Stimuli-responsive polysaccharide-based smart hydrogels for diabetic wound healing: Design aspects, preparation methods and regulatory perspectives

Diabetes adversely affects wound-healing responses, leading to the development of chronic infected wounds. Such wound microenvironment is characterized by hyperglycaemia, hyperinflammation, hypoxia, variable pH, upregulation of matrix metalloproteinases, oxidative stress, and bacterial colonization. These pathological conditions pose challenges for the effective wound healing. Therefore, there is a paradigm shift in diabetic wound care management wherein abnormal pathological conditions of the wound microenvironment is used as a trigger for controlling the drug release or to improve properties of wound dressings. Hydrogels composed of natural polysaccharides showed tremendous potential as wound dressings as well as stimuli-responsive materials due to their unique properties such as biocompatibility, biodegradability, hydrophilicity, porosity, stimuli-responsiveness etc. Hence, polysaccharide-based hydrogels have emerged as advanced healthcare materials for diabetic wounds. In this review, we presented important aspects for the design of hydrogel-based wound dressings with an emphasis on biocompatibility, biodegradability, entrapment of therapeutic agents, moisturizing ability, swelling, and mechanical properties. Further, various crosslinking methods that enable desirable properties and stimuli responsiveness to the hydrogels have been mentioned. Subsequently, state-of-the-art developments in mono- and multi- stimuli-responsive hydrogels have been presented along with the case studies. Finally regulatory perspectives, challenges for the clinical translation and future prospects have been discussed.

Iatrogenic Cushing's syndrome in a case of allergic bronchopulmonary aspergillosis treated with oral itraconazole and inhaled budesonide

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus that occurs in patients with asthma or cystic fibrosis. Here, we report a case of a young female with bronchial asthma who presented to our hospital with worsening breathlessness on exertion. She was diagnosed to have ABPA and was initiated on oral itraconazole while continuing inhaled long acting beta-2 adrenergic agonist and medium dose inhaled corticosteroid (ICS) for her asthma. Three months after initiation of therapy, the patient had significant improvement in breathlessness. However, she had weight gain, facial puffiness, increased facial hair and development of striae on her inner thighs, calf and lower abdomen. Her serum cortisol levels were found to be suppressed and hence a diagnosis of iatrogenic Cushing's syndrome was made. Our case describes the potentially serious interaction between ICS and oral itraconazole, a treatment very commonly prescribed in patients with ABPA.

Drug Induced Hyperprolactinemia

Introduction: Drugs are a common cause of hyperprolactinemia. It is essential to differentiate this cause from other pathological causes which avoids unnecessary investigations. Detailed history will help us in identifying the responsible drug and withdrawing the same will be rewarding. Here we are reporting a case series of drug induced hyperprolactinemia. Methods: It was a cross-sectional observational study. Subjects were recruited from our outpatient department. Hyperprolactinemia was defined as blood prolactin levels >30 ng/mL in females and >24 ng/mL in males, regardless of the presence of symptoms. Serum prolactin was repeated one week after holding the suspected drug(s). Drug induced hyperprolactinemia is defined as normalisation of serum prolactin on discontinuation of the offending drug. Demographics, clinical presentation and offending drug name were entered in pre designed proforma.

Results: Total of 32 subjects were studied in this study with age of 35.5±10.8years. Predominantly female subjects were present with female to male ratio 5.4. Basal prolactin was 132±68.7ng/mL and after holding the drug prolactin value was 16.9±8.2. Proton pump inhibitors in combination with prokinetics were the leading cause (71.8%) and followed by multiple drug combinations (15.6%), anti-psychiatric drugs(9.3%) and oral contraceptives(3.1%). Overall 86.75% of subjects were having symptomatic presentation. Commonest clinical presentation among the women was galactorrhea (88.9% of female subjects) followed by irregular menstrual cycles (59% of female subjects) and breast heaviness in 29.6%. Among the men erectile dysfunction was common presentation, noted among 80% of them. Asymptomatic presentation was there in 6.25% of subjects. All subjects were improved clinically after withdrawal of the the offending drug(s).

Conclusions: Most of the subjects were clinically symptomatic. Most common symptom in female was galactorrhea followed by irregular menses and breast heaviness, and erectile dysfunction in males. All subjects were improved clinically after withdrawal of the offending drug(s). A detailed drug history is rewarding and avoids unnecessary investigations for hyperprolactinemia

MON-914 Ectopic ACTH Syndrome Caused by Adenocarcinoma of Lung - a Rare Association with Rare Complication

INTRODUCTION Ectopic ACTH constitutes 5-10% of ACTH dependent Cushing’s syndrome. Evolution of symptoms can be rapid. Cortisol & ACTH is usually higher as compared to Cushing’s disease. Imaging studies should be obtained for localization of the source of ACTH. Here, we present a case of Cushing’s syndrome caused by ectopic ACTH production caused by adenocarcinoma lung, which has very rarely been associated with this syndrome CASE A 52-year-old male presented with 3-month H/O bilateral pedal edema & puffiness of face. He noticed bruises over his trunk & darkening of face for 2 months. There was a recent worsening of his HTN (requiring 3 antihypertensives) & recently diagnosed with DM. On examination patient had cushingoid features, acne and ecchymosis. BP - 166/110 mm Hg. Proximal myopathy, Pedal edema, clubbing & cervical lymphadenopathy was present (largest node - 2.5cm). Fasting & postprandial blood sugars were 190 & 285 mg/dl respectively. Serum K⁺ was 3.0 meq/L (3-5-5.0meq/L), 11pm serum cortisol was 51.6 mcg/dl (cutoff < 7,5mcg/dl), 8 am cortisol after overnight 1mg dexamethasone was 60.7 mcg/dl (cutoff<1.8mcg/dl). Serum ACTH(8am) - 178 pg/ml.(>20 pg/ml-ACTH dependent Cushing’s) Biopsy of neck node revealed poorly differentiated adenocarcinoma. PET scan showed left lung upper & lower lobe masses. A diagnosis of ectopic ACTH syndrome was made, the source of which was adenocarcinoma of lung, which has been very rarely reported to be associated with it. Oral ketoconazole was started followed by Chemotherapy with paclitaxel & carboplatin. Within the next 7 days patient developed pleural effusion, neutropenia & worsened rapidly. BAL revealed Nocardia species, known to be associated with hypercortisolism. He was treated with appropriate antibiotics & supportive treatment but succumbed to septic shock. CONCLUSION If a patient presents with rapidly evolving symptoms of Cushing’s syndrome, ectopic ACTH syndrome should be considered. The presence of wasting and weight loss, hypokalemic alkalosis, pedal edema & marked hyperpigmentation should also alert towards the diagnosis. Histopathological confirmation of malignancy is important, as in our case with ectopic ACTH where the source was an adenocarcinoma of the lung, of which only 5 cases have been reported till now (Ectopic ACTH more commonly associated with SCLC). Finally, in cases of severe hypercortisolemia, there should be a high index of suspicion for opportunistic infections including invasive fungal infections, Nocardiosis etc, so that specific antibiotic therapy can be initiated. Typical features like fever, leukocytosis can be absent. Treatment of underlying hypercortisolism with surgical/medical management prior to initiation of chemotherapy has been shown to reduce the frequency of infections.

Association of Non-HDL Cholesterol, Homocysteine and Vitamin D in Acute Coronary Syndrome

BACKGROUND

The role of Low Density Lipoprotein Cholesterol (LDL-C) in the pathogenesis of Coronary Heart Disease (CHD) has been well established. In many studies it was found that Non-HDL cholesterol (total cholesterol minus High Density Lipoprotein Cholesterol [HDL-C] is a better predictor of CHD risk than LDL-C alone. High homocysteine levels are associated with increased risk of cardiovascular and cerebrovascular disease. An inverse relation has been seen between vitamin D serum level and coronary artery calcification. Studies are inadequate among Indians to establish the role of these non-conventional risk factors in acute coronary syndrome.

OBJECTIVES

To correlate the values of non-HDL cholesterol, vitamin D and homocysteine in patients with acute coronary syndrome (ACS) with controls.

METHODS

:For this retrospective study cases were the patients admitted in Poona Hospital and Research Centre between November 2013 and November 2015 with acute coronary syndrome whereas controls were patients admitted in Poona Hospital and Research Centre during the same period with diagnosis other than Acute coronary syndrome. Each patient was subjected to detailed clinical history, clinical examination and investigations such as lipid profile, serum homocysteine, and Vitamin D3. Unpaired t-test was used to compare the quantitative data whereas Chi-square test or Fisher's exact test was used for qualitative data.

RESULTS

ACS group had significantly higher mean total serum cholesterol, mean LDL cholesterol, mean non-HDL cholesterol, and mean plasma homocysteine as compared to control group. However, there was no statistically significant difference between the two groups in Vit D levels. Odds ratio was maximum for Non HDL cholesterol, followed by LDL cholesterol, HDL cholesterol, Serum Homocysteine, and Total cholesterol.

CONCLUSION

Non-HDL cholesterol was a better predictor of cardiovascular diseases than LDL-C, HDL-C or total cholesterol.