Quinomycin A targets Notch signaling pathway in pancreatic cancer stem cells

Cancer stem cells (CSCs) appear to explain many aspects of the neoplastic evolution of tumors and likely account for enhanced therapeutic resistance following treatment. Dysregulated Notch signaling, which affects CSCs plays an important role in pancreatic cancer progression. We have determined the ability of Quinomycin to inhibit CSCs and the Notch signaling pathway. Quinomycin treatment resulted in significant inhibition of proliferation and colony formation in pancreatic cancer cell lines, but not in normal pancreatic epithelial cells. Moreover, Quinomycin affected pancreatosphere formation. The compound also decreased the expression of CSC marker proteins DCLK1, CD44, CD24 and EPCAM. In addition, flow cytometry studies demonstrated that Quinomycin reduced the number of DCLK1+ cells. Furthermore, levels of Notch 1–4 receptors, their ligands Jagged1, Jagged2, DLL1, DLL3, DLL4 and the downstream target protein Hes-1 were reduced. The γ-secretase complex proteins, Presenilin 1, Nicastrin, Pen2, and APH-1, required for Notch activation also exhibited decreased expression. Ectopic expression of the Notch Intracellular Domain (NICD) partially rescued the cells from Quinomycin mediated growth suppression. To determine the effect of Quinomycin on tumor growth in vivo, nude mice carrying tumor xenografts were administered Quinomycin intraperitoneally every day for 21 days. Treatment with the compound significantly inhibited tumor xenograft growth, coupled with significant reduction in the expression of CSC markers and Notch signaling proteins. Together, these data suggest that Quinomycin is a potent inhibitor of pancreatic cancer that targets the stem cells by inhibiting Notch signaling proteins.

Abstract 4214: Quinomycin A affects pancreatic cancer stem cells in part through suppression of notch signaling pathway

Background: Pancreatic cancer (PCa) remains a leading cause of death in the United States. Cancer stem cells (CSC) are responsible for tumor behavior, and therapeutic resistance. Quinomycin (Qui) is an orally administered quinoxaline antibiotic that bifunctionally intercalates with double stranded DNA. As a first step for repurposing this drug, we determined whether Qui affects PCa growth, and if so whether this is by suppressing stem cells.

Method: Growth and apoptosis of PCa lines (MiaPaCa-2, PanC-1, BxPC-3) and normal ductal epithelial cells (HPNE) was measured by hexosaminidase and clonogenicity, and caspase 3/7 assays, respectively. Pancosphere formation and FACS sorting were used for identifying effects on stem cells. For in vivo effects, MiaPaCa-2 xenografts were developed in the flanks of nude mice. Immunohistochemistry was performed for stem cell markers and Notch signaling proteins.

Results: Qui treatment resulted in a dose- and time-dependent inhibition of proliferation and colony formation in all three PCa lines but not HPNE cells. Qui also induced PCa cells to undergo apoptosis. Qui also significantly reduced the number and size of pancospheres, suggesting effects on stem cells. In addition, flow cytometry and western blot analyses showed that Qui suppressed PCa stem cell marker proteins Doublecortin Calmodulin-like kinase 1 (DCLK1), CD44 and CD24. We next determined whether Qui affects the Notch signaling pathway, a pathway that is important in maintaining CSC population. Notch receptor and its ligands are up-regulated in human PCa tissues. Qui treatment significantly downregulated Notch-1, 2 and 3 expression and that of its ligand Jagged-1. Notch activation requires cleavage by the γ-secretase complex. Qui inhibits the expression of members of the complex Presenilin 1 and Nicastrin. Moreover, ectopic expression of the Notch Intracellular domain (NICD) rescued the cells from Qui -mediated growth suppression. These data demonstrate that Qui mediated effects of PCa stem cells is in part through downregulating Notch1 activation. To determine the effect of Qui on tumor growth in vivo, mice carrying MiaPaCa-2 tumor xenografts were administered the compound intraperitoneally (20 μg/kg bw) every day for 21 days. Qui treatment significantly suppressed tumor xenograft growth, with notably lower tumor volume and weight. Western blot and immunohistochemistry analyses demonstrated significant inhibition of CSC marker proteins DCLK1, CD44 and CD24 and also the Notch signaling related proteins in the Qui-treated xenograft tissues.

Conclusion: Together, these data suggest that Qui suppresses PCa growth by inhibiting the Notch signaling pathway. Qui may therefore be a novel compound to target pancreatic cancers.

Citation Format: Dharmalingam Subramaniam, Sivapriya Ponnurangam, Afreen Sayed, Animesh Dhar, Dan A. Dixon, Ossama Tawfik, Rajashri R. Parab, Prabhu Dutt Mishra, Prafull Ranadive, Rajiv Sharma, Girish Mahajan, Aravind Sugumar, Scott J. Weir, Roy A. Jensen, Arun Balakrishnan, Shrikant Anant. Quinomycin A affects pancreatic cancer stem cells in part through suppression of notch signaling pathway. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4214. doi:10.1158/1538-7445.AM2015-4214

Treatment of relapsing autoimmune pancreatitis with immunomodulators and rituximab: the Mayo Clinic experience

BACKGROUND

There is a paucity of data on long-term management of type 1 autoimmune pancreatitis (AIP), a relapsing steroid-responsive disorder.

OBJECTIVE

We describe our experience with treatment of relapses and maintenance of remission using steroid-sparing immunomodulators (IMs) and induction of remission using rituximab (RTX).

METHODS

We obtained details of disease relapse and treatment in 116 type 1 AIP patients from clinic visits, medical records and telephone interviews. We compared relapse free survival in those treated with IMs versus those treated with steroids alone, assessed patients' response to RTX, and identified treatment-related complications.

RESULTS

During a median follow-up of 47 months, 52/116 AIP patients experienced 76 relapse episodes. The first relapse was treated with another course of steroids in 24 patients, and with steroids plus IM in another 27 patients; subsequent relapse-free survival until a second relapse was similar in the two groups (p=0.23). 38 patients received an IM for >2 months; failure or intolerance of IM therapy occurred in 17 (45%). 12 patients with steroid or IM intolerance/resistance were treated with RTX, an antiCD20 antibody; 10 (83%) experienced complete remission and had no relapses while on maintenance therapy. Treatment-limiting side effects related to RTX were uncommon.

CONCLUSIONS

In type 1 AIP relapses are common. Relapse-free survival is similar in those treated with steroids plus IM compared to those treated with steroids alone. Nearly half the patients on IMs will relapse during treatment. RTX is effective in the treatment of both IM resistant and steroid intolerant patients.

Demystifying seronegative autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis (AIP) has been classified into type 1 and type 2 subtypes. Serum immunoglobulin G4 (IgG4) elevation characterizes type 1 AIP. Type 2 AIP and a subset of type 1 AIP are seronegative, i.e., have normal serum IgG4 levels.

AIM

We compared the profiles of the three subsets of AIP to identify the unique characteristics of seronegative type 1 AIP and type 2 AIP.

METHODS

We compared the clinical profiles of 69 seropositive type 1 AIP patients, 21 seronegative type 1 AIP patients and 22 type 2 AIP patients.

RESULTS

Among type 1 AIP, seronegative group had similar clinical profiles when compared to seropositive group except that they were more likely to undergo surgical resection than seropositive patients (p = 0.001). Seronegative type I AIP patients were older (61.9 ± 13.7 vs 45.3 ± 17.4; p = 0.004), and differed in the occurrence of other organ involvement (OOI) (71.4% vs 0%; p < 0.001) and disease relapse (33.3% vs 0%; p = 0.005) when compared with type 2 AIP. All seronegative type 1 AIP patients had at least one of the following -OOI, disease relapse, and age >50 years while none of the type 2 AIP had OOI or disease relapse.

CONCLUSIONS

Seronegative and seropositive type 1 AIP patients have similar clinical profiles, which are distinct from that of type 2 AIP. Among the seronegative AIP group, patients are more likely to have type 1 AIP rather than type 2 AIP if they are older than 50 years or have OOI or disease relapse.

CDK-4 inhibitor P276 sensitizes pancreatic cancer cells to gemcitabine-induced apoptosis

Despite advances in molecular pathogenesis, pancreatic cancer remains a major unsolved health problem. It is a rapidly invasive, metastatic tumor that is resistant to standard therapies. The phosphatidylinositol-3-kinase/Akt and mTOR signaling pathways are frequently dysregulated in pancreatic cancer. Gemcitabine is the mainstay treatment for metastatic pancreatic cancer. P276 is a novel CDK inhibitor that induces G(2)/M arrest and inhibits tumor growth in vivo models. Here, we determined that P276 sensitizes pancreatic cancer cells to gemcitabine-induced apoptosis, a mechanism-mediated through inhibition of Akt-mTOR signaling. In vitro, the combination of P276 and gemcitabine resulted in a dose- and time-dependent inhibition of proliferation and colony formation of pancreatic cancer cells but not with normal pancreatic ductal cells. This combination also induced apoptosis, as seen by activated caspase-3 and increased Bax/Bcl2 ratio. Gene profiling studies showed that this combination downregulated Akt-mTOR signaling pathway, which was confirmed by Western blot analyses. There was also a downregulation of VEGF and interleukin-8 expression suggesting effects on angiogenesis pathway. In vivo, intraperitoneal administration of the P276-Gem combination significantly suppressed the growth of pancreatic cancer tumor xenografts. There was a reduction in CD31-positive blood vessels and reduced VEGF expression, again suggesting an effect on angiogenesis. Taken together, these data suggest that P276-Gem combination is a novel potent therapeutic agent that can target the Akt-mTOR signaling pathway to inhibit both tumor growth and angiogenesis.

Serrated polyps: critical precursors to colorectal cancer

Colorectal polyps have been traditionally classified as either hyperplastic or adenomatous, with only the latter progressing to carcinoma. However, it is now recognized that certain subtypes of serrated polyps have a risk of malignant transformation via a serrated neoplasia pathway. Serrated polyps are a heterogeneous group of lesions with distinct morphologic, histologic and molecular genetics profiles. Based on available evidence, there are reasons to suspect that this pathway may contribute to interval or missed cancers because serrated lesions are more likely than conventional adenomas to be missed on colonoscopy, and the progression of serrated polyps to cancer may be more rapid. Therefore, it is paramount that physicians recognize the importance of serrated polyps and are aware of the latest surveillance guidelines.

Autoimmune pancreatitis

The purpose of this review is to provide a concise view of the existing knowledge of autoimmune pancreatitis (AIP) for practicing clinicians. AIP is a rare disease whose recognition and understanding are evolving. It is a type of chronic pancreatitis that often presents as obstructive jaundice, has a distinctive histology, and is exquisitely sensitive to steroid therapy. This form of chronic pancreatitis has a unique clinical, biochemical, and radiological profile. The term "AIP" encompasses two subtypes: types 1 and 2. Type 1 AIP is the pancreatic manifestation of a systemic fibro-inflammatory disease called immunoglobulin G4-associated systemic diseases. Type 2 AIP has been shown to be associated with inflammatory bowel disease. Existing criteria are geared towards the diagnosis of type 1 AIP. At present, pancreatic histology is a requirement for the definitive diagnosis of type 2 AIP. AIP can mimic most other pancreatic diseases in its presentation, but in clinical practice, it often has to be differentiated from pancreatic cancer. There are established criteria and algorithms not only to diagnose AIP, but also to differentiate it from pancreatic cancer. The utility of these algorithms and the approach to management are discussed here.

Endoscopic retrograde pancreatography criteria to diagnose autoimmune pancreatitis: an international multicentre study

BACKGROUND

Characteristic pancreatic duct changes on endoscopic retrograde pancreatography (ERP) have been described in autoimmune pancreatitis (AIP). The performance characteristics of ERP to diagnose AIP were determined.

METHODS

The study was done in two phases. In phase I, 21 physicians from four centres in Asia, Europe and the USA, unaware of the clinical data or diagnoses, reviewed 40 preselected ERPs of patients with AIP (n=20), chronic pancreatitis (n=10) and pancreatic cancer (n=10). Physicians noted the presence or absence of key pancreatographic features and ranked the diagnostic possibilities. For phase II, a teaching module was created based on features found most useful in the diagnosis of AIP by the four best performing physicians in phase I. After a washout period of 3 months, all physicians reviewed the teaching module and reanalysed the same set of ERPs, unaware of their performance in phase I.

RESULTS

In phase I the sensitivity, specificity and interobserver agreement of ERP alone to diagnose AIP were 44, 92 and 0.23, respectively. The four key features of AIP identified in phase I were (i) long (>1/3 the length of the pancreatic duct) stricture; (ii) lack of upstream dilatation from the stricture (<5 mm); (iii) multiple strictures; and (iv) side branches arising from a strictured segment. In phase II the sensitivity (71%) of ERP significantly improved (p<0.05) without a significant decline in specificity (83%) (p>0.05); the interobserver agreement was fair (0.40).

CONCLUSIONS

The ability to diagnose AIP based on ERP features alone is limited but can be improved with knowledge of some key features.

Serrated polyps of the colon

Until recently, colonic polyps were traditionally classified as either hyperplastic or adenomatous, and only the latter were believed to have the potential to progress to carcinoma. However, it is now appreciated that a subset of serrated polyps also appear to have malignant potential. Serrated polyps are a heterogeneous group of colon polyps that include hyperplastic polyps, sessile serrated adenomas (SSAs), traditional serrated adenomas, and mixed polyps. Insights into these polyps were derived, in part, from studies of patients with the hyperplastic polyposis syndrome. SSAs show a predilection for the right colon, have a distinct histology, and their molecular genetic profile has recently been linked to a pathway for colon tumorigenesis that is characterized by microsatellite instability. Based upon available evidence, it is recommended that patients with serrated adenomas undergo colonoscopic follow-up at the same frequency as for conventional adenomas. It is important that physicians are aware of serrated polyps, particularly serrated adenomas and their relationship to colon cancer, and their proper clinical management.

Differences in clinical profile and relapse rate of type 1 versus type 2 autoimmune pancreatitis

BACKGROUND & AIMS

Autoimmune pancreatitis (AIP) has been divided into subtypes 1 (lymphoplasmacytic sclerosing pancreatitis) and 2 (idiopathic duct centric pancreatitis). We compared clinical profiles and long-term outcomes of types 1 and 2 AIP.

METHODS

We compared clinical presentation, relapse, and vital status of 78 patients with type 1 AIP who met the original HISORt criteria and 19 patients with histologically confirmed type 2 AIP.

RESULTS

At presentation, patients with type 1 AIP were older than those with type 2 AIP (62 +/- 14 vs 48 +/- 19 years; P < .0001) and had a greater prevalence of increased serum levels of immunoglobulin G4 (47/59 [80%] vs 1/6 [17%]; P = .004). Patients with type 1 were more likely than those with type 2 to have proximal biliary, retroperitoneal, renal, or salivary disease (60% vs 0; P < .0001). Inflammatory bowel disease was associated with types 1 and 2 (6% vs 16%; P = .37). During median clinical follow-up periods of 42 and 29 months, respectively, 47% of patients with type 1 and none of those with type 2 experienced a relapse. In type 1 AIP, proximal biliary involvement (hazard ratio [HR], 2.12; P = .038) and diffuse pancreatic swelling (HR, 2.00; P = .049) were predictive of relapse, whereas pancreaticoduodenectomy reduced the relapse rate (vs the corticosteroid-treated group; HR, 0.15; P = .0001). After median follow-up periods of 58 and 89 months (types 1 and 2, respectively), the 5-year survival rates for both groups were similar to those of the age- and sex-matched US population.

CONCLUSIONS

Types 1 and 2 AIP have distinct clinical profiles. Patients with type 1 AIP have a high relapse rate, but patients with type 2 AIP do not experience relapse. AIP does not affect long-term survival.

Drug interaction presenting as acute abdomen

Warfarin is the most common oral anticoagulant prescribed around the world. Adverse drug interactions with warfarin are a huge problem especially in the elderly and in patients who take multiple medications. Most adverse drug interactions involve concomitantly prescribed oral or intravenous medications. Occasionally, topical or mucosally absorbed drugs can interact, leading to fluctuations in warfarin levels with adverse consequences. In this case report, we describe a case of intestinal intramural hematoma, a rare but known consequence of a supra therapeutic international normalized ratio (INR). The supra therapeutic INR was a consequence of mucosally absorbed miconazole, prescribed for vaginal candidiasis. We wish to highlight this rare and potentially fatal drug interaction, along with the need for frequent INR monitoring when new drugs are added or removed in patients taking warfarin.

Distinguishing pancreatic cancer from autoimmune pancreatitis: a comparison of two strategies

Autoimmune pancreatitis is a rare disease which closely mimics pancreatic cancer in its presentation. It is important for clinicians to distinguish one from the other due to vastly different therapeutic and prognostic implications. We compared 2 recently proposed strategies, 1 from Japan and the other from the United States, to distinguish autoimmune pancreatitis from pancreatic cancer. While both strategies have inherent strengths and weaknesses, we believe that the best features of both need prospective validation. The strategy proposed from Japan is simple to use, but is based on a small number of patients and is heavily dependent on imaging criteria. The American strategy while based on a bigger sample of patients is complicated and is most useful in expert hands. Additionally, differences in clinical practice and local preference in the use of certain diagnostic tests need to be considered while adopting either strategy.

A case of malignant abdominal pain

BACKGROUND

Testicular cancer is a common neoplasm in young and middle-aged men. Although the most common presentation is a palpable testicular mass, it can present with atypical symptoms. There is a lack of awareness among primary-care physicians about the less common presentations of testicular tumors. Early detection is a key prognostic variable. This case demonstrates an unusual first presentation of testicular cancer with chylous ascites and abdominal pain.

CASE REPORT

We report a case of a 19-year-old man who presented with severe atypical abdominal pain, which was initially diagnosed as acute appendicitis. He underwent laparoscopic appendectomy and was found to have chylous ascites and a normal-appearing appendix. As part of his work-up for chylous ascites, he was found to have mesenteric lymphadenopathy. These nodes were sampled and revealed a mixed germ cell tumor. The primary tumor was later traced to his right testis.

CONCLUSIONS

The differential diagnosis of atypical abdominal pain in young men should include testicular tumors. A thorough testicular exam should be part of the routine physical exam in such situations.

Autoimmune pancreatitis: pathologic subtypes and their implications for its diagnosis

Autoimmune pancreatitis (AIP) is a rare but treatable form of pancreatic disease that is being increasingly recognized worldwide. The diagnosis of AIP remains a clinical challenge and the difficulty is compounded by the fact that there are no internationally agreed on diagnostic criteria for AIP. One of the reasons for the lack of consensus on diagnostic criteria could be that the term "AIP" likely refers to more than one distinct disease or subtype. This may explain the divide between European and other diagnostic criteria. Recent insights into AIP subtypes should help develop an evidence-based consensus on diagnostic criteria for the disease.

Autoimmune pancreatitis: an update

Autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibroinflammatory disorder. It has been recognized as a distinct clinical entity, only recently. Multiple organs, such bile ducts, salivary glands, kidneys and lymph nodes, can be involved either synchronously or metachronously. It is one of the few autoimmune conditions that predominantly affects male subjects in the fifth and sixth decades of life. Obstructive jaundice is the most common presenting symptom but the presentation can be quite nonspecific. There are established diagnostic criteria to diagnose AIP, most of which rely on a combination of clinical presentation, imaging of the pancreas and other organs (by CT scan, MRI and endoscopic retrograde pancreatography), serology, pancreatic histology and response to steroids to make the diagnosis. It is imperative to differentiate AIP from pancreatic cancer owing to the vastly different prognostic and therapeutic implications. AIP responds dramatically to steroid treatment but relapses are common. Relapse of AIP can often be retreated with steroids. As the collective experience with this condition increases, a better understanding of the natural history of this disease is emerging.

A systematic review of the efficacy of domperidone for the treatment of diabetic gastroparesis

BACKGROUND & AIMS

Despite being widely used in more than 20 countries for the treatment of diabetic gastroparesis for several decades, domperidone is approved only on an investigational basis in the United States. However, because its use is increasing, it is important for gastroenterologists in this country to understand its effectiveness in this condition. The literature on this subject varies considerably with respect to the methods and outcome measures, making a meta-analysis unfeasible.

METHODS

Our objective was to systematically analyze studies of the efficacy of domperidone in diabetic gastroparesis, with a focus on their methodologic and scientific merit. Information from 28 trials (11 full articles and 17 abstracts) from 1981 to 2007 was analyzed.

RESULTS

The average study quality score was 8.3 out of a possible 15 and the total sample size equaled 1016. Overall, 64% of the studies showed significant efficacy of domperidone on the improvement of symptoms. Sixty percent of the studies showed an efficacy in gastric emptying and 67% of the studies proved the drug effective in reducing hospital admissions.

CONCLUSIONS

Overall, our assessment is that there is level 3 evidence for the efficacy of domperidone in diabetic gastroparesis, leading to a grade C recommendation for its use in this condition. These results need to be interpreted very cautiously because of significant methodologic limitations of these studies, including the fact that most positive studies lacked a control arm. It is clear that larger and better-designed studies are needed to further validate the use of this drug in diabetic gastroparesis.

Detection of colorectal disease by stool defensin assay: an exploratory study

BACKGROUND & AIMS

Alpha-defensins 1-3 (human neutrophil peptides [HNP]1-3), reported to be elevated in tumor tissue and serum of patients with colorectal cancer (CRC), have not been studied in stool. We evaluated the neoplasm specificity of HPN1-3 and their discriminant value as stool markers for CRC.

METHODS

Protein and mRNA expression of HPN1-3 were assayed in CRC cell lines, microdissected CRC and normal epithelium, and white blood cells. HNP1-3 proteins in stools were quantified in blinded fashion from 30 normal subjects, 20 patients with CRC, 10 with a large colorectal adenoma, 10 with upper gastrointestinal cancer, and 10 with IBD. Stool lactoferrin was also quantified.

RESULTS

HPN1-3 proteins were not detected in CRC cell lines but were high (>4000 ng/mL) in white blood cells. mRNA levels of HPN1-3 were comparably low in CRC cell lines, microdissected CRC, and normal colon epithelium, but they were >1000-fold and >30,000-fold higher in white blood cells and neutrophils, respectively. Mean stool HPN1-3 levels were 17 ng/mL with normals, 125 ng/mL with CRC, 62 ng/mL with adenoma, 63 ng/mL with upper gastrointestinal cancer, and 231 ng/mL with IBD (P < .01 for each patient group vs normals). HPN1-3 levels in IBD were higher than in CRC (P = .04). At 90% specificity, sensitivity of stool defensins was 35% for CRC, 40% for adenoma, 40% for upper gastrointestinal cancers, and 80% for IBD. Stool defensins and lactoferrin levels correlated (R2 = 0.70, P < .001).

CONCLUSIONS

Alpha-defensins 1-3 levels are nonspecifically elevated in stools from patients with colorectal neoplasia and likely originate from white blood cells. Alpha-defensins 1-3 in stool might serve as markers of inflammatory bowel conditions.

Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide

Metoclopramide, the only drug approved by the FDA for treatment of diabetic gastroparesis, but used off-label for a variety of other gastrointestinal indications, has many potentially troublesome adverse neurologic effects, particularly movement disorders. In this article, we comprehensively review the indications and side effects of metoclopramide, and describe some common pitfalls and strategies to minimize the medicolegal risks to the prescribing physician. Metoclopramide accounts for nearly a third of all drug-induced movement disorders, a common reason for a malpractice suit. The entire spectrum of drug-induced movement disorders, ranging from subtle to life-threatening, can ensue from its use; akathisia and dystonia are generally seen early in the course of metoclopramide-induced movement disorders, whereas tardive dyskinesia and parkinsonism seem to be more prevalent in chronic users. Female sex, age and diabetes are the major risk factors for metoclopramide-induced movement disorders. It is therefore incumbent on gastroenterologists and other prescribing physicians to become familiar with the adverse neurologic effects associated with the use of metoclopramide, and to take appropriate preventive and defensive measures.

Effect of hepatitis C virus infection on the risk of non-Hodgkin's lymphoma: a meta-analysis of epidemiological studies

Although a high prevalence of hepatitis C virus (HCV) infection among non-Hodgkin's lymphoma (NHL) patients had been reported, subsequent epidemiological studies conducted to examine a causal association between HCV and NHL have provided inconsistent results across studies. A strikingly positive association has been reported primarily from Italy and Japan, while no association was found in other regions of the world. To clarify the association between HCV and NHL, we conducted a systematic literature review. Eligible study designs were nested case-control studies, population-based case-control studies, and hospital-based case-control studies using non-cancer subjects as controls. The studies published through January 1991 to August 2003 were searched through Medline. Ultimately, 23 studies with 4049 NHL patients and 1,813,480 controls were identified. Summary statistics were crude odds ratios (ORs) comparing the anti-HCV seropositive and seronegative subjects. As we identified heterogeneity between studies, summary statistics were calculated based on a random-effect model. We did not find any evidence of publication bias. The major sources of variation were the use of blood donor controls and year of publication. The summary OR for NHL was 5.70 (95% confidence interval (CI), 4.09-7.96, P < 0.001). The subgroup analysis by phenotype showed a similar trend for B-cell (5.04, 95% CI: 3.59-7.06) and T-NHL (2.51, 95% CI: 1.39-4.56). In conclusion, we found a strongly positive association between anti-HCV seropositive test subjects and risk of NHL. Further biological studies examining this association are warranted.

Insulin-like growth factor (IGF)-I and IGF-binding protein 3 and the risk of premenopausal breast cancer: a meta-analysis of literature

Biologic evidence suggests substantial effect of insulin-like growth factor (IGF)-I in mammary cell carcinogenesis. However, controversy remains regarding the association between circulating IGF-I levels and the risk of premenopausal breast cancer in epidemiologic studies. In addition, the association of IGF-binding protein (IGFBP)-3, which binds with and modifies the effect of IGF-I, is unclear. To clarify these associations, we performed a meta-analysis of all the published studies. A systematic review of literature was conducted. Eligible study designs were nested case-control and population-based case-control studies that give estimates for menopausal women. The studies published between January 1990 and March 2003 were obtained from Medline. We obtained 7 studies, consisting of 688 premenopausal incident breast cancer cases and 1,366 controls, for our final evaluation. Summary statistics were odds ratios (ORs) comparing the highest and the lowest levels of IGF-I and IGFBP-3 adjusted for confounders other than IGF-I or IGFBP-3. There was neither evidence of heterogeneity between studies nor evidence of publication bias. The confounders considered and the contrast used for the ORs were the major source of variation. The subjects with higher circulating levels of IGF-I had marginally significant increased risk of breast cancer with an OR of 1.74 (95% CI = 0.97-3.13; p = 0.06). No significant difference was observed for IGFBP-3 group (OR = 1.60; 95% CI = 0.84-3.02; p = 0.15). In conclusion, we found a marginally significant association between circulating IGF-I levels and the risk of premenopausal breast cancer.

A study of side effects of lithium

The present report is a study on the side effects experienced by the patients attending the Lithium Clinic of the Institute of Psychiatry, Government Rajaji Hospital, Madurai. Out of the 120 (M 78, F42) patients studied, 97 had side effects. The effects were examined in respect of their frequency, time of onset and course, their relation to one dose and serum levels of lithium and to the clinical response. The duration of therapy ranged from 3 months to 6 years.The most frequent side effects were tremors (26.6%) and polyuria (20.8%). The side effects occurred at varying periods from the onset of therapy. During the first 3 months, tremors, excess salivation, nausea and abdominal discomfort; weight gain, memory defects and polyuria, between 3 months and 1 year; and hypothyroidism, tardive dyskinesia, acne and hair fall beyond one year.

Lithium prophylaxis in affective disorder

Out of 108 patients on the rolls in the Lithium clinic, Madurai Medical College and Govt. Rajaji Hospital, Madurai, India, 47 patients suffering from affective disorders receiving lithium continuously for more than three years were analysed with a view to study the recurrences. Thirteen suffered no relapses while on lithium while nineteen experienced them while on lithium. Four were free from recurrences after lithium was withdrawn- Seven defaulted but suffered recurrences while in four the drug was withdrawn and in both the groups remission was achieved with re-administration of lithium. The study reveals that lithium besides averting the recurrences can reduce the frequency, number, duration, intensity of episodes and improve the amenability to drugs. Among the symptoms, suicidal ideas and behaviour and insight were found to be influenced favourably by lithium. Among the factors that help favourable response to lithium were a positive family history of affective disorder, in the first degree relatives and lesser frequency and number of episodes in the pre-lithium period. A reappraisal of the natural history of the illness is called for in the light of lithium prophylaxis of manic depressive psychosis.

LITHIUM AND KIDNEY: (A study of renal biopsy in Lithium patients)

A study of renal biopsy in 13 lithium treated patients is reported. The light microscopic changes were non-specific and comprised glomerular hypercellularity; cloudy swelling of the tubular epithelium and interstitial fibrosis. Correlation between structural changes and functional alterations could not be established. The duration of therapy did not have any bearing on the intensity of the structural changes. No case of renal failure occurred in well controlled series as ours.