IgG responses against SARS-CoV-2 vaccines AZD1222 and BBV-152 and breakthrough infections among health care workers in southern India

IgG antibodies elicited in response to SARS-CoV-2 are critical in determining the protection achieved through vaccination. The present longitudinal study aims to assess the immune response generated through AZD1222 & BBV-152 vaccination among health care workers (HCWs) in a selected hospital. Serum IgG levels were measured approximately at 1.5 months and 6 months after the first and second vaccination. The final assessment was done 12 months after the first vaccination to analyse the sustained antibody levels. Results showed a progressive increase in antibody titres as a function of time. 26 HCWs in all had SARS-CoV-2 breakthrough infection, but their antibody titres were not significantly higher compared to COVID-19 naïve individuals. However, a comparative analysis showed considerably higher antibody titre in those who received the AZD1222 vaccine among this cohort. AZD1222 vaccination was significantly associated with seropositivity in the first and second assessments. Female HCWs showed significantly higher seropositivity, and participants above 60 years showed considerably reduced antibody titre in the first assessment. However, the final assessment showed no association with these variables, with 97.1 % of participants reporting to be seropositive. The results indicate good antibody response and potential protection against SARS CoV-2.

Do children in India grow well into adolescents? Longitudinal analysis of growth transitions from Young Lives panel survey in India

OBJECTIVES

Studies that examined the growth during late childhood and early adolescence beyond 8 years of age are very limited. Further, most studies have used dichotomized classification of stunting, thereby limiting the understanding of moderate stunting in childhood growth trajectory. We aimed to examine the course of stunting from childhood to adolescence by undertaking robust analyses of the Young Lives Survey (YLS) longitudinal data from India using multilevel categorization of stunting.

STUDY DESIGN

Retrospective cohort analysis was undertaken from YLS in India among 1827 children from the younger cohort born in 2001-02 with complete follow-up data in all five rounds of YLS collected in 2002, 2006, 2009, 2013, and 2016.

METHODS

A three-state multistate Markov model (not stunted, moderate, severe) was performed to estimate annual transition probabilities, mean sojourn-time, and transition-specific risk factors.

RESULTS

Between Round-one and Round-five, cross-sectional prevalence of severe stunting decreased from 10.4% (95% confidence interval [CI]: 7.8%, 13.7%) to 5.3% (95% CI: 3.8%, 7.3%), while moderate stunting increased from 19.9% (95% CI: 16.3%,23.9%) to 21.7% (95% CI: 18.4%, 24.9%). Mean Sojourn time estimation indicated a relatively concise state for moderate stunting. The stunting trajectory had shown gender differential where more faltering to severe stunting and lower recovery to the normal state was observed among girls between 8 and 12 years and among boys between 12 and 15 years. Compared with boys, girls had 40% excess likelihood (Hazard Ratio: 1.40; 95% CI 1.00 to 1.95) for moderate-to-severe stunting transition and also had 19% excess likelihood (Hazard Ratio: 1.19; 95% CI 1.01 to 1.40) of favorable transition (moderate-to-non-stunted).

CONCLUSIONS

The transition trajectory highlights preadolescence, especially among girls, as an additional window of opportunity to ensure better nutrition in adolescent life. With a fifth of adolescents living in India, study findings call for coordinated, multisectoral, age-appropriate, and gender-responsive approach to take India closer to meeting SDG-2.

18F-fluorodeoxyglucose positron emission tomography computed tomography (18F-PET/CT) for the diagnosis of native valve infective endocarditis (NVIE): a prospective study

Background and objectives

18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) / computed tomography (CT) was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with native valve endocarditis (NVE) as well as the clinical impact of PET findings.

Purposes

1. Primary objective: To assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE).

2. Secondary objectives:

– to determine the usefulness of PET/CT concerning embolic or neoplastic detection.

– to describe a new PET/CT feature, i.e. the diffuse splenic uptake.

Methods

Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Patients follow-up was scheduled at one and three months after hospitalization.

Results

Significant cardiac uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (p<0.001) without no change on specificity (p<0.001). Twenty-four patients (38%) were diagnosed with secondary infectious sites or infectious portal of entry. A diffuse splenic uptake was observed in 39 (52%) patients, including 37 (59%) of patients with a final diagnosis of NVE (specificity 83%).

Conclusion

1. The value of 18F-FDG PET/CT in NVE diagnosis is poor (18% sensitivity)

2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection.

3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on 18F-FDG PET/CT

Diffuse splenic uptake

Funding Acknowledgement

Type of funding source: None

The epidemiology of Plasmodium falciparum and Plasmodium vivax in East Sepik Province, Papua New Guinea, pre- and post-implementation of national malaria control efforts

Background

In the past decade, national malaria control efforts in Papua New Guinea (PNG) have received renewed support, facilitating nationwide distribution of free long-lasting insecticidal nets (LLINs), as well as improvements in access to parasite-confirmed diagnosis and effective artemisinin-combination therapy in 2011–2012.

Methods

To study the effects of these intensified control efforts on the epidemiology and transmission of Plasmodium falciparum and Plasmodium vivax infections and investigate risk factors at the individual and household level, two cross-sectional surveys were conducted in the East Sepik Province of PNG; one in 2005, before the scale-up of national campaigns and one in late 2012-early 2013, after 2 rounds of LLIN distribution (2008 and 2011–2012). Differences between studies were investigated using Chi square (χ²), Fischer’s exact tests and Student’s t-test. Multivariable logistic regression models were built to investigate factors associated with infection at the individual and household level.

Results

The prevalence of P. falciparum and P. vivax in surveyed communities decreased from 55% (2005) to 9% (2013) and 36% to 6%, respectively. The mean multiplicity of infection (MOI) decreased from 1.8 to 1.6 for P. falciparum (p = 0.08) and from 2.2 to 1.4 for P. vivax (p < 0.001). Alongside these reductions, a shift towards a more uniform distribution of infections and illness across age groups was observed but there was greater heterogeneity across the study area and within the study villages. Microscopy positive infections and clinical cases in the household were associated with high rate infection households (> 50% of household members with Plasmodium infection).

Conclusion

After the scale-up of malaria control interventions in PNG between 2008 and 2012, there was a substantial reduction in P. falciparum and P. vivax infection rates in the studies villages in East Sepik Province. Understanding the extent of local heterogeneity in malaria transmission and the driving factors is critical to identify and implement targeted control strategies to ensure the ongoing success of malaria control in PNG and inform the development of tools required to achieve elimination. In household-based interventions, diagnostics with a sensitivity similar to (expert) microscopy could be used to identify and target high rate households.

P3666Spondylitis: a frequent and severe complication of infective endocarditis

Background

Spondylodiscitis (SP) is a rare, but severe complication of infective endocarditis (IE). The incidence, clinical features and prognosis of SP in IE are unknown.

Purpose

The primary objective of our study was to assess the incidence, epidemiology, clinical presentation, prognosis, and therapeutic implications of SP in patient with IE. The secondary objectives were to assess factors associated with occurrence of spondylitis and to assess the value of imaging techniques.

Methods

In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1990 to 2018 (n=1755), 150 (8.5%) presented with SP. Clinical, epidemiological, microbiological, and prognostic variables were prospectively recorded and compared between patients with (n=150) and without (n=1605) SP.

Results

Patients with SP were older (mean age 69.7±18 vs 66.2±14; p=0.004), had more arterial hypertension (48% vs 34,5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without SP. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L3-L4. Neurological symptoms were observed in 59% of patients. Enterococci et Gallolyticus streptococci were more frequent (24% vs 12% and 24% vs 11%; p<0,001, respectively) in the SP group. Observed sensitivities of full spine contrast-enhanced MRI and CT were 95% and 89%, respectively. PET/CT had a great power to differentiate infective to degenerative vertebral processes, and to find embolic foci with a sensitivity of 90%. Clinical outcome did not differ between patients with or without SP, including similar in-hospital mortality (16% vs 13,5%, p=0.38).

Conclusions

We describe the largest ever reported series of patients with spondylodiscitis complicating IE. Spondylodiscitis is a more frequent complication of IE than previously reported (8.5% of IE), is observed in older hypertensive patients with Enterococcal or Streptococcus gallolyticus IE and has a similar prognosis than other forms of IE. Since SP is associated with prolonged antibiotic therapy and may need specific surgical therapy, multimodality imaging including MRI, CT, and PET/CT should be used for early diagnosis of this IE complication.

333018F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (PET/CT) for the diagnosis of prosthetic valve infective endocarditis (PVIE): a prospective multicenter study

Background and objectives

18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the value of this new diagnostic algorithm has never been prospectively assessed.

Purposes

1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in prosthetic valve infective endocarditis (PVIE).

2. Secondary objectives: to determine the reproducibility of 18F-FDG PET/CT; to assess its ability to predict embolic events.

Methods

Between 2014 and 2017, 175 patients with suspected PVIE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable or not feasible PET/CT,115 patients were finally included in the analysis, including 91 definite IE and 24 rejected IE, as defined by an expert Consensus of Endocarditis Team after 3-month follow-up as Gold Standard

Nuclear data were blindly analyzed by two independent nuclear medicine physicians.

Patients follow-up was scheduled at one and three months after hospitalization

Results

Significant cardiac uptake by PET/CT (major criterion) was observed in 67 among 91 patients with definite PVIE and 6 patients with rejected IE (sensitivity 73.6%, specificity 75%, positive predictive value 91%, negative predictive value 42%). Considering cardiac uptake as a major criterion, the ESC 2015 classification increased the sensitivity of Duke criteria from 57 to 84% (p<0.001) but decreased its specificity from 84 to 70% (p<0.001).

Intraobserver reproducibility of cardiac uptake evaluation was good (kappa = 0.84) but inter observer reproductibility was less satisfactory (kappa = 0.63).

Embolic events occurred in 31 patients (27%) and were correlated with vegetation size by ECHO (p<0.001), Staphylococcus infection (p=0.003), and PET/CT cardiac uptake (p=0.02).

Conclusion

1. the value of PET CT and ESC criteria is confirmed and may allow earlier diagnosis of PVIE

2. PET CT is associated with an increased risk of false positive results probably related to the technical improvements

3. Reproducibility of nuclear measurements seems unsatisfactory, justifying efforts to standardize PET studies interpretation

4. Our study describes for the first time a positive correlation between a positive PET/Ct and occurrence of embolic events, warranting additional studies.

P2760Prognostic value of 18-fluorodeoxyglucose positron emission tomography/computed tomography in infective endocarditis

Background

18-Fluorodeoxyglucose Positron emission tomography (18F-FDG PET/CT) has been shown to be useful for the diagnosis of IE, but its prognostic value is unknown.

Objectives

This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE).

Methods

We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent a 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event

Results

18F-FDG PET/CT was positive in 98 (57%) patients, 82% (n=88/109) in the PVE and 16% (n=10/64) in the NVE group. At a mean follow of 225±18 days, the primary end-point occurred in 94 (55%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR=2.6, IC95%=1.04 to 6.6; p=0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR=2.1; IC95%=1.1 to 4.0; p=0.03) and to new embolic events, (OR: 8.8; IC95%= 1.1 to 69.5; p=0.02). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point.

Conclusion

In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and to embolic events during the first year following IE episode

Regional cerebral tissue oxygen saturation changes following blood transfusion in neuro-intensive care unit patients - a pilot observational study

BACKGROUND

Although central venous oxygen saturation (ScvO₂ ) is used to decide on red blood cell (RBC) transfusion, whether its improvement is associated with parallel improvement in cerebral oxygenation is not adequately studied. This study looked at changes in regional cerebral tissue oxygen saturation (rSO₂ ) following RBC transfusion in neuro-intensive care unit (ICU) patients.

METHODS

In this prospective observational pilot study, rSO₂ was measured in adult neuro-ICU patients before RBC transfusion, at the end and at 6, 12, 18 and 24 h after RBC transfusion. rSO₂ measurements were taken using cerebral oximetry on both sides of the hemicraniums. Haemoglobin, central venous pressure, ScvO₂ and temperature were recorded during the study period. Arterial oxygen content, central venous oxygen content and cerebral fractional oxygen extraction were calculated. Mann Whitney U test was used to study the changes in variables at baseline and at 24 h following RBC transfusion. Friedman's test was used to study changes in parameters from baseline to 24 h post-transfusion. A P value of <0·05 was considered to be significant.

RESULTS

The data from 13 subjects were analysed. rSO₂ increased significantly following RBC transfusion on both sides of the brain (P = 0·002, P = 0·007), with a corresponding decrease in cerebral fractional oxygen extraction (P = 0·001, P = 0·007).

CONCLUSIONS

RBC transfusion increased rSO₂ significantly on both sides of the brain. As patients' outcomes were not studied, whether this increase in regional cerebral oxygen saturation is beneficial or if it is because of excess DO₂ is still unclear. Further studies are required to clarify this issue.

The effect of blood transfusion on central venous oxygen saturation in critically ill patients admitted to a neurointensive care unit

BACKGROUND

Literature suggests poorer outcomes during anaemia as well as following red blood cell transfusion (BT) in brain injured patients. Recently, central venous oxygen saturation (ScvO₂ ) has been proposed as a physiological trigger to guide red BT. In this study, we looked at ScvO₂ changes following BT in patients admitted to a neurointensive care unit (NICU).

STUDY DESIGN

In this prospective, observational study, adult, acutely ill neurological patients of >18 years were recruited. The following parameters were measured before and immediately after transfusion and then at 6, 12, 18 and 24 h after transfusion: haemoglobin (Hb), ScvO₂ and central venous oxygen partial pressure (PcvO₂ ) (blood sampled from central venous catheter). Simultaneously, hemodynamic parameters [central venous pressure (CVP), heart rate (HR), mean arterial pressure (MAP) and systolic blood pressure (SBP)] were also noted.

RESULTS

Data from 70 adult patients were analysed. Following BT, significant improvement was noted in Hb, ScvO₂ and all hemodynamic parameters. The ScvO₂ changes correlated significantly with the number of units of BT (P = 0·039), pre-transfusion Hb (P = 0·010), ScvO₂ (P = 0·001) and PcvO₂ (P = 0·001). When receiver operating characteristic (ROC) curves were drawn, optimum cut-off values of baseline ScvO₂ and Hb to predict the need for transfusion in terms of oxygen delivery were 70% and 8·6 gm dL^-1 respectively.

DISCUSSION

Baseline ScvO₂ <70% appears to be a useful physiological trigger for deciding the need for BT in brain injured patients. Whether improvement in ScvO₂ leads to improvement in regional brain oxygenation needs to be studied.

Maintenance rituximab after autologous stem cell transplantation in patients with mantle cell lymphoma

BACKGROUND

High-dose therapy and autologous stem cell transplantation (ASCT) improves outcomes for patients with mantle cell lymphoma (MCL), but relapse ultimately occurs in most patients. Recently presented interim results from a phase III prospective trial suggest maintenance rituximab (MR) after ASCT for MCL improves progression-free survival (PFS). The maturation of these data and any benefit of MR on overall survival (OS) remain to be defined.

PATIENTS AND METHODS

In this retrospective study, we examined a cohort of consecutive patients with MCL that underwent ASCT for MCL at our center and evaluated their outcomes according to whether they received MR after ASCT (n = 50) or did not (n = 107). MR was treated as a time-dependent covariate to account for variation in timing of its initiation.

RESULTS

MR was associated with an improved PFS [hazard ratio (HR) 0.44; confidence interval (CI) (0.24-0.80), P = 0.007] and overall survival (OS; HR 0.46; CI 0.23-0.93, P = 0.03) following a multivariate adjustment for confounding factors with a median follow-up of ∼5 years. Grade 4 neutropenia was increased (34% versus 18%, P = 0.04) in the MR group, but no effect on the rate of mortality unrelated to relapse was observed.

CONCLUSIONS

These data support that MR after ASCT for MCL confers a benefit in PFS and additionally suggest it may improve OS. General application of this strategy will require confirmation of benefit in prospective randomized trials.

Serial macro-architectural alterations with levodopa in Parkinson's disease: Polysomnography (PSG)-based analysis

Purpose:

We studied the sleep macroarchitecture with polysomnography (PSG) in drug naïve patients with Parkinson's disease (PD) and reassessed them following treatment with levodopa.

Materials and Methods:

This prospective hospital-based study included 15 patients with PD (age: 59 ± 11.2 years, duration of PD: 11.8 ± 12.3 months; and male: female (M:F) = 11:4). They were assessed for demography, phenotype, modified Hoehn and Yahr staging (H & Y); Schwab and England and Activities of Daily Living (S and E ADL) Scale; and Unified PDRating Scale (UPDRS). Sleep was assessed using Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and National Institute of Mental Health and Neurosciences (NIMHANS) comprehensive sleep disorder questionnaire. They underwent overnight PSG at baseline and after13.3 ± 5.7 months of levodopa (440 mg/day).

Results:

Patients with PD had responded to levodopa as indicated by the significant improvement in UPDRS motor score in ON state compared to OFF state. Nocturnal sleep quality indices did not vary significantly, but the excessive daytime somnolence improved (P = 0.04) with levodopa. Sleep efficiency (P = 0.65), latency to sleep onset (P = 0.19), latency to stage 1 (P = 0.12), and duration of stage 1 (P = 0.55) had increased. Duration of ‘awake in bed’ (P = 0.24), slow wave sleep (P = 0.29), and rapid eye movement (REM) sleep (P = 0.24) decreased with treatment. Periodic leg movements (PLMs) had reduced (P = 0.68) and mean oxygen saturation during sleep improved (P = 0.002). Surprisingly, snore index (P < 0.03) during sleep had increased with levodopa.

Conclusions:

Sleep alterations in PD occur even in early stages due to the disease process. There was improvement in most of the parameters of sleep macroarchitecture with levodopa.

Intensive intravenous regime for acute severe colitis

Acute severe exacerbation of ulcerative colitis is a potentially life threatening medical emergency. The management of acute severe ulcerative colitis depends on early recognition and prompt initiation of intensive intravenous treatment along with continuous objective monitoring for possible medical failure. The intensive regime is the accepted standard of care. This includes primarily a) intravenous corticosteroids, b) intravenous supportive management, and d) intravenous antibiotics in instances. This review discusses the timing, duration and dosage of the intensive intravenous treatment including the evidence based protocol for effective monitoring to enable timely escalation to second line therapy & colectomy.

Effect of yoga therapy on anxiety and depressive symptoms and quality-of-life among caregivers of in-patients with neurological disorders at a tertiary care center in India: A randomized controlled trial

CONTEXT

The concerns of caregivers of patients with neurological disorders have been a felt need for a long time, with many of them experiencing significant psychiatric morbidity.

AIMS

This study aimed to find the effect of yoga in reducing anxiety and depression, as well as improving quality-of-life in caregivers of patients with neurological disorders.

SETTINGS AND DESIGN

The study was conducted using a randomized controlled design, with yoga intervention and waitlisted controls.

METHODOLOGY

SIXTY CONSENTING CAREGIVERS OF INPATIENTS IN NEUROLOGY WARDS WERE RANDOMIZED INTO TWO GROUPS: Yoga and control. Demographic variables except years of education and length of caretaking were comparable in the two groups, as also baseline scores of anxiety, depression and quality-of-life. A specific yoga module comprising yogāsanas, prāṇāyāma, and chanting was taught to the participants in the yoga group by the researcher. At follow-up 43 patients (yoga n=20 and control group n=23) were available. Two-way repeated measures analysis of variance was used to test the change from pre-test to post-test scores within and between groups. Analysis of covariance was performed to compare the post-test scores between the groups adjusting for education and length of caretaking.

RESULTS

Following one month intervention of yoga therapy, there was a significant (P<0.001) decrease in anxiety and depression scores, as well as improved quality-of-life among the participants in the yoga group as compared with the control group.

CONCLUSION

This study highlights the usefulness of a yoga intervention for caregivers of inpatients with neurological problems. The small sample size and lack of blinding were some of the limitations of this study.

Thyroid dysfunction in Down's syndrome and screening for hypothyroidism in children and adolescents using capillary TSH measurement

Thyroid dysfunction is more common in individuals with Down's syndrome (DS) than in the general population, whose clinical features can mask the presenting signs and symptoms of hypothyroidism. Biochemical screening is necessary; however, venepuncture may be difficult.

AIMS

To assess the prevalence of thyroid dysfunction in children and adolescents with DS and the feasibility of screening for hypothyroidism using capillary dried blood spot thyroid stimulating hormone (TSH) from infancy.

METHODS

394 children (217 boys, 177 girls) were clinically assessed for thyroid dysfunction and 305 children (aged 4 months to 18.9 years) were screened for hypothyroidism by capillary whole blood TSH sample.

RESULTS

Thyroid dysfunction was detected in 4.6%, with 50% unscreened since neonatal screening. Parents reported minimal distress by fingerprick screening.

CONCLUSION

DS is associated with an increased prevalence of thyroid dysfunction, particularly in preschool children. Biochemical screening is essential and capillary whole blood TSH sampling for hypothyroidism is feasible, less invasive and acceptable.

Guidelines for the medical management of Irish children and adolescents with Down syndrome

Down syndrome (DS) is the most common chromosomal cause of developmental disability in Ireland. Children with DS have a high incidence of associated treatable medical disorders where early intervention carries a better outcome. Currently there are no agreed protocols for the screening and management of children and adults with DS in Ireland. A cross-sectional study of 394 children and adolescents was undertaken in the Eastern Regional Health Authority (ERHA) to assess the medical needs of children and adolescents with DS, in order to develop medical management guidelines. This study provides evidence-based data that children and adolescents with DS have a high incidence of treatable medical disorders, which supports the need for the medical management guidelines presented.

Isolated duodeno-pancreatic involvement due to metastatic dysgerminoma ovary and its management by a modified pancreatico-duodenal resection

Dysgerminomas of the ovary rarely metastasize to abdominal viscera and when they do, the involvement is a part of a disseminated disease. A 30-year-old woman developed isolated duodenopancreatic dysgerminoma 14 years after salpingo-oophorectomy. The clinical picture was complicated by the presence of tuberculous lesions in the liver which mimicked metastatic disease. Surgical excision was carried out using a modified pancreatic head resection.

Seroepidemiology of hepatitis A infection in India: changing pattern

OBJECTIVE

Recent changes in the epidemiology of hepatitis A virus (HAV) infection and the availability of effective vaccines have renewed interest in this infection. We determined the age-related prevalence of anti-HAV antibodies in India and looked for differences by known risk factors for HAV infection.

METHODS

In this prospective study, serum samples obtained from 1612 subjects aged 1 to 60 at six centers in five cities (Calcutta, Cochin, Indore, Jaipur and Patna) during the period February to August 1998 were tested for anti-HAV antibodies. Demographic and socio-economic information was obtained by questionnaire.

RESULTS

The overall seroprevalence rate was 65.9%, varying from 26.2% to 85.3% in various cities; there was no difference between males and females. Seropositivity increased with age from 52.2% in the 1-5 year age group to 80.8% in those aged 16 years or more. Seroprevalence rates were significantly lower in those aged 1-5 years compared with other age groups (p<0.0001). There was no difference in seroprevalence between those with monthly family income <Rs 5000 and >Rs 5001. Multivariate analysis showed that anti-HAV seroprevalence varied significantly by source of water supply, being highest when the supply was municipal.

CONCLUSION

Our results indicate an epidemiological pattern of intermediate endemicity. This finding has public health implications as it indicates that a significant proportion of the Indian adolescent and adult population is at risk of HAV infection.

Efficacy of herpes simplex virus thymidine kinase in combination with cytokine gene therapy in an experimental metastatic breast cancer model

Immunotherapy in combination with suicide gene therapy for breast cancer was tested using a metastatic animal model. Subcutaneous injection of the nonimmunogenic breast cancer cell line 4T1 in BALB/C mice gave rise to tumors in 100% of mice with both micrometastases and macrometastases in the lung. We used the herpes simplex virus thymidine kinase (HSV-TK) gene along with the cytokine genes granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-2 (IL-2) to determine their effect on tumor regression and inhibition of lung metastasis. Adenoviral (AV) vectors carrying these transgenes, in separate constructs, were used in this study. Intratumoral administration of AV-TK followed by 10 days of ganciclovir treatment resulted in a delay in tumor growth and, in some cases, in a low to moderate reduction in tumor volume. Inclusion of either GM-CSF or IL-2 gene with HSV-TK resulted in a slightly greater reduction in tumor volume, although these data were not significantly different from those obtained for TK treatment alone. However, when both cytokine genes were combined with TK, a substantial reduction in tumor growth was observed compared with HSV-TK alone (P < .02). Tumor weight data also exhibited superior efficacy of TK/GM-CSF/IL-2 treatment when compared with animals treated with TK gene only (P < .01). More importantly, TK/GM-CSF/IL-2 combination gene therapy induced a significant reduction in lung metastasis compared with any other treatment groups in the 4T1 model (P < .001 between TK GM-CSF/IL-2 versus TK only). Surgical excision of primary tumors after TK/GM-CSF/IL-2 plus ganciclovir treatment resulted in anti-metastatic activity that was similar to that observed for animals in which no surgery was performed. Survival analysis showed a significant difference between animals treated with AV-TK/GM-CSF/IL-2 and animals treated with TK only at 35 days after virus injection (P < .01). Immunophenotypic data suggest infiltration of lymphocytes within the tumor microenvironment in TK- and cytokine gene-treated animals. Thus, the overall data presented here demonstrate that TK gene therapy in combination with GM-CSF and IL-2 gene-mediated immunotherapy strategies have important implications in the treatment of breast cancer.

Dendritic cells loaded with MART-1 peptide or infected with adenoviral construct are functionally equivalent in the induction of tumor-specific cytotoxic T lymphocyte responses in patients with melanoma

Immunization with tumor-specific-associated antigen--pulsed dendritic cells has proved to be efficacious in various animal models and is being evaluated for the treatment of cancer in humans. Use of dendritic cells pulsed with specific peptides or transfected with tumor-associated antigen genes has been a focused area of investigation for inducing potent tumor and viral immune responses. In this study, the authors demonstrate transgene expression, including the lacZ and MART-1 genes, in dendritic cells infected with adenoviral constructs. These transiently transduced dendritic cells, derived from melanoma patients' monocytes cultured with granulocyte-macrophage colony-stimulating factor and interleukin-4, express the transgene and can stimulate patients' CD8+ T cells to elicit an antitumor immune response comparable to dendritic cells loaded with a defined peptide. These cytotoxic T lymphocytes were able to recognize both known and unknown tumor-associated antigen epitopes and exhibited cytolytic activity against HLA-matched tumor cells expressing the antigen. The ability to induce tumor-specific cytotoxic T lymphocytes in vitro using gene-modified dendritic cells that transiently express tumor-associated antigens demonstrates the potential use of these antigen-presenting cells for developing in vivo cancer vaccines.

CD4(+) T cells eliminate MHC class II-negative cancer cells in vivo by indirect effects of IFN-gamma

CD4(+) T cells can eliminate tumor cells in vivo in the absence of CD8(+) T cells. We have CD4(+) T cells specific for a MHC class II-restricted, tumor-specific peptide derived from a mutant ribosomal protein expressed by the UV light-induced tumor 6132A-PRO. By using neutralizing mAb specific for murine IFN-gamma and adoptive transfer of CD4(+) T cells into severe combined immunodeficient mice, we show that anti-IFN-gamma treatment abolishes the CD4(+) T cell-mediated rejection of the tumor cells in vivo. The tumor cells were MHC class II negative, and IFN-gamma did not induce MHC class II expression in vitro. Therefore, the tumor-specific antigenic peptide must be presented by host cells and not the tumor cells. Tumor cells transduced to secrete IFN-gamma had a markedly reduced growth rate in severe combined immunodeficient mice, but IFN-gamma did not inhibit the growth of the tumor cells in vitro. Furthermore, tumor cells stably expressing a dominant-negative truncated form of the murine IFN-gamma receptor alpha chain, and therefore insensitive to IFN-gamma, nevertheless were rejected by the adoptively transferred CD4(+) T cells. Thus, host cells, and not tumor cells, seem to be the target of IFN-gamma. Together, these results show that CD4(+) T cells can eliminate IFN-gamma-insensitive, MHC class II-negative cancer cells by an indirect mechanism that depends on IFN-gamma.

Bilateral reflex fracture of the coronoid process of the mandible. A case report

Bilateral fractures of the coronoid process of the mandible occurred following a blow to the left temporal region in an assault. There was no evidence of direct trauma and the zygoma and other facial bones were intact. The probable cause was acute reflex contraction of the temporalis muscles leading to bilateral stress coronoid fractures. Conservative management was followed by complete resolution of symptoms.

Transgene expression in dendritic cells to induce antigen-specific cytotoxic T cells in healthy donors

Immunization with specific tumor-associated antigen (Ag) (TAA)-pulsed dendritic cells (DC) has proven to be efficacious in a variety of animal models and is being investigated for the treatment of cancer patients. Use of DC pulsed with specific peptides or transfected with TAA genes has been a focused area of investigation for the induction of potent tumor and viral immune responses. In this study we demonstrate transgene expression, including expression of the MART-1 gene, in DC transfected with plasmid DNA and cationic liposome complexes. These transiently transfected DC, derived from healthy donor monocytes cultured with granulocyte macrophage colony-stimulating factor and interleukin-4, express the transgene and can stimulate naive CD8+ T cells to elicit an antitumor immune response. These cytotoxic T lymphocytes (CTL) were capable of recognizing both known and unknown TAA epitopes and were able to exhibit cytolytic activity against human histocompatibility leukocyte Ag-matched tumor cells expressing the Ag. In addition to their cytolytic function, the CTL displayed an oligoclonal T-cell receptor repertoire, indicating that the presented Ag induced alterations in the T-cell population. The ability to induce tumor-specific CTL in vitro using gene-modified DC transiently expressing TAAs demonstrates the potential use of these Ag-presenting cells to generate future in vivo cancer vaccine strategies.

Ganglioneuroma: an 'incidentaloma' of childhood

In adults clinically silent adrenal masses can be discovered incidentally in imaging studies. Most of these 'incidentalomas' are benign, non-functioning adenomas. In contradistinction, in infancy and childhood the most common adrenal mass is the neuroblastoma, a malignant neural crest tumour. Four children are described, each with a benign neural crest tumour - ganglioneuroma - incidentally discovered by conventional radiography or sonographic examination. Complete surgical excision resulted in total recovery of all the children.

Active immunization with tumor cells transduced by a novel AAV plasmid-based gene delivery system

Ex vivo genetically engineered cytokine-secreting tumor cell vaccines have been shown to prevent metastatic disease in animal models of lung and breast cancer. Because of the inefficiency of existing modes of gene delivery in transducing primary human tumor cells, it has been difficult to clinically apply this strategy. In this study, liposome-mediated delivery of an adeno-associated virus (AAV)-based plasmid containing the sequence for murine gamma-interferon (gamma-IFN) (pMP6A-mIFN-gamma) was used to generate cytokine-secreting murine tumor cell vaccines. High levels of gamma-IFN and elevated class I major histocompatibility complex expression after transfer of pMP6A-mIFN-gamma into the murine lung cancer cell line, D122, was demonstrated. The efficiency of gene transfer was determined by two different methods and was estimated to be 10-15%. Irradiated gamma-IFN D122 cells generated by this novel gene delivery system (D122/pMP6A-mIFN-gamma) and also by standard retroviral methods (DIF2) were administered as weekly vaccinations by intraperitoneal injection to animals bearing 7-day-old intrafootpad D122 tumors. Hindlimb amputation was performed when footpad diameters reached 7 mm, and lungs were harvested 28 days later. Animals vaccinated with gamma-IFN-secreting D122 cells produced by AAV-based plasmids delivery demonstrated a significant delay in footpad tumor growth when compared with controls and DIF2 cells. Fifty-seven percent of animals vaccinated with D122/pMP6A-mIFN-gamma were free of pulmonary metastases 28 days after amputation, significantly improved from the 0, 7, and 15% observed in animals vaccinated with irradiated parental D122 cells, irradiated D122 cells lipofected with an empty-cassette vector (pMP6A), or DIF2 cells, respectively. These results and the ability to transfer genes with this delivery system to a broad range of tumor types support its use in the generation of cytokine-secreting tumor cell vaccinations for use in clinical trials.

Gene modification of primary tumor cells for active immunotherapy of human breast and ovarian cancer

We have previously shown that cationic liposomes facilitate adeno-associated virus (AAV) plasmid transfections of primary and cultured cell types. To test the clinical feasibility of using genetically modified tumor vaccines for the treatment of breast and ovarian cancers, we have constructed an expression plasmid pMP6IL2 and investigated the use of liposome-mediated gene delivery into primary, uncultured human breast and ovarian tumor cells to produce interleukin 2 (IL-2)-secreting tumor cells. We have demonstrated significant levels of IL-2 expression in tumor cell lines and primary breast and ovarian tumor cells using this AAV-based expression plasmid complexed to cationic liposomes. Transfections with the non-AAV plasmid containing the identical expression cassette as the AAV plasmid induced IL-2 expression in the tumor cell line but failed to produce IL-2 in primary tumor cells. Significant levels of IL-2 were induced with the AAV plasmid regardless of liposome compositions used for transfection. The transfected breast cell line and primary tumor cells were able to express the transgene product for up to 28 days after lethal radiation. The transfection efficiency was comparable for both the tumor cell line and primary tumor cells and ranged from 20 to 50% for both cell types as assessed by intracellular IL-2 staining. Although the primary tumor cell preparations consist of mixed population of cells, at least 40% of the tumor cells expressed the transgene as assessed by immunostaining for IL-2. The ability to efficiently express transgenes in freshly isolated, nondividing tumor cells may potentiate active immunotherapy strategies for gene-based cancer treatment.

Efficient gene transfer with adeno-associated virus-based plasmids complexed to cationic liposomes for gene therapy of human prostate cancer

We have shown previously that treatment of rats bearing the Dunning R3327 MatLyLu prostatic tumor with human interleukin 2 (IL-2) gene-modified tumor cell preparations induces potent antitumor immunity in the animal. To test the clinical feasibility of using genetically modified tumor vaccines for the treatment of prostate cancer, we have explored the use of a simplified gene delivery system based on liposomes to introduce and express the IL-2 gene in the Dunning rat R3327 MatLyLu prostatic tumor cell line (MatLyLu) and in short-term cultures of primary human prostatic tumor cells. Liposome-DNA complexes containing the adeno-associated virus inverted terminal repeats exhibited 3-10-fold higher levels of gene transfer and IL-2 expression than did liposome complexes with non-adeno-associated virus containing plasmids. Single transfections resulted in IL-2 expression for an extended period of time that exceeded severalfold the amount of IL-2 secreted from retrovirally transduced MatLyLu cells. X-irradiation of cells (4000 rads) prior to transfection did not affect cytokine secretion, indicating that liposome-mediated gene transfer does not depend on cell proliferation. High levels of gene transfer and IL-2 expression were also achieved in short-term cultures of primary human prostatic tumor cells established from tumor specimens obtained following radical prostatectomy of cancer patients. Depending on the type of liposome used, IL-2 levels secreted from the human prostatic tumor cells were comparable to or exceeded the levels of IL-2 secreted from retrovirally transduced MatLyLu cells, which induced antitumor immunity in the rat model. The ability to culture and expand ex vivo human prostatic tumor cells, and the use of a simple and highly efficient gene transfer method to generate genetically modified tumor vaccines, set the stage for clinical exploration of gene-based immunotherapy of prostate cancer.

Enhanced expression of granulosa cell low density lipoprotein receptor activity in response to in vitro culture conditions

Previous studies have shown that the B/E (low density lipoprotein [LDL]) receptor pathway plays a minor role in cholesterol uptake in the intact rat ovary, but when granulosa cells are isolated and maintained in culture, the cells develop a fully functional B/E receptor system. In the current study we examined the development of the B/E receptor over time (96 h) in culture and compared its physiological function, expression of mRNA and protein levels, and morphological events to the upregulation induced in 24 h by hormone (human chorionic gonadotropin [hCG] or Bt2cAMP). With both protocols, increased progestin production occurs and is associated with elevated binding, uptake, and degradation of LDL in the medium although the impact of Bt2cAMP stimulation on all these measurements is several times that observed with time alone. Only the hormone-stimulated LDL receptor response was associated with an increase in receptor protein (Western blot) or mRNA levels (RNase protection assay). We conclude that unstimulated granulosa cells show posttranslational increases in B/E receptor activity with time in culture, but transcriptional changes in B/E receptor follow stimulation with trophic hormone or its second messenger, cAMP.

Evaluation of anthropometric indices of malnutrition in under five children

Anthropometric indices in the assessment of malnutrition in under five children are being indiscriminately used especially when a community based survey is conducted and so the estimated prevalence of malnutrition varies in different methods. In this study a comparison of these common anthropometric measurements is done in order to find out the best method suitable for individual assessment of malnutrition. The evaluation technique discussed in this paper consists of comparison of the efficiency of various anthropometric measurements in detecting malnutrition and was judged in terms of specificity, sensitivity and predictive value. The test is most efficient when the sensitivity and specificity attain unity. In this study it is shown that weight for age and Body Mass Index (BMI) attain higher value of delta [delta = 1-(alpha + beta)], where - alpha is false positive value and beta is false negative value) and low value of delta standard error of which proves that the best method of assessing malnutrition using various anthropometric measurements is weight for age as against body mass index.

Enhanced transcription of the human alpha 2A-adrenergic receptor gene by cAMP: evidence for multiple cAMP responsive sequences in the promoter region of this gene

Expression of the human alpha 2A-adrenergic receptor gene is induced by cAMP. The present studies were designed to define potential cAMP-responsive enhancer elements (CREs) in the promoter region of this gene. Regions from the 5'-flanking sequences of the gene were placed in a promoterless vector with a chloramphenicol acetyltransferase (CAT) reporter gene, and cAMP-stimulated CAT activity was assayed in transfected JEG-3 placental carcinoma cells. Enhancer activity responsive to cAMP was located in DNA sequences both upstream and downstream from the endogenous promoter region. Within the upstream sequences there is a putative "core sequence" homologous to the eight base CRE consensus palindrome, but this region did not function independently as a CRE enhancer; additional upstream sequences were required to provide significant enhancer activity in response to cAMP. Regulation of expression of the alpha 2A-adrenergic gene by cAMP is complex and involves multiple and likely novel DNA sequences.

In vivo gene delivery. Efficient transfection of T lymphocytes in adult mice

We have demonstrated that a single intraperitoneal injection of cationic liposomes complexed to a chloramphenicol acetyltransferase (CAT) gene expression plasmid can transfect the majority of splenic Thy 1.2+ T lymphocytes, as well as significant numbers of bone marrow-derived hematopoietic cells, in adult mice. CAT activity was detected in the spleen for at least 2 weeks, and there was no evidence of treatment-related toxicity. Some degree of tissue-specific transgene expression was achieved by varying the cationic lipid used.

Reusable needles--a major risk factor for acute virus B hepatitis

We conducted a case control study to find the extent to which acute virus B hepatitis was hospital acquired. One hundred and sixty consecutive cases of acute virus B hepatitis were compared with age (+/- 3 years) and sex matched healthy hospital visitors. Exposure to reusable needles, blood or blood products, therapeutic and diagnostic procedures, common razors and sexual practices were elicited by means of a questionnaire. Only exposures in the incubation period (6 weeks to 6 months before the onset of symptoms) were included in the analysis. The odds ratio (OR) for injections for reusable needles was 6.3 [95% confidence interval (CI) = 3.8-10.6]. The OR for single injection (OR = 3.9; 95% CI = 2.0-7.3) was less than that for multiple injections (OR = 9.8; 95% CI = 3.8-26.3), showing a dose response relationship. The proportion of cases of acute virus B hepatitis attributable to hospital related exposures was 67%. Proper aseptic techniques and sterilization practices can substantially reduce the incidence of acute hepatitis B in the population.

Mapping the ligand binding pocket of the human muscarinic cholinergic receptor Hm1: contribution of tyrosine-82

The ligand binding pocket of many G protein-coupled receptors is thought to be located within the core formed by their seven transmembrane domains (TMDs). Previous results suggested that muscarinic antagonists bind to a pocket located toward the extracellular region of the TMDs, primarily at TMDs 2, 3, 6, and 7. Tyrosine-82 (Y82) is located in TMD2 only one helical turn from the presumed membrane surface of Hm1, whereas a phenylalanine (F124) is found in the equivalent position of the closely related Hm3. In order to determine the contribution of Y82 to Hm1 ligand binding and selectivity versus Hm3, we constructed the point mutation Y82 F of Hm1 and measured binding affinities of various ligands, with 3H-N-methylscopolamine (3H-NMS) as the tracer. The Hm1 wild-type receptor and the Y82F mutant were transfected into human embryonic kidney U293 cells. Whereas the affinities of NMS, carbachol, and atropine were either unchanged (carbachol) or enhanced by less than twofold (atropine and NMS), the affinity of the Hm1-selective pirenzepine was reduced threefold by the Y82F mutation. These changes parallel affinity differences of Hm1 and Hm3, indicating that the Y82 F mutation affects the binding pocket and that Y82 contributes to the binding selectivity among closely related muscarinic receptors.