Pneumococcal serotypes and risk factors in adult community-acquired pneumonia 2018-20; a multicentre UK cohort study

Background

Higher-valency pneumococcal vaccines are anticipated. We aimed to describe serotype distribution and risk factors for vaccine-serotype community-acquired pneumonia (CAP) in the two years pre-SARS-CoV-2 pandemic.

Methods

We conducted a prospective cohort study of adults hospitalised with CAP at three UK sites between 2018 and 2020. Pneumococcal serotypes were identified using a 24-valent urinary-antigen assay and blood cultures. Risk factors associated with vaccine-type pneumonia caused by serotypes in the 13-, 15- and 20-valent pneumococcal conjugate vaccines (PCV13, PCV15, PCV20) and 23-valent pneumococcal polysaccharide vaccine (PPV23) were determined from multivariable analysis.

Findings

Of 1921 adults hospitalised with CAP, 781 (40.7%, 95% confidence intervals (CI) 38.5-42.9%) had pneumococcal pneumonia. A single PCV13-serotype was detected in 242 (31.0%, 95% CI 27.8-34.3%) pneumococcal CAP patients, mostly serotype 3 (171/242, 70.7%, 95% CI 64.5-76.0%). The additional two PCV15-serotypes were detected in 31 patients (4%, 95% CI 2.8-5.6%), and PCV20-non13-serotypes in 192 (24.6%), with serotype 8 most prevalent (123/192, 64.1%, 95% CI 57.1-70.5%). Compared to PCV13-serotype CAP, people with PCV20-non13 CAP were younger (median age 62 versus 72 years, p < 0.001) and less likely to be male (44% versus 61%, p = 0.01). PPV23-non13-serotypes were found in 252 (32.3%, 95% CI 29.1-35.6%) pneumococcal CAP patients.

Interpretation

Despite mature infant pneumococcal programmes, the burden of PCV13-serotype pneumonia remains high in older adults, mainly due to serotype 3. PCV20-non13-serotype pneumonia is more likely in younger people with fewer pneumococcal risk factors.

Funding

Unrestricted investigator-initiated research grant from Pfizer, United Kingdom; support from National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham.

Phages for treatment of Salmonella spp infection

Salmonella, is one of the bacterial genera having more than 2500 serogroups is one of the most prominent food borne pathogen that is capable of causing disease out breaks among humans and animals. Recent reports clearly shows that this pathogen is evolved and it developed drug resistant towards most of the commercially available antibiotics. In order to overcome this emerging resistance, Bacteriophage therapy is one of the alternative solutions. It is more pathogen specific, high potency, and thereby highly safe for consumption. This chapter discuss about Rapid screening and Detection Methods Associated with Bacteriophage for Salmonella, commercially available phage products and regulatory status, Salmonella endolysins and future prospects of phage therapy.

Incidence of cognitive impairment and dementia after hospitalisation for pneumonia: a UK population-based matched cohort study

Background

Survivors of common infections may develop cognitive impairment or dementia, however; the risk of these conditions in people hospitalised with pneumonia is not well-established.

Methods

A matched cohort study was conducted using Hospital Episode Statistics (HES) data linked to Clinical Practice Research Database (CPRD). Adults with the first ICD-10 code for pneumonia recorded in HES between 1 July 2002 and 30 June 2017 were included and up to four controls without hospitalisation for pneumonia in CPRD were matched by gender, age, and practice. Cognitive impairment and dementia incidence rates were calculated, and survival analysis was performed comparing those hospitalised with pneumonia to the general population.

Results

The incidence rates of cognitive impairment and dementia were 18 (95%CI 17.3 to 18.7) and 13.2 (95%CI 13 to 13.5) per 1000 person-years among persons previously hospitalised with pneumonia and the matched cohort respectively. People previously hospitalised with pneumonia had 53% higher incidence of cognitive impairment and dementia (aHR 1.53; 95% CI 1.46 to 1.61) than their matched cohort. The highest incidence was observed within 1-year of hospitalisation for pneumonia compared to the general population (aHR=1.89; 95%CI 1.75 to 2.05). Age modified the effect of hospitalisation for pneumonia on cognitive impairment and dementia such that the size of effect was stronger in people between 45 and 60 years old (pinteraction<0.0001).

Conclusion

Cognitive impairment and dementia are more likely to be diagnosed in people who have been hospitalised for pneumonia, especially in the first year after discharge, than in the general population.

Low-glycemic foods with wheat, barley and herbs (Terminalia chebula, Terminalia bellerica and Emblica officinalis) inhibit α-amylase, α-glucosidase and DPP-IV activity in high fat and low dose streptozotocin-induced diabetic rat

Wheat, barley or wheat + barley and herbs (Terminalia chebula, Terminalia bellerica and Emblica officinalis) based low-glycemic-index (low-GI) foods were developed and studied α-amylase, α-glucosidase and DPP-IV inhibition property in vitro and in the streptozotocin-induced diabetic rats. The GI of products ranged from 47 to 53 than control white bread (GI = 95). Total phenolic (20.1 ± 1 mg gallic acid/g dry wt.) and flavonoids (15.2 ± 1 mg quercetin/g dry wt.) were higher in wheat + barley than barley (17.2 ± 1; 13.6 ± 2) and wheat (16.9 ± 1; 14.9 ± 2) products. The in vitro α-amylase (4-10%), α-glucosidase (5-17%) and DPP-IV (3-26%) inhibition (IC₅₀) of methanol extracts were higher than the aqueous extracts. The fasting blood glucose (50.85, 33.22 and 24.52%) and oral glucose tolerance (AUC = 32.1, 36.04, and 27.73%) was lower in barley, wheat, and wheat + barley fed diabetic groups than diabetic control group (1571.5 ± 13.5 mg/dL/120 min). Feeding wheat, barley, and W + B foods for 60 days inhibited the intestinal α-amylase (1.2, 1.1 and 1.5-folds), α-glucosidase (1.3, 1.2 and 1.7-folds) and DPP-IV (1.6, 1.5 and 2.1-folds) activity compared to diabetic control. Low-GI foods lower the systemic glucose level, inhibit the glycolytic enzymes and DPP-IV activity and hence desirable for diabetes management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13197-021-05231-0.

Microbial community composition associated with early developmental stages of the Indian white shrimp, Penaeus indicus

Gut microbiota is known to influence the physiology, health, nutrient absorption, reproduction, and other metabolic activities of aquatic organisms. Microbial composition can influence intestinal immunity and are considered as health indicators. Information on gut microbial composition provides potential application possibilities to improve shrimp health and production. In the absence of such information for Penaeus indicus, the present study reports the microbial community structure associated with its early developmental stages. Bacterial community associated with the early developmental stages (egg, nauplii, zoea, mysis, PL1, PL6 and PL12) from two hatchery cycles were analysed employing 16S rRNA high throughput sequencing. Proteobacteria and Bacteroidetes, were the two dominant phyla in P. indicus development stages. Sequential sampling revealed the constant change in the bacterial composition at genus level. Alteromonas was dominant in egg and nauplii stage, whilst Ascidiaceihabitans (formerly Roseobacter) was the dominant genera in both PL6 and PL12. The bacterial composition was highly dynamic in early stages and our study suggests that the mysis stage is the critical phase in transforming the microbial composition and it gets stabilised by early post larval stages. This is the first report on the composition of microbiota in early developmental stages of P. indicus. Based on these results the formation of microbial composition seems to be influenced by feeding at early stages. The study provides valuable information to device intervention strategies for healthy seed production.

Effects of tobacco smoking on recurrent hospitalisation with pneumonia: a population-based cohort study

The incidence of and risk factors for recurrent hospitalisation for pneumonia were investigated using data from Hospital Episode Statistics, linked to a UK primary care database. Within 90 days and 1 year of follow-up, 1733 (3.1%) and 5064 (9.0%), developed recurrent pneumonia respectively. Smoking status at the time of hospitalisation with index pneumonia was associated with the risk of readmission with recurrent pneumonia within a year of discharge: current versus never smokers: adjusted subhazard ratio (sHR) 1.42, 95% CI 1.32 to 1.53, p<0.001, and ex smokers versus never smokers: adjusted sHR 1.24, 95% CI 1.15 to 1.34, p<0.001. Other independent risk factors associated with recurrent pneumonia were age, gender, deprivation and underlying comorbidities.

Abundance, community structure and diversity of nitrifying bacterial enrichments from low and high saline brackishwater environments

The study reports diversity in nitrifying microbial enrichments from low (0·5-5‰) and high (18-35‰) saline ecosystems. Microbial community profiling of ammonia-oxidizing bacteria (AOB) and nitrite-oxidizing bacteria (NOB) enrichments was analysed by sequencing 16S rRNA and was processed using Mothur pipeline. The α-diversity indices showed the richness of nitrifying bacterial consortia from the high saline environment and were clustering based on the source of the sample. AOB and NOB enrichments from both the environments showed diverse lineages of phyla distributed in both groups with 38 and 34 phyla from low saline and 53 and 40 phyla in high saline sources, respectively. At class level, α- and γ-proteobacteria were found to be more dominant in both the enrichments. AOBs and NOBs in enrichments from low saline environments were dominated by Nitrosomonadaceae, Gallionellaceae (Nitrotoga sp.) and Ectothiorhodospiraceae and Nitrospira, respectively. Though Chromatiaceae were present in both AOB and NOB enrichments, Nitrosoglobus and Nitrosococcus dominated the AOBs while NOBs were dominated by uncultured genera, whereas Rhizobiales were found in both the enrichments. AOBs and NOBs in enrichments from high saline environments were dominated by Nitrospira-like AOBs, Nitrosomonas and Nitrosococcus genera, whereas ammonia-oxidizing archaea (AOA) group included Nitrosopumilus and Nitrososphaera genera comprising and Nitrospirae, respectively. The majority of the genera obtained in both the salinities were found to be either uncultured or unclassified groups. Results of the study suggest that the AOB and NOB consortia have unique and diverse microbes in each of the enrichments, capable of functioning in aquaculture systems practised at different salinities (0-60 ppt).

Co-infection in critically ill patients with COVID-19: an observational cohort study from England

Introduction. During previous viral pandemics, reported co-infection rates and implicated pathogens have varied. In the 1918 influenza pandemic, a large proportion of severe illness and death was complicated by bacterial co-infection, predominantly Streptococcus pneumoniae and Staphylococcus aureus.Gap statement. A better understanding of the incidence of co-infection in patients with COVID-19 infection and the pathogens involved is necessary for effective antimicrobial stewardship.Aim. To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England.Methodology. A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 h following hospital admission, corresponding to community and hospital-acquired co-infections.Results. Of 254 patients studied (median age 59 years (IQR 49-69); 64.6 % male), 139 clinically significant organisms were identified from 83 (32.7 %) patients. Bacterial co-infections/ co-colonisation were identified within 48 h of admission in 14 (5.5 %) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli. The co-infection/ co-colonisation rate >48 h after admission was 27/1000 person-days (95 % CI 21.3-34.1). Patients with co-infections/ co-colonisation were more likely to die in ICU (crude OR 1.78,95 % CI 1.03-3.08, P=0.04) compared to those without co-infections/ co-colonisation.Conclusion. We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay.

Abundance, community structure and diversity of nitrifying bacterial enrichments from low and high saline brackishwater environments

The study reports diversity in nitrifying microbial enrichments from low (0.5-5‰) and high (18-35‰) saline ecosystems. Microbial community profiling of AOB and NOB enrichments were analysed by sequencing 16S rRNA and were processed using Mothur pipeline. The α-diversity indices showed the richness of nitrifying bacterial consortia from the high saline environment and were clustering based on the source of the sample. AOB and NOB enrichments from both the environments showed diverse lineages of phyla distributed in both groups with 38 and 34 phyla from low saline and 53 and 40 phyla in high saline sources respectively. At class level α and ϒ-Proteobacteria were found to be more dominant in both the enrichments. AOB and NOBs in enrichments from low saline environments were dominated by Nitrosomonadaceae, Gallionellaceae (Nitrotoga spp.) and Ectothiorhodospiraeceae and Nitrospira respectively. Though Chromatiaceae were present in both AOB and NOB enrichments Nitrosoglobus and Nitrosococcus dominated the AOB while NOB was dominated by uncultured genera, while Rhizobiales were found in both the enrichments. AOB and NOBs in enrichments from high saline environments were dominated by Nitrospira-like AOBs, Nitrosomonas and Nitrosococcus genera; while AOA group included Nitrosopumilus and Nitrososphaeraea genera comprising and Nitrospirae respectively. The majority of the genera obtained in both the salinities were found to be either uncultured or unclassified groups. Results of the study suggest that the AOB and NOB consortia have unique and diverse microbes in each of the enrichments, capable of functioning in aquaculture systems practiced at different salinities (0-60ppt).

Prognosticating patients with necrotising otitis externa based on response to treatment

INTRODUCTION

Necrotising otitis externa (NOE) is a severe infection of the temporal bone. The traditional severity based staging system does not fully prognosticate all patients with NOE. We hypothesise that a patient response staging system would more accurately capture the disease process and guide prognosis.

METHODS

We carried out a retrospective notes review of patients diagnosed with NOE from January 2017 to December 2018 in a regional tertiary referral centre. Patient outcomes from our proposed patient response staging system were compared to a modified previously published severity based Gleeson staging system with patients requiring prolonged treatment classified as having a poor outcome.

RESULTS

A total of 34 patients were treated for NOE. The majority were male (n=24) and had diabetes (n=25). Patients with the most severe Gleeson staging did not have the worst outcome. Daily delay in resolution of otorrhoea was associated with an increased need for more than six weeks of treatment. Rapid responders are patients who had resolution of otalgia, otorrhoea and C-reactive protein normalisation within 14 days, and all were cured following standard 6 weeks of treatment.

CONCLUSIONS

The Gleeson staging system was valuable in assessing the extent of disease and all early Gleeson staged patients had good outcomes. However, patients with higher severity staging on the Gleeson system did not necessarily require prolonged treatment. There is a role for a joint approach in staging patients based on both modified Gleeson and treatment response, which would subsequently guide prognosis, duration of treatment and early diagnosis of potential fungal NOE.

Distinguishing three Dragon fruit (Hylocereus spp.) species grown in Andaman and Nicobar Islands of India using morphological, biochemical and molecular traits

Dragon fruit (Hylocereus spp.), an important tropical fruit belonging to the family Cactaceae, is rich in essential nutrients such as vitamins, minerals, complex carbohydrates, dietary fibres and antioxidants. This study aims to distinguish three dragon fruit species well adapted to Andaman and Nicobar Island through morphological (34 quantitative and 26 qualitative traits), biochemical (5 traits) and molecular (14 ISSR primers) characterization. Morphological characterization revealed that presence of considerable amount of genetic variations among them especially for fruit characters viz., colour of peel and pulp. Cladode characters such as number of spines (3–5), length of areoles (mm) as 1–4, margin ribs of cladode (convex or concave) and its waxiness (weak or strong white waxy or light waxy) could be used for identification of three Hylocereus spp. under present study. Highest co-efficient of variation (%) obtained for pulp weight (88.7), whereas, lowest in distance of anthers belowstigma (3.3). Fruit and pulp weight (g) ranged from 26.5–419.3 and 10.3–258.8 with mean value of 204.8 and 125.3, respectively. Comparatively, high phenol (71.3–161.3) and flavonoid (26.6–508.2) content observed in peels than pulp (32.5–130.0 and 45.0–258.2) of fruit indicating higher antioxidant potential. Highest total carotenoids (µg 100 g⁻¹), β-carotene (µg 100 g⁻¹) and xanthophyll (µg g⁻¹) content obtained in pulp on DGF3 (33.8), DGF4 (55.9) and DGF3 (32.7), whereas, in peel on DGF2 (24.3), DGF4 (18.5) and DGF2 (24.1), respectively. DPPH-based scavenging activity (%) revealed higher scavenging activity of peels (55.6–81.2) than pulp (36.0–75.3) extracts. Comparatively, ABTS-based scavenging activity (%) was found more than DPPH-based one. Sixteen ISSR primers screened, 14 were produced 178 reproducible amplified bands. Number of amplified bands varied from 5 in UBC887 to 19 in UBC811 with an average of 12.71 bands per primer. Range of polymorphic bands and % polymorphism observed were 1–13 and 20.0–92.8, respectively. The polymorphic information content value of ISSR marker ranged from 0.42 (UBC895) to 0.91 (UBC 856). Cluster analysis distinguished three different Hylocereus species on the basis of geographic origin and pulp colour by forming separate groups and two genotypes each showed 52% (DGF1 and DGF3) and 76% (DGF2 and DGF4) genetic similarity. Key traits identified for distinguishing three different Hylocereus species were: Pulp/ peel colour of fruits, number of spines and length of areoles in cladode. Genotypes with high carotenoid and xanthophylls content (DGF4 and DGF2) identified under present study may be of industrial importance for development of nutraceutical products to meet out the vitamin-A deficiency among humans in tropical regions needed future focus.

Effectiveness of the 23-valent pneumococcal polysaccharide vaccine against vaccine serotype pneumococcal pneumonia in adults: A case-control test-negative design study

BACKGROUND

Vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPV23) is available in the United Kingdom to adults aged 65 years or older and those in defined clinical risk groups. We evaluated the vaccine effectiveness (VE) of PPV23 against vaccine-type pneumococcal pneumonia in a cohort of adults hospitalised with community-acquired pneumonia (CAP).

METHODS AND FINDINGS

Using a case-control test-negative design, a secondary analysis of data was conducted from a prospective cohort study of adults (aged ≥16 years) with CAP hospitalised at 2 university teaching hospitals in Nottingham, England, from September 2013 to August 2018. The exposure of interest was PPV23 vaccination at any time point prior to the index admission. A case was defined as PPV23 serotype-specific pneumococcal pneumonia and a control as non-PPV23 serotype pneumococcal pneumonia or nonpneumococcal pneumonia. Pneumococcal serotypes were identified from urine samples using a multiplex immunoassay or from positive blood cultures. Multivariable logistic regression was used to derive adjusted odds of case status between vaccinated and unvaccinated individuals; VE estimates were calculated as (1 - odds ratio) × 100%. Of 2,357 patients, there were 717 PPV23 cases (48% vaccinated) and 1,640 controls (54.5% vaccinated). The adjusted VE (aVE) estimate against PPV23 serotype disease was 24% (95% CI 5%-40%, p = 0.02). Estimates were similar in analyses restricted to vaccine-eligible patients (n = 1,768, aVE 23%, 95% CI 1%-40%) and patients aged ≥65 years (n = 1,407, aVE 20%, 95% CI -5% to 40%), but not in patients aged ≥75 years (n = 905, aVE 5%, 95% CI -37% to 35%). The aVE estimate in relation to PPV23/non-13-valent pneumococcal conjugate vaccine (PCV13) serotype pneumonia (n = 417 cases, 43.7% vaccinated) was 29% (95% CI 6%-46%). Key limitations of this study are that, due to high vaccination rates, there was a lack of power to reject the null hypothesis of no vaccine effect, and that the study was not large enough to allow robust subgroup analysis in the older age groups.

CONCLUSIONS

In the setting of an established national childhood PCV13 vaccination programme, PPV23 vaccination of clinical at-risk patient groups and adults aged ≥65 years provided moderate long-term protection against hospitalisation with PPV23 serotype pneumonia. These findings suggest that PPV23 vaccination may continue to have an important role in adult pneumococcal vaccine policy, including the possibility of revaccination of older adults.

Co-infections in people with COVID-19: a systematic review and meta-analysis

OBJECTIVES

In previous influenza pandemics, bacterial co-infections have been a major cause of mortality. We aimed to evaluate the burden of co-infections in patients with COVID-19.

METHODS

We systematically searched Embase, Medline, Cochrane Library, LILACS and CINAHL for eligible studies published from 1 January 2020 to 17 April 2020. We included patients of all ages, in all settings. The main outcome was the proportion of patients with a bacterial, fungal or viral co-infection. .

RESULTS

Thirty studies including 3834 patients were included. Overall, 7% of hospitalised COVID-19 patients had a bacterial co-infection (95% CI 3-12%, n=2183, I2=92·2%). A higher proportion of ICU patients had bacterial co-infections than patients in mixed ward/ICU settings (14%, 95% CI 5-26, I2=74·7% versus 4%, 95% CI 1-9, I2= 91·7%). The commonest bacteria were Mycoplasma pneumonia, Pseudomonas aeruginosa and Haemophilus influenzae. The pooled proportion with a viral co-infection was 3% (95% CI 1-6, n=1014, I2=62·3%), with Respiratory Syncytial Virus and influenza A the commonest. Three studies reported fungal co-infections.

CONCLUSIONS

A low proportion of COVID-19 patients have a bacterial co-infection; less than in previous influenza pandemics. These findings do not support the routine use of antibiotics in the management of confirmed COVID-19 infection.

Pneumococcal serotype trends, surveillance and risk factors in UK adult pneumonia, 2013-18

BACKGROUND

Changes over the last 5 years (2013-18) in the serotypes implicated in adult pneumococcal pneumonia and the patient groups associated with vaccine-type disease are largely unknown.

METHODS

We conducted a population-based prospective cohort study of adults admitted to two large university hospitals with community-acquired pneumonia (CAP) between September 2013 and August 2018. Pneumococcal serotypes were identified using a novel 24-valent urinary monoclonal antibody assay and from blood cultures. Trends in incidence rates were compared against national invasive pneumococcal disease (IPD) data. Persons at risk of vaccine-type pneumonia (pneumococcal conjugate vaccine (PCV)13 and pneumococcal polysaccharide vaccine (PPV)23) were determined from multivariate analyses.

FINDINGS

Of 2934 adults hospitalised with CAP, 1075 (36.6%) had pneumococcal pneumonia. The annual incidence of pneumococcal pneumonia increased from 32.2 to 48.2 per 100 000 population (2013-18), predominantly due to increases in PCV13non7-serotype and non-vaccine type (NVT)-serotype pneumonia (annual incidence rate ratio 1.12, 95% CI 1.04 to 1.21 and 1.19, 95% CI 1.10 to 1.28, respectively). Incidence trends were broadly similar to IPD data. PCV13non7 (56.9% serotype 3) and PPV23non13 (44.1% serotype 8) serotypes were identified in 349 (32.5%) and 431 (40.1%) patients with pneumococcal pneumonia, respectively. PCV13-serotype pneumonia (dominated by serotype 3) was more likely in patients in the UK pneumococcal vaccination clinical risk group (adjusted OR (aOR) 1.73, 95% CI 1.31 to 2.28) while PPV23-serotype pneumonia was more likely in patients outside the clinical risk group (aOR 1.54, 95% CI 1.13 to 2.10).

INTERPRETATION

The incidence of pneumococcal CAP is increasing, predominantly due to NVT serotypes and serotype 3. PPV23-serotype pneumonia is more likely in adults outside currently identified clinical risk groups.

Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis

Aim

To summarise and quantify the effect of tobacco smoking on the risk of developing community acquired pneumonia (CAP) in adults.

Methods

We systematically searched MEDLINE, Embase, CINAHL, PsychINFO and Web of Science, from inception to October 2017, to identify case-control and cohort studies and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The review protocol was registered with the PROSPERO database (CRD42018093943). Study quality was assessed by the Newcastle-Ottawa Scale. Pooled odds ratios (ORs) or hazard ratios (HRs) were estimated using a random-effects model.

Results

Of 647 studies identified, 27 studies were included (n = 460,592 participants) in the systematic review. Most of the included studies were of moderate quality with a median score of six (IQR 6–7). Meta-analysis showed that current smokers (pooled OR 2.17, 95% CI 1.70–2.76, n = 13 studies; pooled HR 1.52, 95% CI 1.13–2.04, n = 7 studies) and ex-smokers (pooled OR 1.49, 95% CI 1.26–1.75, n = 8 studies; pooled HR 1.18, 95% CI 0.91–1.52, n = 6 studies) were more likely to develop CAP compared to never smokers. Although the association between passive smoking and risk of CAP in adults of all ages was not statistically significant (pooled OR 1.13, 95% CI 0.94–1.36, n = 5 studies), passive smoking in adults aged ≥65 years was associated with a 64% increased risk of CAP (pooled OR 1.64; 95% CI 1.17–2.30, n = 2 studies). Dose-response analyses of data from five studies revealed a significant trend; current smokers who smoked higher amount of tobacco had a higher risk of CAP.

Conclusion

Tobacco smoke exposure is significantly associated with the development of CAP in current smokers and ex-smokers. Adults aged > 65 years who are passive smokers are also at higher risk of CAP. For current smokers, a significant dose-response relationship is evident.

Endobronchial metastasis of mixed Mullerian tumour of the uterus

Endobronchial metastasis occurs in only 2%-5% of non-pulmonary cancers. Here we report on an 84-year-old woman who presented with breathlessness and light-headedness while on holiday in Australia, 2 years post-treatment for endometrial cancer. Initial CT pulmonary angiogram identified a soft tissue mass in the left hemithorax. A chest radiograph performed after repatriation was consistent with a large left pleural effusion, but bedside ultrasound showed a lobulated mass involving the left hemidiaphragm. A pleural procedure in the traditional 'triangle of safety' would have resulted in inadvertent puncture of the underlying mass. Serial imaging confirmed the mass was rapidly progressing, and metastatic malignant mixed Mullerian endometrial carcinoma was diagnosed by endobronchial biopsy. A tunnelled intrapleural catheter was inserted for symptom relief, and the patient deteriorated and died at home 2 weeks later. To our knowledge, this is the first case of endobronchial metastasis from malignant mixed Mullerian tumour of the uterus.

Effect of feeding lipids recovered from fish processing waste by lactic acid fermentation and enzymatic hydrolysis on antioxidant and membrane bound enzymes in rats

Fish oil recovered from fresh water fish visceral waste (FVW-FO) through lactic acid fermentation (FO-LAF) and enzymatic hydrolysis (FO-EH) were fed to rats to study their influence on lipid peroxidation and activities of antioxidant and membrane bound enzyme in liver, heart and brain. Feeding of FO-LAF and FO-EH resulted in increase (P < 0.05) in lipid peroxides level in serum, liver, brain and heart tissues compared to ground nut oil (control). Activity of catalase (40-235 %) and superoxide dismutase (17-143 %) also increased (P < 0.05) with incremental level of EPA + DHA in diet. The increase was similar to cod liver oil fed rats at same concentration of EPA + DHA. FO-LAF and FO-EH increased (P < 0.05) the Na(+)K(+) ATPase activity in liver and brain microsomes, Ca(+)Mg(+) ATPase in heart microsome and acetylcholine esterase in brain microsomes when fed with 5 % EPA + DHA. There was also significant change in fatty acid composition and cholesterol/phospholipid ratio in microsomes of rat fed with FVW-FO. Feeding FVW-FO recovered by biotechnological approaches enhanced the activity of antioxidant enzymes in tissues, modulates the activities of membrane bound enzymes and improved the fatty acid composition in microsomes of tissues similar to CLO. Utilization of these processing wastes for the production of valuable biofunctional products can reduce the mounting economic values of fish oil and minimize the environmental pollution problems.

Rectal schwannoma on endoscopic polypectomy

Conventional gastrointestinal schwannomas are rare, most frequently occurring in the stomach while colorectal locations are uncommon and only a small number of cases have been reported. We are reporting this case as it is a very rare tumour at a very rare location. Though schwannomas are considered benign neoplasms, rare cases of malignant schwannoma have been reported. Owing to the uncertainty of the prognosis, our patient is under long-term endoscopic surveillance.

Would a Massive Intra-abdominal Malignant Peripheral Nerve Sheath Tumor with Growth into the Inguinal Canal and Scrotum Preclude Surgical Option? A Case Report and Review of Literature

Malignant peripheral nerve sheath tumors (MPNST) are rare spindle-cell sarcomas derived from Schwann cells or pluripotent cells of the neural crest accounting for less than 10 % of all soft tissue sarcomas. They arise from major or minor peripheral nerve fibers or their sheaths. The World Health Organization coined the term MPNST for tumors of neurogenic origin with similar biological behavior replacing all the previous heterogeneous and, often, confusing nomenclature including malignant schwannoma, malignant neurilemmoma, and neurofibrosarcoma. The retroperitoneum and the lower extremities are the most common sites, but MPNST may arise anywhere in the body. Its location in the retroperitoneum in a patient without neurofibromatosis is an exceedingly rare occurrence. Imaging is routinely performed to assess the extent of the disease and to plan surgical resection. Surgical resection is the first line of therapy, ideally with total removal of the tumor. Owing to a high risk of recurrence with incomplete resection, postoperative irradiation and chemotherapy are necessary; however, they are often used as adjuvant therapy even if the tumor is completely resected.

Retinol-deficient rats can convert a pharmacological dose of astaxanthin to retinol: antioxidant potential of astaxanthin, lutein, and β-carotene

Retinol (ROH) and provitamin-A carotenoids are recommended to treat ROH deficiency. Xanthophyll carotenoids, being potent antioxidants, can modulate health disorders. We hypothesize that nonprovitamin-A carotenoids may yield ROH and suppress lipid peroxidation under ROH deficiency. This study aimed to (i) study the possible bioconversion of astaxanthin and lutein to ROH similar to β-carotene and (ii) determine the antioxidant potential of these carotenoids with reference to Na+/K+-ATPase, antioxidant molecules, and lipid peroxidation (Lpx) induced by ROH deficiency in rats. ROH deficiency was induced in rats (n = 5 per group) by feeding a diet devoid of ROH. Retinol-deficient (RD) rats were gavaged with astaxanthin, lutein, β-carotene, or peanut oil alone (RD group) for 7 days. Results show that the RD group had lowered plasma ROH levels (0.3 µmol/L), whereas ROH rose in astaxanthin and β-carotene groups (4.9 and 5.7 µmol/L, respectively), which was supported by enhanced (69% and 70%) intestinal β-carotene 15,15′-monooxygenase activity. Astaxanthin, lutein, and β-carotene lowered Lpx by 45%, 41%, and 40% (plasma), respectively, and 59%, 64%, and 60% (liver), respectively, compared with the RD group. Lowered Na+/K+-ATPase and enhanced superoxide dismutase, catalase, and glutathione-S-transferase activities support the lowered Lpx. To conclude, this report confirms that astaxanthin is converted into β-carotene and ROH in ROH-deficient rats, and the antioxidant potential of carotenoids was in the order astaxanthin > lutein > β-carotene.

Characterization of microalgal carotenoids by mass spectrometry and their bioavailability and antioxidant properties elucidated in rat model

Of the total carotenoids in respective algal samples, beta-carotene in Spirulina platensis was 69.5%, astaxanthin and its esters in Haematococcus pluvialis was 81.38%, and lutein in Botryococcus braunii was 74.6%. The carotenoids were characterized by mass spectrometry. A time-course study of carotenoids in rats after administration of microalgal biomass showed peak levels in plasma, liver, and eyes at 2, 4, and 6 h, respectively. Beta-carotene accumulation in Spirulina-fed rats was maximum in eye tissues at 6 h. Similarly, levels of astaxanthin and lutein in Haematococcus- and Botryococcus-fed rats were also maximal in eye tissues. Astaxanthin from H. pluvialis showed better bioavailability than beta-carotene and lutein. The antioxidant enzymes, catalase, superoxide dismutase, peroxidase, and TBARS were significantly high in plasma at 2 h and in liver at 4 h, evidently offering protection from free radicals. This study implies that microalgae can be a good source of carotenoids of high bioavailability and nutraceutical value.

Identification of carotenoids from green alga Haematococcus pluvialis by HPLC and LC-MS (APCI) and their antioxidant properties

Haematococcus pluvialis, a green alga accumulates astaxathin upto 2-3% on dry weight basis. In the present study, identification of carotenoids from Haematococcus cyst cell extract by HPLC and LC-MS (APCI) and their antioxidant properties were evaluated in vitro model systems. The extract exhibited 89% and 78% antioxidant activity in beta-carotene linoleate model, and hydroxyl radical scavenging model at 9 ppm of total carotenoid respectively. The extract also showed 80%, 85% and 79% antioxidant activity against lipid peroxidation in kidney, brain and liver of rats. Low-density lipoprotein oxidation induced by Cu2+ ions also protected (45%, 64% and 75%) by the extract in a dose dependent manner with different carotenoid levels. Thiobarbituric acid reactive substances concentration in the blood, liver, and kidney of rat was also significantly (p<0.005) decreased in H. pluvialis treated rats. Potent antioxidant activity is attributable to various carotenoids present in the extract.

Phospholipid, oleic acid micelles and dietary olive oil influence the lutein absorption and activity of antioxidant enzymes in rats

This study reports on the results of repeated gavages and dietary feeding of lutein dispersed either in phospholipids or fatty acid micelles or vegetable oils and the effects on lutein bioavailability and antioxidant enzymes in rats. For the gavage study, rats (n = 5/group) were intubated with lutein solubilized either in oleic acid (OLA, 18:1n-9) or linoleic acid (LNA, 18:2n-6) or phosphatidylcholine (PC) or lysophosphatidylcholine (LPC) or no phospholipid (NoPL) micelles for 10 days. For the dietary study, rats (n = 5/group) were fed a diet containing fenugreek leaf (lutein source), either with olive (OO) or sunflower (SFO) or groundnut (GNO, control) oil or L: -alpha-lecithin (PL) for 4 weeks. The gavage study showed that the plasma, liver and eye lutein levels in OLA and LPC groups were higher by 23.9, 20.8 and 25.5% and 16.1, 28.5 and 14.0% than LNA and PC groups, respectively. The dietary study showed the plasma (35.0 and 43.5%) and eye (18.5 and 37.0%) lutein levels in OO were higher than SFO and GNO groups. The plasma and eye lutein levels in the PL group were higher by 20 and 31.3% than in the control. It is evident that OO and PL modulate lutein absorption, which in turn modulates antioxidant enzymes and fatty acids in plasma and tissues compared to SFO. Hence, selection of the fat source may be vital to enhancing the lutein bioavailability.

Nodular regenerative hyperplasia of liver

Nodular regenerative hyperplasia of the liver (NRHL) is a very rare cause of portal hypertension and liver failure. The condition is characterized by diffuse micronodular transformation of hepatic parenchyma without fibrous septa between the nodules. We present our experience with a 32-year-old woman who presented with recurrent episodes of upper gastrointestinal bleeding associated with massive splenomegaly who was subsequently found to have NRHL. This article considers the salient aspects of this rare condition, how it affects the patients and the options available in its management. A plea is made for the need for liver biopsy for all patients with portal hypertension especially those being considered for surgery.

Towards total knowledge management for healthcare: clinical and organizational considerations

Knowledge Management (KM) has made a significant impact on the global healthcare sector. However, it is important to address the link between knowledge, information and engineering. Knowledge Engineering (KE) is often only a small part of a KM-based project, yet some KM practitioners favour wholly KE-biased Knowledge Management projects, disregarding a more necessary holistic stance. This paper analyses some current achievements in the KM field and provides a benchmark from which academics and practitioners can attempt to attain "Total Knowledge Management for Healthcare" (TKMh).

Micellar oleic and eicosapentaenoic acid but not linoleic acid influences the β-carotene uptake and its cleavage into retinol in rats

Improving the bioavailability of beta-carotene is vital to manage vitamin A deficiency. The influence of micellar oleic (OA), linoleic (LA) and eicosapentaenoic (EPA) acids on plasma beta-carotene response and its conversion to retinol has been studied in rats employing single (9 h time course) and repeated (10 days) dose administrations. After a single dose, the levels (area under the curve) of plasma beta-carotene and retinyl palmitate in OA and EPA groups were higher (p < 0.05) by 13, 7 and 11, 6 folds than LA group. The liver beta-carotene level in OA and EPA groups were higher (p < 0.05) by 3 and 1.2 folds than LA group. After repeated dose, the plasma beta-carotene and retinyl palmitate levels in OA (6.2%, 51.7%) and EPA (25.4%, 17.23%) groups were higher (p < 0.05) than LA group. The liver beta-carotene level in OA (21.2%) and EPA (17.6%) groups were higher (p < 0.05) than LA group. In both the experiments, the activity of beta-carotene 15,15'-dioxygenase in the intestinal mucosa and plasma triglyceride levels were also higher in OA and EPA groups than LA group. beta-Carotene excreted through urine and feces of OA and EPA groups was lower than the LA group. These results demonstrate an improved absorption and metabolism of beta-carotene when fed mixed micelles with OA or EPA compared with LA. Although the mechanism involved in selective absorption of fatty acids needs further studies, intestinal beta-carotene uptake and its conversion to vitamin A can be modulated using specific fatty acids.

Modulation of antioxidant enzyme activities, platelet aggregation and serum prostaglandins in rats fed spray-dried milk containing n-3 fatty acid

Spray-dried milk enriched with n-3 fatty acids from linseed oil or fish oil were fed to rats to study its influence on liver lipid peroxides, hepatic antioxidant enzyme activities, serum prostaglandins and platelet aggregation. Significant level of alpha linolenic acid, eicosapentaenoic acid and docosahexaenoic acid were accumulated at the expense of arachidonic acid in the liver of rats fed n-3 fatty acid enriched formulation. The linseed oil and fish oil enriched formulation fed group had 44 and 112% higher level of lipid peroxides in liver homogenate compared to control rats fed groundnut oil enriched formulation. Catalase activity in liver homogenate was increased by 37 and 183% respectively in linseed oil and fish oil formulation fed rats. The glutathione peroxidase activity decreased to an extent of 25-36% and glutathione transferase activity increased to an extent of 34-39% in rats fed n-3 fatty acids enriched formulation. Feeding n-3 fatty acid enriched formulation significantly elevated the n-3 fatty acids in platelets and increased the lipid peroxide level to an extent of 4.2-4.5 fold compared to control. The serum thromboxane B2 level was decreased by 35 and 42% respectively in linseed oil and fish oil enriched formulation fed rats, whereas, 6-keto- prostaglandin F1alpha level was decreased by 17 and 23% respectively in linseed oil and fish oil enriched formulation fed rats. The extent and rate of platelet aggregation was decreased significantly in n-3 fatty acids enriched formulation fed rats. This indicated that n-3 fatty acids enriched formulation beneficially reduces platelet aggregation and also enhances the activities of hepatic antioxidant enzymes such as catalase and glutathione transferase.

Enhanced lutein bioavailability by lyso-phosphatidylcholine in rats

The bioavailability of lutein solubilized in mixed micelles containing either phosphatidylcholine (PC) or lysophosphatidylcholine (lysoPC) was evaluated in male rats. Mixed micelles contained 2.5 mM monooleoylglycerol, 7.5 mM oleic acid, 12 mM sodium taurocholate and 200 microM lutein either with 3 mM PC or lysoPC. To study lutein bioavailability, single and repeated dose experiments were conducted. For single dose study, group of rats (n = 30/group) were fed single dose of lutein solubilized in lysoPC (LPC group), PC (PC group) and no phospholipids (NoPL group) in micellar form. Each group was further divided in to five sub-groups (n = 6/sub group) to measure lutein bioavailability over time up to 9 h. For repeated dose study, group of rats (n = 6/group) were fed daily for 10 days a dose of lutein in mixed micelles with NoPL, PC and LPC. A separate group (n = 6) not fed mixed micelles was considered as zero-time control. In both the experiments, mixed micelles (0.2 ml/rat) were fed to the rat by direct intubation to the stomach. Results of single dose studies showed that the mean lutein levels in the plasma and liver of the PC group was significantly lower (p < 0.05) than those of the other two groups. Moreover, the average lutein level in the plasma and liver was significantly (p < 0.05) different among the groups in the order LPC > NoPL > PC. But, repeated dose experiment followed the order LPC > PC > NoPL. The level of lutein excreted through urine and feces of PC group was significantly higher (p < 0.05) than those of the other two groups. Thus, the results indicate that the PC in the mixed micelles suppressed the intestinal uptake of lutein after single dose but not after repeated dose and that lysoPC enhanced the absorption. In both the experiments, plasma and liver level of lutein was higher in LPC compared with PC group. Results also suggest that the luminal hydrolysis of PC to lysoPC is necessary for intestinal uptake of lutein solubilized in mixed micelles.

Modulation of antioxidant enzyme activities, platelet aggregation and serum prostaglandins in rats fed spray-dried milk containing n-3 fatty acid

Spray-dried milk enriched with n-3 fatty acids from linseed oil (LSO) or fish oil (FO) were fed to rats to study its influence on liver lipid peroxides, hepatic antioxidant enzyme activities, serum prostaglandins and platelet aggregation. Significant level of alpha linolenic acid, eicosapentaenoic acid and docosahexaenoic acid were accumulated at the expense of arachidonic acid in the liver of rats fed n-3 fatty acid enriched formulation. The linseed oil and fish oil enriched formulation fed group had 44 and 112% higher level of lipid peroxides in liver homogenate compared to control rats fed groundnut oil enriched formulation. Catalase activity in liver homogenate was increased by 37 and 183% respectively in linseed oil and fish oil formulation fed rats. The glutathione peroxidase activity decreased to an extent of 25-36% and glutathione transferase activity increased to an extent of 34-39% in rats fed n-3 fatty acids enriched formulation. Feeding n-3 fatty acid enriched formulation significantly elevated the n-3 fatty acids in platelets and increased the lipid peroxide level to an extent of 4.2 to 4.5-fold compared to control. The serum thromboxane B2 level was decreased by 35 and 42% respectively in linseed oil and fish oil enriched formulation fed rats, whereas 6-keto-prostaglandin F1alpha level was decreased by 17 and 23% respectively in linseed oil and fish oil enriched formulation fed rats. The extent and rate of platelet aggregation was decreased significantly in n-3 fatty acids enriched formulation fed rats. This indicated that n-3 fatty acids enriched formulation beneficially reduces platelet aggregation and also enhances the activities of hepatic antioxidant enzymes such as catalase and glutathione transferase.

Supplementation and delivery of n-3 fatty acids through spray-dried milk reduce serum and liver lipids in rats

Indian diets comprising staples such as cereals, millets, and pulses provide 4.8 energy % from linoleic acid (18:2n-6) but fail to deliver adequate amounts of n-3 FA. Consumption of long-chain n-3 PUFA such as EPA (20:5n-3) and DHA (22:6n-3) is restricted to those who consume fish. The majority of the Indian population, however, are vegetarians needing additional dietary sources of n-3 PUFA. The present work was designed to use n-3 FA-enriched spray-dried milk powder to provide n-3 FA. Whole milk was supplemented with linseed oil to provide alpha-linolenic acid (LNA, 18:3n-3), with fish oil to provide EPA and DHA, or with groundnut oil (GNO), which is devoid of n-3 PUFA, and then spray-dried. Male Wistar rats were fed the spray-dried milk formulations for 60 d. The rats given formulations containing n-3 FA showed significant increases (P < 0.001) in the levels of LNA or EPA/DHA in the serum and in tissue lipids as compared with those fed the GNO control formulation. Rats fed formulations containing n-3 FA had 30-35% lower levels of serum total cholesterol and 25-30% lower levels of serum TAG than control animals. Total cholesterol and TAG in the livers of rats fed the formulations containing n-3 FA were lower by 18-30% and 11-18%, respectively, compared with control animals. This study showed that spray-dried milk formulations supplemented with n-3 FA are an effective means of improving dietary n-3 FA intake, which may decrease the risk factors associated with cardiovascular disease.

Do the Progesterone Receptors Have a Role to Play in Gallbladder Cancer?

BACKGROUND

Gallstone disease as well as gallbladder cancer are more common in women and female sex hormones may be involved in their etiology.

AIM AND METHODS

To determine whether female sex hormones have a role in the pathogenesis, of gallbladder carcinoma and in its prognosis, we estimated, by enzyme immunoassay, the estrogen and progesterone receptors (ER and PgR) in the gallbladders of 21 patients with gallbladder cancer, 19 patients with cholelithiasis, and 6 patients who underwent incidental removal of essentially normal gallbladder as a component of wider resection.

RESULTS

ER were present in the gallbladder mucosa in all the three groups in proportions which were not significantly different (9/21 in carcinoma, 4/19 in gallstones, and 1/6 normal), whereas the expression of PgR was greater in carcinomas (13/18), less in cholelithiasis (4/12), and absent in normal gallbladders. PgR expression was higher in tumors of lower stage (7/7) and lower in advanced disease stage IV tumors (6/11). PgR expression was associated with better disease stage (p=0.05) and significantly longer overall survival (median survival of 301 d vs 54 d) as well as better survival within the same stage (269 d vs 54 d for stage IV disease, p=0.011). Cox's regression analysis showed that PgR was an independent risk factor (R=0.2283, p=0.0035).

CONCLUSIONS

Our findings suggest that the female sex hormones may have a role in the pathogenesis of gallbladder cancer and that PgR expression has a prognostic significance. We believe that when this relationship is reaffirmed by larger studies, gallbladder cancer may be treated with appropriate sex hormonal manipulation.

Nutritional status of the protein of corn-soy based extruded products evaluated by rat bioassay

A rat bioassay was conducted to preclinically evaluate nutritional quality of two supplementary foods (SFs) developed based on corn and soy blends for feeding preschool children. The SFs prepared by extrusion cooking and subsequently modified to taste either sweet or salty provide 395 +/- 2 kcal of energy and 20 +/- 2 g protein per 100 g of food. The proximate constituents and energy contents of SFs were within the ranges prescribed for processed weaning foods and could satisfactorily meet the requirements of preschool children. Groups of male weanling rats were fed SFs for 4 weeks to evaluate the protein quality. The body weight gain of rats fed with SFs were significantly higher than those fed with skimmed milk powder (SMP) diet as control. The protein efficiency ratio and net protein utilization results of SFs were not significantly different (p > 0.05) from values of control group. It is inferred that these SFs were nutritionally comparable to SMP.

ACCURACY OF SERUM - ASCITES ALBUMIN GRADIENT IN THE AETIOLOGICAL DIAGNOSIS OF ASCITES

50 adults with ascites admitted to our hospital were studied. Simultaneous samples of ascitic fluid and blood were collected and subjected to analysis including ascitic fluid total protein and serum ascites albumin gradient The cut off value of serum-ascites albumin gradient for differentiating between high and low gradient was taken as 1.1 gm % and of ascitic fluid protein for differentiating exudate and transudate as 2.5 gm%. The sensitivity, specificity, positive predictive value and negative predictive value of high gradient and transudative ascites in diagnosing portal hypertension were 943%, 60%, 84.6%, 81.8% and 62.9%, 133%, 91.7% and 50% respectively. High gradient ascites is a sensitive test in the diagnosis of portal hypertension as a cause of ascites. The exudate-transudate approach has severe limitations in the differential diagnosis of ascites.