HLA Desensitization Based on Results of the Luminex Technique in Kidney Transplant - A Single-center Experience

Background:

There is little experience of human leucocyte antigen (HLA) desensitization in India based on the Luminex single-antigen bead (SAB) testing. We retrospectively analyzed our patients, who underwent HLA desensitization based on Luminex SAB results.

Method:

Between 2014 and 2018, patients with complement-dependent cytotoxicity cross-match (CDC-XM) negativity but flow cytometry crossmatch (FC-XM) positivity were further analyzed with Luminex SAB for donor-specific antibodies (DSAs). A total of 12 patients who had DSA mean fluorescent intensity (MFI) of >1000 and <10,000 were included in the study. Our protocol for desensitization consisted of plasmapheresis (PP) followed by low dose intravenous immunoglobulin (IV IG) 100 mg/kg and induction with antithymocyte globulin (ATG). Patients were taken for transplant when either MFI was <1000 and/or FC-XM was negative.

Results:

All 12 patients were first transplant and 10 had a history of some sensitizing event; pregnancy in 4, blood transfusions in 4, and both in 2 patients. FC-XM was positive for T-cell in 4, B-cell in 6, and both in 2 patients. On evaluation by Luminex SAB, 6 patients had MFI from 1000 to 2000, and 6 had MFI of >2000. All underwent desensitization successfully. Two patients had an increase in posttransplant DSA titers requiring posttransplant PP. The mean follow-up was 26.6 ± 13.9 months. On follow-up, only one patient developed acute T cell-mediated rejection 1 year after transplant, which responded to pulse steroids. There was no graft or patient loss until the last follow-up.

Conclusion:

This study shows that HLA desensitization is feasible and successful in the Indian setting if patients are properly selected.

Brain Studded with Innumerable Larger Stones: Starry Sky at Night Appearance: Multiple Calcified Giant Tuberculoma with 15 Years of Follow-up

Tuberculosis is rapidly reemerging as a major health problem due to rising incidence of HIV cases across the globe. Central nervous system involvement is rare, but rarely multiple intracerebral granulomas can occur or occasional solitary tuberculoma also develops. The authors report a unique case of 24-year-old woman suffering from pulmonary tuberculosis developed headache and vomiting. Cranial CT scan revealed multiple widespread deposit of intracranial granuloma of sizeable lesion mimicking starry sky at night appearance. Excision of one tuberculoma was done for confirmation of definitive diagnosis, and histopathology was suggestive of tuberculoma. The patient also underwent VP shunt surgery. At last follow-up at 15 years following surgery, she was doing well.

Role of Reconstructive Surgery (RCS) in Improving the Quality of Life of Leprosy Afflicted Persons

Since time immemorial, stigma has been associated with leprosy mainly due to deformity and disability which in turn affects the physical, psychological, social and economical well being of some of the leprosy afflicted persons (LAPs). To prevent and correct deformities Government of India has focused on early diagnosis and appropriate treatment. In addition government has been providing services of Reconstructive Surgery (RCS). RCS corrects the deformity and is expected to help in reducing the stigma in society and reintegrate the affected persons in to society so that they become economically self reliant and carry out their normal livelihood activities without any prejudice. As the stigma has cultural background, this study has.been carried out with to assess the existing stigma level in pre RCS in society in parts of Odisha and compare with that of post RCS. The study was conducted in Sonepur district of Odisha. The sample size is the entire universe of all the 60 patients who had undergone the RCS process, during these the recent years. The methods adopted for data collection were the tools like questionnaire schedules, interview, observation, FGD and in depth case studies. Almost 86% of these Leprosy afflicted persons (LAPs) were very satisfied due to improvement in acceptance by their family, friend, relatives and society after surgery because of the correction of deformity by RCS as it enabled them to get back into normal life. The economical status improved in 8/60 (13%) after RCS, some becoming capable of earning more than Rs. 10,000/- per month after RCS. To conclude, in this settings of Sonepur (Odisha). RCS appeared to help the LAPs in improving their social acceptance thereby reducing stigma and also improving their economic status thus empowering them to lead their life as a normal human beings. There is need to enlarge and expand these studies to other parts of state/region so that the link with beliefs, type of disabilities and also type of surgery could be better understood and the knowledge generated could be applied to get optimum results.

Biofilm as a virulence marker in Candida species in Nosocomial blood stream infection and its correlation with antifungal resistance

Nosocomial blood stream infections (BSI) due to fungi especially Candida is increasing steadily. A two year prospective study was conducted in the S.C.B. Medical College with an aim to evaluate the species distribution, antifungal susceptibility and biofilm formation of Candida spp. isolated from nosocomial BSIs. 34 Candida spp. were isolated from 359 blood cultures. Antifungal susceptibility was performed by microbroth dilution technique and both visual and spectrophotometric method were used for biofilm detection. C. tropicalis was the common spp. isolated followed by C. parapsilosis and others. Most (92%) of the isolates were susceptible to Amphoterecin-B and highest resistance was observed against Flucytosine (37%) and Fluconazole(35%). Biofilm production and antifungal resistance was observed more in nonalbicans Candida spp.

Electrospun Fe2O3-Al2O3 nanocomposite fibers as efficient adsorbent for removal of heavy metal ions from aqueous solution

In this study, Iron oxide-alumina mixed nanocomposite fiber was prepared by electrospinning method and its performance was evaluated as a heavy metal ion adsorbent. Here boehmite nanoparticle was synthesized by sol-gel method and was impregnated in PVP-iron acetylacetonate solution in a ratio of 1:1:2. These boehmite impregnated polymer solution was electrospun to form nanocomposite polymer fiber. The electrospun nanofiber was sintered at 1000°C for converting it to pure oxide form for further application as adsorbent. Iron oxide-alumina mixed nanocomposite fiber was characterized by UV-vis-DRS, IR, SEM-EDX, TEM, BET and TGA-DTA analytical techniques. Batch adsorption experiments were carried out to study the sorption behavior of Cu(2+), Pb(2+), Ni(2+) and Hg(2+) ions as a function of initial concentration, contact time and pH. The removal percentage was in the order of Cu(2+)<Pb(2+)<Ni(2+)<Hg(2+). The maximum sorption capacities by applying the Langmuir equation were found to be 4.98 mg/g for Cu(2+), 32.36 mg/g for Ni(2+), 23.75 mg/g for Pb(2+) and 63.69 mg/g for Hg(2+) ions. The regeneration studies of mixed nanocomposite adsorbents were also reported here.

A phase IIb actively controlled study with the TGF-beta-2 inhibitor AP 12009 for recurrent or refractory anaplastic astrocytoma

2025

Background: The TGF-β2 antisense phosphorothioate oligonucleotide inhibitor AP 12009 is a targeted anti-tumor therapy for TGF-β2 overexpressing tumors. In three Phase I/II dose escalation studies complete and long-lasting responses were observed in patients with recurrent or refractory anaplastic astrocytoma. Methods: The Phase IIb actively controlled dose finding study G004 is an open-label, randomized trial in adult patients with recurrent or refractory high-grade glioma (HGG) confirmed by central histopathology. 145 patients were randomized into three groups: Low dose AP 12009 (10 μM), high dose AP 12009 (80 μM), or standard chemotherapy, i.e. TMZ (or PCV if TMZ had already failed). Study objective was to compare the efficacy and safety of the three treatment groups. AP 12009 was applied locoregionally by convection- enhanced delivery (CED) with up to 11 treatment cycles (7-day-on, 7-day-off / per cycle). Results: Here we report on patients with recurrent anaplastic astrocytoma (AA, Grade III; GBM patients see separate abstract). 39 AA patients were treated, 12 pts received AP 12009 10 μM (AP-10), 15 pts 80 μM (AP-80), and 12 pts standard chemotherapy (10 pts TMZ, 2 pts PCV). Preliminary safety data reveal no SAEs related to the study drug in the AP-10 and AP-80 groups vs. one in the control group. Survival rates were higher in both AP 12009 groups compared to the chemotherapy group (see table ). In both AP 12009 groups mOS has not yet been reached. Overall survival at present is 28.6 months for the AP-10 group, 24.2 months for the AP-80 group, and 20.2 months for the control group. Dose finding was achieved, as efficacy and safety results for the AP-10 group were superior to those of the AP-80 group (see table ). Conclusion: AP 12009 revealed a positive benefit-risk profile and demonstrated excellent potential as monotherapy for the treatment of recurrent or refractory AA patients, especially for the AP 12009 10 μM group.

[Table: see text]

[Table: see text]

Results of a phase IIb study in recurrent or refractory glioblastoma patients with the TGF-beta-2 inhibitor AP 12009

12521

Background: The antisense phosphorothioate oligonucleotide compound AP 12009 targets TGF-beta2. Since TMZ is now used in the adjuvant setting in GBM there is a high need for new treatment options in recurrence. In three Phase I/II dose escalation trials with AP 12009 in high-grade glioma (HGG) patients complete and long lasting tumor responses had been observed. Methods: The study G004 is an international open-label, randomized, active controlled, dose-finding Phase IIb study. Objective is a comparison of two doses of AP 12009 and standard chemotherapy. A total of 145 patients with histopathologically confirmed recurrent or refractory HGG (WHO Grades III and IV) were randomized into three treatment arms. Patients received treatment with low dose AP 12009 (10 μM), high dose AP 12009 (80 μMM), or standard chemotherapy TMZ or PCV. AP 12009 was applied by convection-enhanced delivery during using 7-day-on, 7-day-off cycles. Maximum number of cycles was 11. Results: Here we report on patients with recurrent or refractory glioblastoma (GBM, WHO Grade IV; AA patients see separate abstract). Out of 95 GBM patients treated, 28 pts received 10 μM AP 12009, 34 pts AP 12009 80 μM, and 33 pts standard chemotherapy (28 TMZ, 5 PCV). Median age differed between treatment groups (see table ). Dose finding was achieved, as efficacy and safety results for the AP-10 group were superior to those of the AP-80 group (see table ). Comparable hazard ratios for survival were seen in the three treatment groups (see table ). Long lasting responses were observed in both AP 12009 groups. Conclusions: The safety profile of AP 12009 in GBM patients was good. The durable responses in both AP 12009 groups and the survival data confirm the proof of concept obtained in Phase I/II trials for treatment of recurrent GBM patients with AP 12009.

[Table: see text]

No significant financial relationships to disclose.

Results of G004, a phase IIb actively controlled clinical trial with the TGF-b2 targeted compound AP 12009 for recurrent anaplastic astrocytoma

1566

Background: In 3 phase I/II dose-escalation studies the TGF-β2 specific compound AP 12009 proved to be well tolerated and revealed an excellent safety profile. Furthermore, antitumor activity including complete tumor remissions was observed. Methods: G004 is an international open-label, actively controlled, dose finding phase IIb trial in adult patients with histopathologically confirmed recurrent high-grade glioma. 145 patients with recurrent anaplastic astrocytoma (AA, WHO grade III) or glioblastoma (GBM, WHO grade IV) were enrolled into the study. Objective of the current phase IIb study is to compare the efficacy and safety of two doses of AP 12009 and standard treatment. Patients were randomized to receive either one of two doses of AP 12009 (10 μM or 80 μM) or standard chemotherapy (TMZ or PCV). AP 12009 was administered intratumorally by CED. 134 patients received treatment and all of them have completed active treatment. Primary endpoint is tumor response by local and central MRI reading and survival. Results: Here we report on patients with recurrent AA (for GBM see separate Abstract). 38 patients with AA (68% male, 32% female; median age 39, range 22–60; median Karnofsky performance status: 90, range 70–100) were treated. 26 patients received AP 12009 (10 μM or 80 μM), 12 patients were treated with TMZ or PCV. Up to now, in 89 patients treated with AP 12009 (both AA and GBM patients) 6 SAEs possibly related to the study drug and 37 procedure related SAEs (92% mild or moderate) were documented. Partial and complete tumor responses were observed. Exact response rates will be determined after central MRI reading is completed. Responses in the AP 12009 groups are long lasting. The results confirm the good safety profile of AP 12009 as well as the efficacy data seen in phase I studies. The median overall survival is not yet reached. Conclusions: The long-term tumor free survival of several patients may actually hint towards a potential to cure some patients with this devastating disease. Phase III clinical trials in both AA and GBM patients are currently in preparation.

[Table: see text]

Results of G004, a phase IIb study in recurrent glioblastoma patients with the TGF-b2 targeted compound AP 12009

1553

Background: In high-grade glioma (HGG), TGF-β2 expression strongly correlates with tumor grade and is highly predictive of disease outcome. The compound AP 12009 inhibits TGF-β2 expression. Preclinical results revealed strong multimodal activity including reversal of TGF-β induced immunosuppression, inhibition of tumor cell migration and proliferation. In 3 preceding phase I/II dose escalation studies, 24 HGG patients had been treated with AP 12009. Methods: G004 is an international open-label, actively controlled, dose finding phase IIb study. Objective is a comparison of two doses of AP 12009 and standard chemotherapy for efficacy and safety. 145 patients with histopathologically confirmed recurrent anaplastic astrocytoma (AA, WHO grade III) or glioblastoma (GBM, WHO grade IV) were randomized into one of 3 treatment arms. 134 patients received treatment AP 12009 10μM, AP 12009 80μM or standard chemotherapy (TMZ or PCV). AP 12009 was applied locoregionally by convection-enhanced delivery during a 6-month active treatment period with 7-day-on, 7-day-off cycles. Primary endpoint is tumor response by local and central MRI reading. All patients have completed active treatment. Follow-up for survival and tumor response assessed by local and central MRI reading is ongoing. Results: Here we report on patients with recurrent GBM (AA see separate Abstract). 96 GBM patients (37% female, 63% male; median age 51 years, range 20–74; median Karnofsky performance status 90, range 70–100) have been treated. 63 GBM patients received AP 12009 (28 pt. 10 μM, 35 pt. 80 μM), 33 patients received standard chemotherapy. Data were evaluated by an independent Data and Safety Monitoring Board. Up to now, in 89 patients treated with AP 12009 (AA and GBM patients) 6 SAEs possibly related to the study drug and 37 procedure related SAEs (92% mild or moderate) were documented. Several long-term tumor responses were observed by local MRI reading. Exact response rates are being determined by central reading. Conclusions: Responses in patients treated with AP 12009 in both AA and GBM patients are long lasting with a good quality of life. Phase III clinical trials in AA and GBM patients are currently in preparation.

[Table: see text]

Mycobacterium avium intracellularae complex associated extrapulmonary axillary lymphadenitis in a HIV-seropositive infant--a rare case report

Opportunistic infections by Mycobacterium avium intracellulare complex in HIV infected patients, though common in adults, are rarely seen in infants. We herewith report an interesting case of an eight month old infant presenting with isolated axillary lymphadenitis, later on diagnosed to be tubercular lymphadenitis by Mycobacterium avium intracellulare and finally proved to be seropositive for HIV infection born to previously undetected HIV seropositive parents.

Avian influenza A (H5N1): a preliminary review

Humanity has been at the receiving end of many viral diseases since ages. Sudden emergence and re-emergence of new viral diseases in human beings has surprised the medical scientists from time to time. "Avian influenza" or "Bird flu" by H5N1 epidemics is one such surprise. Although many aspects about this disease are clear, there are some dark areas regarding vaccine development that need to be further explored and understood, so as to effectively contain the spread of this disease. The present article details out almost everything known about this interesting disease along with the review of the recent literature.

Pleural empyema due to S. typhi: a case report

In a 35 year old immunocompetent male, clinically diagnosed as a case of hydropneumothorax of left side, Salmonella typhi was isolated as the causative agent of pleural empyema.

Bacterial endocarditis due to Eikenella corrodens: a case report

Of all the causes of bacterial endocarditis, HACEK group consisting of Haemophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella Kingae are rare causative agents. We report a case of bacterial endocarditis by E. corrodens, which is one of the members of the HACEK group.

Long term outcome in patients with severe head injury and bilateral fixed dilated pupils

Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.

Enterobacter cloacae: a predominant pathogen in neonatal septicaemia

A total of 120 blood samples from neonates presenting with clinical signs of septicaemia were subjected for culture using brain heart infusion agar biphasic medium (BHI BPM) and glucose broth. Bacterial agents were isolated from 48 numbers (40%) of cultures. Gram-negative bacilli were isolated in maximum percentage (88.45%) of cases whereas gram-positive bacteria (coagulase negative staphylococci and group B streptococci) in 11.6% of cultures. E. cloacae (39.5%) was maximally isolated among the pathogenic bacteria followed by K. pneumoniae (23.2%), E. coli (11.6%) and others like Acinetobacter spp. (6.9%), Citrobacter freundi (4.6%) and P. mirabillis (2.3%). All the gram-negative bacilli isolates showed 100% susceptibility to amikacin, whereas 85% of E. cloacae isolates were sensitive to the same. Thus E. cloacae was found to be a predominant moderately sensitive pathogen in neonatal septicemia.

Solitary skull metastasis from mucoepidermoid mimicking a parotid tumour

Metastatic parotid tumours in the skull are very rare. An interesting case of a mucoepidermoid parotid tumour metastasizing to the skull vault is described in a patient who had previously been operated for a pituitary adenoma 20 years back with no post operative radiotherapy; however, she required hormonal supplementation therapy. She underwent an operation for a parotid tumour 7 years ago and received postoperative radiotherapy for the parotid tumour away from the site of the skull metastases. No local recurrence of the parotid tumour was noted. The initial diagnosis was that of a solitary intradiploic meningioma. Interesting clinico-radiological findings are presented.

Spinal cord and cauda equina compression in 'DISH'

Diffuse idiopathic skeletal hyperostosis (DISH) has long been regarded as a benign asymptomatic clinical entity with an innocuous clinical course. Precise information is lacking in the world literature. Authors report the results of a retrospective analysis of 74 cases of DISH. Eleven patients presented with progressive spinal cord or cauda equina compression. In nine cases ossified posterior longitudinal ligament (OPLL) and in two cases ossified ligamentum flavum (OLF) were primarily responsible. Surgically treated patients (eight) had far better outcome as compared to the patients managed conservatively, as they had refused surgery. 'DISH' is neither a benign condition, nor it always runs a innocuous clinical course. In fact, in about 15% of the cases, serious neurological manifestations occur, which may require a major neurosurgical intervention.

Nutritional status of preschool children in the drought affected Kalahandi district of Orissa

A community-based cross-sectional study was undertaken to determine the magnitude of undernutrition and protein-energy malnutrition among young children during 1996-97 in drought affected Kalahandi district of Orissa. A total of 751 children aged 0-5 yr were studied for anthropometry and clinical signs of nutritional deficiencies from 15 Gram Panchayats selected using probability proportionate to size sampling. There was no significant difference between boys and girls for nutritional status. According to weight-for-age, 57.1 per cent of the children were suffering from underweight (< median -2SD) and 21.3 per cent of children had very low body weights which were < -3SD of standard. Height-for-age and weight-for-height data showed that 41.8 per cent of children suffered from stunting and 27.9 per cent recorded wasting. The children below one year of age had relatively lower prevalence of malnutrition than the other age groups. The prevalence of clinical PEM in the form of marasmus was found in 0.7 per cent of children, while kwashiorkor was absent. This study showed that malnutrition is still a leading problem among preschool children of Kalahandi district and this has not improved in spite of nutrition intervention programmes which are currently in operation.

Symptomatic calcified subdural hematomas

Two unique cases of chronic calcified subdural hematomas are reported in children as a long-term complication of a ventriculoperitoneal shunt. Both the patients had undergone shunt procedures in infancy for congenital hydrocephalus. In one patient, the cause of the hydrocephalus was aqueduct stenosis, while in the second patient, a lumbar meningomyelocele was associated with hydrocephalus. In both these patients, a ventriculoperitoneal shunt was done in infancy. In one of them, following the shunt surgery, a bilateral subdural collection was noticed which required burr hole evacuation. Both the patients remained asymptomatic for 9 years, when they presented to our center with acute raised intracranial pressure and contralateral hemiparesis. Both the patients had a relatively short history and had altered sensorium at admission. Surprisingly, in both the patients, the CT scan showed significant mass effect producing calcified subdural hematomas. The shunt systems were found to be working well at surgery. Craniotomy and excision of the calcified subdural hematomas was undertaken. Postoperatively, the patients showed satisfactory recovery, and at discharge the patients were doing well. At the follow-up at the outpatient clinic, the patients were asymptomatic.

Synthetic CD4 exocyclic peptides antagonize CD4 holoreceptor binding and T cell activation

We have developed peptide analogs to analyze precise human CD4 substructures involved in MHC class II binding. Forms of the complementarity determining-like regions (CDRs) of the D1 domain of human CD4 were reproduced as synthetic aromatically modified exocyclic (AME) analogs and tested for their ability to block CD4-MHC II interactions and T cell activation. The exocyclic derived from CDR3 (residues 82-89) of human CD4, which specifically associated with CD4 on the T cell surface to create a heteromeric CD4 complex, blocked IL-2 production and antagonized the normal function of the CD4 receptor. The approach of creating novel synthetic antagonistic receptor complexes may represent a new receptor specific pharmaceutical approach to modulate biological function.

Maternal deaths--a ten-year study

In a 10-year retrospective study of maternal deaths at RG Kar Medical College, Calcutta there were 651 maternal deaths with 410 in first 5-year period and 241 in second 5-year period. The leading causes of deaths were due to abortion, toxaemia, haemorrhage (antepartum and postpartum) and jaundice in pregnancy. Direct causes were responsible for death in 77.6% cases, indirect causes in 17.5% cases and unrelated causes in 4.9% cases. Majority (557) were unbooked and mostly multigravida (434) cases. Most of them (251) were in the age group of 20-25 years. Haemorrhage was the single most common cause to claim 188 lives. It was also noted that 155 deaths occurred within 12 hours of hospital admission.