Immunoinformatics and Reverse Vaccinology Driven Predication of a Multi-epitope Vaccine against Borrelia burgdorferi and Validation through in silico Cloning and Immune Simulation.

BACKGROUND: Borrelia burgdorferi is regarded as an extremely dangerous bacteria causing infectious disease in humans, resulting in musculoskeletal pain, fatigue, fever and cardiac symptom. Because of all alarming concerns, no such prophylaxis setup has been available against Borrelia burgdorferi till now. In fact, vaccine construction using traditional methods is so expensive and time-consuming. Therefore, considering all concerns, we designed a multi-epitope-based vaccine design against Borrelia burgdorferi using in silico approaches. OBJECTIVE: To design an effective and safe vaccine that can activate cell-mediated and humoral immunity against Borrelia burgdorferi by using various bioinformatics tools. METHODS: The present study utilized different computational methodologies, covering different ideas and elements in bioinformatics tools. The protein sequence of Borrelia burgdorferi was retrieved from the NCBI database. Different B and T cell epitopes were predicated using the IEDB tool. Efficient B and T cell epitopes were further assessed for vaccine construction using linkers AAY, EAAAK and GPGPG, respectively. Furthermore, the tertiary structure of constructed vaccine was predicated, and its interaction was determined with TLR9 using ClusPro software. In addition, further atomic level detail of docked complex and their immune response were further determined by MD simulation and C-ImmSim tool, respectively. RESULTS: A protein with immunogenic potential and good vaccine properties (candidate) was identified based on high binding scores, low percentile rank, non-allergenicity and good immunological properties, which were further used to calculate epitopes. Additionally, molecular docking possesses strong interaction; seventeen H-bonds interactions were reported, such as THR101-GLU264, THR185-THR270, ARG 257-ASP210, ARG 257-ASP 210, ASP259-LYS 174, ASN263-GLU237, CYS 265-GLU 233, CYS 265-TYR 197, GLU267- THR202, GLN 270-THR202, TYR345-ASP 210, TYR345-THR 213, ARG 346-ASN209, SER350- GLU141, SER350-GLU141, ASP 424-ARG220 and ARG426-THR216 with TLR-9. Finally, high expression was determined in E. coli (CAI = (0.9045), and GC content = (72%)). Using the IMOD server, all-atom MD simulations of docked complex affirmed its significant stability. The outcomes of immune simulation indicate that both T and B cells represent a strong response to the vaccination component. CONCLUSION: This type of in-silico technique may precisely decrease valuable time and expenses in vaccine designing against Borrelia burgdorferi for experimental planning in laboratories. Currently, scientists frequently utilize bioinformatics approaches that speed up their vaccine-based lab work.

Multiple Cranial Nerve Enhancement in Guillain-Barre Syndrome With Clinicoradiological Dissociation.

ABSTRACT: Guillain-Barre Syndrome (GBS) is an acute inflammatory polyradiculoneuropathy which can lead to rapid neuromuscular respiratory failure, with an estimated annual incidence of 1-2 per 100,000 person-years. Even though cranial nerve involvement is known to occur in GBS, radiological correlation on neuroimaging studies are less frequently reported in pediatric population. We hereby report the case of a 14-year-old boy with acute motor axonal neuropathy variant of GBS, who had extensive contrast enhancement of multiple cranial nerves on Magnetic Resonance Imaging brain, associated with clinicoradiological dissociation on presentation.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report.

BACKGROUND: Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor. CASE PRESENTATION: A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable. Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma. CONCLUSIONS: Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner's syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.

Targeting chemokine pathways in esophageal adenocarcinoma.

Esophageal adenocarcinoma (EAC) is one of the fastest growing malignancies in the US and needs newer therapeutic and diagnostic strategies. Chronic inflammation plays a role in the pathogenesis of EAC and contributes to the dysplastic conversion of normal esophageal epithelium to Barrett's esophagus and frank adenocarcinoma. Chemokines play important roles in mediating inflammation and recent evidence implicates these ligands and their receptors in the development and spread of various tumors. We demonstrated that the chemokines IL8, CXCL1 and CXCL3 are significantly overexpressed during esophageal carcinogenesis and accompanied by amplification and demethylation of the chr4q21 gene locus. We also demonstrated that IL8 levels can be detected in serum of patients with EAC and can serve as potential biomarkers. We now demonstrate that inhibition of IL8 receptor, CXCR2, leads to decreased invasiveness of esophageal adenocarcinoma derived cells without affecting cellular proliferation. Taken together, these studies reveal the important roles that chemokines play in development of esophageal cancer and demonstrate that these pathways can serve as potential therapeutic targets.

Hypomethylation of noncoding DNA regions and overexpression of the long noncoding RNA, AFAP1-AS1, in Barrett's esophagus and esophageal adenocarcinoma.

BACKGROUND & AIMS: Alterations in methylation of protein-coding genes are associated with Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Dysregulation of noncoding RNAs occurs during carcinogenesis but has never been studied in BE or EAC. We applied high-resolution methylome analysis to identify changes at genomic regions that encode noncoding RNAs in BE and EAC. METHODS: We analyzed methylation of 1.8 million CpG sites using massively parallel sequencing-based HELP tagging in matched EAC, BE, and normal esophageal tissues. We also analyzed human EAC (OE33, SKGT4, and FLO-1) and normal (HEEpic) esophageal cells. RESULTS: BE and EAC exhibited genome-wide hypomethylation, significantly affecting intragenic and repetitive genomic elements as well as noncoding regions. These methylation changes targeted small and long noncoding regions, discriminating normal from matched BE or EAC tissues. One long noncoding RNA, AFAP1-AS1, was extremely hypomethylated and overexpressed in BE and EAC tissues and EAC cells. Its silencing by small interfering RNA inhibited proliferation and colony-forming ability, induced apoptosis, and reduced EAC cell migration and invasion without altering the expression of its protein-coding counterpart, AFAP1. CONCLUSIONS: BE and EAC exhibit reduced methylation that includes noncoding regions. Methylation of the long noncoding RNA AFAP1-AS1 is reduced in BE and EAC, and its expression inhibits cancer-related biologic functions of EAC cells.

Epoprostenol-induced hypersplenism in portopulmonary hypertension.

Portopulmonary hypertension (POPH) is a not infrequent but serious complication of liver cirrhosis. Continuous intravenous epoprostenol infusion is a treatment option for this condition. Progressive splenomegaly with pancytopenia (hypersplenism) is associated with epoprostenol use in POPH. After recognizing a case of epoprostenol-induced hypersplenism that resolved upon stopping the drug, the authors retrospectively reviewed all patients treated with epoprostenol at the center for both POPH and pulmonary hypertension due to other causes. Five of 11 patients with POPH developed hypersplenism secondary to epoprostenol. In 1 patient, and possibly in a second, the hypersplenism resolved upon discontinuation of epoprostenol. None of 9 patients with pulmonary hypertension due to other causes developed splenomegaly. This report confirms hypersplenism as a complication of epoprostenol therapy for POPH. Furthermore, the authors demonstrate for the first time that hypersplenism may be reversed by stopping the medication and propose a mechanism for this phenomenon.

The OnControl bone marrow biopsy technique is superior to the standard manual technique for hematologists-in-training: a prospective, randomized comparison.

The purpose of this study was to compare a novel bone marrow device with the standard marrow needle in a prospective, randomized study in a teaching hospital employing hematologists-in-training. The new device, the OnControl Bone Marrow (OBM) Biopsy System, utilizes a battery-powered drill to insert the needle. Fifty-four bone marrows (27 standard and 27 OBM) were performed by 11 fellows under the observation and supervision of 3 attending hematologists and 1 research technologist. The primary endpoint of the study, the mean length of the marrow biopsy specimens, a surrogate for marrow quality, was determined by a pathologist in a blinded manner. The mean length of the marrow biopsy specimens was significantly longer (56%) for the OBM group (15.3 mm) than for the standard bone marrow (SBM) group (9.8 mm), P<0.003. An objectively determined secondary endpoint; mean procedure time, skin-to-skin; also favored the OBM group (175 s) versus the SBM group (292 s), P<0.007. Several subjective secondary endpoints also favored the OBM group. Only minor adverse events were encountered in the OBM and SBM study groups. It was concluded that bone marrow procedures (BMPs) performed by hematologists-in-training were significantly faster and superior in quality when performed with the OBM compared to the SBM. These data suggest that the OBM may be considered a new standard of care for adult hematology patients. OBM also appears to be a superior method for training hematology fellows.

Hypotension unawareness in profound orthostatic hypotension.

BACKGROUND: Clinicians depend on history given by the patients when considering the diagnosis of orthostatic hypotension. METHODS: Patients with a decrease in systolic blood pressure more than 60 mm Hg from baseline during a head-up tilt table test were included. They were classified according to their symptoms during the head-up tilt table test. Localization of the cause of orthostatic hypotension was sought in each of these groups. RESULTS: Eighty-eight (43%) patients had typical symptoms, 49 (24%) had atypical symptoms, and 68 (33%) were asymptomatic. The average decrease in systolic blood pressure was 88 mm Hg, 87.5 mm Hg, and 89.8 mm Hg in the typical, atypical, and asymptomatic groups, respectively (P=.81). Patients reported severe dizziness with a similar frequency as lower extremity discomfort. Backache and headache also were common atypical complaints. Patients with peripheral cause of dysautonomia were able to sustain the longest upright position during the head-up tilt table test (21 minutes, compared with central dysautonomia [15 minutes]) (P=.005). There was no correlation between the cause of dysautonomia and the occurrence of symptoms during the head-up tilt table test (P=.58). CONCLUSION: A third of the patients with severe orthostatic hypotension are completely asymptomatic during the head-up tilt table test, and another quarter have atypical complaints that would not lead physicians toward the diagnosis of orthostatic hypotension. These findings suggest that they might not provide adequate information in diagnosing profound orthostatic hypotension in a subset of patients with this disorder.

Immunotherapy for Guillain-Barré syndrome in the US hospitals.

OBJECTIVES: To determine the patterns of hospital utilization of plasma exchange (PE), intravenous immunoglobulin (IVIG), or combination therapy in Guillain-Barré syndrome in a large US cohort. METHODS: Guillain-Barré syndrome patients, older than 18 years, were identified from the Nationwide Inpatient Sample database for the years 2000 through 2005. Patients with documented immunotherapy during hospitalization were included. We used the Cochran-Armitage test to assess the trend of hospital utilization of the type of immune intervention over time. Binomial logistic regression model was used to identify the association between patient and hospital demographics and hospital- associated complications with the type of therapy administered during hospitalization. RESULTS: After data cleansing, 1657 patients were included. There is a decreasing trend in PE utilization and an increasing trend in IVIG use over the 6 years included in this study (P < 0.0001). Patients who received PE were older (mean age of 50.8 +/- 18.5 versus 42.2 +/- 24.2, P < 0.0001) and had higher complication rates including respiratory failure (18.9% versus 7.56%, P < 0.0001) and sepsis (2.85% versus 0.61%, P = 0.003). In addition, the mortality rate is lower in the group treated with IVIG when compared with PE (0.45% versus 3.3%, P < 0.0001). Conversely, 61% of patients treated with IVIG group were discharged to home compared with 42% of patients treated with PE. CONCLUSIONS: The trend analysis supports an increasing use of IVIG over PE. Older population and those with pulmonary or sepsis complications were likely treated with PE. The mortality rate was higher in patients treated with PE.

Guillain-Barré syndrome: incidence and mortality rates in US hospitals.

OBJECTIVE: To determine the incidence, in-hospital mortality, and predictors of death in Guillain-Barré syndrome (GBS) in a large US cohort. METHODS: Our cohort was identified from the Nationwide Inpatient Sample database, 2000 through 2004. We excluded patients younger than 18 years and those who presented with rapidly paralyzing conditions due to other causes. GBS patients who were transferred between hospitals were counted once. The incidence rate adjusted for 20% of the US census reported by the Census Bureau. A logistic regression model was used to identify predictors of death. RESULTS: After data cleansing, 4,954 patients were identified with a primary diagnosis of GBS. The adjusted incidence rate varied between 1.65 and 1.79 per 100,000 during the years included in this study. The in-hospital mortality rate was 2.58% (128/4,954) and did not change significantly over the study period. Eleven percent had variable pulmonary complications, and 9.1% received endotracheal intubation, which was a predictor of mortality (adjusted odds ratio 5.09, 95% CI 3.21-8.05). Other predictors of mortality included older age, composite comorbidity index, cardiac complications, and sepsis. CONCLUSION: The mortality rate in Guillain-Barré syndrome is low, and predictors of death are similar to those predicting poor disability outcome. The disease incidence was stable over the 5 years included in this study.

Gastrointestinal issues in the assessment and management of the obese patient.

As the obesity epidemic spreads across the world, physicians of all specialties will be called on to participate in the management of this condition. Gastroenterologists are no exception and can expect, in the future, to play a major role in all aspects of the care of the obese patient. Thus, gastroenterologists must learn to recognize, prevent, and treat gastrointestinal disorders related to obesity, and they must have an understanding of the risks and benefits of various management strategies. Gastroenterologists may also be called upon to assist in the evaluation and management of liver and gastrointestinal problems that have developed following bariatric surgery. When treating these problems, a thorough understanding of the anatomic and physiologic perturbations associated with a given procedure is essential, as is the knowledge of which complications are linked to weight loss and which are linked to a specific surgical approach.