Beta-thalassemia major complicated by intracranial hemorrhage and critical illness polyneuropathy

Intracranial hemorrhage (ICH) is rarely seen in patients with thalassemia. A seven-year-old male, known case of beta-thalassemia major, on irregular packed cell transfusions (elsewhere) and non-compliant with chelation therapy, presented with congestive cardiac failure (Hb-3 gm/dl). He received three packed red cell transfusions over 7 days (cumulative volume 40 cc/kg). On the 9^th day, he developed projectile vomiting and two episodes of generalized tonic-clonic convulsions with altered sensorium. He had exaggerated deep tendon reflexes and extensor plantars. CT-scan of brain revealed bilateral acute frontal hematoma with diffuse subarachnoid hemorrhage (frontal and parietal). Coagulation profile was normal. CT-angiography of brain showed diffuse focal areas of reduced caliber of anterior cerebral, middle cerebral, and basilar and internal carotid arteries (likely to be a spasmodic reaction to subarachnoid hemorrhage). He required mechanical ventilation for 4 days and conservative management for the hemorrhage. However, on the 18^th day, he developed one episode of generalized tonic-clonic convulsion and his sensorium deteriorated further (without any new ICH) and required repeat mechanical ventilation for 12 days. On the 28^th day, he was noticed to have quadriplegia (while on a ventilator). Nerve conduction study (42^nd day) revealed severe motor axonal neuropathy (suggesting critical illness polyneuropathy). He improved with physiotherapy and could sit upright and speak sentences at discharge (59^th day). The child recovered completely after 3 months. It is wise not to transfuse more than 20 cc/kg of packed red cell volume during each admission and not more than once in a week (exception being congestive cardiac failure) for thalassemia patients.

P2806A novel sirolimus drug eluting stent for Small-Vessel Disease: results from en-ABL e-registry

Objective

The aim of the study was to assess the clinical outcome of Abluminus DES in patients with small vessels.

Background

Percutaneous coronary intervention (PCI) of small coronary vessel (≤2.75 mm) associated with more chances of restenosis and repeat revascularization even when drug eluting stent employed.

Methods

A total of 2,500 patients enrolled in en-ABL e-registry which is a prospective, multicentre observational post market registry. Out of 2,500 patients, 1,253 patients had small vessel (SV, ≤2.75 mm) while 1,247 had large vessel (LV, >3mm) disease. The primary endpoint was major adverse cardiac events (MACE) which is composite of cardiac death, target vessel myocardial infraction (TV-MI) and target lesion/vessel revascularization (TLR) at 1 year follow up. The secondary endpoint were stent thrombosis and MACE up to 2 years.

Results

Baseline characteristics were well matched in both groups. In the SV group had higher prevalence of diabetes as compared to large vessel 43.0% vs 25.7%. Total 1,400 lesions treated with 1,612 Abluminus DES and 1,569 lesions treated with 1,675 Abluminus DES in SV and LV groups respectively. The mean diameter of stent was 2.61±0.23 and 3.3±0.3 mm in SV and LV groups respectively. There was a significant difference in MACE in treatment groups (3.7% vs. 1.4%, p=0.004 respectively) at 1 year. No significant differences were observed between SV and LV groups in terms of death/myocardial infarction or stent thrombosis. There were increment of only one TLR and no stent thrombosis reported at 2-year follow-up.

Conclusion

This result suggests the efficacy and safety of novel Abluminus DES in small vessel disease.

Surface and Aggregation Behavior of Pentablock Copolymer PNIPAM7-F127-PNIPAM7 in Aqueous Solutions

The triblock Pluronic F127 was modified by introducing poly(N-isopropylacrylamide) (PNIPAM) at both the poly(ethylene oxide) ends, and the pentablock copolymer so-prepared was characterized by gel permeation chromatography and (1)H NMR. The degree of polymerization of NIPAM blocks at the two ends was 7. The solution behavior and microstructure of copolymer aggregates in water and aqueous salt solution were examined and compared with F127 by UV-visible absorption spectroscopy, microdifferential scanning calorimetry, dynamic light scattering (DLS), and small-angle neutron scattering (SANS). The behavior of the pentablock copolymer at the air/water interface was determined by Langmuir film balance. Two lower critical solution temperatures were observed for pentablock copolymer, corresponding to poly(propylene oxide) and PNIPAM blocks, respectively. DLS studies show that micelle size increased with increase in temperature and in the presence of salt. SANS measurements provided temperature-dependent structural evolution of copolymer micelles in water and salt solution. The copolymer displays an isotherm with four classical regions (pancake, mushroom, brush, and condensed state). The study has potential applications in controlled drug delivery due to the tunable phase behavior and biocompatibility of the copolymer.

Parallel Gene Expression Changes in Sarcoidosis Involving the Lacrimal Gland, Orbital Tissue, or Blood

IMPORTANCE

Sarcoidosis is a major cause of ocular or periocular inflammation. The pathogenesis of sarcoidosis is incompletely understood and diagnosis often requires a biopsy.

OBJECTIVE

To determine how gene expression in either orbital adipose tissue or the lacrimal gland affected by sarcoidosis compares with gene expression in other causes of orbital disease and how gene expression in tissue affected by sarcoidosis compares with gene expression in peripheral blood samples obtained from patients with sarcoidosis.

DESIGN, SETTING, AND PARTICIPANTS

In a multicenter, international, observational study, gene expression profiling of formalin-fixed biopsy specimens, using GeneChipp U133 Plus 2 microarrays (Affymetrix), was conducted between October 2012 and January 2014 on tissues biopsied from January 2000 through June 2013. Participants included 12 patients with orbital sarcoidosis (7 in adipose tissue; 5 affecting the lacrimal gland) as well as comparable tissue from 6 healthy individuals serving as controls or patients with thyroid eye disease, nonspecific orbital inflammation, or granulomatosis with polyangiitis. In addition, results were compared with gene expression in peripheral blood samples obtained from 12 historical individuals with sarcoidosis.

MAIN OUTCOMES AND MEASURES

Significantly differentially expressed transcripts defined as a minimum of a 1.5-fold increase or a comparable decrease and a false discovery rate of P < .05.

RESULTS

Signals from 2449 probe sets (transcripts from approximately 1522 genes) were significantly increased in the orbital adipose tissue from patients with sarcoidosis. Signals from 4050 probe sets (approximately 2619 genes) were significantly decreased. Signals from 3069 probe sets (approximately 2001 genes) were significantly higher and 3320 (approximately 2283 genes) were significantly lower in the lacrimal gland for patients with sarcoidosis. Ninety-two probe sets (approximately 69 genes) had significantly elevated signals and 67 probe sets (approximately 56 genes) had significantly lower signals in both orbital tissues and in peripheral blood from patients with sarcoidosis. The transcription factors, interferon-response factor 1, interferon-response factor 2, and nuclear factor κB, were strongly implicated in the expression of messenger RNA upregulated in common in the 3 tissues.

CONCLUSIONS AND RELEVANCE

Gene expression in sarcoidosis involving the orbit or lacrimal gland can be distinguished from gene expression patterns in control tissue and overlaps with many transcripts upregulated or downregulated in the peripheral blood of patients with sarcoidosis. These observations suggest that common pathogenic mechanisms contribute to sarcoidosis in different sites. The observations support the hypothesis that a pattern of gene expression profiles could provide diagnostic information in patients with sarcoidosis.

Fibrosis, gene expression and orbital inflammatory disease

BACKGROUND/AIMS

To clarify the pathogenesis of fibrosis in inflammatory orbital diseases, we analysed the gene expression in orbital biopsies and compared our results with those reported for idiopathic pulmonary fibrosis.

METHODS

We collected 140 biopsies from 138 patients (58 lacrimal glands; 82 orbital fat). Diagnoses included healthy controls (n=27), non-specific orbital inflammation (NSOI) (n=61), thyroid eye disease (TED) (n=29), sarcoidosis (n=14) and granulomatosis with polyangiitis (GPA) (n=7). Fibrosis was scored on a 0-3 scale by two experts, ophthalmic pathologists. Gene expression was quantified using Affymetrix U133 plus 2.0 microarray.

RESULTS

Within orbital fat, fibrosis was greatest among subjects with GPA (2.75±0.46) and significantly increased in tissue from subjects with GPA, NSOI or sarcoidosis (p<0.01), but not for TED, compared with healthy controls (1.13±0.69). For lacrimal gland, the average score among controls (1.36±0.48) did not differ statistically from any of the four disease groups. Seventy-three probe sets identified transcripts correlating with fibrosis in orbital fat (false discovery rate <0.05) after accounting for batch effects, disease type, age and sex. Transcripts with increased expression included fibronectin, lumican, thrombospondin and collagen types I and VIII, each of which has been reported upregulated in pulmonary fibrosis.

CONCLUSIONS

A pathologist's recognition of fibrosis in orbital tissue correlates well with increased expression of transcripts that are considered essential in fibrosis. Many transcripts implicated in orbital fibrosis have been previously implicated in pulmonary fibrosis. TED differs from other causes of orbital fat inflammation because fibrosis is not a major component. Marked fibrosis is less common in the lacrimal gland compared with orbital adipose tissue.

Molecular recognition of acute myeloid leukemia using aptamers

Cell surface proteins can play important roles in cancer pathogenesis. Comprehensive understanding of the surface protein expression patterns of tumor cells and, consequently, the pathogenesis of tumor cells, depends on molecular probes against these proteins. To be effectively used for tumor diagnosis, classification and therapy, such probes would be capable of specific binding to targeted tumor cells. Molecular aptamers, designer DNA/RNA probes, can address this challenge by recognizing proteins, peptides and other small molecules with high affinity and specificity. Through a process known as cell-SELEX, we used live acute myeloid leukemia (AML) cells to select a group of DNA aptamers that can recognize acute myeloid leukemia cells with dissociation constants (Kds) in the nanomolar range. Interestingly, one aptamer (KH1C12), compared with two control cell lines (K562 and NB4), showed significant selectivity to the target AML cell line (HL60) and could recognize the target cells within a complex mixture of normal bone marrow aspirates. The other two aptamers KK1B10 and KK1D04 recognize targets associated with monocytic differentiation. Our studies demonstrate that the selected aptamers can be used as a molecular tool for further understanding surface protein expression patterns on tumor cells and thus providing a foundation for effective molecular analysis of leukemia and its subcategories.

Subclinical hypovitaminosis D among exclusively breastfed young infants

OBJECTIVE

To determine Vitamin D status of mother-newborn diads at birth and of their exclusively breastfed (EBF) infants at 3 months.

DESIGN

Longitudinal study.

METHODS

Exclusively breastfed infants born at term with birth weight > 2.5 kg to normal, healthy mothers followed till 3 months. Serum calcium, phosphorous, heat labile alkaline phosphatase (HLAP) and 25(OH)D estimated in 42 mother / cord blood diads and in 35 (EBF) infants followed up at 3 months. Twenty five (OH)D < 15 ng/mL was considered low and 15 to 25 ng/mL low to normal.

RESULTS

Ca, P, HLAP were significantly higher in cord blood (P < 0.001) but mean 25 (OH)D, 19.36 ng/mL was comparable to maternal level of 22.9 ng/mL (r = 0.82, P < 0.001). At 3 months only HLAP was significantly higher compared to cord blood. Higher 25 (OH)D at 3 months correlated with higher 25 (OH)D values in cord blood (r = +0.616, P < 0.001) as well as higher antenatal maternal levels (r = + 0.552, P < 0.001). Serum 25 (OH)D values < 25 ng/mL was observed in 50 % mothers, 62 % cord blood specimens and 80 % infants at 3 months.

CONCLUSIONS

Subnormal maternal vitamin D status is associated with vitamin D deficiency in newborns and persists in exclusively breastfed infants.

Seroepidemiology of hepatitis A infection in India: changing pattern

OBJECTIVE

Recent changes in the epidemiology of hepatitis A virus (HAV) infection and the availability of effective vaccines have renewed interest in this infection. We determined the age-related prevalence of anti-HAV antibodies in India and looked for differences by known risk factors for HAV infection.

METHODS

In this prospective study, serum samples obtained from 1612 subjects aged 1 to 60 at six centers in five cities (Calcutta, Cochin, Indore, Jaipur and Patna) during the period February to August 1998 were tested for anti-HAV antibodies. Demographic and socio-economic information was obtained by questionnaire.

RESULTS

The overall seroprevalence rate was 65.9%, varying from 26.2% to 85.3% in various cities; there was no difference between males and females. Seropositivity increased with age from 52.2% in the 1-5 year age group to 80.8% in those aged 16 years or more. Seroprevalence rates were significantly lower in those aged 1-5 years compared with other age groups (p<0.0001). There was no difference in seroprevalence between those with monthly family income <Rs 5000 and >Rs 5001. Multivariate analysis showed that anti-HAV seroprevalence varied significantly by source of water supply, being highest when the supply was municipal.

CONCLUSION

Our results indicate an epidemiological pattern of intermediate endemicity. This finding has public health implications as it indicates that a significant proportion of the Indian adolescent and adult population is at risk of HAV infection.

Low plasma leptin in response to dietary fat in diabetes- and obesity-prone mice

Despite the fact that mutations resulting in the absence of leptin or its receptor have been associated with severe obesity and diabetes, such mutations do not appear to be responsible for most human obesity. Indeed, diet-induced obesity in animals and humans has been characterized by hyperleptinemia. This has been interpreted as evidence for leptin resistance. However, no careful longitudinal studies evaluating the role of leptin in the development of obesity exist. We report a series of studies in A/J and C57BL/6J (B/6) mice that demonstrate a direct relationship between the ability to increase plasma leptin levels in response to a high-fat diet and resistance to the subsequent development of obesity and diabetes. While leptin levels are similar in lean, low-fat-fed A/J and B/6 mice, the effects of a high-fat diet on plasma leptin differ dramatically between the two strains. After 4 weeks of high-fat feeding, leptin levels in A/J mice increased 10-fold, and this elevated level was maintained independent of weight gain throughout a 14-week feeding period. However, in B/6 mice, leptin levels remained at least twofold lower and only rose very gradually along with a significant increase in adiposity, hyperglycemia, and hyperinsulinemia. These differences in the response of leptin to diet are independent of food intake and plasma insulin levels during the 1st month of feeding. Further, we demonstrated that leptin administration did not influence the expression of the novel uncoupling protein UCP2, which also responds to dietary fat. From these results, we suggest that the response of leptin to fat feeding may be an important predictor of the development of subsequent obesity.

Inverse relationship of peripheral thyrotropin-stimulating hormone levels to brain activity in mood disorders

OBJECTIVE

The author's goal was to investigate relationships between peripheral thyroid hormone levels and cerebral blood flow (CBF) and cerebral glucose metabolism in affectively ill patients.

METHOD

Medication-free inpatients with major depression or bipolar disorder were studied with oxygen-15 water and positron emission tomography (PET) to measure CBF (N = 19) or with [18F] fluorodeoxyglucose and PET to measure cerebral glucose metabolism (N = 29). Linear regression was used to correlate global CBF and cerebral glucose metabolism with serum thyrotropin-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), and free T4 concentrations. Statistical parametric mapping was used to correlate regional CBF and cerebral glucose metabolism with these thyroid indexes. Post hoc t tests were used to further explore the relationships between serum TSH and global CBF and cerebral glucose metabolism.

RESULTS

Serum TSH was inversely related to both global and regional CBF and cerebral glucose metabolism. These relationships persisted in the cerebral glucose metabolism analysis and, to a lesser extent, in the CBF analysis after severity of depression had been controlled for. In contrast, no significant relationships were observed between T3, T4, or free T4 and global or regional CBF and cerebral glucose metabolism.

CONCLUSIONS

These data suggest that peripheral TSH (putatively the best marker of thyroid status) is inversely related to global and regional CBF and cerebral glucose metabolism. These findings indicate relationships between thyroid and cerebral activity that could provide mechanistic hypotheses for thyroid contributions to primary and secondary mood disorders and the psychotropic effects of thyroid axis manipulations.

Prenatal exposure to alcohol in adult rats: relationships between sleep and memory deficits, and effects of glucose administration on memory

Previous studies show that prenatal exposure to alcohol results in sleep deficits in rats, including reductions in paradoxical sleep. Little is known, however, about the extent or duration of sleep impairments beyond the neonatal period. The present experiment examined effects of prenatal exposure on sleep in young adulthood. Three-hour, daytime sleep EEGs were obtained in 6-month-old female rats prenatally exposed to alcohol. Compared to isocaloric pair-fed and ad libitum control groups, the alcohol-exposed group showed reduced paradoxical sleep. Non-paradoxical sleep did not differ between groups. Concurrent deficits were obtained in radial arm maze, but not inhibitory (passive) avoidance, performance. One year later, at the age of 18 months, alcohol-exposed rats showed deficits in spontaneous alternation behavior which were reversed by administration of glucose (100 mg/kg). Deficits in paradoxical sleep at 6 months of age were highly correlated with deficits in spontaneous alternation behavior at 18 months of age, in individual, alcohol-exposed animals. These results provide the first evidence that prenatal exposure to alcohol results in selective and persistent deficits in sleep. They also show that measures of paradoxical sleep can predict impaired memory over a large portion of the life span, and suggest that glucose can attenuate memory deficits in this population.

Assessment of myocardial perfusion during cold stress using thallium-201 scintigraphy in diabetic patients with abnormal changes in left ventricular function during cold stress

Eleven type-I (insulin-dependent) diabetic patients with abnormal changes in left ventricular function in response to cold stress (CS) were investigated to try and determine the cause of these abnormal responses. Resting M-mode echocardiography demonstrated that all 11 patients had normal left ventricular dimensions and wall motion, thereby excluding overt cardiomyopathy. Thallium-201 scintigraphy was used to assess myocardial perfusion during CS and eight patients were found to have perfusion defects during stress which persisted in four. It is possible that CS unmasks evidence of myocardial ischemia but it is also possible that the abnormal responses to CS reflect altered vasomotor reactivity in the diabetic patient, producing coronary spasm. Left ventricular function may be influenced by many factors in diabetes and an abnormal CS test may not necessarily indicate structural disease. Such tests, however, may help in the further understanding of the pathophysiology of heart disease in diabetes.

Effect of cold stimulation on myocardial perfusion. An investigation using thallium-201 scintigraphy

Thallium-201 scintigraphy was used to investigate the effects of cold stimulation on myocardial perfusion in 12 patients with documented coronary artery disease (group 1), nine with chest pain but without evidence of structural coronary artery disease (group 2), and 10 normal volunteers (group 3). The scintigrams were assessed both visually and numerically using a circumferential profile technique. Transient perfusion defects were identified by both techniques in six subjects in group 1, three in group 2, and two in group 3. The haemodynamic responses (assessed by the double product) of subjects with or without transient perfusion defects were not significantly different. Thus cold stimulation can provoke abnormalities of myocardial perfusion not only in patients with coronary heart disease but also in those with structurally normal coronary arteries and in some normal subjects. These results may reflect a spectrum of coronary vasomotor responsiveness to cold stimulation in both normal and ischaemic populations, and it is concluded that cold pressor techniques cannot be relied on to differentiate patients with coronary heart disease from those with atypical chest pain syndromes or even from normal subjects.

Cardiac function during stress testing in long-standing insulin-dependent diabetics

Four dynamic tests of cardiac function were compared in a group of 13 long-standing insulin-dependent diabetics who had no clinical evidence of cardio-respiratory disease. One patient developed abnormal features during 24 hour ambulatory electrocardiograms while all 13 patients had normal exercise electrocardiograms. The change in left ventricular ejection fraction during dynamic supine exercise as measured by gated blood-pool scintigraphy was not significantly different from control subjects (p less than 0.1) while during cold stimulation testing the change in left ventricular ejection fraction in the diabetics was highly significantly different from the control subjects (p less than 0.01). Five of the patients had one or more abnormal tests of autonomic function. The cold stimulation test may be a sensitive index of cardiac dysfunction in diabetics but as the mechanism is unclear alternative explanations are possible. While the etiology of heart disease in such patients is uncertain it is likely to be multifactorial and this test may prove useful in investigating the natural history and pathogenesis of cardiac disease in diabetics.

Prolonged effect of nadolol on heart rate in hyperthyroidism

There is extensive experience in the treatment of hyperthyroidism with beta-blockade. Because of the short half-life of propranolol the drug must be taken in divided doses. The effect of a single daily dose of a long-acting beta-blocking drug, nadolol, was investigated in 7 hyperthyroid patients. A satisfactory and prolonged reduction in heart rate was observed during continuous monitoring over a 24-hour period. Nadolol, therefore, is a possible alternative to propranolol in the treatment of hyperthyroidism with an advantage in the poorly-compliant patient.

Relationship among particle size distribution, dissolution profile, plasma values, and anthelmintic efficacy of oxfendazole

Three mean particle sizes of oxfendazole raw material (1.65 micron, lot A; 3.2 micron, 10t B; 12.0 micron, lot C) were prepared and identically formulated as corresponding (A, B, and C) suspensions at 2.26% (W/V) concentration. Studies involving microscopic examination, scanning electron microscope analysis, particle size distribution, and surface area measurement were carried out on raw materials. In vitro dissolution profiles were obtained for the suspensions. A comparative bioavailability study of these 3 suspensions was performed in 12 sheep with each sheep given each formulation in a Latin square crossover study design; oxfendazole was dosed at rate of 5 mg/kg of body weight. Plasma-value measurements were made followed by an analysis of various bioavailability studies. Plasma area values indicated that suspension C (dw = 12.0 micron) was significantly (P less than 0.05) less bioavailable than was suspension A (dw = 1.65 micron); there was no difference between suspension A and suspension B. Significant differences were not seen in biological half-life and maximum plasma concentrations. The term dw refers to that particle diameter (determined by Coulter counting) at which 50% of the oxfendazole mass was in the form of particles having a lesser diameter and 50% was in the form of particles having a greater diameter. In a separate study involving 20 Merino weaner sheep infected with benzimidazole-resistant Haemonchus contortus larvae, oxfendazole's anthelmintic efficacy was demonstrated in the 2.26% suspension dosage form (90% particles less than 10 micron) at a dosing rate of 5 mg/kg. A correlation was found between its anthelmintic activity and plasma area values when compared in individual sheep. Data demonstrated that substantial differences in particle size distribution of oxfendazole could influence its dissolution rate, plasma concentrations, and absorption characteristics, thus indicating that oxfendazole's absorption could be dissolution-rate limited.