Notch Signaling: An Emerging Paradigm in the Pathogenesis of Reproductive Disorders and Diverse Pathological Conditions

The highly conserved Notch pathway, a pillar of juxtacrine signaling, orchestrates intricate intercellular communication, governing diverse developmental and homeostatic processes through a tightly regulated cascade of proteolytic cleavages. This pathway, culminating in the migration of the Notch intracellular domain (NICD) to the nucleus and the subsequent activation of downstream target genes, exerts a profound influence on a plethora of molecular processes, including cell cycle progression, lineage specification, cell-cell adhesion, and fate determination. Accumulating evidence underscores the pivotal role of Notch dysregulation, encompassing both gain and loss-of-function mutations, in the pathogenesis of numerous human diseases. This review delves deep into the multifaceted roles of Notch signaling in cellular dynamics, encompassing proliferation, differentiation, polarity maintenance, epithelial-mesenchymal transition (EMT), tissue regeneration/remodeling, and its intricate interplay with other signaling pathways. We then focus on the emerging landscape of Notch aberrations in gynecological pathologies predisposing individuals to infertility. By highlighting the exquisite conservation of Notch signaling in Drosophila and its power as a model organism, we pave the way for further dissection of disease mechanisms and potential therapeutic interventions through targeted modulation of this master regulatory pathway.

Somatic mutational landscape of hereditary hematopoietic malignancies caused by germline variants in RUNX1, GATA2, and DDX41

Individuals with germ line variants associated with hereditary hematopoietic malignancies (HHMs) have a highly variable risk for leukemogenesis. Gaps in our understanding of premalignant states in HHMs have hampered efforts to design effective clinical surveillance programs, provide personalized preemptive treatments, and inform appropriate counseling for patients. We used the largest known comparative international cohort of germline RUNX1, GATA2, or DDX41 variant carriers without and with hematopoietic malignancies (HMs) to identify patterns of genetic drivers that are unique to each HHM syndrome before and after leukemogenesis. These patterns included striking heterogeneity in rates of early-onset clonal hematopoiesis (CH), with a high prevalence of CH in RUNX1 and GATA2 variant carriers who did not have malignancies (carriers-without HM). We observed a paucity of CH in DDX41 carriers-without HM. In RUNX1 carriers-without HM with CH, we detected variants in TET2, PHF6, and, most frequently, BCOR. These genes were recurrently mutated in RUNX1-driven malignancies, suggesting CH is a direct precursor to malignancy in RUNX1-driven HHMs. Leukemogenesis in RUNX1 and DDX41 carriers was often driven by second hits in RUNX1 and DDX41, respectively. This study may inform the development of HHM-specific clinical trials and gene-specific approaches to clinical monitoring. For example, trials investigating the potential benefits of monitoring DDX41 carriers-without HM for low-frequency second hits in DDX41 may now be beneficial. Similarly, trials monitoring carriers-without HM with RUNX1 germ line variants for the acquisition of somatic variants in BCOR, PHF6, and TET2 and second hits in RUNX1 are warranted.

Allogeneic hematopoietic stem cell transplant outcomes in adults with inherited myeloid malignancies

There is increasing recognition that pathogenic germ line variants drive the development of hematopoietic cancers in many individuals. Currently, patients with hereditary hematologic malignancies (HHMs) receive similar standard therapies and hematopoietic stem cell transplant (HSCT) approaches as those with sporadic disease. We hypothesize that patients with myeloid malignancies and deleterious germ line predisposition variants have different posttransplant outcomes than those without such alleles. We studied 472 patients with myeloid neoplasms, of whom 26% had deleterious germ line variants and 34% underwent HSCT. Deleterious germ line variants in CHEK2 and DDX41 were most commonly seen in American and Australian cohorts, respectively. Patients with deleterious germ line DDX41 variants had a higher incidence of severe (stage 3-4) acute graft-versus-host disease (GVHD) (38%) than recipients with deleterious CHEK2 variants (0%), other HHM variants (12%), or patients without such germ line variants (9%) (P = .002). Importantly, the use of posttransplant cyclophosphamide reduced the risk of severe acute GVHD in patients receiving HSCT for deleterious germ line DDX41-associated myeloid neoplasms (0% vs 53%, P = .03). Based on these results, we advocate the use of posttransplant cyclophosphamide when individuals with deleterious germ line DDX41 variants undergo allogeneic HSCT for myeloid malignancies, even when transplantation has been performed using wild-type donors.

Glycosylation in SARS-CoV-2 variants: A path to infection and recovery

Glycan is an essential molecule that controls and drives life in a precise direction. The paucity of research in glycobiology may impede the significance of its role in the pandemic guidelines. The SARS-CoV-2 spike protein is heavily glycosylated, with 22 putative N-glycosylation sites and 17 potential O-glycosylation sites discovered thus far. It is the anchor point to the host cell ACE2 receptor, TMPRSS2, and many other host proteins that can be recognized by their immune system; hence, glycosylation is considered the primary target of vaccine development. Therefore, it is essential to know how this surface glycan plays a role in viral entry, infection, transmission, antigen, antibody responses, and disease progression. Although the vaccines are developed and applied against COVID-19, the proficiency of the immunizations is not accomplished with the current mutant variations. The role of glycosylation in SARS-CoV-2 and its receptor ACE2 with respect to other putative cell glycan receptors and the significance of glycan in host cell immunity in COVID-19 are discussed in this paper. Hence, the molecular signature of the glycan in the coronavirus infection can be incorporated into the mainstream therapeutic process.

Prostate Disease Severity Score: In the management of benign enlargement of prostate

Objective:

Developing a simple, user-friendly objective severity scoring system for symptomatic benign enlargement of prostate (BEP) and comparing with International Prostate Symptom Score (IPSS).

Subjects and Methods:

In this prospective study, patients with BEP completed IPSS proforma. A grading system was developed for peak flow of urine ( Qmax), transitional zone index (TZI), detrusor wall thickness (DWT) and intravesical prostatic protrusion (IPP). Prostate Disease Severity Score (PDSS) was developed as sum of the variables.

Results:

Among 115 patients, obstructive voiding (70.43%) was predominant symptom followed by storage symptom (10.44%). Among predominant obstructive voiders, grades 1–3 TZI was common (97.53%), followed by IPP (64.19%) and DWT (62.96%) of varying grade. IPP, DWT, TZI and Qmax proved to be strong determinants of obstructive voiding ( p < 0.05). The components of PDSS correlated well with total score ( p < 0.05), positively correlated with IPP, DWT and TZI, and negatively with Qmax ( p < 0.05); correlation with IPSS was statistically significant ( p < 0.05). According to PDSS, 92.5% (37/40) patients with severe, 73.02% (46/63) with moderate, 8.33% (1/12) with mild degree of obstruction needed surgical intervention.

Conclusion:

The objective nature, comparable correlation with IPSS, potentiality to predict future need for surgical intervention, makes PDSS, a potential user-friendly assessment tool in management of BEP.

Level of evidence:

Not applicable

Challenges and gender-based differences for women in the Indian urological workforce: Results of a survey

Introduction

Entry of women into urology has not kept pace with that in other surgical branches with only 1% of Urological Society of India (USI) members being female. The objective of this study was to explore the personal and professional challenges, practice barriers, and level of satisfaction among female urologists/urology trainees in India.

Methods

A strictly confidential and anonymous 26-item questionnaire with respect to professional and personal challenges, workplace discrimination, and family satisfaction was circulated as a Google form through email and WhatsApp to all the female members of the USI (full and associate) and trainees (n = 48) based on identification from the USI directory.

Results

Thirty-three out of 48 female urologists responded (68%). Among the respondents (n = 33), majority had <5 years of experience (60.6%), of which 30.3% were residents, which reflected a recent surge in women joining urology. Majority (57.7%) chose to subspecialize, commonly in "female urology". Many (72.7%) were encouraged to take this subspecialty. Gender discrimination at workplace was reported by 54.5%, commonly by patients and consultants. 68% of respondents had conceived either before or during residency, leading to additional domestic responsibilities. 9.1% suffered a pregnancy-related complication, which they believed was a direct consequence of their work environment. These obstacles led to 30.3% of women reporting that their personal life had compromised their careers. Professional dissatisfaction was reported by 60.1% of women, with common causes being less operative time than male counterparts and lack of mentorship. Despite these challenges given a chance, 78.7% would choose urology again, and 66.7% would encourage their daughter to pursue a career in urology.

Conclusion

Professional and personal challenges as perceived by women responding to our survey include gender discrimination in training and work, lack of mentorship, pregnancy-related compilations, and compromised career due to family responsibilities. Despite these, most would choose this specialty again.

GATA2 deficiency syndrome: A decade of discovery

GATA2 deficiency syndrome (G2DS) is a rare autosomal dominant genetic disease predisposing to a range of symptoms, of which myeloid malignancy and immunodeficiency including recurrent infections are most common. In the last decade since it was first reported, there have been over 480 individuals identified carrying a pathogenic or likely pathogenic germline GATA2 variant with symptoms of G2DS, with 240 of these confirmed to be familial and 24 de novo. For those that develop myeloid malignancy (75% of all carriers with G2DS disease symptoms), the median age of onset is 17 years (range 0-78 years) and myelodysplastic syndrome is the first diagnosis in 75% of these cases with acute myeloid leukemia in a further 9%. All variant types appear to predispose to myeloid malignancy and immunodeficiency. Apart from lymphedema in which haploinsufficiency seems necessary, the mutational requirements of the other less common G2DS phenotypes is still unclear. These predominantly loss-of-function variants impact GATA2 expression and function in numerous ways including perturbations to DNA binding, protein structure, protein:protein interactions, and gene transcription, splicing, and expression. In this review, we provide the first expert-curated ACMG/AMP classification with codes of published variants compatible for use in clinical or diagnostic settings.

Is preoperative neutrophil-to-lymphocyte ratio a red flag which can predict high-risk pathological characteristics in renal cell carcinoma?

Introduction

Renal cell carcinoma (RCC) is known to invoke both immunological and inflammatory responses. While the neutrophils mediate the tumor-induced inflammatory response, the lymphocytes bring about the various immunological events associated with it. The neutrophil-to-lymphocyte ratio (NLR) is a simple indicator of this dual response. We investigated the association between preoperative NLR and histopathological prognostic variables of RCC intending to find out whether it can be of value as a red flag capable of alerting the clinician as to the biological character of the tumor under consideration.

Methods

Preoperative NLR and clinicopathological variables, namely histological subtype, nuclear grade, staging, lymphovascular invasion, capsular invasion, tumor necrosis, renal sinus invasion, and sarcomatoid differentiation of 60 patients who underwent radical or partial nephrectomy, were analyzed to detect the association between the two.

Results

We found that mean preoperative NLR was significantly higher in clear-cell carcinomas (3.25 ± 0.29) when compared with nonclear-cell carcinomas (2.25 ± 0.63). There was a linear trend of NLR rise as the stage of the disease advanced. A significant rise in preoperative NLR was noted in tumors with various high-risk histopathological features such as tumor size, capsular invasion, tumor necrosis, and sarcomatoid differentiation.

Conclusion

Preoperative measurement of NLR is a simple test which may provide an early clue of high-risk pathological features of renal cell cancer.

Clinical and therapeutic implications of sex steroid hormone receptor status in urothelial bladder cancer

Studies on the clinical profile of urothelial bladder cancer (UBC) have shown significant gender differences, namely, higher occurrence in males (male-to-female ratio of 3.5:1) and an advanced stage of disease at the time of diagnosis with rapid progression of the disease after initial diagnosis seen more commonly in females. The relationship between gender and UBC is complex and probably influenced by biological and epidemiological factors. Potential contributory factors such as sex steroid hormone pathway, gender difference in environmental carcinogen exposure, metabolic enzyme activity, and disparities in the intensity of diagnostic evaluation could probably explain the demographic trends in UBC. This comprehensive review of Medline publications during the period 2009–2019 attempts to identify the possible role of sex hormone receptors in gender variation and sexual dimorphism in the occurrence and progression of UBC. The clinical implications of identifying sex steroid receptors on factors such as disease prognostication and the therapeutic role of anti-androgens in the prevention and progression of UBC are critically reviewed. There is now significant evidence in literature to suggest the possible role of sex steroid hormone receptor-mediated signals in the genesis and progression of UBC. These receptors include androgen receptors, estrogen receptors, progesterone receptors, and various other orphan receptors. Excessive or reduced expression of these receptors, as well as alterations in their upstream or downstream pathways, correlate well with the clinical and therapeutic outcomes of UBC.

Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy

Introduction

Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN.

Materials and Methods

We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality.

Results

The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%.

Conclusion

Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.

Can new, improvised Visual Prostate Symptom Score replace the International Prostate Symptom Score? Indian perspective

Introduction:

Visual Prostate Symptom Score (VPSS) was introduced to overcome the drawbacks of the International Prostate Symptom Score (IPSS). However, this score also has potential for improvement.

Materials and Methods:

The primary objective of this study was to evaluate the utility of VPSS in patients with benign enlarged prostate (BEP) after uroflowmetric validation of the stream component. The secondary objective was to improve VPSS by adding a new severity grading and to assess if the “new upgraded VPSS” can replace IPSS in terms of ease of completion without assistance and the time taken.

Results:

Of 115 patients, 42.60% of them were of the age group between 61–70 years; mean ± standard deviation age was 64.75 years ± 8.042 (range 48–90 years). Nineteen (16.52%) patients, who had education level ≥10th grade completed IPSS without assistance. One hundred and eight (93.91%) patients completed VPSS without assistance (P = 0.000). None of those (0/6) with no formal education (but able to read and write) could complete the IPSS without assistance, whereas 66.67% completed the VPSS without assistance. Six minutes and two minutes was the average time taken to complete IPSS (4–10 min) and VPSS (1–3 min), respectively. Responses to different variables of VPSS were statistically significant (P < 0.001) compared to the IPSS. Correlation between the severity grading of the two scores was statistically significant (P < 0.001), with a statistically significant positive correlation between VPSS and IPSS (r = +0.582, P < 0.001). The new severity grading system developed on par with the IPSS, improvising the existing VPSS, showed statistically significant positive correlation to the IPSS (r = +0.587, P < 0.001).

Conclusions:

VPSS correlated well with IPSS. The “new improvised VPSS” developed by incorporating severity grading is a potential tool that can replace IPSS by overcoming its limitations.

Multiple functions of the scaffold protein Discs large 5 in the control of growth, cell polarity and cell adhesion in Drosophila melanogaster

Background

Scaffold proteins support a variety of key processes during animal development. Mutant mouse for the MAGUK protein Discs large 5 (Dlg5) presents a general growth impairment and moderate morphogenetic defects.

Results

Here, we generated null mutants for Drosophila Dlg5 and show that it owns similar functions in growth and epithelial architecture. Dlg5 is required for growth at a cell autonomous level in several tissues and at the organism level, affecting cell size and proliferation. Our results are consistent with Dlg5 modulating hippo pathway in the wing disc, including the impact on cell size, a defect that is reproduced by the loss of yorkie. However, other observations indicate that Dlg5 regulates growth by at least another way that may involve Myc protein but nor PI3K neither TOR pathways. Moreover, epithelia cells mutant for Dlg5 also show a reduction of apical domain determinants, though not sufficient to induce a complete loss of cell polarity. Dlg5 is also essential, in the same cells, for the presence at Adherens junctions of N-Cadherin, but not E-Cadherin. Genetic analyses indicate that junction and polarity defects are independent.

Conclusions

Together our data show that Dlg5 own several conserved functions that are independent of each other in regulating growth, cell polarity and cell adhesion. Moreover, they reveal a differential regulation of E-cadherin and N-cadherin apical localization.

Two monogenic disorders masquerading as one: severe congenital neutropenia with monocytosis and non-syndromic sensorineural hearing loss

BACKGROUND

We report a large family with four successive generations, presenting with a complex phenotype of severe congenital neutropenia (SCN), partially penetrant monocytosis, and hearing loss of varying severity.

METHODS

We performed whole exome sequencing to identify the causative variants. Sanger sequencing was used to perform segregation analyses on remaining family members.

RESULTS

We identified and classified a pathogenic GFI1 variant and a likely pathogenic variant in MYO6 which together explain the complex phenotypes seen in this family.

CONCLUSIONS

We present a case illustrating the benefits of a broad screening approach that allows identification of oligogenic determinants of complex human phenotypes which may have been missed if the screening was limited to a targeted gene panel with the assumption of a syndromic disorder. This is important for correct genetic diagnosis of families and disentangling the range and severity of phenotypes associated with high impact variants.

The resurgence of estrogens in the treatment of castration-resistant prostate cancer

Use of exogenous estrogens in manipulating the androgenestrogen equilibrium was one of the earliest therapeutic strategies developed to treat prostate cancer which followed close on heels the discovery of hormone dependence of this tumor. Despite its well-documented benefit, estrogen therapy fell out of favor with the advent of other forms of androgen deprivation therapy (ADT) as the former registered a higher incidence of cardiovascular complications and poorer overall survival. Clearer understanding of the mechanism of action of estrogen coupled with the adoption of alternative routes of administration has triggered a renewed interest in estrogen therapy. Since then, many studies have not only proved the therapeutic benefit of estrogens but also explored the ways and means of minimizing the dreaded side effects deterring its use. Further, the fact that estrogen therapy offered a clear advantage of reduced cost of treatment over other treatments has led many countries to readopt it in the treatment of advanced prostatic cancer. We reviewed the published data on the use of estrogens in CRPC, which may affect its revival as an efficacious treatment option having minimal side effects, with modified dosage and route of administration. Estrogen therapy would be a less expensive option having equivalent or even better therapeutic effect than ADT in advanced carcinoma of prostate.

A Phase III open-label, randomized, active controlled clinical study to assess safety, immunogenicity and lot-to-lot consistency of a bovine-human reassortant pentavalent rotavirus vaccine in Indian infants

BACKGROUND

A heat-stable bovine-human rotavirus reassortant pentavalent vaccine (BRV-PV, ROTASIIL®) was developed in India. In this study, the vaccine was tested for safety, immunogenicity and clinical lot-to-lot consistency.

METHODS

This was a Phase III, open label, randomized, equivalence design study. The primary objective was to demonstrate lot-to-lot consistency of BRV-PV. Subjects were randomized into four arms, three arms received Lots A, B, and C of BRV-PV and the control arm, received Rotarix®. Three doses of BRV-PV or two doses of Rotarix® and one dose of placebo were given at 6, 10, and 14 weeks of age. Blood samples were collected four weeks after the third dose to assess rotavirus IgA antibody levels. The three lots of BRV-PV were equivalent if the 95% Confidence Intervals (CIs) of the geometric mean concentration (GMC) ratios were between 0.5 and 2. Solicited reactions were collected by using diary cards.

RESULTS

The study was conducted in 1500 randomized infants, of which 1341 infants completed the study. The IgA GMC ratios among the three lots were around 1 (Lot A versus Lot B: 1.07; Lot A versus Lot C: 1.06; and Lot B versus Lot C: 0.99). The 95% CIs for the GMC ratios were between 0.78 and 1.36. The IgA GMCs were: BRV-PV group 19.16 (95% CI 17.37-21.14) and Rotarix® group 10.92 (95% CI 9.36-12.74) (GMC ratio 1.75; 90% CI 1.51-2.04). Seropositivity rates were 46.98% (95% CI 43.86-50.11) and 31.12% (95% CI 26.17-36.41). The incidence of solicited reactions was comparable across the four arms. No serious adverse events were associated with the study vaccines, except two gastroenteritis events in the BRV-PV groups.

CONCLUSION

Lot-to-lot consistency of BRV-PV was demonstrated in terms of GMC ratios of IgA antibodies. The vaccine safety and immunogenicity profiles were similar to those of Rotarix®. Clinical Trials.Gov [NCT02584816] and Clinical Trial Registry of India [CTRI/2015/07/006034].

Non-interference of Bovine-Human reassortant pentavalent rotavirus vaccine ROTASIIL® with the immunogenicity of infant vaccines in comparison with a licensed rotavirus vaccine

Background

A newly developed bovine-human reassortant pentavalent vaccine (BRV-PV, ROTASIIL®) was tested for its potential effect on the immunogenicity of concomitantly administered EPI vaccines in infants in a randomized controlled study in India.

Methods

In this Phase III, multicenter, open label, randomized, controlled study, three doses of BRV-PV or two doses of Rotarix® and one dose of placebo were given to healthy infants at 6, 10, and 14 weeks of age. Subjects also received three doses of DTwP-HepB-Hib (diphtheria, tetanus, whole-cell pertussis, hepatitis B, and haemophilus influenzae type b conjugate – pentavalent vaccine) and oral polio vaccine concomitantly at 6, 10, and 14 weeks of age and a single dose of inactivated polio vaccine at 14 weeks of age. Blood samples were collected four weeks after the final vaccination to assess immune responses to all the vaccines administered. For diphtheria, tetanus, hepatitis B, Hib, polio type 1, and polio type 3 antibodies, non-interference was to be supported if the lower limit of the two-sided 90% confidence interval (CI) for the seroprotection rate difference for the BRV-PV group minus the Rotarix® group was >10.0%. For pertussis antibodies, non-interference was to be supported if the lower limit of the two-sided 90% CI for the ratio of geometric mean concentrations (GMCs) was >0.5.

Results

A total of 1500 infants were randomized to either BRV-PV (1125 infants) or Rotarix® (375 infants), of which 1341 completed the study as per the protocol. More than 97% of subjects achieved seroprotective antibody titres against diphtheria, tetanus, hepatitis B, Hib, polio type 1, and polio type 3 in both groups. The difference in seroprotection rates between the BRV-PV group and the Rotarix® group for all these antibodies was less than 1%. The ratio of GMCs of anti-pertussis IgG concentrations for the BRV-PV group versus Rotarix® was 1.04 [90% CI: 0.90; 1.19].

Conclusion

BRV-PV does not interfere with the immunogenicity of concomitantly administered routine infants vaccines.

Immunogenicity and safety of measles-mumps-rubella vaccine delivered by disposable-syringe jet injector in India: A randomized, parallel group, non-inferiority trial

•

We compared MMR vaccine administration by disposable-syringe jet injector (DSJI) and needle and syringe (N-S).

•

The study was conducted in 340 toddlers who had received a measles vaccine at 9 months.

•

On day 35, seropositivity for all three viruses was more than 97% in both the groups.

•

Reactogenicity by both methods was comparable.

•

MMR vaccination via DSJI is as immunogenic and safe as vaccination by N-S.

Background

We conducted a randomized, non-inferiority, clinical study of MMR vaccine by a disposable-syringe jet injector (DSJI) in toddlers in India in comparison with the conventional administration.

Methods

MMR vaccine was administered subcutaneously by DSJI or needle-syringe (N-S) to toddlers (15–18 months) who had received a measles vaccine at 9 months. Seropositivity to measles, mumps, and rubella serum IgG antibodies was assessed 35 days after vaccination. Non-inferiority was concluded if the upper limit of the 95% CI for the difference in the percent of seropositive between groups was less than 10%. Solicited reactions were collected for 14 days after vaccination by using structured diaries.

Results

In each study group, 170 subjects received MMR vaccine. On day 35, seropositivity for measles was 97.5% [95% CI (93.8%, 99.3%)] in the DSJI group and 98.7% [95% CI (95.5%, 99.8%)] in the N-S group; for mumps, 98.8% [95% CI (95.6%, 99.8%)] and 98.7% [95% CI (95.5%, 99.8%)]; and for rubella, 98.8% [95% CI (95.6%, 99.8%)] and 100% [95% CI (97.7%, 100.0%)]; none of the differences were significant. The day 35 post-vaccination GMTs in DSJI and N-S groups were measles: 5.48 IU/ml [95% CI (3.71, 8.11)] and 5.94 IU/ml [95% CI (3.92, 9.01)], mumps: 3.83 ISR [95% CI (3.53, 4.14)] and 3.66 ISR [95% CI (3.39, 3.95)] and rubella: 95.27 IU/ml [95% CI (70.39, 128.95)] and 107.06 IU/ml [95% CI (79.02, 145.06)]; none of the differences were significant.

The DSJI group reported 173 solicited local reactions and the N-S group reported 112; most were mild grade. Of the total of 156 solicited systemic adverse events, most were mild, and incidence between the two groups was similar.

Conclusions

MMR vaccination via DSJI is as immunogenic as vaccination by N-S. Safety profile of DSJI method is similar to N-S except for injection site reactions which are more with DSJI and are well-tolerated.

Registration

US National Institutes of Health clinical trials identifier – NCT02253407.

Clinical trial registry of India identifier – CTRI/2013/05/003702

Assemblage composition of fungal wood-decay species has a major influence on how climate and wood quality modify decomposition

The interactions among saprotrophic fungal species, as well as their interactions with environmental factors, may have a major influence on wood decay and carbon release in ecosystems. We studied the effect that decomposer diversity (species richness and assemblage composition) has on wood decomposition when the climatic variables and substrate quality vary simultaneously. We used two temperatures (16 and 21°C) and two humidity levels (70% and 90%) with two wood qualities (wood from managed and old-growth forests) of Pinus sylvestris. In a 9-month experiment, the effects of fungal diversity were tested using four wood-decaying fungi (Antrodia xantha, Dichomitus squalens, Fomitopsis pinicola and Gloeophyllum protractum) at assemblage levels of one, two and four species. Wood quality and assemblage composition affected the influence of climatic factors on decomposition rates. Fungal assemblage composition was found to be more important than fungal species richness, indicating that species-specific fungal traits are of paramount importance in driving decomposition. We conclude that models containing fungal wood-decay species (and wood-based carbon) need to take into account species-specific and assemblage composition-specific properties to improve predictive capacity in regard to decomposition-related carbon dynamics.

Institutionalize patient related communication in the Emergency Department of Hamad General Hospital through the use of SBAR approach

Background: It has been found that 89% of the ED staff in HGH has very low knowledge on the approach of SBAR, due to which they don't converse it accordingly with other staff especially during endorsements, face-face & critical call scenarios.

Aim: To increase and standardize the usage of SBAR as a communication tool among the clinical staff in the ED of high to 100% by FEB 2016.

Methods: The project was done in an iterative four-step continuous improvement method through careful monitoring in various areas of ED to collect the baseline data. SBAR champions were chosen from each area to facilitate and coordinate the project to most of ED. SBAR endorsement form was introduced for the nurses between shifts to notify information. Nurse educators & quality reviewers decided on educational sessions for the ED-nurses which consisted of role play, scenario based & simulation training for the nurses to make them understand the relevance of SBAR. A monitoring tool was developed for secret audit on SBAR usage to know the efficacy in the area.

Results: There has been a spike in the usage of SBAR by the nurses during the endorsement time and between the work schedules. With the help of the CN's and SBAR champions who regularly change from day to day, Careful monitoring has been placed in various areas of the ED which has led to such significant achievement. As of now the measurement and the testing has been done with the nurses, physicians, ECG technicians, respiratory therapists and also the quality reviewers. we are soon planning to include ems for the same training by end of February, we will make sure the whole ED will be talking & reporting in SBAR.

Conclusions: Interprofessional communication activity is needed at the entry level for all professionals. SBAR - teachable skill that is recognized by all healthcare workers as safe effective method of communicating among providers. We will soon spread this communication between units & during transfers also. Registration number: 0000-0003-0866-6512.

Evaluation of an intervention to decrease false positive blood culture contamination rates in Emergency Department

Background: The HGH Microbiology lab indicator showed that our blood culture contamination rate has been consistently higher than the international benchmark thereby we aim to reduce it in the critical area of Emergency Department by 50% by the end of July 2015 and at least 90% by end of February 2016.

Methods: A pilot area was chosen in the Emergency Department to do a study for 44 weeks after which blood culture kits (previously trolleys & trays were used) containing sterile gloves, masks, and blood culture supplies were introduced into the Critical area of ED-HGH in August 2015. Training included- new instructions to have two staff members present when drawing blood cultures (preceptor-preceptee methodology) thereby prohibiting drawing blood cultures from pre-existing lines and proper follow-up of every step. False positive blood culture rates were measured in the weeks preceding and the weeks following, this intervention.

Results: In the 8 weeks following the intervention, the average false positive blood culture contamination rate in HGH ED reached 1.9% (which was the benchmark) out of 318 blood culture samples. In the 6 months preceding, the blood culture contamination rates ranged from 4% to 1.5% each month.

Conclusions: Blood culture kits and educational training on proper technique resulted in significant reduction (>60%) in the false positive blood culture rate in the Critical areas of ED-HGH. Studies at other institutions have suggested that reducing the false positive blood culture rate could decrease costs by preventing unnecessary hospitalizations and administration of unnecessary antibiotics, as well as helping to prevent the development of multi-drug resistant organisms. 0000-0003-0866-6512 0000-0002-1057-2438.

Immunogenicity of a new routine vaccination schedule for global poliomyelitis prevention: an open-label, randomised controlled trial

BACKGROUND

Polio eradication needs a new routine immunisation schedule--three or four doses of bivalent type 1 and type 3 oral poliovirus vaccine (bOPV) and one dose of inactivated poliovirus vaccine (IPV), but no immunogenicity data are available for this schedule. We aimed to assess immunogenicity of this vaccine schedule.

METHODS

We did an open-label, randomised controlled trial in four centres in India. After informed consent was obtained from a parent or legally acceptable representative, healthy newborn babies were randomly allocated to one of five groups: trivalent OPV (tOPV); tOPV plus IPV; bOPV; bOPV plus IPV; or bOPV plus two doses of IPV (2IPV). The key eligibility criteria were: full-term birth (≥37 weeks of gestation); birthweight ≥2·5 kg; and Apgar score of 9 or more. OPV was administered at birth, 6 weeks, 10 weeks, and 14 weeks; IPV was administered intramuscularly at 14 weeks. The primary study objective was to investigate immunogenicity of the new vaccine schedule, assessed by seroconversion against poliovirus types 1, 2, and 3 between birth and 18 weeks in the per-protocol population (all participants with valid serology results on cord blood and at 18 weeks). Neutralisation assays tested cord blood and sera collected at 14 weeks, 18 weeks, 19 weeks, and 22 weeks by investigators masked to group allocation. This trial was registered with the India Clinical Trials Registry, number CTRI/2013/06/003722.

FINDINGS

Of 900 newborn babies enrolled between June 13 and Aug 29, 2013, 782 (87%) completed the per-protocol requirements. Between birth and age 18 weeks, seroconversion against poliovirus type 1 in the tOPV group occurred in 162 of 163 (99·4%, 95% CI 96·6-100), in 150 (98·0%, 94·4-99·6) of 153 in the tOPV plus IPV group, in 153 (98·7%, 95·4-99·8) of 155 in the bOPV group, in 155 (99·4%, 96·5-100) of 156 in the bOPV plus IPV group, and in 154 (99·4%, 96·5-100) of 155 in the bOPV plus 2IPV group. Seroconversion against poliovirus type 2 occurred in 157 (96·3%, 92·2-98·6) of 163 in the tOPV group, 153 (100%, 97·6-100·0) of 153 in the tOPV plus IPV group, 29 (18·7%, 12·9-25·7) of 155 in the bOPV group, 107 (68·6%, 60·7-75·8) of 156 in the bOPV plus IPV group, and in 121 (78·1%, 70·7-84·3) of 155 in the bOPV plus 2IPV group. Seroconversion against poliovirus type 3 was achieved in 147 (90·2%, 84·5-94·3) of 163 in the tOPV group, 152 (99·3%, 96·4-100) of 153 in the tOPV plus IPV group, 151 (97·4%, 93·5-99·3) of 155 in the bOPV group, 155 (99·4%, 96·5-100) of 156 in the bOPV plus IPV group, and 153 (98·7%, 95·4-99·8) of 155 in the bOPV plus 2IPV group. Superiority was achieved for vaccine regimens including IPV against poliovirus type 3 compared with those not including IPV (tOPV plus IPV vs tOPV alone, p=0·0008; and bOPV plus IPV vs bOPV alone, p=0·0153). 12 serious adverse events occurred (six in the tOPV group, one in the tOPV plus IPV group, three in the bOPV group, zero in the bOPV plus IPV group, and two in the bOPV plus 2IPV group), none of which was attributed to the trial intervention.

INTERPRETATION

The new vaccination schedule improves immunogenicity against polioviruses, especially against poliovirus type 3.

FUNDING

WHO, through a grant from Rotary International (grant number 59735).

Splice factor mutations and alternative splicing as drivers of hematopoietic malignancy

Differential splicing contributes to the vast complexity of mRNA transcripts and protein isoforms that are necessary for cellular homeostasis and response to developmental cues and external signals. The hematopoietic system provides an exquisite example of this. Recently, discovery of mutations in components of the spliceosome in various hematopoietic malignancies (HMs) has led to an explosion in knowledge of the role of splicing and splice factors in HMs and other cancers. A better understanding of the mechanisms by which alternative splicing and aberrant splicing contributes to the leukemogenic process will enable more efficacious targeted approaches to tackle these often difficult to treat diseases. The clinical implications are only just starting to be realized with novel drug targets and therapeutic strategies open to exploitation for patient benefit.

Revealing Missing Human Protein Isoforms Based on Ab Initio Prediction, RNA-seq and Proteomics

Biological and biomedical research relies on comprehensive understanding of protein-coding transcripts. However, the total number of human proteins is still unknown due to the prevalence of alternative splicing. In this paper, we detected 31,566 novel transcripts with coding potential by filtering our ab initio predictions with 50 RNA-seq datasets from diverse tissues/cell lines. PCR followed by MiSeq sequencing showed that at least 84.1% of these predicted novel splice sites could be validated. In contrast to known transcripts, the expression of these novel transcripts were highly tissue-specific. Based on these novel transcripts, at least 36 novel proteins were detected from shotgun proteomics data of 41 breast samples. We also showed L1 retrotransposons have a more significant impact on the origin of new transcripts/genes than previously thought. Furthermore, we found that alternative splicing is extraordinarily widespread for genes involved in specific biological functions like protein binding, nucleoside binding, neuron projection, membrane organization and cell adhesion. In the end, the total number of human transcripts with protein-coding potential was estimated to be at least 204,950.

A Japanese Encephalitis Vaccine From India Induces Durable and Cross-protective Immunity Against Temporally and Spatially Wide-ranging Global Field Strains

BACKGROUND

Japanese encephalitis (JE) is a vaccine-preventable acute disease. We report the results of a phase 2/3 trial of JENVAC, a Vero cell-derived vaccine developed using an Indian strain of JE virus (JEV).

METHODS

JENVAC was administered in 2 doses 28 days apart, and immunogenicity was compared to that from a single dose of SA-14-14-2, the only approved JE vaccine and regimen at the time in India.

RESULTS

After both the doses, seroconversion and seroprotection were >90% for JENVAC. For SA-14-14-2, seroconversion and seroprotection were 57.69% and 77.56%, respectively, on day 28 and 39.74% and 60.26%, respectively, on day 56. The geometric mean titers at day 28 and day 56 were 145.04 and 460.53, respectively, for JENVAC and 38.56 and 25.29, respectively, for SA-14-14-2. With a single dose of JENVAC, seroprotection titers lasted at least 12 months in >80% of the subjects. Following receipt of 2 doses, 61.17% of subjects retained seroprotection titers at 24 months, and immunogenicity criteria were higher than that for SA-14-14-2 at 12, 18, and 24 months each. Sera from JENVAC subjects neutralized JEV genotypes I, II, III, and IV equally well. Adverse events were not significantly different between the 2 vaccines.

CONCLUSIONS

JENVAC elicits long-lasting, broadly protective immunity.

CLINICAL TRIALS REGISTRATION

CTRI/2011/07/001855.

Patellar clunk in total knee arthroplasty using modified Sigma posterior stabilized femoral component

AIM

The purpose of this study was to evaluate the efficacy of the enhanced PS femoral component design released in 2008 by DePuy. The patellar clunk syndrome has been reported in a significant number of patients following total knee arthroplasty. Design modifications of the implant have been made to reduce the incidence of the patellar clunk, especially in the posterior substituted designs.

METHODS

130 total knee replacements performed using the enhanced PS femoral components were followed-up with clinical and radiographic evaluations.

RESULTS

Patellar clunk was seen in 3 of the 130 knees (2%). This is much less than the incidence of patellar clunk reported until now.

CONCLUSIONS

Removal of the sharp ridge in the intercondylar groove in the newer implant seems to have been effective in reducing the incidence of the patellar clunk. It also indicates that the sharp ridge was the most probable cause of the clunk.