When a synonymous mutation breaks the silence in a thalassaemia patient

Synonymous mutations were considered to lack functional roles in human diseases; however, distinguishing deleterious synonymous mutations from benign ones is still a challenge. In this article, we identified a deleterious synonymous mutation β-codon 16 (C>T). HBB: c.51C>T, in compound heterozygous form with known β-thalassaemia mutation patients who clinically presented as non-transfusion-dependent thalassaemia (NTDT). A total of 9 families with 11 compound heterozygous index cases were reported. In the heterozygous state, codon 16 (C>T) mutation results in borderline HbA2 (3.18 ± 0.36%) and slightly reduced RBC indices (RBCs: 4.73 ± 0.75 × 106 /μL, Hb: 12.26 ± 2.60 g/dL, MCV: 79.48 ± 8.40 fL, MCH: 25.95 ± 4.15 pg). The compound heterozygous patients showed elevated HbA2 (5.98 ± 1.17%) and HbF (12.75 ± 7.51%) and presented clinically as NTDT with a mean Hb of 6.95 ± 1.29 g/dL. Many of them were dependent on few transfusions and had mild splenomegaly. Of the 11 patients, 5 (45.4%) were treated with hydroxyurea. This study highlights the clinical significance of synonymous mutation, when inherited with other β-thalassaemia mutations leading to the phenotype of NTDT. Thus, the study would help to improve screening protocols for β-thalassaemia carriers, which will ultimately improve the prevention programme.

Small size silver nanoparticles loaded with glycoside rich portion of Boerhavia Diffusa Linn. promotes wound healing: in-silico and in-vivo studies

Silver nanoparticles (Ag-NPs) are increasingly used in various fields, including medicine, owing to their unique physicochemical properties. Due to their smaller size, the contact with biological components is increased, and consequently, it performs better as an antibacterial and antimicrobial. In this study, the authors have focused on the synthesis of small-sized spherical silver nanoparticles (Ag-NPs) by a chemical reduction method using two different capping agents and concentrations of AgNO3 as a precursor. Additionally, various amounts of Glycoside Rich Portion (GRP) isolated from the roots of Boerhaavia diffusa L. were loaded onto synthesised Ag-NPs. Punarnavoside, a glycoside found in GRP, has been reported to have antifibrinolytic properties. The docking study of punarnavoside present in GRP has shown good binding affinity with various antifibrinolytic targets. The surface plasmon resonance band, particle size, polydispersity index, and zeta potential values have been used to analyse the interaction and kind of bonding between GRP and Ag-NPs. A batch of trisodium citrate (TSC)-capped Ag-NPs loaded with 0.1 ml of 1% GRP solution showed particle size smaller than 50 nm with a stable zeta potential value of - 55.3 mV. Fourier transform infrared spectroscopic results showed CO and C-O bonds in GRP interacted with Ag-NPs. A batch of TSC-capped GRP-loaded Ag-NPs (1%)-based gel was developed using carbopol as a polymer. The TSC-capped GRP-loaded silver nanogel had greater wound closure in rats, as observed during the histopathological studies in the excision wound model. The antifibrinolytic activity of GRP, when coupled with the antibacterial and bactericidal properties of silver, demonstrated an increased wound healing effect.

Abstract 462: A novel and potent Cblb inhibitor demonstrates robust immunological profile and anti-tumor efficacy

Background: Casitas B-lineage lymphoma b (Cbl-b), a RING finger E3 ligase, is a negative regulator of immune cell activation1. Genetic deletion or pharmacological inhibition of Cbl-b resulted in hyper-reactive and co-stimulation independent T cell activation and cytokine production1. In syngeneic tumor models, CD8 T-cell and NK-cell mediated rejection of tumours were observed1. These findings point to Cbl-b as a therapeutic target in cancer immunotherapy. Inhibition of Cbl-b also demonstrated the potential to enhance the efficacy of check-point blockers like anti-PD-1 antibody, an unmet need in the clinic.

Methods: Using intuitive medicinal chemistry design supported by computational approaches, we identified a lead Cbl-b inhibitor. SAR was developed using a battery of biochemical assays, functional read-outs and primary human in vitro T-cell activation and exhaustion assays. In vivo efficacy was demonstrated in syngeneic mouse colon tumor model.

Results: Our lead Cbl-b inhibitor demonstrated potent binding to Cbl-b, robust anti-tumor cytokine secretion in human and mouse T cells, whole blood and potent reversal of T cell exhaustion. A strong tumor growth inhibition was demonstrated by the lead compound in a mouse colon tumor model. Compared to single agent, a combination of the lead compound with anti-PD-1 antibody induced enhanced complete tumor rejections.

Conclusions: We have identified a novel, potent and orally bioavailable Cbl-b inhibitor that demonstrated robust in vitro and in vivo anti-tumor profiles.

Acknowledgements: We thank Sanjib Das, Ajit Patil, Gauri Gawas, Savita Pandita, Priya Yadav, Sneha Pusadkar, Mayura Behere, Subhadip Das, Shravankumar Kolli and Radheshyam Yadav for their contributions to the project

References: 1. Clinical and Experimental Immunology, 204: 14-31, 2020

Citation Format: Murugan Chinnapattu, Sandeep Shelke, Prashant Ingale, Nayan Waghmare, Nanasaheb Kadlag, Manoj Pawar, Akshay Kangane, Sachin S. Chaudhari, Jagmohan Saini, Vidya Kattige, Arti Joshi, Colina Dutta, Debjyoti Boral, Sheetal Kadam, Varada Potdar, Jiju Mani, Pooja Sawant, Megha Marathe, Madhavi Mulay, Akshata Virdikar, Sravan Mandadi, Atul Akarte, Anuj Singh, Chandrasekhar Misra, Pandurang Lambade, Chaitanya Tirumalasetty, Raju Patole, Vikas Karande, Dayanidhi Behera, Pankaj Jain, Vishwanath Kurawattimath, Nagaraj Gowda, Pravin S. Iyer. A novel and potent Cblb inhibitor demonstrates robust immunological profile and anti-tumor efficacy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 462.

Potential of Herbal Extracts as Sunscreens and Antihyperpigmentation Treatment

Background:

Skin pigmentation is one of the most serious problems in the adult population of all races. The underlying factors of skin pigmentation are excessive exposure to UV radiation, oxidative stress, and other provocative causes that cause melasma, black spots, and post-inflammatory hyperpigmentation. Hence, treating hyperpigmentation disorders is challenging.

Objective:

Skin pigmentation occurs as a process of melanin biosynthesis triggered by UV exposure. Tyrosinase, an enzyme that catalyzes the rate-confining step in melanogenesis, if inhibited, can cause skin hypopigmentation. This has evoked an interest in reviewing plant extracts/ phytoconstituents, which can serve the purpose of sun protection and treat hyperpigmentation, ensuring skin glow for a better quality of life.

Method:

A literature search on Medline, PubMed, Embase, and Scopus databases was done using various keywords like hyperpigmentation, melasma, skin-lightening agents, and sunscreen.

Result:

Sun protection products for canopy with photo-aging and skin pigmentation are recommended. Tyrosinase inhibitors are first-line topical medicines available as single or combined topical formulations. Hydroquinone, retinoids, corticosteroids, and kojic acid are clinically proven as exceptionally powerful. However, the adverse effects reported with these small molecules largely impact skin appearance, dermatitis, and exogenous ochronosis. Currently, there is a rising trend towards comfortable, fascinating, and well-endured skin depigmenting agents from natural products that might be utilized by a wide populace.

Conclusion:

This present study aimed at exploring plant and fruit extracts together with their active ingredients as potential multitargeted anti-hyperpigmentation agents with sunscreen properties, tyrosinase inhibition, and skin whitening effects.

848 Novel small molecule HPK1 inhibitor PCC-1 induces strong anti-tumor activity

Background

Hematopoietic progenitor kinase 1 (HPK1, MAP4K1), is a negative regulator of T and B cell receptor signaling.1 2 3 A strong anti-tumor immunogenic response and tumor rejection was observed in mice with HPK1 gene knocked out.3 Treatment of HPK1 kinase dead mice with immune check-point blockers (ICBs) demonstrated enhanced tumor growth inhibition.3 Hence, HPK1 is an attractive therapeutic strategy for immuno-oncology based treatment in cancers. In comparison to our previous HPK1 small molecule inhibitor, PCC,4 we present here a differentiated novel HPK1 inhibitor, PCC-1 with good anti-T cell kinases selectivity and stronger anti-tumor efficacy in CT26 tumor model. In addition, using the syngeneic model of MC38 expressing human PD-L1, we present for the first time, the combination efficacy of a HPK1 inhibitor with the clinical ICB, Atezolizumab.

Methods

Intuitive medicinal chemistry complemented by structure-based drug design was used to identify & develop potent inhibitors of HPK1 with optimal kinase selectivity, PK and in vivo efficacy profile. The SAR efforts were guided by biochemical assays, functional read-outs and primary human in vitro T-cell activation assays. In vivo target engagement and pharmacodynamic data was generated using CT26 and MC38-hPD-L1 tumor models.

Results

PCC-1 has sub-nanomolar HPK1 inhibition potency and strong target engagement resulting in pSLP76 inhibition, enhanced anti-tumor cytokine production of IL-2 and/or IFNgamma in Jurkat cells, human PBMCs and human whole blood. PCC-1 also demonstrated nanomolar potency in inducing a complete reversal of PGE2 or adenosine mediated immunosuppression. Oral dosing of PCC-1 as a single agent, induced strong tumor growth inhibition (TGI) in the syngeneic model of CT26 and MC38-hPD-L1 tumor models. Combination of PCC-1 with anti-CTLA4 in CT26 tumor model induced significantly greater TGI than anti-CTLA4 alone. Moreover, as a first, the combination of PCC-1 with clinical ICB, Atezolizumab in MC38-hPD-L1 induced enhanced rejection of tumors. These results strongly suggest PCC-1 as a promising candidate for HPK1 inhibition and as a combination partner with ICBs in clinic.

Conclusions

PCC-1 is a novel, orally active HPK1 inhibitor that demonstrates excellent stand-alone efficacy and enhances current immunotherapy efficacy. Further evaluation of PCC-1 is ongoing to advance towards clinic.

Acknowledgements

We thank Dnyaneshwar Dahale, Sanjay Patale, Sandip Patil, Vidya Kattige, Jiju Mani, Namrata Singh, Ekta Kashyap, Sandeep Thorat, Pankaj Jain and Pramod Sagar for their contributions to the project

Trial Registration

N/A

References

Kiefer F, et al. The EMBO Journal 1996.

Hu, et al. Genes and Development 1996.

Sawasdikosol, Burakoff. eLife 2020;9:e55122.

Sachin S Chaudhari, et al. Poster#1709, AACR Annual Meeting April-May 2021.

Ethics Approval

The studies involving animals have obtained ethics approval from Institutional Animal Ethics Committee (IAEC), The Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA), New Delhi, India, GRC/IAEC/472/2020-1. Participants of the studies have given informed consent before taking part.

Abstract 1709: Novel small molecule HPK1 inhibitor induces immunogenic anti-tumor effects

Background Hematopoietic progenitor kinase 1 (HPK1, MAP4K1), a member of the MAP4K family of protein serine/threonine kinases1,2 is a negative regulator of TCR and BCR3. Immunosuppressive mediators PGE2 and adenosine regulate activation of HPK13. In vivo anti-tumor activity by HPK1 gene deletion, kinase dead HPK1 and small molecule HPK1 inhibitors have been demonstrated in multiple immunogenic syngeneic tumor models3,4. Enhanced anti-tumor efficacy in these models was achieved by combining HPK1 inhibitors with immune check-point blockers (ICBs) like anti-PD-1, anti-PD-L1or anti-CTLA4 antibodies3,4. HPK1 inhibition is a target for immuno-oncology treatment in cancers responsive or non-responsive to current ICBs.

Methods Creative medicinal chemistry design complemented by structured-based support was used to identify & develop inhibitors of HPK1 with pico/nano-molar potency, optimal kinase selectivity, PK and efficacy profile. Our SAR efforts were guided by biochemical assays, functional read-outs and primary human in vitro T-cell activation assays. In vivo target engagement and pharmacodynamic data was generated using mouse models of the lung (LLC) and colon (MC38 and CT26) cancer.

Results We describe novel and potent HPK1 inhibitors that can inhibit pSLP76 and enhance IL-2 production in Jurkat cells, IL-2 and IFN-γ production in human PBMCs, whole blood and primary T cells and TNF-α production by dendritic cells following stimulation. A reversal of PGE2 or adenosine mediated immunosuppression was also achieved by the inhibitors. These compounds on oral dosing showed strong tumor growth inhibition (TGI) in syngeneic models refractory to ICBs (subcutaneous LLC) as well as responsive to ICBs (subcutaneous MC38 and CT26; orthotopic LLC). TGI was accompanied by the immune response of increased cytokine (IL-2/IFNγ) levels and tumor infiltrating lymphocytes (TILs). Combination with ICBs induced enhanced TGI correlating with enhanced cytokine induction and TILs. We confirmed the immune-mediated mechanism of inhibitors by their lack of efficacy in immune-compromised mice. The lead compound demonstrated cardiac safety (hERG assay), lack of genotoxicity and very good safety margins in the mouse exploratory toxicology studies up to 28-days.

Conclusion We have discovered a novel, orally active HPK1 inhibitor that demonstrates excellent stand-alone efficacy in multiple tumor models and also offers the potential to enhance current immunotherapy regimens in both responsive and refractory cancers. Further evaluation of our lead molecule towards the clinic is underway.

Acknowledgements Sanjib D, Megha M, Jiju M, Sheetal K, Arti J, Swayam M, Srinivas K, Pradeep V, Vikram B, Abhay K, Jagmohan S, Ravi T, Mohammad Y, Rahul B, Ajit J, Sanjay G, Pramod S.

References 1. Kiefer et al., EMBO Journal 1996; 2. Hu et al., Genes and Development 1996; 3. Sawasdikosol and Burakoff. eLife 2020;9:e55122; 4. AACR Annual Meeting June 22-24 2020

Citation Format: Sachin S. Chaudhari, Malini Bajpai, Sravan Mandadi, Vidya G. Kattige, Sandeep Thorat, Varada Potdar, Priyanka Pangre, Pooja Sawant, Chandrasekhar Misra, Subhadip Das, Atul Akarte, Anuj Singh, Sandeep Mahankali, Pandurang Lambade, Avratanu Das, Raju Patole, Venkatesha Udupa, Pavankumar Sancheti, Pramod K. Pawar, Somesh Kakade, Vinod K. R, Nilanjana Biswas, Heta Shah, Dayanidhi Behera, Pankaj Jain, Nagaraj Gowda, Pravin S. Iyer. Novel small molecule HPK1 inhibitor induces immunogenic anti-tumor effects [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1709.

OP0307 A NOVEL TARGETED APPROACH TO ACHIEVE IMMUNE SYSTEM RESET: CD45-TARGETED ANTIBODY DRUG CONJUGATES AMELIORATE DISEASE IN PRECLINICAL AUTOIMMUNE DISEASE MODELS AND ENABLE AUTO-HSCT

Background:

Resetting the immune system through autologous hematopoietic stem cell transplant (autoHSCT) is a highly effective treatment in selected patients with autoimmune diseases. AutoHSCT can induce long-term remission with 80% progression free survival in multiple sclerosis patients (Muraro 2017, Burt 2019). Use of autoHSCT in scleroderma patients has achieved superior outcomes in two randomized studies compared to standard of care (Tyndall 2014, Sullivan 2018). These impressive results are achieved by a combination of the eradication of autoreactive immune effector cells and re-establishment of self-tolerance, i.e., immune system reset. However, only a small fraction of eligible patients undergo autoHSCT, largely due to toxicity associated with current conditioning protocols.

Objectives:

As part of our goal to enable more patients to benefit from immune system reset, we have generated novel anti-human CD45 ADCs that cross react with nonhuman primates (NHP) and an anti-mouse CD45 ADC to model the approach in mouse models of AID.

Methods:

The human-targeted CD45-ADC is an affinity-matured mAb that targets an epitope present on all human CD45 isoforms, is cross-reactive with NHP CD45, and is conjugated to a payload that efficiently kills both quiescent and cycling cells. This ADC is engineered to eliminate Fc-mediated effector function, enable site-specific conjugation of linker/payload, and enable rapid clearance. This ADC was evaluated in vitro and in vivo in hNSG and NHPs. The murine tool ADC specifically targets the CD45.2 isoform of mouse CD45, and is also engineered to eliminate effector function, allow for site-specific conjugation of linker payload, and be rapidly cleared. The payload for this murine tool ADC is potent and preferentially kills dividing cells. This ADC was tested for the ability to enable immune reset and ameliorate autoimmune disease in multiple disease models.

Results:

The anti-human CD45-ADC showed efficient killing of human HSCs and human and cyno PBMC, including CD3+cells from healthy donors and patients with MS. In hNSG, single doses of the CD45-ADC were well-tolerated and led to substantial depletion of human cells. In NHPs, single doses of CD45-ADC were well tolerated and depleted both peripheral lymphocytes and HSCs. Administration of a single dose of anti-human CD45-ADC to hNSGs with sclerodermatous xenoGVHD resulted in depletion of human T cells and resolution of symptoms. A single-dose of the anti-mouse CD45-ADC enabled full myeloablation and complete durable donor chimerism with congenic HSCT at 16 weeks. In a murine immunization model of MS, MOG-induced EAE, a single dose of the CD45-ADC followed by congenic HSCT prior to disease onset enabled full donor chimerism, significantly delayed disease onset and reduced disease severity. We are generating additional data in an adoptive transfer model of EAE to confirm and extend these results. In a murine model of arthritis, therapeutic treatment with a single dose of the CD45-ADC followed by congenic HSCT enabled complete donor chimerism and halted disease progression, comparable to with the effects of an anti-TNFα antibody. The ADC is being further evaluated in a model of type 1 diabetes and those data will be presented. These data demonstrate that CD45-ADC conditioning followed by congenic HSCT is sufficient for full myeloablation and immune reset.

Conclusion:

These results demonstrate that targeted immune depletion with a single dose of CD45-ADC can enable auto-HSCT and immune reset in multiple AID indications without toxic side effects. Targeted conditioning with CD45-ADC may represent a better tolerated approach for removing disease-causing cells as part of immune reset through auto-HSCT and enable more patients to benefit.

Disclosure of Interests:

Geoffrey Gillard Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Jennifer Proctor Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Sharon Hyzy Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Oliver Mikse Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Tahirih Lamothe Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Sean McDonough Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Nicholas Clark Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Rahul Palchaudhuri Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Anjali Bhat Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Melissa Brooks Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Ganapathy Sarma Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Prashant Bhattarai Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Pranoti Sawant Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Brad Pearse Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Charlotte McDonagh Shareholder of: Magenta Therapeutics, Employee of: Magenta Therapeutics, Tony Boitano Shareholder of: Magenta, Employee of: Magenta, Michael Cooke Shareholder of: Magenta, Employee of: Magenta

Alleviating CYP and hERG liabilities by structure optimization of dihydrofuran-fused tricyclic benzo[d]imidazole series - Potent, selective and orally efficacious microsomal prostaglandin E synthase-1 (mPGES-1) inhibitors: Part-2

In an effort to identify CYP and hERG clean mPGES-1 inhibitors from the dihydrofuran-fused tricyclic benzo[d]imidazole series lead 7, an extensive structure-activity relationship (SAR) studies were performed. Optimization of A, D and E-rings in 7 afforded many potent compounds with human whole blood potency in the range of 160-950 nM. Selected inhibitors 21d, 21j, 21m, 21n, 21p and 22b provided selectivity against COX-enzymes and mPGES-1 isoforms (mPGES-2 and cPGES) along with sufficient selectivity against prostanoid synthases. Most of the tested analogs demonstrated required metabolic stability in liver microsomes, low hERG and CYP liability. Oral pharmacokinetics and bioavailability of lead compounds 21j, 21m and 21p are discussed in multiple species like rat, guinea pig, dog, and cynomolgus monkey. Besides, these compounds revealed low to moderate activity against human pregnane X receptor (hPXR). The selected lead 21j further demonstrated in vivo efficacy in acute hyperalgesia (ED₅₀: 39.6 mg/kg) and MIA-induced osteoarthritic pain models (ED₅₀: 106 mg/kg).

Discovery of furan and dihydrofuran-fused tricyclic benzo[d]imidazole derivatives as potent and orally efficacious microsomal prostaglandin E synthase-1 (mPGES-1) inhibitors: Part-1

This letter describes the synthesis and biological evaluation of furan and dihydrofuran-fused tricyclic benzo[d]imidazole derivatives as novel mPGES-1 inhibitors, capable of inhibiting an increased PGE₂ production in the disease state. Structure-activity optimization afforded many potent mPGES-1 inhibitors having <50 nM potencies in the A549 cellular assay and adequate metabolic stability in liver microsomes. Lead compounds 8l and 8m demonstrated reasonable in vitro pharmacology and pharmacokinetic properties over other compounds. In particular, 8m revealed satisfactory oral pharmacokinetics and bioavailability in multiple species like rat, guinea pig, dog and cynomolgus monkey. In addition, the representative compound 8m showed in vivo efficacy by inhibiting LPS-induced thermal hyperalgesia with an ED₅₀ of 14.3 mg/kg in guinea pig.

Thermodynamic stability and impedance measurements of perovskite LuRhO3(s) in the Lu–Rh–O system

The Gibbs energy of formation of LuRhO₃(s) has been determined using a solid-state electrochemical technique employing an oxide ion conducting electrolyte.

Effect of capsule 'UB03' containing potential probiotic strains for the treatment of patients with irritable bowel syndrome

The objective of this research was to study the efficacy and safety of capsule 'UB03' to treat patients with Irritable Bowel Syndrome (IBS). Thirty patients with Rome II IBS were assigned to receive capsule 'UB03' (10 billion lyophilised bacteria and yeast/capsule produced by Unique Biotech Limited, India) twice daily for 90 days. Assessment of IBS was carried out according with Rome II criteria and their severity for 90 days of treatment with an interval of 30 days. Complete haemogram, serum glutamic pyruvic transaminase, serum creatinine were performed as a part of safety evaluation at the time of inclusion and after 90 days of treatment. There was significant improvement in frequency of defecation (23%), consistency of stool, abdominal discomfort, bloating and flatulence. However, there was no significant change in abdominal pain and mucus in stool. This trial demonstrates that the consumption of capsule 'UB03' containing potential probiotic strains is found to be effective and safe for the treatment of patients with IBS.

Myotonic dystrophy in a patient of celiac disease: a new association?

Celiac disease (CD) has long been known to be associated with neurological and psychiatric manifestations; its in association with myotonic dystrophy however has not yet been reported. We report the case of a 27-year old female patient who presented to us with diarrhoea, weight loss, easy fatigability, irritability and alopecia of 8 months duration and was diagnosed to have celiac disease and put on gluten free diet. 8 weeks later she developed neurological symptoms and was found to have myotoni dystrophy in addition. At six month follow up patient had gained 5 kg, but the neurological symptoms remained the same. Treatment of neurological symptoms associated with gluten hypersensitivity depends on the type of neurological syndrome associated. Only exceptionally do these symptoms improve with gluten restriction and, in some patients, the neurological manifestations even progress despite resolution of both pathologic findings and intestinal symptoms.

HPLC studies in hemoglobinopathies

An accurate diagnosis of beta -thalassemia carriers, homozygous patients and identification of different structural hemoglobin variants is important for epidemiological studies as well as for management and prevention of the major hemoglobin disorders. There are many electrophoretic and chromatographic approaches for estimation of HbA2 and Hb F but cation exchange HPLC (CE-HPLC)using automated dedicated machines like the Variant Hb testing system have become the method of choice for these investigations. CE-HPLC also helps in the presumptive identification of many abnormal hemoglobin variants and has been useful for both neonatal screening of sickle cell disease as well as second trimester prenatal diagnosis of thalassemia by fetal blood analysis. Other applications of HPLC in hemoglobinopathies include separation of globin chains, measuring the ratio of gamma globin chains (Ggamma/Agamma) and the recently described denaturing HPLC for detecting mutations in both alpha and beta globin genes.

Can anti-Helicobacter pylori and anti-CagA antibodies be used to select patients with dyspepsia for gastroscopy?

BACKGROUND

agA IgG antibody in sera may indicate presence of peptic ulcer disease among dyspeptic patients and therefore may be used as a serological marker to identify high risk patients for peptic ulcer who can be subjected to endoscopy. Present study was performed to identify association of CagA IgG antibody in patients with peptic ulcer.

METHODS

Consecutive patients with dyspepsia were subjected to endoscopy and sera was collected from each. Rapid urease test in antral tissue collected from each patient by endoscopic biopsy was performed. Antral tissue was also examined histologically. IgG Antibody against H. Pylori and CagA IgG antibody was tested in each patients sera.

RESULTS

Out of 82 patients with dyspepsia included in the study 28 had peptic ulcer. Of whom 26 were positive for anti IgG H. Pylori antibody. More than 80% patients with peptic ulcer patients had detectable anti Cag A antibody in contrast to 33% patients with non ulcer dyspepsia (P < 0.001).

CONCLUSION

Anti-Cag A antibody may be used as a screening test in patients with dyspepsia to select high risk patients for peptic ulcer for upper gastrointestinal endoscopy.

Efficacy of low dose intradermal hepatitis B vaccine: results of a randomized trial among health care workers

BACKGROUND

Hepatitis B virus (HBV) infection is an occupational health hazard among the healthcare workers. Vaccination against HBV has been established to be the most effective preventive strategy. The present study was designed to assess the efficacy of low dose intradermal HBV vaccine among the nursing staff in a tertiary care hospital setting.

PATIENTS AND METHODS

Staff nurses working in our hospital were included in the study as vaccine recipients. Each staff nurse was tested for HBsAg and anti-HBs (commercial ELISA). Those who tested negative for both the above markers were randomized to receive either three doses of intramuscular (i.m.) HBV vaccine (20 micrograms m each dose) at 0, 1 and 6 month interval or three doses of intradermal HBV vaccine (2 micrograms m each dose) at similar intervals. Each vaccine recipient was tested for the presence of anti HBs (commercial ELISA) at the end of 1 month and 1 year after the last dose of the vaccine. The anti-HBs titres were also estimated simultaneously in them.

RESULTS

Out of 153 staff nurses screened, 19 were either positive for HBsAg (n = 1) or anti HBs (n = 18). 96(72%) of the remaining 134 nurses agreed to receive HBV vaccine (i.m.--48, intradermal--48). At the end of 1 month after last dose of the vaccine, all vaccinees in both the group tested positive for anti-HBs. However the anti-HBs titres at 1 month were significantly higher among intramuscular vaccinees than the nurses receiving the vaccine through intra-dermal route (253 +/- 127.7 mIU/ml vs 151.3 +/- 92.8 mIU/ml, P < 0.001). Eighty four (85.5%) of these 96 vaccine recipient were available for evaluation of anti-HBs titre at the end of 1 year after the last dose of vaccine (1M group = 40, Intradermal group = 44). All the nurses continued to be positive for anti-HBs at the end of 1 year but the anti HBs-titre among i.m. vaccine recipient continued to remain at a significantly higher level than the similar titre among the intradermal vaccine recipients (256.4 +/- 124.7 mIU/ml vs 121.6 +/- 122.4 mIU/ml p < 0.001).

CONCLUSION

Intradermal route for HBV vaccine had similar immunogenic efficacy as the conventional intramuscular route, but the dose required in the former route is one tenth of the intramuscular route. Therefore intradermal route may reduce the cost of HBV vaccine markedly.

Duodenal leiomyoma--a rare cause of haematemesis

Leiomyoma of the duodenum is a rare tumour. Small intestinal tumours contributing to upper gastrointestinal bleed is still rare. They usually present with malena and anaemia, rarely hematemesis. We report a case of leiomyoma of duodenum diagnosed on endoscopic ultrasound that presented with massive haematemesis.

Endoscopic sclerotherapy in children with extrahepatic portal venous obstruction

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) is a common cause of variceal bleeding in children in India. There is paucity of data regarding the results of treatment with endoscopic sclerotherapy.

METHODS

Fifty-nine children (mean age 11 +/- 3.8 years; range 7 months to 12 years; 36 males and 23 females) were studied from February 1990 to September 1999. EHPVO was diagnosed on the basis of portal cavernoma on ultrasonography in 55 patients and on splenoportovenogram in 4 patients. Endoscopic sclerotherapy was caried out at weekly intervals for the first three weeks and at 3 weekly intervals thereafter till complete or near complete thrombosis was achieved. All patients were followed up with check endoscopy every 3-6 months after thrombosis of oesophageal varices.

RESULTS

Over a mean follow up of 25.4 months (range 3 to 87 months) total thrombosis was achieved in 53 (89.8%) of 59 children. The mean number of sclerotherapy sessions required were 7.5 +/- 2.2. The mean number of blood transfusions required per bleeding episode was 3.8 +/- 3.2. Of the 59 children 21 (35.6%) rebled, of which 17 (28.8%) bled during and 4(6.8) after thrombosis of varices. Seven (11.9%) children had more than one episode of bleeding. Once thrombosis of the varices was achieved 15 (26%) of 59 children developed fresh varices on follow up. Gastric varices were detected in 47 (60%) children. In 39 (66%) children it was present at the onset and in 8 (13.5%) children it developed after thrombosis of oesophageal varices. Bleeding from gastric varix occurred in 7(9%) children. Ascites developed in 6(10.6%) children. One child developed oesophageal stricture. There were 3 (5%) deaths. Two died due to upper gastrointestinal bleed while on sclerotherapy schedule and one died due to cerebral abscess.

CONCLUSION

EHPVO is an important and common cause of upper gastrointestinal bleeding in children in Western India. EST is safe and useful in controlling oesophageal variceal bleeding in children.

A review of anaesthetic technique in 15 paediatric patients with temporomandibular joint ankylosis

Temporomandibular joint ankylosis presents a serious problem for airway management. This relatively rare problem becomes even more difficult to manage in children because of their smaller mouth opening with near total trismus, and the need for general anaesthesia before making any attempts to secure the airway. A technique for securing the airway that combines local blocks for nerves of larynx and topical anaesthesia of upper airways for placement of these blocks, and minimal general anaesthesia for these manoeuvres, is described. For general anaesthesia, a combination of halothane and ether by spontaneous ventilation, using bilateral nasopharyngeal airways, was used. Because of the severe trismus, a tongue depressor or tip of a laryngoscope was used with a fibreoptic light source in the buccal sulcus to visualize the tracheal tube in the pharynx. Nasal forceps, with a smaller tip and narrower blade than Magill forceps was used to guide the tracheal tube towards the air bubbles coming out of larynx. No attempt was made to visualize the larynx, but its position was guessed from the direction of these air bubbles. We review the anaesthetic technique in 15 such cases of severe trismus managed successfully between 1986 and 1999.

Colonic tuberculosis: colonoscopic appearance and clinico-pathologic analysis

BACKGROUND

There has been a resurgence of interest in intestinal tuberculosis because of acquired immunodeficiency syndrome (AIDS) epidemic sweeping our country. Role of colonoscopy and colonoscopy directed histology for diagnosing the disease have been emphasised since last few years.

AIMS AND OBJECTIVES

To know the colonoscopic features in patients with intestinal tuberculosis and to study the clinicopathological findings in the same.

METHODS

We studied twenty-one patients with intestinal tuberculosis referred to us between 1993-1997. Colonoscopy was done in all patients and biopsy specimens were collected from the site of lesion during the procedure.

RESULTS

Ileocaecal disease was found in 9 patients, ileocaecal with contiguous ascending colon involvement in eight and segmental colonic tuberculosis in four cases. The colonoscopic findings included nodules in seven patients, nodules with ulcerations in three, ulcerations alone in seven, nodules with strictures in three and polypoidal mass in one patient. Eight cases revealed granuloma on histopathology.

CONCLUSIONS

Though bacteriological and histological assessment of tissue is essential to differentiate tuberculosis from other disorders, we stress the importance of colonoscopic appearances in diagnosing tuberculosis. We also recommend antituberculous chemotherapy in patients with high clinical suspicion of tuberculosis on the basis of colonoscopic appearance alone after ruling other causes on histopathological examination.

Foreign bodies in gut

BACKGROUND

Foreign body ingestion is common and a frightening experience to the patients and relatives. We report our experience with 102 patients, (78 children and 24 adults), with foreign body ingestion.

METHODS

After locating foreign bodies radiologically, 34 (43.6%) foreign bodies in children and 13 (54.2%) foreign bodies in adults were removed endoscopically. General anesthesia was used in 32 children and overtube was used for all sharp foreign bodies.

RESULTS

In our study, 78 (76%) patients were below 12 years of age. Coins (79.5%) were commonest foreign bodies in children while dentures (25%) were commonest in adults. Foreign bodies were most commonly sited in stomach (25.6%) in children and esophagus (58.3%) in adults. In 41 (52.6%) children and in three (12.5%) adults, i.e. total 44 out of 102 (43.1%) patients passed foreign bodies spontaneously. The largest foreign body that passed spontaneously was 4-cm long nail in a child. In 34 (43.6%) children and in 13 (54.2%) adults foreign bodies were removed endoscopically. Only 3.8% children and 33.3% adults required surgery.

CONCLUSIONS

There was no mortality in our series. Majority of foreign bodies do not require any intervention. Sharp foreign bodies are commonest indication for surgery. However, endoscopic removal is safe, effective and is the method of choice for most patients.

Hepatitis B subtypes and hepatitis C genotypes in cirrhosis in western India: results of a pilot study

BACKGROUND

Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the major causes of viral chronic liver diseases in India. HBV subtypes and HCV genotypes have not been reported from Western India. The aims of the study were (i) To study the prevalence of viral markers to HBV and HCV in adult cirrhotics, (ii) To determine HBV subtypes and HCV genotypes using serological and molecular biological methods.

METHODS

A total of 99 adult cirrhotic patients, proven by liver biopsy, laparoscopy, or a combined score of clinical features, biochemical tests, ultrasonography of abdomen, and radioisotope 99m Technetium scan in presence of oesophageal varices were studied. Sera collected from these patients were stored at -8 degrees C and subjected to various tests. HBsAg was determined by ELISA, anti-HBc by ELISA and anti HCV Ab was determined by the third generation ELISA. HBsAg subtypes were determined by enzyme immunoassay. HCV RNA was determined by PCR in those who tested positive for anti HCV antibody. Genotyping of HCV was done with a second generation PCR.

RESULTS

HBsAg was detected in 16, out of which subtyping was possible in 14, adw was found in 6 and ayw in 8. Anti HCV Ab was found in 5. Genotyping was possible in three samples which revealed one to be of genotypes 3, one of genetic group 4, and one of genetic group 5.

CONCLUSIONS

Subtypes and genotypes of HBV and HCV have not been reported from Western India. Their determination can have implications in understanding the spectrum of disease, characteristics and response to treatment.

Gastric mucosal blood flow and hepatic perfusion index in patients with portal hypertensive gastropathy

Endoscopic laser Doppler velocimetry is a simple non-invasive method to measure gastric mucosal blood flow. The present study is an attempt to determine a correlation, if any, between gastric mucosal blood flow and the hepatic perfusion index in patients with portal hypertensive gastropathy and their relationship to the severity of liver disease. Thirty patients with portal hypertensive gastropathy due to cirrhosis of the liver (eight class A, 13 class B, nine class C, according to Child-Pugh Classification) and six normal subjects were recruited into the study. In all subjects, the gastric mucosal blood flow and venous vasomotor reflex response was measured at two sites: the lesser and greater curvature, using endoscopic laser Doppler velocimetry. The hepatic perfusion index was measured using dynamic liver scintigraphy. The hepatic perfusion index (ratio of arterial/portal venous perfusion) in normal subjects and patients with portal hypertensive gastropathy belonging to Child-Pugh class A, B and C were 0.36 +/- 0.02, 0.53 +/- 0.08, 0.62 +/- 0.14 and 1.04 +/- 0.28, respectively. The gastric mucosal blood flow was similar in Child's A, B and C cases, while the venous vasomotor reflex response was reduced according to the Child-Pugh score (Child's A 37.4 +/- 5.4%, normal control 62.3 +/- 10.9%, Child's B 38.3 +/- 18.2%, Child's C 22.5 +/- 15.2%) and was statistically significant. The gastric mucosal blood flow and hepatic perfusion index are inversely correlated. The hepatic perfusion index altered with grading of cirrhotic change. This study confirms that the severity of portal hypertensive gastropathy is correlated with Child-Pugh score.

Bleeding duodenal varix in splenic vein thrombosis and chronic pancreatitis

Isolated duodenal varix is rare. We report a patient with bleeding duodenal varix with splenic vein thrombosis due to chronic pancreatitis.

Hepatic artery pseudoaneurysm associated with amebic liver abscess presenting as upper GI hemorrhage

We report the case of a 40-yr-old man who presented with recurrent hemorrhage of the upper GI tract who was found to have hepatic artery pseudoaneurysm and amebic liver abscess. Our patient is unique in having hepatic artery pseudoaneurysm and amebic liver abscess diagnosed simultaneously, the association of which has not been previously described.

Primary gastric lymphoma in a boy

Primary gastric lymphoma is an extremely uncommon entity in children, and diffuse large-cell-type lymphoma in this age group is still rarer. An 11-year-old boy with primary gastric lymphoma who responded to CHOP regime is reported.

Helicobacter pylori and intestinal metaplasia of gastric mucosa

BACKGROUND

The role of Helicobacter pylori in stomach carcinogenesis is currently under study. H pylori-related chronic gastritis leading to dysplasia or intestinal metaplasia (IM) especially of the colonic type is postulated as one of the mechanisms.

METHODS

We studied 120 patients with or without H pylori infection to determine the frequency of occurrence of IM in the stomach.

RESULTS

IM was found in 16.6% of patients; most cases had the small intestinal type, which is not known to have a malignant potential. There was no relation between H pylori infection and development of IM.

CONCLUSION

H pylori infection leading to IM does not appear to be a factor in the genesis of carcinoma stomach in our population.

Gallbladder varices: diagnosis in children with portal hypertension on duplex sonography

We established the prevalence of gallbladder varices (GBVs) as seen on duplex sonogram of children with portal hypertension. Fifty-five consecutive children with portal hypertension underwent duplex sonographic examination by an experienced sonologist who was blinded to clinical presentation. Forty children had extrahepatic portovenous obstruction (EHPVO), 12 had cirrhosis, and three had noncirrhotic portal hypertension. GBVs were seen on sonography in 10 of 40 children with EHPVO (25%), two of 12 children with cirrhosis (16.6%), and no children with noncirrhotic portal hypertension. Sonographic findings of GBVs were confirmed on duplex sonographic imaging. Among patients with EHPVO, GBVs did not correlate with size of esophageal varices, number of sessions of sclerotherapy, presence or absence of gastric varices, portal gastropathy, or splenorenal shunt placement. In cirrhotic patients, GBVs did not correlate with Child Pugh grade. Children with EHPVO have a higher incidence of developing GBVs. The clinical significance of GBVs is their propensity to bleed during biliary surgery; thus, the operating surgeon should be made aware of them.

Prepyloric diaphragm detected following foreign body ingestion

Prepyloric diaphragms are unusual and are usually detected in adulthood. We report a five-year-old boy who presented with history of ingestion of a coin and was found to have a prepyloric diaphragms on laparotomy.

Asymptomatic spinal tuberculosis presenting as esophageal stricture

Esophageal tuberculosis is rare and is usually due to secondary extension from contiguous structures. We report a patient who presented with dysphagia and was found to have esophageal stricture. Endoscopic biopsy was not suggestive of malignancy or tuberculosis. CT scan of the thorax revealed involvement of the fourth thoracic vertebra with paratracheal lymphadenopathy. The patient responded to anti-tubercular therapy.

Achalasia cardia dilatation using polyethylene balloon (Rigiflex) dilators

OBJECTIVE

Results of 20 dilatation sessions in 15 patients with achalasia cardia were assessed to determine the safety and efficacy of polyethylene balloon achalasia dilators (Rigiflex).

METHODS

All patients underwent an initial dilatation by inflating a 30 mm balloon to 9 psi for one minute. Need for subsequent dilatations was assessed on symptom assessment; 35 mm balloon was used for repeat procedure.

RESULTS

Overall success rate was 93.3%. The 30 mm balloon achieved a satisfactory result in 73.3% and the 35 mm balloon in 75% of the remainder. Only one patient needed surgery. No short-term complications were observed. The only late complication encountered over an average follow-up period of 16.2 months was gastroesophageal reflux in two patients.

CONCLUSIONS

Dilatation using Rigiflex dilators is a safe, effective and simple procedure for treating patients with achalasia.

Esophageal dilation in pediatric patients using balloon along the side of the endoscope

Balloon dilation is an effective modality of treatment for esophageal strictures. As standard through-the-scope balloons do not pass through the biopsy channel of pediatric endoscopes, we have developed a technique by which these balloons can be used in pediatric patients by passing them alongside the endoscope. We report our experience of dilation in four patients using this technique.