Prolonged neutropenia after irinotecan-based chemotherapy in a child with polymorphisms of UGT1A1 and SLCO1B1

Genetic polymorphisms of uridine diphosphate glucuronosyl transferase 1A1 (UGT1A1), and SLCO1B1 coding organic anion-transporter polypeptide 1B1, are independent risk factors known to increase irinotecan toxicity in adults. Although combined occurrence of polymorphisms in these 2 genes is likely to influence susceptibility to irinotecan toxicity, data are scarce, especially in children. We report an 11-year-old female with severe and prolonged neutropenia after irinotecan-based chemotherapy. The patient's genotyping revealed polymorphisms in both UGT1A1 and SLCO1B1. To our knowledge, this is the first case report of combined genotyping of both UGT1A1 and SLCO1B1 in a child with severe irinotecan toxicity.

Prevalence and risk factors for diabetic retinopathy: a population-based assessment from Theni District, south India

AIMS

To estimate the prevalence of diabetic retinopathy (DR) and the possible risk factors associated with DR, in a population of south India.

METHODS

A cross-sectional sample of subjects aged 30 years and older was selected using a cluster sampling technique from Theni district of Tamilnadu state. Eligible subjects were identified through a door-to-door survey and fasting blood glucose estimation. History of diabetes was elicited, and height, weight and blood pressure were measured for all subjects. Ocular examinations including visual acuity and anterior and posterior segment examinations were performed at preselected sites within clusters.

RESULTS

Among the 25 969 persons screened for diabetes mellitus (DM), 2802 (10.8%) (95% CI 9.3 to 12.2%) were found to have DM. DR was detected in 298 (1.2%) of 25 969 subjects. The age-gender-adjusted prevalence of DR is 0.05% (95% CI 0.04 to 0.06%) for rural and 1.03% (95% CI 0.89 to 1.12%) for urban areas. The overall age-gender-cluster adjusted prevalence of DR was 0.74% (95% CI 0.66 to 0.83%). Diabetic retinopathy was present in 12.2% (95% CI 10.4 to 14.1%) of the DM population.

CONCLUSION

Adequate training of ophthalmologists in treating DR and improvement in eye-care infrastructure are needed to tackle this major public health problem in India.

Immunologic, clinical, and radiologic status 14 months after cessation of natalizumab therapy

OBJECTIVE

Natalizumab is a humanized recombinant monoclonal antibody against very late activation antigen-4 approved for the treatment of patients with multiple sclerosis (MS). A phase II study failed to demonstrate a difference between natalizumab treatment groups and the placebo group with regard to gadolinium enhancing lesions on MRI 3 months after discontinuation of therapy. The objective of this study was to assess clinical MS disease activity, surrogate disease markers on MRI, immunologic parameters in peripheral blood and CSF, as well as safety in patients with MS after discontinuation of natalizumab therapy.

METHODS

This study is a longitudinal and serial cross-sectional assessment, in which 23 patients who were treated with natalizumab in the context of two phase III clinical trials were originally enrolled. A subgroup of patients was followed over 14 months. The annual relapse rate, neurologic disease progression assessed by the Expanded Disability Status Scale, disease surrogate markers on MRI, cellular and humoral immune markers in peripheral blood and CSF, and adverse events of the drug were monitored.

RESULTS

With regard to clinical disease activity, neuroimaging, and immune responses, the majority of patients in our cohort were stable. Decreased lymphocyte cell numbers and altered cell ratios returned to normal 14 months after cessation of natalizumab. No infectious complications were observed.

CONCLUSION

This is the first long-term follow-up of patients who discontinued natalizumab. We did not observe a clinical, radiographic, or immunologic rebound phenomenon after discontinuation of natalizumab therapy.

Induced sputum improves the diagnosis of pulmonary tuberculosis in hospitalized patients in Gaborone, Botswana

SETTING

Low sensitivity of acid-fast bacilli (AFB) sputum smears and absence of productive cough are obstacles to the diagnosis of pulmonary tuberculosis (PTB) in hospitals that lack access to bronchoscopy.

OBJECTIVES

To evaluate induced sputum, gastric content, blood and urine specimens to improve PTB diagnosis in patients not diagnosed by expectorated sputum AFB smears.

DESIGN

Patients admitted to the medical wards of a large public hospital in Gaborone, Botswana, were prospectively enrolled if they had symptoms consistent with PTB, an abnormal chest radiograph, were treated empirically with anti-tuberculosis chemotherapy or had no improvement on antibiotics, and had a non-productive cough or AFB smear-negative sputum. Induced sputum was stained for AFB and Mycobacterium tuberculosis cultures were performed on induced sputum, gastric contents, urine and blood.

RESULTS

Of 140 patients meeting the enrollment criteria, 113 (81%) were human immunodeficiency virus (HIV) positive. Fifty-seven (41%) had PTB based on positive cultures from one or more sites, including 48 (84%) from induced sputum, 17 (30%) urine, 13 (23%) gastric contents and 7 (12%) blood. AFB smears were positive in only 18 (32%) culture-proven PTB cases.

CONCLUSION

Induced sputum cultures greatly enhanced M. tuberculosis detection in patients with a high prevalence of HIV/AIDS in a hospital without access to bronchoscopy.

Teleophthalmology-based rural eye care in India

Undoubtedly, blindness is a major trauma, which affects an individual not only physically but also emotionally. There are approximately 46 million visually impaired people throughout the world. It is becoming a global problem. In India alone, 19 million people are totally blind or else have visual defects. Out of this 19 million, 15 million reside in rural areas. India is among the countries which suffers from a shortage of doctors. There are only about 12,000 ophthalmologists in India, with most concentrating their practice in urban localities. Additionally, the inadequate infrastructures of roads, telecommunication, transport and financial status of the patients make it even more difficult to provide health care in rural areas. Teleophthalmology is a new branch of telemedicine that offers solutions to this serious problem. This paper discusses Indian teleophthalmology projects known as Sankara Netralaya Teleophthalmology Project (SNTOP) and Aravind Teleophthalmology Network (ATN). These have proven successful in the state of Tamilnadu, India, both in rural and secondary healthcare centers.

Dissociation of neuropathologic findings and cognition: case report of an apolipoprotein E epsilon2/epsilon2 genotype

BACKGROUND

The apolipoprotein E (APOE) epsilon2 allele has been suggested as having a protective effect and delaying the age at onset of Alzheimer disease.

OBJECTIVE

To describe a dissociation between neuropathologic findings with normal cognition in a woman with severe Alzheimer disease with the APOE epsilon2/epsilon2 genotype.

DESIGN

Case report from a community-based prospective study of persons 90 years or older (The 90+ Study).

PARTICIPANT

A 92-year-old woman without dementia with the APOE epsilon2/epsilon2 genotype who lived independently without significant cognitive or functional loss and was a participant in The 90+ Study. She died in December 2004, and postmortem examination of her brain was performed.

INTERVENTION

Neurologic examination and a battery of neuropsychological tests were performed 6 months and 1 month before death. Neuropathologic examination included Braak and Braak staging for senile plaques and neurofibrillary tangles.

RESULTS

Neuropathologic examination of the brain revealed advanced senile plaque and neurofibrillary tangle disease consistent with a high likelihood of Alzheimer disease. At clinical evaluation, the participant demonstrated no dementia and only mild cognitive deficits.

CONCLUSIONS

The APOE genotype may have contributed to maintenance of cognition despite advanced neuropathologic findings of Alzheimer disease. This case suggests that the APOE epsilon2 isoform may have a protective effect against cognitive decline in Alzheimer disease that may be independent from senile plaques and neurofibrillary tangles.

Characterization of an 18,166 EST dataset for cassava (Manihot esculenta Crantz) enriched for drought-responsive genes

Cassava (Manihot esculenta Crantz) is a staple food for over 600 million people in the tropics and subtropics and is increasingly used as an industrial crop for starch production. Cassava has a high growth rate under optimal conditions but also performs well in drought-prone areas and on marginal soils. To increase the tools for understanding and manipulating drought tolerance in cassava, we generated expressed sequence tags (ESTs) from normalized cDNA libraries prepared from dehydration-stressed and control well-watered tissues. Analysis of a total of 18,166 ESTs resulted in the identification of 8,577 unique gene clusters (5,383 singletons and 3,194 clusters). Functional categories could be assigned to 63% of the unigenes, while another approximately 11% were homologous to hypothetical genes with unclear functions. The remaining approximately 26% were not significantly homologous to sequences in public databases suggesting that some may be novel and putatively specific to cassava. The dehydration-stressed library uncovered numerous ESTs with recognized roles in drought-responses, including those that encode late-embryogenesis-abundant proteins thought to confer osmoprotective functions during water stress, transcription factors, heat-shock proteins as well as proteins involved in signal transduction and oxidative stress. The unigene clusters were screened for short tandem repeats for further development as microsatellite markers. A total of 592 clusters contained 646 repeats, representing 3.3% of the ESTs queried. The ESTs presented here are the first dehydration stress transcriptome of cassava and can be utilized for the development of microarrays and gene-derived molecular markers to further dissect the molecular basis of drought tolerance in cassava.

Response to trans-arterial chemoembolization prior to orthotopic liver transplantation or hepatic resection in patients with hepatocellular carcinoma

15114

Background: Trans-arterial chemoembolization (TACE) is often used as pre-operative therapy for patients with hepatocellular carcinoma (HCC) prior to orthotopic liver transplantation (OLT) or hepatic resection (HR). However, the benefit of response to TACE on overall survival (OS) and progression free survival (PFS) remains unclear. Methods: Complete data was available for 24 patients with HCC who underwent TACE prior to either OLT or HR from 1998–2006. Known prognostic factors including tumor size, histology, number of nodules, Child-Pugh class, Okuda stage, MELD score, CLIP score were recorded. Clinical features before and after TACE were identified and tested by univariate analysis. Results: The mean patient age was age 51 years (range 31–65). Underlying diagnoses included: HBV (17%), HCV (54%), alcohol abuse (63%), cryptogenic (8%), nonalcoholic steotohepatitis (4%). The mean maximum tumor diameter was 6.2 cm (range 1.6–16.1 cm), with 13 tumors (54%) measuring >5 cm. The median number of lesions were 2 (range 1 - 7). The Milan criteria was met in 15 patients (63%). Eighteen subjects underwent OLT, while 6 had HR. Median PFS was 35 months (m) (95% C.I. 17–58 m). One- and three-year OS were 95.8% and 73%, respectively. TACE was performed within a mean time of 2.5 months from diagnosis (range 0.5–9 m). Post-TACE, eleven subjects demonstrated a biologic response, defined as decrease in serum alfa-fetoprotein (AFP) by >50%, or reduction in AFP level to <10 ng/mL. However, biologic response did not predict for improved PFS (p =0.41). Additionally, nine patients had a radiographic response to TACE as measured by RECIST criteria, but this also did not predict for improved PFS (p = 0.79). Only tumor size >5 cm (p = 0.04) and CLIP score (p = 0.01) were found to be independent predictors of improved PFS. Conclusions: Neither radiographic nor biologic responses to TACE appear to serve as selection criteria for OLT or HR. Those patients who fail to demonstrate response to TACE should not necessarily be denied surgical therapy. Larger, prospective trials are needed to better evaluate which patients will benefit most from TACE prior to OLT or HR.

No significant financial relationships to disclose.

Morphological features of TMPRSS2-ERG gene fusion prostate cancer

The TMPRSS2-ETS fusion prostate cancers comprise 50-70% of the prostate-specific antigen (PSA)-screened hospital-based prostate cancers examined to date, making it perhaps the most common genetic rearrangement in human cancer. The most common variant involves androgen-regulated TMPRSS2 and ERG, both located on chromosome 21. Emerging data from our group and others suggests that TMPRSS2-ERG fusion prostate cancer is associated with higher tumour stage and prostate cancer-specific death. The goal of this study was to determine if this common somatic alteration is associated with a morphological phenotype. We assessed 253 prostate cancer cases for TMPRSS2-ERG fusion status using an ERG break-apart FISH assay. Blinded to gene fusion status, two reviewers assessed each tumour for presence or absence of eight morphological features. Statistical analysis was performed to look for significant associations between morphological features and TMPRSS2-ERG fusion status. Five morphological features were associated with TMPRSS2-ERG fusion prostate cancer: blue-tinged mucin, cribriform growth pattern, macronucleoli, intraductal tumour spread, and signet-ring cell features, all with p-values < 0.05. Only 24% (n=30/125) of tumours without any of these features displayed the TMPRSS2-ERG fusion. By comparison, 55% (n=38/69) of cases with one feature (RR=3.88), 86% (n=38/44) of cases with two features (RR=20.06), and 93% (n=14/15) of cases with three or more features (RR=44.33) were fusion positive (p<0.001). To our knowledge, this is the first study that demonstrates a significant link between a molecular alteration in prostate cancer and distinct phenotypic features. The strength of these findings is similar to microsatellite unstable colon cancer and breast cancer involving BRCA1 and BRCA2 mutations. The biological effect of TMPRSS2-ERG overexpression may drive pathways that favour these common morphological features that pathologists observe daily. These features may also be helpful in diagnosing TMPRSS2-ERG fusion prostate cancer, which may have both prognostic and therapeutic implications.

Role of the unfolded protein response in cell death

Unfolded protein response (UPR) is an important genomic response to endoplasmic reticulum (ER) stress. The ER chaperones, GRP78 and Gadd153, play critical roles in cell survival or cell death as part of the UPR, which is regulated by three signaling pathways: PERK/ATF4, IRE1/XBP1 and ATF6. During the UPR, accumulated unfolded protein is either correctly refolded, or unsuccessfully refolded and degraded by the ubiquitin-proteasome pathway. When the unfolded protein exceeds a threshold, damaged cells are committed to cell death, which is mediated by ATF4 and ATF6, as well as activation of the JNK/AP-1/Gadd153-signaling pathway. Gadd153 suppresses activation of Bcl-2 and NF-kappaB. UPR-mediated cell survival or cell death is regulated by the balance of GRP78 and Gadd153 expression, which is coregulated by NF-kappaB in accordance with the magnitude of ER stress. Less susceptibility to cell death upon activation of the UPR may contribute to tumor progression and drug resistance of solid tumors.

Relation of optical coherence tomography and unusual angiographic leakage patterns in central serous chorioretinopathy

PURPOSE

To investigate the anatomic basis of atypical angiographic leaks in central serous chorioretinopathy (CSC) with optical coherence tomography (OCT).

METHODS

Fluorescein angiography (FA) and OCT were performed in three eyes of three patients (two men, one woman) with CSC. The angiographic leaks were treated with transpupillary thermotherapy (TTT) in two patients with long-standing CSC. The investigations were repeated in the treated patients during follow-up visits.

RESULTS

Clinically, all patients demonstrated typical CSC; the female patient had subretinal fibrin under the detachment. FA showed unusual leakage patterns and OCT revealed bridging tissue connecting the pigment epithelial detachment (PED) to the overlying detached retina in all patients. CSC resolved completely in the two patients who underwent TTT along with normalization of the OCT findings. In one patient re-evaluated before complete resolution of CSC, OCT showed a flattened PED with disappearance of the bridging tissue and persistent serous detachment. FA demonstrated conversion of the previously atypical leak into a classic 'smokestack' configuration. Over the next month, leakage resolved completely. CSC and the anatomical findings persisted in the untreated patient.

CONCLUSION

OCT identified a potential anatomic basis for unusual angiographic leakage pattern in all three cases of CSC evaluated.

Surgical outcomes for vitrectomy in Eales' disease

AIM

To present and analyse the anatomical and functional outcomes for vitrectomy in Eales' disease.

METHODS

This retrospective case series enrolled 63 patients (71 eyes) who underwent pars plana vitrectomy (PPV) for the complications of Eales' disease. Indications included nonclearing vitreous haemorrhage (VH) with/without epiretinal membranes in 49 (69%) eyes, and retinal detachments (RD) involving/threatening macula in 22 (31%). Additional procedures (scleral buckling; gas/oil tamponade) were performed at surgeon's discretion. Minimum follow-up was 6 months. The primary outcome measures were change in best-corrected visual acuity (BCVA) and posterior segment status.

RESULTS

The mean age of the patients was 29.6 years (range: 15-70 years); 60 were male (95%). Preoperatively, posterior vitreous detachment (PVD) existed in 28 (39.4%) eyes. Forty (56.3%) eyes underwent only PPV; the rest required additional surgical procedures (q.v.). The mean baseline BCVA (1/60) improved to 6/24 postoperatively (P<0.0001). Fifty-four eyes of 50 patients (76%) showed an improvement of > or =2 equivalent Snellen lines; six eyes (four patients) remained stable (+/-1 line); visual acuity worsened in 11 eyes (nine patients). The mean final BCVA was similar in eyes operated for VH and RD (P=0.08); but the magnitude of change from baseline was greater in the VH group (P=0.009). PVD had a borderline association with final BCVA (P=0.056); but did not influence the functional/anatomical improvement. Thirteen eyes required repeat interventions; 11 (15.49%) eyes experienced surgical failure.

CONCLUSIONS

Although surgical outcomes in Eales' disease depend on preoperative PVD/RD to some extent; good results are possible in the presence of incomplete PVD and tractional sequelae.

Functional roles of immature dendritic cells in impaired immunity of solid tumour and their targeted strategies for provoking tumour immunity

Dendritic cells play a crucial role in initiating tumour immunity as well as in the immune response for invading foreign pathogens such as bacteria and viruses. For bacterial and viral infections, the immature dendritic cells (iDCs) residing in peripheral tissues are efficiently activated and matured by pathogen signals for performing the immune response. In contrast, for self-antigens, the naive T cells are not activated by iDCs but proceed to anergy/deletion, and the generation of regulatory T cells for immune tolerance. The induction of immune response and tolerance is regulated strictly by iDCs as the sensor for homeostasis of immune response in the host. Despite the identification of some tumour antigens, tumour immunity is not provoked successfully. Even though there are some critical obstacles to inhibit effective tumour immunity, tumour cells are able to exploit the functional roles of iDCs for tumour progression, which are induced by tumour-derived soluble factors such as vascular endothelial growth factor (VEGF) and functionally modulated in the microenvironment. The iDCs still remain as the critical target for provoking tumour immunity. In this review, the functional roles of tumour-associated iDCs and the strategy for targeting iDCs in effective tumour immunity for the cancer patient are discussed.