Nederlandse samenvatting
Nederlandse samenvatting Het Hodgkin lymfoom (HL) is een maligniteit van B cellen die uit het kiemcentrum afkomstig zijn. HL heeft een karakteristiek fenotype met een minderheid van tumorcellen in een achtergrond van reactieve cellen. HL kan worden onderverdeeld in twee subtypen, het klassieke HL en de nodulair lymfocyten predominante variant. De tumor cellen van de klassieke variant staan bekend als Hodgkin Reed Sternberg (HRS) cellen. Op basis van de kenmerken van de HRS cellen en de karakteristieken van de reactieve cellen wordt de klassieke variant verder onderverdeeld in de nodulair scleroserende (NS), gemengdcellige (MC), lymfocytenrijke en lymfocytenarme subtypes. In 30-40% van de klassieke HL gevallen in West Europa zijn de HRS cellen positief voor het Epstein Barr virus (EBV). EBV+ HL is sterk geassocieerd met het MC subtype, terwijl EBV- HL vooral voorkomt bij de NS variant. In tegenstelling tot de meeste andere kankers, zien we bij HL een bimodale incidentie curve. De eerste piek bij jong volwassenen in de leeftijd van 15 tot 30 jaar bestaat vooral uit EBV- HL van het NS subtype. De tweede piek zien we na de leeftijd van 50 jaar en deze HL patiënten hebben vaak EBV+ HRS cellen en een MC of NS subtype. Daarnaast hebben jonge kinderen ook vaak EBV+ en MC subtype HL. Op basis van eerder onderzoek is het duidelijk dat er een genetische component is die het risico op het krijgen van HL beïnvloedt. Met name de HLA regio en specifieke klassieke HLA allelen zijn geassocieerd met HL. Het doel van dit promotie onderzoek is om het risico- of beschermingseffect van specifieke HLA allelen op het ontwikkelen van HL verder te onderzoeken. Dit is gedaan voor de totale HL populatie en ook voor specifieke subgroepen gebaseerd op EBV status en leeftijd. Hoofdstuk 2 is een samenvatting van de bestaande literatuur met betrekking tot genetische varianten die geassocieerd zijn met HL of specifieke subgroepen. Daarnaast wordt de literatuur over het effect van genetische varianten op prognose, behandelrespons en secundaire toxiciteit samengevat. Ruwweg zijn er twee benaderingen te onderscheiden, dit zijn de gen specifieke benaderingen en de genoom brede studies. Bij de gen specifieke studies is er vooral veel onderzoek gedaan naar de HLA genen en associaties in de HLA regio werden ook gevonden in genoom brede studies. De HLA klasse I regio is sterk geassocieerd met EBV+ HL, en de klasse II regio met EBV- HL en met de totale HL groep. De genetisch associaties met andere gen loci op het genoom werden niet terug gevonden in de genoom brede associaties studies. Studies over genetische varianten geassocieerd met prognose, behandelrespons en secundaire toxiciteit lieten slechts enkele associaties zien die over het algemeen nog niet gevalideerd zijn in onafhankelijke studies.
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Nederlandse samenvatting In hoofdstuk 3 hebben we gekeken welke HLA allelen geassocieerd zijn met de hele, de EBV+ of de EBV- HL groepen. Twee allelen, HLA-B*51/52 (B5) en HLADRB1*07 waren geassocieerd met de totale HL groep. HLA-B5 dragers hadden een verhoogd risico terwijl HLA-DRB1*07 dragers een verlaagd risico hadden op HL. In de EBV- groep waren de allel frequenties van HLA-DRB1*11/12 (DR5) en van HLADRB1*15/16 (DR2) significant verhoogd in vergelijking met controles. In EBV+ HL vonden we een verhoogde allel frequentie van HLA-A*01, HLA-B*37 en HLADRB1*10 ten opzichte van de controles. Deze drie allelen vormen een haplotype dat relatief veel voorkomt in de westerse populatie en de gevonden associaties zijn dus mogelijk van elkaar afhankelijk. De frequentie van het HLA-A*02 allel was significant verlaagd in de EBV+ HL groep. Het risico effect van HLA-A*01 en het beschermende effect van HLA-A*02 voor de ontwikkeling van EBV+ HL is consistent met het verschil in affiniteit van deze twee allelen voor EBV afkomstige antigene peptiden. In hoofdstuk 4 hebben we de HLA susceptibiliteit onderzocht in relatie tot de leeftijd bij diagnose van de HL patiënten. De HLA-DRB1*15 HLA-DQB1*06 allel frequenties waren significant verhoogd in patiënten ≤45 jaar ten opzichte van controles. Ook de frequentie van het DQB1*06-DRB1*15 haplotype was significant verhoogd in deze leeftijdsgroep. De HLA-DRB1*15 associatie komt overeen met de bevindingen in de EBV- groep en dit kan verklaard worden doordat HL bij jonge patiënten over het algemeen EBV- is. De HLA-B*08 en HLA-DRB1*03 allel frequenties en de frequentie van het HLA-B*08-DRB1*03 haplotype waren significant verhoogd in HL patiënten met een leeftijd van >45 jaar. De frequenties van het HLA-A*02 allel dat onderdeel uitmaakt van het DQB1*06-DRB1*15 haplotype en dat van het HLAA*01 allel dat onderdeel uitmaakt van het B*08-DRB1*03 haplotype laten geen leeftijd associaties zien. Studies in de Chinese HL populatie lieten eerder al zien dat de associatie met HLA-A allelen en EBV+ HL anders zijn. Het HLA-A*02:07 sub allel is een risico allel terwijl de andere HLA-A*02 sub allelen geen risico of beschermend effect hebben. HLA-A*01 is vrij zeldzaam in de Chinese populatie en er zijn geen aanwijzigen dat dit allel een risico allel is. In hoofdstuk 5 hebben we HLA-A associaties in de Braziliaanse HL populatie onderzocht. We vonden een risico profiel gelijk aan dat van de westerse populatie. In hoeverre deze HL populatie representatief is voor de Braziliaanse populatie is nog onzeker aangezien het percentage EBV+ HL veel lager was (34%) dan verwacht. Normaal voor Zuid-Amerika zijn EBV+ percentages van 60 tot 70%. Het kan zijn dat er in onze patiënten populatie relatief veel westerse patiënten zaten. In dit promotie onderzoek hebben we de associatie tussen HLA allelen en specifieke subgroepen van HL verder onderzocht. Het is duidelijk dat er sterke
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Nederlandse samenvatting associaties zijn met de totale populatie maar ook met EBV en leeftijdsspecifieke subgroepen. Aangezien HLA moleculen belangrijke mediatoren zijn van de immuunreactie en een specifieke subset van antigenen peptide presenteren aan het immuunsysteem, is het aannemelijk dat de immuunreactie een essentiële component is in de pathogenese van HL. (Translated by Prof. Dr. Anke van den Berg and Dr. Arjan Diepstra)
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Summary in Kannada
Kannada summary Hodgkin lymphoma, HL)
B
B
HL
Hodgkin Reed Sternberg, HRS) HL ,
classical Hodgkin lymphoma, cHL Nodular lymphocyte predominant Hodgkin
lymphoma, NLPHL) HL
, cHL Nodular sclerosis
(Mixed cellularity, MC ,
NS ,
(Lymphocyte rich, LR)
(Lymphocyte depleted, LD). cHL
-
Epstein Barr virus, EBV)
HRS)
EBV
EBV+ cHL
cHL EBV- cHL)
NS
MC
, cHL
Bimodal age incidence) EBV-, NS
cHL
cHL ,
EBV+
MC
EBV+
MC
cHL
(Human leukocyte
antigen, HLA)
, ,
cHL
, EBV
cHL PhD , EBV
HLA class II)
NS
HLA HLA
HLA class I)
cHL HLA
cHL
HLA
cHL
, cHL
cHL ,
, GWAS)
HLA
157
Kannada summary -
HLA class I EBV + cHL,
HLA class II -
.
: EBV- cHL
HLA
-
GWAS
HLA
,
NS cHL
-HLA
cHL GWAS
,
PRDM HLA
cHL
cHL
HLA I
cHL
HLA II
cHL
cHL
HLA
HLA
HLA-B*51/52 (B5)
EBV
cHL HLA-DRB1*07
EBV- cHL
HLA-DRB1*11/12 (DR5) EBV+ cHL
HLA-DRB1*15/16 (DR2)
HLA-A*01, HLA-B*37
A*01-B*37-DRB1*10
HLA-DRB1*10
, HLA-A*02, EBV+ cHL
. HLA-A*01
HLA-A*02
,
T
cHL
HLA
CHL
, HLA-DRB1*15
.
HLA-DQB1*06 .
, DQB1*06-DRB1*15
EBV- cHL
,
: HLA-DRB1*15 EBV-
HLA-B*08, HLA-DRB1*03
B*08-DRB1*03
cHL , HLA-A*02, EBV+ cHL
A*02-DQB1*06-DRB1*15 ,
,
HLA-A*01, EBV+ cHL
A*01-B*08-DRB1*03
, cHL
158
,
Kannada summary , HLA-A*01
HLA-A*02
EBV+ cHL
cHL
. EBV+ cHL A*02:07
HLA
HLA-
EBV+ cHL
EBV- cHL cHL
,
HLA-A EBV+ cHL
HLA-A*01
HLA-
A*02
, EBV+
EBV+
EBV+ cHL
HLA I
,
HLA II
cHL
cHL HLA
cHL
HLA T cHL ,
(
)
159
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Author’s affiliations Anke van den Berg Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Arjan Diepstra Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Bianca Olver Section of Cancer Genetics Institute of Cancer Research Sutton, United Kingdom Bouke Hepkema Department of Laboratory Medicine University Medical Centre Groningen University of Groningen Groningen, the Netherlands Carlos E. Bacchi Consultoria em Patologia Botucatu-Sao Paulo, Brazil Gabriela Gualco Consultoria em Patologia Botucatu-Sao Paulo, Brazil Gustaaf van Imhoff Department of Hematology University Medical Centre Groningen University of Groningen Groningen, the Netherlands
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Authors affiliations Henrik Hjalgrim Department of Epidemiology Research Statens Serum Institut Copenhagen, Denmark Huang Xin Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Ilby Bouwman Department of Laboratory Medicine University Medical Centre Groningen University of Groningen Groningen, the Netherlands Ilja Nolte Department of Epidemiology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Karin E Smedby Institute of Medical Epidemiology and Biostatistics Karolinska Institute Stockholm, Sweden Klaus Rostgaard Department of Epidemiology Research Statens Serum Institut Copenhagen, Denmark Kushi Kushekhar Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands
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Authors affiliations Lydia Visser Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Niels Kouprie Department of Laboratory Medicine University Medical Centre Groningen University of Groningen Groningen, the Netherlands Pollyanna Domeney Consultoria em Patologia Botucatu-Sao Paulo, Brazil Rianne Veenstra Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands Richard S. Houlston Section of Cancer Genetics Institute of Cancer Research Sutton, United Kingdom Ruth Jarrett MRC-University of Glasgow Centre for Virus Research Glasgow, Scotland Sibrand Poppema Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands
163
Authors affiliations Wierd Kooistra Department of Pathology and Medical Biology University Medical Centre Groningen University of Groningen Groningen, the Netherlands
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Publications Genetic associations in classical Hodgkin lymphoma: a systematic review and insights into susceptibility mechanisms. Kushekhar K, van den Berg A, Nolte I, Hepkema B, Visser L, Diepstra A. Cancer Epidemiol Biomarkers Prev. 2014 Sep 9. pii: [Epub ahead of print]. PMID: 25205514 HLA associations in classical Hodgkin lymphoma: EBV status matters. Huang X, Kushekhar K, Nolte I, Kooistra W, Visser L, Bouwman I, Kouprie N, Veenstra R, van Imhoff G, Olver B, Houlston RS, Poppema S, Diepstra A, Hepkema B, van den Berg A. PLoS One. 2012;7(7). PMID: 22808081 HLA-A*02:07 is a protective allele for EBV negative and a susceptibility allele for EBV positive classical Hodgkin lymphoma in China. Huang X, Hepkema B, Nolte I, Kushekhar K, Jongsma T, Veenstra R, Poppema S, Gao Z, Visser L, Diepstra A, van den Berg A. PLoS One. 2012;7(2):e31865. PMID: 22355400
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Biography Kushekhar was born on May 20th 1985 in Beedikere, a small hamlet in the limits of Bangalore, India. He attended his elementary school in Beedikere. At the age of 10 he was selected to attend a central government funded boarding school, Jawahar Navodaya Vidylaya in Doddaballapur, Bangalore, India. This free boarding school not only gives India’s best education but also responsible overall personality growth of the students. As a part of cultural exchange, he spent one year in Jawahar Navodaya Vidylaya Alirajpur in Madhya Pradesh, India. After spending nearly 10 years in this school, he went to Vishweshwarapura College of science to pursue his bachelors in Biotechnology. He did his bachelors research projects at Veterinary College, Bangalore and Kemepegowda Institute of Medical Sciences, Bangalore. With good grades in the bachelors, he opt Department of Biotechnology, Bangalore University to pursue his masters in Biotechnology. He did research project on isolation and characterization of metal degrading bacterial enzymes in Center for Clean Environmental Technology, Bangalore University. In 2008 he moved to New Delhi to pursue his research interest. He was a junior research fellow in Department of Pediatrics, All India Institute of Medical Sciences. His research project was on evaluation of Chikungunya infection in India. He also worked on T cell IFNγ response to Rotavirus membrane proteins and global analysis of inflammatory cytokines in Chikungunya patients. To get an international exposure, he wanted to move abroad for PhD. He was selected as a PhD student in Lymphoma group led by Prof. Dr. Anke van den Berg at Department of Pathology and Medical Biology University Medical Center Groningen. In April 2010, he started his PhD project on Human leukocyte antigen and classical Hodgkin lymphoma. After the defense of his PhD thesis in January 2015, Kushekhar intend to pursue his academic research career in immunology related field.
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Acknowledgements Whoever responsible for your present condition, obviously cares a great deal. -Rubin Hurricane Carter The trial and tribulations of PhD can overwhelm even the most collected of a person. Given a chance, the feelings of insecurity and guilt are always right around the corner waiting to entrap you within its sinister web. In such an environment, the scientific and social support system becomes a crucial ingredient for the success of any support system. Here, I would like to acknowledge the many faces that have been part of my support system. First of all, my promoter Prof. Dr. Anke van den Berg cuts a great deal. Anke, who has the attitude and substance of a genius with no trappings of pride, she continually and convincingly conveyed a spirit of adventure in regard to research and an excitement in regard to teaching. Without her guidance this thesis would not have been possible. Perhaps, Anke is the only promoter who “always” has time for her students. Outside the work, she is a good friend you can have. I thank Anke with my deepest gratitude. Without Dr. Lydia Visser, I would not have written this anyway. Lydia, who recognized my candidacy for this PhD position is responsible for my arrival to Groningen. Importantly, she took a great care of me both professionally and personally with my whole stay. She is always available for you as a teacher, as a close friend and as a parent. One thing which I take home is her maternal care towards her students. Dr. Arjan Diepstra, although you are one of my co-supervisor, you are rather a better intellectual and helpful friend. These words are not enough express that how thankful I am. With you I feel more comfortable and relaxed to express my thoughts, because your calm listening. You are busy, until I just come inside your office, then discussion goes for an hour. Dear Arjan, I thank you from my deepest heart, you shaped my PhD thesis and my thought process as well. Numbers are not my most favorite, working with Dr. Ilja Nolte I did not realize this lacunae that much. Dear Ilja, thank you so much for you unparalleled help in analysis of complex data. I never thought beyond p<0.05, however you shown me p<0.001 and still we are struggling give its biological sense.
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Acknowledgements HLA is the most complex region of human genome, until you get to know Dr. Bouke Hepkema. Dear Bouke, you are always encouraging and your sparkling hints provided enormous input to my HLA knowledge tank. I will thank you from the deepest heart. I would express my deepest appreciation for the members of the reading committee, Prof. Ruth Jarrett, Prof. Edo Vellenga and Prof. Toos Deamen for reading and approving my PhD dissertation. Dear Ruth, I also tank you for quality time we spent during conferences. Dear Edo, thank you for your valuable discussions during our Monday morning meetings. I want to thank other peers who contributed to my scientific knowledge. Dr. Joost Kluiver, a big brother to our group, for his help in all little things and fruitful scientific discussions. I thank Prof. Wim Timmens head of the Dept. of Pathology. I thank Prof. Sibrand Poppema for his peer check on my research and Dr. Gustaaf Imhoff for his constant help in recruiting patients and collecting blood samples and his quality discussions during our meetings. I also thank Dr. Johan Gibcus, Dr. Klaas Kok, Prof. Annette Gouw, Prof. Philip Kluin, Prof. Ed Schuuring, Prof. Jan-Luuk Hilebrands, Prof. Harry Hollema, Dr. Machteld Hylkema and Dr. Corry-Anke Brandsma for their valuable discussions and ideas during refereran, which are important part of my scientific growth. Many thanks to all my co-authors and collaborators, Ilby Bouwman, Bianca Olver, Richard S. Houlston, Zifen Gao, Henrik Hjalgrim, Karin E Smedby, Klaus Rostgaard, Gabriela Gualco, Pollyanna Domeney and Carlos E. Bacchi who shared their intellectual views and provided their valuable input in publishing my articles. My special thanks to Niels Kouprie, Theo Jongsma and Richard Kuntzel who are coauthors as well as gave their immense help for HLA typing and collecting blood samples for my experiments. Rianne Veenstra, you are the first Dutch friend I met. With whom I had freedom to do stupid technical mistakes in the experiments and still it’s OK. You thought me that Lab O&O is better than my office, which is indeed true. Now, you are my welldeserved paranymfen, many thanks for all the efforts in organizing and making my D-Day a memorable one, for you will be part of my memory down the lane. I want to thank all the people whom I shared the office, lab, my thoughts, my excitement or my sorrows during my course of PhD. Thank you Wouter for introducing me to Dutch work culture and dealing with people and things. I thank Huang for all the initial data and understandings of the project. Rae, thank you for all the time you spent on our sometime stupid discussions. Ahmed, talking with you 170
Acknowledgements opens up my brain. All your basic immunology discussions are worth spending time for. Ali, thanks you recognizing my real talents and appreciating them. Iza, thank you, for all those initial hints for a successful PhD. Yuxuan, I am going to miss your charming and smiling face. Melanie, a sensible talker, I learnt a lot talking with you. Marcel, I thank you for your constant check on my schedule and brotherly help. Mina, I miss you kukus the most. Zheng, common man lets deal our D-Day together. Nato, your smart dressing sense and fun talks are memorable forever. Ben, you are cool guy, with very mature mindset. Those bold gestures of Reny best matches to her personality. My big thanks to Geok, Yuan, Lotte, Sietse, Jan-Lukas for sharing their friendly space and time. Proud will be mine, for the things I learnt in the Lab O&O. I could not have learnt these things without the help people. There is nothing you are lacked with in this lab, the lab manager Hans Vos had make sure everything is in the reach of your hands. Thank you Hans, for recognizing my volley ball talent. Many things were new at this lab, I learnt many techniques with Bea Rutgers, Wierd Kooistra, Marian Bulthuis. It is my pleasure to thank Debora de Jong, Nancy Helsema, Gertrud Kortman, Marrit Otter, Theo Borghuis, Jantine Sietzema, Jasper Koerts, Lorian S Menkema, Tineke van der Sluis, Bart Baake and Geert Harms for their immense support in conducting my experiments. My special thanks to Ilia Vinchtian and Sulima Hoek with whom I shared my first days in the Dept. of pathology. With Xaver, Ben, Til, Chris and Wim, I both thought and learnt science and research techniques. I also thank Rik, Silvana, Martijn, Patricia, Karolin, Hiro, Jing and Siobhan whom I spared time in corridors at least to check on how are the things at our sides. I take this opportunity to thank, Richard Jacobs, Ingrid van der Strate-Tmpert, Jenny Fledderus, Ellen Kuijpers, Harriet Roffel and Marijke Gimberg who helped me in all paper works pertaining to my PhD also constant update on ongoings in the department. I also thank Roel Soesbeek and Peter Wagenaar from ICT department. My special thanks to Freke Dijkhuis from tissue archives, for providing all the tissue blocks for my research. I also thank people from Histology for helping me to cut all the sections I want to thank Maaike Bansema and Mieke Kapteyn from GUIDE for their continuous help in organizing and structuring my PhD into a success. For all bureaucratic solutions, I want to thank Marco van der Vinne and Swaeske de Vries from ISD.
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Acknowledgements My special thanks to Dr. TN Atmaram, Dr. Devaiah, Prof. Sarangi, and Prof. Manjula Kumari from Dept. of Biotechnology, Bangalore University for their continuous support to reach heights in my academic career. Work apart, during my stay in Groningen I spent quality time with many people learning their culture, their sense of humor and sharing all the thoughts about different cultures. All these people helped me to create and evolve myself into a cosmopolitan man. My life in Groningen started with mix of internationals at Winschoterdiep 46, where I learnt to socialize. I will take this opportunity to mesmerize the moments I shared with Michael, Marko, Mustafa, Nikos, Deniz, Mayer and Aiste. I moved from Diep to Kade. At Winschoterkade18, I met Constanza, an Argentinian warm heart, Jenny, caring and sharing, who become my good friends. Also I thank Inken, Sylwia, Hilke, Andres, Nikola, Ben, Magnus, Bjorn, Claudius, Jason, Jakob and Tejas for allowing me into their culture of being and sharing their personal space. The best part of my life in Groningen is meeting Luis, Gry, Linde, Giancarlo, Stefano, Neeraj andVikram and many more. Luis, a bloody good Mexican with intel, I learnt how deal with life in tricky situations and positive thinking. I never met such a downto-earth person like Gry, I think everyone should have person like her in their life. Giancarlo and Stefano, the best Italians I met, their hospitality at Rome will be my one of the best nostalgic event. Neeraj filled my brain with some of his philosophical thoughts and made me to think sometime beyond stars, I like it though. With Vikram, I felt like staying at home but in Europe, those road trips and dinners at his place, a very caring friend. My special thanks to Gaurav, a good and very helpful friend and my paranymfen. If there is a need, there are you. Those are the best times we spent in trips. I take this opportunity to thank him with my full heart for his immense help in organizing my success day at its best. I wish him success in his PhD and his future endeavours. The only opportunity infiltrate into Dutch culture is to meet this student group HOST. In HOST I met these beautiful people Hendrik, Arend, Sezar, Marije, Krina, Trix, Danica, Anahi, Maaike, Maarten, Pieter, Joanne, Elsa, Yaroslav, Olaf, Ibrahim, Esther, Jhonathan, Sjoukje, Henrieke, Margje, Michell, Dragous, Hans-Joann and many more. A special regards to Angelica, for her innocent care and warm heart.
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Acknowledgements My best regards to Hink and his Boer family, for inviting me to their family and showing how things work at farm. My warm regards to Magda, for her sweet friendship. Minnah, for her enthusiastic conversations. Izabel, for her open and warm heart. With Violeta, Ena and Funda I shared lough and with whom somehow Balkan culture matches with Indian culture. I also take this space to extend my regards to Iranian friends Mehran and his wife, Fariba, Shiva Sajari and Narges with whom I felt no different from Indian culture. Those are the best days I spent with Paria, you will be missed. Having Indian friends abroad is always feels like coming home. I thank Eswar who first received me to Groningen and those first days of hospitality. Khyum, never says no, always ready to help. Pramod, Shiva, Siddu, Vijay, Rajinder & Chaitali, Suresh, Gautam, Tushar, Raja, Akshay & Spoorthi, Abhishek, Paul, Swapnil, Rama, Praneeth, Pranov, Lakshmi, Gopi, Saritha, Justin with who I spent a warmth homely Indian time. Having old friends around is best feelings you can ever have in your life. My heartily regards to my friends from Bangalore, Mahesh, Anand, Naveen, Srinivas, Rakesh, Madhavi, Suryakala, Shobha and Pallavi. A talk for a minute with them suffices to get rid of your all sorrows and weather imprisoned depressions at Northern hemisphere. My parents and my sibs, I do not know how to thank them. I thank my three sisters and their husbands, Sushilamma & Narayanaswami, Prabha & Srinivas and Indira & Venkatesh and my brother Govindaraj & Suma for their unconditional love and support. I wish all my niece and nephews a bright future. Having born in a typical Indian nuclear family you have pre-directions to your life and career. But my parents allow me to follow my heart and gave their unbiased support. I will thank them in all my reincarnating lives. My sincere apologies and many thanks for those I have missed here.
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