Individualization of antiretroviral therapy--pharmacogenomic aspect.

Combination therapy with three drug regimens for human immunodeficiency virus (HIV) infection significantly suppresses the viral replication. However, this therapeutic impact is restricted by adverse drug events and response in terms of short and long term efficacy. There are multiple factors involved in different responses to antiretrovirals (ARVs) such as age, body weight, disease status, diet and heredity. Pharmacogenomics deals with individual genetic make-up and its role in drug efficacy and toxicity. In depth genetic research has provided evidence to predict the risk of developing certain toxicities for which personalized screening and surveillance protocols may be developed to prevent side effects. Here we describe the use of pharmacogenomics for optimal use of HAART (highly active antiretroviral therapy).

Urinary Metabolite Diagnostic and Prognostic Liquid Biopsy Biomarkers of Lung Cancer in Nonsmokers and Tobacco Smokers.

PURPOSE: Nonsmokers account for 10% to 13% of all lung cancer cases in the United States. Etiology is attributed to multiple risk factors including exposure to secondhand smoking, asbestos, environmental pollution, and radon, but these exposures are not within the current eligibility criteria for early lung cancer screening by low-dose CT (LDCT). EXPERIMENTAL DESIGN: Urine samples were collected from two independent cohorts comprising 846 participants (exploratory cohort) and 505 participants (validation cohort). The cancer urinary biomarkers, creatine riboside (CR) and N-acetylneuraminic acid (NANA), were analyzed and quantified using liquid chromatography-mass spectrometry to determine if nonsmoker cases can be distinguished from sex and age-matched controls in comparison with tobacco smoker cases and controls, potentially leading to more precise eligibility criteria for LDCT screening. RESULTS: Urinary levels of CR and NANA were significantly higher and comparable in nonsmokers and tobacco smoker cases than population controls in both cohorts. Receiver operating characteristic analysis for combined CR and NANA levels in nonsmokers of the exploratory cohort resulted in better predictive performance with the AUC of 0.94, whereas the validation cohort nonsmokers had an AUC of 0.80. Kaplan-Meier survival curves showed that high levels of CR and NANA were associated with increased cancer-specific death in nonsmokers as well as tobacco smoker cases in both cohorts. CONCLUSIONS: Measuring CR and NANA in urine liquid biopsies could identify nonsmokers at high risk for lung cancer as candidates for LDCT screening and warrant prospective studies of these biomarkers.

Characterization of Circulating Tumor Cells Using Imaging Flow Cytometry in Liver Disease Patients.

Background: Hepatocellular carcinoma (HCC) is asymptomatic at an early stage which delays its timely diagnosis and treatment. Circulating tumor cells (CTCs), derived from a primary or secondary tumor, may help in the management of HCC. Here, we evaluate and characterize CTCs in liver disease patients. Methods: In total, 65 patients, categorized into liver cirrhosis (LC) (n = 30) and HCC (n = 35), were enrolled. Using ImagestreamX MkII imaging flow cytometer, CTCs were detected and characterized using biomarker expression of EpCAM, CK, AFP, CD45, and DRAQ5 in LC and HCC patients. Results: CTCs were detected in 33/35 (94%) HCC patients and in 28/30 (93%) LC patients. In the HCC group, the number of biomarker-positive CTCs was higher in BCLC stage D when compared with others. EpCAM + CK was the most expressed biomarker on CTCs in LC versus HCC (83.3% vs. 77.14%), followed by AFP (80% vs. 65.71%), EpCAM (30% vs. 28.57%), and CK (16.6% vs. 14.28%). The EpCAM cell area was significantly associated (P value = 0.031) with the CTC-positive status. The combination biomarker expression of CTCs cell area (EpCAM, CK, and AFP) performed well with the area under the curve of 0.92, high sensitivity, and specificity in detecting early-stage and AFP-negative HCC as well as in AFP-negative LC cases. Conclusion: Enumeration and cell area of CTCs may be used as a biomarker for early detection of HCC and guiding treatment.

Melanoma-intrinsic NR2F6 activity regulates antitumor immunity.

Nuclear receptors (NRs) are implicated in the regulation of tumors and immune cells. We identify a tumor-intrinsic function of the orphan NR, NR2F6, regulating antitumor immunity. NR2F6 was selected from 48 candidate NRs based on an expression pattern in melanoma patient specimens (i.e., IFN-γ signature) associated with positive responses to immunotherapy and favorable patient outcomes. Correspondingly, genetic ablation of NR2F6 in a mouse melanoma model conferred a more effective response to PD-1 therapy. NR2F6 loss in B16F10 and YUMM1.7 melanoma cells attenuated tumor development in immune-competent but not -incompetent mice via the increased abundance of effector and progenitor-exhausted CD8+ T cells. Inhibition of NACC1 and FKBP10, identified as NR2F6 effectors, phenocopied NR2F6 loss. Inoculation of NR2F6 KO mice with NR2F6 KD melanoma cells further decreased tumor growth compared with NR2F6 WT mice. Tumor-intrinsic NR2F6 function complements its tumor-extrinsic role and justifies the development of effective anticancer therapies.

Innovative Betulin Nanosuspension exhibits enhanced anticancer activity in a Triple Negative Breast Cancer Cell line and Zebrafish angiogenesis model.

We present a nanosuspension of betulin, a BCS class II anticancer drug, particularly effective against resistant breast cancer. As anticancer efficacy of betulin is hampered by poor aqueous solubility, a nanosuspension with surface area was considered to enhance efficacy. An innovative approach wherein the betulin nanosuspension is generated instantaneously in situ, by adding a betulin preconcentrate (BeTPC) comprising drug and excipients, to aqueous medium, is successfully demonstrated. The optimal BeTPC when added to isotonic dextrose solution instantaneously generated an in situ nanosuspension (BeTNS-15) with high precipitation efficiency (92.7 ± 1.21%), average particle size (383.74 ± 7.24 nm) and good stability as per ICH guidelines. TEM revealed elongated particles while DSC and XRD indicated partial amorphization. Significantly higher cytotoxicity of BeTNS-15 (IC50 38.44 µg/ml) compared to betulin (BetS) (IC50 69.54 µg/ml) in the resistant triple negative human breast cancer cell line MDA-MB-231, was attributed to high intracellular uptake confirmed by HPLC and Imaging Flow cytometry (IFC). IFC confirmed superior anti-cancer efficacy of BeTNS-15 mediated by mitochondrial membrane disruption and inhibition of the G0/G1 phase. BeTNS-15 also exhibited significantly greater anti-angiogenic efficacy (p < 0.05) in the zebrafish model confirming superior efficacy. Simplicity of the innovative in situ approach coupled with superior efficacy proposes BeTNS as an innovative and highly promising anticancer formulation.

Applications of imaging flow cytometry in the diagnostic assessment of red cell membrane disorders.

BACKGROUND: Red cell membranopathies refers to phenotypically and morphologically heterogeneous disorders. High throughput imaging flow cytometry (IFC) combines the speed, sensitivity, and phenotyping abilities of flow cytometry with the detailed imagery and functional insights of microscopy to produce high content image analysis with quantitative analysis. We have evaluated the applications of IFC to examine both the morphology as well as fluorescence signal intensity in red cell membranopathies. METHODS: Fluorescence intensity of eosin-5-maleimide (EMA) labeled red cells was measured for diagnosis of RBC membrane protein defect on Amnis ImageStreamX followed by Image analysis on IDEAS software to study features such as circularity and shape ratio. RESULTS: The hereditary spherocytosis (HS) group showed significantly decreased MFI (52,800 ± 9,100) than normal controls (81,100 ± 4,700) (p < .05) whereas non-HS showed 78,300 ± 9,900. The shape ratio of hereditary elliptocytosis (HE) was significantly higher (43.8%) than normal controls (14.6%). The circularity score is higher in HS (64.15%) than the normal controls (44.3%) whereas the circularity score was very less in HE (10%) due to the presence of elliptocytes. CONCLUSIONS: The advantages of the IFC over standard flow cytometry is its ability to provide high-content image analysis and measurement of parameters such as circularity and shape ratio allow discriminating red cell membranopathies (HS and HE) due to variations in shape and size. It could be a single, effective, and rapid IFC test for detection and differentiation of red cell membrane disorders in hematology laboratories where an IFC is available.

Prevalence of Vitamin D Deficiency Amongst Indian Orthopaedic Surgeons.

BACKGROUND: Vitamin D deficiency is a widely prevalent condition with patients in both symptomatic and asymptomatic spectrum. With the lack of routine screening there exists an unknown population of Indian Orthopaedic surgeons who are deficient in Vitamin D and lead to an unexplained loss of quality of work and increased susceptibility to various other diseases. The easiest access to resources for supplementation is available to this group of treating physicians however its use for their personal cure is rarely recognised. This study aims to highlight this endemic disease and to find out its correlation with other parameters. METHODS: It is a prospective observational study including 150 practicing orthopaedic surgeons from entire India who visited our centre during 3 months duration for various educational meetings. Venous sample was collected after due informed consent and analysed at a single laboratory for 25-OH Cholecalciferol levels by a chemiluminescent assay. All the samples were analysed and a questionnaire was sent to the participants via google forms regarding various parameters under study. RESULTS: The mean serum Vitamin D levels were 18.6 ± 9.67 ng/ml in the sample studied. 17 out of 150 participants (11.3%) were found to have sufficient serum levels of 25(OH) Cholecalciferol. 105 participants (70%) were having deficient levels and 28 (18.7%) had insufficient levels of Vitamin D. Overall 88.7% participants had Vitamin D deficiency among the sample studied. CONCLUSION: This widespread prevalence of Vitamin D deficiency warrants frequent screening and routine supplementation of Vitamin D in orthopaedic surgeons thereby providing a low cost solution to improve the troublesome situation among healthcare providers.

Differentially expressed serum host proteins in hepatitis B and C viral infections.

Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection often lead to hepatocellular carcinoma (HCC), which is mostly detected in advanced stage. Hence, its early detection is of paramount importance using a biomarker having sensitivity and specificity both. The present study highlights differentially expressed host proteins in response to HBV/HCV infection at different stages. Comparative proteomic study was done by two-dimensional gel electrophoresis followed by mass spectrometry. Sera from each of chronically infected, liver cirrhosis and HCC in HBV or HCV infection along with controls were selected. Analysis of functional association between differentially expressed proteins with viral hepatitis was extensively carried out. Forty-three differentially expressed spots (≥ 1.5 fold; P < 0.05) on two-dimensional gel electrophoresis were corresponded to 28 proteins by mass spectrometry in variable liver diseases. Haptoglobin protein levels were decreased upon disease progression to HCC due to HBV infection. The other proteins expressed differentially are ceruloplasmin, serum paraoxonase 1, retinol binding protein and leucine rich alpha 2 proteins in plasma maybe associated to HBV HCC. Whereas, upregulation of C4a/C4b showed it as a reliable marker in patients with end stage liver disease related to HCV infection. ApolipoproteinA1 levels in liver diseases in both HBV and HCV infection corresponding to healthy controls may be a common marker for early diagnosis and disease monitoring. Protein interaction studies by extensive pathway analysis using bioinformatics tools such as EnrichNet application and STRING revealed significant associations with specific infections.

Analysis And Outcomes Of Plating Versus Nailing In Humerus Shaft Fractures A Prospective Comparative Study

Fractures of the humeral shaft are commonly encountered by orthopaedic surgeons, accounting for approximately 3% of all fractures [20]. Treatment methods for these injuries continue to evolve as advances are made in both non-operative and operative management. It is generally agreed that most fractures of humeral shaft are treated best non-operatively, although there are indications for primary or secondary operative treatment in some situations [8,18,19]. The encouraging results that have been reported with recent advances in internal fixation techniques and instrumentation have led to an expansion of surgical indications for such fractures and a dilemma about the procedure of choice.

Efficacy and safety of aceclofenac-cr and aceclofenac in the treatment of knee osteoarthritis: a 6-week, comparative, randomized, multicentric, double-blind study.

UNLABELLED: The efficacy and safety of aceclofenac control release (CR) tablets was compared with conventional aceclofenac tablets in patients with knee osteoarthritis (OA). This was a double-blind, double-dummy, randomized, parallel group multicentric study conducted at 6 centers. Two hundred and eighty five patients were randomized to either aceclofenac-CR (n = 143) once daily or conventional aceclofenac tablet (n = 142) twice daily and were followed for 6 weeks. The efficacy parameters were pain intensity score on visual analogue scale, Western Ontario and McMaster (WOMAC) score, patients and investigator's overall study drug assessment and total consumption of acetaminophen and ranitidine tablets. Both treatments showed significant improvement in their efficacy parameters from baseline at the end of therapy. Aceclofenac-CR was comparable to conventional aceclofenac with respect to change in pain intensity and WOMAC score (P > .05) There was no statistically significant difference between the treatment groups in patient's and investigator's overall study drug assessment at the end of therapy (P > .05). Aceclofenac-CR treated patients took fewer acetaminophen and ranitidine tablets during the treatment period as compared to conventional aceclofenac treated patients. Both the study medications were well tolerated with no incidence of serious adverse event (SAE). In conclusion, the new aceclofenac-CR formulation was found to be effective and safe while offering practical advantage of once daily administration. PERSPECTIVE: This article represents the advantages of control release aceclofenac over the conventional aceclofenac tablets. Aceclofenac-CR was found to be similar in terms of efficacy as conventional aceclofenac in knee OA patients with fewer adverse events.

Individualization of antiretroviral therapy - Pharmacogenomic aspect.

Combination therapy with three drug regimens for human immunodeficiency virus (HIV) infection significantly suppresses the viral replication. However, this therapeutic impact is restricted by adverse drug events and response in terms of short and long term efficacy. There are multiple factors involved in different responses to antiretrovirals (ARVs) such as age, body weight, disease status, diet and heredity. Pharmacogenomics deals with individual genetic make-up and its role in drug efficacy and toxicity. In depth genetic research has provided evidence to predict the risk of developing certain toxicities for which personalized screening and surveillance protocols may be developed to prevent side effects. Here we describe the use of pharmacogenomics for optimal use of HAART (highly active antiretroviral therapy).

Study of operative management for complex fracture of upper end of Humerus.

Background: Proximal humerus fractures are very common fractures occurring in the skeleton. They account for approximately 4 – 5% of the fracture attendance at the hospital. It is the most common fracture of shoulder girdle. It is the 3rd most common fracture in elderly. Till date various methods are used including percutaneous and open reduction & fixation according to fracture type. Aims & Objective: To study the occurrence, mechanism of injury and displacement of various types of fractures and different modalities of the fixations in proximal humerus fractures. Come to conclusion about preferred modality of treatment of proximal humerus fractures according to the pattern of fracture. Material and Methods: In present study 44 patients of complex fracture of proximal humerus treated with either open reduction internal fixation or percutaneous fixation from 2009 to 2012. Follow up assessment was done by Constant score. Results: Radiological union occur at about 8 to 12 weeks. Closed reduction and percutaneous k wire or cancellous screws fixation showed excellent results in majority cases of 3 -part fracture. All 4 part fractures are treated with ORIF. Open reduction and internal fixation with locking compression plates showed good results among all implants used. Conclusion: Principle of fixation is reconstruction of the articular surface, including the restoration of the anatomy, stable fixation, with minimal injury to the soft tissues preserving the vascular supply, should be applied. Majority of poor results are due to poor surgical techniques and lack early physiotherapy.

Study of results of ender nailing and cannulated cancellous screw in the treatment of intertrochanteric fracture femur.

Background: Intertrochanteric fracture of femur is one of the most common fractures seen in general population. Till date various fixation devices are used for fixation of this fracture that includes both extra medullary and intramedullary implants. Ender and Simon Weidner popularised the condylocephelic intramedullary nailing for this fracture. But it is seen that fracture treated by ender nailing alone resulted in varus malunion. Aims & Objective: Along with ender nail we added the cannulated cancellous screw which results in controlled collapse of the fracture with union in anatomic position. Material and Methods: We studied 50 patients of intertrochanteric fracture treated by ender nail and cannulated cancellous screw between year 2009 to 2011. Follow up assessment was done by Harris hip score. Results: The union achieved in mean time of 7 weeks. In study of 50 patients we obtained 86% excellent to good results. 14% patient had fair to poor results. Conclusion: We found that use of Ender nail and cannulated cancellous screw results in fracture union in more anatomical position with better patient compliance and early mobilization.

Effect of proximal femoral nailing in proximal third femur fracture.

Background: Proximal third femur fractures are common fractures seen in community. Till date large numbers of intramedullary and extramedullary implant were used in the treatment of these fractures. These fractures differ significantly from femoral shaft fractures and more proximal femoral fractures in mechanisms, treatment and complications. In 1996 AO group has introduced proximal femoral nail (PFN) for treatment of these fractures. The use of PFN in both these fractures resulted in rotational stability along with union in more anatomic position. Aims & Objective: To prove the advantages of PFN like (1) close reduction of fracture which decreases the blood loss and chance of infection; (2) controlled impaction of the fracture; (3) rotational stability; and (4) load bearing capacity of the implant. Material and Methods: We have done a retrospective study of proximal femur fractures operated with proximal femoral nailing at our institute with follow up of 5 – 36 months. Our study included 30 patients with 8 patients having intertrochanteric fracture and 22 patients having subtrochanteric fracture. Patient was asked to come for follow up on 1, 2, 3 and 6 months from the date of surgery. At each follow up patient was assessed clinically as per Harris Hip score12 and x ray AP/LAT view of hip with femur is taken. Results: It concludes that according to Boyd and Griffith classification type II is the most common variety. In our study excellent to good results noted in 74% patients. All of them performing their routine normal activity well. 5 patients had poor results. Complication rate in our study was much lower. There was only one infection which was known case of diabetes mellitus. Conclusion: The procedure takes less time and the patient can be mobilized fast postoperatively as well after fixation with PFN. PFN should always be considered for management of subtrochanteric fractures in young as well as elderly patients who have multiple pre-existing illnesses. PFN is a closed nailing procedure which achieves a Biological Fracture fixation with minimal blood loss, preserving the fracture hematoma and helping easy healing of the unstable subtrochanteric femoral fracture as well as intertrochanteric fracture.