Clinico-radiological-pathological profile and outcomes of Lung transplantation in post covid-19 phenotype: A single centre experience

Background

Lung transplantation (LTx) has come as hope for select patients with post-COVID acute respiratory distress syndrome (ARDS). It has a different phenotype with unique challenges. We aimed to bring out our experience with and outcomes of LTx for post-COVID ARDS.

Methods

This study is retrospective case series from a single center in India. All the patients with post-COVID end stage lung disease (ESLD) who underwent bilateral LTx between 1st May 2020 and 30th August 2021 were included. LTx was performed following no improvement with optimal medical management with adequate time provided for recovery. Information relating to demographics, comorbidities, pretransplant status, perioperative parameters, gross and histopathological findings of explanted lungs, posttransplant morbidity, and mortality were analyzed.

Results

This study included 23 patients. The median age of the patients in this study was 42 years and 20 participants were men (87%). The mean duration of intensive care unit stay was 15.83 ± 6.61 days. Mortality was observed among 8 participants (34.78%). Mean survival time was 34.54 weeks. Among the 8 patients who expired, the cause of death was sepsis for 6 patients (75.0%), neurologic cerebrovascular accident for 1 patient (12.5%), and cytomegalovirus for 1 patient (12.5%). All the deaths were reported in primary graft dysfunction grade 2 & 3 category. No rejections were observed on first and third month surveillance biopsies.

Conclusions

LTx is the definitive option for survival in select patients with severe post–COVID-19–associated ESLD. This study brings out various challenges involved in such phenotypes and also observations in postoperative recovery.

Comparison of Perinatal and Maternal Outcomes in Borderline Versus Normal Amniotic Fluid Index in a Tertiary Care Center in Odisha: An Observational Prospective Study

Background

Amniotic fluid is a protective fluid in the amniotic sac of a gravid uterus that serves many crucial functions by becoming part of an indicator of a functioning fetoplacental unit during the intrauterine life of a fetus. The most commonly used method for measuring amniotic fluid is the amniotic fluid index (AFI). In this study, we aimed to investigate the perinatal and maternal outcomes in borderline AFI versus normal AFI.

Methodology

This observational prospective study included 200 pregnant women who were admitted to Pradyumna Bal Memorial Hospital, Bhubaneswar from September 2019 to February 2021. Women with singleton pregnancy in their third trimester were enrolled in this study after applying inclusion and exclusion criteria. Of the included women, 100 were cases with borderline AFI, and 100 were control with normal AFI. Fetal and maternal outcomes were compared between the two groups. Data analysis was done using SPSS version 23 (IBM Corp., Armonk, NY, USA).

Results

Maternal outcomes such as preterm delivery, meconium-stained liquor, and lower segment cesarean section in women with borderline AFI were significantly higher (p ≤ 0.001). The borderline AFI group had a higher rate of perinatal complications such as Apgar score of <7 (p = 0.001), respiratory distress syndrome (p = 0.001), neonatal intensive care unit admission (p <0.001), intrauterine growth restriction (p < 0.001), and low birth weight (p < 0.001).

Conclusions

The borderline AFI group was associated with adverse perinatal and maternal outcomes which were significantly higher in this group compared to the control group. Therefore, patients with borderline AFI should be monitored carefully during the antepartum and intrapartum period.

Laparoscopic Transabdominal Cervical Cerclage by Broad Ligament Window Technique

Laparoscopic transabdominal cerclage (LTAC) is a well documented procedure for cervical incompetence. In this article we have done a detailed stepwise description of LTAC by broadligament window technique. This technique makes the procedure simpler, safer and easy to reproduce.

Hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies: A single institution Indian experience

BACKGROUND

Cytoreductive surgery followed by hyper- thermic intraperitoneal chemotherapy (HIPEC) has shown better oncological outcomes in peritoneal surface malignancies (PSM). We assessed the feasibility and perioperative outcomes of this procedure in Indian patients.

METHODS

In this prospective observational study from February 2013 to April 2015, we included 56 patients (41 females, 73.2%) with PSM. They had a good performance status, were either treatment-naïve or previously treated by surgery and systemic chemotherapy. They underwent cytoreductive surgery followed by HIPEC using a hyperthermia pump, with the temperature at 42 °C for 30-90 minutes. The chemotherapy regimen was based on the primary malignancy. Perioperative outcome data were collected and analysed. We also analysed the short-term oncological outcomes.

RESULTS

Our patients included those with peritoneum confined ovarian carcinoma (32, 57.1%), colorectal carcinoma (9, 16.1%), pseudomyxoma peritonei (7, 12.5%), meso- thelioma (2, 3.6%), gastric carcinoma (2, 3.6%) and others (4, 7.1%). The median duration of surgery including HIPEC was 9 hours and the median hospital stay was 12 days. The median time for gastrointestinal recovery was 5 days. One-fifth of patients (11, 19.7%) required an extended stay in the inten- sive care unit. The most common grades 3 and 4 complications were hypocalcaemia 32.1%, hypokalaemia 32.1%, anaemia 21.4% and thrombocytopenia 7.1%. Major morbidity requiring surgical intervention occurred in 8.9% of patients. The 60-day operative mortality was 1.8%. At a median follow-up of 16 months, 7.1% developed peritoneal recurrence, 8.9% had systemic recurrence and 7.1% succumbed to the disease. Patients with platinum-resistant ovarian carcinomas had more peritoneal recurrence (3.6%).

CONCLUSION

In patients with PSM, surgical cytoreduction and HIPEC is feasible and potentially beneficial. It can be done with low mortality and acceptable morbidity. It requires a dedicated team of surgeons, anaesthetists and intensivists and proper infrastructure.

Acoustic emission source location in composite structure by Voronoi construction using geodesic curve evolution

Conventional analytical/numerical methods employing triangulation technique are suitable for locating acoustic emission (AE) source in a planar structure without structural discontinuities. But these methods cannot be extended to structures with complicated geometry, and, also, the problem gets compounded if the material of the structure is anisotropic warranting complex analytical velocity models. A geodesic approach using Voronoi construction is proposed in this work to locate the AE source in a composite structure. The approach is based on the fact that the wave takes minimum energy path to travel from the source to any other point in the connected domain. The geodesics are computed on the meshed surface of the structure using graph theory based on Dijkstra's algorithm. By propagating the waves in reverse virtually from these sensors along the geodesic path and by locating the first intersection point of these waves, one can get the AE source location. In this work, the geodesic approach is shown more suitable for a practicable source location solution in a composite structure with arbitrary surface containing finite discontinuities. Experiments have been conducted on composite plate specimens of simple and complex geometry to validate this method.

Inhibition of Na(+)/K(+)-atpase by endothelin-1 in human nonpigmented ciliary epithelial cells

Endothelin-1 (ET-1), a potent vasoconstrictor, lowers intraocular pressure in mammals, either by enhancing the outflow of aqueous humor (AH) via the trabecular meshwork and Schlemm's canal or by reducing AH formation at the ciliary epithelium. Aqueous humor production occurs by passive diffusion of water coupled with active transport of ions, mainly involving Na(+):K(+):2Cl(-) cotransporter and Na(+)/K(+)-ATPase pump from serosal to aqueous side. Presently, we have evaluated the effects of ET-1 on Na(+):K(+):2Cl(-) cotransport and Na(+)/K(+)-ATPase activity in HNPE cells using (86)Rb(+) uptake. ET-1 (100 pM-100 nM) decreased mean (86)Rb(+) uptake by 15% during a 15-min uptake period. ET-1's effect was not prevented by BQ610, an ET(A) receptor antagonist, but was blocked by BQ788, an ET(B) receptor antagonist. ET-1's effect was mimicked by sarafotoxin, an ET(B) agonist. ET-1-induced reduction in (86)Rb(+) uptake was additive with bumetanide, a selective inhibitor of Na(+):K(+):2Cl(-) cotransporter but not with ouabain, a selective inhibitor of the Na(+)/K(+)-ATPase. ET-1 did not affect iberiotoxin-sensitive maxi K(+) channels. This suggests that ET-1-induced reduction in (86)Rb(+) uptake is mediated through the inhibition of the Na(+)/K(+)-ATPase via an ET(B)-like receptor. These findings are consistent with an ET-1 effect on active ion transport activity in HNPE cells that could explain the reduction in aqueous humor production and the lowering of intraocular pressure.

Characterization of a transformed rat retinal ganglion cell line

The purpose of the present study was to establish a rat retinal ganglion cell line by transformation of rat retinal cells. For this investigation, retinal cells were isolated from postnatal day 1 (PN1) rats and transformed with the psi2 E1A virus. In order to isolate retinal ganglion cells (RGC), single cell clones were chosen at random from the transformed cells. Expression of Thy-1 (a marker for RGC), glial fibrillary acidic protein (GFAP, a positive marker for Muller cells), HPC-1/syntaxin (a marker for amacrine cells), 8A1 (a marker for horizontal and ganglion cells) and neurotrophins was studied using reverse transcriptase-polymerase chain reaction (RT-PCR), immunoblotting and immunocytochemistry. One of the retinal cell clones, designated RGC-5, was positive for Thy-1, Brn-3C, Neuritin, NMDA receptor, GABA-B receptor, and synaptophysin expression and negative for GFAP, HPC-1, and 8A1, suggesting that it represented a putative RGC clone. The results of RT-PCR analysis were confirmed by immunocytochemistry for Thy-1 and GFAP. Upon further characterization by immunoblotting, the RGC-5 clone was positive for Thy-1, negative for GFAP, 8A1 and syntaxin. RGC 5 cells were also positive for the expression of neurotrophins and their cognate receptors. To establish the physiological relevance of RGC-5, the effects of serum/trophic factor deprivation and glutamate toxicity were analyzed to determine if these cells would undergo apoptosis. The protective effects of neurotrophins on RGC-5 after serum deprivation was also investigated. Apoptosis was studied by terminal deoxynucleotidyl transferase-mediated fluoresceinated dUTP nick end labeling (TUNEL). Serum deprivation resulted in apoptosis and supplementation with both BDNF and NT-4 in the growth media, protected the RGC-5 cells from undergoing apoptosis. On differentiation with succinyl concanavalin A (sConA), RGC-5 cells became sensitive to glutamate toxicity, which could be reversed by inclusion of ciplizone (MK801). In conclusion, a transformed rat retinal cell line, RGC-5, has certain characteristics of retinal ganglion cells based on Thy-1 and Brn-3C expression and its sensitivity to glutamate excitotoxicity and neurotrophin withdrawal. These cells may be valuable in understanding of retinal ganglion cell biology and physiology including in vitro manipulations in experimental models of glaucoma.

Dependence of insulin secretion from permeabilized pancreatic beta-cells on the activation of Ca(2+)/calmodulin-dependent protein kinase II. A re-evaluation of inhibitor studies

Previous studies utilizing inhibitors of the Ca(2+)/calmodulin-dependent protein kinase II (CaM kinase II) to address the role of this enzyme in insulin secretion have produced contradictory results. In the current study, these inconsistencies have been addressed by evaluating the effect of various CaM kinase II inhibitors to decrease Ca(2+)-induced insulin secretion from permeabilized beta-cells. KN-93 (2-[N-(2-hydroxyethyl)-N-(4-methoxy-benzenesulfonyl)]-amino-N-(4-chlo rocinnamyl)-N-methylbenzylamine) markedly inhibited both CaM kinase II activation and insulin secretion in parallel in alpha-toxin-permeabilized beta-cells. These effects were specific since they were not mimicked by the inactive analog, KN-92 (2-[N-(4-methoxy-benzenesulfonyl)]-amino-N-(4-chlorocinnamyl)-N-methy lbenzylamine). In contrast, KN-62 (1-[N, O-bis(5-isoquinolinesulfonyl)-N-methyl-l-tyrosyl]-4-phenylpiperazine) , while reported to be similar to KN-93 with respect to mechanism of action, did not inhibit Ca(2+)-induced activation of CaM kinase II or insulin secretion in these cell preparations. All three agents suppressed Ca(2+) influx in intact beta-cells induced by depolarization in the presence of elevated extracellular potassium although to different extents. The synthetic peptide inhibitors of CaM kinase II, [Ala(286)]CaMK 281-302 and AIP (autocamtide-2-related inhibitory peptide), strongly inhibited Ca(2+)-induced insulin secretion from electropermeabilized islets, an effect that also correlated with an equivalent inhibition of CaM kinase II activation. This re-evaluation (i) explains a lack of effect of KN-62 on insulin secretion from permeabilized cells based on its inability to inhibit CaM kinase II activation in these preparations; (ii) has revealed that CaM inhibitors, either chemical or peptide in nature, that are capable of preventing enzyme activation uniformly suppress Ca(2+)-sensitive insulin secretion; and (iii) cautions the use of KN-62/93/92 as selective inhibitors of CaM kinase II in intact cell studies. These observations reinforce the suggestion that CaM kinase II plays an important role in insulin exocytosis in the beta-cell.

Cholinergic and adrenergic modulation of the Ca2+ response to endothelin-1 in human ciliary muscle cells

PURPOSE

To determine the cholinergic (carbachol, CCH) and adrenergic (norepinephrine, NE) modulation of Ca2+ response to endothelin-1 in human ciliary smooth muscle (HCSM) cells.

METHODS

Intracellular calcium levels were measured using the Fura-2 calcium imaging system in HCSM cells treated either singly with endothelin-1 (ET-1; 2-200 nM), CCH (1-100 microM), NE (0.1-10 microM) or isoproterenol (ISO; 1 microM) or in combinations of CCH, NE, or ISO with ET-1. Intracellular cAMP levels after NE and ISO treatments were also measured using a radioimmunoassay.

RESULTS

Endothelin-1 dose-dependently increased [Ca2+]i and was characteristically biphasic (peak [Ca2+]i for ET-1: 2 nM, 517 +/- 73 nM; 20 nM, 785 +/- 65 nM; and 200 nM, 2564 +/- 359 nM). Carbachol also dose-dependently increased [Ca2+]i; however, subsequent additions of ET-1 (200 nM) resulted in lower [Ca2+]i (100 microM CCH + ET-1; 300 +/- 21 nM) compared with that observed with 200 nM ET-1 alone (2564 +/- 359 nM). Norepinephrine pretreatment also decreased ET-1-induced [Ca2+]i (10 microM NE + ET-1; 619 +/- 64 nM) compared with ET-1 alone, and NE's effect could be reversed by propranolol (beta-adrenergic antagonist) treatment. Neither CCH nor NE was able to completely abolish ET-1's ability to mobilize calcium in HCSM cells. Isoproterenol (a beta-agonist) mimicked NE's effect on ET-1-induced [Ca2+]i (1 microM ISO + ET-1; 254 +/- 56 nM). Both ISO and NE elevated [cAMP] in HCSM cells.

CONCLUSIONS

In HCSM cells, CCH and ET-1 can activate common as well as specific [Ca2+]i pools. The reduction in ET-1-induced [Ca2+]i after NE/ISO treatment appears to be due to elevated cAMP levels via beta-receptor activation, suggesting the existence of receptor cross talk. The ability of CCH and NE to modulate ET-1's actions on HCSM may be relevant to the regulation of ciliary muscle contraction and aqueous humor outflow.

Identification of endothelin converting enzyme-1 in human non-pigmented ciliary epithelial cells

Endothelins (ETs), potent vasoactive peptides, are present in many ocular tissues including the ciliary epithelium where active ET-1 is produced from the precursor Big ET-1 by a membrane-bound metalloprotease, endothelin-converting enzyme (ECE). Although the role of ocular ET's are uncertain, they are elevated in the aqueous humor of normal as well as glaucomatous eyes and have been shown to lower the intraocular pressure for prolonged periods of time. In the current study, an endothelin-converting enzyme-1 (ECE-1) has been identified and its activity has been studied in SV-40 transformed human non-pigmented ciliary epithelial (HNPE) cells. Western blotting using polyclonal antibodies against ECE-1, detected a 124 kDa protein in the plasma membrane but not in the cytosol. Further characterization of the enzymatic activity of ECE-1 (conversion of Big ET-1 to ET-1) using the plasma membrane fraction of HNPE cells was performed by a novel assay involving(125)I-Big ET-1 (substrate; 80 fmoles mg(-1)protein) and polyclonal antibodies specific for Big ET-1. Mean ECE-1 activity (expressed as fmoles(125)I-ET-1 produced mg protein(-1)time(-1)) increased linearly with time and was similar to that observed in rat lung tissue. ECE-1 activity was enhanced with increasing concentrations of substrate ((125)I-Big ET-1; 30-200 fmoles mg protein(-1)180 min(-1)) as well as with increasing concentrations of protein (5-20 microgram proteins at the substrate concentration of 80 fmoles mg protein(-1)180 min(-1)). Treatments with CGS-26303 (100 micrometer), an inhibitor of ECE-1 and thiorphan (2 mM; a metalloprotease inhibitor), significantly decreased ECE-1 activity. Furthermore, both, acidification of the reaction buffer (from pH 7.4 to 6.4) and the addition of a metal chelator, EGTA (2 mM) decreased ECE-1 activity by nearly 60%. These results suggest that the ECE-1 localized in HNPE cells, is a neutral pH-sensitive metalloprotease which is similar in its activity to that observed in lung tissue and is essential for the production of ET-1 in HNPE cells. The physiological importance of the unusual proteolytic processing by ECE-1 in ocular tissue may reflect on how ET regulates intraocular pressure.

Phenylarsine oxide inhibits phosphate uptake in human ciliary non-pigmented epithelial cells

Phenylarsine oxide (PAO), a sulfhydryl modifying reagent and a widely used inhibitor for tyrosine phosphatases and endocytosis, was tested on the level of phosphorylation in human nonpigmented ciliary epithelial ocular (HNPE) cells. Pretreatment with (PAO, 10 microM) for 30 min followed by incubation with 32Pi to stimulate endogenous phosphorylation surprisingly resulted in a total reduction in 32Pi labeled proteins. PAO (10-50 microM) dose-dependently inhibited both sodium-dependent and -independent phosphate uptake in cells. p-Hydroxymercuribenzoate (pHMB, 10 microM), another sulfhydryl modifying reagent failed to mimic PAO effects. However, metabolic inhibitors (iodoacetamide (0.1 mM) and 2,4-dinitrophenol (DNP, 0.5 mM) also mimicked PAO effects, suggesting that the inhibition of ATP production may be responsible for attenuation of both phosphate uptake mechanisms. However, sodium-dependent phosphate uptake in isolated plasma membrane vesicles pretreated with PAO was also significantly lower than control vesicles treated with dimethlysulfoxide (DMSO), suggesting that PAO may be directly targeting a component of the sodium-dependent cotransporter. It is suggested that PAO is a novel inhibitor of phosphate uptake in HNPE cells that acts indirectly by inhibiting ATP production and directly by inhibiting the Na-dependent cotransporter.

Activation of protein kinase C by tumor necrosis factor-alpha in human non-pigmented ciliary epithelium

Previously, we have shown that tumor necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine, increases the synthesis and release of endothelin-1 (ET-1), a potent vasoactive peptide from human non-pigmented ciliary epithelial (HNPE) cells, in a protein kinase C (PKC)-dependent manner. Diacylglycerol (DAG) and intracellular calcium ([Ca2+]i) are well known activators of PKC. Some cytokines induce PKC activation by stimulating phospholipase C that hydrolyzes phosphatidylinositol bisphosphate (PIP2) into IP3 (intracellular calcium mobilizer) and DAG. In this study, the existence of a similar pathway was evaluated in HNPE cells treated with TNF-alpha, using intracellular calcium ([Ca2+]i) measurements, PKC translocation assays and thin-layer chromatography (TLC) for quantification of DAG. Incubation times for agonists and inhibitors ranged from 1-30 minutes. The increase in DAG levels with TNF-alpha treatment was consistent with the observed translocation of the calcium-dependent PKC alpha isoform from the cytosol to the plasma membrane. However, these observations were not accompanied by a concomitant increase in [Ca2+]i. Similar translocation responses were observed with phorbol ester (phorbol 12-myristate 13-acetate) treatment. Our results indicate that TNF-alpha-induced PKC activation in HNPE cells occurs as a result of elevated DAG levels and is not due to an increase in intracellular calcium. Activated PKC, could enhance the pro-inflammatory responses of TNF-alpha in part by increasing the production of endothelins in the eye.

Endothelin receptor A is expressed and mediates the [Ca2+]i mobilization of cells in human ciliary smooth muscle, ciliary nonpigmented epithelium, and trabecular meshwork

PURPOSE

To identify which endothelin receptor subtype is expressed and is functional in the human ciliary body and trabecular meshwork, tissues that regulate aqueous humor dynamics.

METHODS

Immunocytochemistry was used to characterize the primary culture cells of normal human ocular cells. Endothelin receptor gene expression was probed with reverse transcription of polymerase chain reaction (RT-PCR). Intracellular calcium ([Ca2+]i) mobilization was measured with video image microscopy using Fura-2AM as a fluorescent probe.

RESULTS

Identities of primary cultures, human ciliary smooth muscle (HCSM), ciliary nonpigmented epithelial (HCE), and trabecular meshwork (HTM) cells were confirmed by immunocytochemistry, using cell-specific markers and observing typical cell morphologies. The presence of endothelin receptor A (ETA) was detected with RT-PCR in all three types of cells. The mRNA phenotype was verified with restriction enzyme BamHI digestion. No ETB receptor subtype expression was detected with RT-PCR under the cell culture conditions used. The [Ca2+]i of HCSM cells was increased from 57 +/- 7 nM to 328 +/- 108 nM (n = 23; mean +/- SE; P < 0.05) by 1 nM endothelin-1 (ET-1). In HCE cells, [Ca2+]i increased from 40 +/- 3 nM to 90 +/- 10 nM (n = 55) (P < 0.001) with the same concentration of ET-1. Similarly, ET-1 (1 nM) increased the [Ca2+]i from 51 +/- 6 nM to 185 +/- 47 nM (n = 19) (P < 0.001) in the HTM cells. The agonist for ETB, S6c, had no effect on [Ca2+]i transients in all three cell types. No ETB receptor expression was detected in these cell types under the experimental and culture conditions.

CONCLUSION

ETA receptor is expressed and is possibly responsible for mediating the signal for [Ca2+]i mobilization by ET-1 in human ciliary smooth muscle, ciliary nonpigmented epithelial cells, and trabecular meshwork cells.

Regulation of endothelin-1 in human non-pigmented ciliary epithelial cells by tumor necrosis factor-alpha

Endothelins (ET) are potent vasoactive peptides present in many ocular structures and are formed from precursor Big endothelins (Big ET-1) by the action of an endothelin-converting enzyme (ECE). ET-1 is thought to decrease intraocular pressure by contracting the ciliary muscle thus enhancing the outflow of aqueous humor through the Canal of Schlemm and trabecular meshwork. However, the mechanisms involved in the regulation of endothelin-1 (ET-1) synthesis and release in ocular tissues have not been fully characterized. In this study we examined the effect of tumor necrosis factor-alpha(TNF-alpha; 10 nm), a proinflammatory cytokine, on the cellular mechanisms leading to ET-1 synthesis and release in SV-40 transformed human ciliary non-pigmented epithelial cells (HNPE). ET-1 and Big endothelin-1 (Big ET-1) immunoreactivity was time-dependently increased following TNF-alphatreatment. Phorbol esters (PMA), activators of PKC, also raised the immunoreactive levels of ET-1 and Big ET-1 while, staurosporine, a PKC inhibitor (20 nm), decreased ET-1 levels in TNF-alpha-stimulated cells. Pre-treatment with phosphoramidon (1 micron) an ECE-inhibitor, followed by TNF-alpha stimulation, decreased ir-ET-1 levels. Cycloheximide (9 micron), a protein synthesis inhibitor, decreased TNF-alpha-stimulated levels for ir-ET-1 and ir-Big ET-1, suggesting that TNF-alpha may be directly regulating ET-1 expression at the ET-1 gene. Our data indicates that TNF-alpha regulates ET-1 levels in HNPE cells possibly by activating PKC either to stimulate protein synthesis and/or to enhance ET-1 secretion. These results suggest that ET-1 released from the ciliary body may play an important role in aqueous humor dynamics following cytokine activation.