CHX to be preferably used before-meal and EO after-meal.

Management of a 20-year-old longstanding oroantral fistula: A case report and review of literature

A systematic treatment plan and an appropriate selection of surgical technique are the critical requirements for an effective closure of oroantral fistula (OAF). A 45-year-old female patient had sinus opening after she underwent a surgical tooth extraction 20 years back. On her frequent visits to the dentists some attempts were made for closure including surgical intervention, only for the lesion to return back. Computerized tomography (CT) scan was taken to rule out any bony extension of a lesion, the CT revealed a 1 × 1 cm radiolucency with a through - through communication from the alveolar bone to the right maxillary sinus because of the bony defect in the floor of maxillary sinus along with thickening of the maxillary sinus lining. The closure of the defect was done by a lateral pedicle flap raised from the right side was elevated and laterally slid to cover the defect without tension and was sutured with 4-0 resorbable interrupted suture while maintaining a bare surgical bed covered by the periosteum and a thin layer of connective tissue. This technique provides immediate repair of the defect to the patient, and also maintains comparatively normal anatomic architecture to the oral cavity. Eight months postoperative follow-up revealed a complete closure of OAF without any complications. The findings of this case suggest that lateral sliding pedicle flap can be a conservative approach in managing a long-standing OAF.

Effect of telephone-monitored home-based cardiac rehabilitation exercise on functional capacity and quality of life in heart failure patients in a lower-middle-income country

Funding Acknowledgements

Type of funding sources: None.

Introduction

Chronic heart failure (CHF) prevails as one of the major cardiovascular diseases in lower-middle-income countries (LMICs) like Bangladesh. Home-Based Cardiac Rehabilitation (HBCR) is a cost-effective method of secondary prevention of chronic heart failure which, if provided, might not only improve the health status of the patients but might also reduce the financial and hospitalization burden on the health care system of these countries. The study aims to assess the scope and benefits of HBCR in such low resource settings.

Purpose

The study evaluates the effect of telephone-monitored HBCR exercise programme in improving the functional capacity and quality of life (QoL) in patients of CHF with reduced ejection fraction due to ischemic heart disease (IHD).

Method

This self-controlled interventional study was conducted from August 2019 to July 2020 at a heart failure clinic, a tertiary healthcare centre in Bangladesh. A total of 115 patients of CHF with ejection fraction &lt;40% and in NYHA class II and III were included in the study according to selection criteria. The functional capacity of the patients was evaluated by NYHA classification and 6-minute walk test. The quality of life of the patients was evaluated by Minnesota Living with Heart Failure Questionnaire (MLHFQ). All patients were advised to perform HBCR exercise as per recommended guideline and were telephone-monitored 2-weekly. After the 3-months study period, the participants were divided into compliant and partial compliant groups based on their adherence to the guideline. Repeat evaluation of patients' condition was carried out. Results were then compared within the groups and data was analyzed through appropriate statistical methods.

Results

Significant improvement of NYHA class (p&lt;0.05), and 6-minute walk test distance (6MWTD) (1102.01±215.90 feet vs 1243.30±217.86 feet; p&lt;0.001) were noticed after the rehabilitation programme. Improvement of total MLHFQ score was also observed (35.53±14 vs 28.22±12.84; p&lt;0.001) at 3-months follow up. The functional capacity and quality of life of the patients in both the compliant and partially compliant groups showed significant improvement after the rehabilitation programme (p&lt;0.001); though no difference was found in the indicators when compared between compliant vs partially compliant groups after rehabilitation except for 6MWTD (1302.86±219.61 feet vs 1230.71±212.284 feet, p&lt;0.001).

Conclusion

From the results, it can be concluded that any amount of routine exercise tends to improve quality of life and symptoms in patients of chronic heart failure with reduced ejection fraction. However, to achieve the best effect in functional capacity and overall health status, the addition of a structured exercise programme like HBCR can be beneficial for proper rehabilitation in low resource settings. Further validation of the results is recommended through randomized control trials in larger study groups.

Assessment of Euphorbia retusa and Pulicaria undulata activity against Leishmania major and Toxoplasma gondii

Leishmaniasis and toxoplasmosis are parasitic protozoal diseases that pose serious health concerns, especially for immunocompromised people. Leishmania major and Toxoplasma gondii are endemic in Saudi Arabia and are particularly common in the Qassim Region. The present work was conducted to evaluate the in vitro antileishmanial and antitoxoplasmal activity of methanolic extracts and phytochemical fractions from two plants, Euphorpia retusa and Pulicaria undulata, which are ethnobotanical agents used to treat parasitic infection. Whole E. retusa and P. undulata plants were extracted with methanol and fractionated using petroleum ether, chloroform, ethyl acetate, n-butanol, and water and then were tested in vitro against L. major promastigote and the amastigote stages of T. gondii; the cytotoxicity of the extracts was tested against Vero cell line. The methanolic extracts of E. retusa and P. undulata exhibited promising antitoxoplasmal activity against T. gondii with EC50 values 5.6 and 12.7 μg mL-1, respectively. The chloroform fraction of P. undulata was the most potent, exhibiting an EC50 of 1.4 μg mL-1 and SI value of 12.1. It was also the most active fraction against both L. major promastigotes and amastigotes, exhibiting an EC50 of 3.9 and 3.8 μg mL-1 and SI values 4.4 and 4.5, respectively. The chloroform fraction from P. undulata is a very good candidate for the isolation of active antitoxoplasmal and antileishmanial ingredients; therefore, further phytochemical analysis for active compound isolation is highly recommended.

Extra Skeletal Ewing's Sarcoma Involving Perineum of a Young Male Patient

Ewing's Sarcoma is the second most common primary malignant bone tumor in children and young adults after osteosarcoma but exceptionally it can arise from extra skeletal sites also. Extra skeletal Ewing's sarcoma is of neuroectodermal origin and usually involves extremities, retroperitoneum and paravertebral regions. No case of extra skeletal Ewing's sarcoma involving perineum is yet reported. A 16 years old male patient admitted to colorectal surgery department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh in July 2015 having swellings in perineum as well as both inguinal regions. The swelling was near to anal verge. FNAC from perineal swelling and inguinal lymph node demonstrate small blue round cell tumor. After operation the tumor size was 5cm×4cm, cell type was malignant round cell arranged in sheet and perivascular forming rosette. Extra skeletal Ewing's sarcoma can be a differential diagnosis of soft tissue tumor arising in perineum.

Pattern of Disease among Patients Attending Cardiology Outpatient Department of a Private Hospital of Mymensingh, Bangladesh

Epidemiologic transition is taking place in every part of the world. Cardiovascular diseases became the most common cause of death accounting for 30% of deaths worldwide, with 80% of the burden now occurring in developing countries. The objective of the study was to assess the Pattern of disease among patients attending Cardiology outpatient department of a private hospital. The cross sectional descriptive type of observational study was conducted among 550 patients attending Cardiology outpatient department (COPD) of Sodesh Hospital, Mymensingh, Bangladesh from March 2016 to June 2016. All the new patients attending COPD of Sodesh Hospital were selected purposively for the study. Data were collected by interview, physical examination and laboratory investigations of patients using a case record form. Mean age of the patients was 45.1 years with a SD of 15.6 years. Among the patients male were 291(52.9%), a bit higher than the female 259(47.1%). It was observed that more than half of the patients (281, 51.1%) visited cardiologist with non-cardiac problems. Less than one third of the patients (169, 30.7%) attended with cardiac problems and 100(18.2%) patients visited with both cardiac and non-cardiac problems. Among the cardiac diseases and symptoms hypertension was on the top of the list 176(65.4%). Ischemic heart diseases was present in 35(13.0%) and palpitation was in 30(11.1%) patients. On the other hand among the non-cardiac diseases or presentations, 121(43.1%) patients had non-specific chest pain, 63(22.4%) had shortness of breath and 17(6.1%) had diabetes mellitus. Hypertension was found the most frequent cardiovascular disease (65.4%) followed by ischemic heart disease (13.0%). More than half (51.1%) of the patients visit cardiologist with non-cardiac problems. Screening at the level of general practitioner (GP) and appropriate referral system can reduce extreme burden of patients to the cardiologists in the Cardiology outpatient department.

Deep sequencing in library selection projects: what insight does it bring?

High throughput sequencing is poised to change all aspects of the way antibodies and other binders are discovered and engineered. Millions of available sequence reads provide an unprecedented sampling depth able to guide the design and construction of effective, high quality naïve libraries containing tens of billions of unique molecules. Furthermore, during selections, high throughput sequencing enables quantitative tracing of enriched clones and position-specific guidance to amino acid variation under positive selection during antibody engineering. Successful application of the technologies relies on specific PCR reagent design, correct sequencing platform selection, and effective use of computational tools and statistical measures to remove error, identify antibodies, estimate diversity, and extract signatures of selection from the clone down to individual structural positions. Here we review these considerations and discuss some of the remaining challenges to the widespread adoption of the technology.

Echocardiographic comparison of regional wall motion abnormality between patients with acute anteroseptal and acute extensive anteior ST segment elevation myocardial infarction

Post myocardial infarction (MI) short and long-term clinical outcome is largely determined by the size of the infarcted area. It is generally assumed that as the lead involvement in electrocardiography (ECG) is less in anteroseptal ST segment elevation myocardial infarction (AS-STEMI), where ST segment elevation (STE) is limited to leads V1 to V3, myocardial damage is likely to be less; and in extensive anterior STEMI (EA-STEMI), as the STE extends further upto V6, the myocardial damage is likely to be more. This study was intended to compare regional wall motion abnormality (RWMA) between acute anteroseptal STEMI and acute extensive anterior STEMI patients. 90 patients with AS-STEMI and 106 patients with EA-STEMI, admitted in between October 2012 and September 2013, were included. For each patient, a transthoracic echocardiogram (TTE) was performed within 24-48 hours of MI and was interpreted by an independent investigator blinded to the patient's ECG data. No differences were observed between the two groups in baseline characteristics; except AS-STEMI group had more patients with diabetes and EA-STEMI group had more patients with family history of coronary artery disease. Distribution, extent of wall motion abnormalities and mean number of total involved segments were similar between patients with AS-STEMI and those with EA-STEMI (p > 0.05). Regarding regional dysfunction, the apical septal (99.1% vs. 92.2%, p < 0.05) and apical (76.4% vs. 60.0%, p < 0.05) segments were the only two segments that were affected significantly more in patients with EA-STEMI than in patients with AS-STEMI. So, the term AS-STEMI may be a misnomer, as it implies that only the anteroseptal segments of the left ventricle are involved. This study shows that regional dysfunction in patients with AS-STEMI extends beyond the anteroseptal region. So, any patients with anterior wall involvement, either anteroseptal or extensive anterior STEMI, should be treated with equal importance.

Metabolic syndrome is a risk factor for development of heart failure in acute myocardial infarction

There is a relationship between metabolic syndrome with heart failure. A case control study was designed to see the association of metabolic syndrome with heart failure. The study was conducted from August 2009 to May 2010. Hundred cases were selected as study population which was taken from Department of Cardiology Mymensingh Medical College, Mymensingh. Among them 50 were in Group A, 50 were in Group B. Group A was the patient with acute myocardial infarction (AMI) with metabolic syndrome. Group B was the patient with AMI without metabolic syndrome. It revealed that 23(46%) in Group A and 10 (20%) in Group B developed heart failure. Which is statistically significant (p<0.05). The study concluded that metabolic syndrome is significantly associated with heart failure.

Long-term survival in an un-operated single ventricle

Single ventricle is a rare and complex congenital heart disease. Neonates with single ventricle have a high mortality. Survival into adulthood is rare without surgical intervention. A case of single ventricle with double inlet and double outlet combined with severe valvular pulmonary stenosis and mitral regurgitation (Grade II) is being reported here. A 36 years old man was admitted for bluish discoloration of lips, tongue and fingers; shortness of breath and recurrent palpitation. His ECG showed atrial fibrillation with fast ventricular rate. Chest X-Ray depicted an enlarged cardiac shadow and right sided pleural effusion. Final diagnosis was made by echocardiogram which demonstrated single ventricle with double inlet and double outlet, severe valvular pulmonary stenosis and mitral regurgitation (Grade II) with good ventricular systolic function.

Disseminated tuberculosis presenting as acute coronary syndrome

Tuberculosis is a major public health problem in Bangladesh. Though tuberculosis is common but acute myopericarditis can rarely be caused by tuberculosis infection. A case of disseminated tuberculosis presenting with features of acute coronary syndrome is presenting here. A 26 years old man was admitted for severe central chest pain for 2 days and fever for 2 months. His ECG showed ST segment elevation in chest leads, V1 to V4 with elevated Troponin I and high ESR. Chest X-Ray depicted an enlarged cardiac shadow. Echocardiography demonstrated multiple dynamic cavitary lesions involving interventricular septum as well as anterior wall of the left ventricle within myocardium with moderate pericardial effusion with trivial mitral regurgitation. A CT scan of chest with contrast revealed multiple calcific communicating cavities within endocardium and myocardium involving interventricular septum and anterior wall of the left ventricle of heart and multiple cavitary lesions in the mid zone of left lung with bilateral mild pleural effusion. The patient made an excellent recovery on management of acute coronary syndrome and on antitubercular therapy.

A case report of right ventricular mass

Primary Cardiac tumors are uncommon during infancy and childhood. Myxomas originating in the right ventricles are even less common in paediatric patient. Our patient baby Rani, 3 months of age presented with shortness of breath and chest indrawing. Antenatal history and delivery was uneventful. The baby was under weight and also malnourished but there was no cyanosis and clubbing. Her respiratory rate was 25/minute. On precordium examination, first heart sound (S1) was normal but pulmonary component of second heart sound (P2) was soft. There was an ejection systolic murmur (Grade-3/6) in the left upper para-sternal area. Chest X-ray revealed cardiomegaly. Echocardiogram revealed a large mass (11x10mm) in the right ventricle, dynamically obstructing the right ventricular out-flow tract and compressing the left ventricle. There was a Tricuspid regurgitation (Grade-2) and moderate pulmonary hypertension (PASP-50 mmHg).

Humidity and illumination organic semiconductor copper phthalocyanine sensor for environmental monitoring

In this investigation properties of organic semiconductor copper phthalocyanine (CuPc) capacitive humidity and illumination sensors were studied. Organic thin film was deposited by vacuum evaporation on a glass substrate with silver surface-type electrodes to form the Ag/CuPc/Ag sensor. The capacitance of the samples was evaluated at room temperature in the relative humidity range of 35-92%. It was observed that capacitance of the Ag/CuPc/Ag sensor increases with increase in humidity. The ratio of the relative capacitance to relative humidity was about 200. It is assumed that in general the capacitive response of the sensor is associated with polarization due to absorption of water molecules and transfer of charges (electrons and holes). It was observed that under filament lamp illumination of up to 1,000 lx the capacitance of the Ag/CuPc/Ag photo capacitive detectors increased continuously by 20% as compared to dark condition. It is assumed that photo capacitive response of the sensor is associated with polarization due to transfer of photo-generated electrons and holes. An equivalent circuit of the Ag/CuPc/Ag capacitive humidity and illumination sensor was developed. Humidity and illumination dependent capacitance properties of this sensor make it attractive for use in humidity and illumination multi-meters. The sensor may be used in instruments for environmental monitoring of humidity and illumination.

Axillary and tympanic membrane temperature measurements are unreliable early after cardiopulmonary bypass

BACKGROUND AND OBJECTIVE

Inaccurate measurements of body temperature following cardiopulmonary bypass may be associated with serious complications. The purpose of this study was to determine whether axillary and tympanic temperature measurements correlate with the urinary bladder temperature in the early postcardiac surgery period.

METHODS

Forty-nine adult patients who underwent cardiac surgery under cardiopulmonary bypass at our institution were prospectively studied. Urinary bladder, right axillary, right tympanic and left tympanic temperature measurements were simultaneously recorded at 0, 6, 12 and 18 h following cardiopulmonary bypass. Patients had one to four sets of recordings and a total of 629 temperature measurements were recorded. The mean difference (bias) between the bladder and each of the other methods and limits of agreement were calculated using Bland and Altman method.

RESULTS

The mean core body temperature recorded from the bladder on admission to the intensive care unit was 36.4 degrees C. After 6, 12 and 18 h the mean core body temperature was 37.4 degrees C (range: 35.2-39.0), 37.5 degrees C and 37.45 degrees C, respectively. The mean differences (bias) between the bladder temperature and the other three methods were: left tympanic, 0.65 degrees C (95% CI: -0.24 to 1.58); right tympanic, 0.57 degrees C (95% CI: -0.48 to 1.63) and right axillary, 0.55 degrees C (95% CI: -0.27 to 1.36).

CONCLUSIONS

The axilla and tympanic membrane are unreliable sites for core body temperature measurement early after cardiopulmonary bypass in adult patients and clinical decisions should be based on more reliable methods.

Regioselective Synthesis of 1-Aryl-3,4-substituted/annulated-5-(methylthio)pyrazoles and 1-Aryl-3-(methylthio)-4,5-substituted/annulated Pyrazoles

[reaction: see text] Highly efficient and regioselective synthesis of 1-aryl-3,4-substituted/annulated-5-(methylthio)pyrazoles and 1-aryl-3-(methylthio)-4,5-substituted/annulated pyrazoles has been reported via cyclocondensation of arylhydrazines with either alpha-oxoketene dithioacetals or beta-oxodithioesters.

Standardization of marketed Kumariasava--an Ayurvedic Aloe vera product

Kumariasava is a marketed ayurvedic formulation containing Aloe vera as one of the main ingredients. Present study aims to standardize Kumariasava based upon chromatographic and spectral studies. Various extracts of Kumariasava have been prepared and evaluated. Chloroform extract indicated presence of three well-resolved fluorescent components. Spectral data of these three fractions (III-V) have been reported as a valuable analytical tool for routine standardization of Kumariasava. Fraction V indicated presence of anthraquinones, which is reported as the main constituent of aloe, namely aloin. Hence, isolation and evaluation of aloin has been undertaken. Aloin can be used as possible marker compound for standardization of Kumariasava.

Risk factors for clinical infection in patients colonized with methicillin resistant Staphylococcus aureus (MRSA)

OBJECTIVE

To identify the risk factors involved in development of infection in individuals colonized with Methicillin-resistant Staphylococcus aureus (MRSA) among intensive care unit (ICU) patients.

METHODS

A total of 1431 patients were admitted in ICU of which 63 grew MRSA during January 1998 to December 1999. Patients who developed infection with MRSA in less than 48 hours of their admission to ICU were excluded. Medical records of all patients who grew MRSA were reviewed and 57 patients were identified for inclusion in the study. Thirty-seven of these had features of infection with MRSA and were selected as cases and 20 were identified as asymptomatic colonizers and labeled as controls. Risk factors like age of the patient, duration of ICU stay, gender, co-morbidity, presence and duration of central lines, number of arterial-punctures and number and duration of intubations were compared between cases and controls.

RESULTS

Cases were found to be significantly older (52.8 +/- 15.1) than controls (34.9 +/- 21.2). Other identified risk factors were diabetes mellitus (p = 0.001) and the first 15 days of central line placement (p = 0.025). Although chronic liver disease and hypertension could not be identified as significant risk factors, they clearly showed association. Other risk factors were not significantly different from controls.

CONCLUSION

It is suggested that greater care is required for the elderly, diabetic patients with a central venous line in place especially during the first fifteen days of its introduction.

Gene therapy progress and prospects: therapeutic angiogenesis for limb and myocardial ischemia

After extensive investigation in preclinical studies and recent clinical trials, gene therapy has been established as a potential method to induce therapeutic angiogenesis in ischemic myocardial and limb disease. Advancements in viral and nonviral vector technology including cell-based gene transfer will continue to improve transgene transmission and expression efficiency. An alternative strategy to the use of transgenes encoding angiogenic growth factors is therapy based on transcription factors such as hypoxia-inducible factor-1alpha (HIF-1alpha) that regulate the expression of multiple angiogenic genes. Further understanding of the underlying biology of neovascularization is needed to determine the ability of growth factors to induce functionally significant angiogenesis in patients with atherosclerotic disease and associated comorbid conditions including endothelial dysfunction, which may inhibit blood vessel growth. The safety and tolerability of therapeutic angiogenesis by gene transfer has been demonstrated in phase I clinical trials. However, limited evidence of efficacy resulted from early phase II studies of angiogenic gene therapy for ischemic myocardial and limb disease. The utility of therapeutic angiogenesis by gene transfer as a treatment option for ischemic cardiovascular disease will be determined by adequately powered, randomized, placebo-controlled phase II and III clinical trials.

Vascular effects of spinal cord stimulation in the monkey

Because of clinical reports suggesting beneficial effects of electrical stimulation in peripheral vascular disease, studies have been conducted in the monkey. Regional blood flow was measured prior to, during and following the application of electrical currents to the spinal cord. The flow measurements were made using radioactive microspheres. In addition, tissue temperatures and venous and arterial concentrations of epinephrine and norepinephrine were measured. The results show that electrical stimulation increases blood flow to the skin and muscle. It is hypothesized that the effect is due to sympathetic inactivation secondary to the application of electrical currents.

TNF-alpha and IL-6 expression in perfused rat liver after intraportal candidemia vs. E. coli or S. aureus bacteremia

We tested the hypothesis that regulation of tumor necrosis factor-alpha (TNF-alpha) and IL-6 by the liver differs after intraportal challenge with Candida albicans spp. vs. gram-negative or gram-positive bacteria, independent of microbial clearance kinetics or hepatic O2 consumption (VO2). Buffer-perfused rat livers were infected with equivalent inocula (10(9) colony-forming units) of viable Escherichia coli serotype 055:B5 (EC), exotoxin C-producing Staphylococcus aureus (SA), or two strains of yeast phase C. albicans (CA-1 and CA-2). Microbial clearance and circulating cytokine levels were assessed over 180 min while monitoring VO2 and functional parameters, after which organ-based microbial killing, cell-associated TNF-alpha, and cytokine mRNA levels were determined. Compared with saline controls (normal saline solution; NSS), circulating and cell-associated TNF-alpha and TNF-alpha transcripts minimally increased after CA. In contrast, large increases in perfusate TNF-alpha occurred after EC, peaking at 180 min [135 +/- 32 U/ml (mean + SE)], concomitant with rises in cell-associated cytokine and TNF-alpha transcripts (P < 0.01 vs. NSS). Circulating TNF-alpha also rose after SA but neither cell-associated nor mRNA levels exceeded NSS values. There were no pathogen-specific differences in microbial clearance or VO2. IL-6 gene expression paralleled that for TNF-alpha, but IL-6 bioactivity in perfusates was inhibited by TNF-alpha-dependent and -independent mechanisms. We conclude that hepatic TNF-alpha and IL-6 expression are differentially regulated after taxonomically diverse microbial challenges, with E. coli eliciting the strongest and Candida spp. the weakest stimulatory responses.

A receptor for interleukin 10 is related to interferon receptors

We isolated cDNAs encoding a mouse interleukin 10 receptor (mIL-10R) from mouse mast cell and macrophage cell lines. The two cDNAs are substantially identical and express an approximately 110-kDa polypeptide in COS7 cells, which binds mIL-10 specifically. A mouse pro-B-cell line (Ba/F3) expressing transfected recombinant mIL-10R binds IL-10 with high affinity (approximately 70 pM) and proliferates in response to mIL-10. mIL-10R is structurally related to interferon receptors (IFNRs). Since IL-10 inhibits macrophage activation by IFN-gamma, a possible implication of this relationship interaction of IL-10R and IFN-gamma R or their signaling pathways.

Fluorescence in situ hybridization (FISH) of a whole-arm translocation involving chromosomes 18 and 20 with alpha-satellite DNA probes: detection of a centromeric DNA break?

Fluorescence in situ hybridization (FISH) with alpha-satellite DNA probes was used to study whole-arm chromosome translocation products in a family in which the propositus was shown to have a monosomy 18p/trisomy 20p imbalance. By this approach, we show that the chromosome 18 alpha-satellite DNA block is split into 2 smaller units, whereas the chromosome 20 breakpoint is not included within the alpha-satellite DNA region. We found no evidence to suggest that this split alpha-satellite DNA region has reduced or impaired the function of the centromere or that it contributed to the phenotype of the propositus. The FISH technique critically demonstrated the involvement of a whole-arm translocation in this case and provided accurate identification of breakpoints, which was not possible with standard banding techniques.

Structure of the mouse IL-10 gene and chromosomal localization of the mouse and human genes

The nucleotide sequence of a 7.2-kb segment containing the mouse IL-10 (mIL-10) gene was determined. Comparison to the mIL-10 cDNA sequence (Moore, K. W., et al. 1990. Science 248:1230; 250:494) revealed the presence of five exons that span approximately 5.1 kb of genomic DNA. The noncoding regions of the mIL-10 gene contain sequences that have been associated with transcriptional regulation of several cytokine genes. The mIL-10 gene was mapped to mouse chromosome 1 and the human IL-10 gene was also mapped to human chromosome 1.

Structure of the mouse IL-10 gene and chromosomal localization of the mouse and human genes

The nucleotide sequence of a 7.2-kb segment containing the mouse IL-10 (mIL-10) gene was determined. Comparison to the mIL-10 cDNA sequence (Moore, K. W., et al. 1990. Science 248:1230; 250:494) revealed the presence of five exons that span approximately 5.1 kb of genomic DNA. The noncoding regions of the mIL-10 gene contain sequences that have been associated with transcriptional regulation of several cytokine genes. The mIL-10 gene was mapped to mouse chromosome 1 and the human IL-10 gene was also mapped to human chromosome 1.

Renal functional response to dopamine during and after arteriography in patients with chronic renal insufficiency

The potential renal vasodilatory effect of dopamine in improving renal function after arteriography was studied. Sixty patients with preexisting renal insufficiency were prospectively randomized into two groups. Patients in the treated group (n = 30) received an infusion of dopamine for 12 hours starting at the beginning of arteriography. Patients who received placebo infusion with arteriography (n = 30) served as controls. The study was conducted in two different time intervals. In the first interval, serum creatinine levels and 12-hour creatinine clearance values were obtained before and immediately after arteriography in 12 patients in the dopamine group and 13 patients in the control group. In the second interval, the same variables were measured before arteriography and for 3 consecutive days after arteriography in 18 patients in the dopamine group and 17 patients in the control group. Serum creatinine levels became significantly elevated in the control group on the 1st day and remained so on the 3rd day after arteriography, whereas the dopamine group did not show significant elevation of these levels. Creatinine clearance decreased in the control group on the 1st day, but this deterioration was not sustained on the 3rd day. In the dopamine group, there was no deterioration in creatinine clearance on either day, and mean effective renal plasma flow during and after arteriography was greater.

Homology of cytokine synthesis inhibitory factor (IL-10) to the Epstein-Barr virus gene BCRFI

Complementary DNA clones encoding mouse cytokine synthesis inhibitory factor (CSIF; interleukin-10), which inhibits cytokine synthesis by TH1 helper T cells, were isolated and expressed. The predicted protein sequence shows extensive homology with an uncharacterized open reading frame, BCRFI, in the Epstein-Barr virus genome, suggesting the possibility that this herpes virus exploits the biological activity of a captured cytokine gene to enhance its survival in the host.

Homology of cytokine synthesis inhibitory factor (IL-10) to the Epstein-Barr virus gene BCRFI

Complementary DNA clones encoding mouse cytokine synthesis inhibitory factor (CSIF; interleukin-10), which inhibits cytokine synthesis by TH1 helper T cells, were isolated and expressed. The predicted protein sequence shows extensive homology with an uncharacterized open reading frame, BCRFI, in the Epstein-Barr virus genome, suggesting the possibility that this herpes virus exploits the biological activity of a captured cytokine gene to enhance its survival in the host.

Effect of proximal selective vagotomy on the canine lower esophageal sphincter

The effect of proximal selective vagotomy on the lower esophageal sphincter was studied in 13 dogs by manometry and cinefluorography. The studies, done under resting conditions and during abdominal compression, were repeated 8 weeks after proximal selective vagotomy in seven animals and after truncal vagotomy in six animals. Proximal selective vagotomy had no significant effect on the pressures in the lower esophageal sphincter; the resting pressures were 32.1 +/- 4.1 cm H2O before and 28.9 +/- 3.7 after operation, and the pressures on abdominal compression were 50.6 +/- 6.5 and 41.6 +/- 3.8 cm H2O, respectively (p < 0.05). Truncal vagotomy decreased the lower esophageal sphincter pressures at rest from 28.2 +/- 4.0 to 18.0 +/- 2.2 cm H2O (p = 0.1) and those during abdominal compression from 44.7 +/- 5.6 to 15.5 +/- 2.6 cm H2O (p < 0.01). Gastroesophageal reflux was not seen after proximal selective vagotomy but was seen in one animal in the truncal vagotomy group. Since proximal selective vagotomy does not decrease lower esophageal sphincter function, it offers an advantage over truncal vagotomy in the treatment of duodenal ulcer. The data also indicate that vagal afferents from the proximal stomach are not important in reflex control of lower esophageal sphincter activity.

An experimental study of the correction of gastroesophageal reflux by gastroplasty

The rationale and efficacy of gastroplasty in controlling gastroesophageal reflux were studied by manometry and cinefluorography in the dog. The pressure in a 7 by 3 centimeter gastric tube, constructed from the lesser curvature of the stomach and interposed between the esophagus and the stomach, was 3.6 +/- 1.0 centimeters higher than in the stomach. When abdominal compression was applied, the pressures were similar in the tube and the adjacent stomach, 19.0 +/- 4.0 and 19.4 +/- 4.0 centimeters, and free reflux was demonstrated between the two. When the gastric fundus was wrapped around the gastroplasty tube, its resting pressure was 13.1 +/- 0.5 centimeters higher than gastric pressure. During abdominal compression, the pressure in the gastric tube increased to 23.0 +/- 0.6 centimeters suggesting a flutter-valve arrangement that produced an effective antireflux barrier. These data suggest that gastroplasty can be an effective antireflux method only when combined with fundic wrap.

Evaluation of posterior gastropexy for gastroesophageal reflux

The efficacy of posterior gastropexy as an antireflux procedure and its mechanism of action were studied by manometry and cinefluorography in a canine model. Gastroesophageal incompetence was produced in 13 dogs by dividing the vagi below the diaphragm and displacing the gastroesophageal junction into the chest. Reflux was associated with a decrease in the lower esophageal sphincter (LES) pressure measurements and in its response to abdominal compression. Posterior gastropexy done in seven dogs, improved both the resting and compression pressures in the LES, increased the length of the LES, and corrected reflux in five dogs. Replacement of the LES in the abdomen and crural (Allison) repair resulted in a similar increase in LES pressures and restored competence in four of the six animals. Neither procedure was able to restore the LES response to abdominal compression. Posterior gastropexy, like Allison repair, improves LES function by replacing it below the diaphragm, but does not produce a new valve.