PKM2 promotes neutrophil activation and cerebral thromboinflammation: therapeutic implications for ischemic stroke

There is a critical need for cerebro-protective interventions to improve the suboptimal outcomes of patients with ischemic stroke who have been treated with reperfusion strategies. We found that nuclear pyruvate kinase muscle 2 (PKM2), a modulator of systemic inflammation, was upregulated in neutrophils after the onset of ischemic stroke in both humans and mice. Therefore, we determined the role of PKM2 in stroke pathogenesis by using murine models with preexisting comorbidities. We generated novel myeloid cell-specific PKM2-/- mice on wild-type (PKM2fl/flLysMCre+) and hyperlipidemic background (PKM2fl/flLysMCre+Apoe-/-). Controls were littermate PKM2fl/flLysMCre- or PKM2fl/flLysMCre-Apoe-/- mice. Genetic deletion of PKM2 in myeloid cells limited inflammatory response in peripheral neutrophils and reduced neutrophil extracellular traps after cerebral ischemia and reperfusion, suggesting that PKM2 promotes neutrophil hyperactivation in the setting of stroke. In the filament and autologous clot and recombinant tissue plasminogen activator stroke models, irrespective of sex, deletion of PKM2 in myeloid cells in either wild-type or hyperlipidemic mice reduced infarcts and enhanced long-term sensorimotor recovery. Laser speckle imaging revealed improved regional cerebral blood flow in myeloid cell-specific PKM2-deficient mice that was concomitant with reduced post-ischemic cerebral thrombo-inflammation (intracerebral fibrinogen, platelet [CD41+] deposition, neutrophil infiltration, and inflammatory cytokines). Mechanistically, PKM2 regulates post-ischemic inflammation in peripheral neutrophils by promoting STAT3 phosphorylation. To enhance the translational significance, we inhibited PKM2 nuclear translocation using a small molecule and found significantly reduced neutrophil hyperactivation and improved short-term and long-term functional outcomes after stroke. Collectively, these findings identify PKM2 as a novel therapeutic target to improve brain salvage and recovery after reperfusion.

COVID-19 in Renal Transplant Recipients - A Single Center Experience from India

Introduction

The information on the clinical outcome of renal transplant recipients getting COVID-19 infection is sparse. The aim of this study is to report a single-center experience of renal transplant recipients with COVID-19 from India.

Methods

This was a retrospective study of 23 consecutive renal transplant recipients with COVID-19 infection presenting to our center from May 2020 to August 2020. Clinical parameters, laboratory values, imaging characteristics, and outcome of the patients were collected and analyzed.

Results

Median follow-up duration was 36 (range: 10-110) days. Median age of patients was 54 (23-70) years, and 87% were male. Median duration since transplant was 69 (range: 15-132) months. The most common presenting feature was fever (82.6%), followed by breathlessness (43.5%) and cough (30.4%). Hospitalization rate was 52.2%, while 34.8% required ICU care. Severe to critical disease was seen in 39.1% of patients, and 17.4% required mechanical ventilation. Patients with severe disease had a higher incidence of lymphopenia (P = 0.005) when compared to the ones with mild to moderate disease. Acute kidney injury was seen in 39.1% of patients, and 13% required dialysis. Mortality rate was 13% overall, and 25% in those hospitalized.

Conclusion

Renal transplant recipients with COVID-19 have a poor outcome. Although not all of them need hospitalization, they should be monitored closely. Immunosuppression minimization is an important part of the treatment strategy.

Flipped Classroom Approach in Undergraduate Medical Education: The Need of the Hour

Introduction: In the era of changing medical education system, our teaching methods are not able to cope up with ongoing evolution of medical education. There is a definite need of introducing newer techniques of teaching-learning methods to improve the learning process to higher levels of Bloom’s taxonomy. Aim: To explore the perceptions and attitudes of final year undergraduate medical students and teachers in paediatrics towards Flipped Classroom (FCR) model. Materials and Methods: The present prospective observational study was conducted at the Mahatma Gandhi Institute of Medical Sciences Sevagram, a rural tertiary care institute of central Maharashtra, India from December 2020 to November 2021. The full class strength of 100 undergraduate final year medical students and all eight faculty members participated to conduct FCR sessions on Paediatric infectious diseases. Prereading study material in the form of videos and reading materials was provided for asynchronous learning, while classroom time was spent on solving problem-based questions based on “think-pair-share” with the faculty as facilitators. Student and faculty feedback was recorded via a five-point Likert’s scale. Consequently, small-group discussions were carried out to know the students’ reflections. The data was analysed using Statistical Package for the Social Sciences (SPSS) version 21.0 software. Results: The students showed overall encouraging response to the flipped classroom method with active participation. Eighty two students (82%) were happy about the content of the reading material and time spent on preclass activity. More than 75% of students agreed it to be more interactive with peers and teachers and that it enhanced active learning with development of interest in the given subjects. Seventy-five students (75%) gave positive responses towards the utility of flipped model for future classes as it helped in self directed learning. The faculty members also enjoyed this activity, though they found it time-consuming. Conclusion: FCR is an effective way to motivate and enhance active and self-directed learning. Unlike didactic lectures, it helps the students in conceptual understanding of the subject and makes the teaching-learning experience enjoyable.

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study

BACKGROUND

COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients.

METHODS

We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs).

RESULTS

The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38-54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35-60) d.

CONCLUSIONS

We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

ABO-incompatible kidney transplantation in India: A single-center experience of first hundred cases

Aim:

Material and Methods:

Results:

Conclusion:

Abstract P005: GEN-011: A neoantigen-targeted peripheral blood-derived T cell therapy that has broad neoantigen specificity and high T cell purity while avoiding pro-tumor T cells

Candidate adoptive T cell therapies (ACT), such as tumor infiltrating lymphocyte (TIL) treatments, have resulted in unprecedented and durable efficacy in clinical trials. Despite this, the manufacturing requires viable tumor resection, and TIL expansion conditions have the potential to promote T cell exhaustion. Moreover, a large proportion of patients do not respond to treatment, possibly due to exhaustion or to bystander T cells that are not tumor-specific present in the product candidates. In addition, we have shown that naturally occurring pro-tumor T cell responses to tumor-specific antigens we term Inhibigens™ are generated in nearly every subject with cancer; these T cells may be inadvertently expanded in the non-specific TIL manufacturing process. In animal models, Inhibigen-specific responses drive tumor hyperprogression. To avoid these pro-tumor T cells and improve upon ACT limitations, we are developing GEN-011, a neoantigen-targeted, peripheral T cell (NPT) therapy. GEN-011 is designed to contain primarily tumor-specific T cells with broad specificity and limited exhaustion, starting from easily accessible peripheral blood. Putatively beneficial neoantigen targets and deleterious pro-tumor Inhibigen targets are identified through measurement of cytokines in the assay supernatants of an in vitro ATLAS™ screen, in which each mutation identified in a patient's tumor is screened with the patient's own peripheral CD4+ and CD8+ T cells in a recall (overnight) assay, without algorithm prioritization. Next, the patient's peripheral T cells and monocyte-derived dendritic cells are incorporated into the PLANET™ manufacturing process where they are specifically stimulated with up to 30 ATLAS-verified neoantigens, avoiding Inhibigens, in a scalable, closed system. Development and engineering runs performed at scale show that the NPTs are up to 96% tumor-specific, with responses maintained for up to 89% of the intended neoantigen targets. They are non-exhausted effector and central memory T cells that express both proliferative and tissue homing markers. In addition to being highly polyfunctional, secreting multiple combinations of IFNγ, Granzyme B, TNFα, and MIP1α in response to specific neoantigens, they are also cytolytic in vitro and express memory-progenitor stem-like cell markers. The TITAN™ clinical trial evaluating GEN-011 NPTs is ongoing (NCT04596033). TiTAN is an open-label, multi-center Phase1/2a trial evaluating safety, tolerability, T cell persistence and proliferation, and clinical efficacy. The TiTAN clinical trial is testing two dosing regimens, a repeated lower dose regimen of GEN-011 without lymphodepletion and a single high dose administration of GEN-011 NPTs after lymphodepletion. Both groups will receive interleukin-2 after GEN-011 NPT dosing. By enriching healthy, broadly-specific neoantigen-targeted T cells and avoiding Inhibigens, the GEN-011 NPTs may represent an accessible and promising ACT for treating solid tumors.

Citation Format: James Perry, Pranay D. Khare, Mercay Reuter, Daniel B. DeOliveira, Manish Jain, Colleen Winstead, Hubert Lam, Thomas Davis, Ray Stapleton, Jessica B. Flechtner. GEN-011: A neoantigen-targeted peripheral blood-derived T cell therapy that has broad neoantigen specificity and high T cell purity while avoiding pro-tumor T cells [abstract]. In: Abstracts: AACR Virtual Special Conference: Tumor Immunology and Immunotherapy; 2021 Oct 5-6. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(1 Suppl):Abstract nr P005.

Dihydrotestosterone- A Potential Biomarker of Hyperandrogenaemia in Polycystic Ovary Syndrome: A Case-control Study from North India

Introduction: Polycystic Ovary Syndrome (PCOS) is a complex reproductive disorder characterised by hyperandrogenism, ovulatory dysfunction and polycystic/enlarged ovary. Although clinical and/or biochemical hyperandrogenism is one of the major features of PCOS, biochemical hyperandrogenism in the form of high testosterone and/or Free Androgen Index (FAI) is rarely observed in the Asian Indians. Aim: To assess various androgens to determine best available biomarker of androgens in PCOS from North India. Materials and Methods: This case-control study was conducted at Department of Reproductive Biology, All India Institute of Medical Sciences, New Delhi, India, between January 2016 to December 2019. During this period 137 female with PCOS and 49 female as control were included. Serum total testosterone (T), FAI, Dehydroepiandrosterone Sulphate (DHEAS), androstenedione and Dihydrotestosterone (DHT) were measured besides assessment of hirsutism using the FerrimanGallwey (FG) scale. Statistical differences were derived using Mann-Whitney U test, Receiver Operating Characteristic (ROC) curve analysis and Spearman’s correlation test. Results: There were 87 PCOS cases with phenotype A, 25 PCOS cases with phenotype B, 10 PCOS cases with phenotype C and 15 PCOS cases with phenotype D. The mean age was 23.7 years in the PCOS group and 26.2 years in the control group. The mean body mass index in the PCOS group was 25.23 kg/m2 and in the control was 22.6 kg/m2 . FG score of ≥9 was observed in 75.9% PCOS cases. High (mean+2SD) levels of T (≥0.51 ng/ mL), FAI (≥2.55), DHEAS (≥309 ug/dL), androstenedione (≥2.2 ng/mL) and DHT (≥462 pg/mL) were observed in 35.29%, 56.25%, 14.18%, 18.62% and 61.38%, cases, respectively. Mean DHT value was 584.27 pg/mL in study group whereas in control was 257.16 pg/mL (p-value <0.0001) and area under ROC curve was 0.895. Similarly, area under ROC curve was 0.86, 0.817, 0.721 and 0.63 for FAI, testosterone, DHEAS and androstenedione, respectively. Spearman’s correlation test of androgens with body mass index, age and FG Score did not find any associations with DHT. Conclusion: Dihydrotestosterone (DHT) is best available biomarker and can be considered as diagnostic biomarker of hyperandrogenemia in PCOS women from north India.

An investigation of steroid biosynthesis pathway genes in women with polycystic ovary syndrome

Background:

Polycystic ovary syndrome (PCOS) is a common endocrinopathy whose heterogeneous genetic basis results in a variable clinical presentation. One of the main clinical features of PCOS is hyperandrogenism which occurs due to dysregulation of ovarian and adrenal steroidogenesis.

Aims:

This study aimed to investigate potentially pathogenic variants in steroidogenic genes associated with PCOS.

Settings and Design:

This was a hospital-based observational study.

Materials and Methods:

We recruited 51 women who presented with PCOS. Fasting blood samples were drawn from the participants and their whole-exome sequencing analysis was carried out to look for pathogenic variants involved in steroidogenic pathways. The variants were predicted for their probable deleterious effects on proteins through in silico prediction tools. We evaluated the variants with respect to the hormonal characteristics and clinical outcomes of the patients.

Statistical Analysis Used:

All variables were analysed using GraphPad Prism 8. Kruskal–Wallis t-test and Fisher's exact test were used to compare clinical parameters and frequency differences among PCOS patients with and without variants.

Results:

The data presented here reveal eight heterozygous exonic variants, namely CYP21A2 (p.Ala392Thr, p.Gln319Ter and p.I143N), steroidogenic acute regulatory (p.Arg53 Leu), AKR1C3 (p.Phe205Val), P450 oxidoreductase (p.Val334Ile and p.Val251Met) and HSD17B6 (p.Gly40Ser), of which three were pathogenic, and four variants of uncertain significance in 8 out of 51 patients (15.68%). The identified variants were predicted to cause protein destabilisation, thus likely contributing to the pathogenesis of PCOS. Some of the variants showed significant differences between PCOS patients and population database (P < 0.05).

Conclusion:

The results of this study add to the mutational spectrum of steroidogenic genes and their association with PCOS.

Risk factors and outcomes of COVID associated mucormycosis in kidney transplant recipients

BACKGROUND

Invasive Mucormycosis (IM) is a life-threatening fungal infections occurring mostly in solid organ transplant (SOT)recipients, patients with haematological malignancies, and diabetes. A sudden spurt of mucormycosis has been reported in severe acute respiratory syndrome coronavirus-2 (SARS-COV2) pandemic in India, however there is little data about Coronavirus disease 2019 (COVID -19) associated mucormycosis (CAM) in kidney transplant recipients (KTRs).

METHODS

We describe the clinical presentations, risk factors, treatment and outcomes of 11 mucormycosis cases in Kidney transplant recipients (KTRs) post COVID 19 infection from February 2020 to June 2021 at a single centre in India.

RESULTS

Mucormycosis was seen in 11/102 (10.7%) KTRs during the pandemic. Six patients had mild disease and rest five had moderate disease. Seven patients had pre-existing diabetes mellitus and four developed new onset hyperglycemia after receiving steroids for COVID-19 infection. All had poorly controlled sugars at the time of presentation. Most common presentation was Rhino-orbital-cerebral mucormycosis (ROCM) in 10/11 (89%) patients and one ha pulmonary mucormycosis. All patients received combination of Amphotericin B and surgical debridement/excision of affected tissue followed by Posaconazole prophylaxis. Nine patients recovered, however two patient succumbed to their illness after median of 14(7-21) days from diagnosis. One patient developed acute T cell mediated rejection during the course of recovery. At last follow up, the mean serum creatinine was 2.05 mg/dl as compared to 1.4 mg/dl at presentation.

CONCLUSIONS

Invasive Mucormycosis is a common fungal infection in transplant recipients in India after COVID-19.Early diagnosis and prompt treatment with combination of surgical debridement and liposomal amphotericin B are key to better outcomes in COVID associated mucormycosis. Judicious use of steroids and control of hyperglycemia is key to avoid flaring up of the fungal infection. This article is protected by copyright. All rights reserved.

Microbial fermentation of Fossence™, a short-chain fructo-oligosaccharide, under simulated human proximal colonic condition and assessment of its prebiotic effects-a pilot study

A short-chain fructo-oligosaccharide (sc-FOS) was tested in a simulator of the human gut microbial ecosystem (SHIME) in vitro model to quantify its prebiotic effects according to Prebiotic Index (PI) and Measure of prebiotic effect (MPE) equations. FossenceTM, (sc-FOS, 0.5%) was fermented in a simulated human proximal colonic condition, using a fecal inoculum from a healthy individual. We analysed the pH reduction, substrate utilization, lactate and short-chain fatty acid (SCFA) production and microbial community modulation. Microbial fermentation of sc-FOS strongly reduced the media pH indicating the production of lactate and SCFA with accumulation of lactate and enhanced levels of acetate (34.38 ± 0.38 mM), propionate (20.93 ± 0.56 mM) and butyrate (4.93 ± 0.03 mM) compared to 18.46 ± 0.20 mM, 6.24 ± 0.10 mM and 3.3 ± 0.06 mM in the blank, respectively. Total SCFA production in test media was 61.91 ± 0.87 mM compared to 33.65 ± 0.36 mM in blank and the contribution of free-sugars present in sc-FOS to SCFAs was negligible. Modulation of the microbial community was analysed through 16S rRNA sequencing and we found that sc-FOS greatly stimulated the beneficial bacteria such as Bifidobacteria and Lactobacillus. We report the PI and MPE values for FossenceTM, as 14.9 and 0.01 respectively at the end of 24 h, which is an indicator of a strong prebiotic effect.

Plasticity of Metal-Organic Framework Glasses

Metal-organic framework (MOF) glasses provide new perspectives on many material properties due to their unique chemical and structural nature. Their mechanical properties are of particular interest because glasses are inherently brittle, which limits their applications as structural materials. Here we perform strain-rate-dependent uniaxial micropillar compression experiments on a_gZIF-62, a_gZIF-UC-5, and a_gTIF-4, a series of MOF glasses with different substituting linker molecules, and find that these glasses show substantial plasticity, at least on the micrometer scale. At a quasi-static strain rate of 0.001 s^-1, the micropillars yielded at approximately 0.32 GPa and subsequently deformed plastically up to 35% strain, irrespective of the type of substituting linker. With increasing strain rate, the yield strength of a_gZIF-62 evolved with the strain-rate sensitivity m = 0.024 to reach a yield strength of 0.44 GPa at a strain rate of 510 s^-1. On the basis of this relatively low strain-rate sensitivity and the absence of serrated flow, we conclude that structural densification is the predominant mechanism that accommodates such extensive plasticity.

Hemolytic Anemia and Hypoxic Brain Injury following Mothball Ingestion in a G6PD Nondeficient Infant: A Case Report

Mothballs are a common household item used as repellents and deodorizers. They are potential hazards and rare agents of poisoning in children. They are composed mainly of naphthalene, camphor, and 1, 4-dichlorobenzene in varying amounts depending on the manufacturers. It is essential to rule out poisoning by naphthalene in children presenting with hemolysis by eliciting a proper history. Since mothballs are readily available at home, children are drawn to it because of its attractive color and its consumption is a likely possibility. This is a case of ingestional naphthalene poisoning in a 1-year-old glucose 6-phosphate dehydrogenase nondeficient male child who presented with altered sensorium and hemolytic anemia. The child developed methemoglobinemia and sustained hypoxic brain injury. He was successfully managed by oral ascorbic acid, blood transfusion, and requisite supportive treatments. We report a case of naphthalene toxicity with hemolytic anemia and hypoxic brain damage to highlight the possibility of naphthalene poisoning in young children presenting with hemolytic anemia.

Immunogenicity of Fractional Dose Inactivated Poliovirus Vaccine in India

INTRODUCTION

Following the withdrawal of Sabin type 2 from trivalent oral poliovirus vaccine (tOPV) in 2016, the introduction of ≥1 dose of inactivated poliovirus vaccine (IPV) in routine immunization was recommended, either as 1 full dose (0.5mL, intramuscular) or 2 fractional doses of IPV (fIPV-0.1mL, intradermal). India opted for fIPV. We conducted a comparative assessment of IPV and fIPV.

METHODS

This was a 4-arm, open-label, multicenter, randomized controlled trial. Infants were enrolled and vaccines administered according to the study design, and the blood was drawn at age 6, 14, and 18 weeks for neutralization testing against all 3 poliovirus types.

RESULTS

Study enrolled 799 infants. The seroconversion against type 2 poliovirus with 2 fIPV doses was 85.8% (95% confidence interval [CI]: 80.1%-90.0%) when administered at age 6 and 14 weeks, 77.0% (95% CI: 70.5-82.5) when given at age 10 and 14 weeks, compared to 67.9% (95% CI: 60.4-74.6) following 1 full-dose IPV at age 14 weeks.

CONCLUSION

The study demonstrated the superiority of 2 fIPV doses over 1 full-dose IPV in India. Doses of fIPV given at 6 and 14 weeks were more immunogenic than those given at 10 and 14 weeks. Clinical Trial Registry of India (CTRI). Clinical trial registration number was CTRI/2017/02/007793.

Grafalon® vs. Thymoglobulin® as an Induction Agent in Renal Transplantation - A Retrospective Study

Introduction

Antihuman thymocyte immunoglobulin, used as an induction agent in renal transplantation, is of two types - thymoglobulin and grafalon (formerly ATG-Fresenius). In this study, we compared outcomes with these two agents.

Methods

This was a single-center retrospective study of patients transplanted from January 2017 to October 2019, who received either grafalon or thymoglobulin induction. Grafalon or thymoglobulin was given at 6 and 3 mg/kg, respectively, followed by standard triple immunosuppression of tacrolimus, MMF, and prednisolone.

Results

Median follow up was 22 (3-36) months. Thymoglobulin was given to 255 patients, whereas 78 patients received grafalon. Baseline demographics were similar between the two groups although significantly more patients in the grafalon group received ABO incompatible transplant (15% vs. 4.3%; P = 0.002). Patient survival was similar between the two groups (99% in grafalon vs. 98.8% in thymoglobulin; P = 1.0). Death censored graft survival was also similar (99% in grafalon vs. 100% in thymoglobulin; P = 0.23). Biopsy proven acute rejection (BPAR) was significantly higher in the grafalon group (12.8% vs. 5.1%, P = 0.04). The significance persisted after multivariable regression analysis (P = 0.02). Other outcomes such as infection rate and estimated glomerular filtration rate on last follow up were comparable between the two groups.

Conclusions

Grafalon (6 mg/kg dose) when used as an induction agent was associated with significantly higher rate of BPARs as compared to thymoglobulin (3 mg/kg dose) although with comparable short-term patient and death censored graft survival, graft function, and infection rates.

Childhood encephalitis hospitalizations associated with virus agents in medium-endemic states in India

BACKGROUND

Japanese encephalitis (JE) is the leading cause of childhood acute encephalitis syndrome (AES) in India. We enhanced the AES surveillance in sentinel hospitals to determine trends and virus etiologies in central India.

METHODS

The neurological hospitalizations among children ≤15 years were tracked by using the AES case definition implemented by the national program. Acute and convalescent sera along with cerebrospinal fluid (CSF) specimens were collected and tested at the strengthened site hospital laboratories for anti-JE, anti-Dengue and anti-Chikungunya virus by IgM ELISA; along with Chandipura virus RT-PCR. Herpes simplex and enterovirus testing was undertaken at the reference laboratory.

RESULTS

Among 1619 pediatric neurological hospitalizations reported during 2015-16, AES case definition was fulfilled in 332 (20.5%) cases. After excluding 52 non-AES cases, 280 AES cases resident from study districts were considered eligible for study. The treating physicians diagnosed non-viral causes in 90 cases, therefore 190 (67.9%) of 280 AES cases were suspected with viral etiologies. We enrolled 140 (73.7%) of 190 eligible AES cases. Viral etiologies were confirmed in 31 (22.1%) of 140 enrolled AES cases. JE (n = 22) was the leading cause. Additional non-JE viral agents included Chikungunya (5), Dengue (2) and Chandipura (2). However, only 21 (9.4%) of 222 additional AES cases referred from peripheral hospitals were confirmed as JE.

CONCLUSIONS

Japanese encephalitis virus continues to be the leading cause of childhood acute encephalitis syndrome in central India despite vaccination program. Surveillance needs to be intensified for assessing the true disease burden of Japanese encephalitis following vaccination program implementation.

Managing comorbidities in Covid-19 patients: A drug utilization study in a COVID-dedicated hospital in Northern India

INTRODUCTION

In the prevailing COVID-19 pandemic, the Indian healthcare system has worked hard towards restricting the adverse outcomes to the least possible figures. The present study aims to share the experience of a COVID-dedicated tertiary care government hospital in Northern India of managing COVID-19 patients with comorbidities.

METHODOLOGY

A retrospective, observational study was conducted in a COVID-dedicated tertiary health care government hospital in Northern India. Details on sociodemographic data, hospital admission data, and drug utilization pattern of all laboratory-confirmed COVID-19 patients of all age groups, either gender, having comorbidity (s), and admitted between April and September, 2020 were noted and evaluated.

RESULTS

Among the total study participants (N = 406), 2868 drugs were prescribed. Out of these, 2336 were used for the management of symptoms of COVID-19 and 532 were used for the management of coexistent comorbidity (s). For COVID-19 symptoms, the most commonly prescribed class of drugs were antimicrobials (853, 36.52%), followed by nonsteroidal antiinflammatory drugs (374, 16.01%), proton pump inhibitors (299, 12.80%), antihistamines (232, 9.93%), immunosuppressant drugs (103, 4.41%), and others. For comorbidities most commonly prescribed were antihypertensive (310, 58.60%) drugs, followed by antidiabetic drugs (166, 31.38%), bronchodilators (34, 6.43%), thyroid hormones (11, 2.08%), immunosuppressant drugs (7, 1.32%).

CONCLUSION

The most frequently prescribed antihypertensives were calcium channel blockers (CCBs) and least prescribed was beta blocker+CCB. Among the antidiabetic drugs, most frequently prescribed was insulin and least prescribed was DPP-4 inhibitors and Biguanide+DPP-4 inhibitor both.

Abstract P127: Myeloid-specific PKM2 Deletion Reduces Atherosclerosis By Limiting Inflammation

Introduction: The underlying cause of coronary artery disease (CAD) is atherosclerosis, which is a pathological response to chronic inflammation and hyperlipidemia. The onset of atherogenesis is characterized by infiltration of myeloid cells, including monocytes followed by fatty streak formation and progressive accumulation of smooth muscle cells (SMCs). These microenvironmental changes dictate the balance between inflammatory and anti-inflammatory macrophages. Pyruvate kinase M2 (PKM2), a glycolytic enzyme, is highly expressed in activated proinflammatory macrophages. The mechanistic role of PKM2 in atherosclerosis remains unknown.

Hypothesis: We hypothesize that PKM2 promotes macrophage migration in response to MCP-1 and mediates atherosclerosis by increasing inflammation.

Methods and Results: PKM2 was upregulated in macrophages of Ldlr -/- mice fed a high-fat "Western" diet compared with a control chow diet. We generated the novel myeloid cell-specific PKM2 fl/fl LysMCre +/- on a Ldlr-deficient background (PKM2 fl/fl LysMCre +/- Ldlr -/- ) and evaluated atherosclerosis after 14 weeks high-fat “Western” diet feeding. Controls were littermate PKM2 fl/fl LysMCre -/- Ldlr -/- mice. Myeloid cell-specific deletion of PKM2 led to a significant reduction in lesions in the whole aorta and aortic sinus despite high cholesterol and triglyceride levels. (P<0.05, n=10-12 mice/group). Furthermore, we found decreased macrophage content in the lesions of myeloid cell-specific PKM2 -/- mice compared with control mice that was associated with decreased plasma levels of pro-inflammatory cytokines, including MCP-1, and reduced transmigration of macrophages in response to MCP-1. Macrophages isolated from myeloid-specific PKM2 -/- mice fed a high-fat "Western" diet exhibited reduced expression of pro-inflammatory genes, including MCP-1, IL-1β, IL-12, and increased expression of the anti-inflammatory genes Arg1 and IL-10. Inhibiting PKM2 nuclear translocation in bone marrow-derived macrophages led to a significant reduction in MCP-1 and IL-1β levels and reduced transmigration of macrophages.

Conclusion: Genetic deletion of PKM2 in myeloid cells reduces atherosclerosis by limiting inflammation.

Abstract 107: PKM2 Promotes Neutrophil Activation And Cerebral Thrombo-inflammation: Therapeutic Implications For Ischemic Stroke

In recent years compelling evidence has emerged that implicates role of metabolic reprogramming in the modulation of thrombosis and inflammation. The dimeric form of the metabolic enzyme pyruvate kinase muscle 2 (PKM2) enters nucleus and exerts protein kinase activity. We found that nuclear PKM2 levels were upregulated in neutrophils after the onset of ischemic stroke both in humans and in mice. Therefore, we evaluated the role of PKM2 in promoting thrombo-inflammation and ischemic brain injury.We generated novel myeloid cell-specific PKM2 -/- mice on wild-type ( PKM2 fl/fl LysMCre + ) and hyperlipidemic background ( PKM2 fl/fl LysMCre + Apoe -/- ). We observed that genetic deletion of PKM2 in myeloid cells limited inflammatory response in peripheral neutrophils and reduced neutrophil extracellular traps following cerebral ischemia/reperfusion. In the filament and autologous clot/rtPA stroke models, irrespective of sex, deletion of PKM2 in myeloid cells either in wild-type or hyperlipidemic mice reduced infarcts and enhanced long-term sensorimotor recovery. Laser speckle imaging revealed improved regional cerebral blood flow in myeloid cell-specific PKM2-deficient mice that was concomitant with reduced post-ischemic cerebral thrombo-inflammation (intracerebral fibrin(ogen), platelet (CD41- positive) deposition, neutrophil infiltration, and inflammatory cytokines). Mechanistically, PKM2 regulates post-ischemic inflammation in peripheral neutrophils by promoting STAT3 phosphorylation. Utilizing small molecule inhibitor (ML265) that inhibits PKM2 dimerization, we evaluated ex vivo thrombosis using human whole blood in a microfluidic flow chamber system. We observed a fivefold reduction in the thrombus growth rate in ML265-treated group. Similarly, ML265 treatment in mice resulted into significantly reduced poststroke neutrophil hyperactivation and improved short-term and long-term functional outcomes following stroke. Collectively, these findings identify PKM2 as a novel therapeutic target to improve brain salvage and recovery following reperfusion.