Shrawan Kumar Singh

Apophysomyces elegans: an Emerging Zygomycete in India

ABSTRACT Apophysomyces elegans was considered a rare but medically important zygomycete. We analyzed the clinical records of eight patients from a single center in whom zygomycosis due to A. elegans was diagnosed over a span of 25 months. We also attempted a DNA-based method for rapid identification of the fungi and looked for interstrain polymorphism using microsattelite primers. Three patients had cutaneous and subcutaneous infections, three had isolated renal involvement, one had rhino-orbital tissue infection, and the final patient had a disseminated infection involving the spleen and kidney. Underlying illnesses were found in two patients, one with diabetes mellitus and the other with chronic alcoholism. A history of traumatic implantation was available for three patients. All except two of the patients responded to surgical and/or medical therapy; the diagnosis for the two exceptions was made at the terminal stage of infection. Restriction enzyme (MboI, MspI, HinfI) digestion of the PCR-amplified internal transcribed spacer region helped with the rapid and specific identification of A. elegans. The strains could be divided into two groups according to their patterns, with clustering into one pattern obtained by using microsatellite [(GTG)5 and (GAC)5] PCR fingerprinting. The study highlights the epidemiology, clinical spectrum, and diagnosis of emerging A. elegans infections.

Autophagy in Cancer Stem Cells: A Potential Link Between Chemoresistance, Recurrence, and Metastasis

Abstract Cancer cells require an uninterrupted nutritional supply for maintaining their proliferative needs and this high demand in concurrence with inadequate supply of blood and nutrition induces stress in these cells. These cells utilize various strategies like high glycolytic flux, redox signaling, and modulation of autophagy to avoid cell death and overcome nutritional deficiency. Autophagy allows the cell to generate ATP and other essential biochemical building blocks necessary under such adverse conditions. It is emerging as a decisive process in the development and progression of pathophysiological conditions that are associated with increased cancer risk. However, the precise role of autophagy in tumorigenesis is still debatable. Autophagy is a novel cytoprotective process to augment tumor cell survival under nutrient or growth factor starvation, metabolic stress, and hypoxia. The tumor hypoxic environment may provide site for the enrichment/expansion of the cancer stem cells (CSCs) and successive rapid tumor progression. CSCs are characteristically resistant to conventional anticancer therapy, which may contribute to treatment failure and tumor relapse. CSCs have the potential to regenerate for an indefinite period, which can impel tumor metastatic invasion. From last decade, preclinical research has focused on the diversity in CSC content within tumors that could affect their chemo- or radio-sensitivity by impeding with mechanisms of DNA repair and cell cycle progression. The aim of this review is predominantly directed on the recent developments in the CSCs during cancer treatment, role of autophagy in maintenance of CSC populations and their implications in the development of promising new cancer treatment options in future.

Tamsulosin Facilitates Earlier Clearance of Stone Fragments and Reduces Pain After Shockwave Lithotripsy for Renal Calculi : Results From an Open-Label Randomized Study

OBJECTIVES To evaluate the role of tamsulosin in the clearance of fragments after extracorporeal shock wave lithotripsy (ESWL) to treat renal calculi. METHODS In this open-label prospective randomized study conducted at our institute from 2006 to 2007, 139 patients with normal renal function and a single radiopaque renal calculus, 5-20 mm, undergoing ESWL were enrolled. All patients underwent ESWL every 3 weeks until success or for <or=3 months, whichever was earlier. They were randomly assigned to 2 groups with respect to whether they had received tamsulosin, 0.4 mg/d. The primary endpoint was the success rate, and the secondary endpoints were clearance time, sessions required for clearance, pain intensity, incidence of steinstrasse, and the need for auxiliary procedures. RESULTS Of the 139 patients, 51 in group 1 and 65 in group 2 completed the requisite follow-up. The demographic profile of both groups was comparable. The success rate after 1, 2, and 3 ESWL sessions was greater in group 1 than in group 2 (52.9%, 78.4%, and 94.1% vs 30.8%, 52.3%, and 75.4%; P = .016, P = .004, and P = .007, respectively). The total days required for success (35.53 +/- 19.47 vs 47.22 +/- 23.64; P = .006), total ESWL sessions required for success (1.66 vs 2.16; P = .005), and the pain experienced (visual analog scale score 28.67 +/- 20.35 vs 47.30 +/- 24.98, respectively; P = .0001) were significantly less in group 1. Two patients in group 1 and 9 in group 2 developed steinstrasse (P = .10); conservative management was successful in 1 patient in each group (P = .345). Three patients in group 1 and 10 in group 2 required auxiliary procedures (P = .14). CONCLUSIONS The results of our study have shown that tamsulosin facilitates earlier clearance of fragments after ESWL to renal calculi and helps reduce the severity of the pain. It tended to facilitate spontaneous clearance of steinstrasse; however, this requires additional evaluation.

Urodynamic Profile of Diabetic Patients With Lower Urinary Tract Symptoms: Association of Diabetic Cystopathy With Autonomic and Peripheral Neuropathy

OBJECTIVES To evaluate the association between diabetic cystopathy (DC) and neuropathy (autonomic and peripheral) in patients with diabetes mellitus (DM) presenting with lower urinary tract symptoms (LUTS). METHODS Men with DM who presented with bothersome LUTS were enrolled from January 2008 to June 2009. Their demographic and clinical profiles were noted. Multichannel urodynamic studies were performed using the Solar Silver digital urodynamic apparatus. Hand and foot sympathetic skin responses, and motor and sensory nerve-conduction velocity studies were performed using the Meditronic electromyographic/evoked potentials system. RESULTS A total of 52 men (mean age 61.3 ± 12.1 years, DM duration 11.0 ± 7.5 years) completed the study protocol. Of these 52 men, abnormal sympathetic skin responses, motor and sensory nerve-conduction velocity studies, and combined neuropathy (all 3 tests abnormal) were noted in 80.7% 57.7%, 57.7%, and 51.9%, respectively. Urodynamic studies showed impaired first sensation (>250 mL), increased capacity (>600 mL), detrusor underactivity, detrusor overactivity, high postvoid residual urine volume (more than one third of capacity), and bladder outlet obstruction (Abrams-Griffiths number >40) in 23.1%, 25.0%, 78.8%, 38.5%, 65.4%, and 28.8% of the men, respectively. Both sensory and motor DC correlated with abnormal motor and sensory nerve-conduction velocity studies (P = .015 and P = .005, respectively). Only motor DC correlated with abnormal sympathetic skin responses (P = .015). The correlations were stronger in the presence of combined neuropathy (sensory DC, P = .005; motor DC, P = .0001). CONCLUSIONS Men with DM and LUTS can present with varied urodynamic findings, apart from the classic sensory or motor cystopathy. A large proportion of these patients will have electrophysiologic evidence of neuropathy, and electrophysiologic evidence of neuropathy can moderately predict the presence of cystopathy.

One Week of Nitrofurantoin Before Percutaneous Nephrolithotomy Significantly Reduces Upper Tract Infection and Urosepsis: A Prospective Controlled Study

OBJECTIVES To evaluate the role of nitrofurantoin (NFT) prophylaxis in a prospective randomized control study. Urosepsis is an important complication after percutaneous nephrolithotomy (PNL). Risk increases by around 4 times with larger stones and hydronephrosis (HDN). MATERIAL AND METHODS Patients with stones ≥2.5 cm and/or HDN and sterile urine undergoing PNL were randomized into 2 groups. Standard perioperative antibiotic prophylaxis was the same in both groups. One group received sustained-released NFT 100 mg b.i.d. for 7 days preoperatively, and the other did not. Preoperative urine, intraoperative renal pelvic urine, and stone cultures were obtained. Postoperative occurrence of SIRS was considered urosepsis after excluding other causes. Serum samples were collected immediately after PNL and stored at -20°C. Serum endotoxin was estimated using Limulus Amoebocyte Lysate gelation technique (Sigma Aldrich, Saint Louis, Missouri). The operating surgeons and the microbiologist were blinded to the group distribution. RESULTS Of 101 patients, 48 received nitrofurantoin prophylaxis. Both groups were comparable for age, gender, stone burden, degree of HDN, duration of operation, and intraoperative blood loss. There was significantly low positive pelvic urine culture (0% vs 9.8%, RR 4.95, P = .001), positive stone culture (8.3% vs 30.2%, RR 3.64, P = .001), endotoxemia (17.5% vs 41.9%, OR 0.22, P = .016), and systemic inflammatory response system (19% vs 49%, OR 0.31, P = .01) in patients receiving NFT prophylaxis. CONCLUSIONS Prophylaxis with NFT for a week before PNL is beneficial in the prevention of urosepsis and endotoxemia in patients with larger stones and HDN. NFT covers most of the urinary isolates and is preferred in areas of fluoroquinolone resistance.

Biochemical and molecular markers in renal cell carcinoma: an update and future prospects

Abstract Cancer is a big problem in the developed world as well as in developing countries. Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies and 90–95% of neoplasms arising from the kidney. RCC is more common in men than in women (2:1), and it most often occurs in patients between the ages of 50–70 years. In all cancers the cancerous cells release particular kind of proteins (called tumour markers) and blood tests are used to detect the presence of these markers. These tumour markers nowadays are an area of interest for oncologists who search for a possible solution in the detection and treatment of RCC. Different kinds of biochemical and molecular markers such as ferritin, MN/CA9, apoptotic index, p53, IL-2, gamma-enolase, CD44, CD95, chromosome instability and loss of heterozygosity have been tested in RCC, but so far no marker fulfils one or the other criteria to be considered as an ideal marker for RCC. This review gives basic and updated information about the different kinds of biomarkers studied in RCC and about the role implementation of genomics and proteomics in RCC.

CT in the Evaluation of Complicated Autosomal Dominant Polycystic Kidney Disease

Purpose: We retrospectively reviewed the CT findings in 24 cases of autosomal dominant polycystic kidney disease (ADPKD) to assess the role of CT in the diagnostic work-up of patients with complicated ADPKD. Material and Methods: Twenty-four patients with ADPKD underwent unenhanced and contrast-enhanced CT for flank pain, haematuria, or fever. The images were retrospectively reviewed for presence of complicated cysts, their morphological features and associated findings in the perinephric space/retroperitoneum. Results: Cyst haemorrhage was present in all patients, seen as high-density cysts, which were mostly bilateral. Most of these cysts had sharply outlined contours, sharp interfaces with adjacent renal parenchyma, imperceptible walls, and homogeneous density, and did not enhance following i.v. contrast administration. However, a few haemorrhagic cysts (9 cysts in 6 patients) showed inhomogeneous density (n = 7), dependent layering of high-density blood leading to fluid-fluid level (n = 2), and contour irregularity (n = 3). CT revealed presence of cyst infection in 6 cases; the involved cysts were larger (average size 4.2 cm) than adjacent cysts, had only a mildly increased or near water density, and showed wall thickening and enhancement. Other findings included air within the infected cyst (n = 1), thickening and enhancement of peri- and paranephric fasciae (n = 5), and abscesses in the posterior paranephric space and adjoining psoas muscle (n = 2). In 2 other patients, although CT suggested cyst infection because of presence of wall enhancement, diagnostic needle aspiration revealed only sterile haemorrhagic fluid. In 1 case, CT revealed a soft tissue density enhancing mass in one of the cysts; this proved to be a renal cell carcinoma by fine-needle biopsy. Calculi were observed in 7 patients, and cyst wall calcification in 11 cases. Conclusion: A combination of unenhanced and contrast-enhanced CT allows correct diagnosis and differentiation amongst the various complications affecting patients with ADPKD. However, in a small subgroup of patients, it may not be possible to differentiate between haemorrhage and infection; such cases require diagnostic needle aspiration for diagnosis.

Autophagy inhibition suppresses the tumorigenic potential of cancer stem cell enriched side population in bladder cancer.

The mechanisms that underlie tumor formation and progression have not been elucidated in detail in cancer biology. Recently, the identification of a tumor cell subset defined as cancer stem cells (CSCs), which is enriched for tumor initiating capacity, has engendered new perspectives towards selective targeting of tumors. In this study, we isolated the side population (SP) cells which share characteristics of CSCs from bladder cancer cell lines, T24 and UM-UC-3 by fluorescence activated cell sorting. The cells were cultured in serum free medium and expression profile of stem cell like markers (SOX-2, NANOG, KLF-4 and OCT-4), drug resistant genes (ABCG2 and MDR1) and spheroid forming capability were examined in SP, non-side population (NSP) and bulk T24 and UM-UC-3 cells. We observed that SP cells possessed a higher mRNA expression of SOX-2, NANOG, KLF-4, OCT-4, ABCG2, and MDR1 as well as a higher spheroid forming ability as compared to other bulk cells or NSP cells. The SP cells had low ROS levels and high GSH/GSSG ratio which may contribute to radio-resistance. The SP cells also showed substantial resistance to gemcitabine, mitomycin and cisplatin compared with the NSP counterpart. A high autophagic flux was observed in the SP cells. Both pharmacological and siRNA mediated inhibition of autophagy potentiated the chemotherapeutic effects of gemcitabine, mitomycin and cisplatin in these cells. We concluded that the ABCG2 expressing SP cells show autophagy associated cell survival and may be a potent target for developing more effective treatment in bladder carcinoma to enhance patient survival.

Is There an Adjunctive Role of Tamsulosin to Extracorporeal Shockwave Lithotripsy for Upper Ureteric Stones: Results of an Open Label Randomized Nonplacebo Controlled Study

OBJECTIVES To investigate the role of tamsulosin as an adjunct to management of upper ureteric stones (UUS) with extracorporeal shock wave lithotripsy (SWL). METHODS In this prospective, randomized, open label study, patients with single UUS (for SWL) were randomly assigned into 2 groups based on whether they received 0.4 mg tamsulosin (group A and B, respectively) during treatment. Repeat SWL was performed at week 1, 3, and 5 after first session. Primary outcome variables were success rate and pain intensity. RESULTS A total of 40 patients (20 each group) completed the requisite follow-up. Success rate was higher in group A after 1 SWL-session (55% vs 25%, respectively; P = .05). There was an insignificant trend of decreased number of days (30.7 +/- 19.7 vs 39.0 +/- 19.9; P = .19), number of SWL sessions (1.6 vs 2.0; P = .10), and pain experienced (score on visual analog scale, 25.3 +/- 17.9 vs 38.3 +/- 28.0, respectively; P = .41) in group A. Three in group A and 6 in B developed steinstrasse (P = .69). Overall, 1 in group A required auxiliary procedures as compared with 3 in control group (P = .60). CONCLUSIONS Tamsulosin improves clearance rate of UUS after single SWL. However, it does not provide significant advantage in terms of decreasing pain associated with this treatment.

Role of Tamsulosin, Tadalafil, and Silodosin as the Medical Expulsive Therapy in Lower Ureteric Stone: A Randomized Trial (a Pilot Study)

OBJECTIVE To evaluate the role of 2 different α-1 blockers and 1 phosphodiesterase-5 inhibitor as medical expulsive therapy for distal ureteric calculi. MATERIALS AND METHODS Between January 2011 and December 2012, 285 patients presenting with distal ureteric stones of size 5-10 mm were on consent randomly assigned to 1 of 3 outpatient treatment arms: tamsulosin (group A), silodosin (group B), and tadalafil (group C). Therapy was given for a maximum of 4 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up, and endoscopic treatment and adverse effects of drugs were noted. All 3 groups were compared for normally distributed data by the analysis of variance, Bonferroni or Kruskal-Wallis test, and Mann-Whitney U test, as required. All the classified and categorical data were analyzed for all 3 groups by using the chi-square test. RESULTS There was a statistically significant expulsion rate of 83.3% in group B compared with 64.4% and 66.7% in groups A and C, respectively, with lower time of stone expulsion (P value = .006 and P value = .016, respectively). Statistically significant differences were noted in colicky episodes and analgesic requirement in group B than groups A and C. There was no serious adverse event. CONCLUSION Medical expulsive therapy for the distal ureteric stones using tamsulosin, silodosin, and tadalafil is safe, efficacious, and well tolerated. The result of this pilot study showed that silodosin increases ureteric stone expulsion quite significantly along with better control of pain with significantly lesser analgesic requirement.