A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies

The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.

Impact of COVID-19 Pandemic on Dermatology Teaching Program in India: A Survey on the Faculty and Residents' Perspective

Background

Impact of COVID-19 pandemic has been immense. An innocent casualty of this disaster is medical education and training. Dermatology, which primarily deals with out-patient services, medical and surgical interventions, and in-patient services, was one of the worst hit. The National Medical Commission of India has implemented competency-based medical education (CBME) in Dermatology, Venereology, and Leprosy since 2019. The new curriculum relies on acquiring practical and procedural skills, training skills in research methodology, professionalism, attitude, and communication.

Objectives

The study was undertaken to understand the implications of the COVID-19 pandemic on postgraduate dermatology CBME training in India.

Materials and Methods

A questionnaire-based survey was carried out on postgraduate dermatology teachers and residents in India after obtaining ethics committee approval. An online semi-structured English questionnaire was administered by Google Forms. The calculated sample size was 366 dermatology faculty and 341 postgraduate students. Validity (Content validity ratio (CVR) ≥0.56) and reliability (Cronbach's alpha coefficient 0.7249) of the questionnaire were determined.

Results

Among the 764 responses received, 51.4% reported that their institutes were converted to exclusive COVID hospitals. Domains of dermatology education affected were procedural training (n = 655), bedside clinical teaching (n = 613), outpatient department-based clinical teaching (n = 487), bedside laboratory procedures (n = 463), research activities (n = 453), histopathology (n = 412), and theory classes (n = 302). To keep up with the teaching-learning process, online platforms were mostly utilized: Zoom Meeting (n = 379), Google Meet (n = 287), and WhatsApp Interaction (n = 224). Teaching during ward rounds was significantly more affected in exclusively COVID institutes than non-exclusive COVID institutes (P < 0.001). Psychomotor skill development suffered a major jolt with 26.7% of respondents reporting a standstill (P < 0.001). Communication skills among students suffered due to social distancing, mask, and poor attendance of patients. According to 23.84% of respondents, formative assessment was discontinued.

Conclusion

Online seminars, journal clubs, and assessments have been incorporated during the pandemic. Online modalities should be used as a supplementary method as psychomotor skills, communication skills, research work, and bedside clinics may not be replaced by the e-learning.

Preservation of speech and swallowing after excision of a pharyngeal pouch tumour

A pharyngeal pouch is not an uncommon cause of dysphagia in older population. However, finding a tumour in a pharyngeal pouch is very rare. A 79-year-old gentleman presented with dysphagia and a neck lump. Videofluoroscopy showed a pharyngeal pouch. Rigid endoscopy confirmed a tumour arising from the pharyngeal pouch. The histology showed it to be squamous cell carcinoma. The MRI scan based staging was T3N1M0. The patient underwent modified right radical neck dissection, partial pharyngectomy with primary repair and tracheostomy. He completed postoperative radiotherapy and remained disease-free at 4 years follow-up.

Oral Disintegration Tablets of Stavudine for HIV Management: A New Technological Approach

Stavudine oral disintegration tablets were formulated to minimize the bitter taste and to reduce the first-pass hepatic metabolism. The various precompression parameters like the angle of repose, bulk density, compressibility index and Hausner's ratio were determined for the powder blend. In this study, 14 formulations of stavudine oral disintegration tablet were prepared by direct compression method. The tablets were evaluated for weight variation, percentage friability, disintegration time, hardness, wetting time and water absorption ratio. The in vitro dissolution study results of the batch S1 (stavudine+crospovidone+sodium starch glycollate) are encouraging as highest dissolution rate (99.2% in 100 min) and lowest time of disintegration (56 s) was achieved. The in vivo drug release studies were carried out in rabbits and the relative bioavailability of formulation S1 was found to be 2.83 times greater than that of conventional tablets.

Comparative studies of lamivudine-zidovudine nanoparticles for the selective uptake by macrophages

The present study investigates the specific drug targeting of anti retroviral drugs, such as lamivudine and zidovudine, after intraperitoneal (i.p) injection by incorporation into polymeric nanoparticles (PNs) and solid lipid nanoparticles (SLNs). Our results showed that Glyceryl Monosterate-Poloxamer 188 SLNs (average diameter of 522.466 nm) showed slow drug release rates (63.18% of lamivudine and 62.37% of zidovudine were released in 12 hrs) among all the SLN formulations. For Poly lactic-co-glycolic acid (PLGA)-Poloxamer 188 PNs (average diameter of 70.348 nm), there were faster release rates of both lamivudine and zidovudine (97% and 94.06%, respectively, in 12 hrs). Tissue distribution studies were carried out in mice and concentrations of drugs in different organs were determined using high performance liquid chromatography (HPLC) after i.p. administration. Glyceryl Monosterate-Poloxamer 188 SLNs and PLGA-Poloxamer 188 PNs showed increase in the distribution of lamivudine and zidovudine to liver and spleen when compared to the drugs in solution. Also, Glyceryl Monosterate-P 188 SLNs showed higher concentration of drugs in RES organs than PLGA-P 188 PNs.

Local drug delivery for oral mucosal diseases: challenges and opportunities

There are few topical formulations used for oral medicine applications most of which have been developed for the management of dermatological conditions. As such, numerous obstacles are faced when utilizing these preparations in the oral cavity, namely enzymatic degradation, taste, limited surface area, poor tissue penetration and accidental swallowing. In this review, we discuss common mucosal diseases such as oral cancer, mucositis, vesiculo-erosive conditions, infections, neuropathic pain and salivary dysfunction, which could benefit from topical delivery systems designed specifically for the oral mucosa, which are capable of sustained release. Each condition requires distinct penetration and drug retention profiles in order to optimize treatment and minimize side effects. Local drug delivery may provide a more targeted and efficient drug-delivery option than systemic delivery for diseases of the oral mucosa. We identify those mucosal diseases currently being treated, the challenges that must be overcome and the potential of novel therapies. Novel biological therapies such as macromolecular biological drugs, peptides and gene therapy may be of value in the treatment of many chronic oral conditions and thus in oral medicine if their delivery can be optimized.

Deprivation impedes success of insulin intensification in children and adolescents with Type 1 diabetes; longitudinal linear mixed modelling of a retrospective observational cohort

AIMS

To examine the relationship between social deprivation, intensification of insulin therapy (≥ three injections per day) and diabetes control in children and adolescents.

METHODS

We performed a longitudinal observational study of 283 children and adolescents with Type 1 diabetes from three UK paediatric centres from 2005 to 2007. We used linear mixed modelling to identify the contribution of the Index of Multiple Deprivation 2004, insulin regimen and demographic factors in explaining longitudinal differences in HbA(1c) levels.

RESULTS

Overall mean HbA(1c) levels were 8.9% [sd 1.4, 74 mmol/mol (8 mmol/mol)]. Prescribing of intensive therapy increased from 49.2 to 70.1% (χ(2) = 32.9, P < 0.001), but there was no corresponding improvement in HbA(1c) levels. Those from more educationally deprived backgrounds were less likely to be started on intensive therapy (P = 0.04). In linear mixed modelling, factors independently associated with poor metabolic control were greater social deprivation (P = 0.01), particularly lower educational levels (P = 0.006), and non-White ethnicity (P = 0.04). Nested terms analysis showed that increased deprivation interacted with non-White ethnicity (P = 0.009) and with intensive insulin therapy (P = 0.03) to result in poorer metabolic control. In a subgroup intensified from conventional regimens during follow-up (n = 75), greater social deprivation was associated with least success of intensive therapy (P = 0.02).

CONCLUSIONS

  Social deprivation was associated with low uptake and poor success of insulin intensification and this appeared to be largely mediated via lower educational levels.

Formulation and evaluation of Cetirizine dihydrochloride orodispersible tablet

Cetirizine orodispersible tablets were prepared to achieve quick onset of action and for maximum bioavailability. Tablets were prepared using cetirizine along with camphor and mannitol in the proportion of 1:1:1, 1:1:3, and 1:1:6. The flow property of granules was found to be good for the formulation CZ2 (1:1:3). The hardness and friability of all the formulations were found to be within the standard limit for orodispersible tablets. Disintegration time was found to be rapid in formulation CZ2 (1:1:3).The in vitro dissolution time was found to be 100% in 11 minutes for the formulation CZ2 (1:1:3).

Proniosomes as drug carriers

Approaches to stabilize niosomal drug delivery system without affecting its properties of merits have resulted in the development of the promising drug carrier, proniosomes. Proniosomes is dry formulation using suitable carrier coated with non ionic surfactants and can be converted into niosomes immediately before use by hydration. These proniosome-derived niosomes are as good as or even better than conventional niosomes. The focus of this review is to bring out different aspects related to proniosomes preparation, characterization, entrapment efficiency, in vitro drug release, applications and merits.

Formulation and evaluation of a proniosome hydrocortisone gel in comparison with a commercial cream

Proniosomes, a novel drug delivery approach for increasing permeation of hydrocortisone through the skin, were investigated. Proniosome hydrocortisone gel was prepared by a coacervation-phase separation method using different combinations of non-ionic surfactants with cholesterol and lecithin. Proniosome formulations were characterized for vesicle size, entrapment efficiency, and drug content uniformity. Span 20:Span 40, Span 20:Span 60 and Span 20:Span 80 combinations showed good entrapment compared with Span: Tween combinations (Span 20:Tween 40, Span 20:Tween 60, Span 20:Tween 80). In vitro release in 8h from a Span 20:Span 80 proniosome 1% hydrocortisone formulation was high (58.29 %) compared to the other proniosome formulations. Proniosome hydrocortisone gel shows diffusion type release which was confirmed by Higuchi and Peppas plot. In vivo studies in mice confirmed that the proniosome 1% hydrocortisone formulation was more active than a commercially marketed 1% hydrocortisone cream. Topical application of hydrocortisone in the form of proniosomes leads to prolonged action.

Adult heart block is associated with disease activity in primary Sjögren's syndrome

OBJECTIVES

Congenital heart block occurring in the foetus and neonate may be associated with maternal anti-SS-A/anti-SS-B autoantibodies (anti-SSA/anti-SSB). The adult atrioventricular node is generally thought to be resistant to the damaging effects of anti-SSA/anti-SSB. However, case reports suggest that heart block developing in adult Sjögren's syndrome (SS) patients may be associated with these autoantibodies. Therefore, we investigated the relationship between serum antibodies and heart block in adult SS patients.

METHODS

We abstracted data from clinic patient records. Diagnosis of primary SS was based on American-European classification criteria. Electrocardiograms (EKGs), laboratory immunology parameters, lipid profiles, and focus scores from labial salivary gland biopsies were available for 51 SS patients. Fifteen patients had follow-up EKGs. PR interval200 ms was considered to be first-degree heart block.

RESULTS

Five patients showed prolonged PR intervals; the presence of heart block was not related to the presence of anti-SSA antibodies. However, significant differences between patients with prolonged and normal PR intervals were seen for mean focus scores (p<0.0001), anti-cardiolipin immunoglobulin IgG (p = 0.0009), age (p = 0.01), IgG (p = 0.02), anti-SSB antibodies (p = 0.02), and high density lipoprotein (HDL) cholesterol levels (p = 0.03). These parameters correlated with prolonged PR intervals.

CONCLUSIONS

These results suggest an association between disease activity, the presence of anti-SSB antibodies, and the occurrence of first-degree heart block in adults with primary SS.

Studies on chemically crosslinkable carboxy terminated-poly(propylene fumarate-co-ethylene glycol)-acrylamide hydrogel as an injectable biomaterial

Carboxy terminated-poly(propylene fumarate)-co-ethylene glycol) (CT-PPF-co-PEG) was prepared and set into crosslinked hydrogel material with acrylamide. The setting studies reveal that this copolymer system can be used as an injectable material. The hydrogel material exhibits a higher degree of swelling, good mechanical strength and flexibility. The hydrogel favours adhesion of L929 fibroblast cells without proliferation on the surface. However, cardiac fibroblast cells (isolated from new born rat (Wistar) hearts) adhere and proliferate on the hydrogel due to the formation of synergistic hydrophilic-hydrophobic surface-by-surface reorganization.

Lack of efficacy of etanercept in Sjögren syndrome correlates with failed suppression of tumour necrosis factor alpha and systemic immune activation

OBJECTIVE

To provide insight into the clinical failure of the tumour necrosis factor alpha (TNFalpha) inhibitor, etanercept, in primary Sjögren syndrome (pSS), an extensive analysis of the systemic immune profile of patients with pSS was carried out and the effect of etanercept treatment on these immune parameters monitored.

METHODS

Peripheral blood mononuclear cells of patients with pSS and healthy controls were compared by flow cytometry to determine differences in distribution of specific cell populations (T cells, B cells, monocytes), and to determine their expression of activation markers (CD25, HLA-DR), TNF receptors and chemokine receptors (CXCR1, 2) before and after treatment. Systemic cytokine levels were measured by multiplex ELISA assay in plasma and in lipopolysaccharide-stimulated whole blood from healthy controls and from patients with pSS before and after etanercept treatment. Baseline cytokine levels were correlated with clinical markers of disease.

RESULTS

Before treatment, salivary gland inflammatory focus scores did not correlate with circulating TNF levels. Furthermore, consistent with the lack of evidence of significant clinical benefit, enhanced markers of immune activation, frequency of cell subpopulations and aberrant cytokine profiles were not restored to normal levels by etanercept treatment. Remarkably, the levels of circulating TNFalpha were significantly increased after treatment.

CONCLUSION

Etanercept is an ineffective therapeutic agent in pSS consistent with the absence of suppression of TNFalpha and other indicators of immune activation in this patient population. These data suggest that TNFalpha may not be a pivotal cytokine in the pathogenesis of pSS, impelling continued molecular characterisation of disease parameters to define appropriate intervention targets.

Teenage and adult tonsillectomy: dose-response relationship between diathermy energy used and morbidity

OBJECTIVE

To determine whether an increase in the use of bipolar diathermy energy to perform a tonsillectomy is associated with an increase in postoperative pain and haemorrhage.

STUDY DESIGN

Prospective study.

SETTING

District General Hospital.

METHODS

In all, 101 patients above the age of 13 years who underwent a tonsillectomy that involved the use of bipolar diathermy during the study period were included. The cumulative amount of diathermy energy used to perform each tonsillectomy was calculated with the help of a digital stop clock timing device connected to the diathermy foot-pedal.

MAIN OUTCOME MEASURES

Postoperative pain scores and the incidence of secondary haemorrhage were recorded for each patient at four points in time following surgery, up to the tenth postoperative day. The haemorrhage rates were categorised into three groups (no bleeding, minor bleeding and major bleeding) according to severity. Associations between the diathermy energy used to perform each tonsillectomy and the corresponding postoperative pain scores and secondary bleeding rates were investigated.

RESULTS

There was a statistically significant positive relationship between the total amount of bipolar diathermy energy used per tonsillectomy and the pain scores at all the four recorded points in time (r(s) = 0.44-0.72, P < 0.001). When the median energy consumption in the three groups (no bleeding, minor bleeding and major bleeding) were compared using the Kruskal-Wallis test, we found that there was limited evidence of a difference between the groups, but this was not statistically significant at the 5% level [H (2) = 5.374, P = 0.065, 99% CI 0.058-0.071].

CONCLUSIONS

Increased use of bipolar diathermy during the performance of a tonsillectomy is associated with a statistically significant increased amount of postoperative pain. The dose-response relationship between diathermy energy and postoperative bleeding is less clear. This suggests that there could be other important factors such as surgical instrument characteristics and degree of tonsillar adherence that have an additional influence and are therefore possible areas for future research.

How we do it: Evaluation of nurse-led ENT services in the UK: a preliminary descriptive postal questionnaire survey

There has been a steady growth in the volume and range of nurse led services in ENT practise in the UK. There was very little consistency in the titles of the nurses providing nurse led services but those nurses working in advanced practice roles now require courses, diplomas, degrees and study days related to ENT. Locally or nationally agreed practice guidelines can define nursing practice boundaries and ensure accountability. Monitoring and evaluation of nurse led services also requires attention.

Immunological consequences of thalidomide treatment in Sjögren's syndrome

OBJECTIVE

To study the immunological consequences of systemic thalidomide treatment in patients with Sjögren's syndrome.

METHODS

Cytokine (tumour necrosis factor alpha (TNFalpha), interleukin (IL) 6) and soluble receptor (sIL2R) levels were measured in patient and control plasma (n = 7), before and after thalidomide treatment. Peripheral blood mononuclear cells were examined by FACS analysis for potential changes in specific cell populations (T cells, B cells, monocytes), and for the expression of activation markers (CD25, HLA-DR), costimulatory molecules (CD40, CD40L), TNF receptors, chemokine receptors, and adhesion molecules (L-selectin (L-sel)).

RESULTS

Owing to adverse effects of thalidomide, the treatment interval was limited. None the less, statistically significant changes in markers of cell activation were recorded in the four treated patients. Before treatment, HLA-DR, TNFRI, CXCRI, and CXCRII were raised in the patients compared with healthy controls (p<0.05) and their expression was down regulated after treatment. B cell numbers and expression of the adhesion molecule L-sel also declined with thalidomide.

CONCLUSION

Significant changes in measures of cell activation were detected during thalidomide treatment within this limited study, which upon further investigation may offer insight into the underlying immunoregulatory pathways of thalidomide.

Serum lipid levels in Sjögren's syndrome

OBJECTIVES

Altered lipid levels may occur in autoimmune diseases, for example low cholesterol levels have been described in rheumatoid arthritis (RA). Serum lipid profiles in patients with Sjögren's syndrome (SS) have not been investigated. We hypothesized decreased lipid levels in SS patients and an inverse relationship with disease activity.

METHODS

Serum lipid levels [total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and triglycerides] and additional data regarding disease measures (clinical immunology parameters, focus score from labial salivary gland biopsy, salivary flow and ophthalmological measures) were available for 46 primary SS patients and 12 xerostomic controls.

RESULTS

Significant differences between SS patients and controls means (s.d.) were seen for HDL (P = 0.04) and total cholesterol (P = 0.02). LDL (P = 0.12) and triglyceride (P = 0.08) levels were not different. In SS patients, but not in controls, total cholesterol (P = 0.003) and HDL cholesterol (P = 0.003) predicted immunoglobulin G levels. Anti-SSA antibodies were related to a lower total cholesterol (P = 0.02) and anti-SSB antibodies to a lower HDL cholesterol level (P = 0.0497).

CONCLUSIONS

Significant differences were seen in serum lipid levels of primary SS patients and these were associated with serological measures of inflammation. Our results are comparable to earlier findings in RA patients and raise questions related to adverse cardiovascular consequences in SS.

A national survey amongst UK otolaryngologists regarding the treatment of Ménière's disease

Since Dr Prosper Ménière described the vertiginous syndrome that now bears his name, a large variety of medical and surgical treatments have been introduced. To determine the way in which this condition is currently managed in the United Kingdom, a postal survey amongst consultant otolaryngologists was carried out. It revealed that 52 per cent were actively involved in the treatment of patients with Ménières disease using a wide range of medical and surgical therapies that have little or no evidence base. The survey found that 94 per cent of surgeons prescribe betahistine, 63 per cent diuretics and 71 per cent advise salt restriction to their patients, while 52 per cent of surgeons continue to recommend saccus decompression and 50 per cent are still inserting a grommet. However, two thirds of respondents now advocate the use of gentamicin therapy despite it only being introduced to this country just over 10 years ago. The results of this study and their relevance to the recommended present day management of Meniere's disease are discussed.

B cell MALT lymphoma diagnosed by labial minor salivary gland biopsy in patients screened for Sjögren's syndrome

CASE REPORT

Three patients presented to the Sjögren's syndrome (SS) Clinic at the National Institute of Dental and Craniofacial Research for screening. The records of patients with SS with a diagnosis of lymphoma were examined to determine whether the diagnosis was made in any of the cases as a result of labial salivary gland (LSG) biopsies. All patients had typical features of primary SS according to the American-European Consensus Group criteria. B cell mucosa associated lymphoid tissue (MALT) lymphoma was diagnosed based upon the LSG biopsy.

CONCLUSION

This report underlines the advantages of performing LSG biopsies as a routine part of screening for SS, and shows that it may in some instances lead to early diagnosis of MALT lymphomas in patients who show no signs of pre-existing lymphoma.

Anterosuperior anchoring myringoplasty technique for anterior and subtotal perforations

Anterior and subtotal tympanic perforations are difficult perforations to repair. We used the anterosuperior anchoring technique to repair 105 of those perforations. Our technique utilizes a large temporalis fascia graft using an underlay technique with due emphasis on anterosuperior anchorage. The success rates in paediatric myringoplasty for consultant solo (J.R.K.) and trainees under supervision were 100% and 85.7%, respectively. The overall success rates in adult myringoplasty for consultant solo and trainees under supervision were 93.8% and 82.4%, respectively. Analysis of the 82 successful cases showed statistically significant improvement in air conduction thresholds after myringoplasty at 500 Hz (P < 0.01), 1 kHz (P < 0.05), 2 kHz (P < 0.01) and 4 kHz (P < 0.01). Our study showed that the anterosuperior anchoring technique produced excellent results in the repair of challenging anterior and subtotal perforations in both adults and children.

Role of human amniotic epithelial cell transplantation in spinal cord injury repair research

Human amniotic epithelial cells (HAEC) possess certain properties similar to that of neural and glial cells. In the present work, the potential of HAEC as stem cells for spinal cord injury repair was tested. HAEC obtained from human placenta were labeled with 1,1'-dioctadecyl-3,3,3',3'-tetramethyllindocarbocyanine perchlorate (Dil) in the culture medium. These labeled cells were transplanted into the transection cavities in the spinal cord of bonnet monkeys. Results were analyzed after 15 and 60 days of post-transplantation. HAEC cells survived in the monkey spinal cord for up to the maximum period of observation in the present study, i.e. 60 days. HAEC graft was penetrated by the host axons. There was no glial scar at the transection lesion site. Some of the host spinal neurons and axons were labeled with Dil (used to label HAEC) whereas in lesion control group, there was no such host-neuron labeling. This may be either due to the prevention of death in the axotomized neuron's ensuing lesion or due to the neurotrophic effect exhibited by the transplanted HAEC. Further studies would be required to verify these speculations. Therefore from this pilot study it appears that HAEC survive in the transplanted environment, support the growth of host axons through them, prevent the formation of glial scar at the cut ends and may prevent death in axotomized cells or attract the growth of new collateral sprouting. The abovementioned properties, i.e. serving as a suitable milieu for the host axons to grow, preventing glial scar at the lesion site and rescuing axotomized neurons from death were previously reported in the case of neural transplantation studies. Thus it is speculated that HAEC may be having certain properties equal to the beneficial effects of neural tissue in repairing spinal cord injury. Apart from this speculation, there are two more reasons for why HAEC transplantation studies are warranted to understand the long-term effects of such transplantations. First, there was no evidence of immunological rejection probably due to the non-antigenic nature of the HAEC. Second, unlike neural tissue, procurement of HAEC does not involve many legal or ethical problems.

Salivary gland delivery of pDNA-cationic lipoplexes elicits systemic immune responses

OBJECTIVE

To test the ability of two cationic lipoplexes, Vaxfectin and GAP-DLRIE/DOPE, to facilitate transfection and elicit immune responses from plasmid DNAs (pDNAs) after retrograde instillation into salivary glands.

METHODS

Two pDNA expression vectors encoding either the influenza NP protein or human growth hormone (hGH) were complexed with the cationic lipid transfection reagents, GAP-DLRIE/DOPE or Vaxfectin, and delivered to the submandibular glands of rats. Samples from rats receiving the influenza NP protein pDNA and cationic lipoplexes were analyzed for anti-influenza NP-specific IgG1, IgG2a, and IgG2b in serum, and IgA in saliva, by an enzyme- linked immunosorbent assay (ELISA). Cytotoxic T-cell lymphocyte (CTL) assays were also performed. Transgene protein expression (hGH) was determined from extracts of submandibular glands of rats receiving hGH lipoplexes.

RESULTS

Serum antibodies (IgG) against the NP protein developed and were highest in all rats vaccinated with GAP-DLRIE/DOPE or Vaxfectin. The major serum IgG subclass stimulated by this route of immunization was IgG2b, followed by IgG2a. CTL assay results showed statistically significantly higher percentage killing in the Vaxfectin group than controls (P < 0.05). No rats developed IgA antibodies to NP protein in saliva. Animals receiving plasmid encoding hGH and either lipoplex expressed significantly higher amounts of hGH compared with those receiving the hGH plasmid and water. Although hGH expression was higher in the animals receiving pDNA/Vaxfectin (approximately 30-fold > pDNA/water), the difference with those receiving pDNA/GAP-DLRIE/DOPE (approximately 10-fold > pDNA/water) was not significant.

CONCLUSIONS

Retrograde instillation of pDNA complexed with Vaxfectin into the salivary glands can stimulate cytotoxic and humoral responses to the influenza NP protein antigen. Optimization of the conditions required to stimulate humoral and secretory antibody formation may facilitate use of this tissue for specific clinical applications of pDNA immunization.

Spinal cord injury repair research: a new combination treatment strategy

The optimism that a cure will soon be found for paraplegia and quadriplegia is strongly founded on the series of discoveries in the last two decades which showed that adult mammalian spinal cord axons can be made to regenerate given appropriate conditions and microenvironment. But then, why no cure yet in sight? Why is the delay? Spinal cord scientists are encountering a newfound obstacle in regeneration research. While axons do regenerate up and down through a graft/transplant placed at the injury site, they fail to regenerate further on once they reach healthy cord tissue beyond the injury zone. Research from our laboratory since the 1980s found that the principal reason for this failure of long distance regeneration is that the neural circuitry these axons have to traverse through are in a well-stabilized state which is unreceptive and refractory to new growth. Successful long distance regeneration is possible only within labilized (destabilized) neural tissues. We have shown simple and reliable methods of inducing labile state in adult spinal cord neural circuitry. This is achieved by inducing polyneuronal spinal motor control in the paralyzed limb muscles. We had predicted (Krishnan, 1991, 1983) two outcomes of inductive lability in paraplegia. One is partial revival of functions in the paralyzed limbs. The second outcome addresses effective relinking of the severed cord ends. Our preliminary results from adult paraplegic frogs convince us that inductive lability in these animals is capable of generating new growth and new connections in the distal isolated cord. Locomotor rhythm and function reappeared in the hind limbs, which enabled these animals to swim and progress on surface for long periods of observation up to 120 days. Based on these results we now recommend that inductive lability should be included as an essential component in the treatment strategy for spinal cord injury repair for effective relinking of the severed cord ends.

Oral manifestations in patients with aplastic anemia

OBJECTIVE

The aim of the present study was to characterize the prevalence and risks of oral complications in aplastic anemia (AA).

STUDY DESIGN

Approximately 79 patients with AA (age, 37 +/- 17 years) and 66 control patients with schizophrenia (age, 33 +/- 12 years) were examined. Records were reviewed for demographic, clinical, and radiographic information. Prior medical therapy, laboratory values, disease duration, and medical treatment response were noted for patients with AA. Odds ratios (OR) and 95% CI were calculated for oral manifestations in cases and in control subjects. Univariate analysis identified important variables for logistic regression.

RESULTS

Patients with AA presented more frequently with oral petechiae (OR = 49; 95% CI, 2.9-825), gingival hyperplasia (OR = 27; 95% CI, 1.6-463.5), spontaneous gingival bleeding (OR = 27; 95% CI, 1.6-463.5), and herpetic lesions (OR = 27; 95% CI, 1.6-463.5). Prior cyclosporine use was associated with gingival hyperplasia (P =.0001). No other predictors for oral manifestations or treatment outcomes were found.

CONCLUSIONS

Oral soft tissue changes and infections were more common in patients with AA. Prior cyclosporine use was predictive of the presence of gingival hyperplasia.

Recovery of locomotor function in adult paraplegic frogs by inductive lability in the distal isolated spinal cord neural networks

We postulated (Krishnan, 1991) that in a spinal cord transected adult paraplegic mammal locomotor functions can be revived if polyneuronal innervation is reinduced in the paralyzed hind limb muscles. This procedure destabilizes the neural networks and induces new synaptic growth in the distal isolated cord. In this pilot project we tested the hypothesis in cord-transected adult paraplegic frogs. Polyneuronal innervation was reinduced by crushing the sciatic nerve in the right upper thigh. Left limb sciatic nerve was not crushed and served as control. Another group of adult frogs had only cord transection without nerve crush. Five to seven weeks postnerve crush, full powered flexion-extension movements in the hip and knee joints appeared in the right hind limb and were used for swimming and surface progression. Movements gradually declined over the next weeks, which in some animals was seen preserved even beyond 120 days. Paraplegic frogs without nerve crush did not show any recovery of locomotor function. Interestingly, the uncrushed contralateral limb also produced transient, weak locomotor-like movements. This lasted for 4 to 6 days and waned out completely thereafter. These results validate our hypothesis on methods to generate new synaptic sprouts and reconnections to redrive the locomotor system. We had recommended earlier that destabilization procedure should be included as an essential component in treatment strategies for spinal cord injury repair for effective relinking of the severed cord ends.

Publication rates of scientific papers presented at the Otorhinolarygological Research Society meetings

The aim of this study was to determine the publication rate of scientific papers in peer review journals presented at the Otorhinolarygological Research Society (ORS) meetings from 1978 to 1995 inclusive. The abstracts of the presentations at ORS meetings are published in Clinical Otolaryngology. A MEDLINE search was performed on abstracts presented at ORS meetings from 1978 to 1995 using both authors and key words within the text of the abstract. The publication rate, journal of publication, time to publication, change in contents, change in authors and change in conclusions of abstracts were tabulated. The publication rate for papers presented at ORS meetings from 1978 to 1995 was 69.09%. The average time to publication was 22.5 months. Papers derived from the ORS abstracts were most commonly published in Clinical Otolaryngology (34%) and Journal of Laryngology and Otology (18.64%). The results indicate that nearly 69% of presented material at the biannual ORS meetings eventually get published in peer reviewed journals. This compares favourably with publication rate of other specialities.

Cationic liposome-mediated gene transfer to rat salivary epithelial cells in vitro and in vivo

BACKGROUND

Previously we have shown that gene transfer to salivary gland epithelial cells readily occurs via recombinant adenoviruses, although the response is short-lived and results in a potent host immune response. The aim of the present study was to assess the feasibility of using cationic liposomes to mediate gene transfer to rat salivary cells in vitro and in vivo.

METHODS

Initially, for transfection in vitro, we used two cationic liposome formulations (GAP-DLRIE/DOPE and DOSPA/DOPE) complexed with plasmid encoding human growth hormone (hGH) as a reporter gene. Thereafter, using GAP-DLRIE/DOPE, plasmids were transferred to rat salivary glands in vivo, and hGH levels measured in saliva, serum and gland extracts.

RESULTS

Under optimal conditions, transfection of rat submandibular glands (SMGs) was consistently observed. Approximately 95% of the cells transfected with a plasmid encoding beta-galactosidase were acinar cells. Maximal hGH expression was obtained during the first 48 h post-transfection using a plasmid encoding the hGH cDNA and complexed with GAP-DLRIE/DOPE. hGH was detected in gland extracts and saliva, and occasionally in serum. No systemic or local gland pathology was consistently or significantly observed.

CONCLUSIONS

The levels of the reporter gene product, hGH, obtained after GAP-DLRIE/DOPE-mediated gene transfer are considerably lower (<0.5%) than those achieved with adenoviral vectors (10(8) PFU). Nonetheless, cationic liposome-mediated gene transfer to salivary glands may be useful for potential therapeutic applications.