Cardiac Autonomic and Endothelial Function in Acute Lymphoblastic Leukaemia Patients Immediately After Chemotherapy and at the Three-Month Follow-up

INTRODUCTION

Acute lymphoblastic leukemia (ALL) is a malignant uncontrolled overproduction of immature lymphoid cells in blood and bone marrow. The primary treatment of ALL is chemotherapy. Chemotherapy can have myriad systemic side effects, notably cardiovascular derangement. Autonomic derangement occurrence in cancer patients signifies cardiovascular risk in them and is a determinant of cardiovascular morbidity and mortality. Elevated soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble intercellular adhesion molecule-1 (sICAM-1) levels implicated in the regulation of inflammation indicate endothelial dysfunction. High levels of high-sensitivity C-reactive protein (hsCRP) can be indicative of low-grade inflammation. Hence, in this study the cardiac autonomic function and endothelial and inflammatory biomarker levels in adult patients with ALL were assessed immediately and three months after chemotherapy.

METHODS

In this longitudinal study, 30 ALL patients (23 males, seven females) aged between 18 to 50 years, who had completed chemotherapy regimens, and 30 age and gender-matched healthy participants (controls) were recruited. Cardiac autonomic function tests (short-term heart rate variability (HRV), 30:15 ratio, synaptic excitation and inhibition (E/I) ratio, diastolic blood pressure (DBP) response to isometric hand grip), endothelial markers (sVCAM-1 and sICAM-1), and inflammatory marker (hsCRP) were assessed immediately and at three months after chemotherapy.

RESULTS

Magnitudes of time domain and frequency domain indices, conventional autonomic function test indices, and biomarkers were deranged in ALL patients immediately after chemotherapy. After three months, cardiac autonomic function parameters were found to improve in the form of increased root mean square of successive differences between normal heartbeats (RMSSD), standard deviation of the interbeat intervals of normal sinus beats (SDNN), total power, high-frequency (HF)nu, and decreased low-frequency(LF)nu & LF-HF ratio. Endothelial (sVCAM-1) and inflammatory markers (hsCRP) were lower in the patient group as compared to the controls immediately after chemotherapy. Three months after chemotherapy, the levels of endothelial and inflammatory markers did not show much change.

CONCLUSION

In this study, we found ALL patients showed higher sympathetic drive, decreased parasympathetic modulation, and sympathovagal imbalance immediately after chemotherapy as compared to the controls, indicating cardiovascular risk. After three months, improvement in cardiovascular autonomic function was observed. ALL itself is a state of inflammation with elevated endothelial and inflammatory markers; thus, the decreased endothelial and inflammatory markers could be attributed to the immediate effect of chemotherapy.

Urinary megalin levels in patients with type 2 diabetic nephropathy and its correlation with renal function

Purpose

Megalin is a glycoprotein molecule found on proximal renal tubular epithelial cells. The objectives of this study were to determine urinary megalin levels in non-diabetic subjects and in patients with and without type 2 diabetic nephropathy and to assess the correlation between urinary megalin, urinary albumin, and estimated glomerular filtration rate (eGFR) in diabetic patients.

Materials and Methods

This was a cross-sectional comparative study conducted at a tertiary care teaching hospital in South India for 2 years. Study subjects were divided into three groups: non-diabetic subjects, diabetics with normoalbuminuria, and diabetics with microalbuminuria. Urinary albumin was detected by the dipstick technique in a spot urine sample for all study subjects. Nephelometry was used to quantify urinary albumin levels. The enzyme-linked immunosorbent assay technique estimated urinary megalin.

Results

Urinary megalin levels were higher in non-diabetic subjects compared to diabetic study subjects. There was a significant difference in urinary megalin levels between non-diabetic subjects and diabetic patients with microalbuminuria. No correlation was found between urinary megalin, urinary albumin, and eGFR in patients with diabetic nephropathy.

Conclusion

Urinary megalin levels were higher in non-diabetic subjects than in type 2 diabetic patients. There was no correlation between urinary megalin, urinary albumin, and eGFR in patients with diabetic nephropathy.

Presepsin vs Procalcitonin as Predictors of Sepsis Outcome

BACKGROUND

Sepsis diagnosis and management is aided by the use of newer biomarkers like procalcitonin and presepsin. For prognostication, presepsin may be better than procalcitonin.

METHODOLOGY

Ninety-two participants, suspected to be suffering from sepsis of varied etiologies were included in this study at the time of their presentation to the emergency health services. Presepsin and procalcitonin were estimated and the patient followed up till discharge or death. Receiver operating curve (ROC) curves, sensitivity, specificity, and positive and negative likelihood ratios were calculated. Association between these markers and mortality was estimated.

RESULTS

Out of 92 participants enrolled on day 1, 73 survived till day 3. Patients who had thrombocytopenia, high neutrophil counts, and elevated levels of bilirubin, urea, presepsin, and procalcitonin were associated with poor outcomes. Presepsin and procalcitonin levels increased significantly from day 0 to day 3 in the nonsurvivor group as compared to the survivor group. On comparing the ROC curve of presepsin and procalcitonin, the area under the curve (AUC) of presepsin was more than procalcitonin, signifying that it was a better biomarker of mortality due to sepsis. At a cutoff value of 1.47 ng/dL, presepsin was a predictor of mortality in sepsis [odds ratio (OR) = 14]. It had similar sensitivity but better specificity than procalcitonin in predicting mortality.

A validated and optimized method for separation and quantification of total fatty acids by gas chromatography-ion trap mass spectrometry in human plasma

Fatty acids (FAs) are associated with many physiological functions of tissues, and their alteration has been linked with tissue-specific or systemic diseases. The current situation warrants us to have a sensitive and specific method for analysis of total FAs simultaneously from the biological fluid so that the risk prediction, diagnosis or prognosis of the disease can be made effectively. Because of greater sensitivity and resolution, a method of gas chromatography-ion trap mass spectrometry (GC-IT/MS) has been optimized and validated to quantify simultaneously 19 total FAs levels in plasma and compared with GC-triple quadrupole mass spectrometry. FAs have been transesterified by methanolic acetyl chloride to fatty acid methyl esters (FAMEs). A 65 min GC method separated all 19 FAMEs. The calibration curve had good linearity up to 313-922 μM with a correlation coefficient between 0.9882 and 0.9998. The LODs and LOQs of FAMEs were in the range of 0.63 to 9.55 and 2.12 to 31.8 μM, respectively. The method has recovery up to 144 %, stability at 4 °C for 48 h and one freeze-thaw cycle, and good intra-day and inter-day precision. The optimized method has been used to quantify plasma total FAs in type 2 diabetes mellitus patients with and without acute coronary syndrome. Though a significant difference has been found between IT/MS and triple quadrupole mass spectrometry, the GC-IT/MS can help to quantify total FAs in the clinical setting.

Association of serum calprotectin with peripheral neuropathy in patients with type 2 diabetes mellitus

Introduction

Peripheral neuropathy is a common microvascular complication in patients with type 2 diabetes mellitus with a prevalence of around 50%.

Objectives

This prospective observational cross-sectional study was done to assess serum calprotectin levels among diabetic patients with peripheral neuropathy as compared to those without neuropathy.

Methods

This cross-sectional study was conducted in 126 diabetic patients attending the out-patient department of JIPMER Hospital, Pondicherry from July 2017 to January 2019. The subjects were divided into two groups (with and without peripheral neuropathy) and underwent nerve conduction study of both the lower limbs. Blood samples were collected and stored at -80°C for estimation of serum calprotectin. Serum calprotectin levels were compared between diabetic patients with and without peripheral neuropathy.

Results

Serum calprotectin levels were increased in patients with diabetic peripheral neuropathy (DPN) as compared to those without DPN. However, there was no significant difference in the mean value of serum calprotectin among the various sub-groups of DPN.

Conclusion

Serum calprotectin, an inflammatory biomarker is elevated in patients with diabetic peripheral neuropathy as compared to those without neuropathy.

Association between carbonyl stress markers and the risk of acute coronary syndrome in patients with type 2 diabetes mellitus-A pilot study

BACKGROUND AND AIMS

Carbonyl stress is one of the mechanisms responsible for diabetes and its complications. The study was planned to examine the relationship between carbonyl stress markers and the risk of acute coronary syndrome (ACS) in patients with type 2 diabetes mellitus (T2DM).

METHODS

Forty T2DM patients with ACS and forty T2DM patients without ACS participated in this cross-sectional pilot study. Routine biochemical investigations, creatine kinase-total (CK-T), and creatine kinase-MB (CK-MB) levels were estimated. Serum carbonyl stress markers were analysed by enzyme-linked immunosorbent assay. Binary logistics regression was done to determine the predictive value of carbonyl stress markers for ACS.

RESULTS

Fasting plasma glucose, serum total methylglyoxal (MG), methylglyoxal derived hydroimidazolones-1 (MG-H1), and N^ε-carboxymethyl-lysine (CML) levels were significantly higher in T2DM patients with ACS than in those without ACS. Serum glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and glyoxalase-1 (GLO1) levels were significantly lower in T2DM patients with ACS than in those without ACS. Fasting plasma glucose level was significantly positively correlated with serum MG (r = 0.441, P < 0.001), CML (r = 0.649, P < 0.001), MG-H1 (r = 0.725, P < 0.001), and negatively correlated with serum GAPDH (r = - 0.268, P = 0.012) and GLO1 (r = - 0.634, P = 0.016). Receiver operating characteristic curve analysis showed that serum GAPDH and GLO1 could predict the risk of ACS in T2DM patients.

CONCLUSION

These findings revealed that high carbonyl stress due to lower levels of GAPDH and GLO1 may predispose patients with T2DM for more risk of ACS.

Cardiovascular autonomic neuropathy in patients with type 2 diabetes mellitus and its association with serum omentin and leptin

Cardiovascular autonomic neuropathy (CAN) is a major cause of morbidity and mortality in patients with diabetes as it is associated with a high risk of cardiac arrhythmias.

Association of serum regenerating islet-derived protein 3-beta and oncostatin-M levels with the risk of acute coronary syndrome in patients with type 2 diabetes mellitus - A pilot study

BACKGROUND AND AIMS

Regenerating islet-derived protein 3-beta (Reg3β) and oncostatin-M (OSM), an inducer of Reg3β, are important for the recruitment of macrophages, tissue repair and survival after myocardial infarction. The study was planned to elucidate the diagnostic utility of serum Reg3β and OSM levels for the acute coronary syndrome (ACS).

METHODS

Forty-two type 2 diabetes mellitus (T2DM) patients with ACS as cases and forty-two T2DM patients as controls were recruited. Routine biochemical investigations, creatine kinase-total (CK-T), and creatine kinase-MB (CK-MB) levels were estimated. Serum Reg3β and OSM levels were analysed by enzyme-linked immunosorbent assay.

RESULTS

Serum Reg3β and OSM levels were significantly higher in cases as compared to controls. Serum Reg3β and OSM levels were positively correlated with random blood glucose, serum CK-total, CK-MB levels, and negatively correlated with serum high-density lipoprotein cholesterol (HDL-C) levels. Receiver operating characteristics curve analysis showed that serum OSM and Reg3β levels can be used for the diagnosis of ACS in patients with T2DM as compared to CK-MB levels. On regression analysis, serum Reg3β level was positively associated with body mass index and negatively with serum HDL-C levels and serum OSM level was positively associated with waist circumference and random blood glucose and negatively with serum HDL-C levels.

CONCLUSION

Serum Reg3β and OSM levels may be used as complementary markers besides traditional cardiac markers for the diagnosis of ACS in patients with T2DM. However, further studies are still needed to verify our claim.

Comparison of 10-mg and 5-mg warfarin initiation nomograms in a South Indian population - An open label trial

INTRODUCTION

Early achievement of therapeutic INR leads to shorter hospital stay and lesser cost. Two warfarin initiation nomograms (10 mg nomogram and 5 mg nomogram) are widely used but it is not yet clear which one is better. They have been validated in the West but there are no studies from India. We undertook this study to compare the efficacy and safety of the 10 mg and 5 mg nomograms in the Indian population.

METHODS

169 patients were enrolled between august 2014 to July 2016. Patients with venous thromboembolism or atrial fibrillation secondary to valvular heart disease were included. Patients were allocated to 10 mg or 5 mg nomogram as per the policy of the treating unit.

RESULTS

52% of patients in the 10 mg nomogram achieved therapeutic INR by day 5 as compared to only 17% in the 5 mg nomogram (P = 0.022). The median time to achieve therapeutic INR was much shorter in the 10 mg nomogram (5 days vs 14 days, p = 0.018). Two patients in the 10 mg group (2.3%) and none in the 5 mg group had INR > 4 but they did not have any bleeding.

CONCLUSION

The 10 mg nomogram achieved therapeutic INR significantly earlier with less INR measurements and appears safe. Indian patients require higher a dose of warfarin at initiation and maintenance as compared to other ethnic groups.

N-acetyltransferase 2 (NAT2) gene polymorphism as a predisposing factor for phenytoin intoxication in tuberculous meningitis or tuberculoma patients having seizures - A pilot study

Background & objectives:

Simultaneous administration of phenytoin and isoniazid (INH) in tuberculous meningitis (TBM) or tuberculoma patients with seizures results in higher plasma phenytoin level and thus phenytoin intoxication. N-acetyltransferase 2 (NAT2) enzyme catalyses two acetylation reactions in INH metabolism and NAT2 gene polymorphism leads to slow and rapid acetylators. The present study was aimed to evaluate the effect of allelic variants of N-acetyltransferase 2 (NAT2) gene as a predisposing factor for phenytoin toxicity in patients with TBM or tuberculoma having seizures, and taking INH and phenytoin simultaneously.

Methods:

Sixty patients with TBM or tuberculoma with seizures and taking INH and phenytoin simultaneously for a minimum period of seven days were included in study. Plasma phenytoin was measured by high performance liquid chromatography. NAT2 gene polymorphism was studied using restriction fragment length polymorphism and allele specific PCR.

Results:

The patients were grouped into those having phenytoin intoxication and those with normal phenytoin level, and also classified as rapid or slow acetylators by NAT2 genotyping. Genotypic analysis showed that of the seven SNPs (single nucleotide polymorphisms) of NAT2 gene studied, six mutations were found to be associated with phenytoin intoxication. For rs1041983 (C282T), rs1799929 (C481T), rs1799931 (G857A), rs1799930 (G590A), rs1208 (A803G) and rs1801280 (T341C) allelic variants, the proportion of homozygous mutant was higher in phenytoin intoxicated group than in phenytoin non-intoxicated group.

Interpretation & conclusions:

Homozygous mutant allele of NAT2 gene at 481site may act as a predisposing factor for phenytoin intoxication among TBM or tuberculoma patients having seizures.

Phenotypic interaction of simultaneously administered isoniazid and phenytoin in patients with tuberculous meningitis or tuberculoma having seizures

Treatment of tuberculous meningitis or tuberculoma has become complicated because of adverse drug interactions found amongst antitubercular and anticonvulsant drugs. The aim of the study is to evaluate the effect of simultaneously administered isoniazid (300 mg/day) and phenytoin (300 mg/day) on 60 patients with tuberculous meningitis or tuberculoma having seizures. Plasma samples were analyzed for isoniazid, acetylated-isoniazid (AcINH) and phenytoin levels by high performance liquid chromatography at 3h of drugs administration and patients were classified as rapid or slow acetylator on the basis of metabolic ratio of isoniazid (Rm) and percentage of acetylated-isoniazid (%AcINH). Out of 60 patients studied, 23 were slow acetylators and 37 were rapid acetylators. Slow acetylators revealed higher plasma isoniazid levels and lower plasma AcINH levels, metabolic ratio and %AcINH as compared to rapid acetylators. Plasma phenytoin levels were found to be significantly higher (above therapeutic range) in slow acetylators as compared to rapid acetylators. Plasma phenytoin concentration was moderately strong, negatively correlated with metabolic ratio (r=-0.439, P<0.001) and %AcINH (r=-0.729, P<0.001). Eight comatose patients (34.8%) also showed significantly higher plasma phenytoin levels. Our results suggest that assessment of acetylator status and plasma phenytoin level is critical for dose optimization of isoniazid and phenytoin and to predict the patients at risk of intoxication.