Assessment of auditory perception abilities using temporal envelope and fine structure processing in children with self-limited epilepsy with centrotemporal spikes

OBJECTIVES

Children with self-limited epilepsy with centrotemporal spikes (SeLECTS) exhibit difficulty processing spoken messages without hearing loss. The temporal envelope and fine structure processing abilities are the fundamental aspects of the normal listening process. There is limited literature on the temporal envelope and fine structure processing in children with SeLECTS. We evaluated the temporal envelope and fine structure processing in children with SeLECTS.

DESIGN

The study included 35 children with SeLECTS and 50 typically developing children (TDC). The temporal envelope processing was measured using the temporal modulation transfer function (TMTF) and temporal fine structure using the temporal fine structure low-frequency (TFS LF) test. The TMTF was measured for the modulation rates 4, 8, 16, 32, 64 and 128 Hz. The TFS LF was done for 250, 500 and 750 Hz.

RESULTS

The difference in modulation detection thresholds at 4 Hz was not found to be significant, whereas there was a significant difference in modulation detection thresholds observed for all the other modulation frequencies (p < 0.05) between the children with SeLECTS and TDC. The thresholds at 250, 500 and 750 Hz were higher (poorer) for children with SeLECTS than the TDC and was significant (p < 0.05).

CONCLUSIONS

The TMTF and TFS LF tests were of practical use in evaluating temporal envelope and fine structure processing abilities in children with SeLECTS. The results suggest that children with SeLECTS have a poor temporal envelope and fine structure processing compared to the TDC.

Genetic polymorphisms of microsomal epoxide hydrolase and UDP-glucuronosyltransferase (UGT) and its effects on plasma carbamazepine levels and metabolic ratio in persons with epilepsy of South India: A cross-sectional genetic association study

OBJECTIVES

Carbamazepine (CBZ), an anti-seizure drug, is widely prescribed for the management of focal seizures. At a given therapeutic dose, CBZ exhibits marked interindividual variation in the plasma CBZ levels. The aim wasto study the influence of EPHX1 c.337 T>C and UGT2B7*2 genetic polymorphisms on plasma carbamazepine (CBZ) levels in persons with epilepsy (PWE) from South India.

METHODS

115 PWE belong to South India origin who are on carbamazepine monotherapy were recruited. Genotyping of the two variants weredone using RT-PCR method. PWE who had seizure freedom for one year and their last dose which was not changed for one year duration were included and their plasma levels of CBZ and its active metabolite CBZ 10,11 epoxide were analysed by reverse phase HPLC.

RESULTS

In EPHX1 c. 337 (T>C) polymorphism, the PWE carrying CC had lower plasma CBZ levels when compared to CT genotype (2.45 μg/ml vs 3.15 μg/ml. In UGT2B7*2, PWE carrying homozygous mutant TT had higher levels when compared with CT (3.09 μg/ml vs 2.74 μg/ml) genotype but found no statistical significance. Mutant genotype of EPHX1 (CC) had higher metabolic ratio compared to TT genotype (1.33 vs 1.17) but not found to be statistically significant. Mutant genotype of UGT2B7*2 (TT) was found to be having lower metabolic ratio when compared with CC genotype (1.18 vs 1.35; p value =0.08).

CONCLUSION

PWE carrying EPHX1 c.337 T>C (rs1051740) and UGT2B7*2 (rs7439366) genetic polymorphisms did not affect the plasma CBZ levels and metabolic ratio of PWE of South Indian origin. However, this finding should be confirmed in a larger sample size which may help in optimization and personalized CBZ therapy in South Indians.

Association of serum calprotectin with peripheral neuropathy in patients with type 2 diabetes mellitus

Introduction

Peripheral neuropathy is a common microvascular complication in patients with type 2 diabetes mellitus with a prevalence of around 50%.

Objectives

This prospective observational cross-sectional study was done to assess serum calprotectin levels among diabetic patients with peripheral neuropathy as compared to those without neuropathy.

Methods

This cross-sectional study was conducted in 126 diabetic patients attending the out-patient department of JIPMER Hospital, Pondicherry from July 2017 to January 2019. The subjects were divided into two groups (with and without peripheral neuropathy) and underwent nerve conduction study of both the lower limbs. Blood samples were collected and stored at -80°C for estimation of serum calprotectin. Serum calprotectin levels were compared between diabetic patients with and without peripheral neuropathy.

Results

Serum calprotectin levels were increased in patients with diabetic peripheral neuropathy (DPN) as compared to those without DPN. However, there was no significant difference in the mean value of serum calprotectin among the various sub-groups of DPN.

Conclusion

Serum calprotectin, an inflammatory biomarker is elevated in patients with diabetic peripheral neuropathy as compared to those without neuropathy.

Video teleconsultation services for persons with epilepsy during COVID-19 pandemic: An exploratory study from public tertiary care hospital in Southern India on feasibility, satisfaction, and effectiveness

PURPOSE

During the COVID-19 pandemic, there is a large unmet need for follow-up services, particularly for chronic diseases such as epilepsy. Alternative methods to reach these people have become necessary. We assessed the feasibility, satisfaction, and effectiveness of video teleconsultation using mobile phones for managing persons with epilepsy (PWEs) on follow-up at a tertiary care center in the southern part of India.

PATIENTS AND METHODS

We included PWEs aged 18 years and over who have been evaluated in person within the past six months, with details available in electronic health records (EHRs), and advised regular follow-up after getting telephonic consent. We excluded those requiring emergency care and those seeking teleconsultation for new symptoms. Participants were sent a message in English and in the local language about the possibility of a video teleconsultation. If willing, they were informed about the date, time, and technical requirements such as smartphones, browsing facilities, etc. Feasibility and effectiveness were assessed. Satisfaction/acceptability was assessed using Telemedicine Satisfaction Questionnaire.

RESULTS

From June 2020 to October 2020, we selected 336 PWEs after screening 1100 records, and we tried video teleconsultation in 141 (41.8%) PWEs. We achieved successful video connections in 95 (28.2%) and audio consultations in 46 (13.6%). The median duration for calling the participants, making successful connections, and consultation was 8 (5-14) min. The majority required two (47.4%) or three (32.6%) attempts. Sixty-five PWEs (68.4%) used caretaker's mobile phones. We gave prescriptions to all, and 18 received new drugs. Out of 95 PWEs, 90% either 'agreed' or 'strongly agreed' on 12 out of 14 telemedicine satisfaction questions.

CONCLUSION

Although we need to make video teleconsultation more feasible, our synchronous mobile video teleconsultation model is an effective and acceptable method to follow up PWEs. This real-time model has the advantage that it does not require any mobile application to be downloaded and installed. Further studies are needed to evaluate methods to improve the reach of these services particularly to vulnerable groups of the population.

Adrenoleukodystrophy presenting as glue sniffing

Adrenoleukodystrophy classically presents in childhood with bronze skin, spastic tetraparesis, dysphagia, behavioural abnormalities and adrenal insufficiency. However, atypical presentations are known. Here we report an adolescent with adrenoleukodystrophy who first sought medical attention for glue sniffing.

Telemedicine in epilepsy: How can we improve care, teaching, and awareness?

Telemedicine (TM) is the use of telecommunications' technologies to provide medical information and services. Telehealth (TH) permits broader and psychosocial support for patients and their families. We aimed to highlight the importance of the use of TH for all aspects of epilepsy, either for the scientific aspects (e.g., research, education, care, management, etc.) or for the social matters (e.g., education, sensitization, association support, etc.). There is a deep gap in knowledge and use of TH in the developing and developed countries. Epilepsy is a condition responsible for 1% of the global burden of disease. More than 50 million people have epilepsy, and barriers to care include shortage of human resources, medical facilities, and resources. Eighty (80) percent of people with epilepsy (PWE) live in low- and middle-income countries. Telehealth has the potential of addressing limited resources and improving access to PWE across the globe.

High Frequency of Depressive Symptoms among Adults with Epilepsy: Results from a Hospital-based Study

Context:

Assessment of comorbid burden of depression and associated factors among adult people living with epilepsy (PWE) has the potential to inform clinical evaluation and management to improve outcomes.

Aim:

The aim of this study is to determine frequency of depressive symptoms and factors associated with it among PWE attending a tertiary care hospital.

Setting and Design:

This was a cross-sectional observational study conducted in the outpatient clinic of a tertiary care center.

Subjects and Methods:

One hundred and fifty patients with epilepsy were recruited between May 2016 and August 2016. For assessing depression, Tamil validated version of Patient Health Questionnaire-12 was used. Frequency of depression and its association with various sociodemographic and clinical factors were assessed.

Statistical Analysis Used:

Student t-test and Chi-square test for univariate analysis and logistic regression for multivariate analysis were used for statistical analysis.

Results:

Of the 150 subjects, 89 (59.3%) were males. Generalized tonic–clonic seizures were present in 131 people (87.3%). Genetic and unknown epilepsies contributed higher proportion (44.7%) as compared to structural epilepsies (37.3%). Majority (88%) were on one or two antiepileptic drugs. Thirty-one people (20.3%) had less than one seizure per year. Depressive symptoms were present in 95 patients (63.3%). In multivariate regression analysis, secondary generalized seizures and seizure frequency >1/month emerged as significant predictors of depression ([OR]: 5.48 [95% (CI): 1.35–22.28] and OR: 2.53 [95% CI: 1.11–5.75], respectively).

Conclusion:

Depression is prevalent in a majority of adult PWE. Hence, a routine screening for depression as part of comprehensive epilepsy care is advisable for PWE attending the outpatient clinic.

Role of Ultrasound to Monitor Patients With Carpal Tunnel Syndrome Treated With a Local Corticosteroid

OBJECTIVES

Carpal tunnel syndrome (CTS) is an entrapment neuropathy resulting from compression of the median nerve at the carpal tunnel (CT). We assessed the role of high-resolution ultrasound (US) in monitoring patients with CTS treated with corticosteroid injection.

METHODS

We performed high-resolution US evaluations of the wrists of patients with CTS before and after treatment with local corticosteroid. Thirty-nine and 17 wrists were included for analysis at the end of 1 and 3 months, respectively. The cross-sectional area (CSA) and anteroposterior diameter (APD) of the median nerve at the CT and clinical and electrophysiologic data were recorded. We assessed whether changes in US measurements before and after the treatment correlated with clinical and electrophysiologic parameters.

RESULTS

The Boston symptom severity scale (p < .01), Boston functional status scale (p < .01), median nerve motor latency (p = .017), median nerve sensory velocity (p = .003), and difference in motor latencies (p = 0.03) and difference in sensory latencies (p = .03) between median and ulnar nerves showed significant changes over 1 or/and 3 months compared to baseline values. Changes in the CSA and APD correlated with changes in some clinical and electrophysiologic parameters. However, measurements of the CSA and APD at 1 or 3 months were not significantly different from baseline values.

CONCLUSIONS

High-resolution US parameters such as the APD and CSA of the median nerve at the CT inlet were not useful to monitor patients with CTS treated with corticosteroid injections.

Head to head comparison between neurology residents and a mobile medical application for diagnostic accuracy in cognitive neurology

BACKGROUND

A novel Mobile Medical Application (App) App was created on iOS platform (Neurology Dx®) to deduce Differential Diagnoses (DDx) from a set of user selected Symptoms, Signs, Imaging data and Lab findings. The DDx generated by the App was compared for diagnostic accuracy with differentials reasoned by participating neurology residents when presented with same clinical vignettes.

METHODS

Hundred neurology residents in seven leading Neurology centers across India participated in this study. A panel of experts created 60 clinical vignettes of varying levels of difficulty related to Cognitive neurology. Each neurology resident was instructed to formulate DDx from a set of 15 cognitive neurology vignettes. Experts in Cognitive Neurology made the gold standard DDx answers to all 60 clinical vignettes. The differentials generated by the App and neurology residents were then compared with the Gold standard.

RESULTS

Sixty clinical vignettes were tested on 100 neurology residents (15 vignettes each) and also on the App (60 vignettes). The frequency of gold standard high likely answers accurately documented by the residents was 25% compared with 65% by the App (95% CI 33.1-46.3), P < 0.0001. Residents correctly identified the first high likely gold standard answer as their first high likely answer in 35% (95% CI 30.7-36.6) compared with 62% (95% CI 14.1-38.5), P < 0.0001.

CONCLUSION

An App with adequate knowledge-base and appropriate algorithm can augment and complement human diagnostic reasoning in drawing a comprehensive list of DDx in the field of Cognitive Neurology (CTRI/2017/06/008838).

Complete recovery in Wernicke's encephalopathy complicating hyperemesis gravidarum

Wernicke's encephalopathy (WE) is an uncommon neurological complication in pregnancies complicated with hyperemesis due to thiamine deficiency. In women with hyperemesis, inadvertent glucose administration prior to thiamine supplementation triggers the development of neurological manifestations. Delay in the diagnosis can lead to maternal morbidity, and in one-third of cases may lead to persistence of some neurological deficit. With early recognition and thiamine supplementation, complete recovery is reported. We report a case of WE complicating a case of triplet pregnancy with hyperemesis gravidarum, which highlights the importance of early recognition and treatment, resulting in complete recovery as in the index case.

New-onset interictal headache in Persons with epilepsy (PWE): A case-control study

PURPOSE

In our personal experience, headache is a frequent complaint in Persons with epilepsy (PWE) receiving antiepileptic drugs (AEDs), carbamazepine (CBZ) in particular. There is hardly any systematic study on AEDs-associated headache. We assessed the association of new-onset interictal headache in PWE with CBZ compared with other AEDs and factors associated with it.

METHODS

Two thousand PWE on AEDs were screened, and 165 persons having new-onset interictal headache were identified. Eight persons were excluded because of comorbid illnesses that could potentially contribute to a headache. Finally, 157 were recruited for the study. One hundred fifty-seven age- and sex-matched PWE on AEDs, without headache, were recruited as controls. Headache questionnaire based on the International Classification of Headache Disorders (ICHD-II) criteria was used. Demographic factors, seizure characteristics, type and dose of AEDs, findings on electroencephalogram (EEG), and magnetic resonance imaging (MRI)/computerized tomography (CT) were recorded.

RESULTS

Among PWE with headache, the majority [88 (56.1%)] were on CBZ compared with other AEDs but not significantly different from controls. In 71 (45%) persons, the headache had migrainous character. In both univariate and multivariate analyses, lower seizure frequency and fewer EEG abnormalities were found to be independent predictors of headache.

CONCLUSIONS

New-onset interictal headache is a significant issue in PWE; nonmigrainous headache is more common than the migrainous type. Carbamazepine was not found to have any predilection for new-onset interictal headache compared with other AEDs. A lower frequency of seizures and EEG abnormalities in PWE with headache may suggest that seizures contribute less to the development of headache and may further support the hypothesis that AEDs may be significant contributing factors for the headache.

Sporadic Creutzfeldt-Jakob disease (sCJD) with asymmetric findings

We report a case of a patient with probable Creutzfeldt-Jakob disease (CJD) who had psychiatric manifestation in the form of withdrawn depressive behaviour at the onset, followed by rapidly progressive ataxia, parkinsonism, mutism and cognitive decline with generalised asynchronous multifocal myoclonic jerks. His EEG exhibited focal (lateralised) periodic triphasic sharp waves on the background of generalised delta slowing, which later on became more generalised. MRI of the brain showed hyperintensity in basal ganglia with cortical ribbon sign in bilateral frontal region. Clinical course showed progressive deterioration to an akinetic-abulic stage. He died 2 months after the onset of symptoms.

Refractory status epilepticus complicated by drug-induced involuntary movements

New onset refractory status epilepticus (NORSE) is a neurological emergency and difficult to treat condition. We report a case of involuntary movements resulting from thiopentone sodium infusion during the management of refractory status epilepticus. A young woman was admitted with fever and NORSE in the neurology intensive care unit. In addition to supportive measures, she was treated with intravenous lorazepam, phenytoin sodium, sodium valproate, midazolam and thiopentone sodium. While on thiopentone sodium, she developed involuntary twitches involving her upper limbs and face with EEG showing no evidence of ongoing status epilepticus. Because of the temporal relationship with thiopentone infusion, we tapered the dose of thiopentone sodium, which resulted in the disappearance of the movements. The patient recovered well with no recurrence of the seizures during the hospital stay.

Left-sided Poland's syndrome in a girl with rare associations like spina bifida and diaphragmatic hernia

Poland's syndrome is a rare congenital anomaly characterised by partial or complete absence of sternocostal head of pectoralis major muscle and anomalies of ipsilateral hand and digits. Other associated anomalies involving anterior thoracic wall, breast, diaphragm and vertebrae have also been reported in various cases. We report a case of a 10-year-old girl, with features of left-sided Poland's syndrome associated with spina bifida, dextroposition of the heart and left-sided diaphragmatic hernia. These are rare associations of Poland's syndrome. She was investigated with chest X-ray, contrast-enhanced CT of the thorax, ultrasonography of abdomen and echocardiography which helped in arriving at an accurate diagnosis and assessing all the associated abnormalities.

Status epilepticus: why, what, and how

Status epilepticus (SE) is an important neurological emergency with high mortality and morbidity. The first official definition of SE was the product of 10 th Marseilles colloquium held in 1962 which was accepted by International League Against Epilepsy in 1964. There are as many types of SE as of seizures. SE is supposed to result from failure of normal mechanisms that terminate an isolated seizure. In half of the cases, there is no history of epilepsy and SE is precipitated by some intercurrent infection. In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal. The treatment of SE aims at termination of SE, prevention of seizure recurrence, management of precipitating causes, and the management of complications. The extent of investigations done should be based on the clinical picture and cost benefit analysis. The first line antiepileptic drugs (AED) for SE include benzodiazepines, phenytoin, phosphenytoin, and sodium valproate. Mortality of SE ranges between 7 and 39% and depends on underlying cause and response to AEDs.

Studies on bile acids: The microquantitative separation of cellular bile acids by gas-liquid chromatography

1. A method is described for the quantitative isolation of bile acids from cellular material. Homogenates of rat liver are freeze-dried and extracted exhaustively with 95% (v/v) ethanol containing 0.1% (v/v) of aq. ammonia (sp.gr. 0.88) and purified by anion-exchange chromatography on Amberlyst A-26. 2. The extracted bile acid conjugates are subjected to either of two hydrolytic procedures, one involving chemical and the other enzymic agents. A unique feature in this study is the introduction of an enzyme, a clostridial peptide-bond hydrolase, for the rapid cleavage of bile acid conjugates, replacing the classical drastic chemical hydrolysis with strong alkali. 3. After hydrolysis, free bile acids are methylated and converted into their trifluoroacetates for final determination by gas-liquid chromatography on a triple component column, FS-1265-SE30-NGS. 4. For the purpose of identification of peaks, bile acid methyl esters are converted into their trimethylsilyl ethers by allowing the methyl esters to react with a new and potent silyl donor, bis(trimethylsilyl)acetamide. 5. The technique affords us a means of studying the metabolism of bile acids at the cellular and subcellular levels in tissues.

A clinical, radiological and outcome study of status epilepticus from India

The objective of this study is to evaluate the clinical and radiological characteristics and the outcome of status epilepticus (SE). 117 consecutive patients with SE were evaluated including their demographics, history of epilepsy, antiepileptic drug (AED) default, comorbidities, SE type and duration. The study included 22 children, 77 adults and 18 elderly patients with SE. Blood counts, serum chemistry, ECG, cranial MRI, cerebrospinal fluid and EEG were done. Patients were treated with IV phenytoin, valproate, lorazepam or diazepam as per a fixed protocol and responses to first and second drugs were noted. Death during hospital was recorded. The etiology of SE was infection in 53.8%, drug default in 7.9%, metabolic in 14.5%, stroke in 12.8% and miscellaneous in 11% of patients. 92.3% of patients had convulsive and 7.7% nonconvulsive SE. Cranial MRI was abnormal in 62%. Infection as an etiology was more common in children, drug default and metabolic causes in adults and stroke in adults and elderly. Following first AED, SE was controlled in 50%. 30% of patients remained refractory to second AED which was related to duration of SE and mortality. 29% patients died and death was higher in elderly (44%) compared to children (14%). Acute symptomatic SE is more common in developing countries. Refractory SE is associated with SE duration and mortality.

Status epilepticus in encephalitis: a study of clinical findings, magnetic resonance imaging, and response to antiepileptic drugs

This study evaluates clinical findings, magnetic resonance imaging (MRI), and response to antiepileptic drugs (AEDs) in encephalitis patients with status epilepticus (SE). Encephalitis patients with SE were included and they were grouped into herpes (HSE), Japanese (JE), dengue, and nonspecific encephalitis on the basis of virological studies. The demographic and clinical details, including SE type and duration, were noted. Cranial MRI and cerebrospinal fluid (CSF) were carried out. Response to first, second, and third AEDs were noted and the patients not responding to the second AED were considered refractory SE. The relationships of the mortality and the refractoriness of SE with various clinical findings, MRI, CSF, and the type of encephalitis were evaluated. Thirty SE patients with encephalitis aged 1 to 64 years were included. Nine patients had JE, 4 HSE, 1 dengue, and 16 nonspecific encephalitis. Generalized convulsive SE was present in 26 and nonconvulsive SE in 4 patients. The mean duration of SE was 21 (0.83 to 72) h. MRI was abnormal in 20 patients. A 46.7% of patients responded to the first AED and 36.7% remained refractory to the second AED. In 26.7% patients, the seizure continued even after the third AED. The response to AED was not related to the clinical, MRI, and laboratory variables. Nine patients died and the mortality was related to gender and Glasgow Coma Scale (GCS) score. In encephalitis with SE, 46.7% patients responded to the fist AED and 36.7% remained refractory to the second AED. One third of patients of died, which was related to the depth of coma.

Traditional journal club: a continuing problem

OBJECTIVE

To evaluate the pattern, motivation and facilities for choosing journal club topics by residents in two medical institutions in India.

METHOD

A self-appraisal questionnaire was used to compare motivation for choice of topics, availability of infrastructure, sites and type of articles accessed and formal training in computer based literature search in two medical institutions- a postgraduate institute (PGI) and medical college (MC) which provided mainly specialty and superspecialty training respectively.

RESULTS

One hundred and fifty five out of two hundred and fifty five residents responded to the questionnaire. Super-specialty training was pursued by 58 and specialty training by 97 residents. The residents in PGI more frequently selected journal articles which they considered good and in MC, faculty guidance determined the choice of journal club topics. The super-specialty residents, however, more frequently selected patient management related topics compared to specialty residents. MEDLINE and MD Consult were more frequently accessed by PGI residents where infrastructure and training in literature search were superior to MC.

CONCLUSION

In both the institutions surveyed, journal clubs were of traditional type. Better infrastructure and training at PGI were not reflected in quality of journal club. Successful journal club should focus on current, real patient's problem of most interest to the group.

Studies on the bioavailability of the provitamin A carotenoid, β-carotene, using human exfoliated colonic epithelial cells

The possibility of using exfoliated colonic epithelial cells for assessing the bioavailability of β-carotene was examined. Analysis of exfoliated colonic epithelial cells showed the presence of β-carotene and vitamin A. The β-carotene content was significantly lower in cells from stool samples of subjects on a β-carotene-poor diet than those receiving a single dose of a β-carotene supplement. Colonic epithelial cells isolated from stool samples collected daily during a wash-out period while the subjects were on a β-carotene-poor diet showed a steady decrease in β-carotene content, reaching the lowest value on day 7. Kinetic analysis showed that a single dose of a β-carotene supplement in the form of spirulina (Spirulina platensis) or agathi (Sesbania grandiflora) after the wash-out period caused an increase in the β-carotene content after a lag period of 5–7 d, but the vitamin A levels during these periods were not significantly affected. Analysis of plasma β-carotene concentration also showed similar changes, which correlated with those of exfoliated colonic cells. A relationship between the β-carotene content of the diet and that of the colonic epithelial cells suggests that analysis of the β-carotene content in exfoliated human colonic epithelial cells is a useful non-invasive method to assess the bioavailability of provitamin A β-carotene.

Global outlook on nutrition and the environment: meeting the challenges of the next millennium

As we enter the new millennium, nearly 800 million of the World's population will remain chronically malnourished. Nearly 200 million children are moderately to severely underweight, while 70 million are severely malnourished. And those who are yet to be born will be faced with the same set of circumstances that predispose them to malnutrition and its consequences. Eradication of nutritional deficiencies among women and children on a global scale are needed to ensure improved quality of life for the next generation of citizens. Primary deficiencies in vitamin A, iron, iodine, calcium, folic acid and trace elements such as zinc are compounded by pollutants caused by human activity. Environmental lead, arsenic, mercury, and other heavy metals that enter the food chain can seriously deplete body stores of iron, vitamin C and other essential nutrients leading to decreased immune defenses, intrauterine growth retardation, impaired psycho-social faculties and other disabilities associated with malnutrition. Increased susceptibilities to communicable diseases, and those provoked by water or insect borne vectors are additional risks encountered by malnourished individuals. Migration of populations from rural to urban centers and the expansion of major metropolitan areas have had a significant and adverse impact on the quality of life of these citizens. In the next 20 years most of the growth in urban populations will be in Asia and Latin America. Urbanization and the resultant burden on limited national resources is a major contributory factor to malnutrition. There are many other lifestyle-associated disabilities such as use of tobacco (cancer) and alcoholism that require active intervention. Within the family unit, socioeconomic factors and the status of women (literacy, economic independence) are major determinants of the quality of life. In the coming century, the World will have to meet these challenges by careful planning and international cooperation.

The induction of SOS function in Escherichia coli K-12/PQ37 by 4-nitroquinoline oxide (4-NQO) and fecapentaenes-12 and -14 is bile salt sensitive: implications for colon carcinogenesis

The response of Escherichia coli to genotoxic agents involves the triggering of a complex system of genes known as the SOS response. In E. coli PQ37, a test organism used for the assessment of genotoxicity, lacZ, the beta-galactosidase gene is placed under the control of sfiA, one of the SOS genes through an operon fusion. The induction of beta-galactosidase activity, when the organism is exposed to genotoxic agents, is an indirect measure of the genotoxic activity of the test compound. Incubation of E. coli PQ37 with either 4-nitroquinoline oxide (4-NQO) or one of the fecal mutagens, fecapentaene-12 or -14 (F-12 or F-14) in the presence of sodium taurocholate or sodium deoxycholate resulted in a significant enhancement of induction of beta-galactosidase activity. The molecular mechanisms of 4-NQO-induced mutagenesis in E. coli are similar to those of the effects of UV light in which both replication-dependent and repair-dependent pathways of mutagenesis exist. Since E. coli PQ37 is excision-repair-deficient, alternate pathways are involved in this system. Bile salts by themselves do not trigger the SOS response, and hence their role in enhancing the SOS-inducing potency of mutagens may involve the potentiation of the cleavage-inactivation of lexA (repressor of SOS) by the protein product of the SOS-controlled gene, recA. The potentiating effect of bile salts on the fecal mutagens, F-12 and F-14, has implications in their suspected role in colon carcinogenesis associated with high-fat, low-fiber diets.

Lupus vulgaris of nose - a case report

Lupus vulgaris which is a mucocutaneous form of Tuberculosis is not an uncommon condi-tion. But the disease resulting in excessive destruction is rare today. We report a case of lupus vulgaris which almost completely destroyed the nose.

Lectin binding to human colonocytes is predictive of colonic neoplasia

OBJECTIVE

The aim of this study was to determine whether lectin binding to exfoliated human colonocytes could be used as a noninvasive test for colorectal polyps or cancer.

METHODS

Colonocytes were harvested from 31 patients (10 controls, 10 with adenomatous polyps, and 11 with cancer), incubated with a panel of fluorescent-labeled lectins, and assayed by flow cytometry.

RESULTS

The lectins jacalin (JAC) and wheat germ agglutinin (WGA) were useful in predicting the presence of a colorectal neoplasm (p = 0.0018 for JAC and p = 0.0099 for WGA). For JAC, sensitivity reached 81% with a specificity of 80%, and for WGA the sensitivity and specificity were both 75%.

CONCLUSIONS

Lectin binding to human colonocytes can predict the presence of malignant and premalignant lesions of the colon, and has potential as a noninvasive screening tool for colorectal neoplasms.

Peripheral ameloblastoma involving tongue-a rare case

Peripheral ameloblastoma is a rare tumour of oral cavity. It presents as a mass without bony continuity. Here we report a unique case of peripheral ameloblastoma involving tongue, with review of relevant literature.

Tumor proliferative fraction in infiltrating duct carcinoma

Deregulated cell proliferation is a key factor in malignancy and therefore may be of prognostic significance. Both Proliferating Cell Nuclear Antigen (PCNA) and silver binding Argyrophilic Nucleolar Organizer Regions (AgNORs) have been established as a valuable reflection of the tissue proliferative compartment and hence could be of value in studying the biologic behavior of malignant cells. In the present study, we evaluated the proliferative activity of 120 infiltrating duct carcinomas by analysing for PCNA and AgNOR expression in relation to pathologic variables. The AgNOR scores were significantly greater in the malignant tissue than in benign lesions. Expression of PCNA was also found to be increased in malignant breast tumors, when compared to controls. A strong positive correlation between PCNA immunoreactivity and AgNORs was evident. There was also a positive correlation between histologic grading and AgNOR score in breast cancer (r = 0.92, p = 0.000). Tumor with elevated AgNOR counts were often poorly differentiated. It is therefore apparent that evaluation of AgNORs and PCNA may help in the elaboration of histopathologic grading of infiltrating duct carcinoma and may be of prognostic significance.

p53 tumor suppressor protein and tissue proliferative fraction in infiltrating duct carcinoma

BACKGROUND AND OBJECTIVES

Breast cancer continues to frustrate oncologists worldwide. In India, it is the second most common neoplasm among women and is increasing in incidence. Several molecular markers have been associated with a poor prognosis in patients with breast cancer, and the presence of these markers is often thought to provide information on the biological behavior of the malignant breast tumor. Much attention has recently been focused on the tumor suppressor gene p53. Mutation or alteration in this gene leads to the loss of negative growth regulation and hence to rapid cell proliferation. The present study was designed to evaluate the connection between expression of the p53 protein and its relation to the tissue proliferative compartment as measured by expression of the proliferating cell nuclear antigen (PCNA).

METHODS

Expression of p53 and PCNA were detected by immunocytochemistry in paraffin-embedded sections of infiltrating duct carcinoma and control breast tissue (normal tissue and adenoma).

RESULTS

A significant correlation was observed between expression of p53 and PCNA. A significant correlation was also observed between expression of p53 and grade of tumor and stage of disease.

CONCLUSIONS

Our results support the hypothesis that accumulation of p53 is associated with a high tumor proliferation rate an association that might be expected in view of the role of wild p53 as a negative regulator of cell proliferation.

Chemoprevention of oral leukoplakia with vitamin A and beta carotene: an assessment

We conducted a double-blind placebo-controlled trial to evaluate the chemopreventive potential of either vitamin A alone or beta carotene alone in subjects with oral leukoplakia in Kerala, India. We randomised 160 fishermen and women with oral precancerous lesions to receive oral vitamin A (retinyl acetate 300,000 IU/week x 12 months, n = 50), or beta carotene (360 mg/week x 12 months, n = 55), or placebo (n = 55). Blood, saliva and urine samples were collected at baseline and at exit to study serum micronutrients and mutagenicity assays. Biopsies of the mucosal lesions at entry were performed for histopathological exclusion of malignancy. The subjects were examined once every 2 months to establish clinical response of lesions and toxicity, if any. The results are based on 43 complaint subjects on placebo, 42 on vitamin A and 46 on beta carotene. The complete regression rates were: 10% in the placebo arm, 52% with vitamin A and 33% with beta carotene (P < 0.0001). Homogeneous leukoplakias and smaller lesions responded better than non-homogeneous and larger lesions. No major toxicities were observed. Half of the responders with beta carotene and two thirds with vitamin A relapsed after stopping supplementation. Serum beta carotene concentration increased substantially with beta carotene administration while with vitamin A supplementation there was no change in serum retinol levels. In the vitamin A treated group there was a significant decrease in serum alpha tocopherol. Vitamin A administration resulted in a significant remission of oral leukoplakia without any side effects of prolonged vitamin A supplementation. The results of this study, as well as those from previous studies, appear to provide strong supporting evidence to justify long term trials with vitamin A in subjects with high-risk leukoplakias with oral cancer as an endpoint.

Expression of the antiapoptotic protein bcl-2 is not dependent on the tumor suppressor p53 protein in Indian breast carcinoma

Tissue homeostasis and the maintenance of cell populations depend on a delicate balance between the rates of cell proliferation and cell death. Programmed cell death or apoptosis is believed to play a major role in physiological processes which, when defective, could contribute to the pathogenesis and progression of tumors. A role for altered programmed cell death in cancer stems from the description of alterations on tumor-associated genes involved in the regulation of apoptosis such as p53 and bcl-2. The p53 gene promotes apoptosis in cells with genetic damage, while bcl-2 is an antiapoptotic gene. It is therefore possible that the balance between p53 and bcl-2 may have significant implications for the pathobiology of breast cancer. This study was therefore undertaken to evaluate the expression of these two proteins with opposite functions and their relation to the total growth fraction of the tumor as measured by PCNA immunoreactivity. A significant correlation was observed between expression of p53 and PCNA. In contrast, bcl-2 expression did not correlate with the expression of p53. There was also no correlation observed between expression of bcl-2 and PCNA. A significant correlation was observed between expression of p53 and the grade of the tumor and stage of the disease. Our results thus support the hypothesis that accumulation of p53 is associated with a high tumor proliferation rate, an association that might be expected in view of the role of wild-type p53 as a negative regulator of cell proliferation. Another important observation was the lack of relationship between bcl-2 expression and PCNA immunoreactivity, supporting the hypothesis that bcl-2 is not a major regulator of proliferation.

Effects of dietary fat and fiber on plasma and urine androgens and estrogens in men: a controlled feeding study

We conducted a controlled feeding study to evaluate the effects of fat and fiber consumption on plasma and urine sex hormones in men. The study had a crossover design and included 43 healthy men aged 19-56 y. Men were initially randomly assigned to either a low-fat, high-fiber or high-fat, low-fiber diet for 10 wk and after a 2-wk washout period crossed over to the other diet. The energy content of diets was varied to maintain constant body weight but averaged approximately 13.3 MJ (3170 kcal)/d on both diets. The low-fat diet provided 18.8% of energy from fat with a ratio of polyunsaturated to saturated fat (P:S) of 1.3, whereas the high-fat diet provided 41.0% of energy from fat with a P:S of 0.6. Total dietary fiber consumption from the low- and high-fat diets averaged 4.6 and 2.0 g.MJ-1.d-1, respectively. Mean plasma concentrations of total and sex-hormone-binding-globulin (SHBG)-bound testosterone were 13% and 15% higher, respectively, on the high-fat, low-fiber diet and the difference from the low-fat, high-fiber diet was significant for the SHBG-bound fraction (P = 0.04). Men's daily urinary excretion of testosterone also was 13% higher with the high-fat, low-fiber diet than with the low-fat, high-fiber diet (P = 0.01). Conversely, their urinary excretion of estradiol and estrone and their 2-hydroxy metabolites were 12-28% lower with the high-fat, low-fiber diet (P < or = 0.01). Results of this study suggest that diet may alter endogenous sex hormone metabolism in men.

Uptake and distribution of carotenoids, retinol, and tocopherols in human colonic epithelial cells in vivo

Studies suggest that micronutrients such as the tocopherols, retinol, and the carotenoids have a chemopreventive action against colonic carcinogenesis and that they may be essential for the functioning and structural integrity of the gastrointestinal epithelium. In this study, we have determined the concentrations of tocopherols, retinol, and the carotenoids in human colonic epithelial cells using a noninvasive procedure developed in this laboratory (G.P. Albaugh et al., Int. J. Cancer, 52: 347-350, 1992). In subjects on a normal diet, almost all of these micronutrients were restricted to cells in the density range of rho 1.065-1.090 and rho 1.090-1.110. The lighter fraction (rho 1.033-1.064), representing the most senescent subpopulation, retained these micronutrients only when the subjects were on diets rich in vegetables. Cells isolated from subjects on their usual diets gave the following values expressed as ng/10(7) cells: alpha-tocopherol, 93-151; gamma-tocopherol, 152-280; retinol, 12-20; lutein, 4-18; cryptoxanthin, not detected; lycopene, 0-17; alpha-carotene, 3-7; and beta-carotene, 6-9. Peak responses in specific micronutrients following 5 days on a high carotenoid diet showed a lag period of at least 5 days, corresponding to the turnover rates of the epithelium itself. The evidence suggests that uptake of these micronutrients by the colonic mucosa occurs in the deep cryptal zone where the actively proliferating cells extract the nutrients from the systemic circulation.

Selective responses of hormones involved in carbohydrate and lipid metabolism and properties of erythrocyte membranes during the menstrual cycle in premenopausal women consuming moderate amounts of alcohol

The effects of chronic consumption of moderate amounts of alcohol on hormones associated with lipid and carbohydrate metabolism, plasma concentrations of triacylglycerol and cholesterol, insulin receptors on erythrocyte membranes, and erythrocyte membrane fluidity were studied during three phases of the menstrual cycle in 37 premenopausal women. Subjects were given either 30 g ethanol or an equienergetic fruit juice for three menstrual cycles in a crossover design. Blood samples were analyzed during the luteal, midcycle, and follicular phases. Administration of alcohol induced a significant rise in plasma glucagon and cortisol uniformly across the entire menstrual cycle. A similar rise in plasma growth hormone was observed at midcycle during the period when subjects consumed alcohol. A marginal effect was observed on cholesterol and somatomedin C concentrations. Insulin binding to erythrocyte ghosts was not affected by either alcohol or menstrual-cycle phase. Erythrocyte membranes were more fluid during the follicular phase than during the luteal phase of the menstrual cycle when the women were consuming the alcohol. There were no perceptible interactions between alcohol and phases of the menstrual cycle for the indexes studied, except membrane fluidity.

Flow cytometric identification of cell surface markers on cultured human colonic cell lines using monoclonal antibodies

BACKGROUND

The expression of tumor-associated cell surface antigens is a reflection of the state of cell differentiation of tumor cells in culture.

METHOD

Monoclonal antibodies (MoAbs) against the tumor-associated antigens carcinoembryonic antigen (CEA) and CA19-9 and the extracellular matrix protein CD44 were used to label the cell surface of human colonic cells in culture. The binding of each antibody to its respective antigen was measured by fluorescence-activated flow cytometry and expressed as a percentage of positive cells.

RESULTS

The human colon adenocarcinoma cell (HCAC) line, LS-180, showed strong binding with CEA (81%), CA 19-9 (87%), and CD44 (83%). LS-174t cells, a trypsinized variant of LS-180 cells, showed less binding with CEA (66%) and CA 19-9 (49%), but no binding with CD44. With cells from HCAC line HT-29, antigen expression was highly variable for CEA (13% +/- 18) and CD44 (31% +/- 35) but was consistently positive for CA19-9 (33% +/- 13). The expression of CEA in the Caco-2 cell line was weak (24%), whereas there was no expression of CA19-9 and CD44. Normal human colon fibroblast cells (CCD-18Co) did not recognize the monoclonal antibodies to CEA or CA 19-9, but were strongly positive with the CD44 antibody (97%).

CONCLUSIONS

These results support the concept that the expression of the tumor associated markers CEA and CA19-9 and the cell surface marker CD44 on human colonic cell lines varies with the degree of cellular differentiation. Carcinoembryonic antigen and/or CA19-9 were expressed in all four human colon adenocarcinoma cell lines, but not in the normal colon fibroblast cells (CCD-18Co). Using these two MoAbs appeared to be a more reliable measure of the state of differentiation of human colon adenocarcinoma cells.

Evaluation of chemoprevention of oral cancer with Spirulina fusiformis

The blue-green microalgae Spirulina, used in daily diets of natives in Africa and America, have been found to be a rich natural source of proteins, carotenoids, and other micronutrients. Experimental studies in animal models have demonstrated an inhibitory effect of Spirulina algae on oral carcinogenesis. Studies among preschool children in India have demonstrated Spirulina fusiformis (SF) to be an effective source of dietary vitamin A. We evaluated the chemopreventive activity of SF (1 g/day for 12 mos) in reversing oral leukoplakia in pan tobacco chewers in Kerala, India. Complete regression of lesions was observed in 20 of 44 (45%) evaluable subjects supplemented with SF, as opposed to 3 of 43 (7%) in the placebo arm (p < 0.0001). When stratified by type of leukoplakia, the response was more pronounced in homogeneous lesions: complete regression was seen in 16 of 28 (57%) subjects with homogeneous leukoplakia, 2 of 8 with erythroplakia, 2 of 4 with verrucous leukoplakia, and 0 of 4 with ulcerated and nodular lesions. Within one year of discontinuing supplements, 9 of 20 (45%) complete responders with SF developed recurrent lesions. Supplementation with SF did not result in increased serum concentration of retinol or beta-carotene, nor was it associated with toxicity. This is the first human study evaluating the chemopreventive potential of SF. More studies in different settings and different populations are needed for further evaluation.