Impact of breath hold on regional nodal irradiation and heart volume in field in left breast cancer adjuvant irradiation

PURPOSE

Compared to the free-breathing technique, adjuvant left breast irradiation after breast-conserving surgery or mastectomy using the breath-hold method significantly reduces the heart mean dose, Left anterior descending artery, and ipsilateral lung doses. Movement with deep inspiration may also reduce heart volume in the field and regional node doses.

MATERIALS AND METHODS

Pre-radiotherapy planning CT was performed in the free-breathing, and breath-hold techniques using RPM, demographic information, clinicopathological data, heart volume in the field, heart mean dose, LAD mean dose, and regional nodal doses were calculated in both free breathing and DIBH. Fifty patients with left breast cancer receiving left breast adjuvant radiation were enrolled.

RESULTS

There was no significant difference in axillary LN coverage between the two techniques, except for SCL maximum dose, Axilla I node maximum dose, and Axilla II minimum dose in favor of the breath hold technique. The mean age was 47.54 years, 78% had GII IDC, 66% had positive LVSI results, and 74% of patients had T2. The breath hold strategy resulted in considerably decreased mean heart dose (p = 0.000), LAD dose (p = 0.000), ipsilateral lung mean dose (p = 0.012), and heart volume if the field (p = 0.013). The mean cardiac dosage and the dose of the LAD were significantly correlated (p = 0.000, R = 0.673). Heart volume in the field and heart mean dosage was not significantly correlated (p = 0.285, r = - 0.108).

CONCLUSION

When compared to free breathing scans, DIBH procedures result in considerably reduced dosage to the OAR and no appreciable changes in dose exposure to regional lymph node stations in patients with left-sided breast cancer.

Analytical dosimetric study of intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) for prostate cancer

PURPOSE

The study aimed to compare the dosimetric results and treatment delivery efficiency among four techniques to explore the preferred technique in prostate treatment.

MATERIALS AND METHODS

7 IMRT, 9 IMRT, 1 ARC, and 2 ARC plans were created for 30 prostate cancer patients using the Eclipse™ treatment planning system (Varian Medical Systems). All the plans were designed to deliver 80.0 Gy in 40 fractions to the prostate planning target volume (PTV). Target coverage, organs at risk (OARs), number of monitor units, homogeneity, and conformity were compared across the four techniques to assess the quality of the plans.

RESULTS

The study revealed better Planning Target Volume (PTV) dose coverage in the VMAT-2A than in the other plans. At the same time, VMAT-2A plans were found to be significantly lower in terms of Bladder and rectum doses than other techniques. In addition, VMAT has the advantage of considerably reducing the number of monitor units and treatment time.

CONCLUSION

For prostate cancer, VMAT may offer a favorable dose gradient profile, conformity, and MU and treatment time compared to IMRT.

A Review of Endocrine Therapy in Early-stage Breast Cancer: The Journey From Crudeness to Precision

Endocrine therapy (ET) is the standard of care for hormone receptor-positive early-stage breast cancer in the adjuvant setting. However, response to ET can vary across patient subgroups. Historically, hormone receptor expression and clinical stage are the main predictors of the benefit of ET. A "window of opportunity" trials has raised significant interest in recent years as a means of assessing the sensitivity of a patient's cancer to short-term neoadjuvant ET, which provides important prognostic information, and helps in decision-making regarding treatment options in a time-efficient and cost-efficient manner. In the era of genomics, molecular profiling has led to the discovery and evaluation of the prognostic and predictive abilities of new molecular profiles. To realize the goal of personalized medicine, we are in urgent need to explore reliable biomarkers or genomic signatures to accurately predict the clinical response and long-term outcomes associated with ET. Validation of these biomarkers as reliable surrogate endpoints can also lead to a revolution in the clinical trial designs, and potentially avoid the need for repeated tissue biopsies in the surveillance of disease response. The clinical potential of tumor genomic profiling marks the beginning of a new era of precision medicine in breast cancer treatment.

True aneurysm of the dorsalis pedis artery

OBJECTIVES

Aneurysm of the pedal arteries is uncommon. I present a case of non-traumatic fusiform true aneurysm of the dorsalis pedis artery in an otherwise well 45-year-old man. Color flow duplex imaging revealed aneurysmal dilation, involving all layers of the artery wall, measuring 16.5 * 10 mm with irregular intraluminal thrombus across a 6.33-mm segment. Due to concerns over embolization, our patient underwent successful ligation of the dorsalis pedis artery. He had an uneventful post-operative recovery.

METHODS

Case report.

RESULTS

No postoperative complication or signs of ischemia.

CONCLUSIONS

Treatment of asymptomatic dorsalis pedis artery aneurysm may be of value to prevent risk of thrombo-embolic complications, foot ischemia, or rupture without warning signs. Patency of the pedal arch is important to avoid foot ischemia in case of dorsalis pedis artery ligation.

Impact of Extended Adjuvant Temozolamide Beyond 6 Months in the Management of Glioblastoma Patients

OBJECTIVES

Our study aimed to assess the benefit of prolonging adjuvant temozolomide (TMZ) therapy beyond 6 cycles in glioblastoma multiform patients.

MATERIALS AND METHODS

The medical records of 329 patients in 2 cancer centers in Egypt were reviewed from January 2008 to December 2018 who were diagnosed with diffuse gliomas. Data were collected on patient demographics, presenting complaints, tumor size, treatment modalities (extent of surgery, radiotherapy dose and technique, concomitant TMZ, and the number of adjuvant TMZ cycles), and reported adverse events.

RESULTS

In the studied cohort, 105 patients were treated with adjuvant TMZ, 33 patients received <6 cycles (TMZL), 41 patients received the standard 6 cycles (TMZS), and 31 patients received >6 cycles (TMZE). Our results showed the median overall survival in the TMZL arm was 8.47 months compared with 15.83 months in the TMZS arm and 27.33 months in the TMZE arm ( P < 0.001). Furthermore, a median progression-free survival of 6.35 months was reported in the TMZL group versus, 12.7 and 22.90 months in (TMZS) and (TMZE) groups, respectively( P < 0.001). In the multivariate analysis, the extended adjuvant TMZ with a hazard ratio of 3.106 (95% CI: 2.43-14.46; P < 0.001) was statistically significantly associated with a better outcome.

CONCLUSIONS

Extended adjuvant TMZ therapy beyond 6 cycles may significantly improve the progression-free survival and overall survival in patients with glioblastoma multiform.

Impact of breath-hold technique on incidence of cardiac events in adjuvant left breast cancer irradiation

BACKGROUND

This study aims to compare the incidence of cardiac events and to identify its predictors in left breast cancer patients receiving adjuvant radiotherapy using breath-hold technique (DIBH) versus free breathing technique (FB).

METHODS

We conducted a retrospective multi-center study of two arms; the free breathing arm included 208 patients who were treated with traditional radiotherapy treatment technique, while DIBH arm included 224 patients who were treated with breath-hold technique using The Varian Real-time Position Management (RPM). We retrospectively reviewed the medical records of the patients from January 2010 to December 2017.

RESULTS

The mean dose to the heart and left anterior descending artery were significantly lower in the DIBH arm (2.10 ± 0.39 and 6.16 ± 0.18 Gy) compared with (4.29 ± 0.60 Gy and 12.69 ± 0.93 Gy, respectively) in the FB arm. The incidence of cardiac events was higher in the FB arm than in the DIBH arm, but it was not statically significant. Our analysis revealed that age, diabetes, hypertension, smoking, mean LAD dose, and heart mean dose were significant prognostic factors for the occurrence of cardiac events in the breath-hold arm. Hypertension, smoking, as well as heart mean dose were independent risk factors for the occurrence of cardiac events.

CONCLUSION

Use of the DIBH technique resulted in a significant reduction in doses to the heart, LAD and lesser cardiac events incidence compared to free breathing.

Comparison of Long Term Outcomes After Endovascular Treatment Versus Bypass Surgery in Chronic Limb Threatening Ischaemia Patients with Long Femoropopliteal Lesions

OBJECTIVE

There are currently two treatments available for patients with chronic limb threatening ischaemia (CLTI): open surgical bypass (OSB) and percutaneous transluminal angioplasty with/without stenting (PTA/S). The aim of this study was to compare short and long term outcomes between PTA/S and OSB in CLTI patients with long (GLASS grade III and IV) femoropopliteal disease.

METHODS

This was a two centre retrospective study including all consecutive patients with CLTI undergoing first time lower extremity intervention at two distinct vascular surgical centres. Between 1 January 2012 and 1 January 2018, 1 545 CLTI consecutive limbs were treated for femoropopliteal GLASS grade III and IV lesions at two vascular surgical centres. Using covariables from baseline and angiographic characteristics, a propensity score was calculated for each limb. Thus, comparable patient cohorts (235 in PTA/S and 235 in OSB group) were identified for further analysis. The primary outcomes were freedom from re-intervention in the treated extremity and major amputation. Secondary outcomes were all hospital complications among the two patient groups.

RESULTS

Total overall complication rates were significantly higher in the OSB group (20.42% vs. 5.96%, p < .001), especially wound infection/seroma rate that required prolonged hospitalisation and further treatment (7.65% vs. 0%, p < .001). After the median follow up of 61 months, re-intervention rates were significantly higher in the PTA/S group (log rank test, 44.68% vs. 29.79%, p = .002), but there was no significant difference in terms of major amputation rates between the two group of patients (log rank test, PTA/S 27.23% vs. OSB 22.13%, p = .17).

CONCLUSION

Bypass surgery seems to be superior to PTA/S for GLASS grade III and IV femoropopliteal lesions in patients with CLTI in terms of long term re-intervention rates, but with considerably higher rates of post-operative complications. A larger cohort of patients in currently ongoing randomised trials, as well as prospective cohort studies are necessary to confirm these findings.

Alpha-lipoic acid treatment of acetaminophen-induced rat liver damage

Acetaminophen (paracetamol) is a well-tolerated analgesic and antipyretic drug when used at therapeutic doses. Overdoses, however, cause oxidative stress, which leads to acute liver failure. Alpha lipoic acid is an antioxidant that has proven effective for ameliorating many pathological conditions caused by oxidative stress. We evaluated the effect of alpha lipoic acid on the histological and histochemical alterations of liver caused by an acute overdose of acetaminophen in rats. Livers of acetaminophen-intoxicated rats were congested and showed centrilobular necrosis, vacuolar degeneration and inflammatory cell infiltration. Necrotic hepatocytes lost most of their carbohydrates, lipids and structural proteins. Liver sections from rats pre-treated with lipoic acid showed fewer pathological changes; the hepatocytes appeared moderately vacuolated with moderate staining of carbohydrates and proteins. Nevertheless, alpha lipoic acid at the dose we used did not protect the liver fully from acetaminophen-induced acute toxicity.

Structural and functional analyses of the wheat genomes based on expressed sequence tags (ESTs) related to abiotic stresses

To gain insights into the structure and function of the wheat (Triticum aestivum L.) genomes, we identified 278 ESTs related to abiotic stress (cold, heat, drought, salinity, and aluminum) from 7671 ESTs previously mapped to wheat chromosomes. Of the 278 abiotic stress related ESTs, 259 (811 loci) were assigned to chromosome deletion bins and analyzed for their distribution pattern among the 7 homoeologous chromosome groups. Distribution of abiotic stress related EST loci were not uniform throughout the different regions of the chromosomes of the 3 wheat genomes. Both the short and long arms of group 4 chromosomes showed a higher number of loci in their distal regions compared with proximal regions. Of the 811 loci, the number of mapped loci on the A, B, and D genomes were 258, 281, and 272, respectively. The highest number of abiotic stress related loci were found in homoeologous chromosome group 2 (142 loci) and the lowest number were found in group 6 (94 loci). When considering the genome-specific ESTs, the B genome showed the highest number of unique ESTs (7 loci), while none were found in the D genome. Similarly, considering homoeologous group-specific ESTs, group 2 showed the highest number with 16 unique ESTs (58 loci), followed by group 4 with 9 unique ESTs (33 loci). Many of the classified proteins fell into the biological process categories associated with metabolism, cell growth, and cell maintenance. Most of the mapped ESTs fell into the category of enzyme activity (28%), followed by binding activity (27%). Enzymes related to abiotic stress such as β-galactosidase, peroxidase, glutathione reductase, and trehalose-6-phosphate synthase were identified. The comparison of stress-responsive ESTs with genomic sequences of rice (Oryza sativa L.) chromosomes revealed the complexities of colinearity. This bin map provides insight into the structural and functional details of wheat genomic regions in relation to abiotic stress.

Implication of inclusion complexation of glimepiride in cyclodextrin–polymer systems on its dissolution, stability and therapeutic efficacy

The effect of complexation of glimepiride, a poorly water-soluble antidiabetic drug, with beta-cyclodextrin and its derivatives (HP-beta-CyD and SBE-beta-CyD) in presence of different concentrations of water-soluble polymers (HPMC, PVP, PEG 4000 and PEG 6000) on the dissolution rate of the drug has been investigated. The results revealed that the dissolution rate of the drug from these ternary systems is highly dependent on polymer type and concentration. The dissolution rate of the drug from ternary systems containing PEG 4000 or PEG 6000 seems to be generally higher than from systems containing HPMC or PVP. An optimum increase in the dissolution rate of the drug was observed at a polymer concentration of 5% for PEG 4000 or PEG 6000 and at 20% concentration of HPMC or PVP. The dissolution rate of the drug from the ternary system glimepiride-HP-beta-CyD-5% PEG 4000 was high compared to the other systems. Tablets containing the drug or its equivalent amount of this ternary system were prepared and subjected to accelerated stability testing at 40 degrees C/75% R.H. to investigate the effect of storage on the chemical stability as well as therapeutic efficacy of the tablets. The results revealed stability of the tablets and consistent therapeutic efficacy on storage.

Formulation and biological evaluation of glimepiride-cyclodextrin-polymer systems

Glimepiride is one of the third generation sulfonylureas used for treatment of type 2 diabetes. Poor aqueous solubility and slow dissolution rate of the drug lead to irreproducible clinical response or therapeutic failure in some cases due to subtherapeutic plasma drug levels. Consequently, the rationale of this study was to improve the biological performance of this drug through enhancing its solubility and dissolution rate. Inclusion complexes of glimepiride in beta-cyclodextrin (beta-CyD), hydroxypropyl-beta-cyclodextrin (HP-beta-CyD) and sulfobutylether-beta-cyclodextrin (SBE-beta-CyD), with or without water soluble polymers were prepared by the kneading method. Binary systems were characterized by thermogravimetric analysis, IR spectroscopy and X-ray diffractometry. Phase solubility diagrams revealed increase in solubility of the drug upon cyclodextrin addition, showing A(p) type plot indicating high order complexation. All the ternary systems containing beta-CyD or HP-beta-CyD showed higher dissolution efficiency compared to the corresponding binary systems. The hypoglycemic effect of the most rapidly dissolving ternary system of glimepiride-HP-beta-CyD-PEG 4000 was evaluated after oral administration in diabetic rats by measuring blood glucose levels. The results indicated that this ternary system improves significantly the therapeutic efficacy of the drug. In conclusion, the association of water soluble polymers with glimepiride-CyD systems leads to great enhancement in dissolution rate, increased duration of action and improvement of therapeutic efficacy of the drug.

A chromosome bin map of 16,000 expressed sequence tag loci and distribution of genes among the three genomes of polyploid wheat

Because of the huge size of the common wheat (Triticum aestivum L., 2n = 6x = 42, AABBDD) genome of 17,300 Mb, sequencing and mapping of the expressed portion is a logical first step for gene discovery. Here we report mapping of 7104 expressed sequence tag (EST) unigenes by Southern hybridization into a chromosome bin map using a set of wheat aneuploids and deletion stocks. Each EST detected a mean of 4.8 restriction fragments and 2.8 loci. More loci were mapped in the B genome (5774) than in the A (5173) or D (5146) genomes. The EST density was significantly higher for the D genome than for the A or B. In general, EST density increased relative to the physical distance from the centromere. The majority of EST-dense regions are in the distal parts of chromosomes. Most of the agronomically important genes are located in EST-dense regions. The chromosome bin map of ESTs is a unique resource for SNP analysis, comparative mapping, structural and functional analysis, and polyploid evolution, as well as providing a framework for constructing a sequence-ready, BAC-contig map of the wheat genome.

Chromosome bin map of expressed sequence tags in homoeologous group 1 of hexaploid wheat and homoeology with rice and Arabidopsis

A total of 944 expressed sequence tags (ESTs) generated 2212 EST loci mapped to homoeologous group 1 chromosomes in hexaploid wheat (Triticum aestivum L.). EST deletion maps and the consensus map of group 1 chromosomes were constructed to show EST distribution. EST loci were unevenly distributed among chromosomes 1A, 1B, and 1D with 660, 826, and 726, respectively. The number of EST loci was greater on the long arms than on the short arms for all three chromosomes. The distribution of ESTs along chromosome arms was nonrandom with EST clusters occurring in the distal regions of short arms and middle regions of long arms. Duplications of group 1 ESTs in other homoeologous groups occurred at a rate of 35.5%. Seventy-five percent of wheat chromosome 1 ESTs had significant matches with rice sequences (E < or = e(-10)), where large regions of conservation occurred between wheat consensus chromosome 1 and rice chromosome 5 and between the proximal portion of the long arm of wheat consensus chromosome 1 and rice chromosome 10. Only 9.5% of group 1 ESTs showed significant matches to Arabidopsis genome sequences. The results presented are useful for gene mapping and evolutionary and comparative genomics of grasses.

Development of an expressed sequence tag (EST) resource for wheat (Triticum aestivum L.): EST generation, unigene analysis, probe selection and bioinformatics for a 16,000-locus bin-delineated map

This report describes the rationale, approaches, organization, and resource development leading to a large-scale deletion bin map of the hexaploid (2n = 6x = 42) wheat genome (Triticum aestivum L.). Accompanying reports in this issue detail results from chromosome bin-mapping of expressed sequence tags (ESTs) representing genes onto the seven homoeologous chromosome groups and a global analysis of the entire mapped wheat EST data set. Among the resources developed were the first extensive public wheat EST collection (113,220 ESTs). Described are protocols for sequencing, sequence processing, EST nomenclature, and the assembly of ESTs into contigs. These contigs plus singletons (unassembled ESTs) were used for selection of distinct sequence motif unigenes. Selected ESTs were rearrayed, validated by 5' and 3' sequencing, and amplified for probing a series of wheat aneuploid and deletion stocks. Images and data for all Southern hybridizations were deposited in databases and were used by the coordinators for each of the seven homoeologous chromosome groups to validate the mapping results. Results from this project have established the foundation for future developments in wheat genomics.

Analysis of expressed sequence tag loci on wheat chromosome group 4

A total of 1918 loci, detected by the hybridization of 938 expressed sequence tag unigenes (ESTs) from 26 Triticeae cDNA libraries, were mapped to wheat (Triticum aestivum L.) homoeologous group 4 chromosomes using a set of deletion, ditelosomic, and nulli-tetrasomic lines. The 1918 EST loci were not distributed uniformly among the three group 4 chromosomes; 41, 28, and 31% mapped to chromosomes 4A, 4B, and 4D, respectively. This pattern is in contrast to the cumulative results of EST mapping in all homoeologous groups, as reported elsewhere, that found the highest proportion of loci mapped to the B genome. Sixty-five percent of these 1918 loci mapped to the long arms of homoeologous group 4 chromosomes, while 35% mapped to the short arms. The distal regions of chromosome arms showed higher numbers of loci than the proximal regions, with the exception of 4DL. This study confirmed the complex structure of chromosome 4A that contains two reciprocal translocations and two inversions, previously identified. An additional inversion in the centromeric region of 4A was revealed. A consensus map for homoeologous group 4 was developed from 119 ESTs unique to group 4. Forty-nine percent of these ESTs were found to be homoeologous to sequences on rice chromosome 3, 12% had matches with sequences on other rice chromosomes, and 39% had no matches with rice sequences at all. Limited homology (only 26 of the 119 consensus ESTs) was found between wheat ESTs on homoeologous group 4 and the Arabidopsis genome. Forty-two percent of the homoeologous group 4 ESTs could be classified into functional categories on the basis of blastX searches against all protein databases.

Open-access endoscopy: are age-based guidelines justified? An audit of experience of 1000 open-access endoscopies at a district general hospital

BACKGROUND AND STUDY AIMS

Open-access endoscopy has been developed to meet the increasing demand for endoscopy, and guidelines have been produced for selecting suitable patients. This study was designed to assess the appropriateness of these guidelines in patients referred to open-access endoscopy services at a district general hospital.

PATIENTS AND METHODS

A series of 1000 consecutive patients referred for open-access endoscopy was audited. The waiting time was 18 weeks and patients continued to take any acid-suppressing medication prescribed by their general practitioner. The endoscopy findings were compared in those who met and did not meet currently accepted guidelines. In addition the outcome for all patients in whom gastro-oesophageal malignancy was detected was reviewed.

RESULTS

301 patients (30.1 %) did not meet accepted guidelines for open-access endoscopy. No cases of malignancy would have been missed if the guidelines had been implemented. Gastro-oesophageal malignancy was detected in 17 patients, all of whom died. When malignancy was excluded, there were no statistically significant differences between the detection rates for pathology in the two groups. The commonest finding, in 32.3 % of patients, was of a normal endoscopic appearance.

CONCLUSIONS

If current guidelines are applied, all cases of malignancy may be picked up, but identification of patients with curable disease is poor. Use of the guidelines did not select patients with other upper gastrointestinal disease, although many patients were receiving acid-suppression therapy at the time of their endoscopy. Implementation of test-and-treat strategies would result in a significant reduction in the workload of open-access endoscopy.

Terpenoid constituents of Aster subspicatus and A. ageratoides

Chemical investigation of the aerial parts of Aster subspicatus afforded a new sesquiterpene lactone, 8 alpha-acetoxy-1 alpha-hydroxy-3 alpha,4 alpha-epoxy-5 alpha,7 alpha H-9,11(13)-guaiadien-12,6 alpha-olide (1), in addition to the known compounds arteglasin-B (2), diversoside (3), and 2-phenylethyl beta-D-glucopyranoside. Re-investigation of Aster ageratoides afforded the known compounds crotocorylifuran, and oplopanone. The structure of the new compound was determined by spectroscopic methods particularly high resolution 1H, 13C NMR, DEPT, 2D 1H-1H and 1H-13C COSY NMR and HMBC analysis.

Manoyl oxide alpha-arabinopyranoside and grindelic acid diterpenoids from Grindelia integrifolia

Two new manoyl oxide-alpha-arabinopyranoside diterpenoids, 15-hydroxy-13-epi-manoyl oxide-14-O-alpha-L-arabinopyranoside (tarapacol-14-O-alpha-L-arabinopyranoside) (1) and 15-acetoxy-13-epi-manoyl oxide-14-O-alpha-L-arabinopyranoside (tarapacol-15-acetate-14-O-alpha-L-arabinopyranoside) (2), as well as a new grindelic acid derivative, 19-hydroxygrindelic acid (3), together with five known diterpenoids (tarapacol, tarapacanol A, grindelic acid, methyl grindeloate, 3beta-hydroxygrindelic acid, 4) were isolated from the aerial parts of Grindelia integrifolia. The structures of 1-3 were elucidated by spectral data analysis.

The use of 6-mercaptopurine in patients with inflammatory bowel disease after failure of azathioprine therapy

INTRODUCTION

Azathioprine is a useful therapy in patients with inflammatory bowel disease that is difficult to control. However, 10% of patients are unable to tolerate azathioprine, and the best form of treatment for this group of patients is unknown. The azathioprine metabolite 6-mercaptopurine may be a useful therapy for these patients.

AIM

To review our clinical experience of the use of the 6-mercaptopurine in inflammatory bowel disease patients who are intolerant of azathioprine.

METHODS

All patients who were prescribed 6-mercaptopurine in a 2-year period were identified from pharmacy records. The case notes were reviewed and those who had previously been intolerant of azathioprine were included.

RESULTS

A total of 19 with either ulcerative colitis and Crohn's disease were included. The reasons for discontinuing azathioprine were side-effects (13 patients), failure of efficacy (four patients) and leucopenia (two patients). Eleven of the 19 patients (68%) tolerated 6-mercaptopurine, including seven out of 13 patients (54%) who discontinued azathioprine due to side-effects. The length of follow-up of patients on 6-mercaptopurine was between 126 and 780 days (median 390 days).

DISCUSSION

6-mercaptopurine should be considered in patients with inflammatory bowel disease who require continuing immunosuppressive therapy, but are intolerant of azathioprine.

Predisposition to urinary tract epithelial metaplasia in Schistosoma haematobium infection

Although there is strong epidemiologic evidence linking Schistosoma haematobium infection with carcinoma of the bladder, the utility of cytologic screening for urinary tract cancer has not been critically evaluated in S. haematobium-endemic populations. The present cross-sectional study examined urine cytology findings among 1,014 residents (ages 1 to 91) of the S. haematobium-endemic Msambweni area of Coast Province, Kenya. Among 705 evaluable cytology specimens, prevalence of inflammation (39%), hyperkeratosis (30%), metaplasia (33%), and frank atypia (0.4%) was notably higher than in previously studied, non-endemic populations. Overall, S. haematobium infection was strongly associated with increased risk for cytologic abnormality (> 2.8-fold relative risk of metaplasia or hyperkeratosis; P < 0.001). Age-group analysis confirmed parallel increases in metaplasia and S. haematobium infection prevalence early in life (from age I to 15 for both boys and girls). However, above age 20, metaplasia prevalence persisted at 33-45% prevalence despite a decline in infection prevalence and intensity. Prevalence of advanced (moderate or severe) metaplasia showed two age-related peaks: the first at 10-14 years of age (at the time of peak infection), and the second among subjects > or = 60 years old. No cancers were detected in the study population either on cytology or on follow-up ultrasound examination. These data suggest an age-dependent progression of cellular abnormalities in the urinary epithelium that is associated with chronic S. haematobium infection, which becomes independent of concurrent infection intensity as subjects grow older. Implications for cancer screening are discussed.

Diterpenoid acids from Grindelia nana

Two new norditerpenoid acids of the labdane-type (norgrindelic acids), 4,5-dehydro-6-oxo-18-norgrindelic acid (1) and 4beta-hydroxy-6-oxo-19-norgrindelic acid (2), as well as a new grindelic acid derivative, 18-hydroxy-6-oxogrindelic acid (3), were isolated from the aerial parts of Grindelia nana. In addition, the known compounds, 6-oxogrindelic acid, grindelic acid, methyl grindeloate, 7alpha,8alpha-epoxygrindelic acid, and 4alpha-carboxygrindelic acid were also isolated. The structures of the new compounds were characterized on the basis of spectroscopic analysis.

Presumed periorbital lupus vulgaris with ocular extension

OBJECTIVE

To report an unusual case of lupus vulgaris that spread to the left anterior ocular surface.

DESIGN

Case report.

PARTICIPANT

An 18-year-old woman presented with an 8-month history of an infiltrative skin lesion affecting the left lower eyelid and cheek area, left globe, right lacrimal sac area, together with a cystic lesion in the foot area. TESTING/INTERVENTION: The authors describe the clinical findings, radiologic study, and histopathologic study of the conjunctiva, skin, liver, and ankle lesion. The patient was treated with antituberculous medications for 3 months.

MAIN OUTCOME MEASURES

Healing of the skin, conjunctival, and bone lesions.

RESULTS

The lesion of the face healed, leaving scar tissue. The left eye showed symblepharon with loss of its anterior surface features. The right eye showed no symblepharon, the bones of the foot healed with no deformity, and the liver function test results normalized after 3 months of antituberculous medications.

CONCLUSION

Lupus vulgaris can be associated with multiple system involvement. Its clinical presentation and behavior depend on the patient's immunity and duration of the disease. Early diagnosis and appropriate management may cure the disease with no life-threatening sequelae.

Long-term suppression of adult bladder morbidity and severe hydronephrosis following selective population chemotherapy for Schistosoma haematobium

Repeated selective population chemotherapy of school age children reduces infection and morbidity associated with Schistosoma haematobium infection. To examine the long-term effect of this treatment on susceptibility to re-infection and late disease, a cohort of Kenyans (n = 194) were re-examined for infection and urinary tract morbidity 7-13 years after they underwent annual ultrasonography and treatment for an average of 5 years beginning in 1984 as children. Controls were previously untreated age-matched individuals residing in the same or adjacent villages. The overall prevalence and intensity of infection were equivalent between the 2 groups. In contrast, the prevalence of bladder wall pathology was 11-fold lower in previously treated (1.5%) versus untreated subjects (17%). Severe hydronephrosis was completely reversed. These data demonstrate that treatment significantly reduced urinary tract morbidity despite re-infection, and suggest that the important risk factors for urinary tract morbidity in adulthood are cumulative intensity and duration of infection during early adolescence.

A xanthanolide diol and a dimeric xanthanolide from Xanthium species

Extracts of the aerial parts of Xanthium strumarium and fruit of X. pungens afforded a new Xanthanolide diol derivative, 11alpha,13-dihydroxyxanthatin and a new dimeric xanthanolide sesquiterpene lactone, pungiolide C, in addition to some known compounds. The structures of the new compounds were determined by spectroscopic methods particularly high resolution (1)H-, (13)C-NMR and 2D (1)H- (1)H and (1)H- (13)C COSY NMR analysis.

Increased levels of soluble interleukin-4 receptor in the sera of patients with visceral leishmaniasis

Kenyan subjects with visceral leishmaniasis were examined for evidence of increased production of soluble interleukin-4 receptor (sIL-4R). Soluble IL-4R regulates the bioactivity of IL-4, a cytokine important in mediating progressive forms of leishmaniasis. Persons with visceral leishmaniasis sustained 8- to 10-fold more circulating sIL-4R compared with Papua New Guinea residents with documented filariasis or uninfected Kenyan and North American subjects. Soluble IL-2R concentrations were elevated nonspecifically in both visceral leishmaniasis and filariasis patients. These findings are significant given that IL-4 induces sIL-4R in mice, and treatment with recombinant sIL-4R cures progressive murine leishmaniasis dependent on IL-4 bioactivity. Further studies are indicated to determine whether the immunologic detection of IL-4 produced in human visceral leishmaniasis is obscured because of sequestration by soluble receptor and whether the production of sIL-4R is relevant to the pathogenesis of visceral leishmaniasis.

Xanthanolides and xanthane epoxide derivatives from Xanthium strumarium

From the aerial parts of Xanthium strumarium, three new xanthanolide and xanthane-type sesquiterpenoids, 11alpha,13-dihydroxanthatin, 4beta,5beta-epoxyxanthatin-1alpha,4alpha-endoperoxide, and 1beta,4beta,4alpha,5alpha-diepoxyxanth-11(13)-en-12-oic acid have been isolated, together with seven known compounds. The structures were determined by spectroscopic methods, particularly high resolution 1D, 2D NMR spectroscopy and NOE experiments.

Expression of glutathione S-transferase activity and glutathione content in squamous cell carcinoma of bladder associated with schistosomiasis in a population in Egypt

The present study was designed to describe the expression of the glutathione S-transferase/glutathione system in squamous cell carcinoma of the bladder in a population in Egypt. The glutathione-S transferase activity was significantly higher in bladder cancer specimens (n = 40) in comparison with schistosomiasis cystitis tissue (n = 42) (4-fold, p = 1 x 10(-12)) and with healthy control samples (n = 9) (10-fold, p = 1 x 10(-6)). The glutathione content was also significantly higher in bladder cancer than in cystitis tissue (2-fold, p = 8 x 10(-6)) and in control samples (6-fold, 8 x 10(-6)). When control mucosa and cystitis samples were compared, 2-fold increased values were obtained for glutathione-S transferase (p = 4 x 10(-3)) and glutathione (p = 1 x 10(-3)) in schistosomiasis bladder tissue. Results describe an over-expression of glutathione-S transferase and glutathione levels in squamous cell carcinoma of the bladder, and indicate a possible role in chemoresistance to pharmacological therapy.

Mice with a targeted deletion of the IgE gene have increased worm burdens and reduced granulomatous inflammation following primary infection with Schistosoma mansoni

Although IgE has been considered to play an essential role in host defense against parasitic helminth infections such as Schistosoma mansoni, in vivo evidence of a protective function of IgE in infected mice is lacking. In the present study, mice with a null mutation of the C epsilon gene, and thus incapable of making IgE (IgE deficient), were infected by S. mansoni cercariae percutaneously. In two independent experiments, IgE-deficient mice were significantly more susceptible to primary infection, developing worm burdens twofold greater than those of wild-type mice (p &lt; 0.001). In contrast, resistance to challenge infection following three immunizations with irradiated cercariae was similar in the two groups. The percentage of reduction in worm burdens in immunized IgE-deficient animals compared with unimmunized mice was 50%; immunized wild-type mice had a reduction of 55% compared with the baseline parasite count. Levels of parasite-specific IgG1 were more than twofold lower in IgE-deficient mice after primary infection (p = 0.005), whereas no significant difference was observed in the IgG1 response of animals previously immunized with irradiated cercariae. IgE-deficient animals also developed significantly smaller granulomas (by 37-40%) around schistosome eggs deposited in their livers compared with wild-type animals (p &lt; 0.001). The spleens of IgE-deficient mice contained significantly more Ag-specific IL-4-secreting cells following primary infection. These data show that IgE participates in parasite elimination in primary infection with S. mansoni and in the generation of humoral immunity and cytokine responses to the parasite.

Mice with a targeted deletion of the IgE gene have increased worm burdens and reduced granulomatous inflammation following primary infection with Schistosoma mansoni

Although IgE has been considered to play an essential role in host defense against parasitic helminth infections such as Schistosoma mansoni, in vivo evidence of a protective function of IgE in infected mice is lacking. In the present study, mice with a null mutation of the C epsilon gene, and thus incapable of making IgE (IgE deficient), were infected by S. mansoni cercariae percutaneously. In two independent experiments, IgE-deficient mice were significantly more susceptible to primary infection, developing worm burdens twofold greater than those of wild-type mice (p < 0.001). In contrast, resistance to challenge infection following three immunizations with irradiated cercariae was similar in the two groups. The percentage of reduction in worm burdens in immunized IgE-deficient animals compared with unimmunized mice was 50%; immunized wild-type mice had a reduction of 55% compared with the baseline parasite count. Levels of parasite-specific IgG1 were more than twofold lower in IgE-deficient mice after primary infection (p = 0.005), whereas no significant difference was observed in the IgG1 response of animals previously immunized with irradiated cercariae. IgE-deficient animals also developed significantly smaller granulomas (by 37-40%) around schistosome eggs deposited in their livers compared with wild-type animals (p < 0.001). The spleens of IgE-deficient mice contained significantly more Ag-specific IL-4-secreting cells following primary infection. These data show that IgE participates in parasite elimination in primary infection with S. mansoni and in the generation of humoral immunity and cytokine responses to the parasite.

Tropical medicine. Current problems and possible solutions

The health of the people in tropical and subtropical countries is compromised because of multiple factors including demography, economics, and particularly an ever-increasing burden of illness from infections and parasitic diseases. At the turn of the century, malaria, schistosomiasis, and tuberculosis are three major challenges that the majority of the world population is facing with few effective chemotherapeutic or immunologic tools. Furthermore, the ever-increasing threat of emerging infections is taxing our surveillance and detection procedures. The modern biomedical revolution promises a better outcome if a global effort in investing in health is effectively launched.

New sesquiterpene alpha-methylene lactones from the Egyptian plant Jasonia candicans

Extracts of the plant Jasonia candicans possess antimicrobial activity. ET2O/MeOH extracts were subjected to liquid chromatography, and several sesquiterpenes were isolated and identified including the known compounds confertin [1], 4,11(13)-eudesmadien-12-oic acid [2], and 11-eudesmen-4-ol [3]. Two new diol alpha-methylene lactone antimicrobial agents were identified from nmr and mass spectral data and X-ray crystallography as (4 alpha, 5 alpha, 8 beta, 10 beta)-4,10-dihydroxy-1,11(13)-guaidien-12,8-olide [4] and (4 alpha, 5 alpha, 8 beta, 10 alpha)-4,10-dihydroxyl-1,11 (13)-guaidien-12,8-olide[5], which differ in stereochemistry at the C-10 tertiary alcohol center.

Ultrastructural localization of a protective 68,000 molecular weight antigen in Schistosoma mansoni

Vaccination with SMW 68, an Mr 68,000 glycoprotein of Schistosoma mansoni, induces significant protection in mice against challenge schistosome infection. This resistance occurs without the use of adjuvants and without sensitizing animals to granuloma formation. Likewise, passive transfer of monoclonal antibody (MAb) 31-3B6 against SMW 68 confers partial protection against challenge infection. As a first step in understanding how the immune response to this molecule leads to resistance, SMW 68 was localized in three developmental stages of the parasite by immunoelectron microscopy using MAb 31-3B6 and polyclonal antisera raised against purified SMW 68. In cercariae and schistosomula, MAb 31-3B6 bound electron-dense granules within the head gland and similar granules in the preacetabular glands. In adult worms, SMW 68 or related antigens were found to be widely distributed in tissues. Binding of specific antisera was most pronounced in the gut and tegument of male worms, but less so in subtegumental muscles. We conclude that SMW 68 is presented to the immune system in various ways during parasite development. The protective protein or epitope is excreted, and presented on the surface and in the cytoplasm at various stages of the life cycle. The relationship of the location of this protein to its role in protective immunity is discussed.

Effect of Leishmania major on human polymorphonuclear leucocyte function in vitro

The effect of various antigens of Leishmania major promastigotes on the function of human polymorphonuclear leucocytes (PMNLs) was examined. Different concentrations of L. major antigens were incubated with isolated PMNLs for various periods and the respiratory burst was assessed by Luminol-dependent chemiluminescence. All the Leishmania antigens employed inhibited the PMNL respiratory burst by 35-64%. PMNL viability was not affected either by the concentrations or type of the parasite antigen. Oxygen free radical scavengers enhanced the action of the antigens on the PMNL respiratory burst.

Direct inhibitory action of EGTA-Ca complex on reverse-mode Na/Ca exchange in Myxicola giant axons

Giant axons from the marine annelid Myxicola infundibulum were internally dialyzed with solutions containing 22Na ions as tracers of Na efflux. In experiments performed in Li-substituted seawater, Na efflux that is dependent on external Ca ion concentration, [Ca2+]o, was measured using dialysis to maintain [Na+]i at 100 mM, which enhances the [Ca2+]o-dependent Na efflux component, (i.e., reverse-mode Na/Ca exchange). When dialysis fluid contained EGTA (1 mM) to buffer the internal Ca concentration, [Ca2+]i, to desired levels, Na efflux lost its normal sensitivity to external calcium. The inhibition was not simply due to the Ca-chelating action of EGTA to produce insufficient [Ca2+]i to activate Na/Ca exchange. The addition of EGTA inhibited Cao-dependent Na efflux even when a large enough excess of [Ca2+]i was present to saturate the EGTA and still produce elevated values of [Ca2+]i. Control experiments showed that these high values of [Ca2+]i resulted in normal Na/Ca exchange in the absence of EGTA. It is concluded that the presence of EGTA itself interferes with the manifestation of reverse-mode Na/Ca exchange in Myxicola giant axons.

Chemotherapy-based control of schistosomiasis haematobia. 3. Snail studies monitoring the effect of chemotherapy on transmission in the Msambweni area, Kenya

Regular snail sampling was performed at 40 sites, representing the principal snail habitats, during a 4 year chemotherapy programme targetted at school-children in the Msambweni area of the coastal plain of Kenya. Populations of Bulinus africanus group snails, primarily from pools, showed seasonal variations, dropping when sites dried out and rising when they were refilled by the rains. Transmission, judged by the recovery of snails shedding typical fucocercous cercariae, continued throughout the treatment period at very low levels (less than 1% of the snails collected were infected) with peaks in October/November and in January/February after seasonal rains. Spatially, most infected snails were recovered from 2 large pools near the sea, close to the school that responded least well to the initial chemotherapy programme. Later, infected snails were found sporadically in inland pools, rice fields and temporary streams near another school where there was evidence of substantial reinfection as the study progressed. The snail findings are consistent with a reduction but not elimination of transmission associated with the chemotherapy programme.

Parasitic protozoa and helminths: biological and immunological challenges

Parasitic protozoans and helminths pose considerable medical as well as scientific challenges. Investigations of the complex and very different life cycles of these organisms, their adaptation to the obligate parasitic mode of life, and their ability to face the hostile host environment have resulted in many exciting discoveries. Invasion of host erythrocytes by plasmodial sporozoites and intact skin by schistosomal cercariae are outlined as examples of the elaborate mechanisms of parasitism. Isolation and characterization of single protective antigens or subunit vaccines from these two organisms are examined as models for vaccine development. Finally, developments in exploring gene regulation in protozoans and free and parasitic nematodes are briefly outlined.

Hepatic microsomal protein and cytochrome P-450 in BALB/c mice infected with Leishmania

The effects of infection of mice with Leishmania major on liver microsomal protein and cytochrome P-450 were examined. The levels of hepatic microsomal protein and cytochrome P-450 were monitored at 6, 7, 9 and 12 weeks post-infection. The results indicated that the amount of hepatic microsomal protein and cytochrome P-450 were unchanged throughout the course of infection with L. major, despite the high degree of parasite proliferation in Kupffer cells and marked reduction in phagocytosis. The current results clearly indicate that Leishmania-induced macrophage suppression has no inhibitory effect on hepatic microsomal protein and cytochrome P-450.

Intensity of Schistosoma mansoni infection in a human population is inversely correlated with antibody response to SmW68, a protective parasite antigen

Vaccination with SmW68, a Schistosoma mansoni surface antigen, significantly protects mice against challenge infection. To investigate the vaccine potential of SmW68 in clinical schistosomiasis, human antibody response to SmW68 was studied as a function of intensity of infection in a chronically infected Egyptian population. In 85 serum samples obtained randomly from families in El Gazairy (population 1,310), antibody to SmW68 (determined by ELISA) was found to increase significantly with age, reaching a plateau at 15-19 y, 1-5 y after peak prevalence and intensity of infection. Among infected individuals (n = 54), antibody response showed a significant inverse correlation (r = -.28, P less than .04) with intensity of infection. In isotype analysis, a higher IgM but not IgG response was significantly associated with low parasite burden. These studies demonstrate that significant antibody response to SmW68 could occur in chronically infected humans. Whether parasite burdens suppress circulating levels of antibody to SmW68 or whether enhanced antibody response to SmW68 represents acquired protective humoral immunity remains to be determined.

Effect of Leishmania major on luminol-dependent chemiluminescence of human whole blood phagocytosis

The aim of this study is to examine the effect of L. major on human whole blood phagocytosis. The phagocytosis was activated by phorbol myristate acetate (PMA) or opsonized zymosan. Various types of Leishmania antigens were tested on luminol-dependent chemiluminescence. In PMA-activated whole blood phagocytosis group, promastigotes and infected medium significantly (P less than 0.001) depressed the maximum peak of chemiluminescence to 5.77 +/- 1.6 and 5.65 +/- 0.45 mV respectively, compared to 9.85 +/- 22 in control group. In a similar fashion a significant reduction of the area under the curve was noted. On the other hand, opsonized zymosan-activated phagocytosis was significantly (P less than 0.025) inhibited in the promastigote treated group only. The maximum peak response was 4.68 +/- 1.5 and 10.8 +/- 0.46 mV in promastigote and control groups, respectively. The above data indicated; a) an inhibition of whole blood phagocytosis induced by Leishmania and b) a marked reduction of the oxygen-reactive metabolites radicals generated by whole blood phagocyte cells and measured by luminol-dependent chemiluminescence suggesting the important role of oxygen free radicals in the pathogenesis of leishmaniasis.

Effects of borehole wells on water utilization in Schistosoma haematobium endemic communities in Coast Province, Kenya

To determine the impact of the introduction of borehole wells on water use patterns and the consequent risk of transmission of Schistosoma haematobium in 3 endemic villages in Kenya, we performed a survey (a 1:6 sample of affected households) to identify sources of water and types of water utilization before and after well introduction. Water usage was also determined in 2 unaffected neighboring villages not given borehole wells, but having continuous access to piped water from communal taps. Prior to borehole well construction, significantly more high-risk water use occurred in the borehole villages vs. comparison villages in terms of water gathered for cooking, drinking, dish washing, and bathing; residents of both types of villages preferred high-risk sources (marshes and ponds) for clothes washing. Following well introduction, there were significant declines in the use of high-risk water for drinking, cooking, and dish washing, but not for bathing or clothes washing. A higher proportion of individuals from the 3 borehole villages reported some type of continued contact with high-risk water sources. Despite well introduction and a 3 year chemotherapy program among school-aged children, a 21-28% incidence of infection persisted among children in the villages, suggesting minimal impact on transmission. Regular monitoring for S. haematobium infected snail sites showed no decline in the number or proportion of infected snails. Borehole well introduction can significantly alter some forms of water usage, but social and water quality factors may limit the ability of communal wells to reduce S. haematobium transmission.