Longitudinal Study to Find the Association of Serum Phosphorus Level with FGF23 in Three Different Hyperphosphatemia Management Groups of Stage 3 and 4 Chronic Kidney Disease (CKD) Patients

Background

There is paucity of clinical evidence on target serum phosphorus levels in early chronic kidney disease (CKD). Present longitudinal study was done to find target phosphorus level and its association with fibroblast growth factor (FGF23) in three different hyperphosphatemia management groups.

Methods

This 1-year, prospective, randomized controlled, open-labelled study was conducted among three equally allocated treatment groups that consisted of 120 screened early CKD patients totally. Group 1 patients were given dietary phosphorus modification (n = 40), group 2 patients were administered calcium-based phosphate binders (n = 40), and group 3 patients were given non-calcium-based phosphate binders (n = 40). Three-monthly dietary assessment, MDRD estimated glomerular filtration rate (eGFR), phosphorus, calcium, iPTH, alkaline phosphatase, and six-monthly FGF23, 2D echocardiography, and X-ray of chest and abdomen were performed. Association of three categories of phosphorus level up to 3.9, 4-5, and >5mg/dl, rate of progression of all parameters, and correlation with FGF23 were studied among all three groups.

Results

At baseline, all clinical and biochemical parameters were equally distributed with a controlled nutritional phosphate among all groups. There was no significant difference of FGF23 levels from all the three categories of phosphorus level among all groups. Serum phosphorus at the level of 5 mg/dl was associated with iPTH and eGFR at 1 year. Over 1 year, there was a significant decline in serum phosphorus levels in group 1 (P 0.02), group 2 (P 0.00), and group 3 (P 0.05). FGF23 declined significantly only in group 3 (P 0.00). There was no correlation of FGF23 with serum phosphorus levels (P 0.13). However, FGF23 correlated positively with iPTH (P 0.03, r = 0.19).

Conclusion

Serum phosphorus levels upto 5mg/dl had no effect on FGF23 at early CKD stages. Although different treatment groups showed significant phosphorus reduction, non-calcium phosphate binder had a major impact on FGF23 reduction.

Displacement Pattern, Stress Distribution, and Archwire Play Dimensions during En-masse Retraction of Anterior Teeth using Sliding Mechanics: A FEM Study

Aims

This finite element study was undertaken to evaluate the pattern of stress distribution around the implant and anterior teeth during en-masse retraction in the premolar extraction case. Displacement of the teeth and play of wire in the bracket slot were also evaluated to determine the most favorable height of the power arm attached to the arch-wire.

Materials and methods

A three-dimensional (3D) finite element model of the maxilla was constructed using computed tomography (CT) scan. A total of 12 models were fabricated with different heights of power arms placed distal to the canine. A retraction force of 1.5 N was applied from the implant placed between the roots of the second premolar and first molar, and the response was predicted using Analysis of Systems (ANSYS) software.

Results

When power-arm height was near the center of resistance of the anterior segment, stability in the stress distribution around the implant site and anterior teeth was observed. Displacement of the teeth varied along the three planes of space with the change in power-arm height.

Conclusion

For en-masse retraction, power-arm height should be kept at a level of the center of resistance. Play in the bracket slot and the archwire show a negative role in the bodily movement of anterior teeth.

Clinical significance

For efficient en-masse retraction of anterior teeth, it is imperative to study the most effective site of application of force. Therefore, our study recommends certain key points to keep in mind during the attachment of the power arm and engaging wire in the bracket slot, which could benefit the orthodontist immensely.

How to cite this article

Singh H, Khanna M, Walia C, et al. Displacement Pattern, Stress Distribution, and Archwire Play Dimensions during En-masse Retraction of Anterior Teeth using Sliding Mechanics: A FEM Study. Int J Clin Pediatr Dent 2022;15(6):739-744.

An Unusual Case of High-Grade Non-Hodgkin Lymphoma Masquerading as Acute Pyelonephritis with Acute Kidney Injury

Renal involvement in non-Hodgkin lymphoma (NHL) has myriad of morphological features. We discuss an unusual case who presented as acute pyelonephritis (leucocytosis and acute kidney injury), ovarian mass and compressive myelopathy finally diagnosed as Non Hodgkins Lymphoma.

Idiopathic Intracranial Hypertension and Endoscopic Optic Nerve Sheath Fenestration

Idiopathic intracranial hypertension (IIH), also called as benign intracranial hypertension is a disorder, which is  considered benign in its course except its' ill effects on vision. Ocular findings in IIH such as papilledema, macular changes, retinal micro haemorrhages, cotton wool spots and tortuosity of vessels are the prominent features in funduscopy examination in these patients. Papilledema is a hallmark feature for evaluation of response to treatment. Ophthalmological rescue is a primary goal of management of idiopathic intracranial hypertension. Among the treatment options described in literature, optic nerve sheath fenestration is a minimally invasive endoscopic technique for the rescue of vision. We present this case-report, which will help ophthalmologists and the surgeons to determine the significance of the funduscopy changes after optic nerve sheath fenestration and help in decision making.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery

OBJECTIVE

To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy.

METHODS

This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions.

RESULTS

A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049).

DISCUSSION

Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy.

IMPLICATIONS FOR PRACTICE

Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community.

REGISTRATION

The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

Role of Triamcinolone Irrigation in Postoperative Outcomes in Patients Operated for Chronic Rhinosinusitis: A Matched-Pair Randomized Controlled Trial

PURPOSE

Endoscopic sinus surgery (ESS) is the standard treatment strategy for chronic rhinosinusitis (CRS) resistant to medical treatment, and it is known to have postoperative complications and recurrences, which in turn result in suboptimal outcomes. Several methods are used to prevent postoperative scarring, adhesions, oedema, infection or recurrences in cavities. The role of steroids in improving postoperative outcomes is well established. They can be administered systemically or locally to enhance drug delivery into paranasal sinuses. In this study, we used triamcinolone irrigation immediately following surgery on one side of the nose, in patients with bilateral disease. The objective of this study was to evaluate the effect of intra-operative triamcinolone irrigation on postoperative outcomes, in patients with bilateral pansinusitis.

METHODS

It was an interventional randomized controlled study, conducted at a tertiary care centre in North India. The analysis of 58 patients with bilateral pansinusitis was done from September 2020 to August 2021. At the conclusion of ESS, each patient was randomized to receive triamcinolone irrigation (4 ml of 40mg/ml solution) once and followed by merocel (polyvinyl acetal) packing on one side, while the contralateral side was packed with merocel soaked with saline. Nasal cavities were evaluated using a Hopkins rod endoscope in the postoperative 1st, 3rd, 8th and 12th weeks to look for the presence of postoperative crusting, oedema, polypoidal changes, and discharge. Perioperative sinus endoscopic scores (POSE) were used for endoscopic staging.

RESULTS

The most commonly affected age group was 31-45 years accounting for 39.7%. Males were affected more (63.7%) than the female population (36.3%). There was a reduction in the average POSE scores at the treatment site at all follow-up stages with a significant reduction in crusting, oedema, and scarring in the treatment site (P-value <0.001).

CONCLUSION

Triamcinolone irrigation effectively improves postoperative outcomes and reduces early postoperative complications in CRS patients.

over-activated p21 protein activated kinase-3 (pak3) leads to myocardial lipotoxicity and cardiac dysfunction in diet-induced metabolic stress

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

In clinics, metabolic stress-induced cardiomyopathy is featured as diastolic/systolic dysfunction, at least partially resulting from impairment of metabolic flexibility in the myocardium, which leads to lipotoxicity and oxidative stress accompanied with cardiomyocytes death. P21-activated kinases (Paks) are a family of serine/threonine kinases, involved in cell survival, proliferation and cytoskeleton remodelling. In spite of the cardioprotective functions of Pak1 and Pak2 in the myocardium, the role of cardiac Pak3 is unexplored.

Purpose

The study is to investigate the function of cardiac Pak3 on myocardial steatosis in response to diet-induced metabolic stress, which will provide proof-of-concept evidence for the therapeutic potential for alleviating cardiac dysfunction by targeting lipotoxicity in the myocardium.

Methods

Pak3 overexpression in the myocardium was achieved by tail vein injection of adeno associated virus (AAV9) delivery of troponin T promoter-driven Pak3 on C57BL/6J mice. The mice were fed with high fat high sucrose diet, the metabolic profiles and cardiac function were measured at 4-week intervals. In addition, cardiac morphological and cellular changes were assessed, including cell size, fibrosis formation, cell death, lipid accumulation and lipid peroxidation. In addition, the transcript levels of the genes either participating lipid metabolism or regulating oxidative stress were also assessed by qPCR.

Results

First, we detected that Pak3 expression and activation was increased in the myocardium from human with obese or diabetes. Consistently, the augmented Pak3 was also detected in the failing heart from C57BL/6J mice, ob/ob and db/db mice. Next, in a time-course study, the mice with AAV9-delivery cardiac Pak3 overexpression were vulnerable to cardiac dysfunction upon diet-induced metabolic stress. Pak3 overexpression did not alter cardiomyocyte size; however, more fibrosis and cell death in the myocardium were detected due to Pak3 enhancement. More importantly, myocardial lipid accumulation and profound lipid peroxidation were determined by immunefluorescent staining of Perilipin 5 (PLIN5) and 4-Hydroxynonenal (4-NHE), respectively. Finally, the abnormal expression of the genes involved in lipid synthesis and fatty acid oxidation was detected in Pak3-overexpressed myocardium under metabolic stress, whereas the levels of anti-oxidative stress genes were decreased.

Conclusion

Altogether, the study has demonstrated that Pak3 over-activation makes the heart more susceptible to myocardial lipotoxicity, which accelerates cardiac steatosis and dysfunction in the fact of metabolic stress.

Paracrine signal emanating from stressed cardiomyocytes aggravates inflammatory microenvironment in diabetic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Cardiovascular issues associated with diabetes, such as diabetic cardiomyopathy (DCM), can lead to heart failure. DCM is etiologically related to myocardial inflammation and can stem from a complex interplay of different cell types. Cardiomyocyte as an active mediator of the inflammatory response is an emerging concept with limited mechanistic understanding.

Purpose

We aimed to address the knowledge gap of cardiomyocyte endoplasmic reticulum (ER) dysfunction-mediated macrophage response and provide functional evidence for the therapeutic feasibility of managing inflammatory paracrine signals in response to diet-induced metabolic stress.

Methods

In vivo mouse model of high fat high sucrose diet-induced diabetes, cardiomyocyte-specific p21-activated kinase 2 (PAK2) knockout model, echocardiography, histology, 3D imaging, qPCR, co-culture of H9c2 culturing medium and bone-marrow derived macrophages, immunoblotting, macrophage isolation from myocardium, flow cytometry and AAV9-gene therapy.

Results

In a time-course study, diet-induced diabetic mice demonstrated an association between cardiac ER stress and sustained myocardial inflammation, with a maladaptive shift in myocardial ER stress response over time. Furthermore, as a cardiac ER dysfunction model, mice with cardiac-specific PAK2 deletion exhibited heightened myocardial inflammatory response in diabetes. Using human and mice diabetic heart samples, we show that ER stress-induced CCAAT/enhancer-binding protein homologous protein (CHOP) is a novel transcriptional regulator of high mobility group box-1 (HMGB1). Cardiac stress-induced active release of HMGB1 facilitated M1 macrophage polarization, and aggravated myocardial inflammatory signatures. Therapeutically, sequestering the extracellular HMGB1 using Glycyrrhizin conferred cardioprotection through its anti-inflammatory action. Also, as functional evidence, we showed that un-mitigated cardiac ER response due to PAK2 loss under diabetes may account as a barrier for leveraging the anti-inflammatory potential of Vildagliptin.

Conclusion

Collectively, we introduce an ER stress-mediated cardiomyocyte-macrophage link, altering the macrophage response in the myocardium, thereby providing insight into therapeutic prospects for diabetes-associated cardiac dysfunction.

Fracture toughness and fractal analysis of ceramic benchmark materials

Previous studies have reported various methods of measuring the fracture toughness of brittle ceramics. The purpose of the present research was to use a new method of fractal dimension measurement on benchmark materials (silica glass, Viosil SX, Shin-Etsu, n = 13, and silicon nitride standard reference material, SRM2100, NIST, n = 10), to compare the fracture toughness calculated using different methods, and to study the effect of noise filtering on the fractal dimension and fracture surface roughness. Fracture toughness was determined using surface crack in flexure method according to ASTM C1421 and fractal analysis method. Fractal dimension was determined using the Minkowski Cover algorithm on atomic force microscope scans of epoxy replicas of fracture surfaces. The mean ± standard deviation of fracture toughness using surface crack in flexure method and fractals method were 0.97 ± 0.18 MPa·m1/2 and 1.03 ± 0.07 MPa·m1/2 for silica glass and 4.62 ± 0.14 MPa·m1/2 and 2.54 ± 0.07 MPa·m1/2 for silicon nitride, respectively. The mean ± standard deviation of fractal dimension was 2.17 ± 0.03 for silica glass and 2.13 ± 0.01 for silicon nitride. The mean ten-point roughness (Rz) before and after noise filtering was 89 ± 102 nm and 87 ± 101 nm for silica glass and 355 ± 132 nm and 357 ± 134 nm for silicon nitride, respectively. Noise filtering had no significance on the fracture surface roughness of the two materials. The newly developed fractal analysis method can be used to predict the baseline fracture toughness of specimens with unknown failure stress.

AB1421 IMPACT OF HOSPITALIZATION ON CLINICAL OUTCOMES IN PATIENTS WITH CONNECTIVE TISSUE DISEASE ASSOCIATED INTERSTITIAL LUNG DISEASE (CTD-ILD) - A SINGLE CENTER OBSERVATIONAL STUDY

Background

Interstitial lung disease(ILD) is major cause of morbidity and mortality in patients with connective tissue disease (CTD). Hospitalization is being increasingly recognized as poor prognostic indicator in these patients.

Objectives

The objective of our study was to assess the impact of hospitalization on clinical outcomes in patients with CTD-ILD.

Methods

We conducted a retrospective chart review of patients with radiologically or biopsy proven ILD associated with rheumatologist diagnosed CTD who were seen at Montefiore Medical Center between January 2007 and December 2018. Patients with age>18 years who had either 2 CT scans of the chest and/or 2 sets of pulmonary function tests (PFT) atleast 6 months apart were included in the study. Clinical demographics, cause of hospitalization, length of stay, use of immunosuppression and mortality were identified. Patients were stratified into 2 cohorts; non-hospitalized and hospitalized patients. The latter cohort was further sub-stratified into patients with cardiopulmonary vs. non-cardiopulmonary hospitalization (Figure 1). Two-sample t-tests and Wilcoxon’s rank sum tests were used for comparing the continuous variables. Chi-square tests and Fisher’s exact tests were used for comparing the categorical variables as appropriate. Kaplan-Meier method was used for calculating the survival probabilities, and log-rank tests were used to compare differences between the groups.

Results

During the study period, we identified 213 patients with CTD-ILD using ICD 9/10 code. Of the 213 patients, 96 met our inclusion criteria and 73 (76%) had at least 1 hospitalization (Figure 1). Both groups were similar in baseline clinical characteristics but we identified significantly higher transplant referrals in the hospitalized group(23.9%) vs. non-hospitalized group(0%) (Table 1). Overall rheumatoid arthritis (29.2%) was the most common CTD associated ILD followed by inflammatory myositis (21.9%) and scleroderma (14.6%). Median time from diagnosis of ILD to first hospitalization was 1.42 years.

Table 1.

Baseline Characteristics of patients with CTD-ILD

CharacteristicEntire Cohort (n = 96)Patients with CTD-ILD and hospitalization (n = 73)Patients with CTD-ILD and no hospitalization (n = 23)p-valueAge(mean ± SD)54.15 ± 13.9754.82 ± 13.7752.00 ± 14.710.40Female, n (%)76 (79.2)56 (76.7)20 (87.0)0.39Race, % (n)0.10 Black38 (39.6)31 (42.5)7 (30.4) White4 (4.2)3 (4.1)1 (4.4) Others54 (56.2)39(53.4)15(65.3)Ethnicity, % (n) (Hispanic)44 (53.7)35 (53.0)9 (56.3)0.82Former or active smoker, % (n)41 (42.7)34 (46.6)7 (30.4)0.17Pulmonary hypertension, % (n)28 (31.1)24 (33.3)4 (22.2)0.36FVC, n (%)0.37Moderately severe(47.1-64.2)37 (44.6)26 (40.6)11 (57.9)Severe(24.3-47.0)7 (8.4)6 (9.4)1 (5.3)DLCO, n(%)0.30Moderate26(31.7)23(37.1)3(15.0)Severe25(30.5)17(27.4)8(40.0)Immunosuppression, n(%)78 (81.3)59 (80.8)19 (82.6)1.00Transplant referral, n(%)17 (18.3)17 (23.9)0 (0)0.01

The patients hospitalized for cardiopulmonary cause were significantly older(57.2 ±13.1 years) than those admitted with non-cardiopulmonary cause(49.2±14.8 years)(Mean±SD). Older age (HR 1.95, p=0.02) and length of stay greater than 7 days for cardiopulmonary cause(HR 4.82,p=0.01) was associated with higher risk of mortality.

Kaplan Meier curve analysis showed that hospitalization (p-value=0.02) was associated with statistically significant increased risk of death.

Conclusion

-Hospitalization in CTD-ILD patients especially length of stay more than 7 days due to cardiopulmonary causes was associated with statistically significant increased risk of death.

Male gender and older age was associated with a worse prognosis in patients who were hospitalized.

References

[1]Ratwani AP, Ahmad KI, Barnett SD, Nathan SD, Brown AW. Connective tissue disease-associated interstitial lung disease and outcomes after hospitalization: A cohort study. Respiratory Medicine. 2019;154:1-5. doi:10.1016/j.rmed.2019.05.020

Disclosure of Interests

None declared

A hypothalamic pathway for Augmentor α-controlled body weight regulation

Augmentor α and β (Augα and Augβ) are newly discovered ligands of the receptor tyrosine kinases Alk and Ltk. Augα functions as a dimeric ligand that binds with high affinity and specificity to Alk and Ltk. However, a monomeric Augα fragment and monomeric Augβ also bind to Alk and potently stimulate cellular responses. While previous studies demonstrated that oncogenic Alk mutants function as important drivers of a variety of human cancers, the physiological roles of Augα and Augβ are poorly understood. Here, we investigate the physiological roles of Augα and Augβ by exploring mice deficient in each or both Aug ligands. Analysis of mutant mice showed that both Augα single knockout and double knockout of Augα and Augβ exhibit a similar thinness phenotype and resistance to diet-induced obesity. In the Augα-knockout mice, the leanness phenotype is coupled to increased physical activity. By contrast, Augβ-knockout mice showed similar weight curves as the littermate controls. Experiments are presented demonstrating that Augα is robustly expressed and metabolically regulated in agouti-related peptide (AgRP) neurons, cells that control whole-body energy homeostasis in part via their projections to the paraventricular nucleus (PVN). Moreover, both Alk and melanocortin receptor-4 are expressed in discrete neuronal populations in the PVN and are regulated by projections containing Augα and AgRP, respectively, demonstrating that two distinct mechanisms that regulate pigmentation operate in the hypothalamus to control body weight. These experiments show that Alk-driven cancers were co-opted from a neuronal pathway in control of body weight, offering therapeutic opportunities for metabolic diseases and cancer.

Silver Nanostructures prepared via novel green approach as an effective platform for biological and environmental applications

Silver nanoparticles play a significant role in biomedical sciences due to their unique properties allowing for their use as an effective sensing and remediation platform Herein, the green synthesis of silver nanostructures (Ag NSs), prepared via aqueous extract of waste Brassica oleracea leaves in the presence of silver nitrate solution (10^-4 M), is reported. The Ag NSs are fully characterized and their efficacy with respect to 4-nitrophenol reduction, glucose sensing, and microbes is determined. Visually, the color of silver nitrate containing solution altered from colorless to yellowish, then reddish grey, confirming the formation of Ag NSs. HRTEM and SEAD studies revealed the Ag NSs to have different morphologies (triangular, rod-shaped, hexagonal, etc., within a size range of 20–40 nm) with face-centered cubic (fcc) crystal structure. The Ag NSs possess high efficacy for nitrophenol reduction (<11 min and degradation efficiency of 98.2%), glucose sensing (LOD: 5.83 µM), and antimicrobial activity (E. coli and B. subtilis with clearance zones of 18.3 and 14 mm, respectively). Thus, the current study alludes towards the development of a cost-effective, sustainable, and efficient three-in-one platform for biomedical and environmental applications.

Effect of Non Incentivised and Incentivised Free COVID-19 Vaccination Camps in Augmentation of State’s Efforts in Achieving Vaccination Targets Necessary for Herd Immunity

Introduction: Most effective way to defeat the Coronavirus Disease-2019 (COVID-19) pandemic is mass vaccination to achieve herd immunity which requires vaccination of about 80% of the population. Aim: To compare the effect of non incentivised and incentivised free COVID-19 vaccination camps on augmentation of state's efforts in achieving vaccination targets of covering 80% of population. Materials and Methods: Free COVID-19 vaccination camps, both non incentivised (8 days) and incentivised (8 days), were organised in month of June and July, 2021 at a hospital in association with an NGO under the supervision of District Immunisation Officer. The retrospective observational study was done and data of all vaccinations done was compared to document the effect of incentivised free vaccination camp as compared to non incentivised camps. Data was represented as frequency, percentage and Chi-square test was used. Results: Total of 4111 vaccinations were done during the free vaccination camps, including 1406 during non incentivised and 2705 during incentivised camps. During non incentivised camps 1114 people were given 1st dose and 292 were given 2nd dose, while during incentivised camps 2334 people were given 1st dose and 371 were given 2nd dose. Analysis of the data showed that the difference in number of 1st dose and 2nd dose vaccinations done during the incentivised vaccination camps was statistically significantly higher as compared to the number of 1st dose and 2nd dose vaccinations done during non incentivised vaccination camps. Similar results showed that the difference in number of vaccination done among the age groups of 18-44 years and >44 years during the incentivised vaccination camps was statistically significantly higher as compared to the number of vaccination among the age groups of 18-44 years and >44 years done during the non incentivised vaccination camps. Conclusion: The present study documented statistically significantly higher number of 1st dose of vaccinations, 2nd dose of vaccinations, vaccinations among 18-44 years age group and >44 years age group done during incentivised vaccination camps as compared to non incentivised vaccination camps. Results of the present study suggest that incentivised vaccination campaigns should be incorporated as an important component of COVID-19 vaccination campaign strategy to vaccinate enough Indian population and achieve herd immunity for protection from COVID-19 pandemic.