Evaluation of different genomic regions of rotavirus B and rotavirus C for development of real-time RT‒PCR assays

BACKGROUND

The causative agents of diarrhea, rotavirus B (RVB) and rotavirus C (RVC) are common in adults and patients of all age groups, respectively. Due to the Rotavirus A (RVA) vaccination program, a significant decrease in the number of gastroenteritis cases has been observed globally. The replacement of RVA infections with RVB, RVC, or other related serogroups is suspected due to the possibility of reducing natural selective constraints due to RVA infections. The data available on RVB and RVC incidence are scant due to the lack of cheap and rapid commercial diagnostic assays and the focus on RVA infections. The present study aimed to develop real-time RT‒PCR assays using the data from all genomic RNA segments of human RVB and RVC strains available in the Gene Bank.

RESULTS

Among the 11 gene segments, NSP3 and NSP5 of RVB and the VP6 gene of RVC were found to be suitable for real-time RT‒PCR (qRT‒PCR) assays. Fecal specimens collected from diarrheal patients were tested simultaneously for the presence of RVB (n = 192) and RVC (n = 188) using the respective conventional RT‒PCR and newly developed qRT‒PCR assays. All RVB- and RVC-positive specimens were reactive in their respective qRT‒PCR assays and had Ct values ranging between 23.69 and 41.97 and 11.49 and 36.05, respectively. All known positive and negative specimens for other viral agents were nonreactive, and comparative analysis showed 100% concordance with conventional RT‒PCR assays.

CONCLUSIONS

The suitability of the NSP5 gene of RVB and the VP6 gene of RVC was verified via qRT‒PCR assays, which showed 100% sensitivity and specificity. The rapid qRT‒PCR assays developed will be useful diagnostic tools, especially during diarrheal outbreaks for testing non-RVA rotaviral agents and reducing the unnecessary use of antibiotics.

Evolutionary analysis of all eleven genes of species C rotaviruses circulating in humans and domestic animals

Species C rotaviruses (RVC) are the second most common rotavirus species known to cause gastroenteritis in humans and pigs and with occurrence documented in cattle, dogs, ferrets, and sloth bears. Despite the host-specific nature of RVC genotypes, cross-species transmission, reassortment, and recombination events are also documented. In the present study, we inferred the evolutionary history of globally circulating RVC strains, including time scale stasis, the most probable ancestral country, and the most probable source host using Bayesian methods implemented in BEAST v.1.8.4. The human-derived RVC strains were majorly monophyletic and further grouped into two lineages. The RVC strains derived from pigs were monophyletic for the VP1 and the remaining genes were classified into 2 to 4 groups based on the high posterior support. The root mean age for all the genes indicated the circulation of RVC for over 800 years. Overall, the time to Most Recent Common Ancestor of human RVC strains dated back to the beginning of the 20th century. The VP7 and NSP2 genes had the lowest rates of evolution compared to other genes. The majority of the genes of RVC showed their origin in Japan except for VP7 and VP4 genes in South Korea. The phylogeographic analysis with the country as a trait showed the role of Japan, China, and India in the dispersion of the virus. In the current study, significant transmission links between different hosts were analyzed for the first time using the host as a trait. Significant transmission links between pigs and other animal species as well as humans indicate possible transmission from the pig as a source host and suggest monitoring of proximity with animals.

Enteric and non-enteric adenoviruses in children with acute gastroenteritis in Western India

Human adenoviruses (HAdVs) are the viral agents responsible for a wide spectrum of acute and chronic diseases. HAdVs are the most important etiological agents of acute gastroenteritis (AGE) and are identified as the major contributor to the deaths of diarrheal children globally. The significant rise in HAdV infections in rotavirus-vaccinated children documented in multiple studies demands continuous monitoring of HAdV strains. After the inclusion of rotavirus vaccines in the immunization schedule of India, public health research regarding prevalence, etiology, and risk factors is highly necessary for evidence-based policies and their implementation to sustain diarrhea prevention programs. In the present study, children admitted for AGE between 2013 and 2016 in seven different hospitals in Maharashtra and Gujrat states of Western India were subjected for investigation. HAdVs were found in 5.2% of the fecal specimens with the dominance of species-F (52.4%) strains, followed by the occurrence of non-enteric adenoviruses of species A (17.4%), C (11.4%), B (8.2%), and D (3.2%). The species-F strains were predominant in Ahmadabad (78.5%), Mumbai (61.5%), and Surat (57.1%) cities, followed by species-A strains. In Pune city, species B strains were detected in all HAdV patients, with none of the species A strains. Clinically, patients infected with enteric and non-enteric HAdV strains were indistinguishable. However, a high viral load was observed in species-F specimens as compared to non-species-F. The present study on fecal specimens collected in the pre-rotavirus vaccination era from hospitalized AGE patients will be important for future comparative analysis to know the exact impact of vaccination in children of Western India.

Rotavirus C infections in asymptomatic piglets in India, 2009-2013: genotyping and phylogenetic analysis of all genomic segments

Asymptomatic infection with rotavirus C (RVC) was observed in pigs in India, with a detection rate of 20%. Sequencing of the VP6, VP7, and NSP4 genes of RVC strains identified the genotypes I7/I10, G1, and E5, respectively. Full genome sequencing of one of these strains revealed that the genotypes of the VP4, VP1, VP2, VP3, NSP1, NSP2, NSP3, and NSP5 genes were P1, R1, C1, M3, A1, N5, T5, and H1, respectively. The detection of porcine RVC strains at two different locations in India at different time points strongly suggests that they are circulating continuously in the pig population through asymptomatic infections.

Outbreak of cholera in a remote village in western India

Background & objectives

Atypical El Tor strains of Vibrio cholerae are frequently implicated in outbreaks of cholera. It is important to understand genetic variations of such strains which impact clinical and epidemiological outcomes. The present study was carried out to characterize an outbreak of cholera which occurred between July 8 and 13, 2018, in a remote settlement in Nashik district, Maharashtra.

Methods

A large number of acute diarrhoea cases were reported in Rahude village, Nashik, Maharashtra since July 8, 2018. Molecular characterization of the isolated strains of V. cholerae was done.

Results

195 cases of cholera were detected from a population of 850 (attack rate 22.9%) with two deaths (Case Fatality Ratio of 1.03). A non-haemolytic polymyxin B sensitive strain of V. cholerae O1 Ogawa was isolated from 5/14 fecal samples. Molecular characterization of the isolates indicated that this strain was an altered El Tor (AET) strain. Deletion of the trinucleotide 'GTA' in the rstB gene, a unique feature of classical strains, was observed.

Interpretation & conclusions

A cholera outbreak caused by a non-haemolytic polymixin B sensitive AET strain, occurred from July 8 to 13, 2018, in a remote settlement in western India. The molecular characterization of the outbreak strains highlighted an assortment of genetic determinants, stressing the need to monitor the genetic attributes of V. cholerae O1 in outbreaks for better understanding and mapping of clinical and epidemiological changes.

Prolonged Shedding of SARS-CoV-2 in Feces of COVID-19 Positive Patients: Trends in Genomic Variation in First and Second Wave

The main route of the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are through respiratory pathways and close contact of human-to-human. While information about other modes of transmission is comparatively less, some published literature supporting the likelihood of a fecal-oral mode of transmission has been accumulating. The diagnosis of SARS-COV-2 infected cases is based on the real-time reverse transcription-PCR (RT-PCR). The fecal excretion of SARS-COV-2 has been reported frequently, however, the role of fecal viral load with the severity of disease is not yet clear. Our study focused on the investigation of SARS-CoV-2 shedding in the fecal samples of patients with coronavirus disease 2019 (COVID-19). A total of 280 RT-PCR-positive patients were enrolled, among them 15.4% had gastrointestinal (GI) symptoms. It was shown that 62% of the patients were positive for SARS-CoV-2 RNA in fecal specimens. This positivity was not related to the presence of GI symptoms and the severity of disease. The next generation sequencing [NGS] of SARS-CoV-2 from fecal samples of patients was performed to analyze mutational variations. Findings from this study not only emphasized the potential presence of SARS-CoV-2 in feces, but also its continuing mutational changes and its possible role in fecal-oral transmission.

Prevalence and genetic diversity of gastroenteritis viruses in hospitalized children < 5 years of age in Maharashtra state, Western India, 2017-2019

Four gastroenteritis viruses were responsible for 54% of the acute gastroenteritis (AGE) cases in children hospitalized between May 2017 and December 2019 in Pune city of Maharashtra state, Western India. The majority (79%) of the children were <2 years of age. The prevalence of Rotavirus A (RVA) was 30.5% followed by 14.3% for norovirus, 8.4% for adenovirus, and 5.5% for astrovirus. The severity of the disease was highest in patients with coinfections compared with the patients with a single infection or negative for all (p = 0.024). Genotyping analysis showed that the majority of the RVA-positive samples (66%) could be typed as G3P[8], 63.6% of the norovirus as GII.4 Sydney [P16], 44% of the adenovirus as type 41%, and 56.2% of the astrovirus as astrovirus type 1. The almost equivalent prevalence of rotavirus and nonrotaviruses and acute gastroenteritis (AGE) cases without known etiology in around 46% of the cases was noted in the present study. Our data highlight that after the recent inclusion of rotavirus vaccines as a part of the National Immunization schedule in India, conducting extensive AGE surveillance in children should include nonrotaviruses such as norovirus.

Investigation of a large waterborne acute gastroenteritis outbreak caused by group B rotavirus in Maharashtra state, India

An acute gastroenteritis outbreak at Devli Karad village, Maharashtra, India with an attack rate of 22.6% affected mainly adolescent and adult population. The viral investigations conducted on fecal specimens of patients hospitalized indicated the presence of rotavirus B (RVB) using RNA polyacrylamide gel electrophoresis and reverse transcription polymerase chain reaction. The samples collected from the source of drinking water also showed the presence of the only RVB. Absence of other viral agents and identification of RVB of genotype G2 as the etiological agent of the acute gastroenteritis outbreak highlights, the necessity of monitoring RVB, the viral agent known for its large outbreak potential.

Evaluation of different genomic regions of Rotavirus A for development of real time PCR

The nucleotide alignment of all 11 genes of human Rotavirus A (RVA) strains revealed suitability of NSP2, NSP3 and VP6 genes for the development of real time PCR (qRT-PCR). Evaluation of qRT-PCR assays using known rotavirus ELISA positive and negative fecal specimens showed non-overlapping ranges of Mean ±3SD cycle threshold (Ct) values for NSP3 and VP6 based assays. Using serial dilutions of purified RVA, high sensitivity of VP6 qRT-PCR assay (1.95 × 10^-5 pg/μL of RNA) was recorded as compared to NSP2 and NSP3 qRT-PCR assays (1.95 × 10^-4 pg/μL of RNA). Further, evaluation of the VP6 qRT-PCR assay involving 266 fecal specimens and frequency polygon analysis of the data indicated cut-off value of 35 for Ct with high sensitivity (126/131, 96%) and specificity (12/12, 100%). This VP6 qRT-PCR assay will be a useful diagnostic tool to evaluate clinical presentations in rotaviral gastroenteritis under different conditions such as breast feeding and administration of rotavirus vaccines.

Evidence of hepatitis A virus infection in the patients with acute encephalitis syndrome in Gorakhpur region, North India

The etiological agent remained unidentified in a large number of patients hospitalized for acute encephalitis syndrome (AES) in 2008-2009 in Uttar Pradesh and Bihar, north India. All patients were found to present with fever and altered sensorium, while 28%, 19% and 13% showed hepatomegaly, splenomegaly and meningeal signs, respectively. Involvement mostly of children with abnormal hepatic features prompted us to undertake an exploratory study on viral hepatitis A to determine its association, if any, with hepatic derangements. AES patients (n = 2515) and healthy children (n = 167) were investigated for the presence of serum anti-hepatitis A virus (anti-HAV) IgM and anti-Japanese encephalitis (anti-JE) virus IgM by ELISA. Cerebrospinal fluids (CSFs, n = 595) and rectal swabs (n = 182) were examined for anti-HAV IgM and/or HAV RNA. Anti-HAV IgM was detected in the sera of 14.6% patients as against 6.6% of healthy children (p = 0.0042). Anti-JE virus IgM positivity was Keywords: acute encephalitis syndrome; cerebrospinal fluid; hepatitis A virus; anti-HAV IgM; non-Japanese encephalitis.

Identification of group B rotavirus as an etiological agent in the gastroenteritis outbreak in Maharashtra, India

Acute gastroenteritis outbreak occurred at Pargaon, Maharashtra, India in 1789 cases with an attack rate of 32.5% between November to December 2015. The stool specimens (n = 32) were investigated for different enteric viral agents using conventional methods. Transmission electron microscopy and RNA polyacrylamide gel electrophoresis respectively identified morphologically distinct rotavirus particles in 28% and RNA migration pattern of Group B Rotavirus (GBR) in 72% of the specimens. Reverse transcription polymerase chain reaction and nucleotide sequencing confirmed presence of GBR in 97% of the samples analyzed. The predominance of GBR infections and absence or insignificant presence of other agents confirmed GBR as an etiological agent of the gastroenteritis outbreak occurred in Maharashtra, India.

Celecoxib-Cyclodextrin Systems: Characterization and Evaluation of In Vitro and In Vivo Advantage

Solid dispersions of Celecoxib were prepared with hydroxypropyl beta cyclodextrin by various methods such as physical mixture, cogrinding, kneading, and coevaporation. The dispersions were characterized by differential scanning calorimetry (DSC), X-ray diffraction patterns, infrared spectroscopy, and nuclear magnetic resonance studies. The DSC thermograms of the dispersions indicated potential of heat-induced interaction between Celecoxib and cyclodextrin that could influence in vitro drug dissolution. The dispersions exhibited faster rates of dissolution compared to that of Celecoxib. The kneaded dispersion with the fastest in vitro dissolution rate when compressed into tablets showed a better release profile compared to the tablets of pure Celecoxib. In vivo studies revealed that the kneaded dispersion provided for quicker response and was more effective in inhibiting rat paw edema as compared to Celecoxib alone, thus confirming the advantage of improved pharmacological activity of Celecoxib when administered as a solid dispersion with cyclodextrin.

Children's acquisition and retention of safety skills: the Lifeskills program

OBJECTIVES

Assessment of safety skills performance and knowledge, to evaluate the education offered by the Lifeskills "Learning for Living" village, Bristol, UK which emphasizes interactive learning-by-doing.

DESIGN

Two quasi-experimental matched control group studies. Study 1: knowledge and performance three months post-intervention. Study 2: knowledge pre-intervention and post-intervention at three time points, to distinguish between immediate learning and longer term retention.

SETTING

The Lifeskills training village, Bristol, UK; primary schools in four education authorities in the area.

PARTICIPANTS

Study 1: 145 children aged 10-11 years; 109 from the Lifeskills program, 36 control. Study 2: 671 children aged 10-11 years; 511 Lifeskills, 160 control.

OUTCOME MEASURES

Three areas (road, home, and fire safety). Five performance tests: observation of children's safety skills. Five knowledge tests: pictorial quiz.

RESULTS

Study 1: Lifeskills/intervention children did better than control children on performance and knowledge tests. The knowledge-performance correlation was r = 0.51. Study 2: intervention children did better than control children immediately after the intervention and three months later on all five knowledge tests. On three tests the intervention group showed retention of knowledge from immediately post-intervention to three months, but on two tests there was some loss. This loss was primarily among children from scholastically lower achieving schools. In all other respects the intervention was equally successful for boys and girls, and for children from higher and lower achieving schools.

CONCLUSIONS

The Lifeskills package improved both knowledge and performance but had shortcomings. Complexity of material did not affect knowledge acquisition but did affect its retention.

Case report: Hepatitis A preceding Guillain–Barré Syndrome

A case of acute hepatitis A with Guillain-Barré Syndrome subtype AMAN (acute motor axonal neuropathy) in a 17-year-old male is reported. Serum and cerebrospinal fluid were positive for anti-hepatitis A virus (HAV) IgM, IgG, and IgA. The onset of the syndrome was evident in week 3 of illness. The remarkably high titers of serum anti-HAV IgG appeared unique to a hepatitis A patient with the syndrome. Phylogenetic analysis of the HAV genome detected in the serum and feces revealed genotype IIIA, circulating commonly in Pune, western India.

Primary rhabdomyosarcoma of the seminal vesicle

Sarcomas of the seminal vesicle are very rare and poorly documented; as it is not always possible to pinpoint a truly vesicular origin of the pelvic mass due to local spread at the time of presentation. The purpose of the article is to document and characterize a rhabdomyosarcoma of the seminal vesicle of which to the knowledge of the authors there has been no previous report in the English literature.

Evaluation of urine as a clinical specimen for diagnosis of hepatitis a

The present study pertains to the evaluation of urine as a specimen for detection of anti-hepatitis A virus (anti-HAV) antibodies. Immunoglobulin M (IgM), IgG, and IgA capture enzyme-linked immunosorbent assays for hepatitis A were performed on paired serum and urine specimens collected from hepatitis A patients (n = 92), healthy individuals (n = 100), non-A hepatitis patients (n = 70), and patients with nonhepatic diseases (n = 64, including 37 renal disease patients). Hepatitis A patients seropositive for anti-HAV IgM showed 95.65% uropositivity. No false-positive reactions were observed in control groups. The uropositivity of anti-HAV IgM persisted during the convalescent phase of the disease. Anti-HAV IgG uropositivity correlated well with corresponding seropositivity in all groups (P > 0.05 for each). No significant difference between the proportions of serum and urine positivity for anti-HAV IgA was noted (P > 0.05 for each). Using seroreactivity as a "gold standard," the sensitivity and specificity for anti-HAV IgM, anti-HAV IgG, and anti-HAV IgA tests with urine as a specimen were found to be 95.65 and 100%, 97.76 and 76.47%, and 92.23 and 88.18%, respectively. Urine appears to be comparable to serum for diagnosis of recent and past infection with hepatitis A.

In situ measurement of nitric oxide production in cardiac isografts and rejecting allografts by an electrochemical method

A number of previous studies have indirectly (electron paramagnetic resonance, nitrite/nitrate, ribonuclease protection assay for inducible nitric oxide synthase (iNOS) mRNA, l-citrulline assay) demonstrated the production of nitrogen monoxide (NO) during early cardiac allograft rejection. This study reports the first direct, quantitative measurement using an electrochemical method of NO produced from rejecting allograft tissue studied in vitro. A rat heterotopic abdominal transplant preparation was utilized. Day 7 isograft (ACI to ACI) or allograft (Lewis to ACI) transplanted hearts were atraumatically harvested and suspended at 4 degrees C in Ringers-Hepes solution. An electrochemical system highly sensitive and specific for NO consisting of a Nafion-coated platinum disk electrode (lower limit, 50 nM NO) coupled to an analysis system measured ongoing oxidation of NO. Measurements were carried out after inserting the electrode in the tissue block and warming the block to 25 degrees C. Additional measurements were also made after incubation of tissue with aminoguanidine (AG), a relatively selective iNOS inhibitor. Direct measurements (mean +/- SEM) from allograft tissue indicated a fourfold increase in NO as compared with isografts (13.41 +/- 4.40 microM NO vs. 3.43 +/- 2.04 microM NO). Incubation of allograft tissue with AG reduced NO levels to isograft levels (13.41 +/- 4.40 microM NO vs. 5.94 +/- 3.14 microM NO); AG had no effect on measured isograft NO levels. Direct, quantitative measurement of NO from tissue is feasible and reproducible, and discrimination between different levels of NO production can be made. These results confirm the imputed results from the previous studies using this experimental model. This technology promises to be a valuable tool for evaluating specific modulators of NO production studied under a variety of physiologic and pathophysiologic conditions.

Reactive oxygen species mediate tumor necrosis factor alpha-converting, enzyme-dependent ectodomain shedding induced by phorbol myristate acetate

Ectodomain shedding of cell surface membrane-anchoring proteins is an important process in a wide variety of physiological events(1, 2). Tumor necrosis factor alpha (TNF-alpha) converting enzyme (TACE) is the first discovered mammalian sheddase responsible for cleavage of several important surface proteins, including TNF-alpha, TNF p75 receptor, L-selectin, and transforming growth factor-a. Phorbol myristate acetate (PMA) has long been known as a potent agent to enhance ectodomain shedding. However, it is not fully understood how PMA activates TACE and induces ectodomain shedding. Here, we demonstrate that PMA induces both reactive oxygen species (ROS) generation and TNF p75 receptor shedding in Mono Mac 6 cells, a human monocytic cell line, and l-selectin shedding in Jurkat T-cells. ROS scavengers significantly attenuated PMA-induced TNF p75 receptor shedding. Exogenous H2O2 mimicked PMA-induced enhancement of ectodomain shedding, and H2O2-induced shedding was blocked by TAPI, a TACE inhibitor. Furthermore, both PMA and H2O2 failed to cause ectodomain shedding in a cell line that lacks TACE activity. By use of an in vitro TACE cleavage assay, H2O2 activated TACE that had been rendered inactive by the addition of the TACE inhibitory pro-domain sequence. We presume that the mechanism of TACE activation by H2O2 is due to an oxidative attack of the pro-domain thiol group and disruption of its inhibitory coordination with the Zn++ in the catalytic domain of TACE. These results demonstrate that ROS production is involved in PMA-induced ectodomain shedding and implicate a role for ROS in other shedding processes.

Electron microscopy of buffalo green monkey kidney cells persistently infected with hepatitis A virus and immunolocalization of HAV antigens

Studies were carried out to analyse the ultrastructural changes and the distribution of hepatitis A virus (HAV)/antigens at subcellular level in buffalo green monkey kidney (BGMK) cells persistently infected with HM-175 strain of HAV. HAV infected BGMK cells showed distinct abnormalities in the endoplasmic reticulum and cytoplasmic membrane as compared to uninfected cells. The abnormalities were characterized by wavy arrays, structures like myelin, annulate lamellae, cytoplasmic inclusion bodies and vesicles. The wavy arrays within the cytoplasm of the host cells appeared to represent degenerating membranes. A complex myelin like body was found in close association with a group of virus like particles. Annulate lamellae like structures involving single paired membrane were detected infrequently whereas the cytoplasmic vesicles were numerous in these cells. An indirect immunogold technique was utilized to localize the HAV antigenin infected cells. A high density immunogold label for HIV like particles was predominantly detected in cytoplasmic vesicles. These results suggest a strong association of membrane substructure in vesicle forms with the compartmentalized replication of HAV within persistently infected host cells.

Effecting and leading change in health care organizations

BACKGROUND

Understanding change is crucial to implementing quality improvement (QI) initiatives. Widespread change will be required to correct what many consider to be outmoded and deficient systems of care. This article summarizes the current literature--within both health care and the fields of business and management--regarding how change occurs at the individual and organizational levels. Part 1 focuses on changing clinician behavior, which is instrumental to any effort directed in the health care setting. Part 2 examines the culture of change. Part 3 addresses issues of leadership, along with the necessary steps to guide change in an organization. Part 4 summarizes key elements of change. Finally, Part 5 provides three case examples of QI initiatives reported in the recent literature to illustrate how the application of the knowledge of change management can assist in the successful implementation of QI programs.

KEY ELEMENTS OF CHANGE

The knowledge base regarding successful change in health care organizations can be summarized in eight crucial strategies or principles: (1) develop a vision for change, (2) focus on the change process, (3) analyze which individuals in the organization must respond to the proposed change and what barriers exist, (4) build partnerships between physicians and the administration, (5) create a culture of continuous commitment to change, (6) ensure that change begins with leadership, (7) ensure that change is well communicated, and (8) build in accountability for change.

CONCLUSION

A knowledge of change management can help leaders of QI programs in health care organizations successfully apply these concepts to bring about much-needed transformations in health care.

Activation of tumor necrosis factor-alpha-converting enzyme-mediated ectodomain shedding by nitric oxide

Ectodomain shedding of cell surface proteins is an important process in a wide variety of physiological and developmental events. Recently, tumor necrosis factor-alpha-converting enzyme (TACE) has been found to play an essential role in the shedding of several critical surface proteins, which is evidenced by multiple developmental defects exhibited by TACE knockout mice. However, little is known about the physiological activation of TACE. Here, we show that nitric oxide (NO) activates TACE-mediated ectodomain shedding. Using an in vitro model of TACE activation, we show that NO activates TACE by nitrosation of the inhibitory motif of the TACE prodomain. Thus, NO production activates the release of cytokines, cytokine receptors, and adhesion molecules, and NO may be involved in other ectodomain shedding processes.

Soft tissue sarcomas: ultrasonographic evaluation of local recurrences

OBJECTIVE

The diagnosis of early local recurrence of soft tissue sarcomas, especially in those treated with surgery and radiotherapy, is a difficult clinical problem. Financial constraints led us to use ultrasonography instead of CT or MR imaging. The aim of this study was to evaluate the role of ultrasonography (US) in detecting local recurrence.

METHODS AND RESULTS

Fifty patients with previous treatment for soft tissue sarcomas were evaluated prospectively for recurrence by US and histopathology. Seven of the 50 patients were clinically suspected to have recurrent tumour. Ultrasonography showed recurrence in 26, no recurrence in 18, benign disease in four and was indeterminate in two cases. Ultrasonography was instrumental in guiding fine needle aspiration biopsies of small local recurrences and indeterminate lesions in 17 patients. In the sonographically tumour positive patients, histopathology confirmed recurrence in 24; one case had benign disease and one patient refused surgery. Thirteen of the 18 sonographically tumour negative patients were operated upon; all were negative for tumour on histopathology. Both the indeterminate cases showed recurrence on histopathology. The benign cases were confirmed by histopathology correlation. Ultrasound guided fine needle aspiration cytology (FNAC) was positive in 14 out of 17 patients (88%). The sensitivity and specificity of US was 92.30% and 94.4% respectively.

CONCLUSION

Our study concludes that US is an extremely useful and cost effective method in the detection of early local recurrences of soft tissue sarcomas and should therefore be used for initial routine follow-up and guided biopsies.

Cellular antioxidant and pro-oxidant actions of nitric oxide

We describe a biphasic action of nitric oxide (NO) in its effects on oxidative killing of isolated cells: low concentrations protect against oxidative killing, while higher doses enhance killing, and these two effects occur by distinct mechanisms. While low doses of NO (from (Z)-1-[N-(3-ammonio propyl)-N-(n-propyl)-amino]-diazen-1-ium-1,2(2) diolate [PAPA/NO] or S-nitroso-N-acetyl-L-penicillamine [SNAP] prevent killing of rat hepatocytes by t-butylhydroperoxide (tBH), further increasing doses result in increased killing. Similar effects occur with rat hepatoma cells treated with PAPA/NO and tBH or H2O2. Increased killing with higher concentrations of NO donor is due to both NO and tBH, because NO donor alone is without effect. Glutathione (GSH) is not involved in either of these actions. Based on measurements of thiobarbituric acid-reactive substances (TBARS) and effects of lipid radical scavenger (DPPD) and deferoxamine, the protective effect, but not the enhancing effect, involves peroxidative chemistry. Fructose has no effect on tBH killing alone but provides substantial protection against killing by higher concentrations of NO plus tBH, suggesting that the enhancing effect involves mitochondrial dysfunction. Hepatocytes, when stimulated to produce NO endogenously, become resistant to tBH killing, indicative of the presence of an NO-triggered antioxidant defensive mechanism. The finding that the protective effects of low concentrations of NO and the harmful effects of high concentrations of NO are fundamentally different in nature suggest that therapeutic interventions could be designed, which selectively prevent its pro-oxidant activity at high concentrations, thus converting NO from a "Janus-faced" modulator of oxidant injury into a "pure" protectant.

Clinical performance improvement series. Classic CQI integrated with comprehensive disease management as a model for performance improvement

BACKGROUND

In recent years, health and disease management has emerged as an effective means of delivering, integrating, and improving care through a population-based approach. Since 1997 the University of Pennsylvania Health System (UPHS) has utilized the key principles and components of continuous quality improvement (CQI) and disease management to form a model for health care improvement that focuses on designing best practices, using best practices to influence clinical decision making, changing processes and systems to deploy and deliver best practices, and measuring outcomes to improve the process. Experience with 28 programs and more than 14,000 patients indicates significant improvement in outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs, and improved clinical process and outcome measures across multiple diseases. DIABETES DISEASE MANAGEMENT: In three months a UPHS multidisciplinary diabetes disease management team developed a best practice approach for the treatment of all patients with diabetes in the UPHS. After the program was pilot tested in three primary care physician sites, it was then introduced progressively to additional practice sites throughout the health system. The establishment of the role of the diabetes nurse care managers (certified diabetes educators) was central to successful program deployment. Office-based coordinators ensure incorporation of the best practice protocols into routine flow processes. A disease management intranet disseminates programs electronically. Outcomes of the UPHS health and disease management programs so far demonstrate success across multiple dimensions of performance-service, clinical quality, access, and value.

DISCUSSION

The task of health care leadership today is to remove barriers and enable effective implementation of key strategies, such as health and disease management. Substantial effort and resources must be dedicated to gain physician buy-in and achieve compliance. The challenge is to provide leadership support, to reward and recognize best practice performers, and to emphasize the use of data for feedback and improvement. As these processes are implemented successfully, and evidence of improved outcomes is documented, it is likely that this approach will be more widely embraced and that organizationwide performance improvement will increase significantly.

CONCLUSIONS

Health care has traditionally invested extraordinary resources in developing best practice approaches, including guidelines, education programs, or other tangible products and services. Comparatively little time, effort, and resources have been targeted to implementation and use, the stage at which most efforts fail. CQI's emphasis on data, rapid diffusion of innovative programs, and rapid cycle improvements enhance the implementation and effectiveness of disease management.

Prevalence of hepatitis a antibodies in western Indian population: changing pattern

This report pertains to a retrospective study conducted between 1983 and 1995 at three time points to evaluate the prevalence of hepatitis A virus (HAV) infection in the population of Bhor Taluk, situated in western India. Serum samples from children and adults were tested for anti-HAV antibodies using blocking ELISA test. There was a significant decrease in anti-HAV prevalence among children aged 5-10 years in 1995 (87.36%) as compared to that of 1983 (97.58%) and 1987 (96.48%). All individuals >11 years of age were seropositive for anti-HAV antibodies. Anti-HAV prevalence was similar in the users of well water, but was significantly reduced in individuals supplied with piped water in 1995 (88.61%) compared with that in 1983 (98.77%). A significant decrease in anti-HAV positivity was noted in children from Bhor Taluk as compared to children from Pune bled in 1992. These results underline the need for periodic surveillance of seroepidemiology of hepatitis A to determine the measures for prevention and control of the disease.

Rat proestrus uterine fluid contains a large molecular-weight protein complex with metalloendopeptidase activity

A neutral metalloendopeptidase has been identified in the secretion of the rat proestrous uterus. The native form of the enzyme secreted in the uterus is a high-mol-wt protein complex, which barely migrates in 3% native polyacrylamide gel electrophoresis. In 2% SDS, the enzyme resolves into 380-, 210-, and 110-kDa subunits. The 380- and 210-kDa proteins demonstrate peptidase activity in SDS-PAGE as detected by an enzyme overlay membrane impregnated with Suc-Ala-Ala-Phe-AFC. The uterine peptidase is substantially inhibited by EDTA, EGTA, 1,10 phenanthroline, thiorphan, DTT, and sodium dodecyl sulfate (SDS). The inhibition by 1,10 phenanthroline is reversed by CO2+. The uterine enzyme has a pH optimum of 7.0, and readily hydrolyzes acetyl tetraalanine and Suc-Ala-Ala-Leu-pNA by releasing alanylalanine and Leu-pNA, respectively. Kinetic analysis of the peptidase using Suc-Ala-Ala-Leu-pNA as substrate yielded Km and Vmax values 0.9 mM and 4.3 microM/min/3.5 microg protein, respectively. Negative staining of the purified uterine metalloprotease demonstrated spherical particles made up of several subunits. The earlier work had indicated that the uterine fluid metalloendopeptidase adhered to the head region of the ejaculated spermatozoa. It is very likely that this peptidase may be involved in assisting the fertilization process.

Diffusion-limited reaction of free nitric oxide with erythrocytes

Concentration changes of nitric oxide (NO) were monitored using an NO-sensitive electrode in phosphate-buffered saline (PBS) with either free oxyhemoglobin (oxyHb) or red blood cells (RBCs). In aerated PBS, the half-life of 0.9 microM NO is greater than 4 min. NO is undetectable (<50 nM) when added to a solution of oxyHb because the reaction of NO with oxyHb is rapid. The disappearance rate of NO in PBS containing RBCs is rapid, compared with PBS, but it is much slower (by a factor of approximately 650) than with an equivalent solution of free oxyHb. The half-life of NO is inversely proportional to the concentration of RBCs, independent of oxyHb concentration inside RBCs, and the disappearance rate of NO is first order in NO concentration and first order in the concentration of RBCs. After all the oxyHb reacts with NO to form methemoglobin, the disappearance rate of NO slows greatly. These data indicate that the reaction of NO with oxyhemoglobin within RBCs is limited by the diffusion of NO into the cell, which has also been shown previously for the reaction of O2 with deoxyhemoglobin. Experimental data show that the half-life of NO in the presence of 2.1 x 10(6) RBCs/ml is 4. 2 s. From this value, we estimate that the half-life of NO in whole blood (5 x 10(9) RBCs/ml) will be 1.8 ms. A simple analytical expression for the half-life of NO in PBS with RBCs was derived in this study based on a spherical diffusion model. The calculated half-life of NO from the expression is in good agreement with the experimental values.

Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients. Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.

Accelerated reaction of nitric oxide with O2 within the hydrophobic interior of biological membranes

We demonstrate herein dramatic acceleration of aqueous nitric oxide (NO) reaction with O2 within the hydrophobic region of either phospholipid or biological membranes or detergent micelles and demonstrate that the presence of a distinct hydrophobic phase is required. Per unit volume, at low amounts of hydrophobic phase, the reaction of NO with O2 within the membranes is approximately 300 times more rapid than in the surrounding aqueous medium. In tissue, even though the membrane represents only 3% of the total volume, we calculate that 90% of NO reaction with O2 will occur there. We conclude that biological membranes and other tissue hydrophobic compartments are important sites for disappearance of NO and for formation of NO-derived reactive species and that attenuation of these potentially damaging reactions is an important protective action of lipid-soluble antioxidants such as vitamin E.

Activation of alveolar macrophages and lung host defenses using transfer of the interferon-gamma gene

Interferon-gamma (IFN-gamma) is a critical cytokine in pulmonary host defenses against both intracellular and extracellular pathogens. To investigate whether this cytokine could be used therapeutically, we constructed an E1-deleted recombinant adenovirus encoding murine IFN-gamma. After intratracheal inoculation in rats, this vector resulted in prolonged expression of functional cytokine in vivo, as demonstrated by increased alveolar macrophage class II major histocompatibility complex expression, enhanced release of tumor necrosis factor in response to lipopolysaccharide, and enhanced host defenses against Pseudomonas aeruginosa. We postulate that this vector may be useful to study the role of exogenous IFN-gamma in a variety of pulmonary intracellular and extracellular pathogens.

Molybdenum cofactor biosynthesis in Escherichia coli mod and mog mutants

The molybdopterin content of Escherichia coli mod and mog mutants was estimated by conversion to the form A derivative. The results are in accord with complete phenotypic repair of mod, and incomplete repair of mog, by culture in high concentrations of molybdate. A possible role for Mog as a molybdochelatase is discussed.

Isolation, cell culture, and characterization of oviduct epithelial cells of the cow

This report describes an easy method of isolation and cell culture of the epithelial cells of cow oviduct. Incubation of cow oviduct with 0.1 mg/ml collagenase in the lumen for 90 minutes helped to dislodge large numbers of ciliated and secretory epithelial cells. The isolated cells, when seeded on plastic, proliferated very quickly and became confluent in 8-10 days in 35 mm Petri dishes. The isolated ciliated cells which attached to the plastic dish lost their cilia after 4-5 days in culture. The cultured epithelial cells were keretin positive. The isolated bovine oviduct epithelial cells, when cultured on plastic precoated with 10 mg/ml matrigel, organized themselves into hollow tubes or spheres with microvilli directed towards the lumen. The epithelial cells seeded on 2 mg/ml matrigel became subconfluent in 15-20 days after seeding. The histoarchitecture of the secretory cells growing in vitro on matrigel resembled that of intact oviduct secretory epithelial cells. Occasional ciliated cells containing large number of mitochondria were observed in the monolayer cultured on 2 mg/ml matrigel substratum but possessed few cilia. The oviduct epithelial cells cultured on 2 mg/ml matrigel incorporated 35S-methionine linearly into protein up to 8 hours in the presence of estradiol or progesterone. The fluorograph of the newly synthesized proteins indicated the presence of an additional 60 kd protein in the cell extract of epithelial cells incubated with estradiol.

Indian and English children's understanding of the distinction between real and apparent emotion

24 preschool and 24 school-entry children in Bombay, India, and 24 preschool and 24 school-entry children in Oxford, England, were tested on their ability to distinguish between real and apparent emotion in response to stories involving child-adult and child-child interactions. Younger Indian girls did better than younger English girls, and the data reveal effects due to age, culture, gender, and story type which suggest a more social model of the understanding of emotion than has been proposed by other researchers using this methodology.

Specific incorporation of molybdopterin in xanthine dehydrogenase of Pseudomonas aeruginosa

All known molybdoenzymes other than nitrogenase contain the metal in association with molybdopterin or one of its dinucleotide variants. All eukaryotic molybdoproteins have been found to contain only molybdopterin, whereas the majority of bacterial enzymes contain one or another of the dinucleotides of molybdopterin. In contrast, xanthine dehydrogenase from Pseudomonas aeruginosa contains molybdopterin rather than a dinucleotide. To examine whether P. aeruginosa contains any dinucleotide of molybdopterin, cells were subjected to an analytical procedure which converts molybdopterin variants to the highly fluorescent Form A derivatives. The results showed that P. aeruginosa cells do contain molybdopterin guanine dinucleotide. The same procedure showed that rat liver does not contain any of the dinucleotides of molybdopterin.