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Salami OM, Habimana O, Peng JF, Yi GH. Therapeutic Strategies Targeting Mitochondrial Dysfunction in Sepsis-induced Cardiomyopathy. Cardiovasc Drugs Ther 2024; 38:163-180. [PMID: 35704247 DOI: 10.1007/s10557-022-07354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/03/2022]
Abstract
Sepsis is an increasingly worldwide problem; it is currently regarded as a complex life-threatening dysfunction of one or more organs as a result of dysregulated host immune response to infections. The heart is one of the most affected organs, as roughly 10% to 70% of sepsis cases are estimated to turn into sepsis-induced cardiomyopathy (SIC). SIC can be defined as a reversible myocardial dysfunction characterized by dilated ventricles, impaired contractility, and decreased ejection fraction. Mitochondria play a critical role in the normal functioning of cardiac tissues as the heart is highly dependent on its production of adenosine triphosphate (ATP), its damage during SIC includes morphology impairment, mitophagy, biogenesis disequilibrium, electron transport chain disturbance, molecular damage from the actions of pro-inflammatory cytokines and many other different impairments that are major contributing factors to the severity of SIC. Although mitochondria-targeted therapies usage is still inadequate in clinical settings, the preclinical study outcomes promise that the implementation of these therapies may effectively treat SIC. This review summarizes the different therapeutic strategies targeting mitochondria structure, quality, and quantity abnormalities for the treatment of SIC.
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Affiliation(s)
| | - Olive Habimana
- International College, University of South China, 28, W Changsheng Road, Hengyang, 421001, Hunan, China
| | - Jin-Fu Peng
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hengyang Medical School, University of South China, 28, W Changsheng Road, Hengyang, 421001, Hunan, China
- Institute of Pharmacy and Pharmacology, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, 28, W Changsheng Road, Hengyang, 421001, Hunan, China
| | - Guang-Hui Yi
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hengyang Medical School, University of South China, 28, W Changsheng Road, Hengyang, 421001, Hunan, China.
- Institute of Pharmacy and Pharmacology, Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, 28, W Changsheng Road, Hengyang, 421001, Hunan, China.
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Kumar S, Srivastava VK, Kaushik S, Saxena J, Jyoti A. Free Radicals, Mitochondrial Dysfunction and Sepsis-induced Organ Dysfunction: A Mechanistic Insight. Curr Pharm Des 2024; 30:161-168. [PMID: 38243948 DOI: 10.2174/0113816128279655231228055842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024]
Abstract
Sepsis is a complex clinical condition and a leading cause of death worldwide. During Sepsis, there is a derailment in the host response to infection, which can progress to severe sepsis and multiple organ dysfunction or failure, which leads to death. Free radicals, including reactive oxygen species (ROS) generated predominantly in mitochondria, are one of the key players in impairing normal organ function in sepsis. ROS contributing to oxidative stress has been reported to be the main culprit in the injury of the lung, heart, liver, kidney, gastrointestinal, and other organs. Here in the present review, we describe the generation, and essential properties of various types of ROS, their effect on macromolecules, and their role in mitochondrial dysfunction. Furthermore, the mechanism involved in the ROS-mediated pathogenesis of sepsis-induced organ dysfunction has also been discussed.
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Affiliation(s)
- Sanni Kumar
- Department of Biotechnology Engineering and Food Technology, University Institute of Engineering, Chandigarh University, Mohali, Punjab 140413, India
| | | | - Sanket Kaushik
- Amity Institute of Biotechnology, Amity University, Rajasthan, Jaipur 303007, India
| | - Juhi Saxena
- Department of Biotechnology, Parul Institute of Technology, Parul University, Vadodara, Gujarat 391760, India
| | - Anupam Jyoti
- Department of Life Sciences, Parul Institute of Applied Sciences, Parul University, Vadodara, Gujarat 391760, India
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3
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Elloumi N, Bahloul M, Benabdallah E, Kharrat S, Fakhfakh R, Bouchaala K, Abida O, Chtara K, Masmoudi H, Bouaziz M. Genes regulating oxidative-inflammatory response in circulating monocytes and neutrophils in septic syndrome. Biol Futur 2023; 74:199-207. [PMID: 37291472 DOI: 10.1007/s42977-023-00168-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 05/13/2023] [Indexed: 06/10/2023]
Abstract
Despite significant progress in the past decades, sepsis still lacks a specific treatment. Under normal conditions, leucocytes play a critical role in controlling infection and it is suggested that their activity is impaired during sepsis which contribute to the dysregulation of immune reactions. Indeed, in response to infection, several intracellular pathways are affected mainly those regulating the oxidative- inflammatory axis. Herein, we focused on the contribution of NF-kB, iNOS, Nrf2, HO-1 and MPO genes in the pathophysiology of septic syndrome, by analyzing the differential expression of their transcripts in circulating monocytes and neutrophils, and monitoring the nitrosative/oxidative status in septic syndrome patients. Circulating neutrophils of septic patients displayed a significant overexpression of NF-kB compared to other groups. In monocytes, patients with septic shock expressed the highest levels of iNOS and NF-kB mRNA. However, genes involved in cytoprotective response had increased expression in patients with sepsis, in particular, the Nrf2 and its target gene HO-1. Moreover, patient monitoring indicates that the iNOS enzyme expression and NO plasma levels may play a role in assessing the severity of septic conditions. Overall, in either monocytes or neutrophils, we pointed out the major role of NF-κB and Nrf2 in the pathophysiological process. Therefore, therapies targeted to redox abnormalities may be useful for better management of septic patients.
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Affiliation(s)
- Nesrine Elloumi
- Research Laboratory LR18/SP12 Auto-Immunity, Cancer and Immunogenetics, Immunology Department, Habib Bourguiba University Hospital, University of Sfax, 3029, Sfax, Tunisia.
| | - Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Emna Benabdallah
- Research Laboratory LR18/SP12 Auto-Immunity, Cancer and Immunogenetics, Immunology Department, Habib Bourguiba University Hospital, University of Sfax, 3029, Sfax, Tunisia
| | - Sana Kharrat
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Raouia Fakhfakh
- Research Laboratory LR18/SP12 Auto-Immunity, Cancer and Immunogenetics, Immunology Department, Habib Bourguiba University Hospital, University of Sfax, 3029, Sfax, Tunisia
| | - Karama Bouchaala
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Olfa Abida
- Research Laboratory LR18/SP12 Auto-Immunity, Cancer and Immunogenetics, Immunology Department, Habib Bourguiba University Hospital, University of Sfax, 3029, Sfax, Tunisia
| | - Kamilia Chtara
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Hatem Masmoudi
- Research Laboratory LR18/SP12 Auto-Immunity, Cancer and Immunogenetics, Immunology Department, Habib Bourguiba University Hospital, University of Sfax, 3029, Sfax, Tunisia
| | - Mounir Bouaziz
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
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Barber G, Tanic J, Leligdowicz A. Circulating protein and lipid markers of early sepsis diagnosis and prognosis: a scoping review. Curr Opin Lipidol 2023; 34:70-81. [PMID: 36861948 DOI: 10.1097/mol.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Sepsis is the extreme response to infection associated with high mortality, yet reliable biomarkers for its identification and stratification are lacking. RECENT FINDINGS Our scoping review of studies published from January 2017 to September 2022 that investigated circulating protein and lipid markers to inform non-COVID-19 sepsis diagnosis and prognosis identified interleukin (IL)-6, IL-8, heparin-binding protein (HBP), and angiopoietin-2 as having the most evidence. Biomarkers can be grouped according to sepsis pathobiology to inform biological data interpretation and four such physiologic processes include: immune regulation, endothelial injury and coagulopathy, cellular injury, and organ injury. Relative to proteins, the pleiotropic effects of lipid species' render their categorization more difficult. Circulating lipids are relatively less well studied in sepsis, however, low high-density lipoprotein (HDL) is associated with poor outcome. SUMMARY There is a lack of robust, large, and multicenter studies to support the routine use of circulating proteins and lipids for sepsis diagnosis or prognosis. Future studies will benefit from standardizing cohort design as well as analytical and reporting strategies. Incorporating biomarker dynamic changes and clinical data in statistical modeling may improve specificity for sepsis diagnosis and prognosis. To guide future clinical decisions at the bedside, point-of-care circulating biomarker quantification is needed.
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Affiliation(s)
- Gemma Barber
- Schulich School of Medicine and Dentistry
- Robarts Research Insitute
| | | | - Aleksandra Leligdowicz
- Schulich School of Medicine and Dentistry
- Robarts Research Insitute
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
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Fast Track Diagnostic Tools for Clinical Management of Sepsis: Paradigm Shift from Conventional to Advanced Methods. Diagnostics (Basel) 2023; 13:diagnostics13020277. [PMID: 36673087 PMCID: PMC9857847 DOI: 10.3390/diagnostics13020277] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/24/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Sepsis is one of the deadliest disorders in the new century due to specific limitations in early and differential diagnosis. Moreover, antimicrobial resistance (AMR) is becoming the dominant threat to human health globally. The only way to encounter the spread and emergence of AMR is through the active detection and identification of the pathogen along with the quantification of resistance. For better management of such disease, there is an essential requirement to approach many suitable diagnostic techniques for the proper administration of antibiotics and elimination of these infectious diseases. The current method employed for the diagnosis of sepsis relies on the conventional culture of blood suspected infection. However, this method is more time consuming and generates results that are false negative in the case of antibiotic pretreated samples as well as slow-growing microbes. In comparison to the conventional method, modern methods are capable of analyzing blood samples, obtaining accurate results from the suspicious patient of sepsis, and giving all the necessary information to identify the pathogens as well as AMR in a short period. The present review is intended to highlight the culture shift from conventional to modern and advanced technologies including their limitations for the proper and prompt diagnosing of bloodstream infections and AMR detection.
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Gupta E, Kumar S, Srivastava VK, Saxena J, Siddiqui AJ, Mehta S, Kaushik S, Jyoti A. Unravelling the Differential Host Immuno-Inflammatory Responses to Staphylococcus aureus and Escherichia coli Infections in Sepsis. Vaccines (Basel) 2022; 10:vaccines10101648. [PMID: 36298513 PMCID: PMC9610428 DOI: 10.3390/vaccines10101648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Previous reports from our lab have documented dysregulated host inflammatory reactions in response to bacterial infections in sepsis. Both Gram-negative bacteria (GNB) and Gram-positive bacteria (GPB) play a significant role in the development and progression of sepsis by releasing several virulence factors. During sepsis, host cells produce a range of inflammatory responses including inducible nitric oxide synthase (iNOS) expression, nitrite generation, neutrophil extracellular traps (NETs) release, and pro-inflammatory cytokines production. The current study was conducted to discern the differences in host inflammatory reactions in response to both Escherichia coli and Staphylococcus aureus along with the organ dysfunction parameters in patients of sepsis. We examined 60 ICU sepsis patients identified based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA II) scores. Pathogen identification was carried out using culture-based methods and gene-specific primers by real-time polymerase chain reaction (RT-PCR). Samples of blood from healthy volunteers were spiked with E. coli (GNB) and S. aureus (GPB). The incidence of NETs formation, iNOS expression, total nitrite content, and pro-inflammatory cytokine level was estimated. Prevalence of E. coli, A. baumannii (both GNB), S. aureus, and Enterococcus faecalis (both GPB) was found in sepsis patients. Augmented levels of inflammatory mediators including iNOS expression, total nitrite, the incidence of NETs, and proinflammatory cytokines, during spiking, were found in response to S. aureus infections in comparison with E. coli infections. These inflammatory mediators were found to be positively correlated with organ dysfunction in both GN and GP infections in sepsis patients. Augmented host inflammatory response was generated in S. aureus infections as compared with E. coli.
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Affiliation(s)
- Ena Gupta
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, Rajasthan, India
| | - Sanni Kumar
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, Rajasthan, India
| | - Vijay Kumar Srivastava
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, Rajasthan, India
| | - Juhi Saxena
- Department of Biotechnology, University Institute of Biotechnology, Chandigarh University, S.A.S Nagar 140413, Punjab, India
| | - Arif Jamal Siddiqui
- Department of Biology, College of Science, University of Ha’il, Ha’il P.O. Box 2440, Saudi Arabia
| | - Sudhir Mehta
- Department of Geriatric Medicine, SMS Medical College & Attached Hospitals, J.L.N. Marg, Jaipur 302004, Rajasthan, India
| | - Sanket Kaushik
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, Rajasthan, India
- Correspondence: (S.K.); (A.J.)
| | - Anupam Jyoti
- Department of Biotechnology, University Institute of Biotechnology, Chandigarh University, S.A.S Nagar 140413, Punjab, India
- Correspondence: (S.K.); (A.J.)
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The Interplay of Oxidative Stress and ROS Scavenging: Antioxidants as a Therapeutic Potential in Sepsis. Vaccines (Basel) 2022; 10:vaccines10101575. [PMID: 36298439 PMCID: PMC9609850 DOI: 10.3390/vaccines10101575] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 12/05/2022] Open
Abstract
Oxidative stress resulting from the disproportion of oxidants and antioxidants contributes to both physiological and pathological conditions in sepsis. To combat this, the antioxidant defense system comes into the picture, which contributes to limiting the amount of reactive oxygen species (ROS) leading to the reduction of oxidative stress. However, a strong relationship has been found between scavengers of ROS and antioxidants in preclinical in vitro and in vivo models. ROS is widely believed to cause human pathology most specifically in sepsis, where a small increase in ROS levels activates signaling pathways to initiate biological processes. An inclusive understanding of the effects of ROS scavenging in cellular antioxidant signaling is essentially lacking in sepsis. This review compiles the mechanisms of ROS scavenging as well as oxidative damage in sepsis, as well as antioxidants as a potent therapeutic. Direct interaction between ROS and cellular pathways greatly affects sepsis, but such interaction does not provide the explanation behind diverse biological outcomes. Animal models of sepsis and a number of clinical trials with septic patients exploring the efficiency of antioxidants in sepsis are reviewed. In line with this, both enzymatic and non-enzymatic antioxidants were effective, and results from recent studies are promising. The usage of these potent antioxidants in sepsis patients would greatly impact the field of medicine.
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Gharamti AA, Samara O, Monzon A, Montalbano G, Scherger S, DeSanto K, Chastain DB, Sillau S, Montoya JG, Franco-Paredes C, Henao-Martínez AF, Shapiro L. Proinflammatory cytokines levels in sepsis and healthy volunteers, and tumor necrosis factor-alpha associated sepsis mortality: A systematic review and meta-analysis. Cytokine 2022; 158:156006. [PMID: 36044827 DOI: 10.1016/j.cyto.2022.156006] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/09/2022] [Accepted: 08/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sepsis is a global health challenge associated with significant morbidity and mortality. Detrimental sepsis effects are attributed to excessive inflammation or a "cytokine storm." However, anti-inflammation therapies have failed to lower sepsis mortality. We aim to characterize levels of key inflammatory cytokines in patients with sepsis and compare levels with those in healthy individuals and relate tumor necrosis factor (TNF) α levels to patient characteristics and outcomes. METHODS We performed a systematic review and meta-analysis. Medline, Embase, Cochrane Library, and Web of Science Core Collection databases were searched between 1985 and May 2020. Analysis was restricted to studies in English. We included randomized controlled trials (RCTs), controlled trials, cohort studies, case series, and cross-sectional studies that reported mean levels of cytokines in the circulation thought to be relevant for sepsis pathogenesis. We also evaluated concentrations of these cytokines in healthy individuals. The Quality in Prognosis Studies tool was used to assess the methodological quality of included studies. We extracted summary data from published reports. Data analyses were performed using a random-effects model to estimate pooled odds ratios (OR) with 95% confidence intervals for cytokine levels and mortality. This systematic review is registered in PROSPERO (CRD42020179800). FINDINGS We identified 3654 records, and 104 studies were included with a total of 3250 participants. The pooled estimated mean TNFα concentration in sepsis patients was 58.4 pg/ml (95% Confidence Interval or CI 39.8-85.8 pg/ml), and in healthy individuals was 5.5 pg/ml (95% CI 3.8-8.0 pg/ml). Pooled estimate means for IL-1β and IFN-γ in sepsis patients were 21.8 pg/ml and 63.3 pg/ml, respectively. Elevated TNFα concentrations associated with increased 28-day sepsis mortality (p = 0.001). In subgroup analyses, we did not detect an association between TNFα levels and sepsis source, sepsis severity, or sequential organ failure assessment (SOFA) score. A TNF-α cutoff level ≥14.7 pg/ml separated sepsis patients from healthy individuals with a sensitivity of 82.6%, a specificity of 91.7%, and a likelihood ratio of 9.9. INTERPRETATION Sepsis mean TNFα concentration is increased approximately 10-fold compared to mean concentration in healthy individuals, and TNFα associated with sepsis mortality but not sepsis severity. The concept that elevated cytokines cause sepsis should be revisited in the context of these data. FUNDING None.
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Affiliation(s)
- Amal A Gharamti
- Department of Internal Medicine, Yale University, Waterbury Hospital, Waterbury, CT, USA
| | - Omar Samara
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anthony Monzon
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gabrielle Montalbano
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sias Scherger
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Stefan Sillau
- Department of Neurology and Department of Biostatistics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jose G Montoya
- Dr. Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto, CA, USA
| | - Carlos Franco-Paredes
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Hospital Infantil de México, Federico Gómez, Mexico City, Mexico
| | - Andrés F Henao-Martínez
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leland Shapiro
- School of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
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Vincent JL, Ince C, Pickkers P. Endothelial dysfunction: a therapeutic target in bacterial sepsis? Expert Opin Ther Targets 2021; 25:733-748. [PMID: 34602020 DOI: 10.1080/14728222.2021.1988928] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Endothelial cells maintain vascular integrity, tone, and patency and have important roles in hemostasis and inflammatory responses. Although some degree of endothelial dysfunction with increased vascular permeability may be necessary to control local infection, excessive dysfunction plays a central role in the pathogenesis of sepsis-related organ dysfunction and failure as it results in dysregulated inflammation, vascular leakage, and abnormal coagulation. The vascular endothelium has thus been proposed as a potential target for therapeutic intervention in patients with sepsis. AREAS COVERED Different mechanisms underlying sepsis-related dysfunction of the vascular endothelium are discussed, including glycocalyx shedding, nitrosative stress, and coagulation factors. Potential therapeutic implications of each mechanism are mentioned. EXPERT OPINION Multiple targets to protect or restore endothelial function have been suggested, but endothelium-driven treatments remain a future potential at present. As some endothelial dysfunction and permeability may be necessary to remove infection and repair damaged tissue, targeting the endothelium may be a particular challenge. Ideally, therapies should be guided by biomarkers related to that specific pathway to ensure they are given only to patients most likely to respond. This enrichment based on biological plausibility and theragnostics will increase the likelihood of a beneficial response in individual patients and enable more personalized treatment.
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Affiliation(s)
- Jean-Louis Vincent
- Dept of Intensive Care, Erasme Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Pickkers
- Dept of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Neutrophil extracellular traps and organ dysfunction in sepsis. Clin Chim Acta 2021; 523:152-162. [PMID: 34537216 DOI: 10.1016/j.cca.2021.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
Sepsis is a clinical syndrome resulting from infection followed by inflammation and is one of the significant causes of mortality worldwide. The underlying reason is the host's uncontrolled inflammatory response due to an infection led to multiple organ dysfunction/failure. Neutrophils, an innate immune cell, are forerunners to reach the site of infection/inflammation for clearing the infection and resolute the inflammation during sepsis. A relatively new neutrophil effector function, neutrophil extracellular traps (NETs), have been demonstrated to kill the pathogens by releasing DNA decorated with histone and granular proteins. A growing number of pieces of shreds of evidence suggest that unregulated incidence of NETs have a significant influence on the pathogenesis of sepsis-induced multiple organ damage, including arterial hypotension, hypoxemia, coagulopathy, renal, neurological, and hepatic dysfunction. Thus, excessive production and improper resolution of NETs are of significant therapeutic value in combating sepsis-induced multiple organ failure. The purpose of this review is intended to highlight the role of NETs in sepsis-induced organ failure. Furthermore, the current status of therapeutic strategies to intersect the harmful effects of NETs to restore organ functions is discussed.
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11
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Cerium oxide nanofiber–based electrochemical immunosensor for detection of sepsis in biological fluid. J Solid State Electrochem 2021. [DOI: 10.1007/s10008-021-05042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Eduardo PM, Mario GL, Carlos César PM, Mayra MA, Sara HY, E BN. Bioelectric, tissue, and molecular characteristics of the gastric mucosa at different times of ischemia. Exp Biol Med (Maywood) 2021; 246:1968-1980. [PMID: 34130514 PMCID: PMC8474982 DOI: 10.1177/15353702211021601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
Gastrointestinal ischemia may be presented as a complication associated with late shock detection in patients in critical condition. Prolonged ischemia can cause mucosal integrity to lose its barrier function, triggering alterations that can induce organ dysfunction and lead to death. Electrical impedance spectroscopy has been proposed to identify early alteration in ischemia-induced gastric mucosa in this type of patients. This work analyzed changes in impedance parameters, and tissue and molecular alterations that allow us to identify the time of ischemia in which the gastric mucosa still maintains its barrier function. The animals were randomly distributed in four groups: Control, Ischemia 60, 90, and 120 min. Impedance parameters were measured and predictive values were determined to categorize the degree of injury using a receiver operating characteristic curve. Markers of inflammatory process and apoptosis (iNOS, TNFα, COX-2, and Caspase-3) were analyzed. The largest increase in impedance parameters occurred in the ischemia 90 and 120 min groups, with resistance at low frequencies (RL) and reactance at high frequencies (XH) being the most related to damage, allowing prediction of the occurrence of reversible and irreversible tissue damage. Histological analysis and apoptosis assay showed progressive mucosal deterioration with irreversible damage (p < 0.001) starting from 90 min of ischemia. Furthermore, a significant increase in the expression of iNOS, TNFα, and COX-2 was identified in addition to apoptosis in the gastric mucosa starting from 90 min of ischemia. Tissue damage generated by an ischemia time greater than 60 min induces loss of barrier function in the gastric mucosa.
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Affiliation(s)
- Peña-Mercado Eduardo
- Posgrado en Ciencias Naturales e Ingenieria, Unidad Cuajimalpa,
Universidad Autonoma Metropolitana, CDMX 05340, Mexico
| | - Garcia-Lorenzana Mario
- Departamento de Biologia de la Reproduccion, Unidad Iztapalapa,
Universidad Autonoma Metropolitana, CDMX 09340, Mexico
| | - Patiño-Morales Carlos César
- Laboratorio de Investigacion en Biologia del Desarrollo y
Teratogenesis Experimental, Hospital Infantil de Mexico, Federico Gomez, CDMX
06720, Mexico
| | - Montecillo-Aguado Mayra
- Doctorado en Ciencias Biologicas, Facultad de Medicina,
Universidad Nacional Autonoma de Mexico, CDMX 04510, Mexico
| | - Huerta-Yepez Sara
- Unidad de Investigacion en Enfermedades Hematoncologicas,
Hospital Infantil de Mexico, Federico Gomez, CDMX 06720, Mexico
| | - Beltran Nohra E
- Departamento de Procesos y Tecnologia, Unidad Cuajimalpa,
Universidad Autonoma Metropolitana, CDMX 05340, Mexico
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13
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Kumar S, Gupta E, Gupta N, Kaushik S, Srivastava VK, Kumar S, Mehta S, Jyoti A. Functional role of iNOS-Rac2 interaction in neutrophil extracellular traps (NETs) induced cytotoxicity in sepsis. Clin Chim Acta 2021; 513:43-49. [PMID: 33309799 DOI: 10.1016/j.cca.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Recent reports from this lab have demonstrated a higher incidence of NETs, nitrosative, as well as oxidative stress, and have a direct correlation with the severity of sepsis and organ damage. However, the mechanistic perspective of NETs induced organ damage has not been understood at the cellular and molecular level. Interaction of inducible nitric oxide synthase (iNOS) with Rac2 in regulating reactive oxygen species (ROS) and reactive nitrogen species (RNS) generation and its implications in microbial killing has been reported. This study was, therefore, undertaken in neutrophils of sepsis patients to investigate the functional importance of iNOS-Rac2 interaction in ROS/ RNS, peroxynitrite generation, NETs generation, and NETs mediated cell death. METHODS The study was conducted on 100 patients with sepsis and 50 healthy volunteers. Interaction between iNOS and Rac2 was performed using co-immunoprecipitation and co-immunolabeling assay. Free radicals involving ROS and RNS were evaluated using cytochrome c reduction assay. NETs formation was evaluated by fluorescence microscopy. The cytotoxic effect of NETs was assessed on lung carcinoma cell line (A549) using colorimetric Alamar blue assay. RESULTS Enhanced interaction between iNOS and Rac2 was found in sepsis neutrophils in comparison with control. This was accompanied by an increased level of superoxide (O2.-), nitric oxide (NO), and peroxynitrite (ONOO-) which were decreased in the presence of NAC, DPI, and 1400 W, signifying the role of iNOS-Rac2 interaction. Enhanced NETs release from activated sepsis neutrophils were abrogated in the presence of DPI. NETs from sepsis neutrophils exert a cytotoxic effect on lung epithelial cells (A549) in a concentration-dependent manner. CONCLUSION Our findings exhibit the functional role of iNOS-Rac2 interaction in ROS/RNS, peroxynitrite generation, NETs generation, and NETs mediated cell death.
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Affiliation(s)
- S Kumar
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India
| | - E Gupta
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India
| | - N Gupta
- Department of Biotechnology, IIS (deemed to be University), Gurukul Marg, SFS, Mansarovar, Jaipur, India
| | - S Kaushik
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India
| | - V K Srivastava
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India
| | - S Kumar
- Amity School of Architecture and Planning, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India
| | - S Mehta
- Department of Medicine, SMS Medical College & Attached Hospitals, J.L.N. Marg, Jaipur, Rajasthan, India
| | - A Jyoti
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur, India.
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14
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Kumar S, Tripathy S, Singh OK, Singh SG. Cerium oxide nanofiber based electroanalytical sensor for TNF-α detection: Improved interfacial stability with Nafion. Bioelectrochemistry 2020; 138:107725. [PMID: 33360954 DOI: 10.1016/j.bioelechem.2020.107725] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/23/2020] [Accepted: 12/10/2020] [Indexed: 12/26/2022]
Abstract
The present work is aimed at improving the adhesion of nanomaterials at the interface of solid state working electrodes. Towards this, herein, an efficient method has been proposed that requires the electrode interface to be decorated with an optimally thin layer of Nafion. This selectively permeable layer ensures the stability of the sensor interface, without hampering the transport of biomolecules and electrons. As a case study, here, electrospun Cerium oxide nanofiber (CeNF) modified Glassy carbon electrodes (GCE) have been used as the sensing interface, and stability and performance of the GCE/CeNF/Nafion interface is evaluated using analytical electrochemistry. The CeNF is synthesized via electrospinning and is characterized using X-ray diffraction spectroscopy, Thermal gravimetry, Fourier transform infrared spectroscopy, and Field emission scanning electron microscopy. Further, detection of sepsis specific biomarker TNF-α from spiked buffer samples is demonstrated, as a case study, towards evaluating the effect of Nafion on the interfacial sensitivity. The achieved LOD of GCE/CeNF and GCE/CeNF/Nafion for TNF-α detection were 2.8 fg/mL and 1.2 fg/mL, respectively. A comparative analysis between the Electrochemical impedance spectroscopic (EIS) results of the GCE/CeNF and the GCE/CeNF/Nafion interfaces confirms the improvement in stability, without affecting the sensitivity and the limiting detection.
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Affiliation(s)
- Sanni Kumar
- Department of Electrical Engineering, Indian Institute of Technology Hyderabad, Telangana 502285, India
| | - Suryasnata Tripathy
- Department of Electrical Engineering, Indian Institute of Technology Hyderabad, Telangana 502285, India
| | - Om Krishan Singh
- Department of Electrical Engineering, Indian Institute of Technology Hyderabad, Telangana 502285, India
| | - Shiv Govind Singh
- Department of Electrical Engineering, Indian Institute of Technology Hyderabad, Telangana 502285, India.
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15
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Navegantes-Lima KC, Monteiro VVS, de França Gaspar SL, de Brito Oliveira AL, de Oliveira JP, Reis JF, de Souza Gomes R, Rodrigues CA, Stutz H, Sovrani V, Peres A, Romão PRT, Monteiro MC. Agaricus brasiliensis Mushroom Protects Against Sepsis by Alleviating Oxidative and Inflammatory Response. Front Immunol 2020; 11:1238. [PMID: 32714320 PMCID: PMC7342083 DOI: 10.3389/fimmu.2020.01238] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/18/2020] [Indexed: 12/23/2022] Open
Abstract
Sepsis is characterized by the host's dysregulated immune response to an infection followed by a potentially fatal organ dysfunction. Although there have been some advances in the treatment of sepsis, mainly focused on broad-spectrum antibiotics, mortality rates remain high, urging for the search of new therapies. Oxidative stress is one of the main features of septic patients, so antioxidants can be a good alternative treatment. Agaricus brasiliensis is a nutraceutical rich in bioactive compounds such as polyphenols and polysaccharides, exhibiting antioxidant, antitumor, and immunomodulatory activities. Here, we investigated the immunomodulatory and antioxidant effects of A. brasilensis aqueous extract in the cecal ligation and puncture (CLP) sepsis model. Our data showed that aqueous extract of A. brasiliensis reduced systemic inflammatory response and improved bacteria clearance and mice survival. In addition, A brasiliensis decreased the oxidative stress markers in serum, peritoneal cavity, heart and liver of septic animals, as well as ROS production (in vitro and in vivo) and tert-Butyl hydroperoxide-induced DNA damage in peripheral blood mononuclear cells from healthy donors in vitro. In conclusion, the aqueous extract of A. brasiliensis was able to increase the survival of septic animals by a mechanism involving immunomodulatory and antioxidant protective effects.
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Affiliation(s)
- Kely Campos Navegantes-Lima
- Neuroscience and Cellular Biology Post Graduation Program, Institute of Biological Sciences, Federal University of Pará, Pará, Brazil
| | - Valter Vinicius Silva Monteiro
- Center for Research in Inflammatory Diseases (CRID), Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.,Graduate Program in Basic and Applied Immunology, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Ana Ligia de Brito Oliveira
- Neuroscience and Cellular Biology Post Graduation Program, Institute of Biological Sciences, Federal University of Pará, Pará, Brazil
| | | | - Jordano Ferreira Reis
- School of Pharmacy, Health Science Institute, Federal University of Pará, Pará, Brazil
| | - Rafaelli de Souza Gomes
- Pharmaceutical Science Post-Graduation Program, Faculty of Pharmacy, Federal University of Pará, Pará, Brazil
| | - Caroline Azulay Rodrigues
- Pharmaceutical Science Post-Graduation Program, Faculty of Pharmacy, Federal University of Pará, Pará, Brazil
| | - Herta Stutz
- Department of Food Engineering, Midwest State University-UNICENTRO, Guarapuava, Brazil
| | - Vanessa Sovrani
- Department of Biochemistry, Federal University of Rio Grande de Sul, Porto Alegre, Brazil
| | - Alessandra Peres
- Laboratory of Cellular and Molecular Immunology, Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Pedro Roosevelt Torres Romão
- Laboratory of Cellular and Molecular Immunology, Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Marta Chagas Monteiro
- Neuroscience and Cellular Biology Post Graduation Program, Institute of Biological Sciences, Federal University of Pará, Pará, Brazil.,School of Pharmacy, Health Science Institute, Federal University of Pará, Pará, Brazil.,Pharmaceutical Science Post-Graduation Program, Faculty of Pharmacy, Federal University of Pará, Pará, Brazil
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16
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Neutrophil Adaptations upon Recruitment to the Lung: New Concepts and Implications for Homeostasis and Disease. Int J Mol Sci 2020; 21:ijms21030851. [PMID: 32013006 PMCID: PMC7038180 DOI: 10.3390/ijms21030851] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/14/2022] Open
Abstract
Neutrophils have a prominent role in all human immune responses against any type of pathogen or stimulus. The lungs are a major neutrophil reservoir and neutrophilic inflammation is a primary response to both infectious and non-infectious challenges. While neutrophils are well known for their essential role in clearance of bacteria, they are also equipped with specific mechanisms to counter viruses and fungi. When these defense mechanisms become aberrantly activated in the absence of infection, this commonly results in debilitating chronic lung inflammation. Clearance of bacteria by phagocytosis is the hallmark role of neutrophils and has been studied extensively. New studies on neutrophil biology have revealed that this leukocyte subset is highly adaptable and fulfills diverse roles. Of special interest is how these adaptations can impact the outcome of an immune response in the lungs due to their potent capacity for clearing infection and causing damage to host tissue. The adaptability of neutrophils and their propensity to influence the outcome of immune responses implicates them as a much-needed target of future immunomodulatory therapies. This review highlights the recent advances elucidating the mechanisms of neutrophilic inflammation, with a focus on the lung environment due to the immense and growing public health burden of chronic lung diseases such as cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD), and acute lung inflammatory diseases such as transfusion-related acute lung injury (TRALI).
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17
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Blann A. British Journal of Biomedical Science in 2019. What have we learned? Br J Biomed Sci 2019; 77:1-6. [PMID: 31818192 DOI: 10.1080/09674845.2019.1692455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In 2019 the British Journal of Biomedical Science published 40 articles in the various disciplines that comprise biomedical science. These were one review, 22 original articles and 17 'In Brief' short reports. Of those citing original data, the majority were in cellular pathology (14 papers), clinical chemistry (9 papers), and microbiology (6 papers: 4 in bacteriology and 2 in virology). There were 3 papers in haematology and 2 in andrology, whilst 5 papers crossed traditional discipline boundaries (such as the molecular genetics of IL6, liver function tests, and hepatocellular carcinoma). Over two-thirds of papers used techniques in molecular genetics. The present report will summarise key aspects of these publications that are of greatest relevance to laboratory scientists.
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Affiliation(s)
- A Blann
- Institute of Biomedical Science, London, UK
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18
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Gunyeli I, Saygin M, Ozmen O. The impact of the sepsis on female urogenital system: the role of pregabalin. Arch Gynecol Obstet 2019; 300:1067-1082. [PMID: 31529363 DOI: 10.1007/s00404-019-05285-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of the study was to investigate the oxidative damage and inflammatory effects of sepsis on the urogenital system in the Lipopolysaccharide (LPS)-induced sepsis model and ameliorating role of Pregabalin (PGB). METHODS Twenty-four female Wistar Albino rats (12 months old) were divided into 3 groups as follows: Sepsis group (Group S) (5 mg/kg LPS, i.p, single dose); Sepsis+ PGB group (Group SP) (5 mg/kg LPS, i.p, single dose and 30 mg/kg PGB); Control group (Group C) (0.1 ml/oral and i.p. saline, single dose), 6 h after LPS administration, the animals were killed. Subsequently, analyses of urogenital tissue oxidant/antioxidant status, histopathological and immunohistochemical analyses were performed. RESULTS Total oxidative status (TOS) and oxidative stress index (OSI) values in the urogenital tissues were increased in Group S (Total anti-oxidative status (TAS) decreased) compared to the Control group (p < 0.05). PGB improved these values (p < 0.05). The immunohistochemical markers [Caspase-3, granulocyte colony-stimulating factor (G-CSF), interleukin-6 (IL-6), Serum Amyloid A (SAA) and inducible nitric oxide synthase (iNOS)] were significantly increased in Group S except for bladder (p < 0.001). Statistically significant immunohistochemical positiveness was found only for IL-6 in urinary bladder, though all the others values were negative. With the administration of PGB (Group SP), the expressions of these immunoreactions were markedly decreased (p < 0.001). CONCLUSIONS These findings demonstrated that sepsis caused oxidative stress and inflammation in the urogenital tissues. We have revealed that PGB ameliorated tissue damage caused by sepsis.
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Affiliation(s)
- Ilker Gunyeli
- Department of Gynaecology and Obstetrics, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey.
| | - Mustafa Saygin
- Department of Physiology, Faculty of Medicine, Suleyman Demirel University Isparta, Isparta, Turkey
| | - Ozlem Ozmen
- Department of Pathology, Faculty of Veterinary Medicine, Mehmet Akif Ersoy University, Burdur, Turkey
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19
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Kumar S, Gupta E, Kaushik S, Srivastava VK, Saxena J, Mehta S, Jyoti A. Quantification of NETs formation in neutrophil and its correlation with the severity of sepsis and organ dysfunction. Clin Chim Acta 2019; 495:606-610. [PMID: 31181192 DOI: 10.1016/j.cca.2019.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/06/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous study from this lab has discerned oxidative, nitrosative stress and their relationship with cytokines contributing to the severity of sepsis and organ dysfunction. Cytokines are known to induce neutrophil extracellular traps (NETs) formation via free radicals generation. Hyper-activation of neutrophil leads to the increased NETs formation or ineffective clearance of NETs would likely increase the risk of auto-antibody generation against NETs components and being partly responsible for the sepsis severity and organ dysfunction. The present study was undertaken to further assess the status of NETs formation and their correlation with severity of sepsis, with the cytokines and organ dysfunction. METHODS The level of NETs formation, DNA release, elastase release, and inflammatory cytokines was determined in 80 sepsis patients and 45 healthy volunteers. Their linearity with organ parameters and associations with sepsis severity were also assessed. RESULTS NETs formation experiment was carried out and it was significantly higher in sepsis (70%) compared to control (30%). NETs % were positively correlated with severity of sepsis and organ dysfunction. Pearson's correlation coefficient demonstrated a direct relation between NETs components and organ parameters with Sepsis severity scores. CONCLUSION NETs formation is significantly higher due to which it is contributing to the sepsis severity and organ failure.
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Affiliation(s)
- Sanni Kumar
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, India
| | - Ena Gupta
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, India
| | - Sanket Kaushik
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, India
| | - Vijay Kumar Srivastava
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, India
| | - Juhi Saxena
- Dr. B. Lal Institute of Biotechnology, 6-E, Malviya Industrial Area, Jaipur 302017, India
| | - Sudhir Mehta
- Department of General Medicine, SMS Medical College & Attached Hospitals, J.L.N. Marg, Jaipur 302004, India
| | - Anupam Jyoti
- Amity Institute of Biotechnology, Amity University Rajasthan, Amity Education Valley, Kant Kalwar, NH-11C, Jaipur-Delhi Highway, Jaipur 303002, India.
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