Subphenotypes of SARS-CoV-2-Associated ARDS Overlap Each Other: A Retrospective Analysis

Background  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-associated pneumonia and acute respiratory distress syndrome (ARDS) were often associated with hyperinflammation and elevation of several serum inflammatory markers but usually less than what is observed in non-coronavirus disease (COVID) ARDS. Elevated inflammatory markers such as C-reactive protein, interleukin (IL)-6, etc., are associated with severe infection. This study identified subphenotypes of COVID-19 ARDS patients by latent profile analysis in a cohort of Indian patients. Methods  Data of n  = 233 adult Indian patients with laboratory-confirmed SARS-CoV-2 infection admitted to a tertiary care teaching hospital were analyzed in this retrospective study. Only patients with acute respiratory failure (defined by partial pressure of oxygen/fraction of inspired oxygen ratio < 200 mm Hg) and chest X-ray showing bilateral infiltrates were included. Results  The patients' mean (standard deviation) age was 53.3 (14.9) years, and 62% were male. A two subphenotypic model was formulated based on the lowest Bayesian information criterion. Neutrophil-to-lymphocyte ratio and serum IL-6 were latent variables in that model (entropy 0.91). The second phenotype (hyperinflammatory) had lower platelet count ( p  = 0.02), higher serum creatinine ( p  = 0.004), higher C-reactive protein ( p  = 0.001), higher ferritin ( p  < 0.001), and serum lactate dehydrogenase ( p  = 0.009). Age-adjusted hospital mortality ( p  = 0.007), duration of hospital stay ( p  < 0.001), and duration of intensive care unit stay ( p  < 0.001) were significantly higher in the second subphenotype. Conclusion  Two distinct but overlapping subphenotypes were identified in SARS-CoV-2-associated respiratory failure. Hyperinflammatory subphenotype was associated with significantly poor short-term outcomes.

Assessment of Stability of Prothrombin Time, International Normalized Ratio, and Activated Partial Thromboplastin Time Under Different Storage Conditions in Human Plasma

Background

In this study, we aimed to determine the effects of storage time and temperature on commonly performed coagulation tests such as prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT) in human plasma.

Methodology

Whole blood samples from 100 patients were collected in a 3.2% sodium citrate vacutainer. The blood was centrifuged within two hours of collection at 2,000 g for 10 minutes, and the platelet-poor plasma (PPP) obtained was analyzed for PT, INR, and APTT tests at zero hours (baseline) and repeated at 12 hours, 24 hours, and 36 hours on a fully automated coagulation analyzer at various storage conditions (room temperature, refrigerator, and freezer). The results were categorized into two groups: group 1 comprised results with normal coagulation profile and group 2 comprised results with abnormal coagulation profile. The percentage change of the results from baseline (zero hours) for PT, INR, and APTT tests was also studied. A percentage change of more than ±10% from baseline was considered as a clinically significant change.

Results

In this study, a total of 95 PPP samples were evaluated. The median age of all patients was 44 years (range: 19-65 years). The male-to-female ratio was 0.9:1. The baseline PT, INR, and APTT values were 12.1 seconds, 1.06, and 26.5 seconds, respectively, in group 1, whereas the baseline PT, INR, and APTT values were 19.1 seconds, 1.80, and 36.0 seconds, respectively, in group 2. In the freezer, the samples were stable for PT, INR, and APTT tests at 12 hours, 24 hours, and 36 hours showing a change of <10% from baseline at all three time-points. In the refrigerator, the samples were stable for PT and INR tests for up to 24 hours showing a change of <10% from baseline. In comparison, the samples for the APTT test were not stable at 12 hours, 24 hours, and 36 hours showing a change of 12.1%, 15.5%, and 17.9%, respectively, from the baseline (zero hours). Finally, at room temperature, the samples deteriorated at 12 hours for all coagulation parameters (PT, INR, and APTT).

Conclusions

The patient plasma samples for PT, INR, and APTT tests could be safely stored for up to 36 hours in the freezer. In the refrigerator, samples for PT and INR tests could be safely stored for up to 24 hours while the samples for APTT deteriorated at 12 hours. All patient samples for PT, INR, and APTT tests deteriorated at 12 hours at room temperature.

Unusually Low Serum Alkaline Phosphatase Activity in a Patient with Acute on Chronic Liver Failure and Hemolysis

A 28-year-old male with acute on chronic liver failure (ACLF) and hepatic encephalopathy had deranged liver function with curiously low level (0-15 IU/L) of serum alkaline phosphatase (ALP). Peripheral smear examination suggested hemolytic anemia. The finding of persistent low ALP, after ruling out pre-analytical causes, in ACLF has been reported in Wilson's disease (WD) with/ without autoimmune hemolytic anemia (AIHA). Definitive evidences of WD were not seen in our case. Positive DCT and histological features suggest a diagnosis of autoimmune hepatitis with secondary hemochromatosis and cholangitis. Low ALP might not always be a determinant of bile duct pathology in patients of ACLF with AIHA.

Increased level of organochlorine pesticides in chronic kidney disease patients of unknown etiology: role of GSTM1/GSTT1 polymorphism

Chronic kidney disease (CKD) of unknown etiology represents about 16% of CKD patients in Indian subcontinents and 10% worldwide. The aetiology of CKD of unknown etiology remains unclear though epidemiological studies indicate the involvement of the environmental toxins. Organochlorine pesticides (OCPs) have been detected in general population in India. It is possible that polymorphism of xenobiotic metabolizing enzymes (XMEs) may play an important role in this process. In this we intend to find out blood levels of OCPs in CKD patients of unknown etiology and to evaluate the consequence of glutathione S-transferase (GST) gene polymorphism on the same. We have assessed 270 CKD patients and 270 age-sex-matched healthy controls for this study. The blood OCP levels were analyzed by gas chromatograph. GSTM1, GSTT1 genotyping were carried out by multiplex PCR. Blood levels of HCH, endosulfan and total pesticides were significantly higher in CKD patients and negatively correlated with eGFR. The combined frequency of GSTM1(-)/GSTT1(-) genotype increased the risk of CKD by 1.8-fold as compared to healthy controls. To find out the dependence of blood OCPs level on genotype, we carried out logistic regression analysis and results revealed that GSTM1(-)/GSTT1(-) genotype associated significantly with a number of OCPs namely γ-HCH, p,p'-DDT and total pesticides. Polymorphism of XMEs not only increased accumulation of pesticides but also aggravates kidney dysfunction as evident from significant decrease in eGFR.

Association of CYP1A1 gene polymorphism with chronic kidney disease: a case control study

CYP1A1 is an important xenobiotic metabolizing enzyme, present in liver and kidney. Expression of CYP1A1 enzyme increases manifold when kidney cells are exposed to nephrotoxins/chemicals leading to oxidative stress-induced cell damage. To study the association of CYP1A1 gene polymorphism in patients of chronic kidney disease with unknown etiology (CKDU), we recruited 334 CKDU patients and 334 age and sex matched healthy controls. CYP1A1*2A and *2C polymorphisms were studied by PCR-RFLP and allele specific-PCR respectively. Subjects carrying at least one mutant allele of CYP1A1*2A (TC, CC) and *2C (AG, GG) were shown to be associated with 1.4-2-fold increased risk of CKDU. Also, genotypic combinations of hetero-/homozygous mutants of CYP1A1*2A (TC, CC) with hetero-/homozygous mutant genotypes of CYP1A1*2C (AG, GG) i.e. TC/AG (p<0.01), TC/GG (p<0.05), CC/AG (p<0.05) and CC/GG (p<0.01) were associated with CKDU with an odd ratio ranging 1.8-3.3 times approximately. This study demonstrates association of CYP1A1 polymorphisms with CKDU.

Prevalence of unsuspected glucose intolerance in coronary artery disease (CAD) patients: Importance of HbA1c

BACKGROUND

The mortality and morbidity rates are two to fourfold higher among Coronary Artery Disease (CAD) patients with type 2 diabetes mellitus (DM). American Diabetes Association (ADA) and World Health Organization (WHO) define different criteria for the diagnosis of glucose intolerance. This study compares the available diagnostic criteria for DM in Indian men and their importance in CAD patients.

METHODS

This cross-sectional study was done on 794 male volunteers; 483 individuals from general population and 311 patients undergoing angiography for evaluation of CAD. Individuals with previous clinical history of diabetes mellitus were excluded.

RESULTS

More than 90% of diabetics by ADA criteria could be diagnosed by Fasting plasma glucose (FPG) and HbA1c criteria while FPG and pg2h plasma glucose (WHO criteria) could detect only 74%. Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) was present in 36.7% of individuals diagnosed to be diabetic based on HbA1c; more in CAD +ve group (53.8%) than in general population (23.6%). ROC analysis suggests >121 mg/dl of FPG or >6.2% of HbA1c as optimum cut-off for the diagnosis of DM. FPG and HbA1c criteria have higher Relative Risk for presence of coronary artery occlusion and HOMA-IR.

CONCLUSION

Inclusion of HbA1c in the criteria for diagnosis of DM (ADA criteria) can detect large number of cases with persistent hyperglycemia in the non-diagnostic range of DM (IFG or IGT) among general population and CAD patients. This has special relevance to epidemiological studies as the diagnosis of DM can be made on single fasting blood sample.

Are old-age security and the utility of children in rural India really unimportant?

Abstract Extract In their recent paper in this journal M. and Carol Vlassoff are to be commended for helping to remedy the dearth of empirical studies on the old-age security motive for children (and particularly sons) in rural areas of developing countries.(1) However, while the questionnaire which they applied to 357 ever-married men in a rural village in Maharashtra state in India is potentially useful, several of the conclusions they derive from it are unwarranted and, if left unquestioned, would undoubtedly have the effect of setting back the serious investigation of the effects of this motive rather than furthering it. The invalid or at least questionable inferences are taken up one at a time in the order of their appearance:

Association of glutathione S-transferase M1 and T1 gene polymorphism with oxidative stress in diabetic and nondiabetic chronic kidney disease

BACKGROUND AND OBJECTIVE

Glutathione S-transferases (GSTs) belong to a family of ubiquitous and multifunctional enzymes that work as one of the endogenous antioxidants in our body. This study was designed to look into the association of GST polymorphism with oxidative stress in both diabetic and nondiabetic chronic kidney disease (CKD).

DESIGN AND METHODS

Three groups of patients (50 in each): diabetics without CKD (DM), diabetic CKD (DM-CKD), and nondiabetic CKD (NDM-CKD) and 50 age- and sex-matched healthy controls were recruited. Genotyping was done for GSTM1 and GSTT1 genes using a multiplex polymerase chain reaction. Serum GST and malondialdehyde (MDA) as a marker of oxidative stress were measured spectrophotometrically.

RESULTS

Based on genotyping, subjects were categorized as GSTM1+/GSTT1+, GSTM1-/GSTT1+, GSTM1+/GSTT1-, and GSTM1-/GSTT1-. Serum GST levels were lower among subjects with deletion in one/both GST genes, whereas MDA levels were found to be correspondingly raised. A negative correlation for MDA versus GST levels was observed among genotypes with one/both gene deletions. Presence of GSTM1+/GSTT1- and GSTM1-/GSTT1- was significantly higher among patients with CKD in both diabetics and nondiabetics.

INTERPRETATIONS AND CONCLUSIONS

GSTM1 and GSTT1 deletions singly or together were associated with lower GST levels and higher oxidative stress in both diabetic and nondiabetic CKD. Interestingly, GSTT1 deletion appears to be associated with both diabetic and nondiabetic CKD irrespective of the GSTM1 status.

Effect of GSTM1 and GSTT1 double deletions in the development of oxidative stress in diabetic nephropathy patients

Association of diabetic nephropathy (DN) with the deletion of GSTT1 and GSTM1 genes is well reported. Oxidative stress (OS) has also been associated with the development of DN. The present study was conducted to find out, whether these deletions had any contributory role in the development of OS in patients with DN. Pre-dialysis venous blood samples were obtained from 60 patients with diabetic end-stage renal disease (stages 4 and 5). Reduced-glutathione (GSH), glutathione S-transferase (GST) activity and malondialdehyde (MDA) levels were measured for the assessment of OS. Genetic polymorphism analysis of DN patients revealed the following distribution pattern: GSTM1 null 46.7%; GSTT1 null 55%; both null 30% and both positive 28.3%. Patients with both null genotypes were found to have significantly increased levels of MDA and low GST activity as compared to other genotypic groups. Lower GSH levels were observed in all the genotypic groups as compared to both positives. Double deletions involving GSTT1 and GSTM1 may result in decreased GST levels, leading to increased OS as reflected by increased MDA levels. As GST is a multi-functional enzyme involved in xenobiotic metabolism, this double null genotype population has a greater risk of development of DN. Further studies using increased sample size to find out the allelic distribution and their role in the development of DN are in progress.

Susceptibility to Coccidioides species in C57BL/6 mice is associated with expression of a truncated splice variant of Dectin-1 (Clec7a)

Coccidioides posadasii spherules stimulate macrophages to make cytokines via TLR-2 and Dectin-1. We used formalin-killed spherules and 1,3-beta-glucan purified from spherules to stimulate elicited peritoneal macrophages and myeloid dendritic cells (mDCs) from susceptible (C57BL/6) and resistant (DBA/2) mouse strains. DBA/2 macrophages produced more TNF-alpha and IL-6 than macrophages from C57BL/6 mice, and the amount of TNF-alpha made was dependent on both TLR2 and Dectin-1. DCs from C57BL/6 mice made more IL-10 and less IL-23p19 and IL-12p70 than did DBA/2 DC. These responses were inhibited by a monoclonal antibody to Dectin-1. DBA/2 mice expressed full-length Dectin-1, whereas C57BL/6 mice spliced out exon 3, which encodes most of the stalk. RAW cells transduced to express the full-length Dectin-1 responded better to FKS than cells expressing truncated Dectin-1. We compared the isoform of Dectin-1 expressed by 34 C57BL/6 X DBA/2 recombinant inbred (BXD RI) lines with their susceptibility to Coccidioides immitis. In 25 of 34 RI lines susceptibility or resistance corresponded to short or full-length isoforms, respectively. These results suggest that alternative splicing of the Dectin-1 gene contributes to susceptibility of C57BL/6 mice to coccidioidomycosis, and affects the cytokine responses of macrophages and mDCs to spherules.

Cost implications of specialized coagulation testing for acute ischemic stroke

BACKGROUND AND PURPOSE

Hypercoagulable states are a rare but recognized cause of ischemic stroke. Evaluation for these coagulation disorders is costly, but establishing a diagnosis may lead to a change in treatment. We estimated the incremental cost of specialized coagulation testing per additional ischemic stroke patient placed on a regimen of warfarin therapy.

METHODS

The cost-effectiveness analysis was performed based on data from a consecutive series of 674 adult ischemic stroke patients admitted to an academic medical center over a 3-year period. Those with atrial fibrillation or warfarin contraindications were excluded. Specialized coagulation test costs (protein C, protein S, antithrombin III, plasminogen, activated protein C resistance/factor V Leiden mutation, lupus anticoagulant, and anticardiolipin antibodies) were based on Medicare reimbursement rates. Effectiveness was defined as the difference in proportions of patients tested for coagulation disorders (coagulopathy present, normal complete battery, or incomplete) and treated with warfarin versus those patients who were not tested and treated with warfarin (the comparator). The incremental cost-effectiveness ratio (ICER) was defined as the cost associated with changing 1 patient to warfarin therapy.

RESULTS

The base case ICER was $1,102 per additional patient treated with warfarin. The only factor that led to a significant change in the ICER was the proportion of untested patients treated with warfarin. The results of 2-way sensitivity analyses revealed a minimum ICER of $496 and a maximum ICER of $2,959.

CONCLUSIONS

Strategies optimizing the selection of patients for specialized coagulation testing are needed. Outcomes-based cost-effectiveness cannot be determined until the impact of secondary prevention with anticoagulation in patients with specific coagulopathies is known.

Vaccination greatly reduces disease, disability, death and inequity worldwide

In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health.

Vaccination greatly reduces disease, disability, death and inequity worldwide

In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health.

Immunogenicity and safety of combined diphtheria tetanus whole cell pertussis hepatitis B/ Haemophilus influenzae type b vaccine in Indian infants

OBJECTIVE

To evaluate the immunogenicity of the Hepatitis B and Haemophilus influenzae type b components and the overall safety and reactogenicity of the DTPw-HBV/Hib vaccine when given as primary vaccination to Indian infants.

DESIGN AND METHODS

At 3 centers in India, 225 healthy infants (who had received HBV at birth) received three doses of DTPw-HBV/Hib vaccine at 6, 10 and 14 weeks of age. Serum anti-HBs and anti-PRP antibody levels were measured prior to vaccination and one month post dose 3. Solicited local and general symptoms reported during the 4-day follow-up period and unsolicited adverse event reported during the 30-day follow-up period after each dose were recorded. Serious adverse events were recorded throughout the study.

RESULTS

A total of 219 subjects completed the study. 2.7% and 11.5% of all administered doses led to redness and swelling >20 mm, respectively; only 3.6% of doses were followed by severe pain (cried when limb was moved, spontaneously painful) within 4 days after vaccination. Fever exceeding 39.5C was recorded following only one dose in one subject. The percentage of doses followed by severe solicited general symptoms (symptoms that prevented normal activity) did not exceed 0.8%. Two SAEs were reported, neither of which were considered as related to vaccination. One month post-dose 3, all subjects had seroprotective antiPRP antibody concentrations (> or =0.15 microgram/mL) and 98.6% had concentrations > or =1 microgram/mL; 99% were seropositive for antiHBs (concentrations > or = 3 mIU/mL) and 99% were seroprotected (concentrations > or = 10 mIU/mL).

CONCLUSION

The combination DTPw-HBV/Hib vaccine is immunogenic (for the antigens tested), safe and well tolerated in Indian infants.

Safety and reactogenicity of a low dose diphtheria tetanus acellular pertussis vaccine (Boostrix) in pre-school Indian children

OBJECTIVE

To evaluate the safety and reactogenicity of a reduced-antigen-content combined Diphtheria Tetanus Acellular Pertussis (dTpa) vaccine in Indian preschool children.

METHODS

GlaxoSmithKline Biologicals combination dTpa vaccine was administered as a single booster dose to 347 children aged 46 years in seven centers across India. All children were subsequently followed up for two weeks for safety and reactogenicity assessment.

RESULTS

A total of 345 subjects completed the study and two subjects were lost to follow-up. One serious adverse event (head injury) unrelated to vaccination was reported. Otherwise, all subjects were in good health throughout the study period. Three subjects (0.9%) reported transient general symptoms (such as irritability and drowsiness), which prevented normal activity. Pain at injection site, swelling and redness was reported in 31.1%, 18.2% and 8.9% subjects respectively. Five subjects (1.4%) reported severe pain preventing normal movement. This resolved within 48 hours in all cases. There were no other severe local reactions including large injection site reactions.

CONCLUSION

The reduced antigen content combined dTpa vaccine is safe and well tolerated in Indian pre-school children.

Development of NaCl-tolerant strain in Chrysanthemum morifolium Ramat. through in vitro mutagenesis

One NaCl-tolerant chrysanthemum (Chrysanthemum morifolium Ramat.) variant (E2) has been developed in a stable form through IN VITRO mutagenesis using ethylmethane sulfonate (EMS) as the chemical mutagen. Salt tolerance was evaluated by the capacity of the plant to maintain both flower quality and yield under stress conditions. Enhanced tolerance of the E2 variant has been attributed to the increased activity of superoxide dismutase (SOD), ascorbate peroxidase (APX), and dehydroascorbate reductase (DHAR), and, to a lesser extent of membrane damage than NaCl-treated control plants. Isoform analysis revealed that an increase in total SOD activity in the E2 variant was solely due to significant activation of the Cu/Zn isoform. Elevated levels of carotenoids and ascorbate in E2 leaves have been reflected in their higher free radical scavenging capacity (RSC) expressed in terms of DPPH (2,2-diphenyl-1-picrylhydrazyl) scavenging ability. Data reflect that a proper balance between enzymatic and non-enzymatic defence systems is required for combating salinity stress in chrysanthemum. Better performance of the E2 progeny under same salinity stress condition, even in the second year, confirms the genetic stability of the salt-tolerance character. On the whole, the E2 variant, developed through 0.025 % EMS treatment, might be considered as a NaCl-tolerant strain showing positive characters towards NaCl stress.

Molecular characterization of marker-free transgenic lines of indica rice that accumulate carotenoids in seed endosperm

A single Agrobacterium strain harbouring two binary plasmids was successfully used for the first time to develop a marker-free transgenic rice of improved nutritional value. Sixty-eight T0 co-transformants were obtained in three indica rice cultivars--two popular high-yielding Bangladeshi varieties (BR28 and BR29), and one high-iron rice cultivar (IR68144). Marker-free lines were obtained from 14 out of 24 selected co-transformants screened in the T1 generation. The accumulation of total carotenoids in polished T2 rice seeds of the primary transgenic VPBR29-17-37 reached levels of up to 3.0 microg/g, with the level of beta-carotene reaching 1.8 microg/g. In the cultivars BR28 and IR68144, total carotenoid levels in the transformants reached 2.0 microg/g of polished rice seeds. The levels of lutein and other carotenoids in the seeds were also significantly enhanced. T1 plants obtained from primary transgenics with simple gene-integration patterns tended to have a lower carotenoid content than the original parental lines. This study describes the development of marker-free transgenic rice lines containing high levels of carotenoids, and addresses the relationship between the rearrangement of transgenes and the presence of metabolic end products in transgenic rice.

Analgesic, antiinflammatory and CNS depressant activities of sesquiterpenes and a flavonoid glycoside from Polygonum viscosum

Analgesic, antiinflammatory and CNS depressant activities of four sesquiterpenes, viscosumic acid, viscozulenic acid, viscoazucine and viscoazulone, and a flavonoid glycoside, quercetin-3-O-(6''-feruloyl)-beta-D-galactopyranoside isolated form the aerial parts of Polygonum viscosum (Polygonaceae) have been assessed. All test compounds exhibited CNS depressant activity in open field test, all but viscoazulone showed analgesic activity in Eddy's hot plate test, all sesquiterpenes inhibited acetic acid induced abdominal writhing in mice, and all but viscoazucine and the flavonoid glycoside exhibited mild to moderate antiinflammatory effect on carrageenan induced rat paw edema.

In vitro activity of cefazolin and ampicillin

An in vitro antimicrobial sensitivity of Cefazolin and Ampicillin towards 85 strains of Staphylococcus aureus and 52 strains of Esch. Coli was carried out by Kirby-Baurer's Technique at Microbiology Dept. Nepalgunj Medical College, Nepal. 47% Staphylococcus aureus and 25% Esch. coli. were found sensitive to Cefazolin where as sensitivity pattern of Ampicillin was 19% and 7.74% respectively.

Amplatzer Device closure of Atrial Septal Defects and Patent Ductus Arteriosus: Initial Experience

Surgical closure of Atrial Septal Defects (ASD) and Patent Ductus Arteriosus (PDA) can be performed successfully with low mortality. However, the morbidity associated with general anaesthesia, thoracotomy, cardiopulmonary bypass, postoperative monitoring in the intensive care unit, several days of hospital stay and the requirement of blood products is considerable. The expense associated with this morbidity, operative scar and the psychologic trauma to the patient and parents are additional disadvantages of surgery. Hence, the closure of these defects by transcatheter methods with various devices has been evaluated worldwide. We report the initial experience at our centre with closure of secundum ASDs and large PDAs with the Amplatzer Septal Occluder and Amplatzer Duct Occluder.

Pyramiding transgenes for multiple resistance in rice against bacterial blight, yellow stem borer and sheath blight

Here we describe the development of transgene-pyramided stable elite rice lines resistant to disease and insect pests by conventional crossing of two transgenic parental lines transformed independently with different genes. The Xa21 gene (resistance to bacterial blight), the Bt fusion gene (for insect resistance) and the chitinase gene (for tolerance of sheath blight) were combined in a single rice line by reciprocal crossing of two transgenic homozygous IR72 lines. F4 plant lines carrying all the genes of interest stably were identified using molecular methods. The identified lines, when exposed to infection caused by Xanthomonas oryzae pv oryzae, showed resistance to bacterial blight. Neonate larval mortality rates of yellow stem borer ( Scirpophaga incertulas) in an insect bioassay of the same identified lines were 100%. The identified line pyramided with different genes to protect against yield loss showed high tolerance of sheath blight disease caused by Rhizoctonia solani.

Elastic guided waves in a layered plate with rectangular cross section

Guided waves in a layered elastic plate of rectangular cross section (finite width and thickness) has been studied in this paper. A semianalytical finite element method in which the deformation of the cross section is modeled by two-dimensional finite elements and analytical representation of propagating waves along the length of the plate has been used. The method is applicable to arbitrary number of layers and general anisotropic material properties of each layer, and is similar to the stiffness method used earlier to study guided waves in a laminated composite plate of infinite width. Numerical results showing the effect of varying the width of the plate on the dispersion of guided waves are presented and are compared with those for an infinite plate. In addition, effect of thin anisotropic coating or interface layers on the guided waves is investigated.

Dominant NZB contributions to lupus in the (SWR x NZB)F1 model

(SWR x NZB)F1 (or SNF1) mice succumb to lupus nephritis. Analysis of NZB x SNF1 backcross mice has recently revealed the existence of four dominant SWR loci (H2 on Chr 17, Swrl-1 on Chr 1, Swrl-2 on Chr 14 and Swrl-3 on Chr 18), and two NZB loci (Nba1 and Lbw2/Sbw2, both on Chr 4) conferring lupus susceptibility. The present study focusing on a panel of 88 SWR x SNF1 backcross mice reveals the existence of five suggestive loci for antinuclear antibody formation, consisting of three dominant NZB contributions (Nba4 on Chr 5, Lbw4 on Chr 6, and Nba5 on Chr 7), and two recessive SWR contributions (Swrl-1 on Chr 1, and Swrl-4 on Chr 10). In addition, this study reveals a dominant NZB locus for GN (Nba3 on Chr 7, peak at 31 cM), and a dominant NZB locus linked to early mortality, on Chr 10 (peak at 4 cM). Collectively, these studies suggest that lupus in the SNF1 strain is the epistatic end-product of four dominant SWR loci and four dominant NZB loci. The immunological functions and molecular identities of these loci await elucidation.

Angioplasty for chronic total coronary occlusions: safety and efficacy

OBJECTIVE

To determine the short term results and safety of angioplasty in chronic coronary occlusions.

METHODS

Eighty consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for chronic coronary occlusions were prospectively analyzed for acute success rate and safety of the procedure.

RESULTS

The mean age was 46.7 years (range 30-78 years). There were 72 males and eight females. Clinical presentation was recent myocardial infarction (MI) in four cases (5%), unstable angina in 20 (25%), chronic stable angina in 24 (30%) and past history of MI in 32 (40%) cases. Vessel distribution was left anterior descending artery (LAD) in 40 (50%), left circumflex artery (LCx) in 12 (15%) and right coronary artery (RCA) in 28 (35%) cases. Lesion length varied from 8 mm to 37 mm with a mean of 16.7 mm. Acute success rate was 70% (56/80). Twenty four cases (30%) had unsuccessful result due to failure to cross with wire (18 cases) or inability to cross with the balloon (six cases). One major complication in the form of type III coronary perforation was encountered which was successfully managed surgically.

CONCLUSION

Percutaneous transluminal coronary angioplasty (PTCA) in chronic total occlusion has a reasonable success rate and very low complication rate.

Genetic contributions of nonautoimmune SWR mice toward lupus nephritis

(SWR x New Zealand Black (NZB))F(1) (or SNF(1)) mice succumb to lupus nephritis. Although several NZB lupus susceptibility loci have been identified in other crosses, the potential genetic contributions of SWR to lupus remain unknown. To ascertain this, a panel of 86 NZB x F(1) backcross mice was immunophenotyped and genome scanned. Linkage analysis revealed four dominant SWR susceptibility loci (H2, Swrl-1, Swrl-2, and Swrl-3) and a recessive NZB locus, Nba1. Early mortality was most strongly linked to the H2 locus on chromosome (Chr) 17 (log likelihood of the odds (LOD) = 4.59 - 5.38). Susceptibility to glomerulonephritis was linked to H2 (Chr 17, LOD = 2.37 - 2.70), Swrl-2 (Chr 14, 36 cM, LOD = 2.48 - 2.71), and Nba1 (Chr 4, 75 cM, LOD = 2.15 - 2.23). IgG antinuclear autoantibody development was linked to H2 (Chr 17, LOD = 4.92 - 5.48), Swrl-1 (Chr 1, 86 cM, colocalizing with Sle1 and Nba2, LOD = 2.89 - 2.91), and Swrl-3 (Chr 18, 14 cM, LOD = 2.07 - 2.13). For each phenotype, epistatic interaction of two to three susceptibility loci was required to attain the high penetrance levels seen in the SNF(1) strain. Although the SWR contributions H2, Swrl-1, and Swrl-2 map to loci previously mapped in other strains, often linked to very similar phenotypes, Swrl-3 appears to be a novel locus. In conclusion, lupus in the SNF(1) strain is truly polygenic, with at least four dominant contributions from the SWR strain. The immunological functions and molecular identities of these loci await elucidation.

Off-axis propagation of ultrasonic guided waves in thin orthotropic layers: theoretical analysis and dynamic holographic imaging measurement

The elastic properties of many materials in sheet or plate form can be approximated with orthotropic symmetry. In many sheet material manufacturing industries (e.g., the paper industry), manufacturers desire knowledge of certain anisotropic elastic properties in the sheet for handling and quality issues. Ultrasonic wave propagation in plate materials forms a method to determine the anisotropic elastic properties in a nondestructive manner. This work explores exact and approximate analysis methods of ultrasonic guided wave propagation in thin layers, explicitly dealing with orthotropic symmetry and propagation off-axis with respect to the manufacturing direction. Recent advances in full-field ultrasonic imaging methods, based on dynamic holography, allow simultaneous measurement of the plate wave motion in all planar directions within a single image. Results from this laser ultrasonic imaging approach are presented that record the lowest anti-symmetric (flexural) mode wavefront in a single image without scanning. Specific numerical predictions for flexural wave propagation in two distinctly different types of paper are presented and compared with direct imaging measurements. Very good agreement is obtained for the lowest anti-symmetric plate mode using paper properties independently determined by a third party. Complete determination of the elastic modulus tensor for orthotropic layers requires measurement of other modes in addition to the lowest anti-symmetric. Theoretical predictions are presented for other guided wave modes [extensional (S), flexural (A), and shear-horizontal (SH)] in orthotropic plates with emphasis on propagation in all planar directions. It is shown that there are significant changes in the dispersion characterization of these modes at certain frequencies (including off-axis mode coupling) that can be exploited to measure additional in-plane elastic moduli of thin layers. At present, the sensitivity of the imaging measurement approach limits experimental investigation to relatively large amplitudes easily produced by flexural wave motion (> 0.1 nm). Extension of the measurement range and application to other plate wave modes are in progress and shall be reported in future work.

Immunostimulatory DNA-based vaccines elicit multifaceted immune responses against HIV at systemic and mucosal sites

Immunostimulatory DNA sequences (ISS, also known as CpG motifs) are pathogen-associated molecular patterns that are potent stimulators of innate immunity. We tested the ability of ISS to act as an immunostimulatory pathogen-associated molecular pattern in a model HIV vaccine using gp120 envelope protein as the Ag. Mice immunized with gp120 and ISS, or a gp120:ISS conjugate, developed gp120-specific immune responses which included: 1) Ab production; 2) a Th1-biased cytokine response; 3) the secretion of beta-chemokines, which are known to inhibit the use of the CCR5 coreceptor by HIV; 4) CTL activity; 5) mucosal immune responses; and 6) CD8 T cell responses that were independent of CD4 T cell help. Based on these results, ISS-based immunization holds promise for the development of an effective preventive and therapeutic HIV vaccine.

Isolation and structure elucidation of viscoazucine, a novel sesquiterpene from Polygonum viscosum

A new sesquiterpene, 1,4-dimethoxycarbonyl-7-(1-methylethyl)- 3,3a,6,7,8,8a-hexahydroazulene (viscoazucine) (1), and a known flavone, 3',5,7-trihydoxy-3,4',5'-trimethoxyflavone (4), have been isolated from Polygonum viscosum. The structures of these compounds were elucidated by spectroscopic analyses, notably UV, MS and NMR.

Regulatory defects in Cbl and mitogen-activated protein kinase (extracellular signal-related kinase) pathways cause persistent hyperexpression of CD40 ligand in human lupus T cells

To identify intrinsic defects in lupus, we studied short-term, CD4(+) T cell lines that were established from 16 lupus patients (active or inactive) and 15 normal subjects by stimulating once with anti-CD3, anti-CD28, and IL-2. After resting, the pure CD4(+) T cells were exposed to anergy-inducing stimulation with plate-bound anti-CD3 mAb in the absence of APC. Lupus T cells showed prolonged high level expression of CD40 ligand (CD40L, CD154) even in the face of anergy protocol, which shut down CD40L expression in normal T cells. The sustained CD40L expression in lupus T cells did not correlate with memory status or Th deviation, and was relatively independent of IL-2 or other autocrine or paracrine signals via CD28 or CTLA-4. Cyclosporin A could block CD40L expression by lupus T cells when added early during the anti-CD3 stimulation period, but only partially when added later, indicating that another mechanism regulates the prolonged hyperexpression of CD40L besides the Ca(2+) --> calcineurin-dependent NF-AT pathway. When exposed to the anergy protocol, lupus T cells, in marked contrast to normal T cells, did not phosphorylate Cbl/Cbl-b but continued to express strongly phosphorylated extracellular signal-regulated kinase (ERK); U0126, a specific inhibitor of mitogen-activated protein kinase kinase --> ERK, could block both the early and the prolonged hyperexpression of CD40L. Thus, pathways regulating the activities of Cbl and one particular mitogen-activated protein kinase, ERK, are involved in the prolonged hyperexpression of CD40L in lupus T cells.

On ultrasonic guided waves in a thin anisotropic layer lying between two isotropic layers

In this paper, dispersion of guided waves in a three-layered sandwich plate is considered. The focus here is on a configuration consisting of a thin anisotropic layer sandwiched between two identical isotropic layers. This configuration could model, for example, a superconducting tape where the middle layer is a brittle superconductor and the surrounding layers are isotropic and ductile. An approximate dispersion relation correct to O(h) governing the guided waves is obtained by expanding the field inside the thin middle layer in powers of the small thickness h of the layer. Numerical examples are given for two specific systems with superconducting middle layers. Some characteristic features, particularly at low frequencies, are investigated. Comparison between the exact and approximate dispersion relations are made to show that the approximation works well in the frequency interval of interest. The characteristic features may be useful for ultrasonic measurements of the anisotropic elastic constants of the thin layer.

The use of enzyme therapy to regulate the metabolic and phenotypic consequences of adenosine deaminase deficiency in mice. Differential impact on pulmonary and immunologic abnormalities

Adenosine deaminase (ADA) deficiency results in a combined immunodeficiency brought about by the immunotoxic properties of elevated ADA substrates. Additional non-lymphoid abnormalities are associated with ADA deficiency, however, little is known about how these relate to the metabolic consequences of ADA deficiency. ADA-deficient mice develop a combined immunodeficiency as well as severe pulmonary insufficiency. ADA enzyme therapy was used to examine the relative impact of ADA substrate elevations on these phenotypes. A "low-dose" enzyme therapy protocol prevented the pulmonary phenotype seen in ADA-deficient mice, but did little to improve their immune status. This treatment protocol reduced metabolic disturbances in the circulation and lung, but not in the thymus and spleen. A "high-dose" enzyme therapy protocol resulted in decreased metabolic disturbances in the thymus and spleen and was associated with improvement in immune status. These findings suggest that the pulmonary and immune phenotypes are separable and are related to the severity of metabolic disturbances in these tissues. This model will be useful in examining the efficacy of ADA enzyme therapy and studying the mechanisms underlying the immunodeficiency and pulmonary phenotypes associated with ADA deficiency.

Field performance of transgenic elite commercial hybrid rice expressing bacillus thuringiensis delta-endotoxin

Here we describe development of transgenic elite rice lines expressing a Bt fusion gene derived from cryIA(b) and cryIA(c) under the control of rice actinI promoter. The lines used in the study were indica CMS restorer line of Minghui 63 and its derived hybrid rice Shanyou 63. The level of Bt fusion protein CryIA(b)/CryIA(c) detected in Minghui 63 (T51-1) plants was 20 ng/mg soluble protein. The Bt Shanyou 63 was field-tested in natural and repeated heavy manual infestation of two lepidopteran insects, leaffolder and yellow stem borer. The transgenic hybrid plants showed high protection against both insect pests without reduced yield.

On approximating guided waves in plates with thin anisotropic coatings by means of effective boundary conditions

In this paper, effective boundary conditions for elastic wave propagation in plates with thin coatings are derived. These effective boundary conditions are used to obtain an approximate dispersion relation for guided waves in an isotropic plate with thin anisotropic coating layers. The accuracy of the effective boundary conditions is investigated numerically by comparison with exact solutions for two different material systems. The systems considered consist of a metallic core with thin superconducting coatings. It is shown that for wavelengths long compared to the coating thickness there is excellent agreement between the approximate and exact solutions for both systems. Furthermore, numerical results presented might be used to characterize coating properties by ultrasonic techniques.

Quercetin 3-O-(6"-caffeoyl)-beta-D-galactopyranoside from Polygonum viscosum

The methanol extract of the whole plant parts of Polygonum viscosum has yielded a flavonol glycoside, 3-O-(6"-caffeoyl)-beta-D-galactopyranoside (1), the structure of which has been determined unambiguously by UV and a series of one- and two-dimensional NMR experiments, notably, (1)H, (13)C, DEPT, COSY45, HMBC and HMQC.

A sesquiterpene acid and flavonoids from Polygonum viscosum

4-Isobutyl-6-methyl-5-oxo-3a,4,5,7a-tetrahydro-1H-inden-13-oic acid (named viscosumic acid) and quercetin 3-O-(6"-feruloyl)-beta-D-galactopyranoside, and the known 3',5-dihydroxy-3,4',5',7-tetramethoxyflavone have been isolated from Polygonum viscosum. The structures of these isolates were determined primarily on the basis of extensive 1D and 2D NMR spectral analyses, notably, 13C PENDANT, COSY45, TOCSY, GOESY, NOESY, HMQC and HMBC.

Major peptide autoepitopes for nucleosome-specific T cells of human lupus

We tested 154 peptides spanning the entire length of core histones of nucleosomes for the ability to stimulate an anti-DNA autoantibody-inducing T helper (Th) clone, as well as CD4(+) T-cell lines and T cells, in fresh PBMCs from 23 patients with lupus erythematosus. In contrast to normal T cells, lupus T cells responded strongly to certain histone peptides, irrespective of the patient's disease status. Nucleosomal peptides in histone regions H2B(10-33), H4(16-39) (and overlapping H4(14-28)), H4(71-94), and H3(91-105) (and overlapping H3(100-114)) were recurrently recognized by CD4 T cells from the patients with lupus. Remarkably, these same peptides overlap with major epitopes for the Th cells that induce anti-DNA autoantibodies and nephritis in lupus-prone mice. We localized 2 other recurrent epitopes for human lupus T cells in H2A(34-48) and H4(49-63). All the T-cell autoepitopes have multiple HLA-DR binding motifs, and the epitopes are located in histone regions recognized by lupus autoantibodies, suggesting a basis for their immunodominance. Native nucleosomes and their peptides H4(16-39), H4(71-94), and H3(91-105) induced a stronger IFN-gamma response, whereas others, particularly, H2A(34-48), favored an IL-10- and/or IL-4-positive T-cell response. The major autoepitopes may reveal the mechanism of autoimmune T-cell expansion and lead to antigen-specific therapy of human lupus.

Antigen-specific therapy of murine lupus nephritis using nucleosomal peptides: tolerance spreading impairs pathogenic function of autoimmune T and B cells

In the (SWR x NZB)F1 mouse model of lupus, we previously localized the critical autoepitopes for nephritogenic autoantibody-inducing Th cells in the core histones of nucleosomes at aa positions 10-33 of H2B and 16-39 and 71-94 of H4. A brief therapy with the peptides administered i.v. to 3-mo-old prenephritic (SWR x NZB)F1 mice that were already producing pathogenic autoantibodies markedly delayed the onset of severe lupus nephritis. Strikingly, chronic therapy with the peptides injected into 18-mo-old (SWR x NZB)F1 mice with established glomerulonephritis prolonged survival and even halted the progression of renal disease. Remarkably, tolerization with any one of the nucleosomal peptides impaired autoimmune T cell help, inhibiting the production of multiple pathogenic autoantibodies. However, cytokine production or proliferative responses to the peptides were not grossly changed by the therapy. Moreover, suppressor T cells were not detected in the treated mice. Most interestingly, the best therapeutic effect was obtained with nucleosomal peptide H416-39, which had a tolerogenic effect not only on autoimmune Th cells, but autoimmune B cells as well, because this peptide contained both T and B cell autoepitopes. These studies show that the pathogenic T and B cells of lupus, despite intrinsic defects in activation thresholds, are still susceptible to autoantigen-specific tolerogens.

Combinatorial interactions regulate cardiac expression of the murine adenylosuccinate synthetase 1 gene

The mammalian heart begins contracting at the linear tube stage during embryogenesis and continuously pumps, nonstop, throughout the entire lifetime of the animal. Therefore, the cardiac energy metabolizing pathways must be properly established and efficiently functioning. While the biochemistry of these pathways is well defined, limited information regarding the regulation of cardiac metabolic genes is available. Previously, we reported that 1.9 kilobase pairs of murine adenylosuccinate synthetase 1 gene (Adss1) 5'-flanking DNA directs high levels of reporter expression to the adult transgenic heart. In this report, we define the 1.9-kilobase pair fragment as a cardiac-specific enhancer that controls correct spatiotemporal expression of a reporter similar to the endogenous Adss1 gene. A 700-base pair fragment within this region activates a heterologous promoter specifically in adult transgenic hearts. Proteins present in a cardiac nuclear extract interact with potential transcription factor binding sites of this region and these cis-acting sites play important regulatory roles in the cardiac expression of this reporter. Finally, we report that several different cardiac transcription factors trans-activate the 1.9HSCAT construct through these sites and that combinations result in enhanced reporter expression. Adss1 appears to be one of the first target genes identified for the bHLH factors Hand1 and Hand2.

Regulation of forestomach-specific expression of the murine adenosine deaminase gene

The maturation of stratified squamous epithelium of the upper gastrointestinal tract is a highly ordered process of development and differentiation. Information on the molecular basis of this process is, however, limited. Here we report the identification of the first murine forestomach regulatory element using the murine adenosine deaminase (Ada) gene as a model. In the adult mouse, Ada is highly expressed in the terminally differentiated epithelial layer of upper gastrointestinal tract tissues. The data reported here represent the identification and detailed analysis of a 1. 1-kilobase (kb) sequence located 3.4-kb upstream of the transcription initiation site of the murine Ada gene, which is sufficient to target cat reporter gene expression to the forestomach in transgenic mice. This 1.1-kb fragment is capable of directing cat reporter gene expression mainly to the forestomach of transgenic mice, with a level comparable to the endogenous Ada gene. This expression is localized to the appropriate cell types, confers copy number dependence, and shows the same developmental regulation. Mutational analysis revealed the functional importance of multiple transcription factor-binding sites.