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

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

Neurotrophin mimetics and tropomyosin kinase receptors: a futuristic pharmacological tool for Parkinson's.

Parkinson's disease is a complex age-related progressive dopaminergic neurodegenerative disease consistently viewed as a disorder of movement and is characterized by its cardinal motor symptoms. While the motor symptoms and its clinical manifestations are attributed to the nigral dopaminergic neuronal death and basal ganglia dysfunction, studies have subsequently proven that the non-dopaminergic neurons in various brain regions are also additionally involved with the disease progression. Thus, it is now well accepted that the involvement of various neurotransmitters and other ligands accounts for the non-motor symptoms (NMS) associated with the Parkinson's disease. Consequently, this has demonstrated to possess remarkable clinical concerns to the patients in terms of various disability, such impaired to compromised quality of life and increased risk of morbidity and mortality. Currently, available pharmacological, non-pharmacological, and surgical therapeutic strategies neither prevent, arrest, nor reverse the nigral dopaminergic neurodegeneration. Thus, there is an imminent medical necessity to increase patient's quality of life and survival, which in turn decreases the incidence and prevalence of the NMS. The current research article reviews the potential direct involvement of neurotrophin and its mimetics to target and modulate neurotrophin-mediated signal transduction pathways to enlighten a new and novel therapeutic strategy along with the pre-existing treatments for Parkinson's disease and other neurological/neurodegenerative disorders which are associated with the downregulation of neurotrophins.

Identification and characterization of 30 novel pathogenic variations in 69 unrelated Indian patients with Mucolipidosis Type II and Type III.

Mucolipidosis (ML) (OMIM 607840 & 607838) is a rare autosomal recessive inherited disorder that occurs due to the deficiency of golgi enzyme uridine diphosphate (UDP)- N-acetylglucosamine-1-phosphotransferase (GlcNAc-phosphotransferase) responsible for tagging mannose-6-phosphate for proper trafficking of lysosomal enzymes to lysosomes. Variants in GlcNAc-phosphotransferase (GNPTAB (α, ß subunits) and GNPTG (γ subunits) are known to result in impaired targeting of lysosomal enzymes leading to Mucolipidosis (ML) Type II or Type III. We analyzed 69 Indian families of MLII/III for clinical features and molecular spectrum and performed in silico analysis for novel variants. We identified 38 pathogenic variants in GNPTAB and 5 pathogenic variants in GNPTG genes including missense, frame shift, deletion, duplication and splice site variations. A total of 26 novel variants were identified in GNPTAB and 4 in GNPTG gene. In silico studies using mutation prediction software like SIFT, Polyphen2 and protein structure analysis further confirmed the pathogenic nature of the novel sequence variants detected in our study. Except for a common variant c.3503_3504delTC in early onset MLII, we could not establish any other significant genotype and phenotype correlation. This is one of the largest studies reported till date on Mucolipidosis II/III in order to identify mutation spectrum and any recurrent mutations specific to the Indian ethnic population. The mutational spectrum information in Indian patients will be useful in better genetic counselling, carrier detection and prenatal diagnosis for patients with ML II/III.

Identification and characterization of 20 novel pathogenic variants in 60 unrelated Indian patients with mucopolysaccharidoses type I and type II.

Mucopolysaccharidoses (MPS), a subgroup of lysosomal storage disorders, are caused due to deficiency of specific lysosomal enzyme involved in catabolism of glycosaminoglycans. To date more than 200 pathogenic variants in the alpha-l-iduronidase (IDUA) for MPS I and ∼500 pathogenic variants in the iduronate-2-sulphatase (IDS) for MPS II have been reported worldwide. The mutation spectrum of MPS type I and MPS type II disorders in Indian population is not characterized yet. In this study, we carried out clinical, biochemical, molecular and in silico analyses to establish the mutation spectrum of MPS I and MPS II in the Indian population. We conducted molecular analysis for 60 MPS-affected patients [MPS I (n = 30) (Hurler syndrome = 17, Hurler-Scheie syndrome = 13), and MPS II (n = 30) (severe = 18, attenuated = 12)] and identified a total of 44 [MPS I (n = 22) and MPS II (n = 22)] different pathogenic variants comprising missense, nonsense, frameshift, gross deletions and splice site variants. A total of 20 [MPS I (n = 14), and MPS II (n = 6)] novel pathogenic sequence variants were identified in our patient cohort. We found that 32% of pathogenic variants detected in IDUA were recurrent and 25% in MPS II. This is the first study revealing the mutation spectrum of MPS I and MPS II patients in the Indian population.

Oral candidiasis following steroid therapy for oral lichen planus.

OBJECTIVES: The purpose of this multicentre study was to determine the incidence of oral candidiasis in patients treated with topical steroids for oral lichen planus (OLP) and to determine whether the application of a concurrent antifungal therapy prevented the development of an oral candidiasis in these patients. MATERIALS AND METHODS: Records of 315 patients with OLP seen at four Oral Medicine practices treated for at least 2 weeks with steroids with and without the use of an antifungal regimen were retrospectively reviewed. RESULTS: The overall incidence of oral fungal infection in those treated with steroid therapy for OLP was 13.6%. There was no statistically significant difference in the rate of oral candidiasis development in those treated with an antifungal regimen vs those not treated prophylactically (14.3% vs 12.6%) (P = 0.68). CONCLUSIONS: Despite the use of various regimens, none of the preventive antifungal strategies used in this study resulted in a significant difference in the rate of development of an oral candidiasis in patients with OLP treated with steroids.

GALNS mutations in Indian patients with mucopolysaccharidosis IVA.

Mucopolysaccharidosis IV A (Morquio syndrome A, MPS IVA) is a lysosomal storage disease caused by the deficiency of N-acetylgalactosamine-6-sulfatase (GALNS). The mutation spectrum in this condition is yet to be determined in Indians. We aimed to analyze the mutations in the GALNS gene in Asian Indians with MPS IVA. All the exons and the adjacent intronic regions of the gene were amplified and sequenced in sixty-eight unrelated Indian families. We identified 136 mutant alleles comprising of 40 different mutations. We report twenty-two novel mutations that comprise of seventeen missense (p.Asn32Thr, p.Leu36Arg, p.Pro52Leu, p.Pro77Ser, p.Cys79Arg, p.His142Pro, p.Tyr191Asp, p.Asn204Thr, p.Gly188Ser, p.Phe216Ser, p.Trp230Cys, p.Ala291Ser, p.Gly317Arg, p.His329Pro, p.Arg386Ser, p.Glu450Gly, p.Cys501Ser), three splice-site variants (c.120+1G>C, c.1003-3C>G, c.1139+1G>A), one nonsense mutation (p.Gln414*) and one frameshift mutation (p.Pro420Leufs*440). Eighteen mutations have been reported earlier. Among these p.Ser287Leu (8.82%), p.Phe216Ser (7.35%), p.Asn32Thr (6.61%) and p.Ala291Ser (5.88%) were the most frequent mutations in Indian patients but were rare in the mutational profiles reported in other populations. These results indicate that the Indian patients may have a distinct mutation spectrum compared to those of other populations. Mutant alleles in exon 1, 7 and 8 accounted for 44.8% of the mutations, and sequencing of these exons initially may be a cost-effective approach in Asian Indian patients. This is the largest study on molecular analysis of patients with MPS IVA reported in the literature, and the first report from India.

Clinical utility of multiplex ligation-dependent probe amplification technique in identification of aetiology of unexplained mental retardation: a study in 203 Indian patients.

BACKGROUND & OBJECTIVES: Developmental delay (DD)/mental retardation also described as intellectual disability (ID), is seen in 1-3 per cent of general population. Diagnosis continues to be a challenge at clinical level. With the advancement of new molecular cytogenetic techniques such as cytogenetic microarray (CMA), multiplex ligation-dependent probe amplification (MLPA) techniques, many microdeletion/microduplication syndromes with DD/ID are now delineated. MLPA technique can probe 40-50 genomic regions in a single reaction and is being used for evaluation of cases with DD/ID. In this study we evaluated the clinical utility of MLPA techniques with different probe sets to identify the aetiology of unexplained mental retardation in patients with ID/DD. METHODS: A total of 203 randomly selected DD/ID cases with/without malformations were studied. MLPA probe sets for subtelomeric regions (P070/P036) and common microdeletions/microduplications (P245-A2) and X-chromosome (P106) were used. Positive cases with MLPA technique were confirmed using either fluorescence in situ hybridization (FISH) or follow up confirmatory MLPA probe sets. RESULTS: The overall detection rate was found to be 9.3 per cent (19 out of 203). The detection rates were 6.9 and 7.4 per cent for common microdeletion/microduplication and subtelomeric probe sets, respectively. No abnormality was detected with probe set for X-linked ID. The subtelomeric abnormalities detected included deletions of 1p36.33, 4p, 5p, 9p, 9q, 13q telomeric regions and duplication of 9pter. The deletions/duplications detected in non telomeric regions include regions for Prader Willi/Angelman regions, Williams syndrome, Smith Magenis syndrome and Velocardiofacial syndrome. INTERPRETATION & CONCLUSIONS: Our results show that the use of P245-A2 and P070/P036-E1 probes gives good diagnostic yield. Though MLPA cannot probe the whole genome like cytogenetic microarray, due to its ease and relative low cost it is an important technique for evaluation of cases with DD/ID.

Osseointegrated silicone finger prosthesis using dental implants: a renovated technique.

AIM AND BACKGROUND: In clinical practice, we come across patients with traumatically amputated or congenitally missing partial or complete fingers that can be restored using microsurgical replantation or transplantation procedures. However, in some cases this might not be possible due to systemic or local factors and the lost or missing part has to be replaced prosthetically to offer psychological and functional wellbeing. These prostheses can be constructed with various materials like acrylics or silicone retained with the help of auxiliary aids. However, these prostheses cause some hindrance in performing functions like writing, typing, etc. The aim of the present trial was to ameliorate the existing design of implant supported finger prosthesis. TECHNIQUE: Distal phalange of middle finger replaced with implant supported silicone finger prosthesis is modified by utilizing a metal framework to support silicone material to improve rigidity while working. CONCLUSION AND CLINICAL SIGNIFICANCE: We could achieve a good function, esthetics and tactile sensibility with this modified design. Whenever, feasible this design can improve the performance and patients feel a deep sense of satisfaction and improved self-esteem with this modified prosthesis.

Exome Sequencing in Monogenic Forms of Rickets.

OBJECTIVE: To understand the phenotypic and genotypic spectrum of genetic forms of rickets in 10 families. METHODS: Detailed clinical, radiographic, and biochemical evaluation of 10 families with phenotypes suggestive of a genetic cause of rickets was performed. Molecular testing using exome sequencing aided in the diagnosis of six different forms of known genetic causes. RESULTS: Eleven disease-causing variants including five previously reported variants (CYP27B1:c.1319_1325dup, p.(Phe443Profs*24), VDR:c.1171C>T, p.(Arg391Cys), PHEX: c.1586_1586+1del, PHEX: c.1482+5G>C, PHEX: c.58C>T, p.(Arg20*)) and six novel variants (CYP27B1:c.974C>T, p.(Thr325Met), CYP27B1: c.1376G>A, p.(Arg459His), CYP2R1: c.595C>T, p.(Arg199*), CYP2R1:c.1330G>C, p.(Gly444Arg),SLC34A3:c.1336-11_1336-1del, SLC2A2: c.589G>C, p.(Val197Leu)) in the genes known to cause monogenic rickets were identified. CONCLUSION: The authors hereby report a case series of individuals from India with a molecular diagnosis of rickets and provide the literature review which would help in enhancing the clinical and molecular profile for rapid and differential diagnosis of rickets.

Genotype-phenotype spectrum of 130 unrelated Indian families with Mucopolysaccharidosis type II.

MPS II is an X linked recessive lysosomal storage disorder with multi-system involvement and marked molecular heterogeneity. In this study, we explored the clinical and molecular spectrum of 144 Indian patients with MPS II from 130 unrelated families. Clinical information was collected on a predesigned clinical proforma. Sanger method was employed to sequence all the exons and exon/intron boundaries of the IDS gene. In cases where causative variation was not detected by Sanger sequencing, MLPA and RFLP were performed to identify large deletions/duplications and complex rearrangements. Cytogenetic microarray was done in one patient to see the breakpoints and extent of deletion. In one patient with no detectable likely pathogenic or pathogenic variation, whole-genome sequencing was also performed. Novel variants were systematically assessed by in silico prediction software and protein modelling. The pathogenicity of variants was established based on ACMG criteria. An attempt was also made to establish a genotype-phenotype correlation. Positive family history was present in 31% (41/130) of patients. Developmental delay and intellectual disability were the main reasons for referral. Macrocephaly, coarse facies and dysostosis were present in almost all patients. Hepatosplenomegaly, joint contractures and short stature were the characteristic features, seen in 87% (101/116), 67.8% (74/109) and 41.4% (41/99) patients respectively. Attenuated phenotype was seen in 32.6% (47/144) patients, while severe phenotype was seen in 63% (91/144) patients. The detection rate for likely pathogenic or pathogenic variants in our cohort is 95.5% (107/112) by Sanger sequencing, MLPA and RFLP. We also found two variants of unknown significance, one each by Sanger sequencing and WGS. Total of 71 variants were identified by Sanger sequencing and 29 of these variants were found to be novel. Amongst the novel variants, there was a considerable proportion (51%) of frameshift variants (15/29). Almost half of the causative variants were located in exon 3,8 and 9. A significant genotype-phenotype correlation was also noted for both known and novel variants. This information about the genotype spectrum and phenotype will be helpful for diagnostic and prognostic purposes.

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

AIMS: To examine the relationship between social deprivation, intensification of insulin therapy (≥ three injections per day) and diabetes control in children and adolescents. METHODS: We performed a longitudinal observational study of 283 children and adolescents with Type 1 diabetes from three UK paediatric centres from 2005 to 2007. We used linear mixed modelling to identify the contribution of the Index of Multiple Deprivation 2004, insulin regimen and demographic factors in explaining longitudinal differences in HbA(1c) levels. RESULTS: Overall mean HbA(1c) levels were 8.9% [sd 1.4, 74 mmol/mol (8 mmol/mol)]. Prescribing of intensive therapy increased from 49.2 to 70.1% (χ(2) = 32.9, P < 0.001), but there was no corresponding improvement in HbA(1c) levels. Those from more educationally deprived backgrounds were less likely to be started on intensive therapy (P = 0.04). In linear mixed modelling, factors independently associated with poor metabolic control were greater social deprivation (P = 0.01), particularly lower educational levels (P = 0.006), and non-White ethnicity (P = 0.04). Nested terms analysis showed that increased deprivation interacted with non-White ethnicity (P = 0.009) and with intensive insulin therapy (P = 0.03) to result in poorer metabolic control. In a subgroup intensified from conventional regimens during follow-up (n = 75), greater social deprivation was associated with least success of intensive therapy (P = 0.02). CONCLUSIONS: Social deprivation was associated with low uptake and poor success of insulin intensification and this appeared to be largely mediated via lower educational levels.

Local drug delivery for oral mucosal diseases: challenges and opportunities.

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

Proniosomes as drug carriers.

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

Formulation and evaluation of Cetirizine dihydrochloride orodispersible tablet.

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

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

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

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

OBJECTIVE: To provide insight into the clinical failure of the tumour necrosis factor alpha (TNFalpha) inhibitor, etanercept, in primary Sjögren syndrome (pSS), an extensive analysis of the systemic immune profile of patients with pSS was carried out and the effect of etanercept treatment on these immune parameters monitored. METHODS: Peripheral blood mononuclear cells of patients with pSS and healthy controls were compared by flow cytometry to determine differences in distribution of specific cell populations (T cells, B cells, monocytes), and to determine their expression of activation markers (CD25, HLA-DR), TNF receptors and chemokine receptors (CXCR1, 2) before and after treatment. Systemic cytokine levels were measured by multiplex ELISA assay in plasma and in lipopolysaccharide-stimulated whole blood from healthy controls and from patients with pSS before and after etanercept treatment. Baseline cytokine levels were correlated with clinical markers of disease. RESULTS: Before treatment, salivary gland inflammatory focus scores did not correlate with circulating TNF levels. Furthermore, consistent with the lack of evidence of significant clinical benefit, enhanced markers of immune activation, frequency of cell subpopulations and aberrant cytokine profiles were not restored to normal levels by etanercept treatment. Remarkably, the levels of circulating TNFalpha were significantly increased after treatment. CONCLUSION: Etanercept is an ineffective therapeutic agent in pSS consistent with the absence of suppression of TNFalpha and other indicators of immune activation in this patient population. These data suggest that TNFalpha may not be a pivotal cytokine in the pathogenesis of pSS, impelling continued molecular characterisation of disease parameters to define appropriate intervention targets.

Thermal expansion and corrosion resistance of cobalt-chromium alloys fabricated by contemporary manufacturing processes: an in vitro study / Expansión térmica y resistencia a la corrosión de aleaciones de cobalto-cromo fabricadas mediante procesos de abricación contemporáneos: un estudio in vitro

In Purpose: The fabrication technique can influence the mechanical properties of Cobalt-Chromium (Co-Cr) dental alloys. Hence, the present study aims to determine the corrosion resistance and thermal expansion of alloys manufactured using three contemporary techniques. Material and Methods: A total of nine specimens of Co-Cr alloy were prepared according to ISO 22674 by each one of the three manufacturing processes (three in each process); conventional casting, direct metal laser sintering (DMLS) and milling (MIL). All these specimens were tested for coefficient of thermal expansion and corrosion resistance. The data was tabulated and analyzed statistically. Results: The difference in the thermal expansion of alloys fabricated using three techniques was non-significant at almost all the temperatures from 50 ºC to 950 ºC (p>0.05), except 450 ºC and 600 °C. The polarization resistance of specimens manufactured using the conventional method was more compared to DMLS and MIL at pH 5 (Conventional>MIL>DMLS) (p<0.001). Conclusion: The thermal expansion behavior of alloys manufactured using the three selected techniques were similar, whereas, at acidic pH, the corrosion resistance of conventional and MIL were better than the DMLS.

Antecedentes: La técnica de fabricación puede influir en las propiedades mecánicas de las aleaciones dentales de cobalto-cromo (Co-Cr). Por lo tanto, el presente estudio tiene como objetivo determinar la resistencia a la corrosión y la expansión térmica de aleaciones fabricadas con tres técnicas contemporáneas. Material y Métodos: Se prepararon un total de nueve probetas de aleación de Co-Cr según ISO 22674 por cada uno de los tres procesos de fabricación (tres en cada proceso); fundición convencional, sinterización directa de metal por láser (DMLS) y fresado (MIL). Todos estos especímenes fueron probados para determinar el coeficiente de expansión térmica y la resistencia a la corrosión. Los datos fueron tabulados y analizados estadísticamente. Resultados: La diferencia en la dilatación térmica de las aleaciones fabricadas con las tres técnicas no fue significativa en casi todas las temperaturas desde 50ºC hasta 950ºC (p>0,05), excepto 450ºC y 600ºC. La resistencia a la polarización de las muestras fabricadas con el método convencional fue mayor en comparación con DMLS y MIL a pH 5 (Convencional>MIL>DMLS) (p<0, 0 01). Conclusión: El comportamiento de expansión térmica de las aleaciones fabricadas con las tres técnicas seleccionadas fue similar, mientras que, a pH ácido, la resistencia a la corrosión de la convencional y la MIL fue mejor que la de la DMLS.