The Importance of Considering Common Variable Immunodeficiency in Patients With Chronic Diarrhea

Chronic diarrhea poses a diagnostic challenge due to its diverse etiology, encompassing various gastrointestinal disorders. This case report emphasizes the clinical significance of considering common variable immunodeficiency (CVID) as a potential underlying cause in a patient presenting with chronic diarrhea. In this case study, we describe a 36-year-old female with a 9-year history of chronic diarrhea, recurrent sinopulmonary infections, and weight loss for 3 years, where previous evaluations failed to yield a diagnosis. This case underscores the diagnostic hurdles faced by healthcare professionals, often causing a delay in identifying fewer common conditions like immunodeficiency syndromes. Early recognition of CVID is crucial, enabling timely intervention with immunoglobulin replacement therapy, markedly enhancing patients' quality of life and averting complications. This report highlights the necessity for a comprehensive evaluation of non-responsive chronic diarrhea cases and raises awareness about CVID as an essential consideration, facilitating precise diagnoses and tailored treatments.

Immunization coverage in a rural area of Bareilly district: a cross-sectional community-based study

INTRODUCTION: Infectious diseases are a major cause of morbidity and mortality in children. Immunization remains a cost-effective method for child survival against vaccine-preventable diseases. Despite all the interventions put in by the government for 100% immunization coverage, there remain pockets of low coverage, especially in rural areas.Our aim was to estimate the immunization coverage and assess sociodemographic factors associated with immunization among children aged 12-23 months in a rural area of Bareilly. METHODS: The present cross-sectional study was carried out in the field practice area under RHTC from January 2016 to June 2016 using a 30 by 7 cluster sampling technique. A total of seven children aged 12-23 months were interviewed from each cluster on a preformed, pretested, and semi-structured questionnaire, thus giving a sample size of 210. Statistical analysis was done using the Chi-square test. RESULTS: More than two-thirds (69%) of study participants were completely vaccinated, whereas about 31% were partially or not vaccinated. Immunization coverage was found to be highest for BCG (80.4%) and lowest for the third dose of DPT (69.0%). The most common reason for partial or non-immunization was found to be unawareness (45.5%) and fear of side effects (43.9%). CONCLUSION: There is a need to create awareness and increase knowledge among caretakers of children about the importance and benefits of getting immunization for their children as a major step toward achieving Sustainable Development Goals (SDGs) goals.

Perioperative GMCSF limits the proangiogenic plasma protein changes associated with colorectal cancer resection

AIMS

Colorectal resection (CR) increases plasma VEGF levels which may promote residual tumor growth. This study assessed the effect of perioperative GMCSF on plasma levels of sVEGFR1, Ang-1 and Ang-2 and also the impact of post-GMCSF plasma on in vitro endothelial cell (EC) growth and invasion. Ang-2 increases while sVEGFR1 and Ang-1 impede angiogenesis.

METHODS

Fifty-nine CR cancer patients were randomized to 7 perioperative doses of GMCSF or saline for 3days prior and 4days after CR. Blood samples were taken pre-drug (PreRx) and on several postoperative days (POD). Protein levels were assessed and PreRx and POD 5 plasma added to EC cultures after which branch point formation (ECBPF) and invasion (ECI) were measured.

RESULTS

sVEGFR1 levels were significantly higher on POD 1 and POD 5 in both groups but the GMCSF POD 5 level was twice the control value (p=0.002). Ang-2 levels were higher on PODs 1 and 5 in both groups (p<0.05) but the control POD 5 value (vs. GMCSF) was greater (p=0.03). Ang-1 decreases were noted in all (p=not significant, ns). The control group POD 5 ECBPF was 35.8% greater than Pre Rx (p=0.001) while the GMCSF result was 18.0% lower (p=ns); the control POD 5 median percent change from baseline was greater than the GMCSF result(p=0.008). The POD 5 ECI was +12.2% for the control group vs. baseline (p=ns) and -17.2% for the GMCSF group (p=ns): the control median percent change was greater than in the GMCSF group(p=0.045).

CONCLUSION

CR-related plasma changes are proangiogenic (>Ang-2) and anti-angiogenic (>sVEGFR1); the net effect is promotion of in vitro ECBPF. GMCSF limits the proangiogenic changes (higher POD 5 sVEGFR1 levels and lower Ang-2 elevations, lower POD 5 ECBPF and ECI). The clinical import of these effects is unclear; perioperative GMCSF has anti-angiogenic plasma effects that may limit tumor growth. Further investigation is warranted.

Perioperative sargramostim (recombinant human GM-CSF) induces an increase in the level of soluble VEGFR1 in colon cancer patients undergoing minimally invasive surgery

INTRODUCTION

Experimentally, laparotomy is associated with increased tumor growth. In humans, abdominal surgery is associated with immunosuppression and elevated plasma VEGF levels that might stimulate tumor growth early after surgery. Avoidance of these surgery-related changes and their consequences may be advantageous. Granulocyte-macrophage colony stimulating factor (GMCSF) is a non-specific immune system up-regulator that has also been associated, experimentally, with increased release of soluble VEGF Receptor 1 (sVEGFR1) which is an endogenous inhibitor of VEGF. This study's purpose was to determine the impact of perioperatively administered recombinant human GMCSF (rhu-GMCSF) on both immune function and plasma sVEGFR1 levels in colorectal cancer patients.

METHODS

This randomized placebo-controlled study included 36 colorectal cancer patients who underwent minimally invasive resection (17 GMCSF, 19 Placebo). Patients received 7 subcutaneous injections of either rhu-GMCSF, 125 microg/m2, or saline on preoperative days 3, 2 and 1 and on postoperative days (POD) 1, 2, 3 and 4. A number of immune parameters were followed and plasma levels of soluble VEGF Receptor 1 (sVEGFR1) and VEGF were determined.

RESULTS

The total WBC, neutrophil, eosinophil, and monocyte counts were significantly higher after surgery in the GMCSF group; no differences were noted for the other immune parameters. In the GMCSF group, median plasma sVEGFR1 levels were significantly elevated on POD 1 (188.1 pg/ml), and on POD 5 (142.8 pg/ml) when compared to pre-GMCSF levels (0 pg/ml) (p-value<0.05 for all comparisons). In the placebo group, the POD5 median sVEGFR1 level (116.3 pg/ml) was elevated and of borderline significance (p=0.05) vs the pre-treatment result (0 pg/ml). Of note, both groups had significantly elevated median plasma VEGF levels on POD 5 (Control 435.7 pg/ml; GMCSF 385.3 pg/ml) when compared to their preoperative results (Control 183.3 pg/ml, p=0.0013; GMCSF 171.5 pg/ml, p=0.0055).

CONCLUSIONS

Perioperative GMCSF was not associated with an immune function benefit in this study, however, such treatment leads to increased plasma sVEGFR1 levels. Colorectal resection, with or without GMCSF, was also associated with increased VEGF levels postoperatively. Increased plasma levels of sVEGFR1 after surgery might limit the pro-angiogenic tumor stimulatory effects of VEGF. Further study of GMCSF's impact on angiogenesis appears warranted.

Is IV tissue plasminogen activator beneficial in patients with hyperdense artery sign?

OBJECTIVE

To evaluate the effect of IV recombinant tissue plasminogen activator (rt-PA) in patients with hyperdense artery sign (HAS) on initial CT scan.

METHODS

The authors determined the differential effect of IV rt-PA (0.9 mg/kg) in patients with HAS by testing the interaction of rt-PA and HAS in a logistic regression model after adjusting for age, sex, initial NIH Stroke Scale score (NIHSSS), time to randomization, systolic blood pressure, serum glucose, body temperature, and rt-PA in 616 patients treated within 3 hours of symptom onset. Outcomes evaluated included intracranial hemorrhage, modified Rankin scale (mRS) 0-1, Barthel Index (BI) of > or = 95, Glasgow Outcome Scale (GOS) of 0-1, NIHSSS 0-1, and death at 90 days.

RESULTS

HAS was detected on the initial CT scan in 91 (15%) of the 616 patients by an independent neuroradiologist. Significantly lower rates of mRS 0-1, BI > or = 95, GOS of 0-1, or NIHSSS 0-1 at 90 days were observed among patients with HAS. IV rt-PA significantly increased the rates of mRS 0-1, BI > or = 95, GOS of 0-1, or NIHSSS 0-1 at 90 days after adjusting for potential confounders without any significant modifying effect (interaction) of HAS. Among the 91 patients with HAS, rt-PA use demonstrated a trend or significance for increased adjusted rates of favorable outcomes by mRS (p = 0.04), BI (p = 0.1), GOS (p = 0.03), and NIHSSS (p = 0.01).

CONCLUSION

Although hyperdense artery sign is associated with poor outcome, IV recombinant tissue plasminogen activator may be beneficial in this subgroup of patients with ischemic stroke.