Ocular Cicatricial Pemphigoid in Young Patients

PURPOSE

The purpose of this study is to report ocular cicatricial pemphigoid (OCP) occurring in young patients. Relevant literature is also reviewed.

METHODS

Medical records of patients aged 30 years or younger who were treated for OCP between August 2021 and May 2023 at a tertiary care eye institute were reviewed. The most common differential diagnoses of cicatrizing conjunctivitis, such as Stevens-Johnson syndrome sequelae, chemical injury, chronic topical/systemic drug use, autoimmune connective tissue disorders, or allergic eye diseases, were ruled out based on clinical history, examination, and the Cicatrizing Conjunctivitis Score described by Shanbhag et al. The diagnosis of OCP was confirmed by positive direct immunofluorescence of oral mucosal and/or conjunctival biopsy in a majority of the patients.

RESULTS

Seven patients fulfilled the criteria for a diagnosis of OCP. The mean age at presentation was 21.86 ± 5.25 years (13-28 years). Some of the patients presented with relatively atypical features for OCP such as corneal immune ring infiltrate and bilateral corneal perforation. Six patients exhibited systemic mucosal lesions, and the direct immunofluorescence yield was 85.71%. All patients required aggressive immunosuppressive treatment.

CONCLUSIONS

OCP is classically described as a rare disease that occurs in old age. This case series highlights the importance of a higher index of suspicion for diagnosing OCP at a younger age. Early administration of immunosuppressive agents can potentially control severe ocular surface inflammation and its sequelae.

The Implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Program at a Level 1 New England Trauma Center: Feasibility and Early Outcomes

OBJECTIVES

We evaluated the feasibility of implementing a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) program at our urban level 1 trauma center and evaluated early outcomes.

DESIGN

A multidisciplinary committee including physicians (trauma surgery, emergency medicine, vascular surgery, and interventional radiology) and nurses created clinical practice guidelines for the placement of REBOA at our institution. All trauma surgeons and critical care board certified emergency medicine physicians were trained in placement and nurses received management training. A formal review process was implemented to identify areas for improvement. Finally, we instituted refresher training to maintain REBOA competency. Trauma patients with noncompressible torso hemorrhage from blunt or penetrating injuries who were partial or nonresponders to blood product resuscitation were included. Pregnant patients, children, or patients with significant hemothorax or suspected aortic or cardiac injury were excluded.

RESULTS

Over seven months, eight catheters were successfully placed, all on the first attempt, including six in Zone 3 and two in Zone 1. All Zone 3 catheters were placed for pelvic fracture-related bleeding which were subsequently embolized. The Zone 1 catheters were placed immediately preoperatively for intraabdominal bleeding. Upon committee review, one critique was made regarding zone selection. One patient developed an arteriovenous fistula after placement which resolved without intervention. There were no other complications and all patients survived to discharge.

CONCLUSIONS

An REBOA program is feasible and safe following a comprehensive multidisciplinary effort. The efforts described here can be utilized by similar trauma programs for adaptation of this endovascular approach to bleeding control.

Clinical outcomes of corneal neurotization using sural nerve graft in neurotrophic keratopathy

OBJECTIVE

To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure.

METHODS

A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization.

RESULTS

Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6-12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months.

CONCLUSION

This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure.

Dead bag syndrome-in the capsular bag subluxated intraocular lens centration and refixation: A new technique

We describe a technique of scleral IOL fixation and optic centration of in the capsular bag subluxated IOL in a patient of "dead bag syndrome." A 29-year-old male diagnosed case of thalassemia presented with painless progressive diminution of vision in the left eye following uncomplicated sequential phacoemulsification in both eyes 15 years back. The right eye revealed completely centered IOL with significant amount of anterior capsular opacification (ACO), while the left eye revealed inferior subluxation of the IOL within capsular bag. The capsular bag was dilated, diaphanous with clear anterior and posterior capsule without any evidence of capsular fibrosis or opacification. Thus, a diagnosis of "dead bag syndrome" was made. The haptics were sutured to sclera (Hoffman's pockets) using two loops of 9-0 polypropylene, passed anterior and posterior to IOL haptics within the capsular bag. Postoperatively, the patient had a vision of 20/40 with a centered intraocular lens.

Corneal and corneal epithelial thickness distribution characteristics in healthy North Indian eyes using spectral domain optical coherence tomography

Purpose

To determine the pattern of corneal thickness and epithelial thickness distribution in healthy North Indian eyes by using spectral domain optical coherence tomography (SD-OCT).

Methods

The observational study measured total corneal and epithelial thickness in the central 2 mm zone and eight sectors each in paracentral 2-5 mm (ring 1) and midperipheral 5-7 mm (ring 2) zones on SD-OCT.

Results

The study included 67 eyes of 67 subjects with a male:female ratio of 32:35 and mean age of 25.04 ± 4.54 years. The mean central corneal and epithelial thicknesses were 505.97 ± 30.12 μm and 60.48 ± 8.37 μm, respectively. The epithelium of inferior and infero-nasal sectors in ring 1 and inferior sector in ring 2 was significantly thicker than the radially opposite sectors of the respective rings (P = 0.001; P = 0.01 and P = 0.02, respectively). Sector-wise analysis did not reveal any significant correlation between the total corneal thickness and epithelial thickness (all P > 0.05) except in the outer superior sector where there was a weak positive correlation (r = 0.28, P = 0.02). Central epithelial thickness in males (60.59 ± 9.28 μm) and females (60.37 ± 7.58 μm) was comparable (P = 0.91). Pachymetry was thinnest in the inferior, inferonasal, and inferotemporal sectors in 44.79% of eyes (n = 30), while thinnest epithelium was seen in the superior, superonasal, and superotemporal quadrants in 50.75% of eyes (n = 34).

Conclusion

The epithelial thickness distribution in this sample of topographically normal healthy North Indian eyes was nonuniform and independent of the underlying corneal thickness. Epithelium was thinner in the superior cornea, whereas total corneal thickness was minimum in the inferior part.

Globicatella sanguinis corneal abscess with endophthalmitis

Globicatella sanguinis is a rare microorganism known to affect the bloodstream, urinary tract, and central nervous system. We report a case of Globicatella sanguinis ocular infection in a 9-year-old boy, who presented with a corneal abscess with endophthalmitis, following trauma. Isolation of the infection using matrix-assisted laser desorption ionization time-of-flight mass spectrometry and determination of its antibiotic sensitivity via Vitek 2 highlight the important role of microbiology laboratories for the diagnosis and management of infections caused by atypical microorganisms.

Computational screening for finding new potent cox-2 inhibitors as anticancer agents

Background:

Breast cancer ranks first in women and the second most common type of cancer overall. It is the most important barrier to the rise of life expectancy, globally affecting disease modalities. Cyclooxygenase-2 (COX-2) has become a prominent hallmark as inhibition target for breast cancer, and this therapeutic target for anti-inflammatory drugs regulates cell proliferation, angiogenesis, tumor growth and apoptosis. There is a need to explore new anti-cancerous drugs for searching the best possible hit candidates for cancer treatment. The computer-aided drug design approach was conducted to discover the new alternative COX-2 inhibitors.

Objective:

The research framework of this study is to identify new potent inhibitors for the COX-2 using computer-aided drug design.

Methods:

In the present investigation, an in-silico approach was used to screen with the best established three biological databases (Zinc15, ChemSpider and BindingDB) and docked against the COX-2 protein structure (PDB ID: 5IKR). Molecular docking was carried out using the Schrodinger Maestro suite. The compounds were filtered out based on their physicochemical, ADMET, and other drug-like properties. Several computational approaches such as molecular docking, binding free energy calculation, ADMET analysis, protein-ligand interaction and MD simulation were performed to determine the suitability of correct ligands for selected COX-2 target.

Results:

The two ligands showed relatively better binding affinities (-10.028 kcal/mol for compound A and -10.007 kcal/mol for ZINC000048442590) than the standard (-9.751 kcal/mol). These compounds followed Lipinski’s rule and drug-likeness index, which exhibited a good predicted therapeutic druggability profile. The interaction of the protein-ligand complex correlates with the COX-2. The MD simulation of the protein-ligand complex showed good stability in the time period of 10ns.

Conclusion:

It is the first study in which two new compounds ZINC000048442590 and compound A were found to be highly promising and have active potential in inhibiting cyclooxygenase-2 enzyme and could be effective as the potential drug candidates for breast cancer against COX-2 protein. Hopefully, in the future, these compounds as anti-inflammatory drug molecules could be used as new templates for the development of anticancer agents.

Role of GeneXpertMTB/RIF in the diagnosis of cutaneous tuberculosis

BACKGROUND

cutaneous involevemtn is an important extrapulmonary manifestation of tuberculosis. It is a paucibacillary condition and has diverse clinical presentations. Sufficient data is not available regarding role of GeneXpertMTB/RIF in cutanoues tuberculosis.

METHODS

in this study, BacT/Alert3D and response to antitubercular therapy were taken as gold standard and performance of GeneXpertMTB/RIF was evaluated against it in clinically and histopathologically suspected cases of cutaneous tuberculosis.

RESULTS

forty seven patients were included in the study of which commonest presentation was scrofuloderma (42.6%) followed by lupus vulgaris (40.4%). Granulomatous inflammation on histopathology was seen in 75.5% patients on skin biopsy. Sic patients had extracutaneous focus of tuberculosis. In 14 (29.79%), culture of skin biopsy was positive for M. tuberculosis and all showed complete response to ATT in 6 months. GeneXpertMTB/RIF detected M. tuberculsois in 4 samples.

CONCLUSION

GeneXpertMTB/RIF is not a reliable tool for diagnosis of cutaneous tuberculosis. Clinic-histopathological correlation along with response to ATT is needed for confirmation of diagnosis of cutaneous tuberculosis.

Phacoemulsification in posterior polar cataract: Experience from a tertiary eye care Centre in North India

Purpose:

To determine the rate of posterior capsular rupture (PCR) and assess the postoperative outcomes in patients of posterior polar cataract (PPC) undergoing phacoemulsification using a combination of “V” or “λ” nucleofractis and viscodissection.

Methods:

It was a retrospective study of 80 eyes of 64 patients undergoing surgery for PPC. All surgeries were performed by a single surgeon. After completion of the continuous curvilinear capsulorrhexis (CCC), controlled hydrodelineation was used to separate the endonucleus from the epinuclear shell with limited viscodissection. Phacoemulsification was then carried out by making a “V” or lambda-shaped nucleofractis with the phaco tip followed by multiple chopping of the nucleus, ensuring the integrity of the epinuclear part of the lens. The epinuclear plate was removed after viscodissection.

Results:

The overall rate of PCR was 7.5% (6 out of 80 eyes). Of the 6 eyes, 4 eyes had been documented to have a pre-existing posterior capsular defect on slit-lamp examination. The rate of “on table” PCR, that is, PCR occurring intraoperatively was only 2.6% (2 of 76 eyes). Nucleus drop was not encountered in any case. Overall 87.5% eyes achieved a final visual acuity of 20/40 or better with 68.75% being 20/20 or better. Of the eyes developing PCR, two-third achieved a visual acuity of 20/30 or better.

Conclusion:

Using a combination of surgical techniques of V groove or lambda technique for nucleofractis and removal of epinucleus by viscodissection can result in a low rate of PCR and extremely good postoperative outcomes in cases of PPC.

Between eye asymmetry in keratoconus in an Indian population

PURPOSE

The purpose of this study was to assess the clinical as well as topographic asymmetry between the eyes in keratoconus.

METHODS

Clinical examination including retinoscopy, distant direct ophthalmoscopy, manual keratometry (Bausch & Lomb), slitlamp biomicroscopy and topography (Nidek ARK10000) was carried out on 44 eyes of 22 subjects. At least four high quality topographical images, which were within 0.25 D of one another as measured by simulated keratometry (SimK), were obtained for each eye. Of these, the one with the best alignment and at least six digitised rings was selected for analysis.

RESULTS

The visual acuity (logMAR), and spherical and cylindrical errors showed marked asymmetry with means of 0.3 +/- 0.3 (SD),-5.2 +/- 6.2 D,-3.1 +/- 2.5 D in the better eyes and 0.5 +/- 0.3,-9.8 +/- 8.5 D,-5.0 +/- 2.5 D in the worse eyes (p = 0.01, 0.05, 0.01, respectively). Scissoring retinoscopy reflex, oil droplet sign, Munson's sign, Vogt's striae, scarring and keratometry readings were significantly greater in the more affected eyes. The inferior-superior steepening, central corneal power and apex power as deduced from topography were significantly greater in the more affected eyes with values of 20.3 +/- 15.7 D, 51.4 +/- 10.1 D, 56.7 +/- 11.0 D in the better eyes and 30.4 +/- 18.6 D, 60.1 +/- 10.9 D, 68.7 +/- 19.6 D in the worse eyes (p = 0.05, 0.01, 0.02).

CONCLUSION

Keratoconus is essentially a bilateral but asymmetric corneal degeneration. Seven of our patients had clinically unilateral keratoconus but on topography, based on KISA% index, six of the unaffected eyes were diagnosed as keratoconus though much milder than in the other eye.

Keratoconus in Asian eyes at a tertiary eye care facility

BACKGROUND

The purpose of this study was to assess the demographic variables, age at diagnosis, keratometry and slitlamp signs in keratoconus.

METHODS

Thirty-one patients with 61 keratoconic eyes were selected provided they met one of two criteria: 1. They had an irregular corneal surface, Vogt's striae, Fleischer's ring or apical sub-epithelial corneal scarring characteristic of keratoconus; 2. Corneal topography revealed an average simulated keratometry of more than 45.2 D, central corneal power higher than 47.2 D or infero-superior asymmetry greater than 1.4 D. The main outcome measures were demographic variables, age at diagnosis, disease severity on keratometry and biomicroscopic signs.

RESULTS

The patients' mean age at presentation was 20.2 +/- 6.4 years. Based on average keratometry values, 67.2 per cent of eyes had severe and 32.8 per cent had moderate keratoconus. Eyes with severe keratoconus presented at a younger average age (18.8 +/- 5.35 years) than moderate keratoconus (23.69 +/- 8.07 years). Thirty-eight eyes (92.5 per cent) with severe and 13 eyes (65 per cent) with moderate keratoconus demonstrated biomicroscopic signs of keratoconus. Twenty eyes (32.7 per cent) demonstrated apical sub-epithelial cornea scarring and 95 per cent of these eyes had severe keratoconus.

CONCLUSIONS

The majority of keratoconic eyes in Asian-Indian patients demonstrate the severe stage of the disease by the second decade.

Decoding Psoriasis: Integrated Bioinformatics Approach to Understand Hub Genes and Involved Pathways

BACKGROUND

Psoriasis is a chronic immune mediated skin disorder with global prevalence of 0.2- 11.4%. Despite rare mortality, the severity of the disease could be understood by the accompanying comorbidities, that has even led to psychological problems among several patients. The cause and the disease mechanism still remain elusive.

OBJECTIVE

To identify potential therapeutic targets and affecting pathways for better insight of the disease pathogenesis.

METHOD

The gene expression profile GSE13355 and GSE14905 were retrieved from NCBI, Gene Expression Omnibus database. The GEO profiles were integrated and the DEGs of lesional and non-lesional psoriasis skin were identified using the affy package in R software. The Kyoto Encyclopaedia of Genes and Genomes pathways of the DEGs were analyzed using clusterProfiler. Cytoscape, V3.7.1 was utilized to construct protein interaction network and analyze the interactome map of candidate proteins encoded in DEGs. Functionally relevant clusters were detected through Cytohubba and MCODE.

RESULTS

A total of 1013 genes were differentially expressed in lesional skin of which 557 were upregulated and 456 were downregulated. Seven dysregulated genes were extracted in non-lesional skin. The disease gene network of these DEGs revealed 75 newly identified differentially expressed gene that might have a role in development and progression of the disease. GO analysis revealed keratinocyte differentiation and positive regulation of cytokine production to be the most enriched biological process and molecular function. Cytokines -cytokine receptor was the most enriched pathways. Among 1013 identified DEGs in lesional group, 36 DEGs were found to have altered genetic signature including IL1B and STAT3 which are also reported as hub genes. CCNB1, CCNA2, CDK1, IL1B, CXCL8, MKI 67, ESR1, UBE2C, STAT1 and STAT3 were top 10 hub gene.

CONCLUSION

The hub genes, genomic altered DEGs and other newly identified differentially dysregulated genes would improve our understanding of psoriasis pathogenesis, moreover, the hub genes could be explored as potential therapeutic targets for psoriasis.

Ethionamide induced blue vision (cyanopsia): Case report

Ethionamide is part of a group of drugs used in the treatment of drug resistant TB. With the advent of increasing drug resistance in pulmonary TB cases, use of Ethionamide, a second line anti tubercular drug is increasing. Vision changes are rare with ethionamide. Cyanopsia i.e., bluish tinted vision of surroundings with ethionamide is not known in literature. Here, we report a case of DRTB patient who developed cyanopsia soon after introducing ethionamide. Although reversible, ethionamide may sometimes need withdrawal because of significant distress caused to patient.

The Association of Metabolic Syndrome and Psoriasis: A Systematic Review and Meta-Analysis of Observational Study

Background:

Metabolic syndrome worsens complications in psoriasis patients by predisposing them to cardiovascular diseases. Psoriasis has been widely associated with metabolic syndrome; however, it has still not been proven owing to a limited number of studies and some of those reporting conflicting results.

Objective:

Psoriasis has reportedly been associated with metabolic syndrome; however, it has yet not been established beyond doubt owing to conflicting literature. The present meta-analysis of observational studies aims to evaluate the prevalence of metabolic syndrome in psoriasis patients and establish an inferring point that psoriasis patients are certainly susceptible to metabolic syndrome. The study will benefit clinicians to assess and monitor psoriasis patients for several associated comorbid conditions and in its treatment.

Methods:

A systematic web search for ‘Psoriasis’, ‘Metabolic Syndrome’, ‘Hypertension’, ‘Plasma Glucose’, ‘Dyslipidaemia’, ‘Waist Circumference’ was performed, collecting all original observational studies on humans up to April 30, 2018. Depending on the inclusion and exclusion criteria, articles were screened for eligibility. Due to the presence of significant heterogeneity, the Odds Ratio (OR) was calculated using a random-effect model with Der-Simonian and Laird method. The statistical heterogeneity was determined using I2 statistics. Comprehensive Meta-Analysis Software, Version 3 was used to perform all the analysis.

Results:

Sixty-three studies encompassing 15,939 psoriasis patients and 103,984 controls were included in this meta-analysis. Among them, 30.29 % of psoriasis patients were reported with metabolic syndrome in comparison to 21.70 % of subjects in the control group. The present study clearly indicates an increased prevalence of metabolic syndrome among psoriasis patients (OR: 2.077 [95% CI, 1.84 - 2.34]).

Conclusions:

The findings support the fact that psoriasis patients have a higher incidence of metabolic syndrome. Our study also recommends that psoriasis patients should be regularly monitored for metabolic syndrome complications and its associated risk factors such as hypertension, raised triglyceride, lowered HDL Cholesterol, increased fasting plasma glucose, and waist circumference.

Iridocorneal endothelial syndrome: Evaluation of patient demographics and endothelial morphology by in vivo confocal microscopy in an Indian cohort

Purpose:

To evaluate the patient demographics and morphological characteristics of corneal endothelium by in vivo confocal microscopy (IVCM), in patients with Iridocorneal Endothelial (ICE) Syndrome.

Methods:

In this retrospective observational series, IVCM acquired endothelial images of patients with ICE syndrome were evaluated. ‘ICE cells’ morphology was classified as “−” or “+” if they were larger or smaller than contralateral normal endothelium. It was correlated with patient demographics and clinical manifestations.

Results:

IVCM was performed on 41 eyes of 21 patients, with 13 males (62%) and 8 females (38%). The disease was unilateral in 19 (90.5%) and bilateral but asymmetric in two (9.5%) patients. Total ICE was seen in 91% eyes. Eighty percent patients (12 out of 15) with ICE—cells were males while 83.3% (5 out of 6) patients with ICE + cells were females. Mean age of patients with ICE- cell type and ICE + cell type was 45.8 ± 17.8 years and 40.3 ± 9.2 years respectively (P = 0.02). Both ICE – and ICE + eyes had similar incidence (33.3%) of corneal edema. ICE + eyes had more severe (grades 2/3) glaucoma (n = 5/6 eyes, 83.3%) compared to ICE – eyes (n = 8/15 eyes, 53.3%).

Conclusion:

A male preponderance, predilection of ICE – and + cell variants for male and female gender respectively, lack of association of the endothelial cell morphology with corneal edema, and apparent association of ICE + phenotype with more severe glaucoma occurring at a relatively younger age, are some novel findings of the present study. In the clinical setting correlation of patient demographics with these IVCM findings may help in better long-term prognostication of eyes with ICE syndrome.

Haemostatic functions and metabolic profile of subclinical hypothyroid and hypothyroid patients

Objectives: Both hypercoagulable and hypocoagulable states have been proposed for hypothyroidism, whether in overt or subclinical spectrum. The status of haemostatic functions, metabolic profile and their relationship in hypothyroid disorders need to be evaluated.Methods and Material: This prospective case control study was undertaken in 30- 50 years old female subclinical and hypothyroid patients. Haemostatic functions like bleeding time (BT), clotting time (CT), prothrombin time (PT), activated partial thromboplastin time (APTT), platelet count and metabolic parameters like plasma glucose and lipid levels and clinical variables like blood pressure and body mass index were noted and compared. In addition the strength of correlation of TSH, T4, T3, lipid profile with the haemostatic functions was evaluated.Results: Both groups of patients were obese, normotensive with normal haemostatic parameters. The platelet count correlated with TSH in subclinical hypothyroid patients and with T4 levels in hypothyroid patients. Although within normal range, total cholesterol and LDL cholesterol levels were higher and postprandial plasma glucose (PPPG) levels lower in hypothyroid patients compared to subclinical hypothyroid patients. A positive correlation was seen between TSH and LDL, PPPG levels, between fT3 and BMI, and also of antiTPO with total cholesterol, LDL, Fasting plasma glucose (FPG) in hypothyroid patients. The BMI was negatively associated with fT3 levels in subclinical hypothyroid patients.Conclusion: This study found normal haemostatic and metabolic functions in both subclinical and hypothyroid patients. Although within normal range, hypothyroid patients had higher total and LDL cholesterol. TSH and antiTPO levels correlated with LDL levels in these patients. Correlation of platelet count with TSH in subclinical hypothyroid and T4 levels in hypothyroid patients advocate a difference in mechanism involved. Therefore it can be connoted that thyroid status influences metabolic profile, and platelet count.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.532-536

Development of immunodetection system for botulinum neurotoxin serotype E

Background & objectives

Botulism, a potentially fatal paralytic illness, is caused by the botulinum neurotoxins (BoNTs) secreted by Clostridium botulinum. It is an obligate anaerobic, Gram-positive, spore-forming bacterium. BoNTs are classified into seven serotypes based on the serological properties. Among these seven serotypes, A, B, E and, rarely, F are responsible for human botulism. The present study was undertaken to develop an enzyme-linked immunosorbent assay (ELISA)-based detection system for the detection of BoNT/E.

Methods

The synthetic gene coding the light chain of BoNT serotype E (BoNT/E LC) was constructed using the polymerase chain reaction primer overlapping method, cloned into pQE30UA vector and then transformed into Escherichia coli M15 host cells. Recombinant protein expression was optimized using different concentrations of isopropyl-β-D-1-thiogalactopyranoside (IPTG), different temperature and the rBoNT/E LC protein was purified in native conditions using affinity column chromatography. The purified recombinant protein was checked by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and further confirmed by western blot and matrix-assisted laser desorption ionization-tandem time-of-flight (MALDI-TOF). Polyclonal antibodies were generated against rBoNT/E LC using Freund's adjuvant in BALB/c mice and rabbit. Sandwich ELISA was optimized for the detection of rBoNT/E LC and native crude BoNT/E, and food matrix interference was tested. The developed antibodies were further evaluated for their specificity/cross-reactivity with BoNT serotypes and other bacterial toxins.

Results

BoNT/E LC was successfully cloned, and the maximum expression was achieved in 16 h of post-induction using 0.5 mM IPTG concentration at 25°C. Polyclonal antibodies were generated in BALB/c mice and rabbit and the antibody titre was raised up to 128,000 after the 2^nd booster dose. The developed polyclonal antibodies were highly specific and sensitive with a detection limit about 50 ng/ml for rBoNT/E LC and 2.5×10^[3] MLD₅₀ of native crude BoNT/E at a dilution of 1:3000 of mouse (capturing) and rabbit (revealing) antibodies. Further, different liquid, semisolid and solid food matrices were tested, and rBoNT/E LC was detected in almost all food samples, but different levels of interference were detected in different food matrices.

Interpretation & conclusions

There is no immune detection system available commercially in India to detect botulism. The developed system might be useful for the detection of botulinum toxin in food and clinical samples. Further work is in progress.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients

INTRODUCTION

Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

METHODS

This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups.

RESULTS

In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73-1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79-1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71-1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000).

CONCLUSION

This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Sonography in diagnosis of adhesive capsulitis of the shoulder: a case-control study

PURPOSE

Adhesive capsulitis (AC) of the shoulder has been a diagnosis of exclusion on sonography due to lack of specific diagnostic criteria. This study prospectively assesses the efficacy of sonography using multiple static and dynamic parameters for diagnosis of AC.

MATERIALS AND METHODS

Shoulder sonography was performed independently by two musculoskeletal radiologists on 90 subjects (60 symptomatic and 30 controls). All symptomatic subjects were subjected to an MRI. Based on clinical and MRI diagnosis, three groups were made: AC (n = 30), painful shoulders (PS) (n = 30), and control group (CL) (n = 30). The sonographic parameters studied were: coracohumeral ligament (CHL) thickness, increased soft tissue in rotator interval (static parameters) and restriction of abduction and external rotation on dynamic scanning. These were compared within the three groups and the accuracy of each parameter in isolation and in combination for diagnosis of AC was calculated.

RESULTS

Sonographic visualisation of CHL (96.7%) and its mean thickness (1.2 mm) were highest in the AC group (p < 0.01). A cut-off value of 0.7 mm was found to be accurate (sensitivity 93.1%, specificity 94.4%) for diagnosing AC. Increased soft tissue in the rotator interval was seen in the AC group and had a high sensitivity of 86.2% and specificity of 92.8%. On dynamic scanning, restriction of external rotation was specific (sensitivity 86.2%, specificity 92.8%), whereas restriction in abduction was non-specific (specificity 6.7%). Inter-observer agreement was substantial for CHL visualisation (kappa 0.66). Overall, sonography, using multiple parameters, revealed a high sensitivity and specificity (100 and 87%, respectively) for diagnosis of AC of the shoulder.

CONCLUSION

Sonography revealed a high accuracy for diagnosing AC of the shoulder and in differentiating it from other causes of painful shoulder. It, thus, has the potential to be adopted as a preferred imaging modality.

Uncertainty in the response of terrestrial carbon sink to environmental drivers undermines carbon-climate feedback predictions

Terrestrial ecosystems play a vital role in regulating the accumulation of carbon (C) in the atmosphere. Understanding the factors controlling land C uptake is critical for reducing uncertainties in projections of future climate. The relative importance of changing climate, rising atmospheric CO2, and other factors, however, remains unclear despite decades of research. Here, we use an ensemble of land models to show that models disagree on the primary driver of cumulative C uptake for 85% of vegetated land area. Disagreement is largest in model sensitivity to rising atmospheric CO2 which shows almost twice the variability in cumulative land uptake since 1901 (1 s.d. of 212.8 PgC vs. 138.5 PgC, respectively). We find that variability in CO2 and temperature sensitivity is attributable, in part, to their compensatory effects on C uptake, whereby comparable estimates of C uptake can arise by invoking different sensitivities to key environmental conditions. Conversely, divergent estimates of C uptake can occur despite being based on the same environmental sensitivities. Together, these findings imply an important limitation to the predictability of C cycling and climate under unprecedented environmental conditions. We suggest that the carbon modeling community prioritize a probabilistic multi-model approach to generate more robust C cycle projections.

Oxidized Hemoglobin Is Antigenic and Immunogenic in Lupus

Hemolysis-associated anemia is characteristic of diseases such as atherosclerosis, lupus, malaria, and leishmaniasis; the toxic effects of free hemoglobin (Hb) have been extensively described. This study was based on the premise that release of this sequestered, inflammatory molecule can result in deleterious immunological consequences, particularly in the context of pre-existing lupus. IgG anti-Hb responses were detected in the sera of lupus patients. Lupus-prone mice exhibited heightened plasma Hb levels, and ferric (Fe³⁺) Hb triggered preferential release of lupus-associated cytokines from splenocytes derived from aging lupus-prone mice. Anti-Hb B cell precursor frequencies were heightened in such mice, which also expressed increased titers of anti-Hb antibodies in serum and in kidney eluates. Fe³⁺ Hb preferentially increased the functional maturation of bone marrow-derived dendritic cells (BMDCs) from lupus-prone mice, effects abrogated upon the inhibition of Stat3. Hb interacted with lupus-associated autoantigens extruded during apoptosis and coincubation of Hb and apoptotic blebs had additional maturation-inducing effects on lupus BMDCs. Immunization with Hb in lupus-prone mice induced antigen spreading to lupus-associated moieties; Hb-interacting autoantigens were preferentially targeted and increased complement deposition and glomerulosclerosis were observed. Hb therefore demonstrates both antigenicity and immunogenicity and triggers specific immuno-pathological effects in a lupus milieu.

The Demographic Study of Otorhinolaryngological Trauma Among Patients with Head and Neck Trauma and Their Management in a Tertiary Care Centre

The trauma has been increasing in frequency, especially in recent decades because of the higher number of automobile accidents and violence. The ear, nose and face region is the area in the body that is commonly involved in head and neck injury. Trauma to this region is often associated with mortality and varying degree of physical, functional and psychological damage. To study the demography, aetiology, clinical presentation, outcome of ENT trauma in our tertiary care centre and to compare our study with previous studies to see the changing trends with passage of time. A prospective study was conducted on 200 head and neck patients with ENT injuries during a period of 1 year from July 2014 to July 2015, who were admitted in ENT Department and Trauma Centre of Gajra Raja Medical College and J.A. Group of Hospital, Gwalior. Most of the patients were young adult males of age group 18-40 years (45, 22.5%) with a male:female ratio 1.78:1. Among them 53% patients were from rural area while 47% were from urban area. RTA is the most prevalent cause of ENT trauma (37%), followed by interpersonal violence (25%). 27% of the patients had facial injury and multiple region injury each. Among 200 patients 33% were managed conservatively on the other hand 66% patients required surgical interventions. Mortality rate was 8%. Among all 184 survivors 25.5% suffered from hearing loss, 14.5% had tympanic membrane perforation with hearing loss, 12% had pinna disfigurement, 10% had change in voice, 6.5% had permanent nasal deformity, 2% had facial nerve palsy. Young male adults were the most prevalent victims of ENT trauma, and Road traffic accidents were responsible for majority of the ENT injuries. Screening of all the patients with head and neck injuries for the presence of trauma in the ENT region should be introduced to enable early detection and therefore prevention of complications.

In-Vivo Neutralization of Botulinum Neurotoxin Serotype E Using Rabbit Polyclonal Antibody Developed against BoNT/E Light Chain

BACKGROUND

Clostridium botulinum is an obligate anaerobic, Gram positive bacterium that secretes extremely toxic substances known as botulinum neurotoxins (BoNTs) that cause serious paralytic illness called botulism. Based upon the serological properties, these neurotoxin have been classified into seven serotypes designated from A to G. Due to extreme toxicity of BoNTs, these neurotoxins have been designated as category A biowarfare agents. There is no commercial neutralizing antibody available for the treatment of botulism. Hence there is an urgent need to develop therapeutic intervention for prevention and cure of botulism within short period. BoNT antiserum injection is still the effective treatment.

METHOD

In the present study, the recombinant light chain of BoNT/E was successfully purified in soluble form. The purified rBoNT/E LC was used for the generation of polyclonal antibody in rabbit. In order to find out the neutralizing capacity of generated antisera, rabbit antiserum was incubated with 20 LD50 of botulinum neurotoxin type E for 1 hour at 37°C and then injected intraperitoneally (IP) into mice. Further in another set of experiments antiserum was administered in different ways that included administration of - antiserum and BoNT/E toxin simultaneously without preincubation, one after another at the same and different time points for its therapeutic ability. To find out cross neutralization capacity, rBoNT/E LC antiserum was pre-incubated with 5 LD50 of BoNT/A, BoNT/B, BoNT/F and then injected (IP) into mice. In all the cases mice were observed continuously for 96 hours.

RESULT

The results clearly indicate that developed polyclonal rabbit antiserum showed serotype specific neutralization of BoNT/E toxin only but not of BoNT/A, BoNT/B and BoNT/F.

CONCLUSION

The developed antibodies will be used for preventive and therapeutic intervention of type 'E' botulism.

Black brown discoloration and hairy tongue - A rare linezolid side effect

INTRODUCTION

Linezolid was approved for clinical use for methicillin resistant Staphylococcus aureus and vancomycin-resistant Enterococci. Additionally it is used in the management of drug resistant tuberculosis. It is well-tolerated however bone marrow suppression and neuropathies may occur in patients taking this antibiotic for more than 2 weeks. Black discoloration and black hairy tongue (BHT) due to linezolid is rarely reported. We report two cases of BHT.

CASE REPORTS

Two patients of drug resistant pulmonary tuberculosis developed benign hairy tongue with linezolid 600mg per day. In both the cases black colored/hairy tongue was reported within 2-3 weeks of linezolid treatment. Both patients improved after withdrawal of linezolid. Subsequent reintroduction of linezolid with good oral hygiene was well tolerated and both patients completed the treatment of 2 years duration without any recurrence.

CONCLUSION

Black discoloration and BHT is a rare but transient adverse reaction with linezolid. Reintroduction of linezolid with good oral hygiene is well tolerated.

Solitary rectal ulcer syndrome: clinical, endoscopic, histological and anorectal manometry findings in north Indian patients

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is a chronic, benign defecation disorder often related to excessive straining. SRUS is diagnosed on the basis of clinical symptoms, endoscopic and histological findings.

METHODS

All patients diagnosed with SRUS by colonoscopy and confirmed by histopathology from October 2012 to August 2014 in the Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, India, were included in the study. Out of 92 patients, thirty-four patients underwent anorectal manometry. Twenty age-matched healthy volunteers were also studied with anorectal manometry to serve as controls.

RESULTS

Mean age of the group was 41 ± 19 years with age range of 10-82 years; males were 58 (63%) with male to female ratio of 1.7:1. Bleeding per rectum was present in 83%, constipation in 46.7%, abdominal pain in 27.2%, and diarrhea in 25% of the patients. On endoscopy, ulcerative lesions were seen in 83% patients of whom solitary and multiple lesions were present in 44% and 39%, respectively. Polypoidal lesions were reported in 17.4% whilst rectal polyps and erythematous mucosa were found in 5.4% and 2.2%, respectively. Histological examination revealed fibromuscular obliteration in 100% of patients, surface ulceration in 70.6% and crypt distortion in 20.65% of patients. Anal relaxation and balloon expulsion test was significantly abnormal in SRUS patients compared to healthy controls (53% vs. 20%, p < 0.01).

CONCLUSION

Rectal bleeding was the most common symptom and ulcerative lesions the most common endoscopic finding. Fecal evaluation disorder was more prevalent inpatients with SRUS.

Les styles cognitifs des consommateurs

La première partie de cet article présente le concept de style cognitif à partir de nombreux travaux sur le sujet. Les auteurs s'attachent plus particulièrement à l'analyse de la complexité cognitive dont ils étudient les diverses dimensions (différenciation, discrimination, intégration) et le niveau de généralité: les individus dits «complexes» au niveau cognitif le sont-ils dans toutes les situations auxquelles ils sont confrontés? La seconde partie de l'article traite de l' «accommodation» cognitive, c'est-à-dire de la façon dont les individus règlent et contrôlent les informations venant de l'environnement. Le concept de tolérance à l'ambiguïté est au centre de ces analyses. La conclusion porte sur une comparaison des apports respectifs des concepts de «style cognitif» et de «style de vie».

Higher Order Aberrations and Visual Outcomes in Wavefront-Optimized Sub-Bowman Keratomileusis: Flap Creation Using Femtosecond Laser Versus Mechanical Microkeratome

PURPOSE

The aim of this study was to compare the outcomes of wavefront-optimized sub-Bowman keratomileusis (SBK) performed using the 150 KHz IntraLase femtosecond (IFS) laser (Abbot Medical Optics) with those using the Moria Evo 3 One Use-Plus SBK mechanical microkeratome (Moria SA).

DESIGN

A prospective comparative clinical trial.

METHODS

Fifty patients had bilateral wavefront-optimized SBK performed for myopia or myopic astigmatism. In 25 patients, the flap was created with the 150 KHz IFS laser (group 1) and in the other 25 with the Moria One Use-Plus SBK mechanical microkeratome (group 2). All other treatment parameters were the same. Results were reported for 1 eye per patient in each group (ie, 25 eyes in each group).

RESULTS

Efficacy, refractive stability, predictability, and safety profiles were comparable between the 2 groups. Although higher order aberrations (HOAs) increased significantly in both groups after laser in situ keratomileusis, intergroup comparison revealed that group 1 was associated with a significantly higher induction of both total HOAs [mean root mean square (RMS), 0.63 ± 0.20 in group 1 vs 0.52 ± 0.14 in group 2; P = 0.031] and spherical aberrations (RMS, 0.37 ± 0.17 in group 1 vs 0.22 ± 0.09 in group 2; P < 0.001) as compared with group 2.

CONCLUSIONS

Flaps created using the Moria Evo 3 One Use-Plus SBK mechanical microkeratome were associated with significantly lower induction of total HOAs and spherical aberrations as compared with 150 KHz IFS flaps at the end of 3 months follow-up.

Correlation of age and hepatitis B virus DNA levels with histological activity in HBeAg negative chronic hepatitis B patients

BACKGROUND

The relationship between age and serum HBV DNA levels with histological activity in chronic hepatitis B inactive carriers is still unclear. We evaluated the correlation between age and hepatitis B viral DNA levels with Metavir score in inactive chronic HBV carriers.

METHODS

50 patients (30 males and 20 females) were enrolled in the study after informed consent. Their blood samples were taken for routine investigations and specific tests for the study. Serum HBV DNA levels were quantified by real-time PCR. Metavir score was used for histologic grading.

RESULTS

A1F0, A1F1, A1F2, A2F2 and A2F3 metavir scores were found in 41 (82%), 4 (8%), 1 (2%), 3 (6%), and 1 (2%) patients, respectively. There was significant correlation between age > 40 years and Metavir scores (p < 0.001). However there was no significant correlation between HBV DNA level with Metavir score (p = 0.074).

CONCLUSION

Inactive carriers of 40 years of age or more should undergo liver biopsy to look for presence of significant histological findings despite having low HBV DNA level and normal SGPT level.

Structural and functional analysis of chitinase gene family in wheat (Triticum aestivum)

Chitinases are the hydrolytic enzymes which protect plants against pathogen attack. However, the precise role of chitinases in disease resistance has not been explored in wheat. In the present study, in silico approach, including secondary structure analysis, detailed signature pattern study, cis-acting regulatory elements survey, evolutionary trends and three-dimensional molecular modeling was used for different chitinase classes of wheat (Triticum aestivum). Homology modeling of class I, II, IV and 3 chitinase proteins was performed using the template crystal structure. The model structures were further refined by molecular mechanics methods using different tools, such as Procheck, ProSA and Verify3D. Secondary structure studies revealed greater percentage of residues forming a helix conformation with specific signature pattern, similar to casein kinase II phosphorylation site, amidation site, N-myristoylation (N-MYR) site and protein kinase C phoshorylation site. The expression profile suggested that wheat chitinase gene was highly expressed in cell culture and callus. We found that wheat chitinases showed more functional similarity with rice and barley. The results provide insight into the evolution of the chitinase family, constituting a diverse array of pathogenesis-related proteins. The study also provides insight into the possible binding sites of chitinase proteins and may further enhance our knowledge of fungal resistance mechanism in plants.

Nano-level monitoring of Mn(2+) ion by fabrication of coated pyrolytic graphite electrode based on isonicotinohydrazide derivatives

The two ionophores N'(N',N‴E,N',N‴E)-N',N‴-((((oxybis(ethane-2,1-diyl))bis(oxy)) bis(2,1-phenylene))bis(methanylylidene))di(isonicotinohydrazide) (I1) and (N',N‴E,N',N‴E)-N',N‴-(((propane-1,3-diylbis(oxy))bis(2,1-phenylene))bis(methanylylidene))di(isonicotinohydrazide) (I2) were synthesised and investigated as neutral carrier in the fabrication of Mn(2+) ion selective sensor. Several membranes were prepared by incorporating different plasticizers and anionic excluders and their effect on potentiometric response was studied. The best analytical performance was obtained with the electrode having a membrane of composition of I2: PVC: o-NPOE: NaTPB in the ratio of 6:34:58:2 (w/w, mg). Comparative studies of coated graphite electrode (CGE) and coated pyrolytic graphite electrode (CPGE) based on I2 reveal the superiority of CPGE. The CPGE exhibits wide working concentration range of 1.23×10(-8)-1.0×10(-1) mol L(-1) and a detection limit down to 4.78×10(-9) mol L(-1) with a Nernstian slope of 29.5±0.4 mV decade(-1) of activity. The sensor performs satisfactorily over a wide pH range (3.5-9.0) and exhibited a quick response time (9s). The sensor can work satisfactorily in water-acetonitrile and water-methanol mixtures. It can tolerate 30% acetonitrile and 20% methanol content in the mixtures. The sensor could be used for a period of four months without any significant divergence in performance. The sensor reflects its utility in the quantification of Mn(2+) ion in real samples and has been successfully employed as an indicator electrode in the potentiometric titration of Mn(2+) ion with ethylenediaminetetraacetic acid (EDTA).

Screening of some weeds for larvicidal activity against Aedes albopictus, a vector of dengue and chikungunya

BACKGROUND & OBJECTIVES

Screening of crude extracts of plants facilitates the establishment of highly effective extract for mosquito control. This practice should be preferred before in depth study of plant extracts rather than spending much efforts and energy in detailed examinations for practically ineffective extracts. In this study, leaf powders of four weed plants were used for the quick screening of effective plant extract as larvicide against III instar larvae of Aedes albopictus Skuse. At the same time, effect of different seasons on the larvicidal efficacy of plants and selection of proper solvents for further investigation were also studied.

METHODS

Leaves of Vernonia cinerea, Prosopis juliflora, Hyptis suaveolens and Malvastrum coromandelianum plants were collected in summer, winter and rainy seasons from Madhya Pradesh region (India). To assess the larvicidal efficacy the suspensions of leaf powders in different solvents (isopropanol, methanol, acetone, dimethylsulfoxide and water) were used for larvicidal bioassay. The mortality counts were made after 24 h and the LC50 and LC90 values were calculated.

RESULTS

Results showed that leaf powder of V. cinerea in acetone collected during summer showed highest efficacy with LC50 value of 0.22 g/l and LC90 of 0.96 g/l followed by methanolic solution of P. juliflora with LC50 of 0.44 g/l and LC90 value as 1.85 g/l. Amongst all solvents, leaf powder in acetone; while among seasons, summer collected plant materials were found to be more effective larvicides as compared to others.

INTERPRETATION & CONCLUSION

Summer and winter collected leaves of V. cinerea and P. juliflora dissolved in the solvents of medium polarity range showed significant larval toxicity and thus suggests a detailed study on these plants as potential larval control agents.

Does a 'direct' transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study

OBJECTIVE

National guidelines recommend 'early' coronary angiography within 96 h of presentation for patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Most patients with NSTE-ACS present to their district general hospital (DGH), and await transfer to the regional cardiac centre for angiography. This care model has inherent time delays, and delivery of timely angiography is problematic. The objective of this study was to assess a novel clinical care pathway for the management of NSTE-ACS, known locally as the Heart Attack Centre-Extension or HAC-X, designed to rapidly identify patients with NSTE-ACS while in DGH emergency departments (ED) and facilitate transfer to the regional interventional centre for 'early' coronary angiography.

METHODS

This was an observational study of 702 patients divided into two groups; 391 patients treated before the instigation of the HAC-X pathway (Pre-HAC-X), and 311 patients treated via the novel pathway (Post-HAC-X). Our primary study end point was time from ED admission to coronary angiography. We also assessed the length of hospital stay.

RESULTS

Median time from ED admission to coronary angiography was 7.2 (IQR 5.1-10.2) days pre-HAC-X compared to 1.0 (IQR 0.7-2.0) day post-HAC-X (p<0.001). Median length of hospital stay was 3.0 (IQR 2.0-6.0) days post-HAC-X v 9.0 (IQR 6.0-14.0) days pre-HAC-X (p<0.0005). This equates to a reduction of six hospital bed days per NSTE-ACS admission.

CONCLUSIONS

The introduction of this novel care pathway was associated with significant reductions in time to angiography and in total hospital bed occupancy for patients with NSTE-ACS.

Acute inhalation toxicity of smoke of fentanyl and its 1-substituted analogs in Swiss albino mice

Fentanyl (N-(1-phenethyl-4-piperidinyl)propionanilide) is a synthetic, potent narcotic analgesic agent. However, it is known to have several side effects, which led to synthesis and evaluation of its new analogs for the management of pain. We have earlier reported the comparative bioassay of fentanyl and its eight 1-substituted analogs (1-8) in mice. Three compounds, viz., N-(1-(2-phenoxyethyl)-4-piperidinyl)propionanilide (2), N-isopropyl-3-(4-(N-phenylpropionamido)piperidin-1-yl)propanamide (5), and N-t-butyl-3-(4-(N-phenylpropionamido)piperidin-1-yl)propanamide (6) were found to be more effective and less toxic compared to fentanyl. The present study reports the comparative acute inhalation toxicity of smoke of fentanyl and its three analogs, viz., 2, 5, and 6 in mice. Animals were exposed to different concentrations of smoke generated by heating the compounds. Exposure was performed in a head only all glass static exposure assembly for 15 min to determine the median lethal concentration (LC50). The breathing pattern and various respiratory parameters of the animals were also monitored online using a polygraph. Out of three compounds tested, analog 5 was found to be most toxic (LC50 = 2820 mg/m3) while 2 was least toxic (LC50 = >8000 mg/m3). All the compounds caused long lasting respiratory depression in a dose-dependent manner, which did not completely resolve even after discontinuation of exposure. Aerodynamic median diameter and geometric standard deviation of smoke particles was determined employing eight-stage Andersen sampler. The particles were found to be within the respirable range. The study, however, concludes that due to possible decomposition of the compounds by heating or its poor absorption by the alveolar surface, the present inhalation technique cannot be employed to generate smoke of fentanyl and its analogs for any medical or surreptitious use.