Insight on Vernonia Plant for its Pharmacological Properties: A Review

Vernonia is a woody shrub of the family Asteraceae. Over 1500 species are distributed in tropical and subtropical regions of Africa and Asia. There are more than 54 species known to possess similar morphological features with the characteristic bitter taste. The pharmacological properties of different parts like seeds, leaves, and roots are well documented in folk medicine. They are rich in biologically active constituents such as alkaloids, phenolics, flavonoids, terpenoids, steroid tannins, and carotenoids having broad therapeutic activities like antiinflammatory, hypoglycemic, hyperlipidemia, antimicrobial, antitumor, antioxidative, antiproliferative, antihypertensive, hepatoprotective, etc. The present study summarizes and discusses the phytochemical profile, pharmacological properties, and toxicological effects of the Vernonia plant.

Punica Granatum Peel Waste- An Underutilized Substrate of Therapeutic Potential: An Overview

India is the second largest consumer and producer of fruits globally. It leads to ample solid waste per year from fruit processing industries that have been proven hazardous to the surroundings. Punica granatum (Pomegranate) belongs to the Lythraceae subfamily Punicoideae, which exhibits immense nutritional properties and delicious flavoring components. The weight of this fruit mainly consists of peel, i.e., 50%, followed by 40% of arils and 10% of seeds. Thus, the major byproduct is a peel that holds many valuable bioactive compounds in higher concentrations viz saponins, carotenoids, steroids, polyphenols, quercetin derivatives, caffeic acid, phenolic acids, flavonoids, ellagitannins, p-coumaric acid, chlorogenic acid, quinic acid, anthocyanidins, triterpenoids, glycosides, tannins, and many more. Consequently, it results in wide-ranging therapeutic applications, including antioxidative, anti-microbial, antihypertensive, anti-carcinogenic, anti-genotoxic, anti-inflammatory, glucoregulation, cardio-protective, hepato-protective and nephroprotective effects along with prebiotic potential. Considering their nutritional and therapeutic aspects, these peels can be used for many purposes rather than being disposed of. With a value-added approach, it is utilized in many food and non-food sectors. So, this review aims to explore the therapeutic potential of P. granatum peel and enlighten its diverse applications in the food industry.

Unravelling the Differential Host Immuno-Inflammatory Responses to Staphylococcus aureus and Escherichia coli Infections in Sepsis

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.

Barriers and facilitators to the conduct of critical care research in low and lower-middle income countries: A scoping review

Background

Improvements in health-related outcomes for critically ill adults in low and lower-middle income countries need systematic investments in research capacity and infrastructure. High-quality research has been shown to strengthen health systems; yet, research contributions from these regions remain negligible or absent. We undertook a scoping review to describe barriers and facilitators for the conduct of critical care research.

Methods

We searched MEDLINE and EMBASE up to December 2021 using a strategy that combined keyword and controlled vocabulary terms. We included original studies that reported on barriers or facilitators to the conduct of critical care research in these settings. Two reviewers independently reviewed titles and abstracts, and where necessary, the full-text to select eligible studies. For each study, reviewers independently extracted data using a standardized data extraction form. Barriers and facilitators were classified along the lines of a previous review and based on additional themes that emerged. Study quality was assessed using appropriate tools.

Results

We identified 2693 citations, evaluated 49 studies and identified 6 for inclusion. Of the included studies, four were qualitative, one was a cross-sectional survey and one was reported as an ‘analysis’. The total number of participants ranged from 20–100 and included physicians, nurses, allied healthcare workers and researchers. Barriers identified included limited funding, poor institutional & national investment, inadequate access to mentors, absence of training in research methods, limited research support staff, and absence of statistical support. Our review identified potential solutions such as developing a mentorship network, streamlining of regulatory processes, implementing a centralized institutional research agenda, developing a core-outcome dataset and enhancing access to low-cost technology.

Conclusion

Our scoping review highlights important barriers to the conduct of critical care research in low and lower-middle income countries, identifies potential solutions, and informs researchers, policymakers and governments on the steps necessary for strengthening research systems.

Vital Bioactive Compounds Present in Punica granatum Peel and Its Functional Effects on Human Health

Abstract:

Inclination of the world towards natural and super foods have intended the researchers and nutritionist to develop foods that are highly nutritious, feasible, eco-friendly as well as can act as an immuno-booster. Massive amounts of agro-industrial waste generation throughout the world have drawn attention for its utilization and transformation from waste to wealth. A healthy Indian diet includes food from all food groups in which one-fourth part of diet is covered by fruits and vegetables. Pomegranate (Punica granatum) and its various parts are one amongst the most familiar fruit for its therapeutic applications and wonderful flavor since traditional times. Million tons of pomegranate peels are produced per annum around the world and is a considerable source of phytochemicals, vitamins, minerals, and numerous bioactive compounds like phenolics, flavonoids, anthocyanins, flavonols, flavones etc. Consequently, providing many health benefits like cardio-protective, nephro-protective, hepato-protective, anticancer, antimutagenic, antidiabetic, antimicrobial, anti-inflammatory, antioxidative and many other chronic diseases. Its safety and efficacy for consumption had been proved by the incorporation in food products and industrial applications. The main aim of this chapter is to focus on the presence of vital bioactive compounds in pomegranate peel and their functional benefits on human health.

Impact of Nutrition in the Management of Nutritional Status of Covid-19 Patients

Abstract:

The second outbreak of severe acute respiratory syndrome coronavirus (SARS-CoV-2) is of great concern due to its awful mortality and morbidity rate with decreasing nutritional status and poor lifestyle as well as noteworthy food crisis and affected economy of the world. Increasing food prices, food crisis, global hunger and decreasing availability and feasibility of food are the foremost causes of decreasing nutritional status, which increases the risk of susceptibility to infection and, in turn, leads to unfavorable outcomes of the diseases. Although, in times of the Covid- 19 pandemic, nutrition is of potential attention, and there is a requirement for more exploration in the field of nutrition for the prevention of diseases arising from coronavirus infection. Elderly and individuals with co-morbidity, such as respiratory diseases, cardiovascular diseases, diabetes mellitus and metabolic diseases, are more prone towards getting infected with the coronavirus. Good nutrition is mandatory for healthy immune responses, which can be improved by the inclusion of vitamin A, B6, B12, C, D, E, zinc, selenium, iron, copper and an antioxidant-rich diet.

An Overview on Physico-chemical Characteristics and Postharvest Treatments of Litchi (Litchi chinensis Sonn.)

Background:

Litchi chinensis is an evergreen and arboreal tree with grey-black bark, shiny branches, and deep green lanceolate dense round shape leaves. The litchi peel is very thin and rigid and comes out easily, revealing jelly-like white color pulp with excellent flavor due to sugar and acid content. Litchi is an excellent source of antioxidants, vitamin C, vitamin Bcomplex and flavonoids that help in the prevention of chronic diseases.

Aim:

The quality of litchi fruit is generally estimated by aroma volatiles, color, physicochemical parameters, and fruit composition (minerals and vitamins). Worldwide, the concern is rising regarding the use of sulfating agents in vegetables and fresh fruits. Therefore, there is a requirement of declaration from U.S. Food and Drug Administration regulations for its acceptable levels as sulfur dioxide (SO2) is officially defined as a pesticide that is nowadays used as a fumigant for litchi.

Conclusion:

This review summarizes the outcome of diverse post-harvest treatments, types of packaging, storage period and their effects on physicochemical characters, sensory evaluation, quality retention, and changes during storage of litchi fruit, along with exploring suitable alternative technologies to replace SO2 fumigation.

Characteristics of Serrated Adenomas in Non-Hispanic Whites and African Americans Undergoing Screening Colonoscopy

Background and aim

Adenomatous polyps are precursor lesions for colorectal cancer (CRC). Serrated adenomas/polyps are considered a risk factor for the development of proximal and interval CRC. African-Americans are at higher risk for right-sided CRC. Minimal data evaluating serrated adenoma characteristics by race/ethnicity on initial screening colonoscopy (SC) exist. The aim of this investigation was to compare the characteristics of serrated adenomas found in non-Hispanic whites (nHw) and African-Americans (AA) undergoing initial SC.

Methods

The University of Florida-Jacksonville endoscopy database was searched for all SC performed between January 2000 and December 2014. Inclusion criteria were nHw or AA race/ethnicity and histologically proven serrated adenoma found at SC. Data were collected for all included age at SC, sex, number, location, and size of serrated adenomas found.

Results

A total of 8693 individuals (nHw - 4199 and AA - 4494) underwent SC between January 2000 and December 2014. Serrated adenomas were found in 479 individuals (nHw, n=294; AA, n=185), and AA were significantly less likely than nHw to have serrated adenomas on SC (AA 4.1% vs nHw 7%; p< 0.0001). No difference was observed in mean age, location, or size between nHw and AA with serrated adenomas.

Conclusions

Serrated adenomas are more frequent in nHw compared to AA at initial SC. No difference was seen in size or location of serrated adenomas, as well as patient age, between AA and nHw. A study of genetic factors predisposing to serrated adenoma formation and the impact of socioeconomic disparities should be performed across ethnic groups to understand this difference.

Use of direct oral anticoagulants in chronic thromboembolic pulmonary hypertension: a systematic review

Direct oral anticoagulants (DOACs) are being increasingly used in patients with chronic thromboembolic hypertension (CTEPH), however, the data on their safety and efficacy are scarce and contradictory. We systematically searched MEDLINE and Google Scholar databases from January 2010 to January 2021 for studies of DOACs in CTEPH. Three observational studies, 2 abstracts and one case series met our inclusion criteria. While these studies reported similar or even less rates of major bleeding in patients receiving DOACs compared with vitamin K antagonists, there were concerns about the possibility of increased risk of venous thromboembolism recurrence with DOAC therapy. Further studies are warranted to better define the role of DOACs in CTEPH.

The use of transbronchial cryobiopsy for diffuse parenchymal lung disease in critically ill patients with acute hypoxemic respiratory failure-A case series

OBJECTIVES

Accurate diagnosis and management of undifferentiated diffuse parenchymal lung disease (DPLD) in critically ill patients is challenging. Transbronchial forceps biopsies have limited utility and surgical lung biopsies can be detrimental for critically ill patients. Transbronchial cryobiopsy (TBC) has shown increased diagnostic yield compared to conventional forceps biopsy in DPLD. However, TBC has not been studied in intensive care unit (ICU) patients. In this case series, we describe our experience with TBC for diagnosis of DPLD in ICU patients with acute hypoxemic respiratory failure.

METHODS

This case series includes critically ill patients who underwent TBC at two different tertiary care hospitals. Procedures were performed by the same interventional pulmonologist using the two therapeutic bronchoscopes with a 2.8-mm working channel, and a 1.9- or 2.4-mm cryoprobe.

RESULTS

We performed TBC in 17 patients of which 12 (70.1%) were performed at bedside in ICU without fluoroscopic guidance. Pathological diagnosis was made in 15 (88%) patients which resulted in changes in management in most of these patients. Six patients (35.3%) developed pneumothorax post-procedure with 5 (29.4%) requiring a chest tube. Moderate bleeding was noted in one (6%) patient and no severe or fatal bleeding occurred. Our 30-day ICU mortality was 47% (n = 8); however, no deaths were directly attributable to the procedure.

CONCLUSIONS

TBC is a feasible technique with an acceptable complication rate and a fairly high histopathological yield in ICU patients with DPLD and acute hypoxemic respiratory failure. Appropriate diagnosis can be crucial in making management decisions for these patients.

Functional role of iNOS-Rac2 interaction in neutrophil extracellular traps (NETs) induced cytotoxicity in sepsis

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.

Tracheobronchopathia osteochondroplastica: rare but not to be forgotten

We report a case of a 59-year-old male with a one-month history of pleuritic chest pain who was diagnosed with tracheobronchopathia osteochondroplastica (TO). TO is a rare benign condition characterized by protruding submucosal nodules into the tracheobronchial lumen. The disease is generally asymptomatic, with rare cases of progressive nodularity, cough, dyspnoea, and haemoptysis. Diagnosis can be made via bronchoscopic visualization of bony and cartilaginous nodules on tracheal walls. Although generally benign, the rarity of this condition makes diagnosis difficult even for trained pulmonologists and frequently predisposes patients to unnecessary invasive diagnostic testing and improper management of symptoms and contributing co-morbid conditions. We present this case to increase physician and patient awareness about this disease to help improve diagnostic strategy and knowledge of disease manifestations and potential complications.

Incidence of Multidrug Resistant Infections in Emergency Department Patients with Suspected Sepsis

BACKGROUND

Inappropriate antibiotic therapy in sepsis is associated with poor outcomes, clinicians often provide routine coverage for multidrug resistant (MDR) bacteria. However, these regimens may contribute to problems related to antibiotic overuse. To understand the incidence and related factors of multidrug resistant bacterial infections in ED patients with sepsis, we examined how often patients with sepsis in our emergency department had MDR infections. We also explored risk factors for, and outcomes from, MDR bacterial infections.

METHODS

We reviewed records of patients presenting to our emergency department (ED) meeting criteria for severe sepsis or septic shock from March 2012 to July 2013. Patient demographics, comorbidities, preadmission location, and APACHE II scores were analyzed, as were clinical outcomes.

RESULTS

A total of 191 episodes were examined. 108 (57%) cases were culture-positive, and of these, 23 (12.0%) had an MDR pathogen recovered. Among patients with positive cultures, MDR patients used mechanical ventilation more often 29% vs. 52% (P = 0.03) and had longer mean ICU and hospital length of stays: 4.0 vs 9.3 (P < 0.08) and 10.6 vs 20.8 (P = 0.01), respectively. We did not identify statistically significant predictors of MDR infection.

CONCLUSIONS

The overall number of infections due to MDR bacteria was low, and MDR gram-negative infections were uncommon. The use of multiple empiric antibiotics for resistant gram-negative infections in the ED may be beneficial in only a small number of cases. Additionally, empiric coverage for vancomycin-resistant enterococci may need to be considered more often. Larger studies may help further elucidate the rates of MDR infections in ED patients, and identify specific risk factors to rationally guide empiric antibiotic treatment.

Elucidating the Phytochemical and Pharmacological Potential of Myristica fragrans (Nutmeg)

Myristica fragrans or nutmeg is a ground spice of the family Myristicaceae. Its tree has dark leaves mainly cultivated in Grenada, Malaysia, and Kerala. It is majorly a source of two spices derived from its fruit: nutmeg (jaiphal) from its seed and mace (javitri) from the covering of seed. The important bioactive constituents present in nutmeg include macelignan, carvacrol, myristicin, β-caryophyllene, β-pinene, α-pinene, p-cymene, and eugenol. Low doses of nutmeg do not cause any side effects whereas after consuming 5g toxic overdose occurs, and central nervous system (CNS) effects were induced after consuming 1 to 2 mg/kg b.wt. of nutmeg. Various therapeutic or medicinal applications were shown by nutmeg such as antioxidant, antimicrobial, aphrodisiac, anticancer, hepatoprotective, anti-inflammatory, antidepressant, and cardioprotective activity. This review chapter focuses on ethnobotany, phytochemistry, acceptable daily intake, and different pharmacological actions of this medicinal plant.

Quantification of NETs formation in neutrophil and its correlation with the severity of sepsis and organ dysfunction

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.

Impact of cancer in pulmonary embolism presentation and outcomes: A large academic center study

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Background: The risk of venous thromboembolism is increased 4- to 7-fold in patients with malignancy, emphasizing the need to identify and treat these patients early to improve outcomes. We aimed to study the clinical presentation and outcomes of pulmonary embolism (PE) in patients with and without cancer. Methods: We performed a retrospective analysis of consecutive patients diagnosed with PE via CT scan from 2014-2016 at Jefferson Hospital. We compared patient characteristics, presentation, PE characteristics and mortality of patients with and without cancer. Cox proportional regression hazards model was used for survival-time analysis. Results: Our study included 581 patients, of which 187 (32.1%) had active cancer. Cancer patients were less likely to have chest pain (18.2% vs 37.4% p < 0.01), syncope (2.7% vs 6.6% p = 0.05), bilateral PEs (50% vs 60% p = 0.025), and right heart strain (RHS) (48% vs 58% p = 0.024). Indwelling catheters (IC) were present in 41.2% (n = 77) of cancer patients. However, presence of IC was not associated finding of incidental PEs (26% vs 18.2% p = 0.201). There was no difference in hospital length of stay (8.9 vs 9.4 days p = 0.61) or intensive care unit admission (31.9% vs 33.3% p = 0.75). There were fewer massive PE (3.2% vs 7.1% p = 0.06) in patients with cancer, but this difference was not statistically significant. Cancer patients elected comfort care at higher rates (15.2% vs 5.4% p = 0.01). Cancer patients had higher 1-year mortality as compared to non-cancer (adj HR 6.9, 95% CI 3.3- 14.7, p < 0.01). Among cancer patients, 52.7% had metastasis with a higher 1-year mortality (adj HR 2.5, 95% CI 1.8- 4.9, p < 0.1) and 35.8% were on active chemotherapy with no difference in 1-year survival (adj HR 1.1, 95% CI 0.6-1.8, p = 0.79). The most represented cancers were genitourinary, lung and head and neck (35.3%, 23.0%, 13.4%, respectively). Conclusions: Cancer patients presented with less severe pulmonary emboli which may be due to increased health care contact and pre-clinical suspicion. The presence of IC did not affect the size, location of PE or incidental PEs among cancer patients. Although cancer patients have higher 1-year mortality, PE may not be as large as a contributor as previously perceived.

Bio-fabrication of silver nanoparticles by Pseudomonas aeruginosa: optimisation and antibacterial activity against selected waterborne human pathogens

Multiple drug resistance and treatment of contaminated water has become a serious issue in past years. Silver nanoparticles (AgNPs), being bactericidal, non-toxic, cheap and environment friendly behaviour, have drawn attention to overcome these problems. This study has been designed to synthesise AgNPs from Pseudomonas aeruginosa. AgNPs formation was confirmed by colour change and UV-vis spectroscopy. Furthermore, Fourier transform infrared spectroscopy peaks demonstrated the presence of capped proteins as reducing and stabilising agent. Transmission electron microscopy micrograph revealed spherical shape AgNPs with the size ranging between 10 and 20 nm. Antibacterial activity of AgNPs was evaluated against the most prevalent waterborne pathogens enterohaemorrhagic Escherichia coli and Salmonellae typhimurium. Moreover, the antibacterial activity of AgNPs was tested for the treatment of contaminated water which showed attenuation in bacterial load within 8 h as demonstrated by growth kinetics data. Furthermore, AgNPs did not exhibit haemolytic effects on human red blood cells (RBCs) even at 100 mg L-1 concentration of AgNPs. The results herein suggest that AgNPs synthesised by P. aeruginosa under optimised conditions exhibit microbicidal property against waterborne pathogens and having no toxic effect on human RBCs. These AgNPs could be employed for treatment of contaminated water after process optimisation.

Association between aspirin use and deep venous thrombosis in mechanically ventilated ICU patients

Deep venous thrombosis (DVT) is common in intensive care unit (ICU) patients. It is often silent and may be complicated by pulmonary embolism and death. Thromboprophylaxis with heparin does not always prevent venous thromboembolism (VTE). Aspirin (ASA) reduces the risk of VTE in surgical and high-risk medical patients but it is unknown if ASA may prevent DVT in mechanically ventilated ICU patients. We performed a retrospective chart review of critically ill patients who received mechanical ventilation for >72 h and underwent venous ultrasonography for suspected DVT between Jan 2012 and Dec 2013. We excluded patients who were on therapeutic doses of anticoagulation or had coagulopathy. We used multivariable logistic regression to evaluate association between aspirin use and DVT during hospitalization. There were 193 patients. The mean ± SD age was 58 ± 15.7 years. Half were male. DVT was found in 49 (25.4%). DVT was found in the first 15 days of hospitalization in 67.3% of the patients. The majority (82.8%) received thromboprophylaxis with unfractionated or low molecular weight heparin. Fifty-six (29%) were on ASA. On multivariable regression analysis, ASA use was associated with a significant reduction in the odds of finding DVT (OR 0.39, 95% CI 0.16-0.94; p = 0.036). DVT is common in mechanically ventilated ICU patients despite the use of thromboprophylaxis. Aspirin may prevent DVT in such patients.

A scoping review of the uses of the care index in children

OBJECTIVE

To conduct a scoping review of literature to describe how the care index (CI) and restorative index (RI) are used in child populations and to determine whether they are fit for purpose.

BASIC RESEARCH DESIGN

Scoping review conducted using the Arksey and O'Malley (2005) framework.

METHOD

Electronic and manual literature searches (1980-2015) were conducted. Titles and abstracts were screened, full-texts of potential studies were reviewed two reviewers extracted data independently, followed by data charting and summarising.

RESULTS

Out of 104 articles meeting all criteria, most were cross-sectional (92%), and 56% were conducted in UK and Brazil. Most commonly (63%) studies used CI and RI to obtain epidemiological data on dental care levels. Of the studies that defined CI and RI, most used and specified the standard definition. The CI and RI scores varied either due to patient related factors such as age, gender or dental care related factors including, cost of treatment and method of provider remuneration.

CONCLUSION

Overall, it is recommended that future studies should clearly state the definitions and thresholds used to obtain CI and RI, which would enable comparison between communities and allow temporal trends to be studied. Additionally, deriving separate CI and RI scores for groups based on caries extent would help to highlight inequalities in the provision of care. Further research is needed to explore the applicability of CI and RI to changing approaches to caries management with current care recommendations emphasising on minimal treatment and secondary prevention.

Neutrophil Extracellular Traps: Formation and Involvement in Disease Progression

Neutrophils are the forerunner in innate immunity by defending the host organisms against infectious pathogens. During such process, neutrophils reach the site of inflammation/infection and eliminate the pathogens by phagocytosis as well as by forming the neutrophil extracellular traps (NETs). NETs trap and eradicate a number of microbes including bacteria, fungi, protozoa, viruses. NETs consist of DNA which is decorated with histones and granular proteins such as neutrophil elastase (NE), gelatinase, myeloperoxidase. NETosis (a process of NETs formation) is also involved in many inflammatory and autoimmune disorders with a major contribution to acute respiratory distress syndrome, sepsis, cystic fibrosis, periodontitis. Hyper NETosis or ineffective clearance of NETs would likely increase the risk of auto-antibody generation against NETs components and contribution in auto-inflammatory diseases. The purpose of this review is intended to highlight the molecular mechanisms of NETosis and its antimicrobial effect. Furthermore, a current status of NETosis in the pathogenesis of inflammatory and autoimmune disorders has been reviewed for better understanding.

Evaluation of oxidative stress and antioxidant status: Correlation with the severity of sepsis

Sepsis is a condition caused by infection followed by unregulated inflammatory response which may lead to the organ dysfunction. During such condition, over-production of oxidants is one of the factors which contribute cellular toxicity and ultimately organ failure and mortality. Antioxidants having free radicals scavenging activity exert protective role in various diseases. This study has been designed to evaluate the levels of oxidative and antioxidative activity in sepsis patients and their correlation with the severity of the sepsis. A total of 100 sepsis patients and 50 healthy controls subjects were enrolled in this study from the period October 2016 to June 2017. The investigation included measurements of oxidative enzyme, myeloperoxidase (MPO), antioxidant enzymes including superoxide dismutase activity (SOD) and catalase activity (CAT) and cytokines (TNF-α, IL-8 and IFN-γ). Furthermore, the level of these activities was correlated with severity of sepsis. Augmented levels of oxidants were found in sepsis as demonstrated by DMPO nitrone adduct formation and plasma MPO level activity (1.37 ± 0.51 in sepsis vs 0.405 ± 0.16 in control subjects). Cytokines were also found to be increased in sepsis patients. However, plasma SOD and CAT activities were significantly attenuated (P < .001) in the sepsis patients compared with controls subjects. Moreover, inverse relation between antioxidant enzymes (SOD and CAT) and organ failure assessment (SOFA), physiological score (APACHE II), organ toxicity specific markers have been observed as demonstrated by Pearson's correlation coefficient. This study suggests that imbalance between oxidant and antioxidant plays key role in the severity of sepsis.

Hepatitis C Virus-associated Membranoproliferative Glomerulonephritis Treated with Directly Acting Antiviral Therapy

Hepatitis C virus (HCV) infection has been shown to affect kidneys with various histopathological pattern on the kidney biopsy. These commonly include a membranoproliferative glomerulonephritis (MPGN) pattern with mixed cryoglobulinemia (CG), thrombotic microangiopathy, membranous nephropathy, and vasculitis affecting medium and small vessels of the kidneys causing polyarteritis nodosa. It has been rarely associated with MPGN without detectable CG. We present one such patient who presented to us with HCV-associated MPGN without detectable CG, who recovered completely with directly acting antiviral therapy without any immunosuppression.

Anticancer Potential of Steviol in MCF-7 Human Breast Cancer Cells

Objective:

This study aimed to investigate the cytotoxicity, apoptosis induction, and mechanism of action of steviol on human breast cancer cells (Michigan Cancer Foundation-7 [MCF-7]).

Materials and Methods:

Sulforhodamine-B assay was performed to analyze cytotoxic potential of Steviol whereas flow cytometer was used to analyze cell cycle, apoptosis, and reactive oxygen species generation.

Results:

Studying the viability of cells confirms the IC₅₀ of Steviol in MCF-7 cells which was 185 μM. The data obtained from fluorescence-activated cell sorter analysis reveal Steviol-mediated G2/M-phase arrest (P < 0.05) in addition to the presence of evident sub-G0/G1 peak (P < 0.05) in the MCF-7 cells, signifying the ongoing apoptosis.

Conclusion:

Thus, results suggest that induction of apoptosis in MCF-7 cells was due to dose-dependent effect of Steviol. Our first in vitro findings indicate Steviol as a promising candidate for the treatment of breast cancer.

SUMMARY

Steviol remarkably inhibited the growth MCF-7 HBCCs in a dose dependent manner

It abolishes cell cycle progression by arresting cells at G2/M phase

Steviol induces the cells to undergo apoptosis

Steviol induces the cells to generate reactive oxygen species (ROS).

Abbreviations used: MCF-7: Michigan Cancer Foundation-7; SRB: Sulforhodamine-B assay; FACS: Fluorescence-activated cell sorter; ROS: Reactive oxygen species; DNA: Deoxyribonucleic acid.

Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for dental anxiety; however, access to therapy is limited. The current study aimed to develop a self-help CBT resource for reducing dental anxiety in children, and to assess the feasibility of conducting a trial to evaluate the treatment efficacy and cost-effectiveness of such an intervention. A mixed methods design was employed. Within phase 1, a qualitative "person-based" approach informed the development of the self-help CBT resource. This also employed guidelines for the development and evaluation of complex interventions. Within phase 2, children, aged between 9 and 16 y, who had elevated self-reported dental anxiety and were attending a community dental service or dental hospital, were invited to use the CBT resource. Children completed questionnaires, which assessed their dental anxiety and health-related quality of life (HRQoL) prior to and following their use of the resource. Recruitment and completion rates were recorded. Acceptability of the CBT resource was explored using interviews and focus groups with children, parents/carers and dental professionals. For this analysis, the authors adhered to the Mixed Methods Appraisal Tool criteria. There were 24 families and 25 dental professionals participating in the development and qualitative evaluation of the CBT resource for children with dental anxiety. A total of 56 children agreed to trial the CBT resource (66% response rate) and 48 of these children completed the study (86% completion rate). There was a significant reduction in dental anxiety (mean score difference = 7.7, t = 7.9, df = 45, P < 0.001, Cohen's d ES = 1.2) and an increase in HRQoL following the use of the CBT resource (mean score difference = -0.03, t = 2.14, df = 46, P < 0.05, Cohen's d ES = 0.3). The self-help approach had high levels of acceptability to stakeholders. These findings provide preliminary evidence for the effectiveness and acceptability of the resource in reducing dental anxiety in children and support the further evaluation of this approach in a randomized control trial. Knowledge Transfer Statement: This study details the development of a guided self-help Cognitive Behavioral Therapy resource for the management of dental anxiety in children and provides preliminary evidence for the feasibility and acceptability of this approach with children aged between 9 and 16 y. The results of this study will inform the design of a definitive trial to examine the treatment- and cost-effectiveness of the resource for reducing dental anxiety in children.

Correlation between two chemiluminescence based assays for quantification of hepatitis B surface antigen in patients with chronic hepatitis B infection

PURPOSE

Hepatitis B surface Antigen (HBsAg) is the hallmark in diagnosing hepatitis B virus (HBV) infection. In India many commercial assays are available for detection of HBsAg but very few can measure it quantitatively. The present study presents the comparative evaluation of two methods and their correlation with serum HBsAg in chronic hepatitis B (CHB) patients.

MATERIALS AND METHODS

Consecutive patients of CHB were included and there HBsAg levels were measured by two methods: (i) Elecsys, Roche Diagnostics, a qualitative assay and (ii) Architect, Abbott Diagnostics, a quantitative assay. The HBV DNA was measured by real-time polymerase chain reaction (qPCR).

RESULTS

Total of 136 patients were included in the study and there was a significant overall correlation between both the assays (correlation coefficient [r] = 0.83; P < 0.001). Assays correlated well with each other across all subgroups of CHB: treatment naοve (r = 0.73; P < 0.001, n = 32), on treatment (r = 0.56; P < 0.05, n = 104), hepatitis Be (HBe) antigen positive (r = 0.67; P < 0.001, n = 62) and anti-HBe positive (r = 0.61; P < 0.05, n = 74) group. On correlation with serum HBV DNA, Architect assay demonstrated good correlation (r = 0.73; P < 0.001, n = 136) as compared to the Elecsys assay (r = 0.27; P = 0.068, n = 136). Architect HBsAg QT assay (A1) also correlated well with HBV DNA in the treatment naοve group (r = 0.69; P < 0.001, n = 32).

CONCLUSIONS

Our study hence proved that both the assays are comparable and a simple qualitative assay with in-house modification can be used easily for quatitation of HBsAg in clinical samples.

Association of Inhaled Corticosteroids with Incident Pneumonia and Mortality in COPD Patients; Systematic Review and Meta-Analysis

BACKGROUND

Inhaled corticosteroids are commonly prescribed for patients with severe COPD. They have been associated with increased risk of pneumonia but not with increased pneumonia-associated or overall mortality.

METHODS

To further examine the effects of inhaled corticosteroids on pneumonia incidence, and mortality in COPD patients, we searched for potentially relevant articles in PubMed, Medline, CENTRAL, EMBASE, Scopus, Web of Science and manufacturers' web clinical trial registries from 1994 to February 4, 2014. Additionally, we checked the included and excluded studies' bibliographies. We subsequently performed systematic review and meta-analysis of included randomized controlled trials and observational studies on the topic.

RESULTS

We identified 38 studies: 29 randomized controlled trials and nine observational studies. The estimated unadjusted risk of pneumonia was increased in randomized trials: RR 1.61; 95% CI 1.35-1.93, p < 0.001; as well as in observational studies: OR 1.89; 95% CI 1.39-2.58, p < 0·001. Six randomized trials and seven observational studies were useful in estimating unadjusted risk of pneumonia -case-fatality: RR 0.91; 95% CI 0.52-1.59, p = 0.74; and OR 0.72; 95% CI 0.59-0.88, p = 0.001, respectively. Twenty-nine randomized trials and six observational studies allowed estimation of unadjusted risk of overall mortality: RR 0.95; 95% CI 0.85-1.05, p = 0.31; and OR 0.79; 95% CI 0.65-0.97, p = 0.02, respectively.

CONCLUSIONS

Despite a substantial and significant increase in unadjusted risk of pneumonia associated with inhaled corticosteroid use, pneumonia fatality and overall mortality were found not to be increased in randomized controlled trials and were decreased in observational studies.

Severe Hyponatremia Due to Valproic Acid Toxicity

Hyponatremia is a very commonly encountered clinical entity with potentially dangerous effects and for which many precipitating factors have been identified. We present a case of valproic acid (VPA) overdose causing profound hyponatremia, with one of the lowest serum sodium levels ever documented in literature. A 54-year-old woman with hypothyroidism, hypertension and bipolar disorder presented with somnolence after intentionally ingesting 7,500 mg VPA. She was drowsy but easily arousable with no hemodynamic compromise and an unremarkable physical exam. There was no clinical suspicion for organic neurological or pulmonary disease, adrenal insufficiency or volume depletion. She was found to have a serum sodium of 99 mEq/L, low plasma osmolality (211 mOsm/kg H₂O), and high urine osmolality (115 mOsm/kg H₂O). Her urine sodium was 18 mEq/L. She was euthyroid (TSH: 3.06 mIU/L) and compliant with thyroxine replacement. She was admitted to the intensive care unit for close monitoring and VPA was withheld. Over 36 hours her VPA level fell from 59.3 mg/L to 22.8 mg/L, serum sodium steadily rose to 125 mEq/L and there was concomitant improvement in her mental status. At 72 hours, she was transferred for an inpatient psychiatric evaluation and her sodium level was 135 mEq/L. She luckily did not experience any seizures or decline in neurological function. The clinical presentation in this patient is consistent with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) leading to a dramatic fall in sodium to a level of 99 mEq/L. Chronic VPA use has been associated with SIADH and chronic hyponatremia. Review of records in this patient from 1 year prior revealed that her last measured sodium level was 127 mEq/L. It is therefore most likely that our case is one of acute on chronic hyponatremia provoked by VPA overdose in the setting of chronic VPA use. Whilst our patient’s course was relatively benign, this case illustrates a rare consequence of VPA toxicity, which if unnoticed in another patient may be tragic.

Oral Health Inequalities

Recent research has emphasized the relationships between environmental and individual factors that may influence population oral health and lead to health inequalities. However, little is known about the effect of interactions between environmental and individual factors on inequalities in clinical (e.g., decayed teeth) and subjective oral health outcomes (e.g., oral health–related quality of life [OHQoL]). This cohort study aimed to explore the direct and mediated longitudinal interrelationships between key environmental and individual factors on clinical and subjective oral health outcomes in adults. Self-reported measures of OHQoL and individual (sense of coherence [SOC], social support, stress, oral health beliefs, dental behaviors, and subjective socioeconomic status [SES]) and environmental factors (SES and social network) were collected at baseline and 3-mo follow-up, together with a baseline clinical examination of 495 adult employees of an automobile parts manufacturer in India. Lagged structural equation modeling was guided by the adapted Wilson and Cleary/Brunner and Marmot model linking clinical, individual, and environmental variables to quality of life. The study provides tentative evidence that SES may influence levels of resources such as social support and SOC, which mediate stress and in turn may influence subjective oral health outcomes. Accordingly, the present findings and the adapted Wilson and Cleary/Brunner and Marmot model on which they are predicted provide support for the psychosocial pathway being key in the SES–oral health relationship. The pathways through which environmental factors interact with individual factors to impact subjective oral health outcomes identified here may bring opportunities for more targeted oral health promotion strategies.

Effect of preoperative angina pectoris on cardiac outcomes in patients with previous myocardial infarction undergoing major noncardiac surgery (data from ACS-NSQIP)

The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). Multivariable logistic regression models evaluated the impact of stable angina on outcomes. Of 1,568 patients (median age 70 years; 35% women) with previous MI who underwent major noncardiac surgery, 5.5% had postoperative MI and/or cardiac arrest. Patients with history of preoperative angina had significantly greater incidence of primary outcome compared to those without anginal symptoms (8.4% vs 5%, p = 0.035). In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication.

Chronic pelvic ischemia: etiology, pathogenesis, clinical presentation and management

Overactive Bladder (OAB) and Bladder Pain Syndrome (BPS) although common, are vaguely defined and difficult to diagnose and manage etiologies of storage--type lower urinary tract symptoms (LUTS). The lack of optimal management options is a direct consequence of deficient understanding of the pathophysiologic mechanisms underlying these conditions. These conditions are especially prevalent in females, and cumulative contemporary epidemiological, clinical and laboratory evidence implicates ischemia as one of the key players in the pathophysiologic foundation of both these disorders. Taken together they make up 'the' diagnostic as well as therapeutic black--hole in urologic practice. Much akin to chronic ischemic heart disease, chronic ischemia--reperfusion has been shown to cause degenerative changes at cellular and sub--cellular level in the bladder mucosa, smooth muscle fibers, and vesical neural and microvascular structures leading to a hypersensitive, hyperactive bladder initially, which with time invariably progresses into a failed, fibrotic and pressurized bladder. Diagnosis and management of these diseases are currently symptom focused and remains a source of much frustration. Consideration of role of ischemia connotates hope and could lead to a paradigm shift in the management of these patients with a completely new therapeutic armamentarium attacking the pathology itself.

Chronic pelvic ischemia: etiology, pathogenesis, clinical presentation and management

Overactive bladder (OAB) and bladder pain syndrome (BPS) although common, are vaguely defined and difficult to diagnose and manage etiologies of storage-type lower urinary tract symptoms (LUTS). The lack of optimal management options is a direct consequence of deficient understanding of the pathophysiologic mechanisms underlying these conditions. These conditions are especially prevalent in females, and cumulative contemporary epidemiological, clinical and laboratory evidence implicates ischemia as one of the key players in the pathophysiologic foundation of both these disorders. Taken together they make up "the" diagnostic as well as therapeutic black-hole in urologic practice. Much akin to chronic ischemic heart disease, chronic ischemia-reperfusion has been shown to cause degenerative changes at cellular and subcellular level in the bladder mucosa, smooth muscle fibers, and vesical neural and microvascular structures leading to a hypersensitive, hyperactive bladder initially, which with time invariably progresses into a failed, fibrotic and pressurized bladder. Diagnosis and management of these diseases are currently symptom focused and remains a source of much frustration. Consideration of role of ischemia connotates hope and could lead to a paradigm shift in the management of these patients with a completely new therapeutic armamentarium attacking the pathology itself. The aim of the current review is to provide a clinical thought perspective on the etiology/pathophysiology of chronic pelvic ischemia and its role as a precursor to the aforementioned conditions, and shed some light upon the potential management strategies to consider.

Relevance of hepatitis B surface antigen levels in patients with chronic hepatitis B during 5 year of tenofovir treatment

The role of quantitative hepatitis B surface antigen (HBsAg) levels in patients receiving highly potent oral antiviral therapy is controversial, and here, we determined the HBsAg response in 121 chronic hepatitis B patients treated with tenofovir 300 mg daily. During tenofovir treatment, HBsAg decline of ≥ 1.0 log from baseline was seen in 16.1%, 16.3%, 18.4%, 34.6%, 36.4% and 11.8%, 15.2%, 14.8%, 28.6%, 20% at years 1, 2, 3, 4, 5 for HBeAg-positive and HBeAg-negative patients, respectively. Early decline in HBsAg levels at week 4 was predictive of subsequent significant HBsAg level decline. HBeAg seroconversion occurred in 29.9% of HBeAg-positive patients. On multinomial logistic regression, HBsAg level decline from baseline at week 4 and week 12 or any time subsequently did not correlate with HBeAg seroconversion and HBV DNA level decline from baseline at week 4 and week 12 (OR = 3.704; 95% CI = 1.511-9.076; P = 0.006 and OR = 1.732; 95% CI = 1.032-2.867; P = 0.037, respectively) was significantly predictive of seroconversion. A small proportion of chronic HBV-infected patients treated with tenofovir exhibit a significant (≥ 1.0 log) decline in HBsAg levels. Early decline in HBsAg levels at week 4 was predictive of subsequent and significant HBsAg level decline. The HBsAg decline did not correlate with HBeAg seroconversion in HBeAg-positive patients. Reduction in HBV DNA levels at week 4 and 12 correlated with seroconversion.