Liposomal amphotericin B (Fungisome) for the treatment of cryptococcal meningitis in HIV/AIDS patients in India: a multicentric, randomized controlled trial

BACKGROUND

There is need to investigate the use of liposomal amphotericin B in cryptococcal meningitis in India.

AIMS

To compare the efficacy, safety, duration of treatment and cost of two doses of liposomal amphotericin B (Amp B) (Fungisome) in cryptococcal meningitis in HIV/AIDS patients.

SETTINGS AND DESIGN

Prospective, randomized, multicenter study in tertiary care hospitals across India.

MATERIALS AND METHODS

Adult patients with culture-proven cryptococcal meningitis with HIV/AIDS were randomized to receive either 1 (Group A) or 3 mg/kg/day of Fungisome (Group B). Clinical efficacy and tolerability, laboratory evaluations and mycological response were assessed daily, twice weekly and weekly respectively. The patients were assessed at four and eight-week follow-up.

STATISTICS

We calculated average and standard deviation for the various parameters.

RESULTS

The time to show clinical response was 13.66 days (1 mg) and 9.55 days (3 mg). In Group B (n=6 complete response), 50% patients responded within one week by microbial conversion, 83% in two weeks and 100% in three weeks. Patients with 1 mg dose (n=4 complete response), none showed microbial conversion within one week, 75% responded in two weeks, whereas one patient took four weeks. The average duration of treatment was 36.5+/-14.4 and 26.5+/-5.89 (S.D.) days in 1 and 3 mg/kg/day respectively. Drug was tolerated with little renal, hepatic or hematological toxicity. The cost was found to be 3.81 lacs and 1.74 lacs with 3mg/kg/day and 1mg/kg/day respectively.

CONCLUSION

Higher dose showed better efficacy and quicker microbial conversion of Cerebrospinal fluid (CSF) (cerebrospinal fluid) than 1 mg/kg/day. It shortened the duration of treatment in days by 27% while drug cost almost doubled (

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN 52812742).

Steroid responsive prolonged thrombocytopenia in dengue

Prolonged thrombocytopenia in a usual case of dengue virus infection is uncommon. Dengue-related thrombocytopenia is self-limiting and responds within 3-5 days. An underlying immunological disorder may be responsible for delayed return of platelet count to a normal level. We present a case of prolonged thrombocytopenia in a case of dengue hemorrhagic fever. The response to steroids suggests a possible immunological dysfunction.

Ion selectivity from local configurations of ligands in solutions and ion channels

Probabilities of numbers of ligands proximal to an ion lead to simple, general formulae for the free energy of ion selectivity between different media. That free energy does not depend on the definition of an inner shell for ligand-counting, but other quantities of mechanistic interest do. If analysis is restricted to a specific coordination number, then two distinct probabilities are required to obtain the free energy in addition. The normalizations of those distributions produce partition function formulae for the free energy. Quasi-chemical theory introduces concepts of chemical equilibrium, then seeks the probability that is simplest to estimate, that of the most probable coordination number. Quasi-chemical theory establishes the utility of distributions of ligand-number, and sharpens our understanding of quasi-chemical calculations based on electronic structure methods. This development identifies contributions with clear physical interpretations, and shows that evaluation of those contributions can establish a mechanistic understanding of the selectivity in ion channels.

An integrative computational model for intestinal tissue renewal

OBJECTIVES

The luminal surface of the gut is lined with a monolayer of epithelial cells that acts as a nutrient absorptive engine and protective barrier. To maintain its integrity and functionality, the epithelium is renewed every few days. Theoretical models are powerful tools that can be used to test hypotheses concerning the regulation of this renewal process, to investigate how its dysfunction can lead to loss of homeostasis and neoplasia, and to identify potential therapeutic interventions. Here we propose a new multiscale model for crypt dynamics that links phenomena occurring at the subcellular, cellular and tissue levels of organisation.

METHODS

At the subcellular level, deterministic models characterise molecular networks, such as cell-cycle control and Wnt signalling. The output of these models determines the behaviour of each epithelial cell in response to intra-, inter- and extracellular cues. The modular nature of the model enables us to easily modify individual assumptions and analyse their effects on the system as a whole.

RESULTS

We perform virtual microdissection and labelling-index experiments, evaluate the impact of various model extensions, obtain new insight into clonal expansion in the crypt, and compare our predictions with recent mitochondrial DNA mutation data.

CONCLUSIONS

We demonstrate that relaxing the assumption that stem-cell positions are fixed enables clonal expansion and niche succession to occur. We also predict that the presence of extracellular factors near the base of the crypt alone suffices to explain the observed spatial variation in nuclear beta-catenin levels along the crypt axis.

Perception and knowledge of clinical trials and factors affecting participation of regional and rural cancer patients of North Queensland

e17558

Background: The best treatment option for most cancers is participation in clinical trials. Participation in trials is generally low and among rural patients it is likely to be even lower. The aim of this study was to assess knowledge about and attitudes towards clinical trials among rural and regional cancer patients of North Queensland. Methods: A questionnaire-based survey was conducted in outpatient clinics at the Townsville Cancer Centre on all types of cancer patients. Results: The mean age of the 178 participants was 56 years and 45.4% lived in rural or remote areas. Median distance to the trial centre (Townsville) for rural participants was 180 km (range 80 - 1300 km). Being asked whether they would take part in a RCT, 13.2% of participants said no, 56.3% said yes, and 30.5% were unsure. There were no significant relationships between willingness to participate and rurality (p = 0.896) or education level (p = 0.943). For the majority of patients, the number of clinic visits and blood tests required did not matter. Cost of travel (41.1% rural/remote; 23.5% regional; p < 0.001) and the need for family or friends to accompany (38.9% rural/remote; 24.1% regional; p = 0.021) were more important for rural/remote than regional patients as factors affecting participation. Only 16.4% of participants were aware of early studies. After education, percentage of patients willing to participate in phase I and II studies were 57% and 84%, respectively. Rural patients were less willing to participate in phase I studies than regional patients (33.9% vs 52.6%, p = 0.029). Conclusions: Rural patients are as interested in participating in clinical trials as urban patients except for phase 1 trials and should not be excluded because of rurality. Knowledge of trials is poor and there is a need for education early. Cost of travel seems more important for rural patients and as such budgets should include cost of travel to encourage participation of rural patients.

No significant financial relationships to disclose.

Acute leukemia/myelodysplastic syndrome as a sequelae of carcinoma breast: a report of five cases from north India

A second malignant neoplasm has been found to be more frequent than might be expected from the general population rates. Therapy-related myelodysplastic syndrome and acute leukemia are dreaded long-term complications of five cases of hematological malignancies following treatment for successful breast cancer therapy (therapeutic drugs or radiotherapy). We encountered carcinoma from north India over a 7-year period from 1999 to 2005. The patients presented 2-5 years after treatment of breast carcinoma. Three patients underwent surgery and received chemoradiotherapy. One patient received chemotherapy after surgery. One patient underwent only surgery and after 3 years presented with acute myeloid leukemia and bone marrow metastasis of carcinoma of the breast. At the time of presentation, all the patients had either bicytopenia or pancytopenia. A close follow-up with complete blood cell counts of the patients who previously had carcinoma of the breast is suggested for early detection of hematological abnormalities. However, the poor prognosis, limited financial resources and poor health insurance coverage results in few patients and their family members opting for treatment.

Periodic index-modulated plasma waveguide

We demonstrate a wire-obstructed cluster flow technique for making periodically modulated plasma waveguides in hydrogen, nitrogen, and argon with sharp, stable voids as short as 50 microm with a period as small as 200 microm. These gaps persist as the plasma expands for the full lifetime of the waveguide. We demonstrate guided propagation at intensities up to 2 x 10(17) W/cm(2), limited by our laser energy currently available. This technique is useful for quasi-phase matching applications where index-modulated guides are superior to diameter modulated guides.

Trapping and destruction of long-range high-intensity optical filaments by molecular quantum wakes in air

We report the first observation of the strong effect of quantum rotational wave packets in atmospheric air on the long-range filamentary propagation of intense femtosecond laser pulses. In a pump-probe experiment, we find that the probe filament can be sucked into the pump filament's molecular quantum wake and trapped or be destroyed by it.

Chemical warfare agents

Chemical warfare agents (CWA's) are defined as any chemical substance whose toxic properties are utilised to kill, injure or incapacitate an enemy in warfare and associated military operations. Chemical agents have been used in war since times immemorial, but their use reached a peak during World War I. During World War II only the Germans used them in the infamous gas chambers. Since then these have been intermittently used both in war and acts of terrorisms. Many countries have stockpiles of these agents. There has been a legislative effort worldwide to ban the use of CWA's under the chemical weapons convention which came into force in 1997. However the manufacture of these agents cannot be completely prohibited as some of them have potential industrial uses. Moreover despite the remedial measures taken so far and worldwide condemnation, the ease of manufacturing these agents and effectiveness during combat or small scale terrorist operations still make them a powerful weapon to reckon with. These agents are classified according to mechanism of toxicity in humans into blister agents, nerve agents, asphyxiants, choking agents and incapacitating/behavior altering agents. Some of these agents can be as devastating as a nuclear bomb. In addition to immediate injuries caused by chemical agents, some of them are associated with long term morbidities and psychological problems. In this review we will discuss briefly about the historical background, properties, manufacture techniques and industrial uses, mechanism of toxicity, clinical features of exposure and pharmacological management of casualties caused by chemical agents.

Studies of self-organized nanostructures on InP(111) surfaces after low energy Ar+ ion irradiation

We report formation of self organized InP nano dots using 3 keV Ar+ ion sputtering, at 15 degrees incidence from surface normal, on InP(111) surface. Morphology and optical properties of the sputtered surface, as a function of sputtering time, have been investigated by Scanning Probe Microscopy and Raman Scattering techniques. Uniform patterns of nano dots are observed for different durations of sputtering. The sizes and the heights of these nano dots vary between 10 to 100 nm and 20 to 40 nm, respectively. With increasing of sputtering time, t, the size and height of these nano dots increases up to a certain sputtering time t(c). However beyond t(c), the dots break down into smaller nanostructures, and as a result, the size and height of these nanostructures decrease. The uniformity and regularity of these structures are also lost for sputtering beyond t(c). The crossover behavior is also observed in the rms surface roughness. Raman investigations of InP nano dots reveal optical phonon softening due to phonon confinement in the surface nano dots.

KeV ion-induced effective surface modifications on InP

In the present study, we have analyzed the changes in surface morphology leading to formation of periodic structures known as ripples which arise due to an interplay between sputtering and surface diffusion. The 1.5 keV Ar atoms with a flux of 14.8 mA/cm2 are used in the present study. The InP(100) samples were bombarded at an incidence angle of 45 degrees to the normal at a base pressure of 1 x 10(-6) Torr at room temperature with fluences varying from 4 x 10(16) to 3.2 x 10(17) atoms/cm2. The rippled InP(100) surface was characterized with AFM. An increase in the ripple wavelengths, from 60 nm to 150 nm with the fluence has been observed. The width of the ripples varies from 38 nm to 128 nm and ripple amplitude varies from 0.8 nm to 16 nm with increasing fluence. One can control the dimension of the ripples in nano scale by controlling the fluence. Scaling studies have been performed to understand the mechanism responsible for such kind of surface evolution. The roughness parameter, alpha was found to be between 0.65 to 0.75 and the growth parameter, beta, as 1.14 +/- 0.12. The XPS characterization has also been employed to study the changes in the behavior of the InP with varying fluence.

Scaling studies of nano dots formed on InP(111) surfaces via MeV implantation

The scaling parameters have been studied here for InP(111) surfaces that evolve after implantation with MeV ions. The surfaces show the development of nano pattern and kinetic roughening. Growth exponent beta, roughening exponent alpha and the characteristic wavelength have been studied here at several fluences. Scaling parameters suggest that the surface evolution can not be explained by linear Bradley Harper model or by Kuramoto-Sivashinsky model alone.

Cytomegalovirus pneumonia in adult acute lymphoblastic leukemia

Cytomegalovirus (CMV) is an important cause of morbidity and mortality in immunosuppressed patients. Though acute lymphoblastic leukemia (ALL) is an immunosuppressed state, CMV disease has been reported infrequently. We present a patient of adult B lineage ALL who was on maintenance chemotherapy and developed CMV pneumonia. Patient was managed with intravenous ganciclovir and had successful outcome. However, three weeks later patient had a relapse of ALL and died shortly after high dose chemotherapy.