Comparison of Perioperative Complication Rates of Total Extraperitoneal and Transabdominal Preperitoneal Repairs in Primary Inguinal Hernia.

Background: Hernia may be defined as a protrusion of viscus through layers anatomically designed to contain that viscus. Most abdominal hernias occur at well-described sites of potential weakness. Repair of inguinal hernia is one of the most common operations in general surgery. Objectives: To compare the perioperative complication rates of total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs of primary inguinal hernias. Materials and Methods: It is a randomised comparative study, conducted at the department of general surgery. A total of 50 patients were included and divided into two groups with 25 in each. Group A represents the laparoscopic TEP repair and group B represents the laparoscopic TAPP repair. Patients above 18 years with primary unilateral inguinal hernia were included. Patients having complicated inguinal hernia and history of previous abdominal surgery were excluded. Results: We observed that hernia occurrence is more common in the 31-50 years of age group and right-sided hernia is more common. Scrotal oedema and conversion to open surgery chances are similar in both TEP and TAPP groups. The duration of surgery in TEP is significantly higher as compared to TAPP. Patients who underwent TEP experienced less pain as compared to TAPP as per visual analogue scale. Postoperative hospital stay and time taken to resume the routine activity were significantly less in case of TEP. Conclusion: TEP is preferred over TAPP for laparoscopic hernia repair because it preserves the peritoneal integrity and has lesser postoperative pain. The early recovery and return to the routine work were seen with the patient treated with the TEP and also showed better visual analogue score than the TAPP repair group.

Comparative Study of Different Treatment Options of Grade III and IV Diabetic Foot Ulcers to Reduce the Incidence of Amputations.

THIS STUDY AIMS TO COMPARE THE EFFICACY OF ANTISEPTIC DRESSINGS, HYPERBARIC OXYGEN THERAPY, AND RECOMBINANT HUMAN PLATELET DERIVED GROWTH FACTOR (RHPDGF) FOR TWO REASONS: i) to reduce the incidence of lower limb amputations in diabetic foot ulcer; ii) to limit the duration of stay in the hospital. A prospective randomized trial was conducted on 60 patients with stage III and IV diabetic foot ulcers (International Association of Enterostomal Therapy classification) and patients were divided randomly in three different therapy groups - antiseptics, hyperbaric oxygen therapy, recombinant platelet derived growth factor, with 20 patients in each group. Patients were managed initially on inpatient and then on outpatient basis till the ulcer healed completely. Results among three groups were compared using unpaired T test and the level of significance was set at P<0.05 using ANOVA. This study compares the efficacy of hyperbaric oxygen therapy, antiseptic dressings, and rhPDGF in grade III and IV diabetic foot ulcers. P value (0.0348) was significant for complete wound contraction while p value healing time (0.6534) and ulcer size (0.0593) in the groups was not significant. PDGF is safe, effective and easy to apply. Results are comparable with hyperbaric oxygen (HBO) therapy and cost of treatment is lower than other therapies. Diabetic foot ulcer management requires multidisciplinary and aggressive approach. PDGF should be recommended for all grade III and IV diabetic foot ulcer at least 8 weeks old. HBO is equally good an option but has limitations and side effects.

Dose-dependent changes in the locomotor responses to methamphetamine in BALB/c mice: low doses induce hypolocomotion.

The overall goal of the present study was to determine the effects of different doses of (+)-methamphetamine (meth) on locomotor activity of Balb/C mice. Four experiments were designed to test a wide range of meth doses in BALB/c female mice. In Experiment 1, we examined locomotor activity induced by an acute administration of low doses of meth (0.01 and 0.03mg/kg) in a 90-min session. Experiment 2 was conducted to test higher meth doses (0.3-10mg/kg). In Experiment 3, separate sets of mice were pre-treated with various meth doses once or twice (one injection/week) prior to a locomotor challenge with a low meth dose. Finally, in Experiment 4, we tested whether locomotor activation would be affected by pretreatment with a low or moderate dose of meth one month prior to the low meth dose challenge. Results show that low doses of meth induce hypolocomotion whereas moderate to high doses induce hyperlocomotion. Prior exposure to either one moderate or high dose of meth or to two, low doses of meth attenuated the hypolocomotor effect of a low meth dose one week later. This effect was also attenuated in mice tested one month after administration of a moderate meth dose. These results show that low and high doses of meth can have opposing effects on locomotor activity. Further, prior exposure to the drug leads to tolerance, rather than sensitization, of the hypolocomotor response to low meth doses.

Spontaneous rupture of kidney: a rare presentation of nephrolithiasis.

Spontaneous rupture of kidney is a rare clinical entity. A 35-year-old female presented in emergency with left flank pain and features suggestive of haemorrhagic shock. Investigations showed rupture of kidney with perinephric haematoma. Emergency left nephrectomy was done. Patient was discharged in satisfactory condition. Nephrolithiasis with secondary bacterial infection rarely presents as spontaneous kidney rupture. In presence of haemorrhagic shock management is emergency surgery.

Vaccines for cocaine abuse.

Treatments for cocaine abuse have been disappointingly ineffective, especially in comparison with those for some other abused substances. A new approach, using vaccination to elicit specific antibodies to block the access of cocaine to the brain, has shown considerable promise in animal models, and more recently in human trials. The mechanism of action for the antibody effect on cocaine is very likely to be the straightforward and intuitive result of the binding of the drug in circulation by antibodies, thereby reducing its entry into the central nervous system and thus its pharmacological effects. The effectiveness of such antibodies on drug pharmacodynamics is a function of both the quantitative and the qualitative properties of the antibodies, and this combination will determine the success of the clinical applications of anti-cocaine vaccines in helping addicts discontinue cocaine abuse. This review will discuss these issues and present the current developmental status of cocaine conjugate vaccines.

Substance abuse vaccines.

Conventional substance-abuse treatments have only had limited success for drugs such as cocaine, nicotine, methamphetamine, and phencyclidine. New approaches, including vaccination to block the effects of these drugs on the brain, are in advanced stages of development. Although several potential mechanisms for the effects of antidrug vaccines have been suggested, the most straightforward and intuitive mechanism involves binding of the drug by antibodies in the bloodstream, thereby blocking entry and/or reducing the rate of entry of the drug into the central nervous system. The benefits of such antibodies on drug pharmacodynamics will be influenced by both the quantitative and the qualitative properties of the antibodies. The sum of these effects will determine the success of the clinical applications of antidrug vaccines in addiction medicine. This review will discuss these issues and present the current status of vaccine development for nicotine, cocaine, methamphetamine, phencyclidine, and morphine.

The future of vaccines in the management of addictive disorders.

Conventional substance abuse treatments have had only limited success. As a result, new approaches, including vaccination to block the effects of drugs such as cocaine, nicotine, methamphetamine, and phencyclidine, are in development. Although a number of possible rationales for the effects of antidrug vaccines have been suggested, the most straightforward and intuitive mechanism would involve binding of the drug by antibodies in the bloodstream, thereby blocking entry or reducing the rate of entry of the drug into the central nervous system. The theoretical parameters that would influence vaccine-induced drug pharmacodynamics are presented in this review, along with the current status on vaccine development for nicotine, cocaine, methamphetamine, and phencyclidine.

Activation of refractory T cell responses against hepatitis C virus core protein by ablation of interfering hydrophobic domains.

Hepatitis C virus (HCV) is the major pathogen of chronic hepatitis and liver disease, but currently there are no prophylactic HCV vaccines available. The HCV core protein-encoding sequence is among the most conserved genes in the HCV genome, making it a prime candidate for a component of a vaccine. The core protein localizes to the endoplasmic reticulum (ER) through a C-terminal hydrophobic region that is cotranslationally inserted into the ER membrane. Here we show that removal of the C-terminal hydrophobic region confers nuclear localization and enhances proteasomal degradation of the core protein in mammalian cells. This efficient protein proteolysis induces enhanced core-specific CD8(+) T cell responses in BALB/c mice immunized with plasmids expressing C-terminal deletions of the HCV core protein. These results suggest that more potent HCV vaccines can be achieved by targeting the core protein for proteasomal degradation by deletion of its C-terminal hydrophobic domain.

Re-engineered CD40 receptor enables potent pharmacological activation of dendritic-cell cancer vaccines in vivo.

Modest clinical outcomes of dendritic-cell (DC) vaccine trials call for the refinement of DC vaccine design. Although many potential antigens have been identified, development of methods to enhance antigen presentation by DCs has lagged. We have engineered a potent, drug-inducible CD40 (iCD40) receptor that permits temporally controlled, lymphoid-localized, DC-specific activation. iCD40 is comprised of a membrane-localized cytoplasmic domain of CD40 fused to drug-binding domains. This allows it to respond to a lipid-permeable, high-affinity dimerizer drug while circumventing ectodomain-dependent negative-feedback mechanisms. These modifications permit prolonged activation of iCD40-expressing DCs in vivo, resulting in more potent CD8(+) T-cell effector responses, including the eradication of previously established solid tumors, relative to activation of DCs ex vivo (P < 0.01), typical of most clinical DC protocols. In addition, iCD40-mediated DC activation exceeded that achieved by stimulating the full-length, endogenous CD40 receptor both in vitro and in vivo. Because iCD40 is insulated from the extracellular environment and can be activated within the context of an immunological synapse, iCD40-expressing DCs have a prolonged lifespan and should lead to more potent vaccines, perhaps even in immune-compromised patients.

Differential activation of ERK, p38, and JNK required for Th1 and Th2 deviation in myelin-reactive T cells induced by altered peptide ligand.

Autoreactive T cells can be induced by altered peptide ligands to switch Th1 and Th2 phenotypes. The underlying molecular mechanism is critical for understanding of activation of autoreactive T cells and development of novel therapeutic strategies for autoimmune conditions. In this study, we demonstrated that analog peptides of an immunodominant epitope of myelin basic protein (residues 83-99) with alanine substitution at Val(86) and His(88) had a unique partial agonistic property in the induction of Th1 or Th2 deviation in MBP(83-99)-reactive T cell clones typical of Th0 phenotype. The observed phenotypic switch involved differential activation of ERK, p38, and JNK MAPKs. More specifically, Th1 deviation induced by peptide 86V-->A (86A) correlated with enhanced p38 and JNK activities, while Th2 deviation by peptide 88H-->A (88A) was associated with up-regulated ERK activity and a basal level of p38 and JNK activity. Further characterization revealed that a specific inhibitor for ERK selectively prevented Th2 deviation of MBP(83-99)-specific T cells. Conversely, specific inhibitors for p38 and JNK blocked Th1 deviation in the same T cell preparations induced by peptide 86A. The findings have important implications in our understanding of regulation of ERK, p38, and JNK by altered peptide ligands and their role in cytokine regulation and phenotype switch of autoreactive T cells.

Repertoire and immunofocusing of CD8 T cell responses generated by HIV-1 gag-pol and expression library immunization vaccines.

Several gene-based vaccine approaches are being tested to drive multivalent cellular immune responses to control HIV-1 viral variants. To compare the utility of these approaches, HLA-A*0201 transgenic mice were genetically immunized with plasmids encoding wild-type (wt) gag-pol, codon-optimized (CO) gag-pol, and an expression library immunization (ELI) vaccine genetically re-engineered to express non-CO fragments of gag and pol fused to ubiquitin for proteasome targeting. Equimolar delivery of each vaccine into HLA-A*0201 transgenic mice generated CD8 T cell responses, with the ELI vaccine producing up to 10-fold higher responses than the wt or CO gag-pol plasmids against cognate and mutant epitopes. All three vaccines generated multivalent CD8 responses against varying numbers of epitopes after priming. However, when the animals were immunized again, the wt and CO gag-pol vaccines boosted only the responses against a subset of epitopes and attenuated the responses against all other Ags including epitopes from clade and drug-resistant viral variants. In contrast, the ELI vaccine boosted CD8 responses against all of the gag-pol Ags and against mutant epitopes from clade and drug-resistant variants. These data suggest that HIV-1 vaccines expressing structurally intact gag and pol proteins drive immunofocused CD8 responses that reduce the repertoire of T cell responses. In contrast, the genetically re-engineered ELI vaccine appears to better maintain the multivalent CD8 responses that may be required to control HIV-1 viral variants.

Expression library immunization to discover and improve vaccine antigens.

Genetic immunization is a novel method for vaccination in which DNA is delivered into the host to drive both cellular and humoral immune responses against its protein product. While genetic immunization can be potent, it requires that one have, in hand, a gene that encodes a protective protein antigen. Therefore, for many diseases, one cannot make a genetic vaccine because no protective antigen is known or no gene for this antigen is available. This lack of candidate antigens and their genes is a considerable bottleneck in developing new vaccines against old infectious agents, new emerging pathogens, and bioweapons. To address this limitation, we developed expression library immunization (ELI) as a high-throughput technology to discover vaccine candidate genes at will, by using the immune system to screen the entire genome of a pathogen for vaccine candidate. To date, ELI has discovered new vaccine candidates from a diverse set of bacterial, fungal, and parasitic pathogens. In addition, the process of applying ELI to the genome of pathogens allows one to genetically re-engineer these antigens to convert immunoevasive pathogen proteins into immunostimulatory vaccine antigens. Therefore, ELI is a potent technology to discover new vaccines and also generate genomic vaccines with amplified, multivalent immunostimulatory capacities.

The role of T cell antagonism and original antigenic sin in genetic immunization.

To counter highly mutable pathogens like HIV-1, a number of vaccines are being developed to deliver multiple mutant forms of viral Ags to provoke multivalent antiviral CTLs. However, it is uncertain whether such multiple mutant epitope vaccines will generate the diverse CTL responses desired or will instead create immune interference. To characterize the role of immune interference by mutant epitopes in this process, we have tested a "worst case" scenario in which the immunodominant epitope of OVA (SIINFEKL) and its in vitro TCR antagonist (SIINFEDL) have been used to genetically immunize C57BL/6 mice. We demonstrate here that sequential delivery of these mutant epitopes provokes original antigenic sin in CD8 T cells as demonstrated by attenuation of CTLs, intracellular IFN-gamma production, and MHC I peptide-tetramer staining. By contrast, simultaneous exposure of the immune system to this agonist/antagonist pair not only fails to generate T cell antagonism in vivo, but also avoids original antigenic sin. These observations suggest that simultaneous immunization with vaccines containing mutant epitopes, even T cell antagonists, can indeed generate a diverse array of T cell responses and that at least some immune interference can be avoided by delivering mutant Ags to the immune system simultaneously.

Generation of genome-wide CD8 T cell responses in HLA-A*0201 transgenic mice by an HIV-1 ubiquitin expression library immunization vaccine.

HIV-1 is a fundamentally difficult target for vaccines due to its high mutation rate and its repertoire of immunoevasive strategies. To address these difficulties, a multivalent, proteasome-targeted, live genetic vaccine was recently developed against HIV-1 using the expression library immunization approach. In this HIV-1 vaccine all open reading frames of HIV-1 are expressed from 32 plasmids as Ag fragments fused to the ubiquitin protein to increase Ag targeting to the proteasome to enhance CTL responses. In this work we demonstrate the ability of the HIV-1 library vaccine to simultaneously provoke robust HLA-A*0201-restricted T cell responses against all 32 HIV-1 library vaccine Ags after single immunization by gene gun. These CD8 T cell responses included HLA-A*0201-restricted CTL activity, CD8/IFN-gamma T cell responses, and HLA tetramer binding against defined immunodominant epitopes in gag, pol, env, and nef as well as potent CD8/IFN-gamma responses against undefined HLA-A*0201-restricted epitopes in all remaining Ags of the library. CD8 responses mediated by single gag, pol, env, and nef plasmids from the vaccine demonstrated little reduction in specific T cell responses when these plasmids were diluted into the context of the full 32-plasmid library, suggesting that Ag dominance or immune interference is not an overt problem to limit the efficacy of this complex vaccine. Therefore, this work demonstrates the ability of the HIV-1 library vaccine to generate robust multivalent genome-wide T cell responses as one approach to control the highly mutable and immunoevasive HIV-1 virus.