Inhibition of NS2B-NS3 protease from all four serotypes of dengue virus by punicalagin, punicalin and ellagic acid identified from Punica granatum

Despite a major threat to the public health in tropical and subtropical regions, dengue virus (DENV) infections are untreatable. Therefore, efforts are needed to investigate cost-effective therapeutic agents that could cure DENV infections in future. The NS2B-NS3 protease encoded by the genome of DENV is considered a critical target for the development of anti-dengue drugs. The objective of the current study was to find out a specific inhibitor of the NS2B-NS3 proteases from all four serotypes of DENV. To begin with, nine plant extracts with a medicinal history were evaluated for their role in inhibiting the NS2B-NS3 proteases by Fluorescence Resonance Energy Transfer (FRET) assay. Among the tested extracts, Punica granatum was found to be the most effective one. The metabolic profiling of this extract revealed the presence of several active compounds, including ellagic acid, punicalin and punicalagin, which are well-established antiviral agents. Further evaluation of IC50 values of these three antiviral molecules revealed punicalagin as the most potent anti-NS2B-NS3 protease drug with IC50 of 0.91 ± 0.10, 0.75 ± 0.05, 0.42 ± 0.03, 1.80 ± 0.16 µM against proteases from serotypes 1, 2, 3 and 4, respectively. The docking studies demonstrated that these compounds interacted at the active site of the enzyme, mainly with His and Ser residues. Molecular dynamics simulations analysis also showed the structural stability of the NS2B-NS3 proteases in the presence of punicalagin. In summary, this study concludes that the punicalagin can act as an effective inhibitor against NS2B-NS3 proteases from all four serotypes of DENV.Communicated by Ramaswamy H. Sarma.

Punicalagin, a pomegranate polyphenol sensitizes the activity of antibiotics against three MDR pathogens of the Enterobacteriaceae

BACKGROUND

Multidrug resistance (MDR) in the family Enterobacteriaceae is a perniciously increasing threat to global health security. The discovery of new antimicrobials having the reversing drug resistance potential may contribute to augment and revive the antibiotic arsenal in hand. This study aimed to explore the anti-Enterobacteriaceae capability of bioactive polyphenols from Punica granatum (P. granatum) and their co-action with antibiotics against clinical isolates of Enterobacteriaceae predominantly prevalent in South Asian countries.

METHODS

The Kandhari P. granatum (Pakistani origin) extracts were tested for anti-Enterobacteriaceae activity by agar well diffusion assay against MDR Salmonella enterica serovar Typhi, serovar Typhimurium and Escherichia coli. Predominant compounds of active extract were determined by mass spectrometry and screened for bioactivity by agar well diffusion and minimum inhibitory concentration (MIC) assay. The active punicalagin was further evaluated at sub-inhibitory concentrations (SICs) for coactivity with nine conventional antimicrobials using a disc diffusion assay followed by time-kill experiments that proceeded with SICs of punicalagin and antimicrobials.

RESULTS

Among all P. granatum crude extracts, pomegranate peel methanol extract showed the largest inhibition zones of 25, 22 and 19 mm, and the MICs as 3.9, 7.8 and 7.8 mg/mL for S. typhi, S. typhimurium and E. coli, respectively. Punicalagin and ellagic acid were determined as predominant compounds by mass spectrometry. In plate assay, punicalagin (10 mg/mL) was active with hazy inhibition zones of 17, 14, and 13 mm against S. typhi, S. typhimurium and E. coli, respectively. However, in broth dilution assay punicalagin showed no MIC up to 10 mg/mL. The SICs 30 μg, 100 μg, and 500 μg of punicalagin combined with antimicrobials i.e., aminoglycoside, β-lactam, and fluoroquinolone act in synergy against MDR strains with % increase in inhibition zone values varying from 3.4 ± 2.7% to 73.8 ± 8.4%. In time-kill curves, a significant decrease in cell density was observed with the SICs of antimicrobials/punicalagin (0.03-60 μg/mL/30, 100, 500 μg/mL of punicalagin) combinations.

CONCLUSIONS

The P. granatum peel methanol extract exhibited antimicrobial activity against MDR Enterobacteriaceae pathogens. Punicalagin, the bacteriostatic flavonoid act as a concentration-dependent sensitizing agent for antimicrobials against Enterobacteriaceae. Our findings for the therapeutic punicalagin-antimicrobial combination prompt further evaluation of punicalagin as a potent activator for drugs, which otherwise remain less or inactive against MDR strains.

Surface-Enhanced Raman Scattering (SERS) in Combination with PCA and PLS-DA for the Evaluation of Antibacterial Activity of 1-Isopentyl-3-pentyl-1H-imidazole-3-ium Bromide against Bacillus subtilis

In the current study, surface-enhanced Raman scattering (SERS) was performed to evaluate the antibacterial activity of lab-synthesized drug (1-isopentyl-3-pentyl-1H-imidazole-3-ium bromide salt) and commercial drug tinidazole againstBacillus subtilis. The changes in SERS spectral features were studied for unexposed bacillus and exposed one with various dosages of drug synthesized in the lab (1-isopentyl-3-pentyl-1H-imidazole-3-ium bromide salt), and SERS bands were assigned associated with the drug-induced biochemical alterations in bacteria. Multivariate data analysis tools including principal component analysis (PCA) and partial least-squares discriminant analysis (PLS-DA) have been utilized to analyze the antibacterial activity of the imidazole derivative (lab drug). PCA was employed in differentiating all the SERS spectral data sets associated with the various doses of the lab-synthesized drug. There is clear discrimination among the spectral data sets of a bacterial strain treated with different concentrations of the drug, which are analyzed by PLS-DA with 86% area under the curve in receiver operating curve (ROC), 99% sensitivity, 100% accuracy, and 98% specificity. Various dominant spectral features are observed with a gradual increase in the different concentrations of the applied drug including 715, 850, 1002, 1132, 1237, 1396, 1416, and 1453 cm-1, which indicate the possible biochemical changes caused in bacteria during the antibacterial activity of the lab-synthesized drug. Overall, the findings show that imidazole and imidazolium compounds generated from tinidazole with various alkyl lengths in the amide substitution can be effective antibacterial agents with low cytotoxicity in humans, and these results indicate the efficiency of SERS in pharmaceuticals and biomedical applications.

Synthesis, Characterization, and Evaluation of Antifungal Activity of 1-Butyl-3-hexyl-1H-imidazol-2(3H)-selenone by Surface-Enhanced Raman Spectroscopy

In the present research work, a selenium N-heterocyclic carbene (Se-NHC) complex/adduct was synthesized and characterized by using different analytical methods including FT-IR, 1HNMR, and 13CNMR. The antifungal activity of the Se-NHC complex against Aspergillus flavus (A. flavus) fungus was investigated with disc diffusion assay. Moreover, the biochemical changes occurring in this fungus due to exposure of different concentrations of the in-house synthesized compound are characterized by surface-enhanced Raman spectroscopy (SERS) and are illustrated in the form of SERS spectral peaks. SERS analysis yields valuable information about the probable mechanisms responsible for the antifungal effects of the Se-NHC complex. As demonstrated by the SERS spectra, this Se-NHC complex caused denaturation and conformational changes in the proteins as well as decomposition of the fungal cell membrane. The SERS spectra were analyzed using two chemometric tools such as principal component analysis (PCA) and partial least-squares discriminant analysis (PLS-DA). The fungal samples' SERS spectra were differentiated using PCA, while various groups of spectra were discriminated with ultrahigh sensitivity (98%), high specificity (99.7%), accuracy (100%), and area under the receiver operating characteristic curve (87%) using PLS-DA.

Identification of additional mechanistically important residues in the multidrug transporter styMdtM of Salmonella Typhi

Multidrug efflux is a well-established mechanism of drug resistance in bacterial pathogens like Salmonella Typhi. styMdtM (locus name; STY4874) is a multidrug efflux transporter of the major facilitator superfamily expressed in S. Typhi. Functional assays identified several residues important for its transport activity. Here, we used an AlphaFold model to identify additional residues for analysis by mutagenesis. Mutation of peripheral residue Cys185 had no effect on the structure or function of the transporter. However, substitution of channel-lining residues Tyr29 and Tyr231 completely abolished transport function. Finally, mutation of Gln294, which faces peripheral helices of the transporter, resulted in the loss of transport of some substrates. Crystallization studies yielded diffraction data for the wild-type protein at 4.5 Å resolution and allowed the unit cell parameters to be established as a = b = 64.3 Å, c = 245.4 Å, α = β = γ = 90°, in space group P4. Our studies represent a further stepping stone towards a mechanistic understanding of the clinically important multidrug transporter styMdtM.Communicated by Ramaswamy H. Sarma.

Spinal Schwannomas; Classification, Management And Outcomes

Schwannomas are benign tumours of the peripheral nerve sheath. When they occur in spine, they are most commonly found in intradural-extramedullary location. Surgery is the mainstay of treatment. Radiation has a limited role in the management of residual or recurrent lesions not suitable for surgery. Here we discuss the existing literature on the outcomes of spinal schwannoma after surgery.

Agonistic antibacterial potential of Loigolactobacillus coryniformis BCH-4 metabolites against selected human pathogenic bacteria: An in vitro and in silico approach

Lactic acid bacteria are known to produce numerous antibacterial metabolites that are active against various pathogenic microbes. In this study, bioactive metabolites from the cell free supernatant of Loigolactobacillus coryniformis BCH-4 were obtained by liquid-liquid extraction, using ethyl acetate, followed by fractionation, using silica gel column chromatography. The collected F23 fraction effectively inhibited the growth of pathogenic bacteria (Escherichia coli, Bacillus cereus, and Staphylococcus aureus) by observing the minimum inhibitory concentration (MIC) and minimum bactericidal concentrations (MBC). The evaluated values of MIC were 15.6 ± 0.34, 3.9 ± 0.59, and 31.2 ± 0.67 μg/mL and MBC were 15.6 ± 0.98, 7.8 ± 0.45, and 62.5 ± 0.23 μg/mL respectively, against the above-mentioned pathogenic bacteria. The concentration of F23 fraction was varying from 1000 to 1.9 μg/mL. Furthermore, the fraction also exhibited sustainable biofilm inhibition. Using the Electrospray Ionization Mass Spectrometry (ESI-MS/MS), the metabolites present in the bioactive fraction (F23), were identified as phthalic acid, myristic acid, mangiferin, 16-hydroxylpalmatic acid, apigenin, and oleandomycin. By using in silico approach, docking analysis showed good interaction of identified metabolites and receptor proteins of pathogenic bacteria. The present study suggested Loigolactobacillus coryniformis BCH-4, as a promising source of natural bioactive metabolites which may receive great benefit as potential sources of drugs in the pharmacological sector.

Spinal meningiomas: Management and outcomes

Spinal meningiomas are relatively rare, benign, intradural, extramedullary tumours, that are typically slow-growing and well-defined. Surgery is always the first line for treating spinal meningiomas. Here, we have discussed the existing literature on spinal meningiomas and the role of surgery in determining the outcomes.

Prospective Assessment of the Prevalence of Enter Hyperoxalosis in Kidney Transplant Candidates

Enteric hyperoxalosis (EH) is an emerging cause of kidney transplantation (KT) dysfunction. We sought to determine the prevalence of EH and factors that affect plasma oxalate (POx) among at-risk KT candidates.

Methods

We prospectively measured POx among KT candidates evaluated at our center from 2017 to 2020 with risk factors for EH namely bariatric surgery, inflammatory bowel disease, or cystic fibrosis. EH was defined by a POx ≥10 μmol/L. Period-prevalence of EH was calculated. We compared mean POx across 5 factors: underlying condition, chronic kidney disease (CKD) stage, dialysis modality, phosphate binder type, and body mass index.

Results

Of 40 KT candidates screened, 23 had EH for a 4-y period prevalence of 58%. Mean POx was 21.6 ± 23.5 μmol/L ranging from 0 to 109.6 μmol/L. 40% of screened had POx >20 μmol/L. Sleeve gastrectomy was the most common underlying condition associated with EH. Mean POx did not differ by underlying condition (P = 0.27), CKD stage (P = 0.17), dialysis modality (P = 0.68), phosphate binder (P = 0.58), and body mass index (P = 0.56).

Conclusions

Bariatric surgery and inflammatory bowel disease were associated with a high prevalence of EH among KT candidates. Contrary to prior studies, sleeve gastrectomy was also associated with hyperoxalosis in advanced CKD. POx concentrations observed in EH reached levels associated with tissue and potentially allograft deposition. Concentrations can be as high as that seen in primary hyperoxaluria. More studies are needed to assess if POx is indeed a modifiable factor affecting allograft function in patients with EH.

Subclinical hyperthyroidism presenting with hypokalemic periodic paralysis in the emergency department

Subclinical hyperthyroidism (SH) is a condition in which blood levels of Thyroxine (T4) and Triiodothyronine (T3) are normal in the presence of low levels of thyroid-stimulating hormone (TSH). Patients with SH have either no symptoms or mild nonspecific symptoms. Hypokalemic periodic paralysis (HPP) is one of the rare presentations of overt hyperthyroidism; however, only a few cases are reported to date to occur with SH. This case report presents a case of a young Asian male who was admitted to the emergency department (ED) with paralysis of the lower extremities that progressed to the upper extremities and neck muscles in 2 days. Clinically, he was euthyroid; however, his thyroid profile revealed normal levels of T3 and T4 with undetectable TSH levels. This case report aims to add to the limited literature on SH that presents with HPP in the ED.

Efficacy of pentamidine-loaded chitosan nanoparticles as a novel drug delivery system for Leishmania tropica

The present study compares the in vitro effects of nanoparticles loaded pentamidine drug and conventional pentamidine on Leishmania tropica. Herein, pentamidine-loaded chitosan nanoparticles (PTN-CNPs) have been synthesized through an ionic gelation method with sodium tripolyphosphate (TPP). Next, the physical characteristics of PTN-CNPs were determined through the surface texture, zeta potential, in vitro drug release, drug loading content (DLC), and encapsulation efficacy (EE) and compared its efficacy with free pentamidine (PTN) drug against promastigotes and axenic amastigotes forms of L. tropica in vitro. The PTN-CNPs displayed a spherical shape having a size of 88 nm, an almost negative surface charge (-3.09 mV), EE for PTN entrapment of 86%, and in vitro drug release of 92% after 36 h. In vitro antileishmanial activity of PTN-CNPs and free PTN was performed against Leishmania tropica KWH23 promastigote and axenic amastigote using 3-(4, 5- dimethylthiazol-2-yl)-2, 5-diphenyletetrazolium bromide (MTT) assay. It was observed that the effect of PTN-CNPs and free PTN on both forms of the parasite was dose and time dependent. Free PTN presented low efficacy even at higher dose (40 µg/ml) with 25.6 ± 1.3 and 26.5 ±1.4 mean viability rate of the promastigotes and axenic amastigotes, respectively after 72 hrs incubation. While PTN-CNPs showed strong antileishmanial effects on both forms of parasite with 16 ± 0.4 and 19 ± 0.7 mean viability rate at the same higher concentration (40 µg/ml) after 72 hrs incubation. Half maximal inhibitory concentration (IC50) values of PTN-CNPs toward promastigotes and amastigotes were obtained as 0.1375 µg/ml and 0.1910 µg/ml, respectively. In conclusion, PTN-CNPs effectively inhibited both forms of the L. tropica; however, its effect was more salient on promastigotes. This data indicates that the PTN-CNPs act as a target drug delivery system. However, further research is needed to support its efficacy in animal and human CL.

The Antibacterial and Larvicidal Potential of Bis-(2-Ethylhexyl) Phthalate from Lactiplantibacillus plantarum

Lactic acid bacteria produce a variety of antibacterial and larvicidal metabolites, which could be used to cure diseases caused by pathogenic bacteria and to efficiently overcome issues regarding insecticide resistance. In the current study, the antibacterial and larvicidal potential of Bis-(2-ethylhexyl) phthalate isolated from Lactiplantibacillus plantarum BCH-1 has been evaluated. Bioactive compounds were extracted by ethyl acetate and were fractionated by gradient column chromatography from crude extract. Based on FT-IR analysis followed by GC-MS and ESI-MS/MS, the active compound was identified to be Bis-(2-ethylhexyl) phthalate. Antibacterial potential was evaluated by disk diffusion against E. coli (12.33 ± 0.56 mm inhibition zone) and S. aureus (5.66 ± 1.00 mm inhibition zone). Larvicidal potency was performed against Culex quinquefasciatus Say larvae, where Bis-(2-ethylhexyl) phthalate showed 100% mortality at 250 ppm after 72 h with LC50 of 67.03 ppm. Furthermore, after 72 h the acetylcholinesterase inhibition was observed as 29.00, 40.33, 53.00, 64.00, and 75.33 (%) at 50, 100, 150, 200, and 250 ppm, respectively. In comet assay, mean comet tail length (14.18 ± 0.28 μm), tail DNA percent damage (18.23 ± 0.06%), tail movement (14.68 ± 0.56 µm), comet length (20.62 ± 0.64 µm), head length (23.75 ± 0.27 µm), and head DNA percentage (39.19 ± 0.92%) were observed at 250 ppm as compared to the control. The current study for the first time describes the promising antibacterial and larvicidal potential of Bis-(2-ethylhexyl) phthalate from Lactiplantibacillus plantarum that would have potential pharmaceutical applications.

Bioprotection of Zea mays L. from aflatoxigenic Aspergillus flavus by Loigolactobacillus coryniformis BCH-4

Fungal infection causes deterioration, discoloration, and loss of nutritional values of food products. The use of lactic acid bacteria has diverse applications in agriculture to combat pathogens and to improve the nutritional values of cereal grains. The current research evaluated the potential of Loigolactobacillus coryniformis BCH-4 against aflatoxins producing toxigenic Aspergillus flavus strain. The cell free supernatant (CFS) of Loig. coryniformis was used for the protection of Zea mays L. treated with A. flavus. No fungal growth was observed even after seven days. The FT-IR spectrum of untreated (T1: without any treatment) and treated maize grains (T2: MRS broth + A. flavus; T3: CFS + A. flavus) showed variations in peak intensities of functional group regions of lipids, proteins, and carbohydrates. Total phenolics, flavonoid contents, and antioxidant activity of T3 were significantly improved in comparison with T1 and T2. Aflatoxins were not found in T3 while observed in T2 (AFB1 and AFB2 = 487 and 16 ng/g each). HPLC analysis of CFS showed the presence of chlorogenic acid, p-coumaric acid, 4-hydroxybenzoic acid, caffeic acid, sinapic acid, salicylic acid, and benzoic acid. The presence of these acids in the CFS of Loig. coryniformis cumulatively increased the antioxidant contents and activity of T3 treated maize grains. Besides, CFS of Loig. coryniformis was passed through various treatments (heat, neutral pH, proteolytic enzymes and catalase), to observe its stability. It suggested that the inhibitory potential of CFS against A. flavus was due to the presence of organic acids, proteinaceous compounds and hydrogen peroxide. Conclusively, Loig. coryniformis BCH-4 could be used as a good bioprotecting agent for Zea mays L. by improving its nutritional and antioxidant contents.

Metabolomics of Dietary Acid Load and Incident Chronic Kidney Disease

OBJECTIVE

Blood biomarkers of dietary intake are more objective than self-reported dietary intake. Metabolites associated with dietary acid load were previously identified in 2 chronic kidney disease (CKD) populations. We aimed to extend these findings to a general population, replicating their association with dietary acid load, and investigating whether the individual biomarkers were prospectively associated with incident CKD.

METHODS

Among 15,792 participants in the Atherosclerosis Risk in Communities cohort followed up from 1987 to 1989 (baseline) to 2019, we evaluated 3,844 black and white men and women with dietary and metabolomic data in cross-sectional and prospective analyses. We hypothesized that a higher dietary acid load (using equations for potential renal acid load and net endogenous acid production) was associated with lower serum levels of 12 previously identified metabolites: indolepropionylglycine, indolepropionate, N-methylproline, N-δ-acetylornithine, threonate, oxalate, chiro-inositol, methyl glucopyranoside, stachydrine, catechol sulfate, hippurate, and tartronate. In addition, we hypothesized that lower serum levels of these 12 metabolites were associated with higher risk of incident CKD.

RESULTS

Eleven out of 12 metabolites were significantly inversely associated with dietary acid load, after adjusting for demographics, socioeconomic status, health behaviors, health status, and estimated glomerular filtration rate: indolepropionylglycine, indolepropionate, N-methylproline, threonate, oxalate, chiro-inositol, catechol sulfate, hippurate, methyl glucopyranoside (α + β), stachydrine, and tartronate. N-methylproline was inversely associated with incident CKD (hazard ratio: 0.95, 95% confidence interval: 0.91, 0.99, P = .01). The metabolomic biomarkers of dietary acid load significantly improved prediction of elevated dietary acid load estimated using dietary data, beyond covariates (difference in C statistics: 0.021-0.077, P ≤ 1.08 × 10-3).

CONCLUSION

Inverse associations between candidate biomarkers of dietary acid load were replicated in a general population. N-methylproline, representative of citrus fruit consumption, is a promising marker of dietary acid load and could represent an important pathway between dietary acid load and CKD.

An Investigation of Vascular Endothelial Growth Factor (VEGFR-1 and VEGFR-2) in Burn Wound Healing

Burn damage is a complicated trauma that causes local and general tissue edema as a result of cell breakage and capillary leak syndrome. Angiogenesis plays a key part in the mechanisms that are initiated by tissue damage (e.g., burns) since it works directly and precisely on endothelial cells. The primary mediators of angiogenesis are vascular endothelial growth factor (VEGF) and its receptors (VEGFR-1 and VEGFR-2). This study aimed to figure out what functions VEGF and its receptors play in wound healing after burn, and the systemic release of VEGF in people following severe burn damage. This study included 23 burnt adult serum and 20 healthy controls. The enzyme-linked immunosorbent test was used to assess circulating VEGF serum levels and its receptors (VEGFR-1 and VEGFR-2). VEGF serum levels were considerably higher in this study, compared to VEGF levels in healthy controls. The levels of VEGFR-1 and VEGFR-2 have significantly risen; moreover, VEGF and its receptors have a significant impact on edema-related problems in severely burned individuals. Burn is a frequent disease that damages the skin and induces the production of mediators that cause neovasculature in the majority of patients. VEGF, which causes vasculogenesis and angiogenesis, is one of the most important factors in the skin.

Cyclo(L-Leucyl-L-Prolyl) from Lactobacillus coryniformis BCH-4 inhibits the proliferation of Aspergillus flavus: an in vitro to in silico approach

Fungal spoilage led to a considerable economic loss of foodstuff which ultimately affects public health due to mycotoxins production. Moreover, the consumption of commercial antifungal drugs creates side effects and develops antifungal resistance. To overcome these challenges, the current work was aimed to investigate novel antifungal cyclic dipeptide (CDP) from Lactobacillus coryniformis (Loigolactobacillus coryniformis) BCH-4. CDPs have flexible, cyclic, and stable conformation. The proline-based CDPs provide additional structural compatibility and bio-functional values. Keeping in view, high-performance liquid chromatography (HPLC) was performed to explore cyclo(L-Leu-L-Pro) from L. coryniformis BCH-4. The HPLC detected concentration (135 ± 7.07 mg/mL) exhibited in vitro antifungal activity of 5.66 ± 0.57 mm (inhibitory zone) against Aspergillus flavus. Based on these results, cyclo(L-Leu-L-Pro) was used as a bioprotectant for selected food samples (grapes, lemon, cashew nuts, and almonds). A significant impact of cyclo(L-Leu-L-Pro) was observed in contrast with MRS broth (control) and cell-free supernatant. In silico molecular docking analysis of this CDP was carried out against FAD glucose dehydrogenase, dihydrofolate reductase, and urate oxidase of A. flavus as target proteins. Among these proteins, FAD glucose dehydrogenase exerted strong interactions with cyclo(L-Leu-L-Pro) having S-score of  - 8.21. The results evaluated that the detected CDP has strong interactions with selected proteins, causing excellent growth inhibition of A. flavus. Therefore, cyclo(L-Leu-L-Pro) could be used as a potent bioprotectant against food-borne pathogenic fungi.

Rituximab-associated hypogammaglobulinemia in ANCA-associated vasculitis: Incidence and time course

OBJECTIVE

Rituximab (RTX) is approved for remission induction and maintenance of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV). Observational studies demonstrate decline in immunoglobulin (IgG) in AAV post-RTX. The time course for the onset of hypogammaglobulinemia (Hypo-IgG) post-RTX is unknown. This is a key determinant in deciding whether to continue RTX for reinduction or maintenance of remission for AAV. We evaluated the trends of Hypo-IgG among AAV patients post-RTX therapies.

METHODS

An observational single-tertiary-center study of AAV patients treated with RTX for remission induction or maintenance (induction therapy, maintenance therapy, and combined induction and maintenance therapy) between 1998 and 2018. Poisson regression was used to compare the inciden- ces of Hypo-IgG: mild (450-700 mg dL-1), moderate (200-450 mg dL-1), and severe (􏰃200 mg dL-1). Ig levels were measured every 3-6 months after RTX use.

RESULTS

Mean (SD) age at last visit was 59 (16) years, 93% were Caucasians, 64% were females, and 71 (63%) had granulomatosis with polyangiitis (GPA). Hypo-IgG occurred in 47 patients: one (2%) severe, 13 (28%) moderate, and 33 (70%) mild. Lower incidences of mild Hypo-IgG post-RTX were seen during induction compared to maintenance (IR 5.04 per 100 000 days vs 5.45 per 100 000 days, incidence rate ratio (IRR) 1.08, 95% CI 0.34, 3.19). Moderate Hypo-IgG occurred at 2.29 per 100 000 days during induc- tion and 1.82 per 100 000 days during maintenance (IRR 0.79, 95% CI 0.08, 4.84).

CONCLUSION

Hypo-IgG is common among AAV treated with RTX, occurring in 42% of patients in this single-center cohort. The nadir IgG levels occur during remission induction, and the IgG levels remain relatively stable or increase over time in those receiving RTX for remission maintenance.

Mutational Diversity in the Quinolone Resistance-Determining Regions of Type-II Topoisomerases of Salmonella Serovars

Quinolone resistance in bacterial pathogens has primarily been associated with mutations in the quinolone resistance-determining regions (QRDRs) of bacterial type-II topoisomerases, which are DNA gyrase and topoisomerase IV. Depending on the position and type of the mutation (s) in the QRDRs, bacteria either become partially or completely resistant to quinolone. QRDR mutations have been identified and characterized in Salmonella enterica isolates from around the globe, particularly during the last decade, and efforts have been made to understand the propensity of different serovars to carry such mutations. Because there is currently no thorough analysis of the available literature on QRDR mutations in different Salmonella serovars, this review aims to provide a comprehensive picture of the mutational diversity in QRDRs of Salmonella serovars, summarizing the literature related to both typhoidal and non-typhoidal Salmonella serovars with a special emphasis on recent findings. This review will also discuss plasmid-mediated quinolone-resistance determinants with respect to their additive or synergistic contributions with QRDR mutations in imparting elevated quinolone resistance. Finally, the review will assess the contribution of membrane transporter-mediated quinolone efflux to quinolone resistance in strains carrying QRDR mutations. This information should be helpful to guide the routine surveillance of foodborne Salmonella serovars, especially with respect to their spread across countries, as well as to improve laboratory diagnosis of quinolone-resistant Salmonella strains.

Higher Prevalence of Concurrent Thrombocytopenia in Patients Receiving Continuous Renal Replacement Therapy in the Cardiac Intensive Care Unit

INTRODUCTION

Thrombocytopenia (TCP) is a common finding in patients receiving continuous renal replacement therapy (CRRT).

OBJECTIVE

The purpose of this study was to assess the nature of TCP in patients receiving CRRT.

METHODS

This is a single-center case-control observational study of 795 patients involving over 166,950 h of delivered CRRT at Johns Hopkins Hospital. Concurrent TCP in patients receiving CRRT was defined as a decrease in platelet count of ≥50% any time within 72 h of initiation of CRRT with strict exclusion criteria.

RESULTS

There was a higher incidence of TCP in the cardiac intensive care unit (CICU) (22.5%) compared to medical ICU (MICU) (13.1%). Using logistic regression, the odds of developing concurrent TCP in patients receiving CRRT was 2.46 (95% CI 1.32-3.57, p < 0.05) times higher in the CICU compared with the MICU. There was no difference in the incidence of severe or profound TCP or timing of acute TCP between the CICU and MICU.

CONCLUSION

Safe delivery of dialysis care in the ICU is paramount and creating awareness of potential risks such as concurrent TCP in patients receiving CRRT should be part of this care.

Involvement of soluble proteins in growth and metabolic adjustments of drought-stressed Calligonum mongolicum seedlings under nitrogen addition

The planting of seedlings is the most effective measure for vegetation restoration. However, this practice is challenging in desert ecosystems where water and nutrients are scarce. Calligonum mongolicum is a sand-fixing pioneer shrub species, and its adaptive strategy for nitrogen (N) deposition and drought is poorly understood. Thus, in a pot experiment, we studied the impacts of four N levels (0, 3, 6, 9 gN·m^-2 ·year^-1 ) under drought or a well-watered regime on multiple eco-physiological responses of 1-year-old C. mongolicum seedlings. Compared to well-watered conditions, drought considerably influenced seedling growth by impairing photosynthesis, osmolyte accumulation and activity of superoxide dismutase and enzymes related to N metabolism. Nitrogen addition improved the productivity of drought-stressed seedlings, as revealed by increased water use efficiency, enhanced superoxide dismutase and nitrite reductase activity and elevated N and phosphorus (P) levels in seedlings. Nevertheless, the addition of moderate to high levels of N (6-9 gN·m^-2 ·year^-1 ) impaired net photosynthesis, osmolyte accumulation and nitrate reductase activity. N addition and water regimes did not markedly change the N:P ratios of aboveground parts; while more biomass and nutrients were allocated to fine roots to assimilate the insufficient resources. Soluble protein in assimilating shoots might play a vital role in adaptation to the desert environment. The response of C. mongolicum seedlings to N addtion and drought involved an interdependency between soluble protein and morphological, physiological and biochemical processes. These findings provide an important reference for vegetation restoration in arid lands under global change.

Role of endophytic Penicillium species and Pseudomonas monteilii in inducing the systemic resistance in okra against root rotting fungi and their effect on some physiochemical properties of okra fruit

AIMS

The efficacy of three isolates of endophytic Penicillium species that have shown significant suppressive effect on root rotting fungi in our previous study were further evaluated in pots and field plot experiments for their effect on root diseases of okra, induction of systemic resistance and physiochemical properties of okra fruit.

METHODS AND RESULTS

Aqueous suspensions of endophytic Penicillium and Pseudomonas monteilii were applied in pots and field plots using okra as test plant. Data on the fungal infection of roots, plant growth, plant resistance markers like polyphenol, salicylic acid and antioxidant status of plant were determined. These isolates significantly suppressed root diseases and induced systemic resistance via increasing level of resistance markers, polyphenol and salicylic acid besides improving antioxidant activity of Penicillium and P. monteilii-treated plants as compared to control plants. GC-MS analysis of n-hexane extract of mycelium of P. nigricans revealed the presence of 15 different volatile compounds.

CONCLUSIONS

Endophytic Penicillium and P. monteilii have potential against root-infecting fungi of okra and can improve plant growth and yield.

SIGNIFICANCE AND IMPACT OF THE STUDY

Endophytic Penicillium species and P. monteilii can suppress root rotting fungi by direct mechanism or induction of systemic resistance in plants.

In Vitro Antimicrobial and Antioxidant Activities of Lactobacillus coryniformis BCH-4 Bioactive Compounds and Determination of their Bioprotective Effects on Nutritional Components of Maize (Zea mays L.)

Lactic acid bacteria (LAB) can synthesize antimicrobial compounds (AMCs) with nutritional and bioprotective properties in crops and food products. In the current study, AMCs of Lactobacillus coryniformis BCH-4 were evaluated to control fungal spoilage in maize grains. On maize grains treated with 75%-100% (v/v) concentrated AMCs, no fungal growth was observed even after 72 h of Aspergillus flavus inoculation. Proximate analysis of treatments A1 (raw grains), A2 (A. flavus inoculated grains) and A3 (A. flavus + AMCs inoculated grains) revealed that moisture was significantly (p ≤ 0.05) high in A2 than A3 and A1. Meanwhile, protein, fat, fiber and ash contents were significantly decreased in A2 compared to A1 and A3. Moreover, β-carotene contents were not statistically different between A1 and A3, while in A2 it was significantly decreased. HPLC analysis revealed the presence of 2-oxopropanoic acid, 2-hydroxypropane-1,2,3-tricarboxylic acid, 2-hydroxybutanedioic acid, 2-hydroxypropanoic acid, propanedioic acid and butanedioic acid, which also showed antifungal activity against Aspergillus flavus. FTIR spectroscopy revealed the presence of hydroxyl, carbonyl and ester-groups along with organic and fatty acids, thereby indicating their participation in inhibitory action. Furthermore, the AMCs were found to be a good alternative to chemical preservatives, thereby not only preserving the nutritive qualities but increasing the shelf life as well.

Pharmacotherapeutic options for kidney disease in HIV positive patients

INTRODUCTION

Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected.

AREAS COVERED

In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS.

EXPERT OPINION

The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m², (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m² or rising creatinine (≥0.5mg/dl) during drug-drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Transcriptional regulation of drug resistance mechanisms in Salmonella: where we stand and what we need to know

Salmonellae have evolved a wide range of molecular mechanisms to neutralize the effect of antibiotics and evade the host immune system response. These mechanisms are exquisitely controlled by global and local regulators and enable the pathogens to use its energy as per need and hence allow the pathogen to economize the consumption of energy by its cellular machinery. Several families that regulate the expression of different drug resistance genes are known; some of these are: the TetR family (which affects tetracycline resistance genes), the AraC/XylS family (regulators that can act as both transcriptional activators and repressors), two-component signal transduction systems (e.g. PhoPQ, a key regulator for virulence), mercury resistance Mer-R and multiple antibiotic resistance Mar-R regulators, LysR-type global regulators (e.g. LeuO) and histone-like protein regulators (involved in the repression of newly transferred resistance genes). This minireview focuses on the role of different regulators harbored by the Salmonella genome and characterized for mediating the drug resistance mechanisms particularly via efflux and influx systems. Understanding of such transcriptional regulation mechanisms is imperative to address drug resistance issues in Salmonella and other bacterial pathogens.

A Modified Technique in Submandubular Salivary Gland Excision: Preservation of Facial Artery

Cutting and ligation of facial artery is the conventional practice for excision of submandibular gland. Facial artery is the main arterial supply to the lower face. Its preservation results in preservation of large proportion of vascularity to the lower face, preserves vascularity of platysma myocutaneous flap, allows repair of lower lip using Bernard's technique; facial artery is one of the most important recipient artery for microvascular free flap in modern reconstructive surgery in head and neck oncology. This prospective study was carried out in Department of Otolaryngology, Bangabandhu Sheikh Mujib Medical University Hospital (BSMMU), Dhaka, Bangladesh from October 2005 to October 2012 on 31 cases. Chronic submandibular sialoadenitis, benign submandibular gland tumours and cases of neck dissection where level I cervical lymph nodes were not involved by metastasis were included in this study. The facial artery was identified proximal to the gland and was dissected free from the gland by ligating or cauterizing its glandular branches to mobilize the gland. Appropriate anatomical aspects were noted and the time required for separation of the artery from the gland was recorded. Thirty-one consecutive cases were studied. The indications were chronic sialoadenitis (67.7%), pleomorphic adenoma (12.9%) and as a part of neck dissection for oncologic clearance of neck (19.4%). The mean duration of time for separation of the artery from the gland was 10.26 minutes. In two cases the facial artery could not be safely separated due to excessive adhesion from chronic inflammation. No significant complications were noted. Preservation of facial artery in submandibular gland excision is a simple procedure. So it should not be routinely sacrificed during this surgery.

Characterization of the highly immunogenic VP2 protrusion domain as a diagnostic antigen for members of Birnaviridae family

Birnaviridae is a family of viruses (birnaviruses) which consists of four genera, members of which cause diseases in fish, birds, mollusks, and insects. The genome of birnaviruses encodes the highly immunogenic VP2 capsid protein. In order to demonstrate that the VP2 protein can be exploited as a diagnostic antigen for birnaviruses, we developed a lateral flow assay based on the surface-exposed VP2 protrusion domain of a representative birnavirus, infectious bursal disease virus (IBDV) of serotype 1 which causes the highly devastating infectious bursal disease in chickens. The biophysical characterization of the purified domain reveals that the domain predominantly consists of β-sheets, exists in a trimeric form, and remains folded at high temperatures, making it suitable for diagnostic purposes. Owing to its highly immunogenic nature and excellent biophysical properties, we employed the VP2 protrusion domain in a gold nanoparticle-based lateral flow assay for rapid detection of anti-IBDV antibodies in serum samples of infected chickens. Our results indicate that the domain binds anti-IBDV antibodies with high specificity during laboratory testing and on-site testing. The lateral flow assay reported here yields comparable results in a qualitative manner as obtained through a commercial enzyme-linked immunosorbent assay (ELISA). As VP2 is a common capsid protein of birnaviruses, the lateral flow assay can be generalized for other birnaviruses, and members of Tetraviridae and Nodaviridae families which contain homologous VP2 capsid proteins.

Eosinophilia and risk of incident end stage kidney disease

BACKGROUND

Eosinophils in kidney disease are poorly understood and are often incidental findings on kidney biopsy. Eosinophilia in blood and renal biopsy tissue is associated with a host of immune and non-immune kidney diseases. The significance of eosinophilia in renal diseases has not been well addressed. We evaluated the presence of peripheral eosinophilia (> 4% of blood leukocytes) with biopsy tissue eosinophilia and their association with end-stage-kidney-disease (ESKD).

METHODS

A nested case-control (2:1) of patients who underwent kidney biopsies at Johns Hopkins Hospital and Medical University of South Carolina from 2004 to 2018 were included in the study. From the 616 eligible patients, 178 patients were identified through the registry of kidney biopsies as 18 years or older without missing biopsy reports or hematology results. Controls (n = 154) had no ESKD at the time of case (n = 24) designation and were assembled using incident density sampling and matched on age and sex. The association of peripheral eosinophilia (> 4% of peripheral blood leukocytes) with the risk of progression to ESKD was evaluated using conditional logistic model after adjusting for clinical demographics.

RESULTS

Among 178 patients, 65 (37%) had peripheral eosinophilia and 113 (63%) had no eosinophilia. Compared to patients without eosinophilia, patients with peripheral eosinophilia were notably male and had a higher serum creatinine at the time of their biopsy. Peripheral eosinophilia was associated with higher risk of ESKD (OR 15.9 [1.9, 134.7]) adjusted for patient demographics including hypertension, proteinuria and eGFR at the time of kidney biopsy. Peripheral eosinophilia had a significant linear association with kidney tissue eosinophils, 22 (standard deviation [SD] 20) per high power field (hpf) in 4-10% peripheral eosinophilia, 19 (SD 18) per hpf in ≥10% eosinophilia and 3 (SD 7) per hpf in no eosinophilia (P <  0.001).

CONCLUSIONS

Peripheral eosinophilia is an independent predictor of tissue eosinophilia and subsequent progression to ESKD. Peripheral eosinophilia may be an early biomarker for underlying inflammation and disease, but further studies to investigate this clinical association are warranted.

Real-time forecasting of epidemic trajectories using computational dynamic ensembles

Forecasting the trajectory of social dynamic processes, such as the spread of infectious diseases, poses significant challenges that call for methods that account for data and model uncertainty. Here we introduce an ensemble model for sequential forecasting that weights a set of plausible models and use a frequentist computational bootstrap approach to evaluate its uncertainty. We demonstrate the feasibility of our approach using simple dynamic differential-equation models and the trajectory of outbreak scenarios of the Ebola Forecasting Challenge. Specifically, we generate sequential short-term forecasts of epidemic outbreaks by combining phenomenological models that incorporate flexible epidemic growth scaling, namely the Generalized-Growth Model (GGM) and the Generalized Logistic Model (GLM). We rely on the root-mean-square error (RMSE) to quantify the quality of the models' fits during the calibration periods for weighting their contribution to the ensemble model while forecasting performance was evaluated using the RMSE of the forecasts. For a given forecasting horizon (1-4 weeks), we report the performance for each model as the percentage of the number of times each model outperforms the other models. The overall mean RMSE performance of the GLM and the GGM-GLM ensemble models outcompeted that of participant models of the Ebola Forecasting Challenge. We also found that the ensemble model provided more accurate forecasts with higher frequency than the GGM and GLM models, but its performance varied across forecasting horizons. For instance, across all of the Ebola Challenge Scenarios, the ensemble model outperformed the other models at horizons of 2 and 3 weeks while the GLM outperformed other models at horizons of 1 and 4 weeks.

Association of frequency of hereditary hemochromatosis (HFE) gene mutations (H63D and C282Y) with iron overload in beta-thalassemia major patients in Pakistan

Objectives:

To evaluate any association between the frequency of hereditary hemochromatosis (HFE) gene mutation (H63D and C282Y) and iron overload in beta-thalassemia major (BTM) patients.

Methods:

The case-control study was conducted from June 2016 to February 2018. Blood samples from 204 BTM patients and 204 normal controls were taken from the Sundas Foundation Blood Bank.

These samples were analyzed for serum ferritin assay and HFE mutation. Ferritin level was measured on the ARCHITECT 1000SR. Both patient and control samples were analyzed for mutations using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

Results:

Serum ferritin levels for all patients were >1000ng/mL. The p.H63D mutation was observed in 23 (11.3%) cases, out of which 19 cases were heterozygous for p.H63D and 4 cases were homozygous. In control samples, 4 cases (2%) were found heterozygous for the p.H63D, and no homozygous mutation was found. Significantly high serum ferritin levels were found in BTM patients with the H63D mutation (p=0.00). In the case of p.C282Y, neither homozygous nor heterozygous mutation was found in patients or in controls.

Conclusion:

H63D polymorphism is associated with iron overload in BTM patients. Larger-scale research is required to give an elaborated view of the association of the HFE mutation with iron overload in these patients and to confirm our conclusion.

Restraining the multidrug efflux transporter STY4874 of Salmonella Typhi by reserpine and plant extracts

Efflux-mediated multidrug resistance is a well-known phenomenon facilitated by multidrug resistant (MDR) transporters. One of the approaches to counteract efflux-mediated resistance is the use of MDR pump inhibitors, and thus be used in combination with the conventional antibiotics to treat deadly diseases like typhoid fever. We have previously reported that STY4874, an efflux transporter of Salmonella serotype Typhi, exhibited promising characteristics as MDR pump. In this study, we aimed to get an insight into possible STY4874 inhibitors of plant origin. STY4874 was overexpressed in Escherichia coli and extracts from pomegranate peel, milk thistle seeds and reserpine, a synthetic plant alkaloid, were screened for inhibition of ciprofloxacin efflux. The extracts of milk thistle seeds and reserpine when incubated with ciprofloxacin showed statistically significant STY4874-mediated inhibitory activity, rendering the efflux pump inactive and hence early growth inhibition of host cells compared with cells expressing efflux pump and incubated only with ciprofloxacin. This efflux pump inhibitory activity was further confirmed by time-kill experiments. This study is the first to report on efflux pump inhibition of S. Typhi STY4874 and results can be extended towards its close homologues such as MdfA and MdtM from E. coli. SIGNIFICANCE AND IMPACT OF THE STUDY: Understanding and combating resistance governed by multidrug efflux transporters is an ongoing research intensive area, affecting treatment of various nosocomial and endemic/epidemic infections. Confronting drug resistance requires that inhibitors debilitating the underlying mechanisms should be included in combination therapy. One such example is the prescription of clavulanic acid as combination therapy with amoxicillin, collectively called as co-amoxiclav to combat β-lactamase-mediated resistance. However, research related to finding the inhibitors of efflux transporters, the resistance mechanism distinct from β-lactamase mediated resistance is at an early stage. The current study finds that plant-derived inhibitors can be an option towards restraining efflux-mediated resistance.

Chryseobacterium Indologenes as a Novel Cause of Bacteremia in a Neonate

Chryseobacterium indologenes is a rare human pathogen. It is an emerging species, least frequently reported from pediatric age group and known to cause pneumonia, bacteremia, and meningitis. The inherent resistant of one of the species to commonly prescribed broad-spectrum antibiotics makes it formidable challenge in the hospital settings. We report the first case of C. indologenes bacteremia from Pakistan, diagnosed in a preterm newborn in an intensive care setting.

Influence of Frequently Used Chemical Insecticides on Mycoflora Carried by Common Housefly, Musca domestica L

The housefly, Musca domestica L. (Diptera: Muscidae), is a major medical and veterinary insect pest. It serves as a vector of many pathogenic microorganisms causing spoilage of food and diseases in human and animals. Use of chemical insecticides is adapted as a principal tool to manage housefly. Insecticides have many unforeseen ecological consequences including effects on non-target organisms. In the present study, we have assessed the effects of 10 different synthetic insecticides on the growth of mycoflora associated with the external body of the housefly by using poison food technique. Our results reveled that all synthetic insecticides enhanced the growth. Surprisingly, in most of the cases, mycelial growth of fungi was significantly increased at high concentration as compared with lower concentration. This study provides useful information about the dangerous effects of synthetic insecticides on environment by increasing the spread of various non-target pathogenic, mycotoxigenic, and food spoiling fungi, carried by houseflies.

Effects of Long-Term Combination LT4 and LT3 Therapy for Improving Hypothyroidism and Overall Quality of Life

Guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists suggest monitoring thyroid-stimulating hormone and serum-free thyroxine to make clinical decisions for starting and monitoring therapy with their mainstay treatment of levothyroxine monotherapy. Although this monotherapy provides adequate control of symptoms for the majority of the population, a strong subset of the population continues to complain of hypothyroidism despite normal thyroid-stimulating hormone and serum-free thyroxine levels. Combination levothyroxine and liothyronine therapy to improve symptoms of hypothyroidism has been a topic of interest for several decades, but the data have been mixed. This study provides insight into the effects of combination therapy because there is no reported retrospective or prospective study in the literature.

Supplemental digital content is available in the text.

Objectives

Hypothyroidism results in decreased mood and neurocognition, weight gain, fatigue, and many other undesirable symptoms. The American Association of Clinical Endocrinologists, the American Thyroid Association (ATA), and The Endocrine Society recommend levothyroxine (LT4) monotherapy as the treatment for hypothyroidism; however, after years of monotherapy, some patients continue to experience impaired quality of life. Combination LT4 and synthetic liothyronine (LT3) therapy or the use of desiccated thyroid extract (DTE), has not been suggested for this indication based on short-duration studies with no significant benefits. Our first observational study examined the role of combination therapy for 6 years in improving quality of life in a subset of a hypothyroid population without adverse effects and cardiac mortality.

Methods

An observational retrospective study examining patients prescribed thyroid replacements with serum triiodothyronine (FT3), LT4 with LT3 (synthetic therapy) or DTE (natural therapy), compared with LT4 alone in the United States from 2010 to 2016. Thyroid-stimulating hormone (TSH), serum thyroxine (FT4), and FT3 levels were documented for each patient in addition to any admissions of myxedema coma, thyrotoxicosis, or cardiovascular complications, such as arrhythmias, atrial fibrillation, and mortality. At the conclusion of the study, a cross-sectional interview assessed quality of life for each combination therapy through the Medical Outcomes Study Short Form-20 questionnaire.

Results

Compared with patients taking only LT4, 89.47% using synthetic therapy had therapeutic TSH (P < 0.05). Similarly, 96.49% using natural therapy had therapeutic TSH (P < 0.05). Less than 5% of patients had supratherapeutic FT3. None of the patients who had abnormally low TSH or elevated FT3 or FT4 levels had hospitalizations for arrhythmias or thyrotoxicosis. On the Medical Outcomes Study Short Form-20 questionnaire, >92% answered feeling “excellent, very good, or good” when questioned about their health while undergoing thyroid replacement compared with levothyroxine alone.

Conclusions

This is the only retrospective study reported to use long-term (mean 27 months) thyroid replacements with combination therapy and to compare between the two forms of therapy: synthetic and natural. For patients undergoing either therapy, we did not identify additional risks of atrial fibrillation, cardiovascular disease, or mortality in patients of all ages with hypothyroidism.

Arteriovenous ratio and papilledema based hybrid decision support system for detection and grading of hypertensive retinopathy

BACKGROUND AND OBJECTIVES

Hypertensive Retinopathy (HR) is a retinal disease which happened due to consistent high blood pressure (hypertension). In this paper, an automated system is presented that detects the HR at various stages using arteriovenous ratio and papilledema signs through fundus retinal images.

METHODS

The proposed system consists of two modules i.e. vascular analysis for calculation of arteriovenous ratio and optic nerve head (ONH) region analysis for papilledema.  First module uses a set of hybrid features in Artery or Vein (A/V) classification using support vector machine (SVM) along with its radial basis function (RBF) kernel for arteriovenous ratio. In second module, proposed system performs analysis of ONH region for possible signs of papilledema. This stage utilizes different features along with SVM and RBF for classification of papilledema.

RESULTS

The first module of proposed method shows average accuracies of 95.10%, 95.64% and 98.09%for images of INSPIRE-AVR, VICAVR, and local dataset respectively. The second module of proposed method achieves average accuracies of 95.93% and 97.50% on STARE and local dataset respectively.

CONCLUSIONS

The system finally utilizes results from both modules to grade HR with good results. The presented system is a novel step towards automated detection and grading of HR disease and can be used as clinical decision support system.

Follicular B Cell Lymphoma with Accompanying Ischemic Gastritis Completely Resolved by Rituximab

Patient: Female, 89

Final Diagnosis: Follicular B-cell lymphoma with accompanying ischemic gastritis completely resolved by rituximab

Symptoms: Nausea • vomiting

Medication: —

Clinical Procedure: —

Specialty: Oncology

An unfortunate case of acquired hemochromatosis: a case report review of the clinical presentation, diagnosis, management, and prognosis

BACKGROUND

While blood transfusions are commonly used for prophylaxis and treatment for acute chest syndromes and strokes in sickle cell patients, accumulation of excess iron resulting in secondary hemochromatosis remains a rare disease. Chelation is the mainstay for preventing and treating iron overload to deter potential end-organ damages; it is rare when therapy fails.

CASE REPORT

A 52-year-old African American woman with chronic anemia secondary to sickle cell anemia and history of multiple blood transfusions presented with elevated serum ferritin (8000 ng/mL) and bilirubin (16.8 mg/dL). She had no previous personal or family history of liver disease. A magnetic resonance cholangiopancreatography (MRCP) and a liver biopsy confirmed the secondary hemochromatosis with marked fibrosis and 4+ iron deposits, but since she was therapeutically on deferasirox, her treatment regimen involved only closer monitoring. Her hemochromatosis led to readmission within a year for rapid progression of cardiac and hepatic failure.

CONCLUSION

Since chronically transfused sickle cell patients are at a significantly higher risk of mortality due to the secondary hemochromatosis and end-stage organ damage, knowledge of prophylactic iron chelation is important. Minimizing unnecessary transfusions should be strongly emphasized to reduce the sequelae as iron burden remains a threat. The effectiveness of iron-chelating therapy is best monitored via periodic magnetic resonance imaging, liver transaminases, bilirubin, creatinine, ferritin, and cardiac function tests. Despite the prophylactic treatment and quarterly blood work, in this case the initial presentation did not correlate with the severity of end-stage liver failure. The damage was not discovered until proven by liver biopsy and MRCP, too late to deter the sequelae and the mortality exactly 1 year after diagnosis of the secondary hemochromatosis.

Design challenges for electronic medication administration record systems in residential aged care facilities: a formative evaluation

INTRODUCTION

Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements.

METHODS

A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system.

RESULTS

The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues. We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows.

DISCUSSION

Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.