Measurement of the cardiac time intervals of the fetal ECG utilising a computerised algorithm: A retrospective observational study

Objective

Establish whether the reliable measurement of cardiac time intervals of the fetal ECG can be automated and to address whether this approach could be used to investigate large datasets.

Design

Retrospective observational study.

Setting

Teaching hospitals in London UK, Nottingham UK and New York USA.

Participants

Singleton pregnancies with no known fetal abnormality.

Methods

Archived fetal ECG's performed using the MonicaAN24 monitor. A single ECG (PQRST) complex was generated from 5000 signal-averaged beats and electrical cardiac time intervals measured in an automated way and manually.

Main Outcome measure

Validation of a newly developed algorithm to measure the cardiac time intervals of the fetal ECG.

Results

188/236 (79.7%) subjects with fECGs of suitable signal:noise ratio were included for analysis comparing manual with automated measurement. PR interval was measured in 173/188 (92%), QRS complex in 170/188 (90%) and QT interval in 123/188 (65.4%). PR interval was 107.6 (12.07) ms [mean(SD)] manual vs 109.11 (14.7) ms algorithm. QRS duration was 54.72(6.35) ms manual vs 58.34(5.73) ms algorithm. QT-interval was 268.93 (21.59) ms manual vs 261.63 (36.16) ms algorithm. QTc was 407.5(32.71) ms manual vs 396.4 (54.78) ms algorithm. The QRS-duration increased with gestational age in both manual and algorithm measurements.

Conclusion

Accurate measurement of fetal ECG cardiac time intervals can be automated with potential application to interpretation of larger datasets.

Practical consensus recommendations regarding the management of HER2 neu positive metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors, including where the cancer has spread, the patient's overall health, and the levels of hormone receptors and HER2 in the tumour. Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours.^{[7],[8],[9],[10]} This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of these agents and the management of HER2 positive MBC for the benefit of community oncologists.

Practical consensus recommendations for neo-adjuvant chemotherapy in triple negative breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to use neoadjuvant chemotherapy in triple negative breast cancer patients.

Efficacy of Mycophenolate Mofetil as a Remission Maintaining Agent in Idiopathic Childhood Nephrotic Syndrome

Of all cases of idiopathic steroid-sensitive nephrotic syndrome (NS) in children, 40%-75% cases need long-term continuous steroids and/or other immunosuppressants to maintain remission, the effects of which on growth and renal function remain an issue of concern. The study aimed at exploring the safety and efficacy of mycophenolate mofetil (MMF) as a remission-maintaining agent in children with a diagnosis of frequent relapsing or steroid-dependent NS (FRNS/SDNS) requiring continuous medication for at least 1 year. Thirty-two children thus included received MMF (1000-1200 mg/m²/day) for 7 months along with tapering doses of oral prednisolone if it was being given from before with an attempt at tapering at 0.25 mg/kg/month ultimately stopping it altogether. Individuals were followed up for at least 5 more months after stopping MMF. Out of 32 children, 26 had SDNS and 6 had FRNS with male:female ratio being 2.2:1. The mean standard deviation (± SD) age of onset of disease was 2.72 ± 1.3 years and that entry to the study was 7.17 ± 2.2 years. Significant fall in number of relapses was observed following the introduction of MMF (110 in pre-MMF12 month period vs. 52 in post-MMF 12 months [p = 0.002]). The mean relapse rate/year/patient also decreased from 3.43 ± 1.26 to 1.62 ± 1.14 after entry in the study. Significant reduction of the cumulative dose of steroid regarding mean ± SD of mg/kg/year was also found following the introduction of MMF (190.9 ± 47.81 vs. 119.09 ± 60.09 [p = 0.001]). MMF is an efficacious agent in maintaining remission and reducing steroid requirement in children with FRNS and SDNS.

Natural killer cells contribute to hepatic injury and help in viral persistence during progression of hepatitis B e-antigen-negative chronic hepatitis B virus infection

Hepatitis B e-antigen negative (e(-)) chronic HBV infection (CHI) encompasses a heterogeneous clinical spectrum ranging from inactive carrier (IC) state to e(-) chronic hepatitis B (CHB), cirrhosis and hepatic decompensation. In the backdrop of dysfunctional virus-specific T cells, natural killer (NK) cells are emerging as innate effectors in CHI. We characterized CD3(-) CD56(+) NK cells in clinically well-defined, treatment-naive e(-) patients in IC, e(-)CHB or decompensated liver cirrhosis (LC) phase to appraise their role in disease progression. The NK cell frequencies increased progressively with disease severity (IC 8.2%, e(-)CHB 13.2% and LC 14.4%). Higher proportion of NK cells from LC/e(-)CHB expressed CD69, NKp46, NKp44, TRAIL and perforin, the last two being prominent features of CD56(bright) and CD56(dim) NK subsets, respectively. The frequencies of CD3(-) CD56(+) NK cells together with TRAIL(+) CD56(bright) and Perforin(+) CD56(dim) NK cells correlated positively with serum alanine transaminase levels in e(-)CHB/LC. K562 cell-stimulated NK cells from e(-)CHB/LC exhibited significantly greater degranulation but diminished interferon-γ production than IC. Further, Perforin(+) NK cell frequency inversely correlated with autologous CD4(+) T-cell count in e(-) patients and ligands of NK receptors were over-expressed in CD4(+) T cells from e(-)CHB/LC relative to IC. Co-culture of sorted CD56(dim) NK cells and CD4(+) T cells from e(-)CHB showed enhanced CD4(+) T-cell apoptosis, which was reduced by perforin inhibitor, concanamycin A, suggesting a possible perforin-dependent NK cell-mediated CD4(+) T-cell depletion. Moreover, greater incidence of perforin-expressing NK cells and decline in CD4(+) T cells were noticed intrahepatically in e(-)CHB than IC. Collectively, NK cells contribute to the progression of e(-)CHI by enhanced TRAIL- and perforin-dependent cytolytic activity and by restraining anti-viral immunity through reduced interferon-γ secretion and perforin-mediated CD4(+) T-cell lysis.

Validating the GTP-cyclohydrolase 1-feedback regulatory complex as a therapeutic target using biophysical and in vivo approaches

BACKGROUND AND PURPOSE

6R-L-erythro-5,6,7,8-tetrahydrobiopterin (BH4 ) is an essential cofactor for nitric oxide biosynthesis. Substantial clinical evidence indicates that intravenous BH4 restores vascular function in patients. Unfortunately, oral BH4 has limited efficacy. Therefore, orally bioavailable pharmacological activators of endogenous BH4 biosynthesis hold significant therapeutic potential. GTP-cyclohydrolase 1 (GCH1), the rate limiting enzyme in BH4 synthesis, forms a protein complex with GCH1 feedback regulatory protein (GFRP). This complex is subject to allosteric feed-forward activation by L-phenylalanine (L-phe). We investigated the effects of L-phe on the biophysical interactions of GCH1 and GFRP and its potential to alter BH4 levels in vivo.

EXPERIMENTAL APPROACH

Detailed characterization of GCH1-GFRP protein-protein interactions were performed using surface plasmon resonance (SPR) with or without L-phe. Effects on systemic and vascular BH4 biosynthesis in vivo were investigated following L-phe treatment (100 mg·kg(-1) , p.o.).

KEY RESULTS

GCH1 and GFRP proteins interacted in the absence of known ligands or substrate but the presence of L-phe doubled maximal binding and enhanced binding affinity eightfold. Furthermore, the complex displayed very slow association and dissociation rates. In vivo, L-phe challenge induced a sustained elevation of aortic BH4 , an effect absent in GCH1(fl/fl)-Tie2Cre mice.

CONCLUSIONS AND IMPLICATIONS

Biophysical data indicate that GCH1 and GFRP are constitutively bound. In vivo, data demonstrated that L-phe elevated vascular BH4 in an endothelial GCH1 dependent manner. Pharmacological agents which mimic the allosteric effects of L-phe on the GCH1-GFRP complex have the potential to elevate endothelial BH4 biosynthesis for numerous cardiovascular disorders.

New HBV subgenotype D9, a novel D/C recombinant, identified in patients with chronic HBeAg-negative infection in Eastern India

Genome diversity is a hallmark of hepatitis B virus (HBV), which allowed its classification into 10 genotypes (A-J) and numerous subgenotypes. Among them, Genotype D is currently segregated into eight subgenotypes (D1-D8). Here, we report the identification and characterization of a novel subgenotype within genotype D of HBV from chronic hepatitis B e antigen (HBeAg)-negative patients of Eastern India. Phylogenetic tree analysis based on complete genome sequences revealed that six of 39 HBV/D isolates formed a distinct cluster supported by high bootstrap value and had nucleotide divergence >4% relative to the known D subgenotypes (D1-D8), justifying their assignment into a new subgenotype (D9). By comparing the amino acid sequences of the four ORFs of HBV/D9 with D1-D8, 36 specific residues, including a unique one (E(112) in the core region), were identified that could be considered as a signature of D9. Further analysis by Simplot, BootScan and jpHMM demonstrated that D9 resulted from a discrete recombination with genotype C over the precore-core region. This type of recombination has not been described previously as all C/D recombinants reported so far possessed genotype C backbones with mosaic fragments derived from HBV/D. Interestingly, compared to other subgenotypes of HBV/D, D9 isolates had a higher frequency of mutations (A1762T and G1764A) in the basal core promoter region that had been implicated in the development of hepatocellular carcinoma. Further investigations are needed to determine the overall prevalence and clinical significance of these newly characterized D9 strains and to assess the impact of inter-genotypic recombination on viral properties.

Comparative analysis between objective structured clinical examination (OSCE) and conventional examination (CE) as a formative evaluation tool in Pediatrics in semester examination for final MBBS students

BACKGROUND

The use of objective structured clinical examination in pediatrics is not common in undergraduate evaluation process.

OBJECTIVE

To evaluate the effectiveness of objective structured clinical examination as compare to conventional examination as formative assessment tool in Pediatrics.

METHODS

We conducted a cross sectional comparative study in defined population of 9th semester MBBS students to evaluate the effectiveness of objective structured clinical examination as comparison to conventional examination as formative assessment tool in Pediatrics. We analyzed the perception of objective structured clinical examination among the students.

RESULTS

Fifty-two students appeared for the objective structured clinical examination evaluation on the first day and 42 turned up for conventional examination on the next day. The 42 students who turned up for both examinations were asked to respond to the perception evaluation questionnaire. Comparison of the two examination styles showed that students fared better in objective structured clinical examination than in conventional examination both with respect to mean total score (p less than 0.001) as well as mean percentage score. Out of the 42 subjects who appeared in both examinations, all passed in objective structured clinical examination and 35 passed in conventional examination, this difference was significant by McNemar chi-square test (p = 0.016). 73.8% of the students opined in favor of objective structured clinical examination as a better formative assessment tool whereas 9.5% students preferred conventional examination.

CONCLUSIONS

Objective structured clinical examination a statistically significant better evaluation tool with comparison to conventional examination.

Tracking the naturally occurring mutations across the full-length genome of hepatitis B virus of genotype D in different phases of chronic e-antigen-negative infection

Hepatitis B e-antigen (HBeAg)-negative chronic HBV infection is highly prevalent in several parts of the world, including India, with the clinical spectrum ranging from inactive carrier (IC) state to chronic 'e-negative' hepatitis B (CHB) and culminating in advanced liver disease such as cirrhosis (LC). The present study has for the first time investigated the natural diversity of HBV belonging to genotype D in treatment-naïve Indian patients representing the above phases of HBeAg-negative infection to identify candidate mutations associated with each disease state. Studies of full-length HBV/D sequences revealed that the progressive accumulation and persistence of mutations in basal core promoter, negative regulatory element, Pre-core region, the B- and T-cell epitopes of X protein as well as deletions in the PreS region contribute significantly to disease progression from IC through CHB to LC. In addition, the development of CHB was associated with a significant increase in viral variants characterized by mutations in enhancer II, preS1 promoter, T-cell epitope of core and B-cell epitope region of PreS1. While few of the mutations were previously reported in the context of HBV genotypes B and C, others had not been documented before. Our results thus highlight a distinct pattern of mutation in HBV/D that may help in predicting clinical outcomes of HBeAg-negative infection and have implications for better clinical management of the patients.

Disseminated lipogranulomatosis

Farber disease or disseminated lipogranulomatosis is a rare inherited disorder of lipid metabolism resulting from a defect in ceramide degradation. Because of the feature of nodular swellings around various joints, this may sometimes be confused with juvenile idiopathic arthritis. We report a 4-year-old boy with Farber disease who presented with nodular swellings around the joint, angle of the mouth and conjunctiva, and was subsequently diagnosed to be a case of Farber Disease.

A novel and simple approach to enhance ultraviolet photosensitivity: activated-carbon-assisted growth of ZnO nanoparticles

An activated-carbon (AC) assisted route is developed to synthesize a ZnO nanoparticle network. The route involves simple addition of AC to the solution containing the zinc salt and finally removing them by burning at higher temperature to form a sponge-like porous ZnO nanoparticles. The surface area measurements show that AC-assisted ZnO nanoparticles (AC-ZnO) have a higher surface area than those synthesized without AC (B-ZnO), which is further confirmed by the field emission scanning electron microscope (FESEM) and high resolution transmission electron microscope (HRTEM) images. Ultraviolet (UV) absorbance results show that the optical quality remains almost unchanged for both types of nanoparticles. Enhanced and faster UV photosensitivity has been observed for the AC-ZnO. The change in the UV photosensing properties demonstrated here provides a new approach to synthesizing other high surface area materials for novel physical and chemical properties.

Alcohol concentration in the preparation of mother tinctures of vegetable origin. The example of Holarrhena antidysenterica

The strength of solvent affects the therapeutic efficacy of homeopathic tinctures of vegetable origin. On the basis of physical, chemical and biological assay of different tinctures made with different concentrations, in the case of Holarrhena antidysenterica Wall, the best solvent was 70% v/v ethanol. This is different from the standard strong alcohol recommended in homeopathic pharmacopoeia. It may be necessary to review the procedure followed for the preparation of homeopathic mother tinctures of vegetable origin.

Spontaneous contractions of myometrium from humans, non-human primate and rodents are sensitive to selective oxytocin receptor antagonism in vitro

OBJECTIVES

To determine whether: 1. oxytocin receptor antagonists influence spontaneous contractions of myometrium from humans, non-human primates and rodents (in vitro), and 2. vasopressin V1a receptor antagonism is important for inhibition of spontaneous contractions in human myometrium.

DESIGN

In vitro pharmacology of spontaneous contractions of myometrium from humans and animals.

SETTING

The research laboratories of a university department of obstetrics and gynaecology and a pharmaceutical industry research centre.

INTERVENTIONS

Samples of human myometrium were obtained at caesarean section. Tissue strips were suspended in organ baths for isometric force recording. Cumulative concentration effect curves to a selective oxytocin receptor antagonist (L-371,257) and a mixed oxytocin/vasopressin V1a receptor antagonist (atosiban) were obtained. The effect of L-371,257 was also determined in myometrium from non-pregnant rats and marmosets.

MAIN OUTCOME MEASURES

The inhibition of spontaneous myometrial contractions in vitro.

RESULTS

L-371,257 and atosiban significantly inhibited spontaneous activity of human myometrium in a concentration-related manner (P < 0.05), although the effect was more pronounced with L-371,257. Spontaneous contractions of myometrium from non-pregnant rats and marmosets were also inhibited by L-371,257 (atosiban was not tested).

CONCLUSIONS

Spontaneous contractions of myometrium from humans, marmosets and rats are, at least in part, dependent on oxytocin receptor activity, in vitro. L-371,257 and atosiban may be inverse agonists. Selective non-peptide oxytocin receptor antagonists may be effective tocolytics.

Peripheral administration of low pH solutions causes activation and sensitisation of convergent dorsal horn neurones in the anaesthetised rat

This is the first study to examine the effects of peripheral administration of acid on the activity of dorsal horn neurones in vivo. Extracellular recordings from convergent neurones revealed increases in neuronal activity evoked by administration of low pH solutions into the peripheral receptive field. Threshold for activity ranged from pH 5.85 to 2.5. The magnitude of responses increased with decreasing pH; maximum effects were achieved with pH 2.5 (648+/-181 action potentials/60 s, as compared to control-evoked activity of 86.3+/-29 action potentials/60 s). Activity lasted for up to 60 s, likely to represent the time for which the solutions were able to surmount the buffering capacity of the intact hindpaw. Significant sensitisation of the neurones to both innocuous (von Frey filament 9 g) and noxious (30 g) mechanical punctate stimuli was also observed.

Physical, chemical and biological assay of Tylophora indica mother tincture--a comparative study

Successful use of homeopathic medicines is related to the purity and quality of crude and finished products. To maintain the quality of Tylophora indica mother tincture, a comparative study on physical, chemical and biological assay of five samples (reference laboratory and market) of Tylophora indica was carried out. The market sample showed different chromatographic characteristics and may have been prepared from a different species. T. indica has antispasmodic and hypotensive properties.

Successful treatment of hypernatremic thirst deficiency with chlorpropamide

Two patients with hypodipsia and hypernatremia are described. The first patient, whose hypodipsia was of unknown cause, developed hypernatremia unless large volumes of fluid were urged upon him; upon treatment with chlorpropamide normal serum sodium levels were achieved with spontaneous fluid intake. The second patient had hypodipsia and diabetes insipidus resulting from a craniopharyngioma. Treatment with vasopressin and a prescribed daily water intake resulted in frequent hyper- and hyponatremia, but treatment with chlorpropramide yielded serum sodium values which were more often normal and less variable. In neither patient could the improved water regulation be attributed to an effect of chlorpropamide on renal water excretion. Possible mechanisms for the effect of chlorpropamide on thirst are discussed.

Thin-layer acrylamide gel electrophoresis

A thin-layer acrylamide gel electrophoresis technique suitable for analysis of serum or urine proteins is described in detail. The method gives sharp differentiation of protein fractions and is particularly suitable for the analysis of biological solutions containing proteins in low concentration.

Evaluation of haptoglobin phenotype 0-0 in cirrhotic and non-cirrhotic hospital populations

The haptoglobin phenotypes of 3,332 individuals, consisting of 2,930 caucasians and 402 negroes living in the greater Boston area, were determined. Of these, 3,222 were hospitalized medical patients fully documented regarding diagnoses. One hundred and twentyeight of the total population studied were shown to exhibit starch gel anhaptoglobinaemia (3.7%). Re-evaluation on acrylamide gel of 118 0-0 samples revealed that the majority (94%) were derived from patients exhibiting hypohaptoglobinaemia rather than anhaptoglobinaemia.