Do Not Throw Away Your Shot: Pilot Study in Improving Medical School Curricula Through Focused Vaccine Education

Introduction

With widely prevalent vaccine hesitancy and medical mistrust, future healthcare providers require knowledge of vaccines and comfort in discussing vaccines with patients. However, many U.S. medical schools do not offer formal or elective curricula focused on vaccine education.

Methods

We sought to identify the need for such a curriculum and student gaps in knowledge through a pilot study surveying first- and second-year medical students at a large Pennsylvania medical school to assess knowledge about vaccine initiatives/policies, comfort in discussing vaccines, attitudes toward curricular changes, and effects of COVID-19 on willingness for vaccine education.

Results

Many participants (>40%) reported insufficient knowledge of vaccine policy, vaccine development and testing, and community vaccine initiatives. The majority (>50%) indicated discomfort in discussing vaccines in a clinical setting. Importantly, 79% of participants reported insufficient coverage of vaccine topics in the current curriculum. A total of 54% decisively wanted formal/mandatory education versus 72% who decisively wanted elective education. Desiring formal education was associated with less comfort in discussing vaccines overall and with vaccine-hesitant people in clinical settings. Reassuringly, 74% of participants noted that the COVID-19 pandemic made them want to learn more about vaccines. Guided by these findings, we conducted a pilot elective teaching about vaccines through case studies, interactive discussions, and role-playing scenarios. Pre- and postcourse surveys showed improvement in student knowledge in all vaccine-related topics assessed.

Conclusions

These data can inform the development of formal and elective curricula that effectively prepare medical students for patients' vaccine questions.

A Cross-Sectional Analysis of Community Perceptions of Flu and COVID-19 Vaccines at Turtle Creek Primary Care Center

BACKGROUND

Influenza (flu) and COVID-19 vaccination rates are subpar across the US, especially in racial and/or socioeconomic minority groups who are understudied in public health literature.

OBJECTIVE

The objective of this mixed-methods study was to elucidate attitudes of patients at the Turtle Creek Primary Care Center, a clinic that cares for ∼70% non-white patients, towards flu and COVID-19 vaccines, with the goal of establishing vaccine education gaps and increasing vaccine uptake in minority communities.

DESIGN/PATIENTS

This study was conducted as a cross-sectional analysis. Authors completed 123 patient phone surveys of patients cared for at the Turtle Creek clinic inquiring about flu and COVID-19 infection status and vaccination uptake (August 26-October 10, 2021).

APPROACH/KEY RESULTS

We found that rates of vaccination were subpar in the Turtle Creek community, with only 54% having received the COVID-19 vaccine and only 44% receiving the flu vaccine regularly. There was a strong association between COVID-19 and flu vaccine acceptance and a notable correlation between vaccine acceptance and age. When assessing how vaccine acceptance was influenced by trusted sources of information, those who cited trusting "medical professionals" and "word of mouth" had higher odds of COVID-19 vaccine acceptance but those who cited trusting "social media" had decreased odds of acceptance. Finally, we uncovered 14 common factors for either vaccine acceptance or refusal that clustered into four overarching themes of trust, need, safety, and availability.

CONCLUSION

These data highlight the necessity of improved vaccine education and reveal targetable populations and approaches for disseminating vaccine information.

Reduced mitophagy is an early feature of NAFLD and liver-specific PARKIN knockout hastens the onset of steatosis, inflammation and fibrosis

Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of pathologies that includes steatosis, steatohepatitis (NASH) and fibrosis and is strongly associated with insulin resistance and type 2 diabetes. Changes in mitochondrial function are implicated in the pathogenesis of NAFLD, particularly in the transition from steatosis to NASH. Mitophagy is a mitochondrial quality control mechanism that allows for the selective removal of damaged mitochondria from the cell via the autophagy pathway. While past work demonstrated a negative association between liver fat content and rates of mitophagy, when changes in mitophagy occur during the pathogenesis of NAFLD and whether such changes contribute to the primary endpoints associated with the disease are currently poorly defined. We therefore undertook the studies described here to establish when alterations in mitophagy occur during the pathogenesis of NAFLD, as well as to determine the effects of genetic inhibition of mitophagy via conditional deletion of a key mitophagy regulator, PARKIN, on the development of steatosis, insulin resistance, inflammation and fibrosis. We find that loss of mitophagy occurs early in the pathogenesis of NAFLD and that loss of PARKIN accelerates the onset of key NAFLD disease features. These observations suggest that loss of mitochondrial quality control in response to nutritional stress may contribute to mitochondrial dysfunction and the pathogenesis of NAFLD.

Reduced hepatocyte mitophagy is an early feature of NAFLD pathogenesis and hastens the onset of steatosis, inflammation and fibrosis

Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of pathologies that includes steatosis, steatohepatitis (NASH) and fibrosis and is strongly associated with insulin resistance and type 2 diabetes. Changes in mitochondrial function are implicated in the pathogenesis of NAFLD, particularly in the transition from steatosis to NASH. Mitophagy is a mitochondrial quality control mechanism that allows for the selective removal of damaged mitochondria from the cell via the autophagy pathway. While past work demonstrated a negative association between liver fat content and rates of mitophagy, when changes in mitophagy occur during the pathogenesis of NAFLD and whether such changes contribute to the primary endpoints associated with the disease are currently poorly defined. We therefore undertook the studies described here to establish when alterations in mitophagy occur during the pathogenesis of NAFLD, as well as to determine the effects of genetic inhibition of mitophagy via conditional deletion of a key mitophagy regulator, PARKIN, on the development of steatosis, insulin resistance, inflammation and fibrosis. We find that loss of mitophagy occurs early in the pathogenesis of NAFLD and that loss of PARKIN hastens the onset but not severity of key NAFLD disease features. These observations suggest that loss of mitochondrial quality control in response to nutritional stress may contribute to mitochondrial dysfunction and the pathogenesis of NAFLD.

A Cross-Sectional Factor Analysis of COVID-19 and Influenza Vaccination Decisions in a Racially Diverse Western Pennsylvania Community

INTRODUCTION

Influenza and COVID-19 vaccination rates remain suboptimal, demanding new community-centric approaches that improve targeted counseling and increase vaccine uptake. Notably, racially diverse communities show high vaccine hesitancy, yet most existing vaccine studies focus on white, college-educated cohorts.

OBJECTIVE

Here, we identify factors influencing vaccination decisions of patients at Turtle Creek Primary Care clinic in Turtle Creek, PA, a racially-diverse borough.

DESIGN

A retrospective mixed-methods study of the predominantly non-white patient population at Turtle Creek Primary Care clinic, a clinic caring for >70% minority patients.

RESULTS

Fourteen factors emerged that patients reported were crucial to vaccine decision-making. Of these factors, top reasons for COVID-19 vaccine hesitancy were trust in vaccines, vaccine side effects, perceived vaccine knowledge, and faith/religion. Top reasons for influenza vaccine hesitancy were perceived need, vaccine side effects, trust in vaccines, and habitual behaviors. We also uncovered correlations between vaccine decision factors and sociodemographic factors. Participants > 65-years-old were more likely to cite personal safety in choosing to get the COVID-19 vaccine, while non-white participants were more likely to cite others' safety. Participants > 65-years-old were also more likely to cite personal safety in influenza vaccine decision-making, and non-female participants were more likely to cite perceived need for influenza vaccines.

CONCLUSIONS

These data uncover targetable factors contributing to vaccine hesitancy and aid in developing community-centered, personalized vaccine education approaches in Turtle Creek and analogous minority communities.

Hepatocyte-derived GDF15 suppresses feeding and improves insulin sensitivity in obese mice

Growth differentiation factor 15 (GDF15) is a stress-induced secreted protein whose circulating levels are increased in the context of obesity. Recombinant GDF15 reduces body weight and improves glycemia in obese models, which is largely attributed to the central action of GDF15 to suppress feeding and reduce body weight. Despite these advances in knowledge, the tissue-specific sites of GDF15 production during obesity are unknown, and the effects of modulating circulating GDF15 levels on insulin sensitivity have not been evaluated directly. Here, we demonstrate that hepatocyte Gdf15 expression is sufficient for changes in circulating levels of GDF15 during obesity and that restoring Gdf15 expression specifically in hepatocytes of Gdf15 knockout mice results in marked improvements in hyperinsulinemia, hepatic insulin sensitivity, and to a lesser extent peripheral insulin sensitivity. These data support that liver hepatocytes are the primary source of circulating GDF15 in obesity.

Implementation and challenges of portable blood gas measurements in air medical transport

OBJECTIVES

Ventilator management in prehospital settings using end-tidal CO₂ can lead to inappropriate ventilation in the absence of point of care blood gas (POCBG) measurements. Implementation of POCBG testing in helicopter Emergency Medical Services (HEMS) is limited in part because of concern for preanalytical and analytical errors due to altitude, vibration, and other associated environmental factors and due to insufficient documentation of implementation challenges.

METHODS

We performed accuracy and precision verification studies using standard materials tested pre-, in-, and post-flight (n=10) in a large HEMS agency. Quality assurance error log data were extracted and summarized for common POCBG errors during the first 31 months of use and air medical transport personnel were surveyed regarding POCBG use (n=63).

RESULTS

No clinically significant differences were found between pre-, in-, and post-flight blood gas measurements. Error log data demonstrated a reduction in device errors over time. Survey participants found troubleshooting device errors and learning new clinical processes to be the largest barriers to implementation. Continued challenges for participants coincided with error log data including temperature and sampling difficulties. Survey participants indicated that POCBG testing improved patient management.

CONCLUSIONS

POCBG testing does not appear to be compromised by the HEMS environment. Temperature excursions can be reduced by use of insulated transport bags with heating and cooling packs. Availability of POCBG results in air medical transport appeared to improve ventilator management, increase recognition of ventilation-perfusion mismatch, and improve patient tolerance of ventilation.

Practical consensus recommendations regarding the use of hormonal therapy in metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors. One of these factors is the levels of hormone receptors (HRs) in the tumor. Cancers with high levels of HRs, called HR-positive, use the hormones estrogen and progesterone to grow and spread. Hormonal therapy is a type of treatment specifically for HR-positive breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of hormonal therapy and the management of HR-positive MBC for the benefit of community oncologists.

Assessing the Use of Portable Blood Gas Measurements (iSTAT Instrument) in Emergency Air Transport

Hyper and hypoventilation of patients on ventilators leads to poor outcomes. Traditionally, mechanical ventilation protocols in air medical transport are guided by pulse oximetry (SpO2) and continuous end tidal CO2 (EtCO2), which can lead to over-ventilation of patients. The use of portable blood gas measurements is a desirable adjunct in the air medical transport setting due to the complexity and duration of management of critical patients with only limited, noninvasive monitoring options. Previously, protocols relied on SpO2 and EtCO2 to control ventilator settings during in-flight patient management. The iSTAT is a hand-held point of care device often used in acute hospital setting to obtain arterial blood gas results within minutes using a disposable test cartridge and small specimen size. However, iSTAT use in air medical transport has been limited due to analytical and durability concerns in the uncontrolled helicopter environment. The purpose of this study was to test these concerns including the effects of vibrations on the microfluidic transport of blood in the cartridge, pressure changes at altitude on the processing of the cartridge, and temperature changes on the iSTAT instrument between readings during in-flight use. To ensure accurate inflight testing, we assessed precision and accuracy of inflight blood gas measurements compared to pre- and post- flight measurements on quality control material.

Precision of initial instrument verification met the manufacturer’s coefficient of variation (CV) claims (lactate = 3.59%, pH = 0.059%, pCO2 = 4%, pO2 = 3%). Initial accuracy was assessed by instrument comparison. Bias of iSTAT compared to the laboratory radiometer ABL800 instrument was acceptable for clinical use (lactate = -7.95%, pH = -0.041%, pCO2 = 1%, pO2 = -2%). For the majority of tests (pH, pCO2, pO2, HCO3, BE, and SO2) we found no significant differences between inflight absolute values compared to pre- and post- flight measurements by one-way anova (p>0.05), and no significant difference in precision (CV) between in air and pre- and post- flight measurements for both low and high quality control samples. In measuring lactate levels, we found significant differences between inflight absolute values compared to pre- and post- flight measurements (p<0.0001) but these were determined to be clinically insignificant (mean (mmol/L): preflight = 6.87, inflight = 6.77, postflight = 6.69). Vibration and pressure differences in air compared to on land were therefore considered clinically insignificant. To keep the instruments at an operable temperature in flight between readings, we found utility in using an insulated lunch box with additional styrofoam placed in the bottom to prevent heat transfer. Most importantly, improved clinical outcomes from proper ventilation of patients were achieved. The results of this study demonstrate that the iSTAT instrument provides clinically accurate blood gas measurements in air as compared to standard in-hospital use.

Liver-specific Prkn knockout mice are more susceptible to diet-induced hepatic steatosis and insulin resistance

Objective

PARKIN is an E3 ubiquitin ligase that regulates mitochondrial quality control through a process called mitophagy. Recent human and rodent studies suggest that loss of hepatic mitophagy may occur during the pathogenesis of obesity-associated fatty liver and contribute to changes in mitochondrial metabolism associated with this disease. Whole-body Prkn knockout mice are paradoxically protected against diet-induced hepatic steatosis; however, liver-specific effects of Prkn deficiency cannot be discerned in this model due to pleotropic effects of germline Prkn deletion on energy balance and subsequent protection against diet-induced obesity. We therefore generated the first liver-specific Prkn knockout mouse strain (LKO) to directly address the role of hepatic Prkn.

Methods

Littermate control (WT) and LKO mice were fed regular chow (RC) or high-fat diet (HFD) and changes in body weight and composition were measured over time. Liver mitochondrial content was assessed using multiple, complementary techniques, and mitochondrial respiratory capacity was assessed using Oroboros O₂K platform. Liver fat was measured biochemically and assessed histologically, while global changes in hepatic gene expression were measured by RNA-seq. Whole-body and tissue-specific insulin resistance were assessed by hyperinsulinemic-euglycemic clamp with isotopic tracers.

Results

Liver-specific deletion of Prkn had no effect on body weight or adiposity during RC or HFD feeding; however, hepatic steatosis was increased by 45% in HFD-fed LKO compared with WT mice (P < 0.05). While there were no differences in mitochondrial content between genotypes on either diet, mitochondrial respiratory capacity and efficiency in the liver were significantly reduced in LKO mice. Gene enrichment analyses from liver RNA-seq results suggested significant changes in pathways related to lipid metabolism and fibrosis in HFD-fed Prkn knockout mice. Finally, whole-body insulin sensitivity was reduced by 35% in HFD-fed LKO mice (P < 0.05), which was primarily due to increased hepatic insulin resistance (60% of whole-body effect; P = 0.11).

Conclusions

These data demonstrate that PARKIN contributes to mitochondrial homeostasis in the liver and plays a protective role against the pathogenesis of hepatic steatosis and insulin resistance.

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Mitochondrial respiratory capacity is reduced in liver-specific Prkn knockout mice.

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Liver-specific Prkn knockout mice develop more severe steatosis during high-fat diet feeding.

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Pathogenesis of NAFLD, including insulin resistance and markers of fibrosis, is enhanced in liver-specific Prkn knockout mice.

Prenatal hypoxia increases susceptibility to kidney injury

Prenatal hypoxia is a gestational stressor that can result in developmental abnormalities or physiological reprogramming, and often decreases cellular capacity against secondary stress. When a developing fetus is exposed to hypoxia, blood flow is preferentially redirected to vital organs including the brain and heart over other organs including the kidney. Hypoxia-induced injury can lead to structural malformations in the kidney; however, even in the absence of structural lesions, hypoxia can physiologically reprogram the kidney leading to decreased function or increased susceptibility to injury. Our investigation in mice reveals that while prenatal hypoxia does not affect normal development of the kidneys, it primes the kidneys to have an increased susceptibility to kidney injury later in life. We found that our model does not develop structural abnormalities when prenatally exposed to modest 12% O2 as evident by normal histological characterization and gene expression analysis. Further, adult renal structure and function is comparable to mice exposed to ambient oxygen throughout nephrogenesis. However, after induction of kidney injury with a nephrotoxin (cisplatin), the offspring of mice housed in hypoxia exhibit significantly reduced renal function and proximal tubule damage following injury. We conclude that exposure to prenatal hypoxia in utero physiologically reprograms the kidneys leading to increased susceptibility to injury later in life.

Von Hippel-Lindau Acts as a Metabolic Switch Controlling Nephron Progenitor Differentiation

BACKGROUND

Nephron progenitors, the cell population that give rise to the functional unit of the kidney, are metabolically active and self-renew under glycolytic conditions. A switch from glycolysis to mitochondrial respiration drives these cells toward differentiation, but the mechanisms that control this switch are poorly defined. Studies have demonstrated that kidney formation is highly dependent on oxygen concentration, which is largely regulated by von Hippel-Lindau (VHL; a protein component of a ubiquitin ligase complex) and hypoxia-inducible factors (a family of transcription factors activated by hypoxia).

METHODS

To explore VHL as a regulator defining nephron progenitor self-renewal versus differentiation, we bred Six2-TGCtg mice with VHLlox/lox mice to generate mice with a conditional deletion of VHL from Six2+ nephron progenitors. We used histologic, immunofluorescence, RNA sequencing, and metabolic assays to characterize kidneys from these mice and controls during development and up to postnatal day 21.

RESULTS

By embryonic day 15.5, kidneys of nephron progenitor cell-specific VHL knockout mice begin to exhibit reduced maturation of nephron progenitors. Compared with controls, VHL knockout kidneys are smaller and developmentally delayed by postnatal day 1, and have about half the number of glomeruli at postnatal day 21. VHL knockout nephron progenitors also exhibit persistent Six2 and Wt1 expression, as well as decreased mitochondrial respiration and prolonged reliance on glycolysis.

CONCLUSIONS

Our findings identify a novel role for VHL in mediating nephron progenitor differentiation through metabolic regulation, and suggest that VHL is required for normal kidney development.

Anti-quorum sensing and antibiofilm potential of Alternaria alternata, a foliar endophyte of Carica papaya, evidenced by QS assays and in-silico analysis

In the present study, secondary metabolites from an endophytic fungus, Alternaria alternata, colonizing Carica papaya, demonstrated antiquorum sensing properties against Pseudomonas aeruginosa. This study reports the antagonistic effects of fungal crude extract of A. alternata against the various quorum sensing (QS) associated virulent factors such as percentage decrease in production of pyocyanin, alginate, chitinase and rhamnolipid; significant decrease in proteases activity such as LasA protease activity, staphylolytic activity, Las B elastase; and a marked decrease in biofilm formation and associated factors such as exopolysaccharide (EPS) production and cell surface hydrophobicity (CSH). Further, motility pattern i.e., swimming and swarming was also found to be inhibited. This down regulation of QS and associated factors are further supported by in-silico analysis of interaction between QS receptor LasR and bioactive molecules viz., sulfurous acid, 2-propyl tridecyl ester and 1,2-benzenedicarboxylic acid, bis(2-methylpropyl) ester present in fungal crude extract, found based on GCMS analysis, sketches the modulating ability of QS expression. This is the first report on an endophytic fungus of C. papaya having a role in QS inhibition against P. aeruginosa and lays a platform to explore further the endophytes for potent therapeutic agents in QS.

Electron paramagnetic resonance and photoluminescence investigation on ultraviolet-emitting gadolinium-ion-doped CaAl₁₂O₁₉ phosphors

The gadolinium doped CaAl12O19 phosphor has been prepared by a low temperature solution combustion method in a short time and characterized using powder X-ray diffraction, energy dispersive analysis of X-ray mapping, electron paramagnetic resonance (EPR) and photoluminescence spectroscopic techniques. EPR and optical analysis of the sample confirm the presence of Gd(3+) in the CaAl12O19 matrix.

Reversible symptoms and clearance of mutant prion protein in an inducible model of a genetic prion disease in Drosophila melanogaster

Prion diseases are progressive disorders that affect the central nervous system leading to memory loss, personality changes, ataxia and neurodegeneration. In humans, these disorders include Creutzfeldt-Jakob disease, kuru and Gerstmann-Straüssler-Scheinker (GSS) syndrome, the latter being a dominantly inherited prion disease associated with missense mutations in the gene that codes for the prion protein. The exact mechanism by which mutant prion proteins affect the central nervous system and cause neurological disease is not well understood. We have generated an inducible model of GSS disease in Drosophila melanogaster by temporally expressing a misfolded form of the murine prion protein in cholinergic neurons. Flies accumulating this mutant protein develop motor abnormalities which are associated with electrophysiological defects in cholinergic neurons. We find that, upon blocking the expression of the mutant protein, both behavioral and electrophysiological defects can be reversed. This represents the first case of reversibility reported in a model of genetic prion disease. Additionally, we observe that endogenous mechanisms exist within Drosophila that are capable of clearing the accumulated prion protein.

Kikuchi's disease: an uncommon cause of cervical lymphadenopathy

Kikuchi Fujimoto's disease is a benign self limiting disorder presenting with localised cervical lymphadenopathy, fever, weight loss and night sweats. It is a rare disease with worldwide distribution but commonly reported from Asia. It is diagnosed by excision biopsy of the lymph nodes. Clinical features suggest a viral aetiology though not proven. It is often misdiagnosed as either systemic lupus erythematosus or malignant lymphoma. Better understanding as well as high clinical suspicion would aid in the diagnosis of the disease. Treatment is mainly symptomatic, with non-steroidal analgesics and antipyretics. Corticosteroids are rarely indicated. Although patients show a spontaneous recovery in 1-4 months, a follow-up of several years would be required to study the development of SLE in these patients.

Hypokalaemic paralysis and normocalcaemic tetany--a rare presentation of Sjogren's syndrome

38 year old woman was admitted with acute onset of quadriplegia. Biochemical investigation revealed severe hypokalaemia with hyperchloraemic metabolic acidosis, alkaline urine, and positive urinary anion gap which are the hallmark of distal tubular acidosis. In addition she also had hypophosphataemia, normoglycaemic glycosuria, aminoaciduria, and hyperphosphaturia suggestive of proximal tubular dysfunction. Further evaluation confirmed the diagnosis of Sjogren's syndrome. Interestingly our patient also had carpopedal spasm despite normal calcium and magnesium level. Quadriplegia and carpopedal spasm improved with correction of hypokalaemia and acidosis. Proximal tubular abnormalities (except albuminuria) were normalised at the time of discharge. Distal tubular acidosis is a well known renal manifestation of Sjogren's syndrome. But this type of transient proximal tubular dysfunction with distal tubular acidosis in Sjogren's syndrome is very rare and hypokalaemic tetany also deserves mention.

"Herbal remedy is natural and safe"--truth or myth?

Neem oil is often used externally as a traditional medicine in India. Its ingestion, even in small doses produces toxic effects like severe metabolic acidosis, seizures, renal failure and encephalopathy. Management is supportive and prognosis is generally good but fatalities may occur. Herein we report an unusual case of neem oil toxicity in a previously normal adult.

Protein losing enteropathy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic immunologic disorder that may affect multiple organ systems and present with myriad of clinical features. Gastro-intestinal (GI) manifestations are oral ulcers, dysphagia and abdominal pain caused by autoimmune peritonitis/intestinal vasculitis. Hypoalbuminaemia due to GI loss is uncommon. Protein losing enteropathy (PLE) is a group of clinical entities where there is loss of protein through GI tract. PLE due to SLE is rare but it can be the initial manifestation. Patients usually present with pedal oedema mimicking nephrotic syndrome clinically. It is diagnosed by excluding other causes of hypoalbuminaemia. Radio nucleotide labelled albumin scan is useful in confirming albumin loss through GI tract. Often there is a good response to corticosteroids and immunosuppressive drugs. Here we present two SLE patients whose presenting manifestation was protein losing enteropathy and both improved with corticosteroids.

Atrial flutter and pericarditis--a rare complication of right lobe amoebic liver abscess

A 38 year old gentleman presented with fever and right hypochondrial pain. On further evaluation he was detected to have an amoebic liver abscess (ALA) in the right lobe of the liver. The abscess yielded anchovy sauce pus on percutaneous drainage. Following the percutaneous drainage the patient developed tachycardia. Electrocardiogram revealed atrial flutter with rapid ventricular rate and ST elevation in all leads suggestive of pericarditis. The atrial flutter was reverted to sinus rhythm by cardioversion. The patient then had an uncomplicated convalescence. Amoebic pericarditis, though rare, is a serious complication of amoebic liver abscess. Pericardial complications are usually seen with left lobe liver abscess due to its proximity. Both pericarditis and cardiac arrhythmias due to amoebic liver abscess especially from right lobe are very rare.

Disseminated infection with Strongyloides stercoralis in a diabetic patient

A 58-year-old male diabetic who was operated for carcinoma larynx 4 years back was admitted with exertional dyspnoea and bilateral leg swelling for the past 2 years. Over the last 2 months, there was a progressive worsening of symptoms. Echocardiography done 2 years back showed pericardial effusion. Echo done during the current admission also showed pericardial effusion with preserved left ventricular function; cytological examination of the pericardial fluid showed larvae of Strongyloides stercoralis. He was treated with antinematodal drugs. A follow-up echo done at discharge showed no pericardial effusion and the patient was completely asymptomatic. To our knowledge, this is the first reported case of Strongyloides pericardial effusion in a diabetic patient.

Blister beetle dermatitis

Blister beetle dermatitis or paederus dermatitis is an irritant contact dermatitis due to accidental crush of insects belonging to paederus family on the skin. The characteristic features of blister beetle dermatitis are linear erythematous itchy vesicles over the exposed parts of body and kissing lesions. This condition is commonly seen during or after rainy season. The treatment is removal of irritant by gentle washing and topical steroids. It is often misdiagnosed and causes significant morbidity among the rural population.

Alpha-fetoprotein as a tumor marker in hepatocellular carcinoma: investigations in south Indian subjects with hepatotropic virus and aflatoxin etiologies

OBJECTIVES

The prevalence of hepatitis B virus (HBV) is reportedly the main cause of hepatocellular carcinoma (HCC) in India, where hepatitis C virus (HCV)-associated HCC is believed to be relatively less prevalent. We verified the usefulness of alpha-fetoprotein (AFP) as a tumor marker and analyzed the influence of viral etiology on AFP levels in HCC.

METHODS

Of a total of 1012 cases with liver disease, 202 were investigated for the presence of AFP (142 HCC cases, 30 cirrhosis cases, and 30 chronic liver disease (CLD) cases). In addition, serum samples from 30 healthy patients, 30 hepatitis B surface antigen (HBsAg) carriers, and 30 acute viral hepatitis cases were included as controls. AFP was quantitatively determined using a commercial ELISA (Quorum Diagnostics, Canada). Out of the 142 HCC cases screened for AFP, aflatoxin B1 (AFB1) detection was carried out in 38 HCC cases using an in-house immunoperoxidase test.

RESULTS

In HBV and HCV co-infected HCC cases, the AFP positivity was 85.7%. In HBV alone-associated HCC, the positivity was 62.9%, and 54.5% of AFB1 positive HCC cases showed AFP positivity. In HBV and HCV negative HCC cases, the positivity was 20.5%, and in HCV-associated HCC it was 17.6%. The HBV/HCV co-infected group and HBV alone positive HCC cases had significantly elevated levels of AFP. When AFP positivity was analyzed based on the marker profile of HBV, 89.7% of AFP positive cases were HBV-DNA positive.

CONCLUSIONS

The overall positivity pattern of AFP in HCC does indicate that higher levels of AFP are observed with hepatitis virus positivity, especially with HBV. Further studies must be carried out to correlate the serum levels of AFP with the size, number, and degree of differentiation of HCC nodules.

Prevalence of aflatoxin B1 in liver biopsies of proven hepatocellular carcinoma in India determined by an in-house immunoperoxidase test

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death in the world. The incidence of HCC in India is reportedly low and varies from 0.2 to 1.9 %. Aflatoxins, secondary metabolites produced by Aspergillus flavus and Aspergillus parasiticus, are potent human carcinogens implicated in HCC. The prevalence of aflatoxin B1 (AFB1) as co-carcinogen was analysed using an in-house immunoperoxidase test in 31 liver biopsies and 7 liver-resection specimens from histopathologically proven HCC, and in 15 liver biopsies from cirrhosis patients (control group). Serum was tested for hepatitis B and C serological markers using commercial assays, and for AFB1 using an in-house ELISA with a sensitivity of approximately 1 ng ml(-1) for AFB1. In spite of positive AFB1 immunostaining in HCC cases, all serum specimens, from both HCC and the control groups, were AFB1-negative. There were 18 (58.1 %) HCC cases that revealed AFB1 in liver biopsies; 68.8 % (n=11) of non-B non-C hepatitis cases with HCC and 46.1 % (n=6) of the hepatitis B surface-antigen-positive subjects were positive for AFB1. Out of the two hepatitis B/hepatitis C virus co-infected cases, one was positive for AFB1. Of seven tumour-resection samples, six were positive for AFB1. Only one case revealed AFB1 in the non-tumour area of the resected material. Thus AFB1 staining was significantly associated with tumour tissue (P=0.03). Aflatoxins proved to have a significant association with HCC in this peninsular part of the subcontinent. The impact seems to be a cumulative process, as revealed by the AFB1 deposits in HCC liver tissue, even though the serum levels were undetectable.

Antidiabetic and antihyperlipemic effects of Clemeo felina

Petroleum ether and benzene extracts of Clemeo felina, given orally at doses of 300 mg kg(-1) day(-1) for 30 days, were found to be antidiabetic and antihyperlipemic on alloxan diabetic rats. Moreover, a significant decrease in the activities of serum enzymes like alkaline phosphatase, acid phosphatase and HMGCoA reductase activity in the liver was observed. However, treatment of rats with the extracts as well as standard antidiabetic drugs increased liver hexakinase activity and serum LDH activity.

Diagnosis of hepatitis C virus infection by ELISA, RIBA and RT-PCR: a comparative evaluation

OBJECTIVES

To evaluate the efficacy of second-generation ELISA (ELISA-2), third-generation ELISA (ELISA-3) and third-generation recombinant immunoblot assay (RIBA 3.0) for detection of antibodies to hepatitis C virus (anti-HCV) in comparison with reverse transcriptase-polymerase chain reaction (RT-PCR) to detect HCV RNA for the diagnosis of hepatitis C.

METHODS

Sera of 108 patients with chronic liver disease (CLD) were analyzed by ELISA-2, ELISA-3, RIBA 3.0 and RT-PCR in the first part of the study; in the second part, sera of 105 patients with non-chronic liver disease were evaluated with ELISA-3, RIBA 3.0 and RT-PCR.

RESULTS

In the CLD group, anti-HCV was positive in 4.6%, 14.8% and 16.6% by ELISA-2, ELISA-3 and RIBA 3.0, respectively. Among these anti-HCV positive cases, HCV RNA was positive in 100%, 58.9% and 64%, respectively. ELISA-2 did not give false-positive results, but missed substantial number of anti-HCV positive cases (p < 0.001). In the second group, anti-HCV was positive in 76.3% by ELISA-3 and 68.6% by RIBA 3.0 (p:ns). HCV-RNA was positive in 88.7% of ELISA- and RIBA-positive cases; in 60% of ELISA-positive, RIBA-indeterminate cases; and in 46.4% of ELISA-negative, RIBA-negative cases.

CONCLUSIONS

ELISA-2 is not a suitable assay for routine screening. ELISA-3 was at par with RIBA 3.0 and it can be recommended for routine screening for anti-HCV. RT-PCR for HCV is of value in detecting early viremic, anti-HCV negative cases; this may be of importance in the treatment of hepatitis C.

Inhibition of invasion in vitro and stimulation of aggregation by 13-cis retinoic acid correlates with the clustering of N-CAM in c-Ha-ras transformed glial cells

Invasion distinguishes malignant from benign primary brain tumors. The molecular mechanisms which permit malignant brain tumor cells to escape from the primary tumor mass and by which they can migrate through normal brain tissue are largely unknown. 13-cis retinoic acid (cRA) can induce morphological, biochemical and functional differentiation characteristics in various malignant tumors. Upon treatment of diffusely invasive hamster glial cells (CxT24neo3) with 30 mu M cRA, we found a significant reduction in cell proliferation in monolayer and spheroid cultures. cRA also inhibits invasion of CxT24neo3 through a reconstituted basement membrane (Matrigel(R)) in a dose dependent manner. Homotypic cell-cell adhesion, on the contrary, is stimulated in the absence of extracellular Ca++ by either treatment or pretreatment of CxT24neo3 with cRA. These phenotypic changes correlate with the induction of the clustering of the neural cell adhesion molecule: N-CAM at sites of cell-cell contact. This phenomenon is observed following immunohistochemical staining for N-CAM of CxT24neo3 cells that were treated with cRA in monolayer cultures. The relationship between reduction of proliferation and invasion in vitro and the increased homotypic cell-cell adhesion with clustering of N-CAM implicates N-CAM as a molecular effector molecule for reduction of malignancy by cRA.