Immature dendritic cells generated with low doses of GM-CSF in the absence of IL-4 are maturation resistant and prolong allograft survival in vivo

Dendritic cells (DC) were cultured from mouse bone marrow (BM) progenitors in low concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF) (GM(lo) DC) by two different protocols. The phenotype and functional properties of these GM(lo) DC were compared to those of standard BM-DC cultures generated in high concentrations of GM-CSF (GM(hi) DC) or in low GM-CSF plus IL-4 (GM(lo)/IL-4 DC). An effect of IL-4 on maturation was observed only at low but not high doses of GM-CSF. Compared to mature DC, GM(lo) DC were phenotypically immature, weak stimulators of allogeneic and peptide-specific T cell responses, but substantially more potent in presentation of native protein. Immature GM(lo) DC were resistant to maturation by lipopolysaccharide, TNF-alpha or anti-CD40 monoclonal antibodies, as the expression of co-stimulatory molecules was not increased, and stimulatory activity in oxidative mitogenesis was not enhanced. These maturation-resistant immature GM(lo) DC induced T cell unresponsiveness in vitro and in vivo. GM(lo) DC also prolonged haplotype-specific cardiac allograft survival (from 8 days to >100 days median survival time) when they were administered 7 days (but not 3, 14 or 28 days) before transplantation. Our findings may have important implications for future studies in T cell tolerance induction in vivo.     

TP53 polymorphisms in gliomas from Indian patients: Study of codon 72 genotype, rs1642785, rs1800370 and 16 base pair insertion in intron-3

Several single nucleotide polymorphisms of the TP53 gene have been reported, amongst which polymorphism in codon 72 (rs1042522) has received significant attention and shown to be associated with disease susceptibility in different cancer types. However, there are variable reports on this polymorphism in gliomas from worldwide with inconsistent results. In addition, the implications of other polymorphic loci are not much explored in gliomas. Hence, in the present study the TP53 sequence was analyzed for all polymorphism and mutations in a total of 84 gliomas of different types and grades from patients of Indian origin. The complete sequence of all coding exons (2 to 11) and introns 2, 3, 5 and 8 of TP53 gene were studied while for introns 1, 4, 6, 7, 9 and 10, only exon flanking regions could be studied. The polymorphic loci were compared with control population. In addition to the well known codon 72 polymorphism (rs1042522), three other polymorphisms rs1642785, rs1800370 and a 16 base pair insertion in intron-3 were found. At codon 72, our study showed higher Arg/Arg genotype in gliomas compared to normal population (38% versus 13%). The Arg allele frequency in glioma patients was comparatively higher than controls (0.55 versus 0.45; P = 0.037). The Arg allele frequency was also high in adult glioblastomas compared to paediatric counterparts (0.55 versus 0.36). However, there was no significant association of TP53 mutations with any genotype of codon 72. At rs1642785, the G allele frequency was significantly higher in gliomas than in control population (0.55 versus 0.36, P = 0.005). The genotype at a 16 base pair insertion in intron-3 was almost similar in case and control. However, the polymorphism at rs1800370 was exclusive to gliomas. This is the first report of TP53 gene polymorphism in glioma patients from India. Our study also delineates the frequency of four polymorphisms in gliomas for the first time. The codon 72 variant (rs1042522) and rs1642785 polymorphisms possibly poses risk to glioma development in Indian population. However, the functional significance of these polymorphism needs further elucidation.     

Bromodeoxyuridine incorporation and Ki 67 expression in oral hairy leukoplakia

OBJECTIVES: Oral hairy leukoplakia (HL) is an acan-thotic, hyperparakeratotic lesion characterised by the presence of a replicative Epstein-Barr virus (EBV) infection in the superficial and adjoining layers of the epithelium. EBV or its gene products are capable of modifying epithelial differentiation. The aim of this study was to establish whether the presence of EBV was associated with an alteration in cell turnover by assessing bromodeoxyuridine (BrdU) incorporation and Ki 67 expression in lesional tissue and control mucosa.
METHODS: Biopsies of HL together with age, site and sex matched controls ( n = 7 and 8 respectively) were incubated in 200 μM BrdU in vitro , fixed in methacarn and processed to paraffin wax. Following acid hydrolysis, incorporated BrdU and Ki 67 were identified in serial 5 fim sections using a three-stage immunoperoxidase technique and cell density expressed as the number of positive cells per mm basement membrane length.
RESULTS: Overall, there was no difference in the number of BrdU positive cells per mm basement membrane length between control and HL tissue. However, within HL alone, the presence'of focal EBV replication was associated with a significant reduction in the number of basal cells incorporating BrdU compared to adjacent EBV free areas (P < 0.05). There was no significant difference between Ki 67 positive cells in control and HL tissue and no evidence of a reduction of Ki 67 positive cells in areas associated with EBV replication.
CONCLUSIONS: These results suggest that there is no evidence of a generalised alteration of the proliferative capacity of basal cells in HL, although the focal reduction in BrdU incorporation may reflect subtle changes on cell turnover by EBV infection.     

Emergency surgery comparison of right versus left acute colonic diverticulitis: A 10-year outcome analysis

IntroductionThe difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery.MethodWe conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated.ResultsIn total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p < 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p < 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6).ConclusionRight colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease.     

Strangulation in child abuse: CT diagnosis

The central nervous system is commonly affected in child abuse. Between April 1985 and July 1986 three infants were identified in whom the primary mode of injury had been strangulation. In each case computed tomography (CT) demonstrated a large cerebral infarction confined to vascular territories associated with small subdural hematomas. There was no history or visible evidence of significant head trauma. Autopsy of one infant confirmed the presence of a hemispheric infarct, thin subdural hematoma, and an area of subintimal hemorrhage in the carotid artery ipsilateral to the infarct. The remaining two patients survived with residual hemiparesis. CT findings of a large cerebral infarction with an associated subdural hematoma in an infant without a history of a significant trauma should suggest the possibility of child abuse and may be the primary manifestation of abuse in some patients.     

Apoptosis as a form of cell death in intracerebral hemorrhage

OBJECTIVE: The goals of this study were to identify and quantify the presence of programmed cell death (apoptosis) in intracerebral hemorrhage (ICH) among human subjects. Recent evidence from laboratory models suggests that cell death in the perihematoma region may involve apoptosis. METHODS: Retrospective clinical and histological analyses were performed for patients with spontaneous ICH who underwent surgical evacuation. Quantification of apoptotic cells was performed in sections obtained from the perihematoma region from 12 patients with ICH and stained with the terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling method. Necrosis was identified on the basis of morphological criteria, using hematoxylin and eosin staining. RESULTS: Evidence of apoptosis was present in surgical specimens obtained from 10 of the 12 patients. The mean number of apoptotic cells in the perihematoma region in each patient specimen was 38% (range, 0-90%). For five patients, more than one-half of the total cells observed were apoptotic. Apoptosis was observed in specimens obtained within 1 day, 2 days, and 5 days after the onset of symptoms. No terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling-positive cells were observed in specimens from the two patients with cerebellar hematomas. The mean proportion of necrotic cells in the perihematoma region in each patient specimen was 25% (range, 0-100%). There was a prominent excess of apoptotic cells, in comparison with necrotic cells, for 6 of the 12 patients who underwent hematoma evacuation. For five other patients, similar proportions of apoptotic and necrotic cells were observed. Necrosis was the predominant finding for only one patient, who underwent late surgical evacuation on Day 5. CONCLUSION: These observations suggest that apoptosis represents a prominent form of cell death associated with ICH in the perihematoma region. Further studies are required to define the mediators of apoptosis in ICH.     

Comparison of the structure of human intervertebral discs in the cervical,thoracic and lumbar regions of the spine

Posterior and anterior heights, cross-sectional area and shape were measured for all the intervertebral discs in four spines from elderly human cadavers. Disc height was a minimum at the T4-5 level; thoracic discs were less wedge-shaped than those in the cervical and lumbar regions. Cross-sectional area increased from the cranial to caudal extremity; at the L5-S1 level the nucleus pulposus occupied a high proportion of this area. Cervical discs tended to have an elliptical cross-sectional shape, thoracic discs were more circular and lumbar discs tended to have an elliptical cross-section which was flattened or re-entrant posteriorly. This shape distribution was quantified by defining a shape index which had a maximum value of 1 for a circular cross-section. Orientations of the reinforcing fibres in the outer lamellae of the anterior annulus fibrosus were measured from 27 discs by X-ray diffraction. For these measurements, C3-4, T7-8 and L2-3 were chosen as representative of cervical, thoracic and lumbar discs. The fibre tilt, with respect to the axis of the spine, was significantly less in the cervical discs (at 65 degrees) than in the thoracic and lumbar discs (about 70 degrees). These findings are interpreted in relation to differing functional requirements and possible mechanisms of failure in the cervical, thoracic and lumbar regions of the spine in the light of current knowledge on the biomechanics of the intervertebral disc.     

Surgical management of giant intracranial aneurysms

OBJECTIVES: The natural history of giant intracranial aneurysms is generally morbid. Mortality and morbidity associated with giant aneurysms is also higher than for smaller aneurysms. This study was carried out to assess the demographic profile, presenting features, complications, and outcome after surgical treatment of giant intracranial aneurysms. PATIENTS AND METHODS: A retrospective review of the medical records of all patients with giant intracranial aneurysms treated in the Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, from January 1995 through June 2007 was performed. The demographic profiles, presenting features, radiological findings, surgical treatments, and outcomes were assessed. RESULTS: A total of 1412 patients harboring 1675 aneurysms were treated. Out of these, 222 patients had 229 (13.7%) giant aneurysms, and of those, 181 aneurysms in 177 patients were managed surgically while 48 were treated with endovascular therapy. In the patients treated with surgery, common clinical presentations included subarachnoid hemorrhage (SAH) in 110 (62%) cases followed by mass effect in 57 (32%) cases. In patients who presented with SAH, the Hunt and Hess SAH grading was: grade I in 43 (39%), grade II in 40 (36%), grade III in 23 (21%), grade IV in two (2%), and grade V in 2 (2%) patients. One hundred and seven aneurysms (in 103 patients) were treated using direct surgical clipping. Forty-six patients with good collateral circulation were treated by gradual occlusion and ligation of the internal carotid artery (ICA) in the neck with a Silverstone clamp. Another nine patients with good collateral circulation, but persisting symptoms after ICA ligation, required trapping for obliteration of the aneurysm. Eleven patients with poor collateral circulation required extracranial-intracranial (EC-IC) bypass before proximal ICA ligation. A post-operative digital subtraction angiography (DSA) was performed in 118 patients and revealed well-obliterated aneurysm in 106 patients. The total treatment mortality rate was 9%. In the last 5 years, 117 patients were operated on with four operative deaths. Overall, the outcome was excellent in 131 (74.0%), good in 22 (12.4%), and poor in eight (4.5%) cases. CONCLUSIONS: It is concluded that 14% of all intracranial aneurysms are giant. The most common clinical presentation is SAH followed by features of an intracranial mass lesion. The cavernous ICA is the most common portion of the ICA affected. Direct surgical clipping is a safe and effective method of treatment and should be considered the first line of treatment whenever possible. With proper case selection, optimal radiological evaluation, and appropriate surgical strategy, it is possible to achieve a favorable outcome in almost 90% of the cases.     

Pregnancy outcome in Budd Chiari Syndrome-a tertiary care centre experience

Background

Pregnancy management is a crucial issue in women with Budd-Chiari Syndrome (BCS) and there are no established guidelines on the management.

Aim

To report our experience of pregnancy outcome with BCS.

Material and Methods

We report outcome of 13 pregnancies in three women, with favourable outcome after the diagnosis of the condition and its treatment using intervention to bypass obstruction and anticoagulant therapy during pregnancy.

Results

Three women had a total of 13 pregnancies; three after the diagnosis and decompressive treatment of the disease. Disease was diagnosed during index pregnancy in two women. Anticoagulation was given in all the three pregnancies (Robertson et al., Br J Haematol, 132:171–196, 2006). Pregnancies prior to diagnosis and treatment resulted in a live birth.

Conclusion

Pregnancy does not seem to be a contraindication in well treated and controlled BCS. Maternal outcome is good with close multidisciplinary surveillance. Foetal outcome, however, may still be poor due to underlying prothrombotic condition.