Investigation of ATR Inhibitor VX970 as a Radiosensitizer in Colorectal Cancer Cells

PURPOSE/OBJECTIVE(S)

Colorectal cancer (CRC) is the second leading cause of combined cancer-related mortality in males and females in the U.S. Traditional treatment of locally advanced rectal cancer consists of neoadjuvant chemoradiation followed by surgery and adjuvant chemotherapy. Emerging data suggests that higher response rates can be achieved with total neoadjuvant therapy (TNT) where delivery of all chemotherapy and radiation therapy (RT) occurs prior to surgery. In addition, for patients with a complete response to TNT, non-operative management (NOM) can be considered. However, despite the use of TNT, pathologic complete response rates remain below 40% and NOM is only achieved in approximately 50% of rectal cancer patients. A strong need remains for more active anti-cancer therapies in rectal cancer to both reduce pelvic recurrence and facilitate NOM. Here, we tested the hypothesis that inhibition of the ataxia telangiectasia and Rad3-related protein kinase (ATR), a critical regulator of cellular DNA damage response, could increase the sensitivity of CRC to RT.

MATERIALS/METHODS

VX970, a highly potent and selective ATR inhibitor, was investigated as a radiosensitizer in SW48 and LoVo CRC cell models. In vitro, IC50 of VX970 was assessed by alamarBlue cytotoxicity assay, while radiosensitivity was revealed by radiation clonogenic assays (0, 2, 4, 6, 8 Gy). ATR activity was determined by p-Chk1 using immunoblotting, and cell cycle distribution was analyzed by propidium iodide flow cytometry. CRC xenografts were generated using both LoVo and SW48 cells injected in the left flanks of athymic nude mice to explore the radiosensitizing effects of VX970 in vivo. Tumors were allowed to grow to 100-150 mm3, and the mice were randomized into multiple groups [vehicle alone, RT alone (10 Gy/5 fractions), VX970 alone, and VX970+RT]. Mouse weights and tumor size were measured three times weekly. Comparison of treatment groups was performed using the log-rank test with P<0.05 considered significant.

RESULTS

The IC50 concentrations of VX970 on SW48 and LoVo cells were about 500 and 100 nM, respectively. VX970 at doses of 3 nM did not alter the viability of CRC cells, but significantly sensitized CRC cells to radiotherapy (P<0.05), with DER of 1.43 and 1.59, respectively, in SW48 and LoVo cells. VX970 efficiently attenuated p-Chk1 expression and significantly abrogated radiation induced G2/M cell cycle arrest (P<0.05). In addition, VX970 in combination with radiotherapy significantly prolonged tumor growth delay of CRC xenografts compared to radiation alone (P<0.05), with minimal toxicity observed.

CONCLUSION

Inhibition of the ATR-Chk1 pathway by targeting ATR kinase with VX970 sensitizes CRC to radiotherapy in vitro and in vivo. Our findings support that ATR inhibition by VX970 is a promising new approach to improve the therapeutic ratio of radiotherapy for patients with CRC and warrants further clinical testing.

Immune contexture analysis in immuno-oncology: applications and challenges of multiplex fluorescent immunohistochemistry

The tumor microenvironment is an integral player in cancer initiation, tumor progression, response and resistance to anti-cancer therapy. Understanding the complex interactions of tumor immune architecture (referred to as 'immune contexture') has therefore become increasingly desirable to guide our approach to patient selection, clinical trial design, combination therapies, and patient management. Quantitative image analysis based on multiplexed fluorescence immunohistochemistry and deep learning technologies are rapidly developing to enable researchers to interrogate complex information from the tumor microenvironment and find predictive insights into treatment response. Herein, we discuss current developments in multiplexed fluorescence immunohistochemistry for immune contexture analysis, and their application in immuno-oncology, and discuss challenges to effectively use this technology in clinical settings. We also present a multiplexed image analysis workflow to analyse fluorescence multiplexed stained tumor sections using the Vectra Automated Digital Pathology System together with FCS express flow cytometry software. The benefit of this strategy is that the spectral unmixing accurately generates and analyses complex arrays of multiple biomarkers, which can be helpful for diagnosis, risk stratification, and guiding clinical management of oncology patients.

Tradeoff between metabolic i-proteasome addiction and immune evasion in triple-negative breast cancer

In vitro studies have suggested proteasome inhibitors could be effective in triple-negative breast cancer (TNBC). We found that bortezomib and carfilzomib induce proteotoxic stress and apoptosis via the unfolded protein response (UPR) in TNBC cell lines, with sensitivity correlated with expression of immuno-(PSMB8/9/10) but not constitutive-(PSMB5/6/7) proteasome subunits. Equally, the transcriptomes of i-proteasome-high human TNBCs are enriched with UPR gene sets, and the genomic copy number landscape reflects positive selection pressure favoring i-proteasome activity, but in the setting of adjuvant treatment, this is actually associated with favorable prognosis. Tumor expression of PSMB8 protein (β5i) is associated with levels of MHC-I, interferon-γ-inducible proteasome activator PA28β, and the densities of stromal antigen-presenting cells and lymphocytes (TILs). Crucially, TILs were protective among TNBCs that maintain high β5i but did not stratify survival amongst β5i-low TNBCs. Moreover, β5i expression was lower in brain metastases than in patient-matched primary breast tumors (n = 34; P = 0.007), suggesting that suppression contributes to immune evasion and metastatic progression. Hence, inhibiting proteasome activity could be counterproductive in the adjuvant treatment setting because it potentiates anti-TNBC immunity.

Recovery Pattern in Different Surgical Approaches on Thoracic Enhanced Recovery based Fourteen-Step Protocol in Patients Undergoing Cardio-thoracic Surgery at University Hospital of Nepal

Background Cardio-thoracic surgery involves open and minimally invasive techniques. Enhanced recovery after surgery is used for early recovery from surgery. Enhanced recovery after surgery decreases hospital stay duration. Patients undergoing Enhanced recovery after surgery after video assisted thoracic surgery use less pain killers and have less hospital cost. There has not been any study on outcomes on patient who follow physiotherapy protocol designed in our setting. Objective To find the physiotherapy outcomes in patients undergoing thoracic enhanced recovery after surgery (T-ERAS) based 14 step protocol locally designed at Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH). Method This is a retrospective cross sectional observational study. All the cases who underwent cardiothoracic surgery were classified based on the approach of chest surgery performed into groups Sternotomy, Thoracotomy and Video Assisted Thoracic Surgery (VATS) groups. Patients were advised for Thoracic Enhanced recovery after surgery based on the protocol that has been devised at Dhulikhel Hospital. The recovery of patients based on activities they could perform was noted and analyzed. Result Both ICU stay and hospital stay in number of days were highest in thoracotomy (6.04 days) group while that was lowest in video assisted thoracic surgery group (1.67 days). There is a similar recovery until step 5, i.e. 2 days and rapid progression in further steps in video assisted thoracic surgery group while it is much slower in both sternotomy and thoracotomy groups. Conclusion Postoperative mobilization and physiotherapy enhance early healing and decrease hospital stay. Mean hospital stay and ICU stay were shorter for video assisted thoracic surgery cases compared to Thoracotomy and Sternotomy groups and the mean days to achieve different steps varied within the protocol between groups compared.

Impact of pre-therapy glioblastoma multiforme microenvironment on clinical response to autologous CMV-specific T-cell therapy

Objectives

Clinical response to antibody-based immunotherapies targeting checkpoint inhibitors is critically dependent on the tumor immune microenvironment (TIME). However, the precise impact of the TIME on adoptive cellular immunotherapy remains unexplored. Here we have conducted a long-term follow-up analysis of patients with recurrent glioblastoma multiforme (GBM) who were treated with autologous CMV-specific T-cell therapy to delineate the potential impact of the TIME on their clinical response.

Methods

Multiplexed immunohistochemical analysis of CD3, PD-L1 and Sox-2 in GBM tissue biopsies obtained before autologous T-cell therapy was carried out and correlated with long-term survival of GBM patients adoptively treated with T-cell therapy.

Results

Tumor microenvironment analyses revealed that the pre-treatment cellular composition of the tumor tissue may influence the subsequent response to adoptive T-cell therapy. GBM patients who showed prolonged overall survival following T-cell therapy had a significantly lower number of tumor-infiltrating CD3⁺ T cells in recurrent tumors than that in patients with short-term survival. Furthermore, long-term surviving patients showed low or undetectable PD-L1 expression in tumor cells in recurrent GBM biopsies.

Conclusion

We hypothesise that lack of PD-L1-mediated immunosuppression in the TIME may allow efficient immune control following adoptive T-cell therapy. Future studies combining anti-PD-L1 or genetically modified T cells with PD-1 receptor knockdown could be considered to improve clinical responses in patients who have high PD-L1 expression in their tumors.

Differential Hepatotoxic Effects of Sodium Valproate at Different Doses in Albino Rats

Background Liver plays an essential role for transforming and clearing chemicals that may cause harmful effects to it. Sodium Valproate, renowned to be a potent antiepileptic drug, when taken in overdose may cause toxic effects to liver and other organs as well. Liver damage can be assessed with histological changes and measurement of enzymes produced by it. Objective To investigate the histological changes induced by different doses of Sodium Valproate ranging from 100-500 mg/kg/day and observe its correlation with liver enzymes level in serum. Method Three-months old albino rats were divided into six groups, five in each. Control group was treated with normal saline and rest five groups with Sodium Valproate in different doses 100, 200, 300, 400 and 500 mg/kg/day respectively. Then, liver of those experimented rats were examined histologically under the light microscope. Furthermore, Liver enzymes; Alanine Transaminase and Aspartate transaminase were measured to assess the micro-anatomical changes in liver. Result Distorted hepatic lobular architecture with aggregations of nuclei at certain interval was observed in the groups of higher doses; 300 mg/kg/day and above. However, accumulation of adipocytes was observed in all the Sodium Valproate treated rats unlike the control group. When compared the enzyme levels among the groups, it was found to be significantly increased in dose dependent manner. Besides, it also showed skin lesions in all rats treated with the dose 400 mg/kg/day and above. Conclusion Higher doses of Sodium Valproate; 300 mg/kg/day and above induces hepatotoxicity and skin lesions in adult albino rats.

Mutant p53 upregulates alpha-1 antitrypsin expression and promotes invasion in lung cancer

Missense mutations in the TP53 tumor-suppressor gene inactivate its antitumorigenic properties and endow the incipient cells with newly acquired oncogenic properties that drive invasion and metastasis. Although the oncogenic effect of mutant p53 transcriptome has been widely acknowledged, the global influence of mutant p53 on cancer cell proteome remains to be fully elucidated. Here, we show that mutant p53 drives the release of invasive extracellular factors (the 'secretome') that facilitates the invasion of lung cancer cell lines. Proteomic characterization of the secretome from mutant p53-inducible H1299 human non-small cell lung cancer cell line discovered that the mutant p53 drives its oncogenic pathways through modulating the gene expression of numerous targets that are subsequently secreted from the cells. Of these genes, alpha-1 antitrypsin (A1AT) was identified as a critical effector of mutant p53 that drives invasion in vitro and in vivo, together with induction of epithelial-mesenchymal transition markers expression. Mutant p53 upregulated A1AT transcriptionally through the involvement with its family member p63. Conditioned medium containing secreted A1AT enhanced cell invasion, while an A1AT-blocking antibody attenuated the mutant p53-driven migration and invasion. Importantly, high A1AT expression correlated with increased tumor stage, elevated p53 staining and shorter overall survival in lung adenocarcinoma patients. Collectively, these findings suggest that A1AT is an indispensable target of mutant p53 with prognostic and therapeutic potential in mutant p53-expressing tumors.

A Study on Nutritional Status of Rural School going Children in Kavre District

Background Childhood is a time of active growth in terms of physical size, mental, emotional and psychological development. Normal growth is dependent on adequate nutrition and encompasses major transformations from birth to adulthood. Nutrition is a focal point for health and well being; and has special significance in countries with disadvantages in socioeconomic and hygienic standards. Objective The objective of the present study was to assess the nutritional status in terms of prevalence of underweight, stunting and thinness among rural school going children. Method The present study was cross-sectional study, conducted on 438 rural school going children (169 male and 259 female) with the age group 4-16 years, during the period from April 2014 to July 2014. Age was recorded in year; height and weight were measured in centimeter and kilogram respectively. BMI was calculated by using standard equation. Result The present study concluded that the nutritional status in terms of prevalence of underweight, stunting and thinness were found to be 30.85%, 24.54% and 10.05% respectively among rural school going children of Kavre district. It was revealed that 37.87% was underweight, 29.59% was stunted and 11.25% was thinness among male children whereas in female children, 26.27% was underweight, 21.24% was stunted and 9.27% was thinness. Hence, high prevalence of underweight, stunting and thinness were observed in male than in female children. Conclusion The present study has successfully documented the nutritional status in terms of prevalence of underweight, stunting and thinness among the rural school going children of Kavre district. The results of the present study will be useful for policy makers in their endeavor to formulate various developmental and health care programs.

Abstract A04: Alpha-1-Antitrypsin is a secreted protein driven by mutant p53 and associated with EMT, migration and invasion in-vivo

Half of all human tumors harbor mutations in TP53 gene. Such mutations not only lead to the expression of a protein unable to impart its normal tumor suppressor ability, but also endow the mutant p53 protein with newly acquired gain-of-function (GOF) properties that drive invasion and metastasis. Although it is widely established that mutant p53-expressing tumors have a high capacity to metastasize and are associated with poor outcomes, the key molecular mechanism utilized by mutant p53 are largely unknown. Since, p53 mutations are predominantly found in pre-invasive stages of lung adenocarcinomas, the identification of critical pathways that mediate mutant p53 gain of function (GOF) properties may uncover new targets for cancer therapy. In this study, we investigated the global impact of mutant p53 induced secretome on cancer cell proteome. A1AT is a secreted protein encoded by SERPINA1, a secreted serine protease inhibitor that neutralizes the effect of proteases, and A1AT involvement in mutant p53 driven tumorigenesis is unclear.

Methodology: We have developed a panel of H1299 lung adenocarcinoma derivatives that can inducibly re-express various mutant p53 proteins into a p53 null background. Expression levels were assessed by western blot analyses and real time PCR. Using iTRAQ (isobaric tag for relative and absolute quantification) and Liquid chromatography tandem mass spectrometry (LC-MS/MS) analyses, the proteome of conditioned media from H1299 cells expressing either induced p53 mutants (R175H and R248) or their isogenic un-induced counterparts were identified and quantified. Mutant p53 and p63 bindings sites were analyzed by chromatin immune-precipitation (ChIP) assays. In vitro migration/invasion and in vivo Chicken Chorio-allantoic membrane (CAM) invasion were performed in A1AT knockdown lung adenocarcinoma cells harboring p53 mutation. Public microarray, Kaplan-Meir datasets of human non-small cell lung carcinoma (NSCLCs) and A1AT immunohistochemistry (IHC) of stage I-III lung adenocarcinoma patients tissue microarray (TMA) samples (n=107) with matching normal were analyzed to correlate A1AT with prognosis and clinical significance.

Results: Induction of mutant p53 in H1299 cells drove an invasive phenotype through the release of a pro-invasive secretome, providing a novel avenue through which mutant p53 may be driving invasion and metastasis. Through proteomic characterization of induced conditioned medium from H1299 versus un-induced counterparts, we identified A1AT as a novel secreted mediator and a putative metastasis marker of mutant p53 tumors. To determine the role for A1AT as a downstream mediator of mutant p53 oncogenic pathways, we developed a double inducible H1299 system whereby we can simultaneously (i) induce expression of EI-H1299 R248Q mutant p53 and (ii) induce knockdown of the expression of its target A1AT. Remarkably, silencing the expression of A1AT significantly attenuated mutant p53 dependent migration and invasion both in vitro and in vivo. Importantly, knockdown of A1AT did not alter the basal level of motility in the absence of induced mutant p53, suggesting that the role of A1AT is specific to the mutant p53 pathway. Knockdown of A1AT significantly altered epithelial-mesenchymal transition (EMT) markers expression and reduced the ability of p53 mutant cells to grow in an anchorage independent environment. Treatment of cells with conditioned medium containing secreted A1AT enhanced the cell invasion while A1AT knockdown elicited the opposite effect. A1AT-blocking antibody attenuated the mutant p53 driven migration and invasion, strongly suggesting that mutant p53 is using secretory gene targets to potentiate its gain-of-function. In addition, A1AT intracellular levels were directly regulated by mutant p53 through the involvement with p63, indicating that A1AT is a direct target of mutant p53 transcriptomic regulation.

In public microarray dataset, A1AT mRNA expression was higher in lung adenocarcinoma (AC) and associated with shorter overall survival. Consistent with these findings, immunohistochemistry of 107 lung adenocarcinoma TMA showed upregulation of A1AT expression compared with matching normal tissues. The A1AT signal was cytoplasmic in tumor but not in the core of the tumor. A1AT overexpression in tumor cells correlated with increased tumor size (P&lt;0.046), and strongly with increased tumor progression (advanced T stage; P&lt;0.0006) and shorter survival (P&lt;0.001). In addition, we detected a clear correlation between elevated p53 staining and high levels of A1AT (P&lt;0.018). This indicates A1AT expression is predominantly driven by mutant p53 gain-of-function.

Conclusion: We conclude A1AT is an essential mediator of mutant p53 driven gain-of-function properties and our results highlight crucial roles of A1AT in driving oncogenic transformations. We suggest that A1AT is a potential therapeutic target in lung adenocarcinoma patient tumors expressing mutant p53.

Citation Format: Reshma Shakya, Andrew G. Turner, Wendy Cooper, Noor A. Lokman, Carmela Ricciardelli, Gerard Tarulli, Paul M. Neilsen, David F. Callen. Alpha-1-Antitrypsin is a secreted protein driven by mutant p53 and associated with EMT, migration and invasion in-vivo. [abstract]. In: Proceedings of the AACR Special Conference: Developmental Biology and Cancer; Nov 30-Dec 3, 2015; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(4_Suppl):Abstract nr A04.

Hormone-sensing mammary epithelial progenitors: emerging identity and hormonal regulation

The hormone-sensing mammary epithelial cell (HS-MEC-expressing oestrogen receptor-alpha (ERα) and progesterone receptor (PGR)) is often represented as being terminally differentiated and lacking significant progenitor activity after puberty. Therefore while able to profoundly influence the proliferation and function of other MEC populations, HS-MECs are purported not to respond to sex hormone signals by engaging in significant cell proliferation during adulthood. This is a convenient and practical simplification that overshadows the sublime, and potentially critical, phenotypic plasticity found within the adult HS-MEC population. This concept is exemplified by the large proportion (~80 %) of human breast cancers expressing PGR and/or ERα, demonstrating that HS-MECs clearly proliferate in the context of breast cancer. Understanding how HS-MEC proliferation and differentiation is driven could be key to unraveling the mechanisms behind uncontrolled HS-MEC proliferation associated with ERα- and/or PGR-positive breast cancers. Herein we review evidence for the existence of a HS-MEC progenitor and the emerging plasticity of the HS-MEC population in general. This is followed by an analysis of hormones other than oestrogen and progesterone that are able to influence HS-MEC proliferation and differentiation: androgens, prolactin and transforming growth factor-beta1.

Medication Adherence to Oral Hypoglycemic Agents Among Type II Diabetic Patients and Their Clinical Outcomes with Special Reference to Fasting Blood Glucose and Glycosylated Hemoglobin Levels

Background Oral hypoglycemic agents (OHAs) are the major treatment for people with type 2 diabetes mellitus (DM2). However, non-adherence to OHAs remains as one of the main reasons for poor glycemic control. Objectives To assess the adherence pattern to OHAs and clinical outcomes with special reference to fasting blood glucose (FBG) level and glycosylated hemoglobin (HbA1c) levels. Methods Informed consent was obtained from patients fulfilling the criteria and from the patient party in case of incapacitated patients. Information was obtained by interviewing them and filled in the appropriate questionnaire. All the medical information of the patients was obtained from the medical case records and laboratory reports. Results OHAs had been discontinued by 25% of patients. Overall 38% had ever discontinued and/ or often missed OHAs. Intentional discontinuation of OHAs attributed for 72% of the patients, followed by forgetfulness (42.9%), carelessness (30.6%), and hypoglycemia, (24%). There were 50.50% patients who had uncontrolled FBG (>130 mg/dl) level and 39% had uncontrolled HbA1c (≥ 7%) level. Taking reference age group 51-60 years, control of FBG level was found to be statistically associated with the decreasing age group (p = 0.006, OR = 4.8) as well as increasing age group (p = 0.008, OR = 4.034). There was significant association between controlled HbA1c level and patients’ knowledge about the precautions to be taken while using OHAs (p = 0.044, OR = 4). However, there was no significant association between glycemic control and OHAs adherence. Conclusion Majority of the patients who had missed OHAs attributed it to forgetfulness. Hypoglycemia may also be one of the contributing factors for poor adherence to OHAs. However no association was found between adherence and various other factors like age groups, treatment complexity, health literacy and social or family support. DOI: http://dx.doi.org/10.3126/kumj.v11i3.12508 Kathmandu Univ Med J 2013; 43(3):226-232

Spectrum of bacterial pathogens and their antibiogram from cases of urinary tract infection among renal disorder patients

Urinary tract infection (UTI) is the commonest bacterial infection occurring in renal disorder patients and is associated with significant morbidity. Resistance to antibiotics is highly prevalent in bacterial isolates and is an emerging problem in UTI. A hospital based cross sectional study was conducted from April 2011 to September 2011 to determine the frequency and bacterial profile of urinary tract infections in the patients with renal disorders visiting KIST Hospital along with their antimicrobial susceptibility pattern. Urine samples were collected from 300 clinically-suspected cases of UTI among renal disorder patients and investigated by conventional semi-quantitative culture technique, microscopy and antibiotic susceptibility test. Significant bacteriuria were detected in 34% of the total subjects, mostly from patients with Chronic Kidney Disease. Incidence of bacteriuria was found higher in females (40.40%) than in males (27.52%) and mostly occurred in elderly patients. Escherichia coli (62.75%) was the predominant isolate followed by Klebsiella pneumoniae (10.78%), Staphylococcus aureus (9.80%), Coagulase negative Staphylococcus aureus (CoNS) (5.88%), Enterococcus spp (3.92%), Klebsiella oxytoca (2.00%), Pseudomonas aeruginosa (2.00%), Proteus mirabilis (2.00%) and Proteus vulgaris (1.00%). Multidrug resistance was observed in 68.82% of the total bacterial isolates.

Use of head circumference as a predictor of height of individual

BACKGROUND

Establishing personal identity is one of the main concerns in forensic investigations. In forensic anthropology, estimation of height from head circumference has a significant role in establishing personal identity.

OBJECTIVE

The objective of the present study was an attempt to understand the relationship between height and head circumference of an individual and to derive regression formulae to estimate the height from the head circumference.

METHOD

The present study consisted of 440 (258 male and 182 female) students of age group 17 to 25 years studying in Kathmandu University School of Medical Sciences, Dhulikhel, Nepal during the period from November 2012 to October 2013. Height and head circumference of an individual were measured in centimeter. Data were analyzed by using statistical software SPSS-16.

RESULT

The findings of the present study were significant correlation between height and head circumference (r = 0.443, p < 0.01 for male, r = 0.302, p<0.01 for female, and r = 0. 398, p < 0.01 for combined (male and female). The regression equation for height and head circumference was found to be Y = 1.734X + 70.36 (R2 = 0.196) for male, Y = 0.916X + 106.8 (R2 = 0.091) for female, and Y = 1.648 X + 71.69 (R2 = 0.158) for combined (male and female), where Y is the height of Individual and X is the Head Circumference.

CONCLUSION

Head circumference showed highly significant positive correlation with individual's height. Therefore, the present study will help in medico-legal cases in establishing the identity of an individual and this would also be useful for Anatomists and Anthropologists.

Reporting Adverse Drug Reactions Among Hospitalized Medical Patients: A Prospective Study From Tertiary Care Hospital in Western Nepal

Background    The risk of adverse drug reaction ranges nearly from zero to high level depending upon the drug itself and the patient factor. The process of detection, assessment, monitoring and reporting of adverse drug reaction is necessary to prevent its occurrence in future. Materials and Methods Information related to suspected Adverse Drug Reactions(ADRs) were collected by pharmacists from general medical ward using ADRs reporting form from Manipal Teaching Hospital (MTH)during ward rounds. The details of suspected drug, drug reaction and all related data were documented. Naranjo Algorithm, modified Hartwig and Siegel and modified Shumock and Thornton scale were used for assessment of causality, severity and preventability respectively. All suspected ADRs were reported to National Pharmacovigilance Center and then to Uppsala Monitoring centre through the electronic online data base named Vigiflow.  Results Among 1,105 patients, 51 patients experienced ADR (4.61%). Incidents of ADRs were higher with antibiotics (47.06%) and Ceftriaxone was at top of list (15.69 %). Dermatological system (25.49%) and gastrointestinal system (19.61%) were affected more. About 33.33% of suspected drugs were discontinued. About 41.18% of ADRs required medical treatment where antihistaminic (24.32%) and antipruritic (21.62%) were most commonly used to treat ADRs. To sum up, 64.71% of ADRs were probable, 62.75% were mild in nature and 60.78% were probably preventable. Conclusion Finding of the study suggests that ADRs still pose serious health threat among hospitalized patients and as a matter of fact over 60% of them are preventable. Reporting of ADR scan provide effective measures to prevent the occurrence in the future in which the role of pharmacist is vital.DOI: http://dx.doi.org/10.3126/nje.v4i1.10135 Nepal Journal of Epidemiology 2014;4 (1): 330-336

Prevalence of intestinal parasitic infection of kindergarten children

INTRODUCTION: Intestinal parasitic infections are the major public health problems of Nepal. Apart from causing mortality and morbidity, infection with intestinal parasites has been associated with stunting of linear growth, physical weakness and low educational achievement in school children. The drinking water is considered as the major cause for parasitic infection. This study aims to determine the prevalence of parasitic infection among the children visiting kindergarten of the Kathmandu, Khusibhu area. MATERIALS AND METHODS: Cross sectional study was done in randomly selected Kindergarten of Khusibhu area. A total of 101 samples were examined. The study was focused in isolating intestinal parasites using normal saline and iodine wet mount method. Both macroscopic and microscopic studies were performed. RESULTS: Among the samples 45.5% (n=46) showed parasitic infection in which the Giardia lambia infection was found the highest 56.5% (n=26) and infection with Ascaris lumbricoides was found lowest 8.7% (n=4). Infection rate was found to be high in children drinking filtered water than among those drinking boiled and filtered water. CONCLUSION: The prevalence of parasitic infection in children is mainly associated with hygiene and food habit of the children. Hence good education about the hygienic practice helps in the prevention of the infection. DOI: http://dx.doi.org/10.3126/ijim.v2i3.8205 Int J Infect Microbiol 2013;2(3):111-113

Study of Pathway to Care among Patients with Epilepsy

Objective: To assess the pathway to care among patients with epilepsy up to the tertiary care centre Methods: It is a hospital based, cross-sectional descriptive study of 47 patients visiting BPKIHS psychiatry OPD. Written informed consent was taken from the patients and the primary caretaker. A semi structured Performa was used to record the basic sociodemographic details. Pathway Interview Schedule developed by WHO was used to collect the data. Results Majority (66.0%) of subjects were male. Generalized Seizures were most common (76.6%) type of seizure followed by complex-partial seizure (10.6%). More than half (51.1%) first contacted dhami-jhakri for treatment of their illness. About sixty two percent of patients had the first contact with the treatment provider less than 4 yrs ago. Thirty eight percent subjects sought treatment as per advice from the family members while only 2.1% sought treatment as per advice from the healthcare worker. The most common presenting complaints were sudden loss of consciousness in 89.4%of patients. In majority of patients (57.4%), problem arised ≤ 4yrs back. Significant high numbers of patients (51.1%) were prescribed alternative forms of treatment like herbal medications, talisman, offerings and sacrifices and jhadphook for their presenting problem. About eighty seven percent patients had to travel ≤12 hours for the treatment while 10.7% had to travel a distance of >24 hrs for treatment. The mean duration that one had to travel for seeking treatment was 7.95±14.58 hours. It was found that the mean duration that one patient spend before coming to a hospital for modern treatment was 5.64 months. Conclusions People suffering from epilepsy are still using the traditional healing practices leading to delay in the patient care. These findings call for a comprehensive educational program that can remove the misconcepts regarding the illness. DOI: http://dx.doi.org/10.3126/jucms.v1i1.8418   Journal of Universal College of Medical Sciences Vol.1(1) 2013:  20-25

Acute appendicitis in elderly patients: a challenge for surgeons

The classic symptoms of acute appendicitis are seldom seen in the elderly patient. More subtle symptoms and the more virulent pathologic course allow the disease to progress rapidly and insidiously. This leads to delayed hospitalization, diagnosis and treatment. The high incidence of concomitant diseases and the multiplicity of differential diagnostic possibilities in this age group are also factors. The aim of this study is to compare the results of appendicitis operated at Lumbini Medical College, Pravas, in patients younger than 60 and patient elder than 60 years of age. All patients aged 60 years and older who underwent appendectomy for appendicitis between January 2008, and December 2011, were studied and compared with the patients who were younger than 60 years of age. All the operations were performed by consultant surgeons at Lumbini Medical College, Pravas, Tansen. Preoperative USG was done in all the cases. Preoperative antibiotics were given in all the cases. All patients underwent appendectomy as an emergency basis. The results were compared with regard to age, sex, pre-operative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. There were 50 patients in group 1 and 150 patients in group 2 who met the inclusion criteria. The mean age (64 years for group 1 and 28 years for group 2), sex, preoperative suggestion of appendicitis (group 1, 35 [70%] of 50 patients; group 2, 135 [90%] of 150 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 1 patients [20%]; group 2, 30 patients [20%]) were similar in both groups. Laparoscopy was used in (group 1, 5 patients [10%]; group 2, 6 patients [4%] and associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time was more in the first group. The mean hospital stay was 5.3 in group 1 and 2.2 in group 2 (p < 0.05). Also duration of Hospital stay was 9.5 days for perforated appendicitis and 5.4 for non perforated appendicitis in both group (p < 0.05). Advanced age adversely affects clinical diagnosis, the stage of the disease and the outcomes. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with poor outcome from surgery.

Morphometric analysis of clavicle in nepalese population

BACKGROUND

Determining the sex of deceased is easy when a complete skeleton is available for examination. On the whole, the bones are heavier, larger and markings of muscular attachments are more pronounced in the male than in the female.

OBJECTIVE

The purpose of this study was attempted to evolve an easily applied formula to enable the assessment of sex in an unknown clavicles and to know about comparative differences between the right and left clavicles, from certain metrical parameters.

METHODS

The study was an observational, cross-sectional and descriptive in nature. The present study was conducted on 257 adult clavicles out of which, 135 were of the right side and 122 of left side. The maximum length of the clavicle (in mm) was taken.

RESULTS

The length of the right clavicles varies from 108 mm to 178 mm with an average of 143.21 mm ± 11.13 mm S.D. The length of the left clavicles varies from 111 mm to 181 mm with an average 145.53 mm ± 11.04 mm S.D. It has been observed that the left clavicle was longer than the right clavicle by 2.32 mm. There was no such single character which can determine the sex of all clavicles. Depending on the length alone, the sex can be decided in 13.33% male and 4.44% female right clavicles and 16.39% male and 9.83% female bones if the left clavicle is considered.

CONCLUSION

The left clavicle was longer than the right clavicle. The determination of sex from the clavicle has a great medico legal significance to the toxicologists. It also helps the anthropologists in their study of evolution of mankind and migration of races.

Monthly pattern of psychiatric morbidity and duration of stay among the patients admitted in Mental Hospital, a central level tertiary care hospital

Psychiatric morbidity is a major public health problem in the world across developed and developing countries. There is a paucity of Nepalese studies on psychiatric morbidity. All the patients who were admitted in mental hospital, Lagankhel from 17th July 2009 to 16th July 2010 were included in this study. Information on their Socio-demographic profiles and hospital diagnosis was extracted from their clinical notes. Eight hundred and fifty two patients were included in this study. Fifty eight percent were males. More than sixty percent of the patients were aged between 21 and 40 years. Sixty patients were married. In terms of ICD 10 diagnosis, the most common diagnoses were Schizophrenia in 427 (50.1%), mood disorders in 286 (33.5%) and substance use disorder in 80 (9.3%). In terms of length of stay, majority of them (56.4%) had stayed for 0-14 days. Thus, there is a need to increase the awareness in the general public regarding the impact of mental illness and the need for timely treatment.

Safety and Efficacy of Misoprostol and Dinoprostone as Cervical Ripening Agents

INTRODUCTION: The study compares safety and efficacy of misoprostol and dinoprostone as cervical ripening agents. METHODS: Patients with term, vertex, singleton pregnancy and Bishop score of 4 or less were randomly assigned to receive misoprostol pessary (n=35, 50 microg intravaginally) or dinoprostone gel (n=31, 0.5 mg intracervically) at 6 hourly intervals. If there were no progress in cervical dilatation or effective uterine contraction even after maximum dose, patients were taken for cesarean section. Patients who achieved Bishop's score more than 7 but the delivery was not progressing, were augmented with oxytocin drip. RESULTS: No uterine hyperstimulation was observed in both groups. However, abnormal fetal heart rate was observed in 3(8.6%) cases inmisoprostol group and 2 (6.5%) in dinoprostone group. There was no statistically significant difference in meconium passage in two groups. Apgar score less than 7 at 1 minute was seen in 6 (19.4%) and 11 (31.4%) neonates in dinoprostone and misoprostol group respectively. However Apgar score less than 7 at 5 minutes was found in only one neonate of dinoprostone treated patient. Both drugs were found to be equally effective in improving Bishops score with no significant difference in mean induction to delivery time. Cesarean section was done among 32.3% and 28.6% respectively in dinoprostone and misoprostol groups. There was significant reduction in the need for oxytocin augmentation in misoprostol (37.1%) group than in dinoprostone (67.7%) group. CONCLUSIONS: Vaginal misoprostol is an effective, safer and cheaper alternative to dinoprostone as a cervical ripening agent in underdeveloped countries. Keywords: Apgar score, Bishops score, cervical ripening, Dinoprostone, induction, Misoprostol

Safety and efficacy of misoprostol and dinoprostone as cervical ripening agents

INTRODUCTION

The study compares safety and efficacy of misoprostol and dinoprostone as cervical ripening agents.

METHODS

Patients with term, vertex, singleton pregnancy and Bishop score of 4 or less were randomly assigned to receive misoprostol pessary (n=35, 50 microg intravaginally) or dinoprostone gel (n=31, 0.5 mg intracervically) at 6 hourly intervals. If there were no progress in cervical dilatation or effective uterine contraction even after maximum dose, patients were taken for cesarean section. Patients who achieved Bishop's score more than 7 but the delivery was not progressing, were augmented with oxytocin drip.

RESULTS

No uterine hyperstimulation was observed in both groups. However, abnormal fetal heart rate was observed in 3(8.6%) cases in misoprostol group and 2 (6.5%) in dinoprostone group. There was no statistically significant difference in meconium passage in two groups. Apgar score less than 7 at 1 minute was seen in 6 (19.4%) and 11 (31.4%) neonates in dinoprostone and misoprostol group respectively. However Apgar score less than 7 at 5 minutes was found in only one neonate of dinoprostone treated patient. Both drugs were found to be equally effective in improving Bishops score with no significant difference in mean induction to delivery time. Cesarean section was done among 32.3% and 28.6% respectively in dinoprostone and misoprostol groups. There was significant reduction in the need for oxytocin augmentation in misoprostol (37.1%) group than in dinoprostone (67.7%) group.

CONCLUSIONS

Vaginal misoprostol is an effective, safer and cheaper alternative to dinoprostone as a cervical ripening agent in underdeveloped countries.

Ritodrine and Isoxsuprine in Managment of Preterm Labor

Introduction: 

Ritodrine and isoxsuprine in management of preterm labor

INTRODUCTION

Preterm delivery is an important cause of perinatal morbidity and mortality. To decrease the medical and economical impact of preterm delivery, tocolytic agents are available among which isoxsuprine and ritodrine are widely used in Nepal. The study on efficacy of ritodrine and isosuprine has not been done yet in Nepelese women. So to observe on efficacy and safety of Ritodrine and Isoxsuprine, this study was conducted.

METHODS

A prospective observational study was conducted with an aim to assess the efficacy and safety of Isoxsuprine 10 mg orally eight hourly versus Ritodrine 10 mg initially infused intravenously along with 5% dextrose at the rate of 10 drops per minute with an increase of 5-10 drops every 30 minutes for 24 hours and then given oral at 5-10 mg eight hourly, in patient with preterm labor requiring uterine tocolysis.

RESULTS

This study found that Ritodrine is more effective and safer than Isoxsuprine in suppressing preterm labor. The failure rate of Isoxsuprine and Ritodrine were 22.22% and 6.5% respectively. The maternal side effects including cardiac side effects were significantly higher in Isoxsuprine. The cardiac side effects caused by Ritodrine can be controlled by adjusting the drip rate. Though Isoxsuprine seems more economical than Ritodrine, it is lesser cost effective to patients due to its higher failure rate, that results in added expenses in terms of increased morbidity and mortality.

CONCLUSIONS

Hence, Ritodrine is superior to Isoxsuprine as it is more efficacious in managing preterm labor and increasing fetal maturity. Also the adverse effects of Ritodrine are less than those of Isoxsuprine which result in better patient compliance and cost effectiveness.

Depression during pregnancy in a tertiary care center of eastern Nepal

This is a cross sectional study, conducted in 45 pregnant women coming for antenatal check ups in the eastern regional hospitals in Nepal. Hamilton -Depression Scale (HAM-d) was applied after initial psychiatry work up to all women who were selected for the interview. Analysis revealed about half of the pregnant women having some form of depression. Life events (e.g. chronic illness in the family, marital disharmony, economic crisis to sustain the family) were found to be important risk factors (P<0.05). Antenatal depression is a more common than generally thought.

Psychiatric Emergencies in a Tertiary Care Hospital

People with psychiatric problems often visit a general hospital. Many of them require emergencyservice. B P Koirala Institute of Health Sciences (BPKIHS) is one of the few health institutes in Nepalproviding comprehensive 24-hour psychiatric emergency service. This study aims to document thepattern of psychiatric emergencies in a tertiary care hospital of Eastern Nepal.All psychiatric emergencies referred from different departments in 30 random days during a sixmonthperiod were enrolled. This is a descriptive study with convenience sampling method wherethe diagnoses were made based on the‘International Classifi cation of Disease and Infi rmity’ (ICD-10).One hundred twenty-nine cases were referred in the study period. The M:F ratio was 1.3:1. Theservice users were predominantly young adults. The majority of cases were seen in the emergencydepartment and medical ward. The most common causes for the consultation were behavioralproblems (39%), altered consciousness (32%) and somatic complaints (17%). Approximately 83%received the diagnosis of Category F of the ICD-10. Mental and behavioral disorder due to substanceuse (F10-19) was the most common disorder (30%), followed by mood/affective disorders (23%)and neurotic, stress-related anxiety disorders (16%). Roughly 46% had co-morbid physical illnessesand 8% received only a physical diagnosis. About 20% had attempted suicide using different means,poisoning being the most common.Emergency psychiatric consultation for mental problems is sought by almost all departments of ageneral hospital. These consultations are most commonly sought for substance use, mood or anxietydisorders.Key Words: Behavioral problems, psychiatric emergency, psychiatric disorders, substance abuse.

Psychiatric emergencies in a tertiary care hospital

People with psychiatric problems often visit a general hospital. Many of them require emergency service. B P Koirala Institute of Health Sciences (BPKIHS) is one of the few health institutes in Nepal providing comprehensive 24-hour psychiatric emergency service. This study aims to document the pattern of psychiatric emergencies in a tertiary care hospital of Eastern Nepal. All psychiatric emergencies referred from different departments in 30 random days during a six-month period were enrolled. This is a descriptive study with convenience sampling method where the diagnoses were made based on the'International Classification of Disease and Infirmity' (ICD-10). One hundred twenty-nine cases were referred in the study period. The M:F ratio was 1.3:1. The service users were predominantly young adults. The majority of cases were seen in the emergency department and medical ward. The most common causes for the consultation were behavioral problems (39%), altered consciousness (32%) and somatic complaints (17%). Approximately 83% received the diagnosis of Category F of the ICD-10. Mental and behavioral disorder due to substance use (F10-19) was the most common disorder (30%), followed by mood/affective disorders (23%) and neurotic, stress-related anxiety disorders (16%). Roughly 46% had co-morbid physical illnesses and 8% received only a physical diagnosis. About 20% had attempted suicide using different means, poisoning being the most common. Emergency psychiatric consultation for mental problems is sought by almost all departments of a general hospital. These consultations are most commonly sought for substance use, mood or anxiety disorders.

Management of antitubercular drugs-induced hepatotoxicity and therapy reintroduction strategy in a TB clinic of Nepal

BACKGROUND

PZA, INH and R have potential for hepatotoxic side effects. Although anti-tuberculosis drug-induced hepatotoxicity is well known, there is no agreement on the clinical approach for cases in whom hepatotoxicity has developed.

OBJECTIVE

To study the management of anti-TB drugs induced hepatotoxicity and the standard anti-TB drugs therapy reintroduction procedure.

DESIGN

In prospective cohort analysis, 4 patients with active TB infection had developed anti-TB drugs induced hepatotoxicity. Retreatment of therapy was done on the basis of severity of hepatitis. If damage is mild, all the drugs were reintroduced at once in a tapering dose and if patient's condition is worse, INH and E is introduced in lower dose, later increasing the dose and the number of drugs.

RESULTS

All the patients tolerated anti-TB drugs well after reintroduction. There was no incidence of recurrence. All the patients completed their 8 months treatment regimen and all are cured.

CONCLUSION

Timely detection and temporary withdrawal of the offending agent can completely cure anti-TB drugs induced hepatotoxicity. The recurrence of hepatotoxicity is rare if reintroduction in done in a well planned manner.

Impaired mammary gland and lymphoid development caused by inducible expression of Axin in transgenic mice

Axin is a component of the canonical Wnt pathway that negatively regulates signal transduction by promoting degradation of beta-catenin. To study the role of Axin in development, we developed strains of transgenic mice in which its expression can be manipulated by the administration of doxycycline (Dox). Animals carrying both mouse mammary tumor virus (MMTV)-reverse tetracycline transactivator and tetracycline response element (TRE)2-Axin-green fluorescent protein (GFP) transgenes exhibited Dox-dependent Axin expression and, when induced from birth, displayed abnormalities in the development of mammary glands and lymphoid tissues, both sites in which the MMTV promoter is active. The transgenic mammary glands underwent normal ductal elongation and side branching during sexual maturation and early pregnancy, but failed to develop lobulo-alveoli, resulting in a defect in lactation. Axin attenuated the expression of cyclin D1, a Wnt target that promotes the growth and differentiation of mammary lobulo-alveoli. Increased apoptosis occurred in the mammary epithelia, consistent with the inhibition of a Wnt/cyclin D1 survival signal by Axin. High levels of programmed cell death also occurred in the thymus and spleen. Immature thymocytes underwent massive apoptosis, indicating that the overexpression of Axin blocks the normal development of T lymphocytes. Our data imply that the Axin tumor suppressor controls cell survival, growth, and differentiation through the regulation of an apoptotic signaling pathway.

Effects of mutations in potential phosphorylation sites on transcytosis of FcRn

The neonatal Fc receptor, FcRn, transports immunoglobulin G (IgG) across intestinal epithelial cells of suckling rats and mice from the lumenal surface to the serosal surface. In cell culture models FcRn transports IgG bidirectionally, but there are differences in the mechanisms of transport in the two directions. We investigated the effects of mutations in the cytoplasmic domain of FcRn on apical to basolateral and basolateral to apical transport of Fc across rat inner medullary collecting duct (IMCD) cells. Basolateral to apical transport did not depend upon determinants in the cytoplasmic domain. In contrast, an essentially tailless FcRn was markedly impaired in apical to basolateral transport. Using truncation and substitution mutants, we identified serine-313 and serine-319 as phosphorylation sites in the cytoplasmic domain of FcRn expressed in Rat1 fibroblasts. Mutations at Ser-319 did not affect transcytosis across IMCD cells. FcRn-S313A was impaired in apical to basolateral transcytosis to the same extent as tailless FcRn, whereas FcRn-S313D transported at wild-type levels. FcRn-S313A recycled more Fc to the apical medium than the wild-type receptor, suggesting that Ser-313 is required to allow FcRn to be diverted from an apical recycling pathway to a transcytotic pathway.

Characterization of source- and sink-specific sucrose/H+ symporters from carrot

To understand how sucrose (Suc) is transported from source leaves to developing tap roots of carrot (Daucus carota L.), we cloned two cDNAs (DcSUT1 and DcSUT2) for proteins with homologies to plant Suc/H+ symporters. The deduced polypeptide sequences are 52% identical and have 12 predicted membrane-spanning domains each. Transport activities were confirmed by expression of the clones in yeast cells. Both transporters had optimal activity below pH 5.0 and Michaelis constant values of 0.5 mM. Suc uptake was inhibited by protonophores, suggesting that Suc transport is linked to the proton electrochemical potential across the plasma membrane. DcSUT1 and DcSUT2 had markedly different expression patterns. Transcripts of DcSUT1 were found only in the green parts of plants, with highest levels in the lamina of source leaves, indicating that DcSUT1 is required for the loading of Suc into the phloem. In leaf lamina expression was diurnally regulated, suggesting that Suc export from the leaves is higher during the day than during the night. The mRNA of DcSUT2 was found mainly in sink organs, and no diurnal expression pattern was detected in the storage root. Here, expression was not restricted to the phloem but was much higher in storage parenchyma tissues of phloem and xylem. The close relationship of DcSUT2 with a Suc/H+ symporter from fava bean, which facilitates Suc uptake into the cotyledons of developing seeds, indicates that this carrot Suc transporter may be involved in loading Suc into storage parenchyma cells.

Comparison of Bronchodilator Effect of Salbutamol Delivered via MDI and DPI in COPD Patients

Introduction : Chronic Obstructive Pulmonary Disease (COPD) is one of the leading problems affecting majority of population all over the world which diminishes the quality of life of the individual and create extra burden to the society as well as country. Inhaled bronchodilator therapy is the mainstay of treatment in the management of COPD. Various inhaled [e.g. metered dose inhaler (MDI) /dry powder inhaler (DPI)] formulations are available and are widely used among the COPD patients in Nepal. Methodology : This is cross sectional prospective study, designed to compare the bronchodilating effect produced when salbutamol is delivered via two devices: MDI (Asthalin® from Cipla) and DPI (Asthalin® rotacap delivered via Rotahaler® from Cipla), in patients with stable COPD. It is proven by previous studies that intervention is necessary to improve the compliance of the patients; all subjects (total n=60; 30 in each group) are counseled and trained to follow correct inhaling technique through particular device. Then their improvements in lung function were measured with reference to the pulmonary function test based on spirometry. Results : Patients enrolled in each group were not statistically different regarding to age (P=0.318), weight (P=0.324) & BMI (P=0.836). Among the total subjects 87% had smoking history and 2% were still smoking and there was no signifi cant difference in smoking habit between the two groups (p-value 0.544 > 0.05). Similarly 91.6 % of the total had exposure to indoor air pollution which had been the major risk factor for COPD. Most of the patients were on stage II COPD (62%). Salbutamol was found to have no effect on vital statistics of patients. Study showed there was no significant difference in the improvement of forced expiratory volume in one second (FEV1) (p=0.802), FVC (p= 0.693), FEV1 % (p=1) and PEF (p=0.448) between MDI and Rotahaler groups. Major side effect associated with the MDI users is headache (79%) while those among Rotahaler users were muscle cramps (79%). Even though intervention improved the inhaler using technique among the patients in both the groups, it was found even after counseling, DPI seemed to be better understood by the patients in comparison to MDI (p=0.003 & 0.00). In addition DPI was preferred by most of the patients who were familiar with both delivery systems. It was also found to be cheaper than the MDI. Conclusion : Overall evidence suggests that although both MDI & DPI improve the lung function of COPD patients to similar extent, DPI is cheaper and more preferred and can be easily handled by the patients which can result in reduction of non-compliance. Keyword : COPD; Salbutamol; DPI; MDI; Spirometry DOI: 10.3126/saarctb.v6i2.3054 SAARC J. Tuber. Lung Dis. HIV/AIDS 2009 VI (2) 22-30