The efficacy of sirolimus in the treatment of patients with refractory uveitis

AIMS

To determine the efficacy of sirolimus in the treatment of patients with severe non-infectious uveitis.

METHODS

Eight patients with severe non-infectious uveitis were recruited to an open study. Inclusion criteria were limited to patients whose disease was not controlled with at least two or more separate steroid sparing immunosuppressants (either because of unacceptable side effects or ineffectiveness of the drug) or who required regular doses of corticosteroids either as high dose systemic or orbital floor injections in order to control their disease. Intraocular inflammation, visual acuity, symptoms, corticosteroid burden, drug toxicity, and side effects were monitored.

RESULTS

Sirolimus therapy was effective in five of the eight patients, all of whom had their dose of corticosteroids reduced or discontinued. Treatment in three patients was considered a failure as it caused intolerable side effects and/or failed to control the uveitis. Side effects were common and were typically gastrointestinal or cutaneous in nature. The severity of symptoms was dose dependent in most cases and occurred at trough blood levels above 25 ng/ml.

CONCLUSION

Sirolimus is an effective and potent immunosuppressive treatment in the majority of patients with non-infectious uveitis and can reduce the need for long term supplementary corticosteroid therapy. Further studies are required to establish the long term efficacy and safety of sirolimus alone or in combination with other steroid sparing immunosuppressants.

Limbal epithelial crypts: a novel anatomical structure and a putative limbal stem cell niche

BACKGROUND/AIMS

There is substantial evidence that mammalian epithelial stem cells are located within well defined niches. Although the corneoscleral limbus is acknowledged as the site of corneal epithelial stem cells no anatomical niche for such cells has yet been described. The authors undertook to re-evaluate the microanatomy of the limbus in order to identify possible sites that may represent a stem cell niche.

METHODS

Systematic serial 5-7 microm sections of human corneoscleral segments obtained from cadaver donors, were examined. The sections were stained with haematoxylin and eosin or toludine blue. Sections with specific areas of interest were further examined immunohistologically for the corneal epithelial marker cytokeratin 14 and the "stem cell" marker ABCG2 transporter protein.

RESULTS

Distinct anatomical extensions from the peripheral aspect of the limbal palisades were identified. These consist of a solid cord of cells extending peripherally or circumferentially. The cells stained positive for CK14 and ABCG2.

CONCLUSIONS

A novel anatomical structure has been identified at the human limbus, which demonstrates characteristics of being a stem cell niche. The authors have termed this structure the limbal epithelial crypt.

Novel dextran–spermine conjugates as transfecting agents: comparing water-soluble and micellar polymers

Recently, a novel cationic polymer, dextran-spermine (D-SPM) was developed for gene delivery. An efficient transfection was obtained using this polycation for a variety of genes and cell lines in serum-free or serum-poor medium. However, transfection using the water-soluble D-SPM-based polyplexes decreased with increasing serum concentration in cell culture in a concentration-dependent manner, reaching 95% inhibition at 50% serum in the cell growth medium. In order to overcome this obstacle, oleyl derivatives of D-SPM (which form micelles in aqueous phase) were synthesized at 1, 10, and 20 mol% of oleyl moiety to polymer epsilon-NH2 to form N-oleyl-D-SPM (ODS). Polyplexes based on ODS transfected well in medium containing 50% serum. Comparison with polyplexes based on well-established polymers (branched and linear polyethyleneimine) and with DOTAP/Cholesterol lipoplexes showed that regarding beta-galactosidase transgene expression level and cytotoxicity in tissue culture, the D-SPM and ODS compare well with the above polyplexes and lipoplexes. Intracellular trafficking using FITC-labeled ODS and Rhodamine-labeled pGeneGrip plasmid cloned with hBMP2 monitored by confocal microscopy revealed that during the transfection process the fluorescent-labeled polymer concentrates in the Golgi apparatus and around the nucleus, while the cell cytoplasm was free of fluorescent particles, suggesting that the polyplexes move in the cell toward the nucleus by vesicular transport through the cytoplasm and not by a random diffusion. We found that the plasmids penetrate the cell nucleus without the polymer. Preliminary results in zebra fish and mice demonstrate the potential of ODS to serve as an efficient nonviral vector for in vivo transfection.

The efficacies of affected-limb care with penicillin, diethylcarbamazine, the combination of both drugs or antibiotic ointment, in the prevention of acute adenolymphangitis during bancroftian filariasis

Repeated attacks of adenolymphangitis (ADL) contribute significantly to the progression of chronic lymphoedema in lymphatic filariasis. They are a cause of stigma and, since they may prevent work and require treatment for which payment must be made, of economic loss. The aim of the present study was to improve the treatment of ADL attacks, which is currently mostly empirical. In a double-blind, placebo-controlled, clinical study, 150 subjects who had each suffered at least two ADL attacks in the preceding year were enrolled and randomly allocated to a programme of self-care of the affected limb (after an intensive training programme) and one of five treatments for 12 months. The subjects were supplied with tablets and ointment so that they could take oral penicillin (800 mg/day), oral diethylcarbamazine (DEC; 1 mg/kg.day) or both of these drugs (at the same doses), or apply framycetin ointment to the affected limb, or just take placebo tablets and apply placebo (zinc-oxide) ointment. Placebo tablets and placebo ointment were used so that neither the subjects nor those assessing the responses to treatment were aware of the treatment arm to which each subject had been assigned. The subjects were requested to continue with the affected-limb care after they had stopped taking the tablets and applying the cream, and were followed-up for 24 months from the first treatment.Overall, the mean incidence of ADL attacks decreased from 2.7 episodes/person-year in the pre-treatment year to just 0.38 episode/person-year during the treatment year (P< 0.01). The greatest reduction in incidence was seen in the 58 subjects who received penicillin (with or without DEC). Even in the placebo group, however, the incidence of ADL in the treatment year was significantly lower than that seen in the pre-treatment year, indicating that affected-limb care on its own helps to prevent some attacks. In all groups except the placebo, the incidence of ADL attacks in the year post-treatment exceeded that seen in the treatment year, indicating that chemoprophylaxis needs to be continued for more than a year if such attacks are to be prevented. In most (84%) of the attacks recorded, titres of anti-streptococcal antibodies were seen to be elevated (compared with those recorded during convalescence),indicating that streptococci have a role in the aetiology of ADL. It is recommended that a combination of penicillin prophylaxis and affected-limb care be incorporated into filariasis-control programmes, to decrease morbidity.

Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India

AIMS

To determine whether current and postpartum maternal depression and low maternal intelligence are risk factors for malnutrition in children.

METHODS

In rural South India 72 children with malnutrition were identified from a central register; 72 controls were matched for age, gender, and residence.

RESULTS

Major depression in the postpartum period (OR 5.0, 95% CI 1.0 to 24.0), current major depression (OR 3.2, 95% CI 1.1 to 9.5), and low maternal intelligence (OR 3.8, 95% CI 1.3 to 11.1) were associated with malnutrition in the child. Low birth weight (OR 2.9, 95% CI 1.2 to 6.8) was also significantly associated with infant malnutrition. Conditional logistic regression adjusting for all other determinants yielded the following results: major depression during the postpartum period (OR 7.8; 95% CI 1.6 to 38.51), current major depression (OR 3.1; 95% CI 0.9 to 9.7), low maternal intelligence (OR 4.6; 95% CI 1.5 to 14.1), and low birth weight (OR 2.7; 95% CI 2.5 to 6.8). The interactions between current maternal depression and low birth weight and between postpartum depression and low maternal intelligence were statistically significant. The level of maternal intelligence was associated with nutritional status. The severity of malnutrition was also significantly associated with major depression during the postpartum period and low maternal intelligence.

CONCLUSION

There is evidence for an association between postpartum maternal depression, low maternal intelligence, and low birth weight with malnutrition in children aged 6-12 months.

Epithelial cell characteristics of cultured human limbal explants

AIM

To determine the immunohistochemical characteristics of putative corneal epithelial stem cells remaining on limbal explants maintained in culture.

METHODS

Human limbal explant cultures were generated from 25 residual corneoscleral donor rims following penetrating keratoplasty. Serial sections of these explants were studied using immunohistochemical techniques with a panel of antibodies, on day 0 and 1, 2, and 3 weeks.

RESULTS

The number of epithelial cells expressing cytokeratin 19 and vimentin increased with duration in culture, while the number of cells expressing cytokeratin 3 decreased. Connexin 43 expression was lost by 1 week in culture. p63 was expressed by cells that had migrated around the explant and the number of p63 positive cells decreased with longer duration in culture. The explants were initially negative for Ki67, but the epithelial cells were positive at 1 week, and expression of Ki67 was progressively lost with increasing duration in culture. The initial uniform staining of the epithelium for epidermal growth factor receptor and alpha enolase remained unchanged at 3 weeks.

CONCLUSIONS

There is an expansion of less differentiated (cytokeratin 3 negative and CK19/vimentin positive) epithelial cells on corneoscleral explants maintained in culture for 3 weeks. The pattern of expression of p63 noted in this study does not support the suggestion that it is a marker of limbal stem cells. The decline in p63 and Ki67 expression among the epithelial cells of the cultured explant button implies that as the epithelial sheet outgrowing from the explant button reaches confluence, the proliferative status of the cells remaining on the explant button declines. These findings are of clinical relevance as explants of limbal tissue are used in limbal stem cell transplantation. There is no information available to date on the fate of epithelial cells on such explants. This study provides some insight into this and suggests that an expansion of the stem cell pool or its progeny may occur in limbal explants.

Ocular surface epithelium induces expression of human mucosal lymphocyte antigen (HML-1) on peripheral blood lymphocytes

BACKGROUND/AIMS

Peripheral blood CD8+ lymphocytes that home to mucosal surfaces express the human mucosal lymphocyte antigen (HML-1). At mucosal surfaces, including the ocular surface, only intraepithelial CD8+ lymphocytes express HML-1. These lymphocytes are retained in the intraepithelial compartment by virtue of the interaction between HML-1 and its natural ligand, E-cadherin, which is expressed on epithelial cells. The purpose of this study was to determine whether ocular surface epithelial cells (ocular mucosa) could induce the expression of human mucosal lymphocyte antigen on peripheral blood lymphocytes.

METHODS

Human corneal and conjunctival epithelial cells were co-cultured with peripheral blood lymphocytes. Both non-activated and activated lymphocytes were used in the experiments. After 7 days of incubation, lymphocytes were recovered and analysed for the antigens CD8/HML-1, CD4/HML-1, CD3/CD8, CD3/CD4, CD3/CD25, CD8/CD25, and CD4/CD25 by flowcytometry.

RESULTS

Significant statistical differences were observed in the CD8/HML-1 expression when conjunctival epithelial cells were co-cultured with non-activated and activated lymphocytes (p = 0.04 for each) and when corneal epithelial cells were co-cultured with non-activated lymphocytes (p = 0.03). Significant statistical difference in CD4/HML-1 expression was observed only when conjunctival epithelial cells were co-cultured with activated lymphocytes (p = 0.02).

CONCLUSION

Ocular surface epithelial cells can induce the expression of human mucosal lymphocyte antigen on CD8+ (and to some extent on CD4+) lymphocytes. This may allow the retention of CD8+ and CD4+ lymphocytes within the epithelial compartment of the conjunctiva and play a part in mucosal homing of lymphocytes.

Stem cell differentiation and the effects of deficiency

Stem cells have several unique attributes, the key features being their potency and plasticity. They have the ability to give rise to multiple cell lineages and to transdifferentiate into totally different cell type(s) when relocated to a novel stem cell niche. Most self-renewing tissues are served by stem cells. At the ocular surface, the corneo-scleral limbus is believed to provide the niche for corneal epithelial stem cells. A large body of circumstantial evidence, both clinical and basic, supports this view. However, specific identification of limbal stem cells has proved elusive. Cytokeratin markers, vimentin, epidermal growth factor receptors, p63, and others have been used to identify epithelial cell populations at the limbus, which could harbour putative stem cells. In contrast, none of the known haematopoietic stem cell markers namely, CD34 and CD133, stain any specific subset of corneal or limbal epithelial cells. Singly or collectively, none of these markers point to any unique cell(s) that could be regarded as stem cells, supporting the notion that the corneal epithelium is served by 'committed progenitors' rather than by stem cells. Disease or destruction of the corneo-scleral limbus is associated with consequential events that eventually lead to visual impairment or blindness. Conjunctivalisation and vascularisation of the corneal surface and persistent or recurring epithelial defects are hallmarks of limbal deficiency.

Symptoms related to the reproductive tract and mental health among women in rural southern India

BACKGROUND

Symptoms related to the reproductive tract and symptoms of psychological distress are commonly seen in women living in South Asia. This study aimed to determine the association, if any, between symptoms related to the reproductive tract and mental health among women in rural southern India.

METHODS

The study was conducted in a community setting of a comprehensive community health programme in a development block in rural southern India. It was a cross-sectional survey with a nested case-control study. The main outcome measure was the probability of mental distress as assessed by the Tamil version of the General Health Questionnaire-12 (GHQ).

RESULTS

Of the 622 subjects recruited, 150 (24.4%) complained of at least one symptom related to the reproductive tract. The commonest symptom was vaginal discharge (17.5%). Significantly higher scores on the GHQ were associated with the presence of many current and past symptoms related to the reproductive tract, and receiving treatment for the same, even after adjusting for age, education, current marital status and type of house, using multiple regression analysis. GHQ scores were positively correlated with a higher number of current and past symptoms. Significantly higher scores were also associated with greater knowledge about prevention of sexually transmitted diseases and reproductive tract infections. Being currently married and educated were significant protective factors. A nested case-control study was done with the presence of a current common mental disorder as the outcome. Symptoms and other factors dated prior to this outcome were considered potential risk factors. Logistic regression models were developed. The presence of a symptom related to the reproductive tract for more than one month (OR 3.6; 95% CI 1.8, 7.2) and a history of similar symptoms over the past year (OR 2.2; 95% CI 1.3, 3.7) were risk factors for the development of common mental disorders. Higher education (OR 0.5; 95% CI 0.3, 0.7) and being currently married (OR 0.2; 95% CI 0.1, 0.6) were protective factors.

CONCLUSION

The cross-sectional data suggest an association between symptoms pertaining to the reproductive tract and psychological distress. The results of the nested case-control study suggest that symptoms related to the reproductive tract are risk factors for common mental disorders, while education and being currently married are protective factors.

Common mental disorders among primary care attenders in Vellore, South India: nature, prevalence and risk factors

OBJECTIVE

The study examined the nature and prevalence of and the factors associated with common mental disorders in primary care in Vellore, South India.

METHOD

Consecutive attenders (N = 327) to a primary health care facility were recruited.

RESULTS

One hundred and eleven (33.9%) subjects satisfied criteria for common mental disorders. Depression was the common presentation (83.8%). Indicators of low socio-economic status (being in debt, inability to buy food, having less than three square meals per day) and illiteracy were significantly associated with caseness.

CONCLUSIONS

Subjects with common mental disorders are commonly seen in primary health care settings. Illiteracy and poverty are associated with caseness. Primary health care research and policy needs to focus on common mental disorders.

MRI and MRS of Coffin-Lowry syndrome: a case report

MRI and MRS were used to examine the brain and the spine of a Coffin-Lowry syndrome (CLS) patient. There were moderately enlarged lateral and third ventricles and subarachnoid space with prominent Virchow-Robin spaces. MRS of basal ganglia and periventricular white matter was normal.

Training teachers of day care centres for primary ear care

The feasibility of training teachers of day care centres for children (balwadi teachers) to recognize and manage common ear problems was studied so that they could provide primary care for ear related morbidity in the community. A training module was designed, piloted on grass root level workers and used to train 19 balwadi teachers. Their knowledge, skills and technique of examination was assessed following training. Pathways for referral were established between the balwadis, secondary and tertiary hospitals. The knowledge score of the balwadi teachers increased from a mean of 28.4% to 86%; they scored an average of 75% in an assessment of their examination technique. Their sensitivity in identifying overall ear related morbidity was 75%, and 96% in identifying children with ear discharge, specifically. Age, education and experience did not affect the outcome of their training. While it may be premature to comment on the impact of the training, periodic supervision, close monitoring and review sessions would sharpen the skills of the balwadi teachers and improve their efficiency.

Necrotizing fasciitis: an unusual cause

A 76-year-old woman was admitted through the accident and emergency department with a paraumbilical lump of 2 weeks' duration and a sinus which was discharging foul-smelling pus since that morning. One month before this, she was treated for abdominal pain with diarrhoea and vomiting by her GP with loperamide. On examination, she was febrile but was stable. Abdominal examination revealed a 10 cm x 5 cm fluctuant paraumbilical swelling with a sinus discharging foul-smelling pus. The surrounding skin was erythematous with patchy blackened areas. The provisional diagnosis at this stage was of an abdominal wall abscess with a possible colocutaneous fistula.

Severe dysplastic lesions in the colon - how aggressive should we be?

INTRODUCTION: Biopsies of colonic lesions are often reported as showing dysplasia, though in reality some lesions may harbour invasive malignancy. AIM: To assess the risk of underlying invasive malignancy in sessile polyps where biopsies had shown severe dysplasia and also to attempt to define a management strategy in such patients. METHODS: Between 1997 and 2001, 30 patients were diagnosed as having severe dysplasia using Morson's criteria in colonic lesions not amenable for endoscopic polypectomy. Severely dysplastic lesions were completely excised by appropriate surgical measures. RESULTS: Out of 30 patients, 15 had invasive cancers. Surgical intervention involved anterior resections, endoanal excisions, sigmoid colectomies, or abdomino-perineal excisions as deemed appropriate. The lesions ranged in size from 0.5 cm to 13 cm (mean 3.4 cm). There were nine T1 lesions (one of which was T1N1) and two each of T2, T3, T4 lesions (10 Dukes' A, 3 Dukes' B, 2 Dukes' C). Complete resection was confirmed histologically in all cases. One patient had a leak following endoanal excision, which required intervention. There was no mortality. DISCUSSION: This study demonstrates that endoscopic sampling can be misleading and severely dysplastic sessile lesions should be managed along the same principles as followed for invasive cancers, rather than adopting a 'wait and watch' policy with repeated endoscopies, biopsies or piece-meal polypectomies.

Immunity of patients surviving 20 to 30 years after allogeneic or syngeneic bone marrow transplantation

The duration of immunodeficiency following marrow transplantation is not known. Questionnaires were used to study the infection rates in 72 patients surviving 20 to 30 years after marrow grafting. Furthermore, in 33 of the 72 patients and in 16 donors (siblings who originally donated the marrow) leukocyte subsets were assessed by flow cytometry. T-cell receptor excision circles (TRECs), markers of T cells generated de novo, were quantitated by real-time polymerase chain reaction. Immunoglobulin G(2) (IgG(2)) and antigen-specific IgG levels were determined by enzyme-linked immunosorbent assay. Infections diagnosed more than [corrected] 15 years after transplantation occurred rarely. The average rate was 0.07 infections per patient-year (one infection every 14 years), excluding respiratory tract infections, gastroenteritis, lip sores, and hepatitis C. The counts of circulating monocytes, natural killer cells, B cells, CD4 T cells, and CD8 T cells in the patients were not lower than in the donors. The counts of TREC(+) CD4 T cells in transplant recipients younger than age 18 years (at the time of transplantation) were not different from the counts in their donors. In contrast, the counts of TREC(+) CD4 T cells were lower in transplant recipients age 18 years or older, even in those with no history of clinical extensive chronic graft-versus-host disease, compared with their donors. The levels of total IgG(2) and specific IgG against Haemophilus influenzae and Streptococcus pneumoniae were similar in patients and donors. Overall, the immunity of patients surviving 20 to 30 years after transplantation is normal or near normal. Patients who received transplants in adulthood have a clinically insignificant deficiency of de novo-generated CD4 T cells, suggesting that in these patients the posttransplantation thymic insufficiency may not be fully reversible.