Phenotyping patients with aortic stenosis using cluster analysis to determine mortality and suitability for transcatheter aortic valve replacement

Background

Current classification of aortic stenosis (AS) is based on guideline-recommended echocardiographic criteria. Heterogeneity of patients with AS is increasingly recognised. Clinical and demographic factors in addition to echocardiographic parameters can determine those who may derive the greatest benefit from transcatheter aortic valvular replacement (TAVR) and influence patient outcomes.

Purpose

Our study aims to define distinct AS echocardiographic and clinical phenotypes and to accurately identify patients most likely to die or benefit from TAVR.

Methods

Patients diagnosed with at least mild AS between 2009 and 2021 (pre-TAVR) from a multicentre echocardiographic database at a quaternary referral centre included. Unsupervised clustering analysis was performed using K-means, partitioning around medoids, density-based spatial clustering, hierarchical clustering algorithms on 56 demographic, echocardiographic and clinical variables. Associations between AS clusters and clinical outcomes (all-cause mortality, cardiovascular death, AS-related death), and effect of TAVR on clinical outcomes were assessed using Cox proportional hazards models.

Results

Four AS clusters were identified amongst 2,456 patients with median follow up of 4.7 years (median age: 77 years, male: 66%).

Cluster 1 (n=542) had the lowest aortic valvular area (AVA, mean 0.89 cm2), highest peak velocity (Vmax) (4.3 m/s), mean gradient (45 mmHg), and the most bicuspid valves (12.7%). Cluster 2 (n=827) had 50% women, mostly in sinus rhythm and less severe echo findings. Cluster 3 (n=592) had predominantly males (85%) with a mean AVA of 1.65 cm2 and the most cardiovascular risk factors (hypertension, diabetes, hyperlipidaemia, stable angina, acute coronary syndrome, and atherosclerosis). Cluster 4 (n=495) had the highest left atrial size (mean 32 cm2), the most atrial fibrillation (82%), heart failure (80%), rheumatic heart disease (26%) and chronic kidney disease (55.8%), but only moderate AS (AVA 1.3 cm2, Vmax 3 m/s). All-cause mortality was highest in Cluster 4 (Hazard ratio (HR) 1.57, 95% CI: 1.33–1.85) and AS-related death was highest in Cluster 1 (HR 3.96, 95% CI: 2.61–5.99, Figure 1A). TAVR reduced AS-related death in only Cluster 1 (HR 0.22, 95% CI: 0.05–0.88, p=0.033, Figure 1B).

Conclusions

We demonstrated that phenotypic classification via a combination of demographics, echocardiography and comorbidities can significantly improve management of AS. This personalised approach can be implemented to identify patients most likely to die and most likely to benefit from TAVR.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia (ID: 102578)National Health and Medical Research Council of Australia (ID: 1191044)

Clinical outcomes from antihypertensive therapies in moderate or severe aortic stenosis: a systematic review and meta-analysis

Background

Hypertension can negatively affect prognosis in moderate or severe aortic stenosis (AS), but antihypertensive therapy (AHT) is often avoided due to possible deleterious effects such as reduced coronary perfusion, left ventricular dysfunction and haemodynamic compromise.

Purpose

We systematically assessed and compared clinical outcomes in adults with moderate or severe AS treated with and without AHT.

Methods

Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature without language restrictions up to September 9, 2019. Conflicts were resolved by the third reviewer. Outcomes of interest included mortality, left ventricular (LV) mass index, systolic blood pressure, diastolic blood pressure, and LV ejection fraction. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R.

Results

Of 3,024 citations, 30 studies (26,224 patients) were included in the qualitative synthesis and 23 studies in meta-analysis. AHT was associated with favourable clinical outcomes and was well tolerated. AHT was associated with lower risk of all-cause mortality (Risk Ratio (RR)=0.69, 95% CI: 0.53–0.90, p=0.01, Figure). The effect size appears to differ with type of aortic valve replacement (AVR). AHT was associated with lower risk of acute kidney injury post-transcatheter AVR (RR=0.13, 95% CI:0.05–0.35, p=0.007). Favourable outcomes such as improved haemodynamic and echocardiographic parameters were demonstrated in some studies, but when pooled in meta-analysis, the differences did not reach statistical significance. However, heterogeneity was significant across studies.

Conclusion

This is the first systematic review and meta-analysis to demonstrate that AHT is safe and has a clinical benefit in patients with advanced stages of AS with significant improvement in survival or reduction in mortality without haemodynamic compromise. Further studies are required to determine the best AHT for patients with moderate or severe AS.

Forest plot of AHT effect on mortality.

Funding Acknowledgement

Type of funding source: None

Effects of patient characteristics and comorbidities on temporal trends of low-flow, low-gradient aortic stenosis phenotypes

Background

Aortic stenosis (AS) is a common primary heart valve disease in the elderly. Low-flow, low-gradient (LFLG) AS is an increasingly important phenotype.

Purpose

To evaluate the temporal changes in incidence of severe AS phenotypes: paradoxical LFLG, classical LFLG and non-LFLG and explore risk factors that contribute to temporal trends.

Methods

We analyzed 25,507 consecutive transthoracic echocardiograms over 6½ years between 2013 and 2019 divided into deciles. LFLG-AS was defined as mean transvalvular pressure gradient <40 mmHg and stroke volume index (SVi) <35 mL/m2, aortic valve area (AVA) <1 cm2 or indexed AVA <0.6 cm2/m2, with either normal (paradoxical LFLG) or decreased (<40%; classical LFLG) left ventricular ejection fraction. Trends and associations with patients characteristics and comorbidities were assessed over time in deciles.

Results

Of 891 cases that fulfilled severe AS criteria, there were 536 cases of LFLG-AS (85 classical and 451 paradoxical LFLG-AS). There was a statistically significant increase in incidence of paradoxical LFLG-AS between each time interval (p<0.0001), while significant reduction in incidence of non-LFLG-AS (p=0.009) that was not seen with classical LFLG-AS (p=0.7) (Figure). More comprehensive echocardiographic assessment of relevant parameters over time assisted with identification of LFLG-AS cases. Intrinsic patient factors such as age and E/e' contributed towards the increasing trend of paradoxical LFLG-AS. There was a rising population aged over 70 years (p=0.01). Multivariate logistic regression analysis showed that age, sex, E/e', obesity, atrial fibrillation and heart rate were potential risk factors responsible for temporal trend towards rising paradoxical LFLG-AS incidence. There was also a gradual increase in number of patients with low transvalvular flow rate (<200mL/s) over time (p=0.04).

Conclusion

The incidence of paradoxical LFLG-AS is rising in a hospital echocardiogram service. The parallel increase in LV filling pressure and age in AS patients suggests the increment in LFLG-AS is related to changes to the LV myocardium.

Subtypes of aortic stenosis over time

Funding Acknowledgement

Type of funding source: None

CHA2DS2-VASc and CHADS2 scores for risk stratification of major adverse cardiovascular events in the COMPASS trial

Background

The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial demonstrated that the combination therapy of rivaroxaban and aspirin reduced major adverse cardiovascular events (MACE) compared to aspirin alone in patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD).

Purpose

We assessed whether the CHA2DS2-VASc (congestive heart failure (CHF), hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack (TIA)/thromboembolism, vascular disease, age 65–75 years, and sex category) and CHADS2 (CHF, hypertension, age ≥75 years, diabetes, stroke/TIA) scores used to predict the risk of stroke in patients with atrial fibrillation, can be used identify vascular patients at highest risk of recurrent events who may derive greatest benefits of treatment.

Methods

In COMPASS patients, the predictive accuracy of CHA2DS2-VASc and CHADS2 scores were assessed for MACE, bleeding and net clinical benefit using Cox proportional hazards model. Kaplan-Meier estimates of cumulative risk and absolute risk differences were used to examine the effects of rivaroxaban plus aspirin compared with aspirin alone over 30 months according to risk score categories.

Results

In 27,395 participants with CAD and/or PAD, a high CHA2DS2-VASc score (6–9) was associated with 3 times greater absolute risk of MACE compared to a low score (1–2) (hazard ratio=3.39, 95% CI: 2.54–4.51, p<0.0001). The effects of combination therapy with rivaroxaban and aspirin on MACE, bleeding and net clinical benefit were consistent across CHA2DS2-VASc and CHADS2 score categories, with the greatest benefit in those with the highest risk scores (Figure 1). The greatest reduction in MACE with rivaroxaban and aspirin compared to aspirin only was observed in patients treated for 30 months with highest CHA2DS2-VASc score (6–9) (23 events per 1000 patients prevented) or highest CHADS2 score (3–6) (25 events per 1000 patients prevented). There was increased bleeding in patients with higher CHA2DS2-VASc and CHADS2 scores, but net clinical benefit was preserved across all risk categories and was greatest in those with the highest risk scores.

Conclusion

The CHA2DS2-VASc or CHADS2 scores can be used in patients with chronic CAD and/or PAD to identify patients who are at highest risk of MACE, and therefore likely to achieve the greatest benefit of dual pathway inhibition with the combination of rivaroxaban and aspirin compared with aspirin alone.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was sponsored by Bayer AG.

WP1-22 DuraGen™ as an encapsulating material for neural stem cell delivery

Objectives

Achieving neural regeneration after spinal cord injury (SCI) represents a significant challenge. Neural stem cell (NSC) therapy offers replacement of damaged cells and delivery of pro-regenerative factors, but >95% of cells die when transplanted to sites of neural injury. Biomaterial scaffolds provide cellular protective encapsulation to improve cell survival. However, current available scaffolds are overwhelmingly not approved for human use, presenting a major barrier to clinical translation. Surgical biomaterials offer the unique benefit of being FDA-approved for human implantation. Specifically, a neurosurgical grade material, DuraGen™, used predominantly for human duraplasty has many attractive features of an ideal biomaterial scaffold. Here, we have investigated the use of DuraGen™ as a 3D cell encapsulation device for potential use in combinatorial, regenerative therapies.

Methods

Primary NSCs were seeded into optimised sheets of DuraGen™. NSC growth and fate within DuraGen™ were assessed using 3D microscopic fluorescence imaging techniques.

Results

DuraGen™ supports the survival (ca 95% viability, 12 days) and 3D growth of NSCs. NSC phenotype, proliferative capacity and differentiation into astrocytes, neurons and oligodendrocytes were unaffected by DuraGen™.

Conclusions

A ‘combinatorial therapy’, consisting of NSCs protected within a DuraGen™ matrix, offers a potential clinically translatable approach for neural cell therapy.

Identification and validation of two peptide markers for the recognition of Clostridioides difficile MLST-1 and MLST-11 by MALDI-MS

OBJECTIVES

Clostridioides difficile infection (CDI) has become the main cause of nosocomial infective diarrhoea. To survey and control the spread of different C. difficile strains, there is a need for suitable rapid tests. The aim of this study was to identify peptide/protein markers for the rapid recognition of C. difficile strains by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS).

METHODS

We analysed 44 well-characterized strains, belonging to eight different multi-locus sequence types (MLST), using ultrahigh-resolution Fourier transform ion cyclotron resonance (FTICR) MS. The amino acid sequence of two peptide markers specific for MLST-1 and MLST-11 strains was elucidated by MALDI-TOF-MS/MS. The investigation of 2689 C. difficile genomes allowed the determination of the sensitivity and specificity of these markers. C18-solid-phased extraction was used to enrich the MLST-1 marker.

RESULTS

Two peptide markers (m/z 4927.81 and m/z 5001.84) were identified and characterized for MLST-1 and MLST-11 strains, respectively. The MLST-1 marker was found in 786 genomes of which three did not belong to MLST-1. The MLST-11 marker was found in 319 genomes, of which 14 did not belong to MLST-11. Importantly, all MLST-1 and MLST-11 genomes were positive for their respective marker. Furthermore, a peptide marker (m/z 5015.86) specific for MLST-15 was found in 59 genomes. We translated our findings into a fast and simple method that allowed the unambiguous identification of the MLST-1 marker on a MALDI-TOF-MS platform.

CONCLUSIONS

MALDI-FTICR MS-based peptide profiling resulted in the identification of peptide markers for C. difficile MLST-1 and MLST-11.

Dermatoglyphic variation among the Limboo of Sikkim, India

Variations in finger and palmar dermatoglyphic patterns are investigated among the Limboo (18-60 years, 150 males and 150 females), a little known population of Sikkim. The results for Limboo were compared with other North-East Indian populations. The most commonly occurring pattern was loop (males: 64.33%; females: 75.00%) followed by whorl (males: 31.00%; females: 21.33%) and finally arch (males: 4.67%; females: 3.66%). There were no significant differences between sexes in pattern types. The overall values of pattern intensity (P.I.I.), Dankmeijer's (D.I.) and Furuhata's (F.I.) indices were 14.08, 12.60 and 96.06 respectively. The P.I.I. was within the range for East Asian populations of North-East India. The D.I. was similar to those reported for Rajbanshi, Kalita, Rabha and Newar populations, while F.I. was higher than in other populations of Eastern Himalaya and North-East India. The most frequently occurring mainline formulae in all palm prints (left and right combined) were 7.5'.5.- followed by 9.7.5.- and finally 11.9.7.- (p>0.05) and these were similar to the reported values for other North-eastern populations of India. The mean values of total finger ridge count (TFRC) and absolute finger ridge count (AFRC) were greater among males (138.03; s=42.26 and 198.78; s=77.4) than females (137.91; s=44.15 and 194.47; s=86.71). The a-b ridge count was greater among females than males. Sex differences in AFRC and a-b ridge count were both statistically significant (p<0.05). The mean TFRC values were within ranges for populations of North-East India. Cluster analysis based on P.I.I., D.I. and F.I. shows affinity of the Limbo to some of the populations of Assam and North-East India.

The usefulness of the Loewenstein Occupational Therapy Cognition Assessment in evaluating cognitive function in patients with stroke

OBJECTIVE

We wished to evaluate the usefulness of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) in early detection of the Vascular Cognitive Impairment, No Dementia (VCIND) in patients with stroke. We also wanted to compare LOTCA with the Mini-Mental State Examination (MMSE).

PATIENTS AND METHODS

Thirty patients with stroke and cognitive impairment comprised the cognitive impairment group. Another 30 patients with stroke and no cognitive impairment served as the stroke control group, while 30 healthy individuals served as the normal control group.

RESULTS

The age, gender, and education level were comparable among three study groups. All subjects were assessed with both tests. Total LOTCA scores strongly and positively correlated with total MMSE scores in patients with cognitive impairment (r = 0.934, p < 0.001). The correlations were also present between every sub-items of LOTCA and those of MMSE (p < 0.01). In addition, total scores and sub-item scores in LOTCA were significantly lower in the cognitive impairment group compared with both stroke control and normal control groups (p < 0.01), especially, with regard to scores of thinking operations, orientation, and visuomotor organization. The sub-item scores in LOTCA, including thinking operations, visuomotor organization, attention, orientation, and spatial perception were significantly lower in the stroke control group compared with normal control group (p < 0.01), especially in thinking operations and visuomotor organization. There is a good agreement between LOTCA and MMSE.

CONCLUSIONS

Compared with MMSE, LOTCA can detect VCIND earlier and more comprehensively, and can, thus, be used clinically for VCIND detection.

Histopathologic changes following neoadjuvant chemotherapy in locally advanced breast cancer

AIMS

To compare the clinical and pathologic assessment of response to neoadjuvant chemotherapy and describe the various histopathologic changes observed.

MATERIALS AND METHODS

We studied a group of 40 patients with locally advanced breast cancer who had their initial workup in the form of clinico-imaging assessment of the size and pretreatment biopsy from the lesion. All the patients received two to six cycles of neoadjuvant chemotherapy, either cyclophosphamide 50 to 60 mg/m 2 IV, doxorubicin 40 to 50 mg/m 2 IV and 5-fluorouracil 500 to 800 mg/m 2 IV (CAF) or cyclophosphamide, epirubicin, and 5-fluorouracil (CEF). Clinical and pathologic assessment of response to chemotherapy was done based on the UICC guidelines.

RESULT

Complete clinical response (cCR) was seen in 10% cases (4/40), thirty percent patients had (12/40) partial response and 60% (24/40) had stable disease after neoadjuvant chemotherapy. Pathologic complete response (pCR) with no evidence of viable tumor was observed in 20% patients (8/40). Fifteen patients (37.5%) showed partial response and 42.5% patients (17/40) had a stable disease. No patient progressed during the course of chemotherapy. Changes in the tumor type were observed following chemotherapy, most common being the mucinous change. Histologic changes like dyscohesion, shrinkage of tumor cells, elastosis, collagenization, necrosis, lymphocytic reaction, giant cell response are some of the common observations seen following treatment with neoadjuvant chemotherapy.

CONCLUSION

Pathologic assessment of response to neoadjuvant chemotherapy is a better predictor than the clinical response. The chemotherapy drugs can be modified based on the response observed after 1-2 cycles of neoadjuvant, the response being based on both tumor and patient's responsiveness.

Benign vs malignant soft tissue neoplasms: limitations of magnetic resonance imaging

AIMS

Various features have been described in the literature to differentiate benign from malignant lesions. The aim of the present study was to study the accuracy of each of these features and that of magnetic resonance imaging (MRI) in diagnosing malignant lesions.

MATERIALS AND METHODS

Fifty-five consecutive patients presenting with neoplastic (both benign and malignant) lesions diagnosed clinically and on ultrasound were studied and their MRI features were compared with the findings on surgical exploration and histopathologic examination.

RESULTS

There were 32 (58%) benign and 23 (42%) malignant masses. Malignant masses were more common in patients older than 20 years (83%), and these had symptoms of less than 6 months duration (75%), as against benign lesions. The swelling was painful in 8 malignant masses and these were more common in the upper limbs (61%). Various features of malignant lesions were size more than 5 cm in 83%, change in signal intensity from homogenous on T1-weighted images to heterogenous on T2-weighted images in 74%, irregular margins in 74%, and heterogenous contrast enhancement in 91%. The accuracy of these features was 76%, 58%, 78%, and 60%, respectively. Most benign and malignant lesions were intramuscular in location. A significant number (38%) of benign lesions were located in the intermuscular facial plane. Definitive diagnosis was made in 42% of the lesions.

CONCLUSIONS

MRI is an excellent modality for evaluating soft tissue neoplasms; however, prediction of a specific diagnosis and differentiation of malignant and benign lesions is not always possible.

Free phenytoin concentration measurement in brain extracellular fluid: a pilot study

This article investigates the relationship between brain extracellular fluid free phenytoin concentration and plasma free phenytoin concentration in adults with acute brain injury. Daily cerebral microdialysate free phenytoin concentration was measured in eight adults with acute brain injury and compared with simultaneous measurement of plasma free phenytoin concentration. The group data revealed no significant correlation between microdialysate and plasma free phenytoin concentration (r = 0.34, p = 0.41). However, in two patients, with a sufficient number of samples for intra-individual analysis, there was a significant correlation between microdialysate and plasma free phenytoin concentration (r = 0.92, p < 0.001 and r = 0.88, p < 0.01). In vitro microdialysis relative recovery for phenytoin was 2.1%. In the context of acute brain injury, measurement of free plasma phenytoin concentration may not provide an accurate reflection of regional brain extracellular fluid free phenytoin concentration and may have limitations with respect to achieving reproducible brain extracellular fluid free phenytoin concentrations. This has implications for dosing regimens relying on plasma phenytoin levels.

Infiltrative ophthalmopathy and primary hypothyroidism: a rare clinical manifestation of a common disease

The association of infiltrative ophthalmopathy with primary hypothyroidism is uncommon. We describe two such cases manifesting at different times during the course of primary hypothyroidism. The successful outcome of the present cases suggests that the timely addition of levothyroxine treatment alone or in combination with steroids is useful and effective in the management of hypothyroid Graves' ophthalmopathy.

Human milk fortification and gastric emptying in the preterm neonate

Fortification of expressed breast milk (EBM) is widely recommended for preterm feeding. Fortification of EBM results in increased caloric density and osmolarity, both of which may retard gastric emptying. As gastric emptying is a major determinant of feed tolerance, we investigated the effect of fortification (with Lactodex HMF) of EBM on gastric emptying in preterm neonates. The half gastric emptying time was measured using real time ultrasonography in 25 consecutive preterm neonates first on EBM alone, then on EBM + Lactodex HMF. Each baby served as its own control. The students t-test was used for statistical analysis. The mean gestation age was 34.48 +/- 0.77 weeks. The mean birth weight was 1.92 +/- 0.14 kg. The mean half gastric emptying time at an age of 5.4 +/- 0.86 days on EBM was 24.00 +/- 5.00 min and 24.40 +/- 5.06 min on EBM + human milk fortifier (HMF). The same at 2nd assessment (15.2 +/- 1.79 days), with EBM was 22.80 +/- 4.58 min vs. 23.60 +/- 4.89 min when given EBM + HMF. These differences were not statistically significant. Fortification of EBM with Lactodex HMF does not affect the gastric emptying in preterm neonates and therefore is unlikely to affect feed tolerance in them.

Metabolic failure precedes intracranial pressure rises in traumatic brain injury: a microdialysis study

BACKGROUND

Cerebral microdialysis (MD) is able to detect markers of tissue damage and cerebral ischaemia and can be used to monitor the biochemical changes subsequent to head injury. In this prospective, observational study we analysed the correlation between microdialysis markers of metabolic impairment and intracranial pressure (ICP) and investigated whether changes in biomarker concentration precede rises in ICP.

METHODS

MD and ICP monitoring was carried out in twenty-five patients with severe TBI in Neurointensive care. MD samples were analysed hourly for lactate:pyruvate (LP) ratio, glutamate and glycerol. Abnormal values of microdialysis variables in presence of normal ICP were used to calculate the risk of intracranial hypertension developing within the next 3 h.

FINDINGS

An LP ratio >25 and glycerol >100 micromol/L, but not glutamate >12 micromol/L, were associated with significantly higher risk of imminent intracranial hypertension (odds ratio: 9.8, CI 5.8-16.1; 2.2, CI 1.6-3.8; 1.7, CI 0.6-3, respectively). An abnormal LP ratio could predict an ICP rise above normal levels in 89% of cases, whereas glycerol and glutamate had a poorer predictive value.

CONCLUSIONS

Changes in the compound concentrations in microdialysate are a useful tool to describe molecular events triggered by TBI. These changes can occur before the onset of intracranial hypertension, suggesting that biochemical impairment can be present before low cerebral perfusion pressure is detectable. This early warning could be exploited to expand the window for therapeutic intervention.

Extracellular fluid S100B in the injured brain: a future surrogate marker of acute brain injury?

The authors describe the measurement of S100B protein in brain extracellular fluid (ECF) of patients with acute brain injury (traumatic brain injury and subarachnoid haemorrhage) using the technique of microdialysis. To our knowledge, this is the first report of S100B measurement in the human brain. Acute Brain Injury (ABI) is a leading cause of death and disability and the need for a practical and sensitive biochemical marker for monitoring these patients is urgent. The calcium binding astrocyte protein, S100B, may be a candidate for this role. Previous serum studies have shown S100B to be a sensitive predictor of mortality and rise in intracranial pressure in ABI, but it has never before been measured directly within the brain. The ECF reflects the local biochemistry of the brain parenchyma, and the use of intracerebral microdialysis opens up the possibility of studying many novel surrogate markers of injury in the laboratory, in addition to the conventional markers it measures at the bedside (lactate, pyruvate, glucose, and glycerol). In this preliminary report of two cases, the authors demonstrate the quantification of S100B in ECF microdialysate, and investigate whether changes in hourly S100B profile can be related to secondary brain injury. It is shown that extracellular concentrations of S100B change markedly in response to secondary brain injury. Further investigation is required to determine whether extracellular S100B measurement in ABI could assist in patient management.

Axonal pathology in subarachnoid and intracerebral hemorrhage

Electrically active axons degenerate in the presence of nitric oxide (NO) in vitro. High CSF NO concentrations have been observed in patients with hemorrhagic brain injury such as subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). This study investigated the evidence for axonal injury in SAH and ICH and related this to CSF NO levels. In this study, neurofilament phosphoforms (NfH(SMI34), NfH(SMI35), NfH(SMI38), NfH(SMI310)), surrogate markers for axonal injury, and NO metabolites (nitrate, nitrite = NOx) were measured by ELISA in cerebrospinal fluid (CSF) from patients with SAH and ICH and from a group of controls. Injury severity was classified using the Glasgow Coma Scale, and survival was used as the outcome measure. Compared to the control group, a higher proportion of patients with SAH and ICH had elevated NfH(SMI34) levels from day 0 to day 6 (p < 0.001), elevated NfH(SMI35) levels from day 1 to 6 (p < 0.001), and elevated NfH(SMI310) levels at day 0, 1, 4, and 6 (p < 0.001). The NOx levels were higher in the SAH and ICH patients than in the controls (p < 0.05) and distinguished the non-survivors from the survivors (p < 0.05). No direct correlation was found for NOx with any of the NfH phosphoforms. This study provides evidence for primary and secondary axonal injury in patients with SAH and ICH, with non-survivors also having higher NOx levels. CSF NfH phosphoforms might emerge as a putative surrogate marker for monitoring the development for secondary axonal degeneration in neurocritical care and guiding targeted neuroprotective strategies.

Use of a herbicide or lysine plus threonine for non-antibiotic selection of transgenic chickpea

A desensitized aspartate kinase (AK) gene has been developed as a non-antibiotic selection marker for use in the production of transgenic chickpea ( Cicer arietinum L.). Transgenic shoots regenerated from embryo explants bombarded with the desensitized AK gene were selected on media containing two amino acids, lysine and threonine (LT). Approximately 15% of the putative transgenic shoots of vars. P-362 and P-1042 survived after 4 weeks of growth on MSB5 medium (MS mineral salts and B5 vitamins) containing 2 microM thidiazuron (TDZ) and 2 mM lysine and 2 m M threonine. These shoots were subsequently grown on MSB5 medium supplemented with 2 micro M TDZ and 5 mM lysine and 5 mM threonine, and nearly 1% continued to grow after 16 weeks of selection. A phosphinothricin (PPT) selection system for Agrobacterium-mediated chickpea transformation was also developed. Three varieties of chickpea, P-362, P-1042 and P-1043, were successfully used for Agrobacterium transformation. Following Agrobacterium infection, 3-8% of the regenerated shoots remained green and continued to grow on MSB5 medium supplemented with 2.5 mg l(-1 )PPT. Increasing the concentrations of PPT to 15 mg l(-1) reduced transgenic shoot production in P-362, P-1042 and P-1043 to 0.7%, 1.2% and 1.1%, respectively. Selected putatively transformed shoots of all three varieties were rooted and grown to maturity. Southern hybridization analysis revealed single as well as multiple integration of genes in selected transgenic lines. The level of AK activity detected in LT-selected plants was higher than that detected in the non-transformed control.

Clinical profile in gelatinous bone marrow transformation

OBJECTIVE

To study the clinical spectrum associated with gelatinous bone marrow transformation (GMT).

METHODS

All subjects whose bone marrow aspiration showed pink purple material on Leishman stain underwent a detail history, clinical examination and investigation (biochemical/microbiological/radiological). Additionally, in each subject the smear was stained with special stains of Periodic Acid Schiff and Alcian blue.

RESULTS

Out of total 1498 marrows, 65 showed evidence of GMT. All of these had anaemia. The associated clinical spectra of diseases noticed were: Infection (31 cases), Nutritional deficiency (5 cases), Haematological disorders (Aplastic/toxic depression) (17 cases), Malignancies (3 cases), and Miscellaneous (9 cases).

CONCLUSION

Based on the heterogenecity of associated clinical disorders, GMT indicates severe illness and not a particular disease. GMT may be a result of bioregulatory process (which presently needs further prospective studies) that are activated in different pathologic conditions but resulting in similar lesion in the bone marrow and so till then it may be concluded that GMT is a symptom of bone marrow.

A prospective study of the rate of falls before and after cataract surgery

BACKGROUND

There has been considerable interest in the development of intervention programmes aimed at reducing the risk of falls. The primary objective was to ascertain whether cataract surgery reduced the risk of falls in elderly patients with age related cataract.

METHODS

97 patients scheduled for cataract surgery were enrolled in this prospective clinical study. The patients were assessed for established risk factors for falls preoperatively and postoperatively. Patients were issued with a diary to record any falls and phoned at 2 monthly intervals during the 6 month preoperative and postoperative periods.

RESULTS

Of the 84 patients who completed the study, 31 recorded falls during the preoperative period (37%). This group showed a statistically significant reduction in the number of fallers in the postoperative period (n = 6, p<0.001)

CONCLUSION

These results suggest that cataract surgery is an effective intervention to reduce the risk of falls in elderly patients with cataract related visual impairment.

p38 MAP kinase activity modulates alpha beta T cell development

Reciprocal interactions between bone marrow derived precursor cells and the thymic environment lead to the generation of the complete repertoire of diverse and functional T cells. We have previously shown that p38 MAP kinase is activated in response to intrathymic signals in thymocytes. In this report we provide evidence that p38 MAP kinase activity is essential for pre-TCR-mediated transition of thymocytes from the CD4- CD8- to the CD4+ CD8+ stage of development. In the absence of p38 MAP kinase activity differentiation of alpha beta T cells, but not gamma delta T cells, was blocked.

Brief communication: Choice of washing method of hair samples for trace element analysis in environmental studies

Determination of inseparable exogenous and endogenous levels of toxic trace elements such as lead in human scalp hair has been used to understand and assess population exposure to such elements. For any such analysis, washing of the hair samples to remove superficial contamination is the foremost requirement. However, the use of such washing methods prior to elemental analysis removes minute quantities of trace elements from the hair strands. This degree of loss is dependent on the washing method employed. In the present study, the element lead has been determined in human scalp hair after three methods of hair washing. It is apparent that the nonionic detergent-acetone method is best suited for securing valid lead analysis results in human scalp hair.

Hydrocortisone replacement dosage influences intraocular pressure in patients with primary and secondary hypocortisolism

BACKGROUND

It has been suggested that the variation of intraocular pressure (IOP) during the day follows the diurnal variation of serum cortisol. There is also a higher risk of ocular hypertension and glaucoma in patients taking excessive oral steroid treatment. We assessed whether different replacement doses of hydrocortisone (HC) influenced IOP.

METHODS

Seventeen patients (six Addison's disease, 11 hypopituitarism; seven males) aged 24-58 years mean 42.7 years and 20 control subjects (nine males) aged 20--59 years mean 38.7 years were studied. On the first visit, the 17 patients had been taking HC replacement doses, 20 mg morning and 10 mg afternoon. Serum cortisol and IOP in both eyes (Goldmann applanation tonometer) were measured at 0900, 1100, 1300, 1500, 1700 hours with HC 20 mg taken after the 0900 h assessment. The dose of HC was then reduced to 10 mg morning and 10 mg afternoon for 1 week and the measurements were repeated in 16 patients, with HC 10 mg taken at 0900 h.

RESULTS

In the patients the peak serum cortisol occurred at 1100 h after the 0900 h HC dose. Cortisol levels were significantly higher at 1100, 1300, 1500 and 1700 h after taking 20 mg compared to 10 mg HC. The mean (SEM) IOP (mmHg) was significantly higher after 20 mg HC compared with 10 mg HC at 1300 h: 14.7(0.6) v 13.1(0.6) (P = 0.004) and at 1500 h: 14.4(0.6) v 13.1(0.5) (P = 0.04). The total mean (SEM) daily IOP score was significantly higher after 20 mg HC compared with 10 mg HC: 14.5(0.3) v 13.5(0.3) (P = 0.0002). The total mean (SEM) daily IOP score after the 20 mg HC dose compared with the control subjects was: 14.5(0.3) v 13.7(0.3) (P = 0.08).

CONCLUSION

Intraocular pressures during the day are influenced by the morning hydrocortisone replacement dosage with significantly higher intraocular pressure levels in the early afternoon following 20 mg compared with 10 mg. A morning hydrocortisone dose of 10 mg leads to a more physiological intraocular pressure profile during the day. These data support the view that a daily replacement dose of 30 mg hydrocortisone may be excessive.

Signal transduction in thymus development

Reciprocal interaction between bone marrow derived lymphoid precursor cells and the thymic environment leads, through a series of developmental events, to the generation of a diverse repertoire of functional T-cells. During thymopoiesis fetal liver or bone marrow derived precursors enter the thymus and develop into mature T-cells in response to cues derived from the environment. The thymic micro-environment provides signals to the lymphoid cells as a result of cell-cell interactions, locally produced cytokines, chemokines and hormones. Developing thymocytes, in turn, influence the thymic stroma to form a supportive micro-environment. Stage-specific signals provide an exquisite balance between cellular proliferation, differentiation, cell survival and death. The result of this intricate signaling concert is the production of the requisite numbers of well educated self-restricted T-cells. Mature T-cells are exported to the peripheral lymphoid organs, where, upon encountering antigen, naive T-cells further mature into effector cells that provide cytolytic or T helper functions. While there are extra-thymic locations for T-cell development, majority of T-cells in peripheral lymphoid organs are thymus derived. In mice and humans, T-cells develop throughout life although the efficacy declines significantly with age. It is not clear if this is a direct consequence of deterioration of the thymic environment by involution, a paucity of bone marrow derived precursors, or both. However, new data clearly shows that the involuted adult thymus retains the ability to generate new T-cells. Recent advances have revealed many components of an exquisitely balanced signaling cascades that regulate cell fate, cellular proliferation and cell death in the thymus. This article describes fundamental features of developing thymocytes and the thymic micro-environment as they relate to the signaling pathways.

Windbeutel is required for function and correct subcellular localization of the Drosophila patterning protein Pipe

Drosophila embryonic dorsal-ventral polarity originates in the ovarian follicle through the restriction of pipe gene expression to a ventral subpopulation of follicle cells. Pipe, a homolog of vertebrate glycosaminoglycan-modifying enzymes, directs the ventral activation of an extracellular serine proteolytic cascade which defines the ventral side of the embryo. When pipe is expressed uniformly in the follicle cell layer, a strong ventralization of the resulting embryos is observed. Here, we show that this ventralization is dependent on the other members of the dorsal group of genes controlling dorsal-ventral polarity, but not on the state of the Epidermal Growth Factor Receptor signal transduction pathway which defines egg chamber polarity. Pipe protein expressed in vertebrate tissue culture cells localizes to the endoplasmic reticulum. Strikingly, coexpression of the dorsal group gene windbeutel in those cells directs Pipe to the Golgi. Similarly, Pipe protein exhibits an altered subcellular localization in the follicle cells of females mutant for windbeutel. Thus, Windbeutel protein enables the correct subcellular distribution of Pipe to facilitate its pattern-forming activity.

Establishment of synchronization in carrot cell suspension culture and studies on stage specific activation of glyoxalase I

The present report summarizes and compares the effects of three cell cycle inhibitors, viz. aphidicolin, hydroxyurea and mimosine, in inducing synchronization of a rapidly proliferating suspension culture of carrot. These treatments efficiently synchronized the cell cycle as the doubling time of the cell population was roughly equal to the total length of one cell cycle. Protoplasts derived from mimosine treated cell suspension culture were resolved via flow cytometry to get an idea of the temporal organization of the cell cycle events. The biochemical analysis showed a rise in stage specific activity of glyoxalase I, an auxin inducible marker enzyme activated at G2-M. This activity peak could be shifted to an early phase of interphase in response to auxin treatment.

The homeobox gene mirror links EGF signalling to embryonic dorso-ventral axis formation through notch activation

Recent studies in vertebrates and Drosophila melanogaster have revealed that Fringe-mediated activation of the Notch pathway has a role in patterning cell layers during organogenesis. In these processes, a homeobox-containing transcription factor is responsible for spatially regulating fringe (fng) expression and thus directing activation of the Notch pathway along the fng expression border. Here we show that this may be a general mechanism for patterning epithelial cell layers. At three stages in Drosophila oogenesis, mirror (mirr) and fng have complementary expression patterns in the follicle-cell epithelial layer, and at all three stages loss of mirr enlarges, and ectopic expression of mirr restricts, fng expression, with consequences for follicle-cell patterning. These morphological changes are similar to those caused by Notch mutations. Ectopic expression of mirr in the posterior follicle cells induces a stripe of rhomboid (rho) expression and represses pipe (pip), a gene with a role in the establishment of the dorsal-ventral axis, at a distance. Ectopic Notch activation has a similar long-range effect on pip. Our results suggest that Mirror and Notch induce secretion of diffusible morphogens and we have identified TGF-beta (encoded by dpp) as such a molecule in germarium. We also found that mirr expression in dorsal follicle cells is induced by the EGF-receptor (EGFR) pathway and that mirr then represses pip expression in all but the ventral follicle cells, connecting EGFR activation in the dorsal follicle cells to repression of pip in the dorsal and lateral follicle cells. Our results suggest that the differentiation of ventral follicle cells is not a direct consequence of germline signalling, but depends on long-range signals from dorsal follicle cells, and provide a link between early and late events in Drosophila embryonic dorsal-ventral axis formation.

Subcutaneous cysticercosis involving the eyelid: sonographic diagnosis

A 25-year-old man and a 14-year-old boy presented with neurocutaneous cysticercosis involving the eyelid. Both patients had hundreds of scattered subcutaneous cysticerci. They were arranged in clusters over the sternocleidomastoid muscle in the neck. Such clustering of cysticerci is highly suggestive of central nervous system (CNS) involvement, as both the sternocleidomastoid muscle and the CNS are supplied by the carotid artery and cysticerci travel via the hematogenous route. We used ultrasonography to diagnose subcutaneous cysticercosis, which showed characteristic low reflective cysts and high reflective scolices inside. Although subcutaneous cysticerci are inconsequential, their verification is important in the diagnosis of more severe CNS involvement. They may be confused with other painless swellings such as lymphadenopathies, neurofibromas, and epidermoid cysts.

Multiple neurilemmomas of the penis

A 10-year-old male with multiple small swellings over the shaft of the penis for 2 years was found to have multiple neurilemmomas on histopathologic examination. The case is reported in view of the extreme rarity of the entity.

Caudal duplication--a case report

Caudal duplication is a rare entity due to incomplete separation of mono-ovular twins. It is usually associated with various congenital malformations involving mainly the genitourinary and gastrointestinal tracts. We report such a case operated upon successfully in which there was no other associated anomaly.