Investigation of liver-targeted peripheral focused ultrasound stimulation (pFUS) and its effect on glucose homeostasis and insulin resistance in type 2 diabetes mellitus: a proof of concept, phase 1 trial

BACKGROUND

Mechanical waves produced by ultrasound pulses have been shown to activate mechanosensitive ion channels and modulate peripheral nerves. However, while peripheral ultrasound neuromodulation has been demonstrated in vitro and in pre-clinical models, there have been few reports of clinical tests.

AIM

We modified a diagnostic imaging system for ultrasound neuromodulation in human subjects. We report the first safety and feasibility outcomes in subjects with type 2 diabetes (T2D) mellitus and discuss these outcomes in relation to previous pre-clinical results.

DESIGN

The study was performed as an open label feasibility study to assess the effects of hepatic ultrasound (targeted to the porta hepatis) on glucometabolic parameters in subjects with T2D. Stimulation (peripheral focused ultrasound stimulation treatment) was performed for 3 days (i.e. 15 min per day), preceded by a baseline examination and followed by a 2-week observation period.

METHODS

Multiple metabolic assays were employed including measures of fasting glucose and insulin, insulin resistance and glucose metabolism. The safety and tolerability were also assessed by monitoring adverse events, changes in vital signs, electrocardiogram parameters and clinical laboratory measures.

RESULTS AND CONCLUSION

We report post-pFUS trends in several outcomes that were consistent with previous pre-clinical findings. Fasting insulin was lowered, resulting in a reduction of HOMA-IR scores (P-value 0.01; corrected Wilcoxon signed-rank test). Additional safety and exploratory markers demonstrated no device-related adverse impact of pFUS. Our findings demonstrate that pFUS represents a promising new treatment modality that could be used as a non-pharmaceutical adjunct or even alternative to current drug treatments in diabetes.

The Prognostic Significance of Hydronephrosis and Role of Ureteric Stenting in Cervical Cancer Patients Treated with Radical Radiation Therapy, Real World Outcomes from a Regional Cancer Centre, South India

Background: The incidence of renal failure in carcinoma cervix ranges from 14% to 44·2%. The interventional strategies like ureteric stenting and percutaneous nephrostomy can be considered to improve renal function. The primary objective of our study is to analyze the impact of hydroureteronephrosis [HUN] in the outcome of cervical cancer patients treated with radical radiation. The secondary objective is to analyze the role of ureteric stenting to protect the renal function while proceeding with radical radiation. Methods: In this retrospective study, all patients with stage IIIB cervical cancer treated with radical radiation therapy at our institution from January 2010 to December 2019 were included. Results: Among the total 483 stage IIIB patients, 146 patients [30·22%] had hydronephrosis.Thirty eight [26·02%] out of 146 patients with HUN underwent ureteric stenting. The five year overall survival [OS] was 61·4 ± 0·04 % and on subset analysis, overallsurvival was 65·7 ± 0·05 % for patients without HUN and 50·6 ± 0·06 % for patientswith HUN. [P value <0·001]. Among patients with hydronephrosis, those with bilateral hydronephrosis or serum creatinine >1·1 mg/dL have benefitted more from stenting. In this high risk subgroup, the one year overall survival was 65·2 ± 0·11 % and 42·4 ±0·13 % for patients with and without stenting. [p value 0·07]. No major stent related morbidity occurred. Conclusions: Hydronephrosis in cervical cancer patients indicates bad prognosis which results in decreased survival. The presence of hydronephrosis should be redesignated as a separate substage, IIIB2 in future FIGO updates, for better prognostication and treatment recommendations. The relief of obstructive uropathy should be sought out inpatients with serum creatinine levels > 1·1 mg/dL or bilateral hydronephrosis before theinitiation of oncological treatment.

Network crack-based high performance stretchable strain sensors for human activity and healthcare monitoring

In this study, high performance wearable and stretchable strain sensors are developed for human activity and healthcare monitoring, and wearable electronics.

Hepatocellular carcinoma patients with portal vein thrombosis treated with robotic radiosurgery: Interim results of a prospective study

BACKGROUND

This is a prospective study evaluating the role of stereotactic body radiotherapy (SBRT) with CyberKnife (CK) in Indian patients suffering from hepatocellular carcinoma with portal vein thrombosis (HCC-PVT).

METHODS

Patients with inoperable HCC-PVT, good performance score (PS), and liver function are accrued for treatment on CK (version M6) and planned with Multiplan (iDMS V2.0). Triple-phase contrast computed tomography (CT) scan was done for contouring, and the gross tumor volume (GTV) included contrast-enhancing mass within main portal vein and adjacent parenchymal disease. Dose prescription was as per-risk stratification protocol (22-50 Gy in 5 fractions) while achieving the constraints of mean liver dose <15 Gy, 800 cc liver <8 Gy, and the duodenum max of ≤24 Gy).

RESULTS

Seventy-two HCC-PVT accrued till date (mean age 63 years [38-76 years], 96% male; Child-Pugh [CP] A 84%, B 9%; Barcelona-Clinic Liver Cancer [BCLC] C 96%; PS0-1: 80%, Karnofsky performance score [KPS]>70: 88%; co-morbidities 42%; infective 12%, alcohol intake 31%, adjuvant sorafenib 39%). CP scores 5, 6, 7, and 8 were in 35%, 32%, 8%, and 18%, respectively. Focal disease with portal vein thrombus (PVT) in 21%, liver involvement >50% and <50% in 46% and 32%. Liver cancer study group of Japan staging-based portal vein invasion VP2, VP3, and VP4 in 22%, 29%, and 40%. Cancer of the Liver Italian Programm (CLIP) scores 1, 2, 3, 4, and 5 were in 8%, 26%, 31%, 26%, and 7%, respectively. Mean follow-up was 7.3 months (median 6 months, standard deviation [SD] 6; range 3-30 months). Mean actuarial overall survival (OS) was 11.4 months (SE 1.587; 95% CI: 8-14.2 months). Six months and 12 months actuarial OS 55% and 38%, respectively. At last follow-up, 25/69 (36%) were alive and 44/69 (64%) were dead. Among 54 patients evaluated for response assessment, 23 (30%) had radiological confirmed PVT response, 1 (3%) had response of IVC thrombus, and 30 (42%) had no or minimal response to SBRT. Actuarial OS in responders and non-responders were 14.4 months (95% CI 9.4-19.2) and 7.4 months (95% CI 4.9-9.7), p-value: 0.022. Six and 12 months survival in responders and non-responders were 65.7% and 37% and 49% and 24.6%, respectively. Post-SBRT, 4 (12%) patients underwent transarterial chemoembolization (TACE) 3 patients (8%) and 1 patient (4%) transarterial radioembolization (TARE). Post-CK, (<4 weeks) 2 patients (4%) had decompensation.

CONCLUSIONS

PVT response or recanalization after SBRT is a statistically significant prognostic factor for survival function in HCC-PVT.

Prospective evaluation of fiducial marker placement quality and toxicity in liver CyberKnife stereotactic body radiotherapy

Background

Evaluate morbidities and “quality” of fiducial marker placement in primary liver tumours (hepatocellular carcinoma [HCC]) for CyberKnife.

Materials and Methods

Thirty-six HCC with portal vein thrombosis (PVT) were evaluated for “quality” of fiducial placement, placement time, pain score, complications, recovery time and factors influencing placement.

Results

One hundred eight fiducials were placed in 36 patients. Fiducial placement radiation oncologist score was “good” in 24 (67%), “fair” in 4 (11%), and “poor” in 3(8%) patients. Concordance with radiologist score in “poor”, “fair”, and “good” score was 2/2 (100%), 4/5 (80%), and 24/27 (89%), respectively (p=0.001). Child-Pugh score (p=0.080), performance status (PS) (p=0.014) and accrued during “learning curve” (p=0.013) affected placement score. Mean placement time (p=0.055), recovery time (p=0.025) was longer and higher major complications (p=0.009) with poor PS. Liver segment involved (p=0.484) and the Barcelona Clinic Liver Cancer (BCLC) stage did not influence placement score. “Good” placement score was 30% in first cohort whereas 93% in last cohort (p=0.023). Time for placement was 42.2 and 14.3 minutes, respectively (p=0.069). Post-fiducial pain score 0–1 in 26 patients (72%) and pain score 3–4 was in 2 (6%). Five patients (14%) admitted in “day-care” (2 mild pneumothorax, 3 pain). Mortality in 1 patient (3%) admitted for hemothorax.

Conclusion

Fiducial placement is safe and in experienced hands, “quality” of placement is “good” in majority. Major complications and admission after fiducial placement are rare. Complications, fiducial placement time, recovery time is more during the “learning curve”. Poor Child-Pugh score, extensive liver involvement, poor PS have higher probability of complications.

2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.

Single-fraction radiation: A promising adjuvant therapy to prevent keloid recurrence

Introduction

Keloids are characterized by collection of atypical fibroblasts with excessive deposition of extracellular matrix components. Keloids are prone to high recurrence (50%-80%) with unimodality treatment. Radiation is a promising approach among the adjuvant modalities in vogue though consensus is lacking on dose-fractionation schedule.

Aim

The present study aimed to analyze the efficacy of single-fraction high-dose adjuvant radiotherapy to prevent keloid recurrence.

Materials and Methods

Details of patients treated for keloids using external beam radiation therapy from January 2011 to December 2016 were retrieved from electronic medical records and radiation therapy charts and analyzed.

Results

Thirty-seven keloid lesions in thirty patients were analyzed. Keloids received radiation within 24-72 h postsurgery using 6 MeV electron beam. 45.9% of keloids were in the chest wall. Dose ranged between 5 Gy and 12 Gy in 1-3 fractions. Eight Gy was used in 78.4%. The single fraction was preferred in 91.9%. Good cosmesis was achieved in all except three who had wound dehiscence. Median follow-up was 32.67 months. 16.2% had recurrence. Median time to recur was 13.6 months, and median recurrence-free interval 21.23 months. Among those who received 8 Gy single fraction, 73.4% remained recurrence-free at 5 years.

Conclusion

Albeit a retrospective analysis, ours is the only study in literature offering 8 Gy single dose, using electrons, as a postoperative adjuvant treatment to prevent recurrence in keloids. Our recurrence rates were similar to that quoted in published series. This hence can be validated in further studies as it is cosmetically acceptable, safe, painless, and cost-effective with good patient compliance.

Pediatric brain tumors: An analysis of 5 years of data from a tertiary cancer care center, India

BACKGROUND

Pediatric brain tumors are the most common solid tumors in children and a leading cause of mortality and morbidity in children worldwide. Even though there are enough data about the epidemiology of pediatric brain tumors in western population, there are only a few reports from developing countries like India.

AIMS

To study the epidemiological patterns of brain tumors in children, to study the patterns of care, and to assess the treatment response.

MATERIALS AND METHODS

A retrospective epidemiological approach is used. The records of children <18 years registered in our department from August 2006 to July 2011 diagnosed as primary brain tumors are selected. Data regarding age, sex, site of the tumor, clinical features, histology, treatment plan, and treatment response are collected. The World Health Organization classification of neoplasms was adopted.

RESULTS

Of 250 cases, females (57%) slightly outnumbered males. The present study revealed that astrocytoma (52%) is the most common brain tumor in childhood. Surgery was the main modality of treatment. Chemotherapy was given to 16% of patients. Even though radiation therapy was offered to 74% of patients, only 42% completed radiotherapy. There was subjective clinical improvement in 68% of patient population after treatment.

CONCLUSIONS

This is the second study from Tamil Nadu that deals with epidemiology of brain tumors. Multimodality management including surgery, chemotherapy, and radiation therapy remains the cornerstone in the management of pediatric brain tumors.

Stereotactic body radiation therapy for early-stage primary lung cancer, is an active breath coordinator necessary? An audit from a tertiary cancer care center

CONTEXT

The hypofractionated stereotactic body radiation therapy (SBRT) has emerged as a safe and effective treatment modality for early-stage nonsmall cell lung carcinoma.

AIMS

An audit SBRT in primary lung cancer treated in our center with and without an active breath coordinator (ABC) was undertaken to evaluate its impact on target volumes and clinical outcomes.

SETTINGS AND DESIGN

This was an observational study.

MATERIALS AND METHODS

Nine patients with lung carcinoma were treated from January 2014 to August 2016. Five patients were simulated using ABC and four patients with free breathing. Volumetric modulated arc therapy plans were generated using Monaco treatment planning software. Three patients were treated with a dose of 54 Gy in three fractions and six patients with a dose of 48 Gy in four fractions.

STATISTICAL ANALYSIS USED

The statistical analysis was performed using Kaplan-Meier survival.

RESULTS

The mean planning target volumes (PTV) in ABC and free breathing groups were 42.19cc and 60.17cc, respectively. The mean volume of lung receiving 20, 10, and 5 Gy (V20, V10and V5) in ABC group were 5.37cc, 10.49cc, and 18.45cc whereas in free breathing 6.63cc, 12.74cc, and 20.64cc, respectively. At a median follow-up of 18 months, there were three local recurrences. No significant toxicity occurred in our series.

CONCLUSION

Our initial results show that SBRT is well tolerated with good local control. Although the PTV volume and irradiated normal lung volume was higher in this group compared to ABC group, this did not translate to any added clinical toxicity.

Stereotactic body radiation therapy for hepatocellular carcinoma: Experience from a tertiary cancer care center in India

AIM

The aim of this retrospective study is to assess the toxicity and tumor response of stereotactic body radiation therapy (SBRT) protocol for hepatocellular carcinoma (HCC) in our institution.

BACKGROUND

Hepatocellular cancer is one of the leading cancers among men in India. In recent years, SBRT has emerged as a promising tool in the treatment of HCC.

MATERIALS AND METHODS

Ten patients diagnosed as HCC with Barcelona Clinic Liver Cancer Stage B and C, treated with SBRT technique from January 2013 to December 2016, were included in this study. SBRT was delivered using 6 MV photons with volumetric modulated arc therapy. Acute and late toxicities were graded, and tumor response was assessed using response evaluation criteria in solid tumors criteria. Kaplan-Meier curves were generated for progression-free survival (PFS) and overall survival (OS).

RESULTS

The median age was 61.5 (52-69) years. The radiation dose ranged from 35 Gy to 60 Gy. All patients obtained partial response during assessment at 3 months after completion of treatment. The median PFS is 8 months (95% confidence interval [CI] - 5.22-10.77 months). The median OS is 51 months (95% CI - 17.64-65.10 months). The OS at 1 and 2 years is 75% and 57%, respectively.

CONCLUSIONS

SBRT is well tolerated by our patients. The 1- and 2-year OS of 75% and 57% is consistent with other prospective and retrospective SBRT studies from the literature.

Adjuvant hypofractionated radiation in carcinoma breast - Photon versus Electron: Comparison of treatment outcome

BACKGROUND

Breast cancer tissue is sensitive to hypofractionation. This is an analysis of patients treated with hypofractionated protocols since 2009, at our tertiary cancer center.

METHODS

Details of breast cancer patients treated with adjuvant hypofractionated external beam radiation therapy (EBRT) from January 2009 to December 2014 were retrieved and analyzed.

RESULTS

One thousand seven hundred and eighty patients received adjuvant EBRT during this period. Three hundred and eight were offered hypofractionated schedule. One hundred and eighty-eight had modified radical mastectomy (MRM) and 120 had breast conservation surgery (BCS). Dose was 40 Gy in 15 fractions to chest wall/breast, and tumor bed boost of 10 Gy in 5 fractions, where indicated, using three-dimensional conformal radiotherapy (3DCRT). Electrons were used in 159 and photons in 149. Single en face electron field was used for chest wall in MRM patients, and tangential photon beams for the whole breast. Patients on follow-up were assessed for locoregional recurrence, chest wall, breast or ipsilateral upper limb edema, brachial neuralgia, local skeletal events, pulmonary and cardiac symptoms, and cosmetic results. Two developed chest wall recurrence, one each in electron and photon arms. No skeletal, cardiac, or pulmonary adverse events were recorded. About 13.6% had arm edema, which was staged according to the International Society of Lymphology lymphedema staging, as Stage I-7.8%, Stage II-3.9%, and Stage III-1.9%. Twenty-six treated with electrons had arm edema. Increased incidence of arm edema in MRM patients could be attributed to combined surgical and radiation morbidity. Five-year overall survival was 81.9%.

CONCLUSION

Hypofractionation is an accepted cost-effective standard of care in adjuvant breast radiation. Single en face electron field is well tolerated, and 3DCRT planning ensures homogeneous chest wall coverage, respecting dose constraints to organs at risk.

Preoperative long-course chemoradiation for localized rectal cancer: A retrospective comparison of response and outcome between 5-fluorouracil/leucovorin versus capecitabine

BACKGROUND

Preoperative concurrent chemoradiation therapy (CRT) with either capecitabine or 5-florouracil/leucovorin (5 FU/LV) is the standard of care in locally advanced rectal cancer (LARC). Literature comparing the toxicity and response of these two regimens in Indian patients is sparse. Our objective was to compare the pathological response (PR) and clinical outcome of capecitabine versus 5 FU/LV in CRT for LARC.

MATERIALS AND METHODS

Sixty patients with LARC treated with preoperative CRT with capecitabine or 5FU/LV from January 2009 to May 2014 were analyzed. Ryan's tumor regression grading was used for PR assessment and tumor downstaging was defined as a reduction in the T and N stages by at least one level. Toxicity was assessed with RTOG acute toxicity assessment criteria and CTCAE 4.0 version. Statistical analysis was done using IBM SPSS 20 software. Percentage of patients with respect to response rates and toxicities was computed in each of the treatment groups. To test the statistical significance of the difference in PR rates and toxicities between the two groups, Chi-square test was used. Kaplan-Meier estimate of survival rate was computed for each group. To test the statistical significance of the difference in survival rate, the log-rank test was applied.

RESULTS AND CONCLUSION

The two groups (5 FU/LV vs. capecitabine) were comparable with respect to pathological complete response (20% vs. 24%), pathological downstaging (76% vs. 69%), sphincter preservation rates, and acute complication rates. Both regimens were well tolerated. Overall survival and disease-free survival also did not show a statistically significant difference between the two groups (P values 0.720 and 0.255, respectively). In summary, our analysis showed the equivalence of both regimens in the preoperative CRT setting.

Epidemiological and clinical pattern of dermatomycoses in rural India

Superficial fungal infections are most common in tropical and subtropical countries. In this study, 297 suspected superficial fungal infection cases were identified among 15,950 patients screened. The collected samples (skin, nail, and hair) were subjected to direct microscopy with potassium hydroxide and cultured on Sabourauds dextrose agar to identify the fungal species. The prevalence of superficial fungal infection was 27.6% (82/297), dermatophytosis was 75.6% (62/82), and non-dermatophytosis was 24.4% (20/82). Among the isolated dermatophytes, Trichophyton rubrum was the commonest species (79%) and Candida (60%) the commonest non-dermatophytic species. Tinea corporis was the commonest (78%) clinical presentation.

A prospective, parallel group, open-labeled, comparative, multi-centric, active controlled study to evaluate the safety, tolerability and benefits of fixed dose combination of acarbose and metformin versus metformin alone in type 2 diabetes

OBJECTIVE

The present study was a prospective, parallel group, open-labeled, comparative, multicentric, active controlled study to evaluate the safety, tolerability and benefits of fixed dose combination of acarbose and metformin versus metformin alone in type 2 diabetic patients.

METHODS

A total of 229 patients with type 2 diabetes were enrolled at 5 medical centers across India. They received either acarbose (50 mg) + metformin (500 mg) bid/tid (n=115) or metformin monotherapy (500 mg) bid/ tid (n=114) for 12 weeks. Primary objective was to evaluate safety and tolerability based on the adverse events reported. Secondary objective was efficacy assessment based on changes in fasting, post prandial blood glucose and HbA1c values.

RESULTS

In the acarbose + metformin group 10 patients reported 14 adverse events while in metformin group 9 patients reported 10 adverse events. No patient reported any serious adverse event or was withdraw from study because of adverse events. In the acarbose plus metformin group fasting blood glucose (FBG) decreased from a baseline of 158.85 +/- 18.14 mg/dl to 113.55 +/- 19.38 mg/dl (p < 0.0001) (decrease of 45.30 +/- 15.30 mg/dl) at 12 weeks, while in the metformin group fasting blood glucose decreased from a baseline of 158.31 +/- 26.53 mg/dl to 130.55 +/- 28.31 mg/dl (p < 0.0001) (decrease of 27.76 +/- 22.91 mg/dl) at 12 weeks. In the acarbose plus metformin group postprandial blood glucose (PPBG) decreased from a baseline of 264.65 +/- 34.03 mg/dl to 173.22 +/- 31.40 mg/dl (p < 0.0001) (decrease of 91.43 +/- 28.65 mg/dl) at 12 weeks, while in the metformin group PPBG decreased from a baseline of 253.56 +/- 36.28 mg/dl to 205.36 +/- 39.49 mg/dl (p < 0.0001) (decrease of 48.20 +/- 32.72 mg/dl) at 12 weeks. In the acarbose plus metformin group glycosylated haemoglobin (HbA1c) decreased from a baseline of 9.47 +/- 0.69% to 7.71 +/- 0.85% (p < 0.0001) (% decrease of 1.76 +/- 1.11) at 12 weeks, while in the metformin group HbAlc decreased from a baseline of 9.32 +/- 0.65% to 8.26 +/- 0.68% (p < 0.0001) (% decrease of 1.06 +/- 0.66) at 12 weeks. The combination of acarbose and metformin was found to be significantly superior in lowering the FBC (p < 0.0001), PPBG (p < 0.0001) and HbA1c (p < 0.0001) at 12 weeks as compared to metformin monotherapy.

CONCLUSIONS

Fixed dose combination of acarbose and metformin was well tolerated and it was superior to metformin monotherapy in controlling FBG, PPBG and HbA(1C) levels in Type 2 Diabetes Mellitus patients.

Validation of a specific activity questionnaire to estimate exercise tolerance in patients referred for exercise testing

BACKGROUND

Physical activity and symptom questionnaires have been used as surrogates for exercise testing to estimate a patient's functional capacity and to individualize an exercise testing protocol in accordance with exercise testing guidelines. To validate these approaches, they must be compared with measured oxygen uptake (peak VO (2)).

METHODS

Before exercise testing was performed, a brief, self-administered questionnaire (Veterans Specific Activity Questionnaire [VSAQ]) was given to 337 patients referred for exercise testing for clinical reasons. The VSAQ was used to estimate exercise tolerance on the basis of symptoms during daily activities to individualize ramp rates on the treadmill so that the test duration would be approximately 10 minutes. Clinical and demographic variables were added to the VSAQ responses in a stepwise regression model to determine their ability to predict both directly measured peak VO (2) and peak metabolic equivalents (METs) predicted from the treadmill workload.

RESULTS

The mean exercise time was 9.6 +/- 3 minutes. Responses to the VSAQ and age were the strongest predictors of both measured and predicted exercise capacity. Small but significant contributions to the explanation of variance in both measured and estimated METs were made by resting heart rate, forced expiratory volume in 1 second expressed as a percentage of normal, exercise capacity predicted for age, and body mass index. The multiple R values from the regression equations for measured and estimated METs were 0.58 and 0.72, respectively.

CONCLUSIONS

Estimating a patient's symptoms associated with daily activities along with age are the strongest predictors of a patient's exercise tolerance. The VSAQ, combined with pretest clinical data, predicts the estimated MET value from treadmill speed and grade better than directly measured METs do. When used for estimating a patient's symptom limits to individualize ramp rates on a treadmill, this approach yields an appropriate test duration in accordance with recent exercise testing guidelines.

Exercise testing with gas exchange analysis

The value of ventilatory gas exchange techniques during exercise testing, including improved precision and a greater yield of clinically useful information, is underscored by a growing body of literature. With technological advances available in the current metabolic systems, the test can be performed with minimal inconvenience to the patient and a minimal time commitment on the part of the operator. Gas exchange techniques have many applications among patients with cardiovascular and pulmonary disease, including the assessment of therapeutic interventions, a better understanding of the pathophysiology of exercise intolerance, and evaluation of disability. Recent studies suggest that the added precision provided by this technology has important prognostic utility. A cardiopulmonary exercise test can supplement other clinical and exercise test information when precision is important, when the patient's symptoms are mixed, or when it is unclear why the patient was referred for testing.

Late onset rheumatoid arthritis--a clinical and laboratory study

AIM

To analyze the clinical and laboratory profile of late onset rheumatoid arthritis in comparison with early onset rheumatoid arthritis.

METHODS

Fifty patients who satisfied 1988 American College of Rheumatology criteria for rheumatoid arthritis with the disease onset at 60 years or over were studied. Handred cases of early onset rheumatoid arthritis were taken as controls. All of them were followed up for 18 months.

RESULTS

Female to male ratio was 1.6:1 in late onset rheumatoid arthritis and 4:1 in early onset group. Shoulder joint involvement was 48% in late onset and 28% in early onset rheumatoid arthritis. Rheumatoid factors was positive in 36% cases in late onset compared to 60% in controls. Most other clinical, laboratory and radiological features were comparable in both the groups.

CONCLUSIONS

Late onset rheumatoid arthritis is characterised by a less female preponderance, more shoulder joint involvement and more seronegativity.

Phosphorylation of dystrophin and alpha-syntrophin by Ca(2+)-calmodulin dependent protein kinase II

A Ca(2+)-calmodulin dependent protein kinase activity (DGC-PK) was previously shown to associate with skeletal muscle dystrophin glycoprotein complex (DGC) preparations, and phosphorylate dystrophin and a protein with the same electrophoretic mobility as alpha-syntrophin (R. Madhavan, H.W. Jarrett, Biochemistry 33 (1994) 5797-5804). Here, we show that DGC-PK and Ca(2+)-calmodulin dependent protein kinase II (CaM kinase II) phosphorylate a common site (RSDS(3616)) within the dystrophin C terminal domain that fits the consensus CaM kinase II phosphorylation motif (R/KXXS/T). Furthermore, both kinase activities phosphorylate exactly the same three fusion proteins (dystrophin fusions DysS7 and DysS9, and the syntrophin fusion) out of a panel of eight fusion proteins (representing nearly 100% of syntrophin and 80% of dystrophin protein sequences), demonstrating that DGC-PK and CaM kinase II have the same substrate specificity. Complementing these results, anti-CaM kinase II antibodies specifically stained purified DGC immobilized on nitrocellulose membranes. Renaturation of electrophoretically resolved DGC proteins revealed a single protein kinase band (M(r) approximately 60,000) that, like CaM kinase II, underwent Ca(2+)-calmodulin dependent autophosphorylation. Based on these observations, we conclude DGC-PK represents a dystrophin-/syntrophin-phosphorylating skeletal muscle isoform of CaM kinase II. We also show that phosphorylation of the dystrophin C terminal domain sequences inhibits their syntrophin binding in vitro, suggesting a regulatory role for phosphorylation.

Yotiao, a novel protein of neuromuscular junction and brain that interacts with specific splice variants of NMDA receptor subunit NR1

The molecular machinery underlying neurotransmitter receptor immobilization at postsynaptic sites is poorly understood. The NMDA receptor subunit NR1 can form clusters in heterologous cells via a mechanism dependent on the alternatively spliced C1 exon cassette in its intracellular C-terminal tail, suggesting a functional interaction between NR1 and the cytoskeleton. The yeast two-hybrid screen was used here to identify yotiao, a novel coiled coil protein that interacts with NR1 in a C1 exon-dependent manner. Yotiao mRNA (11 kb) is present modestly in brain and abundantly in skeletal muscle and pancreas. On Western blots, yotiao appears as an approximately 230 kDa band that is present in cerebral cortex, hippocampus, and cerebellum. Biochemical studies reveal that yotiao fractionates with cytoskeleton-associated proteins and with the postsynaptic density. With regard to immunohistochemistry, two anti-yotiao antibodies display a somatodendritic staining pattern similar to each other and to the staining pattern of NR1. Yotiao was colocalized by double-label immunocytochemistry with NR1 in rat brain and could be coimmunoprecipitated with NR1 from heterologous cells. Thus yotiao is an NR1-binding protein potentially involved in cytoskeletal attachment of NMDA receptors. Consistent with a general involvement in postsynaptic structure, yotiao was also found to be specifically concentrated at the neuromuscular junction in skeletal muscle.

Interaction of muscle and brain sodium channels with multiple members of the syntrophin family of dystrophin-associated proteins

Syntrophins are cytoplasmic peripheral membrane proteins of the dystrophin-associated protein complex (DAPC). Three syntrophin isoforms, alpha1, beta1, and beta2, are encoded by distinct genes. Each contains two pleckstrin homology (PH) domains, a syntrophin-unique (SU) domain, and a PDZ domain. The name PDZ comes from the first three proteins found to contain repeats of this domain (PSD-95, Drosophila discs large protein, and the zona occludens protein 1). PDZ domains in other proteins bind to the C termini of ion channels and neurotransmitter receptors containing the consensus sequence (S/T)XV-COOH and mediate the clustering or synaptic localization of these proteins. Two voltage-gated sodium channels (NaChs), SkM1 and SkM2, of skeletal and cardiac muscle, respectively, have this consensus sequence. Because NaChs are sarcolemmal components like syntrophins, we have investigated possible interactions between these proteins. NaChs copurify with syntrophin and dystrophin from extracts of skeletal and cardiac muscle. Peptides corresponding to the C-terminal 10 amino acids of SkM1 and SkM2 are sufficient to bind detergent-solubilized muscle syntrophins, to inhibit the binding of native NaChs to syntrophin PDZ domain fusion proteins, and to bind specifically to PDZ domains from alpha1-, beta1-, and beta2-syntrophin. These peptides also inhibit binding of the syntrophin PDZ domain to the PDZ domain of neuronal nitric oxide synthase, an interaction that is not mediated by C-terminal sequences. Brain NaChs, which lack the (S/T)XV consensus sequence, also copurify with syntrophin and dystrophin, an interaction that does not appear to be mediated by the PDZ domain of syntrophin. Collectively, our data suggest that syntrophins link NaChs to the actin cytoskeleton and the extracellular matrix via dystrophin and the DAPC.

Juvenile rheumatoid arthritis--Madras experience

In a prospective study of 1,053 consecutive children who attended the Rheumatic Care Centre, Government General Hospital, Madras from 1991 to 1995, 331 children fulfilled the criteria proposed by the American Rheumatism Association as modified by Cassidy et al for the diagnosis of Juvenile Rheumatoid Arthritis. These children were thoroughly examined and investigated and classified into 3 onset types which was then sub-classified into early entry and late entry groups based on the duration of illness. Other arthritic conditions were excluded. There were 44 cases belonging to Systemic onset, 171 belonging to polyarticular onset and 116 belonging to oligoarticular onset type. In the systemic onset type 44/44 patients had fever, 40/44 had lymphadenopathy and 19/44 had skin rash; wrists and knees 31/44 were the most commonly involved joints; neck involvement was present in 13/44 of the cases; ANA was positive in 5/44 cases and anaemia was seen in 24/44 cases. In polyarticular onset type wrists 119/171, knees 143/171, hip joints 105/171 and ankles 113/171 were commonly involved; in the RF +ve subtype 3/23 had subcutaneous nodules and 7/23 were positive for ANA; in the Rf -ve subtype 59/148 were positive for ANA. In the oligoarticular subtype-1 ANA was positive in all cases but iridocyclitis was not seen in any case. In oligoarticular subtype-2 HLA B27 was positive in 13/26 cases while Sacroilitis was seen in 16/26 cases. In oligoarticular type-3 HLA B27 was negative.

Interactions between dystrophin glycoprotein complex proteins

The organization of the dystrophin glycoprotein complex (DGC) was studied by investigating interactions between its components. For this purpose, mouse dystrophin and syntrophin-1 (alpha-syntrophin) sequences were expressed as chimeric fusion proteins and used in overlay binding experiments to probe gel blots of purified rabbit muscle DGC. In order to identify the DGC proteins that bind to different regions of dystrophin, the amino-terminal 385 amino acids, the unique carboxy-terminal domain (amino acids 3266-3678), and the adjacent cysteine-rich region of dystrophin homologous to alpha-actinin (amino acids 3074-3265) were expressed as separate fusion proteins. The cysteine-rich sequences of dystrophin predominantly bound adhalin (gp50) and to full length dystrophin suggesting that these sequences may also be important to dystrophin dimerization. The carboxy-terminal domain sequences strongly bound all of the DGC syntrophins and weakly, adhalin, while the amino-terminal sequences of dystrophin bound none of the proteins of this complex. Fusion proteins containing alpha-syntrophin sequences bound not only to dystrophin but also to all three DGC syntrophins, adhalin, and gp35. The interactions identified here were used to refine the existing model of DGC organization to make it consistent with the current data.

Calmodulin-activated phosphorylation of dystrophin

Purified dystrophin glycoprotein complex (DGC) contains an endogenous protein kinase activity which phosphorylates dystrophin. Mg2+ (or Mn2+) and ATP are required for this phosphorylation. Ca(2+)-calmodulin increases the rate of phosphorylation of dystrophin 12-fold relative to the EGTA control, while other protein kinase activators, cAMP and cGMP, have no effect. Phosphorylation of other proteins in the DGC preparation was observed, with a 59-kDa protein also being phosphorylated in a calmodulin-dependent manner. These phosphorylations were all on serine residues. The DGC protein kinase activity also phosphorylates syntide-2, a peptide substrate for CaM kinase II, and antibodies raised against CaM kinase II cross-react with DGC blotted onto nitrocellulose. Further, purified, baculovirus-expressed CaM kinase II phosphorylates dystrophin and also phosphorylates at least one of the peptides of dystrophin which is phosphorylated by the DGC protein kinase activity, as shown by tryptic peptide maps. CaM kinase II also phosphorylates other proteins present in the DGC preparation that are phosphorylated by the endogenous protein kinase. Finally, dystrophin sequence 2618-3074, produced by recombinant techniques, is phosphorylated by both the DGC protein kinase and purified CaM kinase II. Since dystrophin and two other DGC components have also been shown to bind calmodulin, two important components of signal transduction--calmodulin binding and protein phosphorylation--operate in the DGC.

Childhood systemic lupus erythematosus in south India

Out of 330 adult Systemic Lupus Erythematosus (SLE) cases who attended the Rheumatic Care Centre, Government General Hospital, 59 children were analysed. There was no case with onset before the age of 5 years. There were 49 females and 110 males (M:F = 1:4.9). The initial manifestations were fever (67%), arthritis (61%), skin rash (59%) and lymphadenopathy (27.1%). There was no case of Raynaud's phenomenon. Only 10.1% of patients presented with thrombocytopenic purpura. In the cumulative clinical features, arthritis in 86.6%, fever in 79.8%, skin rash in 69.4%, lymphadenopathy in 61% and hepatosplenomegaly in 39.9% were observed. Renal involvement was seen in 49.1%, neuropsychiatric manifestations in 27.1%, pleuropulmonary in 22% and cardiac manifestations in 10.2%. Anaemia was seen in 50.8%, leukopenia in 18.4%, thrombocytopenia in 11.8%, ANA in 100%, anti-dsDNA in 92.3%, anti-Sm in 34.7%, anti-SSA in 38.5%, anti-SSB in 15.4%, ACL in 30.8%, low C3 in 50% and false positive VDRL in 3.3%. Death occurred in 8 children, 3 due to infection, 2 due to renal causes, 1 due to cardiac and 2 due to central nervous system involvement.

Effect of bed time intermediate acting insulin in NIDDM subjects refractory to a combination of sulphonylureas and biguanides

The effect of a single dose of intermediate acting (Lente) insulin given subcutaneously at 9.00 P.M. in 22 NIDDM subjects refractory to a combination of Sulphonylureas and Biguanides was analysed. Euglycemia was achieved and maintained during the study period of three months with a mean insulin requirement of 14.22 +/- 5.98 units/day. Plasma FFA, Total cholesterol, triglyceride and VLDL-cholesterol also showed significant reduction. The level of FFA modulates hepatic glucose production, which in turn correlates positively with the fasting blood glucose. The therapeutic modality of bed time Lente Insulin based on physiological principles is an effective way of achieving glycemic control in NIDDM subjects who have become non-responsive to oral hypoglycemic agents.

Subcutaneous insulin pulse therapy

Subcutaneous Insulin Pulse Therapy (SIPT) consists of administration of small doses of regular insulin hourly or two hourly in the subcutaneous tissue of anterior abdominal wall through a scalp vein needle. Fifteen Non-Insulin Dependent Diabetes Mellitus (NIDDM) subjects, 8 males and 7 females with mean ages 58 +/- 8.7 years and mean duration of diabetes 11.7 +/- 9.1 years and mean BMI 25.2 +/- 5.64 were admitted for elective surgery. Glycemic control was attempted preoperatively with multiple pre-meal doses of Actrapid MC with a single injection of Monotard MC at bed time. The mean fasting plasma glucose in the 15 subjects with this insulin regimen was 321.28 +/- 69.32 mgm% and the insulin requirement per day was 106.87 +/- 35.77 units. The subjects were put on SIPT for 48 to 72 hours. During SIPT the mean fasting plasma glucose dropped to 123.2 +/- 74.11 mgm% and this marked decline in fasting plasma glucose value was statistically significant (P < .05). The insulin requirement during SIPT was 96.42 +/- 31.36 units, similar to the previous regimen (NS). The subjects were switched back to conventional insulin therapy after SIPT during which period the mean fasting plasma glucose was 125.82 +/- 34.50 mgm% and this value was again significantly lower than the pre SIPT fasting plasma glucose value (P < .05). Insulin requirement during conventional insulin therapy after SIPT was reduced to 71 +/- 21.89 units/day. This dose was significantly lower than the insulin dose administered during SIPT (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Calmodulin specifically binds three proteins of the dystrophin-glycoprotein complex

Dystrophin is the approximately 400,000 Da. protein (p400K) product of the Duchenne muscular dystrophy gene locus. In the sarcolemma membrane, it is associated with several other proteins, many of which are glycoproteins (abbreviated gp) and include gp156K, p59K, gp50K, gp43K, gp35K, and p25K. Here, we show that dystrophin, gp156K, and p59K are calmodulin-binding proteins, the binding is Ca(2+)-dependent, and of high-affinity similar to that seen with calmodulin-activated enzymes. Two putative calmodulin-binding sequences were identified, one at either end of the dystrophin sequence.

Progressive systemic sclerosis in south India

Seventy eight patients with progressive systemic sclerosis (PSS) were seen over a period of 14 years. They were analysed after clinical, haematological, biochemical, immunological and radiological investigations for comparison with other Indian and Western studies. Nine of the 78 were cases of childhood PSS. There was a female preponderance (3.9:1) and the peak age of occurrence was the 4th decade (32.1%). Arthralgia (53.8%) and skin thickening (70.5%) were the common presenting symptoms. Raynaud's phenomenon (28.2%) was less common. Involvement of the skin was present in all the patients and skin biopsy was positive in 96% of the cases. Joints were affected in 66.7%; internal organs were involved in 52.6%. Antinuclear antibody was positive in 56.8%. Abnormal echocardiography (37.6%) and barium studies (20.4%) were seen. Restrictive airway pattern by pulmonary function test was present in 55%. Death occurred in 5 patients, of whom 3 died of severe pulmonary hypertension.

Calmodulin-binding proteins also have a calmodulin-like binding site within their structure. The flip-flop model

The flip-flop model is a mechanistic model proposed to describe how calmodulin activates enzymes. One prediction based upon this model is that calmodulin-activated enzymes would contain a calmodulin-like binding site which, among other attributes, would bind the peptide melittin. Five purified calmodulin-activated enzymes, namely calcineurin, myosin light chain kinase, phosphorylase b kinase, phosphodiesterase, and NAD kinase, were all found to bind biotinylated melittin and to also bind an antimelittin antibody and biotinylated calmodulins. Using gel blots of crude tissue extracts (rat brain and Arabidopsis), most proteins did not bind any of the probes and thus do not have these characteristics. However, among those which bind any of these probes, a strong correlation was found between those proteins which bind biotinylated calmodulins and those which bind melittin and antimelittin. Gel blots of phosphorylase b kinase demonstrate that the alpha, beta, and gamma subunits all bind calmodulin and melittin. A putative calmodulin-like binding site sequence was identified in eight enzymes or subunits which may play an important role in both melittin binding and calmodulin-dependent regulation of these enzymes.

Pattern of rheumatic diseases in south India. IV. Clinical profile of juvenile rheumatoid arthritis

An analysis of 100 consecutive cases of juvenile rheumatoid arthritis from South India revealed a male preponderance (62%), a lower incidence of the systemic onset variety (10%) and equal incidence of systemic features when compared with the West. Knees and ankles were the joints commonly involved. The incidence of elevated erythrocyte sedimentation rate and C reactive protein, with haemoglobin levels below 10 g/dl was highest in the systemic onset variety. The polyarticular and systemic onset group responded well to aspirin, while the pauciarticular group responded well to indomethacin.

Pattern of rheumatic diseases in south India. V. Ankylosing spondylitis. A clinical and radiological study

One hundred and two patients from South India with primary ankylosing spondylitis (AS) were analysed clinically and radiologically. The mean age of onset was 26 years, with a male to female ratio of 16:1. Eleven patients presented as juvenile ankylosing spondylitis. The mode of presentation of AS included axial involvement in 59, peripheral arthritis in 38, heel pain in 18 and acute anterior uveitis (AAU) in 11. The overall incidence of extra axial features was high (90 patients). These included subjects with peripheral arthritis (49), heel pain (35), AAU (14), rib pain (11), aortic regurgitation (8), apical pulmonary fibrosis (5), mitral regurgitation (2) and conduction defects (2). Peripheral arthritis was characteristically asymmetrical and oligo articular, and involved lower limb joints. No renal involvement was noticed. Radiologically, bilateral sacroilitis was seen in 80% of cases.

Fibrodysplasia (myositis) ossificans progressiva in Dominica

Fibrodysplasia (myositis) ossificans progressiva is a rare but severely disabling disease in which ossification forms within muscle and leads to progressive restriction of the movements of the jaw, neck, shoulders and hips. Shortening of the big toes is usually present. It is important to recognise this disease as avoidance of intra-muscular injections, surgery and trauma reduces the risk of further ossification.