Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

RLSuite: An Integrative R-Loop Bioinformatics Framework

We recently described the development of a database of 810 R-loop mapping datasets and used this data to conduct a meta-analysis of R-loops. R-loops are three-stranded nucleic acid structures containing RNA:DNA hybrids and we were able to verify that 30% of expressed genes have an associated R-loop in a location conserved manner.. Moreover, intergenic R-loops map to enhancers, super enhancers and with TAD domain boundaries. This work demonstrated that R-loop mapping via high-throughput sequencing can reveal novel insight into R-loop biology, however the analysis and quality control of these data is a non-trivial task for which few bioinformatic tools exist. Herein we describe RLSuite, an integrative R-loop bioinformatics framework for pre-processing, quality control, and downstream analysis of R-loop mapping data. RLSuite enables users to compare their data to hundreds of public datasets and generate a user-friendly analysis report for sharing with non-bioinformatician colleagues. Taken together, RLSuite is a novel analysis framework that should greatly benefit the emerging R-loop bioinformatics community in a rapidly expanding aspect of epigenetic control that is still poorly understood.

IGF-1 stabilizes goat sperm mitochondrial transmembrane potential and reduces dna fragmentation

BACKGROUND

Antioxidant present in sperm cells protects them from oxidative damage. However, sperm are more susceptible to peroxidative damages due to the loss of these enzymes during cryopreservation and their survival and fertility may be compromised. Insulin like growth factor-1 (IGF-1) has an antioxidant effect and could maintain sperm motility.

OBJECTIVE

To improve seminal parameters, mitochondrial membrane potential (MMP), oxidative status and DNA integrity of buck semen after freeze-thawing by fortification of goat semen diluent with various concentrations of IGF-1.

MATERIALS AND METHODS

Fifty ejaculates were collected and were extended with tris- citric acid- fructose diluent with 10% egg yolk and 6% glycerol with sperm concentrations of 1×108 mL-1. Post-cryopreserved sperm were assessed for motility and a range of other functional parameters.

RESULTS

In post-thaw semen sperm motility, live sperm count, acrosome integrity, hypo-osmotic swelling positive spermatozoa, malondialdehyde (MDA), protein carbonyl content (PCC), TUNEL positive sperm differed significantly (P<0.05) with the various concentrations of IGF-1 used. Sperm functional parameters post-thawing were significantly (P<0.05) better in 250 ng/mL IGF-1. IGF-1 protects against lipid peroxidation by lowering MDA and PCC production, thus reducing the harmful effect of reactive oxygen species. The kidding percentage using the artificial insemination technique was significantly higher ( i.e., 40%) in the group supplemented with 250 ng/mL of IGF-1 than in the non-supplemented group (i.e., 30%).

CONCLUSION

IGF-1 may be used to improve post-thaw semen quality and fertility as measured by actual kidding rate. Doi.org/10.54680/fr23610110312.

Cardio-oncology in China

OPINION STATEMENT

Cardio-oncology is going under rapid development in various areas across an increasing number of provinces in China. However there are still a myriad of challenges that need to be overcome in order to ensure its gradual and consistent expansion. The Cardio-Oncology Knowledge Transfer Model (KTM) forms the basis to allow exponential development of effective cardio-oncology services. This would ensure the implementation of precision-based practice while dynamically evolving cardio-oncology to integrate both Western and Chinese medical practices to become an official clinical sub-speciality in its own right in China, for the ultimate benefit of the patient.

NEUROPLASTICITY AND BRAIN STIMULATION: DEVELOPING INTERVENTIONS TO PROMOTE RECOVERY FROM STROKE AND TRAUMATIC BRAIN INJURY

This article's purpose is to explore how "non-invasive brain stimulation" (NBS) can be used to treat "traumatic brain injury" (TBI) and promote neuroplasticity. Along with the pathophysiological processes that occur after a TBI, "transcranial direct current stimulation" (tDCS) and "transcranial magnetic stimulation" (TMS) are described. These processes are based on a study of the relevant literature. Individualized treatment plans are required because the pathophysiological processes that result from TBI change over time. Given their neurophysiological effects, TMS and tDCS may be used to (a) significant suppression of post-traumatic cerebral hyper excitability; (b) control synaptic plasticity over the long run to prevent unfavorable outcomes; and (c) in addition to other forms of treatment such as physical and behavioral, assist some neural networks to reorganize and consolidate their learning. These treatments have the potential to reduce the disabling symptoms of brain injury.Animal and human research show that NBS may help reduce the severity of injuries and increase plastic changes in lesioned brain tissue, both of which are necessary for the successful acquisition of new knowledge and the restoration of lost functions. However, at present, this evidence is mostly speculative. The relevance of NBS in TBI, further elucidating its therapeutic benefits, and defining appropriate stimulation levels all need investigations in TBI patients due to safety concerns.

Optically detected magnetic resonance spectroscopic analyses on the role of magnetic ions in colloidal nanocrystals

Incorporating magnetic ions into semiconductor nanocrystals has emerged as a prominent research field for manipulating spin-related properties. The magnetic ions within the host semiconductor experience spin-exchange interactions with photogenerated carriers and are often involved in the recombination routes, stimulating special magneto-optical effects. The current account presents a comparative study, emphasizing the impact of engineering nanostructures and selecting magnetic ions in shaping carrier-magnetic ion interactions. Various host materials, including the II-VI group, halide perovskites, and I-III-VI2 in diverse structural configurations such as core/shell quantum dots, seeded nanorods, and nanoplatelets, incorporated with magnetic ions such as Mn2+, Ni2+, and Cu1+/2+ are highlighted. These materials have recently been investigated by us using state-of-the-art steady-state and transient optically detected magnetic resonance (ODMR) spectroscopy to explore individual spin-dynamics between the photogenerated carriers and magnetic ions and their dependence on morphology, location, crystal composition, and type of the magnetic ion. The information extracted from the analyses of the ODMR spectra in those studies exposes fundamental physical parameters, such as g-factors, exchange coupling constants, and hyperfine interactions, together providing insights into the nature of the carrier (electron, hole, dopant), its local surroundings (isotropic/anisotropic), and spin dynamics. The findings illuminate the importance of ODMR spectroscopy in advancing our understanding of the role of magnetic ions in semiconductor nanocrystals and offer valuable knowledge for designing magnetic materials intended for various spin-related technologies.

Glucose-6-phosphate dehydrogenase deficiency with coinherited Gaucher disease: A rare association

ABSTRACT

Anemia coexisting with Gaucher disease (GD) is often associated with non-hemolytic processes. Few cases of GD with autoimmune hemolytic anemia have been reported. However, literature on GD with concomitant nonimmune hemolytic anemia is scarce. A 1-year 6-month-old male child presented in 2018 with complaints of palpable mass in left upper abdomen, fever, cough, and vomiting. On examination, he had pallor, hepatosplenomegaly of 2 cm and 8 cm below costal margin, respectively. A clinical diagnosis of hemolytic anemia was suspected. Complete blood count revealed Hb---6.7 g/dL, TLC---8.9 × 103/mL, platelet count---180 × 103/mL. Peripheral smear showed predominantly microcytic hypochromic anemia with moderate degree of anisocytosis, many nucleated red blood cells, few schistocytes, polychromatophils and corrected reticulocyte count 7.89%. S. Bilirubin was 1.1 mg/dL. Hb high-performance liquid chromatography (HPLC) of the child and his parents was within normal limit. Hematological work up revealed negative results for direct Coombs' test, osmotic fragility test, and sickling test. Test for Glucose-6-phosphate dehydrogenase deficiency was positive (39 units/trillion RBC, normal 146--376). He was transfused intermittently and given steroids to manage his anemia. He was on regular follow up during which his blood counts revealed persistent anemia and thrombocytopenia. In view of this, bone marrow was performed to exclude myelofibrosis. Aspirate smears were cellular and showed normoblastic erythroid hyperplasia. Numerous large histiocytes with basophilic fibrillary cytoplasm exhibiting "crumpled tissue paper" appearance were seen. Similar findings were seen on bone marrow trephine biopsy. Genetic testing revealed pathogenic variations in the GBA gene. Beta glucosidase enzyme levels were low while chitotriosidase was raised (1109.19 nmol/hr/mL). A final diagnosis of G6PD with GD was made. The present study shows rare association of GD with Glucose-6-phosphate dehydrogenase deficiency.

THE MICROBIOME AND METABOLIC DISORDERS: THE LINK BETWEEN THE GUT MICROBIOTA AND METABOLIC SYNDROME

The diverse population of microbes that live in our digestive system, known as the gut microbiota, remains essential for many physiological processes. It plays a role in obtaining energy from food and controls both regional and overall immunity. In addition, changes in the microbiota of the digestive tract are connected to the emergence of an extensive variety of illnesses, such as cancer, gastrointestinal problems, and metabolic disorders. From a metabolic perspective, the gut microbiota can affect processes like lipid accumulation, lipopolysaccharide satisfied, and short-chain fatty acid synthesis, all of which have an effect on food intake, inflammatory reactions, and insulin signaling. Prebiotics, probiotics, specialized anti-diabetic medications, and faecalmicrobiota implantation are a few of the ways that have been discovered to alter the gut microbiota; each has a different influence the human body's metabolism and the emergence of metabolic disorders. These therapies have been reported to be therapeutic strategies for enhancing general wellness and reestablishing a balanced gut flora.

Colloidal Control of Branching in Metal Chalcogenide Semiconductor Nanostructures

Colloidal syntheses of metal chalcogenides yield nanostructures of various 1D, 2D, and 3D nanocrystals (NCs), including branched nanostructures (BNSs) of nanoflowers, tetrapods, octopods, nanourchins, and more. Efforts are continuously being made to understand the branching mechanism in colloidally prepared metal chalcogenides for tailor-making them into various morphologies for dedicated applications in solar cells, light-emitting diodes, stress sensor devices, and near-infrared photodetectors. The vital role of precursors and ligands has widely been recognized in directing nanocrystal morphology during the colloidal synthesis of metal chalcogenide nanostructures. Moreover, a few basic branching mechanisms in nanocrystals have also been derived from decades-long observations of branching in NCs. This Perspective (a) accounts for the mediation of branching in In₂S₃, PbS, MoSe₂, WSe_2, and WS₂; (b) analyzes the underlying mechanisms; and (c) gives a future perspective toward better controlling the BNSs' morphologies and their impact on applications.

Study of growth differentiation factor-15 in polytransfused children with β-thalassemia

Background

Ineffective erythropoiesis is a predominant feature in β-thalassemia major (β-TM), causing marked erythroid expansion leading to highly raised levels of growth differentiation factor-15 (GDF-15), which, in turn, suppresses hepcidin production in liver resulting in increased iron absorption from gut. We aim to study the serum GDF-15 in polytransfused β-TM patients and its correlation with serum ferritin and serum hepcidin.

Method

Thirty-nine polytransfused β-TM children aged between 5 and 17 years and 33 age- and gender-matched healthy controls were enrolled in the study. Complete blood count, serum GDF-15, serum ferritin, and serum hepcidin were performed.

Results

The mean serum GDF-15, serum hepcidin, and serum ferritin levels were 638.65 ± 306.96 pg/ml, 108.21 ± 191.30 ng/ml, and 2274.60 ± 1216.08 ng/ml, respectively, which were significantly higher than control group (P < 0.001, P = 0.003, P < 0.001, respectively). There was significant positive correlation of GDF-15 with blood transfusions (r = 0.415, P = 0.009), positive correlation with serum ferritin (r = 0.653, P = 0), and significant negative correlation with serum hepcidin (r = -0.508, P = 0.001).

Conclusion

The findings of the present study suggest that GDF-15 is an important regulator of hepcidin in β-TM patients. GDF-15 and serum hepcidin together can be used to monitor iron overload and its related complications in such patients.

Hemophagocytic lymphohistiocytosis secondary to T-cell Acute Lymphoblastic Leukemia with membranous tonsillitis

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of excessive immune activation, which is characterized by fever, hepatosplenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, and/or hypofibrinogenemia, and evidence of hemophagocytosis. Secondary HLH is often seen in adults and categorized based on autoimmune, infections-related, and malignancy-associated etiologies such as A-HLH, I-HLH, and M-HLH, respectively. This study presented a rare case of HLH developing concurrently at the time of diagnosis of T-cell Acute Lymphoblastic Leukemia (T- ALL) with a unique presentation of membranous tonsillitis in a 10-year-old boy. In all of the cases of T-ALL reported in the pediatric age group, HLH develops post-therapy or at the relapse. The first presentation of leukemia as membranous tonsillitis and concurrent clinic laboratory findings of HLH is rare and can mislead the diagnosis. Therefore, prompt diagnosis is the mainstay of therapy and can considerably improve the prognosis.

Cardiac Safety in Breast Cancer Patients Receiving Pegylated Liposome Doxorubicin Sequential Anti-HER2 Monoclonal Antibody Therapy

Background: Cardiotoxicity associated with the sequential use of anthracyclines followed by trastuzumab is common in adjuvant therapy of patients with HER2-positive early breast cancer (eBC). However, the cardiac safety of trastuzumab concurrent with pegylated liposomal doxorubicin (PLD) is relatively less studied.

Method: Clinical data of patients with HER2-positive eBC treated with PLD and cyclophosphamide (PLD-C) followed by taxanes plus trastuzumab ± pertuzumab (TH or TPH) who then completed standard anti-HER2 treatment for 12 months from June 2012 to August 2021 were retrospectively collected. The primary endpoints were clinical and subclinical cardiotoxicity.

Result: In total, 70 eligible patients were enrolled. Among them, 55 patients (78.6%) received PLD-C → TH and 15 patients (21.4%) received PLD-C → TPH. The median follow-up time was 41.8 months. Until August 2021, only two patients had recurrent or metastatic diseases, with 2-year and 5-year disease-free survivals of 98.6% and 96.8%, respectively. Clinical cardiotoxicity occurred in six patients (8.6%), and all of them had an absolute decline of ≥16% from baseline left ventricular ejection fraction (LVEF) but not below the lower limit of normal (LLN = 50%). Subclinical cardiotoxicity events occurred in 17 patients (24.3%), and all of them had absolute declines of ≥10% and <16% from baseline LVEF but not below the LLN. No patients were interrupted from treatment, and all patients completed anti-HER2 treatment for 12 months. The sharpest decrease in LVEF was observed at 18 months after the start of PLD treatment. The cumulative incidences of clinical and subclinical cardiotoxicity were 9.8% and 28.3%, respectively. In the univariate analysis, body mass index, age, left chest wall radiotherapy, and ongoing cardiovascular risk factors were not significantly associated with clinical or subclinical cardiotoxicity (p > 0.05). No patients had congestive heart failure or death caused by PLD or anti-HER2 treatment.

Conclusion: The sequential use of PLD and trastuzumab showed a lower incidence of clinical cardiotoxicity, presented as asymptomatic decreased LVEF, compared with the results obtained in previous clinical studies using conventional anthracycline, taxanes and trastuzumab. The study regimen demonstrated good cardiac tolerance and is an alternative strategy for cardioprotection in patients with HER2-positive eBC.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Neurodegeneration and Neuroinflammation in Parkinson's Disease: a Self-Sustained Loop

Purpose of Review

Neuroinflammation plays a significant role in Parkinson’s disease (PD) etiology along with mitochondrial dysfunction and impaired proteostasis. In this context, mechanisms related to immune response can act as modifiers at different steps of the neurodegenerative process and justify the growing interest in anti-inflammatory agents as potential disease-modifying treatments in PD. The discovery of inherited gene mutations in PD has allowed researchers to develop cellular and animal models to study the mechanisms of the underlying biology, but the original cause of neuroinflammation in PD is still debated to date.

Recent Findings

Cell autonomous alterations in neuronal cells, including mitochondrial damage and protein aggregation, could play a role, but recent findings also highlighted the importance of intercellular communication at both local and systemic level. This has given rise to debate about the role of non-neuronal cells in PD and reignited intense research into the gut-brain axis and other non-neuronal interactions in the development of the disease. Whatever the original trigger of neuroinflammation in PD, what appears quite clear is that the aberrant activation of glial cells and other components of the immune system creates a vicious circle in which neurodegeneration and neuroinflammation nourish each other.

Summary

In this review, we will provide an up-to-date summary of the main cellular alterations underlying neuroinflammation in PD, including those induced by environmental factors (e.g. the gut microbiome) and those related to the genetic background of affected patients. Starting from the lesson provided by familial forms of PD, we will discuss pathophysiological mechanisms linked to inflammation that could also play a role in idiopathic forms. Finally, we will comment on the potential clinical translatability of immunobiomarkers identified in PD patient cohorts and provide an update on current therapeutic strategies aimed at overcoming or preventing inflammation in PD.

A study on clinical diagnosis of tuberculosis in free ranging and captive wild animals of India

Background

Tuberculosis (TB) is a disease of paramount importance at the wildlife-livestock-human interface.

Aims

To study the occurrence and Mycobacterium (M) species involved in the TB of free-ranging and captive wild animals in various Indian states.

Methods

A total of 396 clinical samples from 207 different wild animal species from various Indian national parks, zoological gardens, etc., were analyzed by lateral flow assay (LFA), Ziehl-Neelsen (ZN) staining, and PCR. Clinical samples include blood (n=156), faecal swabs (n=103), serum (n=73), and nasal swabs or trunk wash fluids (n=64).

Results

Clinical signs of TB were absent in 202 animals, although 21 wild animals were seropositive for pathogenic Mycobacterium antigens by LFA. Clinical signs like progressive weight loss, and respiratory distress were exhibited by 4 sloth bears (Melursus ursinus) and an elephant (Elephas maximus), which were also found positive for LFA, PCR, and ZN staining. ZN staining showed positivity for acid-fast bacilli (AFB) in 9 (8.74%) faecal and 9 (14.06%) nasal swabs or trunk wash fluids of sloth bears (7 samples) and elephants (2 samples). M. tuberculosis was detected in 7 sloth bears and 2 elephants, whereas M. bovis was found in a spotted deer (Axis axis) by species-specific PCR.

Conclusion

The circulation of TB organisms in wild animals warrants a strict surveillance programme to identify the carrier status of these animals so that effective TB control strategies can be formulated.

Endothelial Activation Markers in Polytransfused Children with Beta Thalassemia: Study from a Tertiary Care Centre in India

Beta thalassemia major is associated with a subclinical hypercoagulable state. Endothelial activation markers like soluble Intercellular adhesion molecule (sICAM-1) and E-selectin have been implicated in the pathogenesis of endothelial dysfunction and hemostatic alterations. In this study we aimed to study serum levels of sICAM-1 and E-selectin in polytransfused children with β thalassemia major and their association with serum ferritin and D-dimer levels. Sixty-two polytransfused β-thalassemia major children aged between 5 and 17 years and 26 age and gender matched healthy controls were enrolled in the study. Complete blood count with peripheral smear, liver function tests, serum ferritin, coagulation tests [PT, APTT, D-dimer] and endothelial activation marker tests [ICAM-1 and E-selectin] were performed. PT, APTT and D-dimer levels were significantly higher in beta-thalassemia major patients than in control group (p = 0.003, p < 0.001, p < 0.001 respectively). Mean ICAM-1 and E-selectin levels were 731.34 ± 343.97 ng/ml and 111.75 ± 40.13 ng/ml respectively which were significantly higher than control group (p < 0.001, p < 0.001 respectively). No significant correlation of ICAM-1 and E-selectin was observed with serum ferritin, PT, APTT and D-dimer levels. The findings of the present study suggest that there is ongoing subclinical activation of coagulation cascade and fibrinolytic system in these patients. Endothelial activation markers may be used as early indicators of endothelial dysfunction to assess the thrombotic complications in beta thalassemia.

Designing Natural Polymer-Based Capsules and Spheres for Biomedical Applications-A Review

Natural polymers, such as polysaccharides and polypeptides, are potential candidates to serve as carriers of biomedical cargo. Natural polymer-based carriers, having a core-shell structural configuration, offer ample scope for introducing multifunctional capabilities and enable the simultaneous encapsulation of cargo materials of different physical and chemical properties for their targeted delivery and sustained and stimuli-responsive release. On the other hand, carriers with a porous matrix structure offer larger surface area and lower density, in order to serve as potential platforms for cell culture and tissue regeneration. This review explores the designing of micro- and nano-metric core-shell capsules and porous spheres, based on various functions. Synthesis approaches, mechanisms of formation, general- and function-specific characteristics, challenges, and future perspectives are discussed. Recent advances in protein-based carriers with a porous matrix structure and different core-shell configurations are also presented in detail.

WAXD, polarized ATR-FTIR and DSC data of stress-annealed poly(3-hydroxybutyrate) fibers

This article summarizes synchrotron wide-angle x-ray diffraction (WAXD) patterns, polarized attenuated Fourier transform infrared spectroscopy (ATR-FTIR) data and differential scanning calorimetry (DSC) data of differently stress-annealed poly(3-hydroxybutyrate) (P3HB) fibers. Additionally, in-situ polarized ATR-FTIR data has been measured under tensile drawing of pre-annealed P3HB fibers under low annealing stress. Modifications to the ATR-FTIR setup and sample holders for performing measurements on P3HB fibers are explained in the experimental section. For more information see 'Reversible mesophase in stress-annealed poly(3-hydroxybutyrate) fibers: A synchrotron x-ray and polarized ATR-FTIR study' [1].

2D Raman, ATR-FTIR, WAXD, SAXS and DSC data of PET mono- and PET/PA6 bicomponent filaments

This data in brief article summarizes structural data obtained from monocomponent melt-spun and offline drawn poly(ethylene terephthalate) (PET) monofilaments, as well as from melt-spun bicomponent core-sheath PET-polyamide 6 (PA6) filaments. The diameters of the single filaments range from 27 µm to 79 µm. Presented analysis techniques and results thereof are (i) Raman mapping of filament cross-sections: 2D maps of peak positions, widths, peak area ratios; (ii) attenuated total reflection Fourier transform infrared spectroscopy (ATR-FTIR): ATR-FTIR spectra and extraction of surface crystallinity; (iii) wide-angle x-ray diffraction (WAXD): WAXD patterns and extraction of average crystallinity; (iv) small-angle x-ray scattering (SAXS): SAXS patterns and determined crystallite sizes and long-spacings; (v) differential scanning calorimetry (DSC): thermograms and extracted average crystallinity as well as thermal properties; (vi) atomic force microscopy (AFM): AFM image of the surface of an embedded fiber cross-section. For more information, see the publication by E. Perret et al. 'High-resolution 2D Raman mapping of mono- and bicomponent filament cross-sections' [1].

Early prognosis of respiratory virus shedding in humans

This paper addresses the development of predictive models for distinguishing pre-symptomatic infections from uninfected individuals. Our machine learning experiments are conducted on publicly available challenge studies that collected whole-blood transcriptomics data from individuals infected with HRV, RSV, H1N1, and H3N2. We address the problem of identifying discriminatory biomarkers between controls and eventual shedders in the first 32 h post-infection. Our exploratory analysis shows that the most discriminatory biomarkers exhibit a strong dependence on time over the course of the human response to infection. We visualize the feature sets to provide evidence of the rapid evolution of the gene expression profiles. To quantify this observation, we partition the data in the first 32 h into four equal time windows of 8 h each and identify all discriminatory biomarkers using sparsity-promoting classifiers and Iterated Feature Removal. We then perform a comparative machine learning classification analysis using linear support vector machines, artificial neural networks and Centroid-Encoder. We present a range of experiments on different groupings of the diseases to demonstrate the robustness of the resulting models.

Comparative analysis of Truenat™ MTB Plus and Xpert® Ultra in diagnosing tuberculous meningitis

BACKGROUND: Diagnostic delay and drug resistance not only worsen the outcomes of tuberculous meningitis (TBM), but are also important impediments to TB elimination efforts. Given the need for a near point-of-care test suitable for primary healthcare centres and simultaneous detection of resistance, Truenat™ MTB Plus assay was evaluated on a large cohort of TBM patients.METHODS: Truenat assay was performed on 148 cerebrospinal fluid specimens (76 definite TBM, 32 probable TBM and 40 non-TBM controls) and its performance was compared with Xpert^® Ultra.RESULTS: The overall sensitivity of Truenat and Ultra was respectively 78.7% and 67.6% in diagnosing TBM, and respectively 85.5% and 96% in diagnosing definite TBM. Twenty-three additional cases were detected using Truenat and 11 using Ultra. Truenat missed seven cases of rifampicin (RIF) resistance and indicated false RIF resistance in four cases.CONCLUSION: Performance of Truenat was comparable to that of Ultra in diagnosing TBM and inferior to Xpert Ultra in determining RIF resistance.

Sonochemically Prepared BSA Microspheres as Adsorbents for the Removal of Organic Pollutants from Water

This work investigates, for the first time, the application of sonochemically prepared bovine serum albumin (BSA) microspheres (BSAMS) as adsorbents of industrial organic pollutant dyes, such as rhodamine B (RhB), rhodamine 6G (Rh6G), and methylene blue (MB). These dyes also serve as model compounds for other organic pollutants such as bisphenol A and 2-nitrophenol. Adsorption kinetics of the dyes by the BSAMS was studied using pseudo-first-order (PFO) and pseudo-second-order (PSO) kinetic models. It was found that RhB follows PFO, with an adsorption capacity, qe,cal, of 7.9 mg/g, which was closer to the experimental adsorption capacity of qe,exp. of 7.6 mg/g. However, MB and Rh6G were controlled by PSO kinetics, with a qe,cal of 5.6 mg/g for MB and 6.6 mg/g for Rh6G, closer to the experimental adsorption capacity of 5.7 and 6.4 mg/g, respectively. The intraparticle diffusion (ID) model applied to the three dyes indicated multi-linearity with ID as the rate-limiting step in the adsorption process. Furthermore, the adsorption equilibria for each of the organic pollutants were studied through various isotherm models such as Langmuir, Freundlich, Temkin, and Halsey, which indicated physical interaction between the BSAMS and the dye pollutants, thus suggesting the applicability of the BSAMS as pollutant adsorbent materials. It was found that the BSAMS can effectively remove RhB, MB, and Rh6G from wastewater with efficiencies of 95.5, 83.3, and 97.9%, respectively.

Sustainable engineering of sewers and sewage treatment plants for scenarios with urine diversion

Urine diversion (UD) has been studied for decades as a way to enable distributed sanitation and to recycle nutrients onto land to fuel circular economies. No study to date has attempted a quantitative technical and economic analysis of the downstream effects of UD on sewage transport and treatment. This work used the SeweX model to reveal for the first time that through UD, hydrogen sulfide concentration in sewer headspaces can be reduced, and consequently sewer corrosion can be reduced. For a long rising main of 5 km, sewer headspace H₂S can be reduced from 280 ppm to 200 ppm by diverting 75% of the urine. The same scenario enables the reduction of sewer corrosion from 12 to 10 mm/yr. Modeling sewage treatment plants with BioWin showed that sewage treatment responds to UD with a sharp reduction of the anoxic volume and a decrease of energy requirement by up to 50% at 75% UD. An upgrade of bioreactors to increase capacity by 20% can be completely avoided if 7% of the catchment's urine is diverted. Reductions in upgrade expenditure by up to 75% can provide the economic incentive for the uptake of UD.

Postmeal optogenetic inhibition of dorsal hippocampal principal neurons increases future intake in a time-dependent manner

Research involving human participants indicates that memories of recently eaten meals limit how much is eaten during subsequent eating episodes; yet, the brain regions that mediate the inhibitory effects of ingestion-related memory on future intake are largely unknown. We hypothesize that dorsal hippocampal (dHC) neurons, which are critical for episodic memories of personal experiences, mediate the inhibitory effects of ingestion-related memory on future intake. Our research program aimed at testing this hypothesis has been influenced in large part by our mentor James McGaugh and his research on posttraining manipulations. In the present study, we used an activity-guided optogenetic approach to test the prediction that if dHC glutamatergic neurons limit future intake through a process that requires memory consolidation, then inhibition should increase subsequent intake when given soon after the end of a meal but delayed inhibition should have no effect. Viral vectors containing CaMKIIα-eArchT3.0-eYFP and fiber optic probes were placed in the dHC of male Sprague-Dawley rats. Compared to intake on a day when no inhibition was given, postmeal inhibition of dHC glutamatergic neurons given for 10 min after the end of a saccharin meal increased the likelihood that rats would consume a second meal 90 min later and significantly increased the amount of saccharin solution consumed during that next meal when the neurons were no longer inhibited. Importantly, delayed inhibition given 80 min after the end of the saccharin meal did not affect subsequent intake of saccharin. Given that saccharin has minimal postingestive gastric consequences, these effects are not likely due to the timing of interoceptive visceral cues generated by the meal. These data show that dHC glutamatergic neural activity is necessary during the early postprandial period for limiting future intake and suggest that these neurons inhibit future intake by consolidating the memory of the preceding meal.

Natriuretic Peptide Levels and Clinical Outcomes among Patients Hospitalized with COVID-19 Infection

Purpose

There is increasing evidence of adverse cardiovascular morbidity associated with SARS-CoV-2 (COVID-19). Pro-B-type natriuretic peptide (proBNP) is a biomarker of myocardial stress associated with outcomes in various respiratory and cardiac diseases. We hypothesized that proBNP level would be associated with mortality and clinical outcomes in hospitalized COVID-19 patients.

Methods

We performed a retrospective analysis of hospitalized COVID-19 patients (n=1232) using adjusted logistic and linear regression to assess the association of admission proBNP (analyzed by both categorical cutoff >125 pg/mL and continuous log transformed proBNP) with clinical outcomes. Covariates included age, sex, race, body mass index (BMI), hypertension, coronary artery disease (CAD), diabetes, smoking history, and chronic kidney disease stage (Model 1), with Troponin I added in Model 2. We performed survival analysis by a multivariate Cox proportional hazard model, incorporating log transformed proBNP. We additionally treated BMI, a strong potential confounder of both proBNP levels and COVID-19 outcomes, as an ordinal variable ordered across tertiles.

Results

Patients were mean age 62.9±17.6, 53.8% male, and 35.9% Black. Preadmission comorbidities were hypertension (57.1%), diabetes (31.6%), CAD (9.0%) and heart failure (HF, 10.6%). In Model 1 and 2, higher proBNP level was significantly associated with death, new HF, length of stay, ICU duration and need for ventilation among hospitalized COVID-19 patients. This significance persisted after ordinal compression of BMI across tertiles. The adjusted hazard ratio of death for log[proBNP] was 1.56 (95% CI: 1.23-1.97; P<0.0001).

Conclusion

Using a relatively large and racially diverse hospitalized COVID-19 patient cohort, we find that proBNP is associated with adverse clinical outcomes, including mortality and new HF in COVID-19. Further prospective investigation is warranted on the utility of proBNP for clinical prognostication in COVID-19.

A35 ASSOCIATIONS BETWEEN AUTONOMIC DYSFUNCTION, COLONIC DYSMOTILITY AND ABSENT DEFECATION REFLEXES IN PATIENTS WITH CHRONIC REFRACTORY CONSTIPATION

Background

A defecation reflex involves sensory information from the colon sent to the central nervous system which results in propulsive motor patterns in the colon through programmed neural activity from the autonomic nervous system. Neurological causes of constipation are recognized but specific neurological pathways that contribute to pathophysiology of the disease is underexplored. Diagnosis and treatment usually do not involve the autonomic nervous system.

Aims

Our objective was to assess autonomic dysfunction and abnormal defecation reflexes as a possible cause of chronic constipation.

Methods

Defecation reflexes were assessed by high-resolution colonic manometry through balloon distention, meal intake, and rectal bisacodyl. Specific heart rate variability (HRV) parameters were used to assess general orthostatic autonomic reactivity, and autonomic functioning during high resolution colonic manometry, in 14 patients with chronic refractory constipation considered for surgery.

Results

All patients had a unique combination of motility, reflex ability and HRV profiles. Patients overall did not generate HAPWs or had lower HAPW amplitude and lower propulsive activity compared to healthy individuals. Half of the 14 patients were tested to have high sympathetic tone based on Baevsky’s stress index prior to HRCM, and 11 of the patients had sympathetic hyper-reactivity and/or low parasympathetic reactivity to at least one type of colonic stimulation during HRCM. Abnormal autonomic tone or autonomic reactivity to colonic stimulation was present in all four patients with absence of the vagosacral defecation reflex. Five of the seven patients with absence of the sacral defecation reflex showed high sympathetic tone or high sympathetic reactivity to stimulation. Only two patients had abnormality in coloanal coordination and this was associated with low parasympathetic reactivity to stimulation in both patients.

Conclusions

The assumption that colonic resection was needed to remove an inert colon was wrong in most patients, but most patients had some form of reflex abnormality. Sympathetic dominance far outweighed parasympathetic dysfunction. Incorporation of assessments of defecation reflexes and autonomic nervous system activity into diagnosis of chronic refractory constipation provides a comprehensive pathophysiological understanding of specific defective neurological pathways contributing to dysmotility. This forms the basis for our individualized treatment efforts through sacral neuromodulation.

Funding Agencies

CIHR

Low-voltage low-noise gate driven quasi-floating bulk self-cascode current mirror operational transconductance amplifier

A gate driven quasi-floating bulk self-cascode current mirror operational transconductance amplifier operable at ±0.9 V supply voltage with DC gain (70 dB), gain bandwidth (250 kHz), noise (2.8 µV/√Hz at 1 Hz), and power consumption (2.96 µW) simulated in 0.18 µm technology has been introduced. Results obtained are superior in comparison to gate driven self-cascode current mirror and regular current mirror OTAs, which can be utilized to improve the performance of analog-mixed signal circuits and systems.

Online Learning in the Face of COVID-19 Pandemic: Assessment of Students' Satisfaction at Chitwan Medical College of Nepal

Background Online learning can play a vital role in the process of teaching and learning during Corona Virus Disease 2019 (COVID-19) pandemic. However, learners' satisfaction is extremely important in effective implementation of the online learning, especially at institutions where it is newly adopted. Objective To assess satisfaction towards online learning and its predictors among students at Chitwan Medical College, Bharatpur. Method A web-based cross-sectional survey was undertaken among 434 undergraduate and postgraduate students from various academic programs who had participated in the online classes started during this COVID-19 pandemic. A structured questionnaire consisting of 31 items (5-point Likert scale) covering four major student satisfaction domains (learners' dimensions, technological characteristics, instructors' characteristics and course management and coordination) was distributed to the students using Google Form. Result More than half (53.5%) of the students were satisfied with the online learning, while 29.7% gave neutral views. Bivariate analyses found that all four domains scores were positively correlated with each other as well as with the students' overall satisfaction towards learning. In multivariate analysis, female gender [aOR: 2.72, p = 0.013], WiFi as internet modality for learning [aOR: 3.36, p = 0.001) and learners' dimension score [aOR: 1.27, p<0.001] were the significant predictors of students' satisfaction. Conclusion Although recently adopted, the satisfaction of the students towards online classes appears good, and prioritizing the identified predictors and working on the weak links could assist in enhancing students' satisfaction and better outcomes.

Intra-abdominal Solitary Myofibroma in a Child: A Rare Case Report

Intra-abdominal masses in children are usually malignant. Benign tumours at this location are not seen frequently. It is even rarer to find solitary myofibromas intra-abdominally as these tumours are known to have predilection for the head and neck region. We present an unusual case of solitary myofibroma with abdominal localisation in a six-year-old male child who presented with abdominal distension since six months. Computed Tomography (CT) abdomen revealed a complex solid-cystic mass extending from umbilicus to right iliac fossa and measuring 9×6×4 cm. Histopathological examination revealed a tumour displaying biphasic nodular pattern with the presence of lighter staining fascicles of mature myoid cells along with darker staining and more cellular areas of smaller primitive cells. On Immunohistochemistry (IHC), tumour cells were positive for vimentin and Smooth Muscle Actin (SMA) with variable reactivity for desmin while these were negative for CD34 and Anaplastic Lymphoma Kinase 1 (ALK). Based on the histopathological and immunohistochemical findings, final diagnosis of myofibroma was made. Recognition of these lesions is extremely challenging owing to their rare presentation intra-abdominally and also because of their close morphological overlap with other spindle cell tumours commonly found at this site. This case highlights the combined role played by histopathology and IHC in making a clear distinction between different entities. It is imperative for both clinicians and histopathologists to establish the correct diagnosis as excision of the solitary myofibroma is curative in most cases and offers better clinical course than the more commonly found malignant tumours at this site.

Topical Corticosteroids in Treatment of Atopic Dermatitis: An Overview of Their Current Status

Atopic dermatitis (AD) is a common skin disease characterized by epidermal changes with immune regulatory abnormalities. The pathogenesis of AD involves skin barrier defects, genetic factors and immune deregulation. The AD therapy includes skin hydration, anti-inflammatory agents, antibacterial medications and treatment of pruritus. Currently, topical corticosteroids (TCs) are the most frequently used drugs for the treatment of AD due to their potent immunosuppressive action. However, TCs are associated with several local and systemic side effects. The topical steroid addiction and phobia are among the major challenges with TC therapy. Over the years, efforts are being made to reduce side effects which involve adjustment of dosing, minimizing use in vulnerable areas, avoiding prolonged drug usage and application of novel drug delivery systems. The present review provides an overview of the current and upcoming delivery systems of TCs along with novel approaches being employed to improve the drug delivery in the treatment of AD.