Effects of PNA Sequence and Target Site Selection on Function of a 4.5S Non-Coding RNA

Peptide nucleic acid (PNA) based antisense strategy is a promising therapeutic approach to specifically inhibit target gene expression. However, unlike protein coding genes, identification of an ideal PNA binding site for non-coding RNA is not straightforward. Here, we compare the inhibitory activities of PNA molecules that bind a non-coding 4.5S RNA called SRP RNA, a key component of the bacterial signal recognition particle (SRP). A 9-mer PNA (PNA9) complementary to the tetraloop region of the RNA was more potent in inhibiting its interaction with the SRP protein, compared to an 8-mer PNA (PNA8) targeting a stem-loop. PNA9, which contained a homo-pyrimidine sequence could form a triplex with the complementary stretch of RNA in vitro as confirmed using a fluorescent derivative of PNA9 (F-PNA13). The RNA-PNA complex formation resulted in inhibition of SRP function with PNA9 and F-PNA13, but not PNA8 highlighting the importance of target site selection. Surprisingly, F-PNA13 which was more potent in inhibiting SRP function in vitro, showed weaker antibacterial activity compared to PNA9 likely due to poor cell penetration of the longer PNA. Our results underscore the importance of suitable target site selection and optimum PNA length to develop better antisense molecules against non-coding RNA.

Giant Pleomorphic Adenoma of Infratemporal Fossa: A Rare Case Report

Of all the head and neck tumors, salivary gland tumors account to 3%. Pleomorphic adenomas are one of the most common benign tumors arising from major salivary glands, although it could also develop from minor salivary glands situated at accessory sites like nasal cavity, pharynx, parapharyngeal space, lacrimal glands etc. Tumors of infratemporal fossa are quite unusual, mainly because of its hidden location in retromaxillary region. We report an unusual case of 65 years old male presenting with complaint of progressive left cheek swelling for 4 years. FNAC revealed pleomorphic adenoma of minor salivary gland tumor. Intraoperatively a giant lobulated tumor was seen occupying almost whole space of infratemporal fossa, which was removed in-toto via open approach. Patient was kept on regular follow up with no evidence of recurrence reported till date.

Outcomes of Palisade Cartilage Tympanoplasty in Chronic Otitis Media: Our Experience at a Tertiary Care Centre

To evaluate the anatomical and functional success rates of palisade cartilage tympanoplasty in chronic otitis media. Thirty patients with chronic otitis media with subtotal perforation underwent palisade cartilage tympanoplasty and were assessed prospectively. The outcomes evaluated were graft uptake and hearing gain. Overall graft uptake was 90% with failure in 3 cases. The preoperative mean air conduction threshold was 22.087 ± 6.120 dB which was improved to 13.387 ± 5.253 dB postoperatively at 12 weeks which was statistically significant. The mean postoperative ABG closure was 8.700 dB with a p value of 0.001 which was statistically significant. Palisade cartilage tympanoplasty demonstrates that subtotal perforations, which are at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the tympanic membrane with reasonable hearing can be achieved.

Evaluation of Pre and Post-operative Pulmonary Artery Pressures in Children with Adenotonsillar Hypertrophy and Correlation with Chronicity: A Prospective Study on 50 Children

Children with grade III or IV of adenotonsillar hypertrophy especially of a longer duration, may show cardiovascular changes due to mouth breathing. These changes can be detected on doppler echocardiocardiography which can be used as a screening tool. Fifty paediatric patients of grade 3 and 4 adenotonsillar hypertrophy underwent adenotonsillar resection after a pre-operative work up which included doppler echocardiography to measure pulmonary artery pressures. A post-operative doppler echocardiography was done after three months. 11 children (22%) showed deranged pulmonary artery pressure values with increased mean pulmonary artery pressure (MPAP) and pulmonary artery systolic pressure (PSAP) on preoperative doppler echocardiography, and 2 out of these 11 children had Pulmonary Artery Hypertension. A significant (p < 0.001) improvement was noted in pulmonary artery pressure values (MPAP and PSAP returned to normal) after adenotonsillectomy in 3-month postoperative echocardiography. Also, a statistically significant correlation was obtained between chronicity of symptoms and raised pulmonary artery pressures. Our study concluded that these children with chronic untreated upper airway obstructive symptoms get predisposed to potential cardiac complications. And these grave consequences can be easily prevented by a timely intervention.

Surgical Outcomes of Type 1 Tympanoplasty in Chronic Otitis Media in Paediatric Patients: A Prospective Study

Objectives: To observe the surgical outcome of type 1 tympanoplasty in paediatric patients in the form of graft uptake and audiological improvement. Materials and methods: A prospective study was done in which 40 paediatric patients in age group 6-16 years, diagnosed of chronic otitis media, were taken up for tympanoplasty under general anaesthesia. Patients were followed in post operative period at 4, 6 and 12 weeks for assessment of graft status and audiological evaluation. Results: In this study, we found surgical success rate in the form of graft uptake in 80% of the cases and audiological improvement in 75% of the cases. Conclusion: Tympanoplasty is safe and effective in children with adequate graft uptake and audiological outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03965-1.

Temporal Bone Osteomyelitis Masquerading as Malignancy: A Diagnostic Challenge

Xanthogranulomatous osteomyelitis is a rare chronic inflammatory disorder. Until now, it has only been reported in long bones. To the best of our knowledge, it has never been reported in temporal bone. We present the case of this rare disease in a 64-year-old male involving the temporal bone, presenting with ear pain, discharge, decreased hearing, and granulation tissue in the external auditory canal, mimicking malignancy clinically and radiologically. The patient was unresponsive to medical management and was taken up for surgical debridement, followed by treatment with systemic and topical antibiotics, with a successful outcome. As this disease has not been reported in the literature yet in the temporal bone and mimics malignancy, it must be differentiated on histopathology to establish a definite diagnosis and provide appropriate management. A long-term follow-up is also necessary to recognize the clinical behavior of this disease, as no treatment protocol has been established yet.

A Rare Presentation of Thyroid Mass as Tubercular Abscess: A Case Report

Isolated thyroid gland tuberculosis is a rare disease, while even rarer is its presentation as an acute abscess. Here we present the case of a 65-year-old female who presented with a neck swelling which progressed to an abscess with multiple discharging sinuses which was proven to be tubercular abscess on histopathology.

Effect of Chronic Suppurative Otitis Media on Gustatory Function of chorda Tympani Nerve : A Prospective Study

Introduction the ability to taste is among the life's finest pleasures and perception of taste can be altered by various disorders or therapeutic regimens as colds or dental procedures. Head trauma patients, patients on certain drugs such as phenylbutanone, carbamazepine and baclofen and patients with inflammatory diseases of the middle ear frequently complain about alterations in their ability to taste. So, assessment of gustatory sensitivity is the prerequisite for the correct diagnosis of taste dysfunction which uses taste strips impregnated with taste stimulants. Material and method in this prospective study, 40 patients were enrolled after assessment of history, general and local examination of ear and finally assessment of gustatory function was done according to Muller technique using taste strips. Results in present study out of 40 patients, 16 (40%) patients had COM squamous, 24 patients (60%) had COM mucosal. In the ipsilateral diseased ear (both COM squamous & mucosal) the mean taste score for various taste sensation was 11.65 ± 2.59. In the contralateral normal ear, the mean taste score was 15.42 ± 0.78. The difference between the two was found to be statistically significant (p < 0.0001). Conclusion a significant difference was obtained in taste scores between diseased (ipsilateral) and normal (contralateral) ears both overall and also when subtypes were compared. Thus, the present prospective study indicates that COM squamous as well as mucosal can induce taste dysfunction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03703-7.

Marked elevations in lung and plasma ceramide in COVID-19 linked to microvascular injury

The pathogenesis of the marked pulmonary microvasculature injury, a distinguishing feature of COVID-19 acute respiratory distress syndrome (COVID-ARDS), remains unclear. Implicated in the pathophysiology of diverse diseases characterized by endothelial damage, including ARDS and ischemic cardiovascular disease, ceramide and in particular palmitoyl ceramide (C16:0-ceramide) may be involved in the microvascular injury in COVID-19. Using deidentified plasma and lung samples from COVID-19 patients, ceramide profiling by mass spectrometry was performed. Compared with healthy individuals, a specific 3-fold C16:0-ceramide elevation in COVID-19 patient plasma was identified. Compared with age-matched controls, autopsied lungs of individuals succumbing to COVID-ARDS displayed a massive 9-fold C16:0-ceramide elevation and exhibited a previously unrecognized microvascular ceramide-staining pattern and markedly enhanced apoptosis. In COVID-19 plasma and lungs, the C16-ceramide/C24-ceramide ratios were increased and reversed, respectively, consistent with increased risk of vascular injury. Indeed, exposure of primary human lung microvascular endothelial cell monolayers to C16:0-ceramide-rich plasma lipid extracts from COVID-19, but not healthy, individuals led to a significant decrease in endothelial barrier function. This effect was phenocopied by spiking healthy plasma lipid extracts with synthetic C16:0-ceramide and was inhibited by treatment with ceramide-neutralizing monoclonal antibody or single-chain variable fragment. These results indicate that C16:0-ceramide may be implicated in the vascular injury associated with COVID-19.

Post-Covid Isolated Mandibular Mucormycosis in a Patient with Chronic Kidney Disease: A Case Report

Mucormycosis is an opportunistic fungal infection which was earlier seen only in immunocompromised patients. With the recent covid pandemic, there had been a drastic surge in cases of mucormycosis worldwide and especially in India. Here, we present an unusual case of biopsy proven invasive mandibular mucormycosis in a patient with chronic kidney disease and a history of COVID-19 infection. The patient was given low-dose amphotericin B and underwent surgical debridement with a successful outcome.

Tensions in Taxonomies: Current Understanding and Future Directions in the Pathobiologic Basis and Treatment of Group 1 and Group 3 Pulmonary Hypertension

In the over 100 years since the recognition of pulmonary hypertension (PH), immense progress and significant achievements have been made with regard to understanding the pathophysiology of the disease and its treatment. These advances have been mostly in idiopathic pulmonary arterial hypertension (IPAH), which was classified as Group 1 Pulmonary Hypertension (PH) at the Second World Symposia on PH in 1998. However, the pathobiology of PH due to chronic lung disease, classified as Group 3 PH, remains poorly understood and its treatments thus remain limited. We review the history of the classification of the five groups of PH and aim to provide a state-of-the-art review of the understanding of the pathogenesis of Group 1 PH and Group 3 PH including insights gained from novel high-throughput omics technologies that have revealed heterogeneities within these categories as well as similarities between them. Leveraging the substantial gains made in understanding the genomics, epigenomics, proteomics, and metabolomics of PAH to understand the full spectrum of the complex, heterogeneous disease of PH is needed. Multimodal omics data as well as supervised and unbiased machine learning approaches after careful consideration of the powerful advantages as well as of the limitations and pitfalls of these technologies could lead to earlier diagnosis, more precise risk stratification, better predictions of disease response, new sub-phenotype groupings within types of PH, and identification of shared pathways between PAH and other types of PH that could lead to new treatment targets. © 2023 American Physiological Society. Compr Physiol 13:4295-4319, 2023.

Characterization of pulmonary vascular remodeling and MicroRNA-126-targets in COPD-pulmonary hypertension

BACKGROUND

Despite causing increased morbidity and mortality, pulmonary hypertension (PH) in chronic obstructive pulmonary disease (COPD) patients (COPD-PH) lacks treatment, due to incomplete understanding of its pathogenesis. Hypertrophy of pulmonary arterial walls and pruning of the microvasculature with loss of capillary beds are known features of pulmonary vascular remodeling in COPD. The remodeling features of pulmonary medium- and smaller vessels in COPD-PH lungs are less well described and may be linked to maladaptation of endothelial cells to chronic cigarette smoking (CS). MicroRNA-126 (miR126), a master regulator of endothelial cell fate, has divergent functions that are vessel-size specific, supporting the survival of large vessel endothelial cells and inhibiting the proliferation of microvascular endothelial cells. Since CS decreases miR126 in microvascular lung endothelial cells, we set out to characterize the remodeling by pulmonary vascular size in COPD-PH and its relationship with miR126 in COPD and COPD-PH lungs.

METHODS

Deidentified lung tissue was obtained from individuals with COPD with and without PH and from non-diseased non-smokers and smokers. Pulmonary artery remodeling was assessed by ⍺-smooth muscle actin (SMA) abundance via immunohistochemistry and analyzed by pulmonary artery size. miR126 and miR126-target abundance were quantified by qPCR. The expression levels of ceramide, ADAM9, and endothelial cell marker CD31 were assessed by immunofluorescence.

RESULTS

Pulmonary arteries from COPD and COPD-PH lungs had significantly increased SMA abundance compared to non-COPD lungs, especially in small pulmonary arteries and the lung microvasculature. This was accompanied by significantly fewer endothelial cell markers and increased pro-apoptotic ceramide abundance. miR126 expression was significantly decreased in lungs of COPD individuals. Of the targets tested (SPRED1, VEGF, LAT1, ADAM9), lung miR126 most significantly inversely correlated with ADAM9 expression. Compared to controls, ADAM9 was significantly increased in COPD and COPD-PH lungs, predominantly in small pulmonary arteries and lung microvasculature.

CONCLUSION

Both COPD and COPD-PH lungs exhibited significant remodeling of the pulmonary vascular bed of small and microvascular size, suggesting these changes may occur before or independent of the clinical development of PH. Decreased miR126 expression with reciprocal increase in ADAM9 may regulate endothelial cell survival and vascular remodeling in small pulmonary arteries and lung microvasculature in COPD and COPD-PH.

Pharmacological sphingosine-1 phosphate receptor 1 targeting in cigarette smoke-induced emphysema in mice

Primarily caused by chronic cigarette smoking (CS), emphysema is characterized by loss of alveolar cells comprising lung units involved in gas exchange and inflammation that culminate in airspace enlargement. Dysregulation of sphingolipid metabolism with increases of ceramide relative to sphingosine-1 phosphate (S1P) signaling has been shown to cause lung cell apoptosis and is emerging as a potential therapeutic target in emphysema. We sought to determine the impact of augmenting S1P signaling via S1P receptor 1 (S1P1) in a mouse model of CS-induced emphysema. DBA2 mice were exposed to CS for 4 or 6 mo and treated with pharmacological agonists of S1P1: phosphonated FTY720 (FTY720-1S and 2S analogs; 0.01-1.0 mg/kg) or GSK183303A (10 mg/kg). Pharmacological S1P1 agonists ameliorated CS-induced lung parenchymal apoptosis and airspace enlargement as well as loss of body weight. S1P1 agonists had modest inhibitory effects on CS-induced airspace inflammation and lung functional changes measured by Flexivent, improving lung tissue resistance. S1P1 abundance was reduced in chronic CS-conditions and remained decreased after CS-cessation or treatment with FTY720-1S. These results support an important role for S1P-S1P1 axis in maintaining the structural integrity of alveoli during chronic CS exposure and suggest that increasing both S1P1 signaling and abundance may be beneficial to counteract the effects of chronic CS exposure.

A 56-Year-Old Man With Emphysema, Rash, and Arthralgia

CASE PRESENTATION

A 56-year-old man presented to the pulmonary clinic with dyspnea and hypoxemia on exertion. He was an avid biker and skier who had noticed a significant decrease in high-level physical activity over the past 3 years. He reported dyspnea, desaturations at altitudes higher than 9,000 feet, dry cough, tachycardia, and palpitations with exercise. Review of systems was also notable for gluten-intolerance, Raynaud's phenomenon, recurrent skin lesions and joint swelling, pain, and stiffness in the areas overlying the jaw, wrists, knees, and ankles (after capsaicin exposure). He denied fever, chills, anorexia, weight loss, hair loss, ocular symptoms, jaw claudication, chest pain, or lower extremity swelling. He had a five pack-year smoking history, no history of prematurity, childhood asthma, recurrent infections, or environmental and occupational exposure. Based on pulmonary function tests from an outside provider, he had received a diagnosis of exercise-induced asthma and had been prescribed an albuterol inhaler to use on an as-needed basis, which failed to improve his symptoms. He was later prescribed a mometasone-formoterol inhaler, still with no symptomatic improvement.

Sphingosine 1 Phosphate (S1P) Receptor 1 Is Decreased in Human Lung Microvascular Endothelial Cells of Smokers and Mediates S1P Effect on Autophagy

Destruction of alveoli by apoptosis induced by cigarette smoke (CS) is a major driver of emphysema pathogenesis. However, when compared to cells isolated from non-smokers, primary human lung microvascular endothelial cells (HLMVECs) isolated from chronic smokers are more resilient when exposed to apoptosis-inducing ceramide. Whether this adaptation restores homeostasis is unknown. To better understand the phenotype of HLMVEC in smokers, we interrogated a major pro-survival pathway supported by sphingosine-1-phosphate (S1P) signaling via S1P receptor 1 (S1P1). Primary HLMVECs from lungs of non-smoker or smoker donors were isolated and studied in culture for up to five passages. S1P1 mRNA and protein abundance were significantly decreased in HLMVECs from smokers compared to non-smokers. S1P1 was also decreased in situ in lungs of mice chronically exposed to CS. Levels of S1P1 expression tended to correlate with those of autophagy markers, and increasing S1P (via S1P lyase knockdown with siRNA) stimulated baseline macroautophagy with lysosomal degradation. In turn, loss of S1P1 (siRNA) inhibited these effects of S1P on HLMVECs autophagy. These findings suggest that the anti-apoptotic phenotype of HLMVECs from smokers may be maladaptive, since it is associated with decreased S1P1 expression that may impair their autophagic response to S1P.

Current status of periodontitis and its association with tobacco use amongst adult population of Sunsari district, in Nepal

BACKGROUND

Tobacco products are considered significant, but preventable factors related to initiation and progression of periodontal diseases. We assessed the prevalence of periodontitis and evaluated its association with tobacco use and other factors amongst the adult population of Sunsari district in eastern Nepal.

METHODS

A community-based, cross-sectional study was conducted in rural municipalities in the province one of eastern Nepal. A total of 440 adults were interviewed with a set of a pre-tested semi-structured questionnaire. Data on social demographics, adverse oral habits followed by periodontal clinical examination were recorded. Prevalence of periodontitis was assessed by a case definition provided by CDC-AAP. Univariate and multivariate logistic regression analysis was done to measure the association between tobacco use and other factors with periodontitis.

RESULTS

The overall prevalence of periodontitis was found to be 71.6%. Majority (85.4%) of tobacco users had periodontitis and they were significantly associated with the disease and its severity. The study identified age groups, 45-65 years (AOR = 7.58, 95% CI 3.93-14.61), plaque accumulation (AOR = 1.01, 95% CI 1.00-1.02), smoking (AOR = 3.14, 95% CI 1.36-7.27), khaini users (smokeless tobacco, AOR = 2.27, 95% CI 1.12-4.61) and teeth loss (AOR = 2.02, 95% CI 1.21-3.38) as the significant factors associated with periodontitis.

CONCLUSION

The prevalence of periodontitis is high in the surveyed rural adult population. Cigarette smoking along with the use of smokeless tobacco in the form of khaini were identified as significant factors associated with periodontitis.

Assessment of Gingival Biotypes in Patients Visiting a Tertiary Care Centre in Eastern Nepal

BACKGROUND

Evaluation of gingival biotype has become a routine procedure in periodontal examination because the type of gingival biotype can positively or negatively affect the outcome of periodontal, restorative, orthodontic and implant therapy. The aim of the study was to assess the proportion of types of gingival biotypes in patients visiting a tertiary care center in eastern Nepal.

METHODS

Two hundred and fifty patients between 25 to 45 years attending the Periodontology and Oral Implantology were assessed. Gingival biotype of the patents was determined with Probe Transparency technique Results: Out 250 patients assessed, 73 patients (approximately 29.2 %) had thin gingival biotype and remaining 177 patients (approximately 70.8 %) had thick gingival biotype. The number of the male with thin biotype was 31 whereas the number of the male with thick biotype was 82. Similarly, out of 137 female, 42 had thin biotype and remaining 95 female had thick biotype. The types of biotypes were not associated with gender (p=0.67).

CONCLUSIONS

Thicker gingival biotype was the more common type of gingival biotype in patients attending the tertiary care center of Eastern Nepal. The occurrence of thick gingival biotype was more common in Adivasi Janajati ethnic community compared to Brahmin / Chhetri ethnic community.

P1854Clinical implications of physical function and resilience in patients undergoing transcatheter aortic valve implantation

Background

Gait speed, as a measure of physical function and marker of frailty, is now routinely screened when evaluating patients with aortic stenosis (AS) for transcatheter aortic valve implantation (TAVI). Assessment of physical function is important to identify patients for whom TAVI may be futile and to assign patients to a procedural risk category. After TAVI, patients may exhibit physical resilience (improvement in physical function) or vulnerability (worsening). Characterizing the trajectory and clinical consequences of physical function after TAVI represent knowledge gaps in the field.

Purpose

Evaluate associations between physical resilience (improved gait speed) vs vulnerability (decline) after TAVI and subsequent death/hospitalization.

Methods

The REPRISE III trial compared a mechanically-expanded vs a self-expanding valve in 912 high/extreme risk patients with symptomatic AS. Patients (n=587) who underwent valve implantation and who had a gait speed recorded both pre- and 1-year post-TAVI were analyzed. Gait speed is based on the 5m walk test (slow: 5m in >6s, <0.83m/s; normal: ≥0.83m/s). Trajectory of physical function after TAVI was characterized in 2 ways. Model 1 examined 4 groups based on slow or normal gait speeds at baseline and 1-year post-TAVI. Model 2 examined gait speed change pre-TAVI to 1 year (adjusted for baseline gait speed). Using a landmark approach, the relationships between baseline and 1-year gait speed were evaluated in multivariable Cox PH models of outcomes between 1 and 2 years post-TAVI.

Results

A clinically-meaningful improvement (≥0.1m/s), no change (±0.1m/s), or decline (≥0.1/ms) in gait speed 1 year after TAVI was observed in 39%, 36%, and 26% of patients, respectively. Among the 4 groups defined by pre- and 1-year post-TAVI gait speeds, 1 to 2 year mortality or hospitalization rates were: 6.6% (normal/normal), 20.9% (normal/slow), 8.0% (slow/normal), and 21.5% (slow/slow). Adjusted hazard ratios of the 2 models are shown (Table).

Table. Outcome by Change in Gait Speed Death/Hospitalization P-value Death P-value Hospitalization P-value Adjusted HR [95% CI] Adjusted HR [95% CI] Adjusted HR [95% CI] Model 1: Baseline/1 year Gait Speed   (Normal/Normal (n=150) [referent])   Normal/Slow (n=59) 3.82 [1.61, 9.08] <0.01 2.75 [0.96, 7.86] 0.06 7.31 [1.94, 27.58] <0.01   Slow/Normal (n=114) 1.39 [0.53, 3.59] 0.50 1.44 [0.50, 4.12] 0.50 1.69 [0.38, 7.60] 0.49   Slow/Slow (n=253) 3.88 [1.91, 7.91] <0.01 2.36 [1.02, 5.46] 0.045 3.89 [1.14, 13.27] 0.03 Model 2: Gait speed change   Baseline to 1 year per 0.1m/s increase 0.83 [0.74, 0.92] <0.01 0.92 [0.80, 1.04] 0.19 0.75 [0.64, 0.88] <0.01

Conclusion

These data reveal there is marked heterogeneity in the trajectory of physical function after TAVI and that this trajectory–more so than baseline physical function–is clinically consequential. Identifying and optimizing factors associated with physical resilience after TAVI may improve outcomes.

Acknowledgement/Funding

Boston Scientific

P4666Higher BNP levels after transcatheter aortic valve implantation are associated with increased mortality and hospitalizations

Background

Among patients with aortic stenosis (AS), the adverse association between increased B-type natriuretic peptide (BNP) levels and worse clinical outcomes, including mortality and hospitalization after valve replacement, has been demonstrated. However, little attention has been paid to the clinical consequences of BNP levels after valve replacement, which may have implications for medical therapy prescribed after the procedure.

Purpose

Evaluate the association between BNP levels after transcatheter aortic valve implantation (TAVI) and subsequent mortality and hospitalizations.

Methods

Among intermediate, high, and extreme risk patients with severe symptomatic AS who received TAVI for native valve AS in the PARTNER II and S3 clinical trials or registries, we included 3260 patients who had BNP measured at baseline. Patients from sites which measured NTproBNP were excluded. To account for factors that influence BNP levels, we developed a regression equation–including age, sex, BMI, creatinine, study site, and the upper limit of normal of the BNP assay used for a given measurement–to determine expected BNP. BNP ratio was determined pre-TAVR and at discharge, 30 days, and 1 year and calculated as the actual BNP/expected BNP. Using a landmark approach, the relationships between (1) BNP ratio at 30 days or (2) delta BNP ratio between discharge and 30 days and subsequent outcomes between 30 days and 1 year were assessed. The primary outcome was a composite of cardiovascular (CV) mortality or hospitalization. Adjustment was made for 20 baseline and post-procedural factors known to influence outcomes.

Results

Higher BNP ratio at 30 days was associated with higher CV mortality or hospitalization between 30 days and 1 year (adjusted hazard ratio [aHR] 1.07 per increase of 1 in the BNP ratio, 95% CI 1.04–1.10, p<0.001), whereas baseline BNP ratio was not (p=0.38). A similar relationship was shown for the components of this composite: CV mortality (aHR 1.08, 95% CI 1.04–1.12, p<0.001) and hospitalizations (aHR 1.04, 95% CI 1.01–1.08, p=0.01). Adjusted for discharge BNP ratio and other factors, a greater decrease in BNP ratio between discharge and 30 days was also associated with lower CV mortality or hospitalization between 30 days and 1 year (aHR 0.95 per decrease of 1 in the BNP ratio, 95% CI 0.92–0.99, p=0.006). Similar relationships were observed for all-cause mortality and when examining the relationship between 1 year BNP ratio and outcomes between 1 and 2 years.

Conclusion

Higher BNP ratio after TAVI is associated with higher subsequent all-cause and CV mortality and hospitalizations, whereas baseline BNP ratio was not. Greater decrease in BNP ratio between discharge and 30 days is associated with better outcomes. Further investigation is warranted to understand these findings and determine whether intensification of medical therapy to decrease BNP after TAVR may improve patient outcomes.

Acknowledgement/Funding

The PARTNER 2 Trial was funded by Edwards Lifesciences

Stability of Vaccines

Vaccines are considered the most economical and effective preventive measure against most deadly infectious diseases. Vaccines help protect around three million lives every year, but hundreds of thousands of lives are lost due to the instability of vaccines. This review discusses the various types of instability observed, while manufacturing, storing, and distributing vaccines. It describes the specific stability problems associated with each type of vaccine. This review also discusses the various measures adopted to overcome these instability problems. Vaccines are classified based on their components, and this review discusses how these preventive measures relate to each type of vaccine. This review also includes certain case studies that illustrate various approaches to improve vaccine stability. Last, this review provides insight on prospective methods for developing more stable vaccines.

Renal replacement therapy in patients with acute respiratory distress syndrome: a single-center retrospective study

Background

Patients with acute respiratory distress syndrome (ARDS) who develop acute kidney injury have increased mortality and frequently require renal replacement therapy (RRT). The optimal timing for initiation of RRT after onset of ARDS to improve survival is not known.

Methods

We retrospectively reviewed clinical data on patients admitted to our health system over a 2-year period. Individual charts were carefully reviewed to ascertain that patients met the Berlin criteria for ARDS and to categorize RRT utilization. The Kaplan–Meier analysis was conducted to compare early (£48 hours postintubation) versus late (>48 hours postintubation) initiation of RRT. Associations between RRT initiation and mortality were evaluated using Cox proportional hazards regression.

Results

A total of 75 patients were identified with ARDS, 95% of whom received RRT. Mortality of patients who required RRT was 56%. The main indications for RRT initiation were fluid overload (75%), metabolic acidosis (64%), and hyperkalemia (33%). The Kaplan–Meier analysis comparing early initiation of RRT to late initiation of RRT showed no survival benefit. Cox proportional hazard models testing the association between timing of RRT initiation with survival and adjusting for sex, race, ethnicity, and Acute Physiology and Chronic Health Evaluation II score did not reach statistical significance (HR=0.94, 95% CI=0.48–1.86).

Conclusion

Timing of RRT initiation was not associated with a survival benefit. Prospective study in the utilization and outcomes of RRT in ARDS could assist in optimizing its usage in this population.

Supracrestal Non-Surgical Therapy in Periodontal Diseases

  Periodontal diseases are the complex disease with a dynamic relationship between biofilm and the host immunoinflammatory response. The goal of periodontal therapy is to preserve the natural dentition and increase their longevity by creation of a favorable environment around the teeth. The mainstay to achieve this is by the non-surgical periodontal therapy, followed by surgical and other recent treatment modalities. However, there seems no sure indication to choose amongst them that are clinically significant and offer long term predictability. We report here two cases that had supracrestal defects and were treated with less invasive instrumentation and repeated full mouth scaling and root planing. This avoided a surgical intervention and was more cost-effective in treating moderate to severe young chronic periodontitis patients. The decision for the type of treatment needs to be critically assessed with a better understanding of the outcome, morphology of the defects, and type of teeth involved. 

Prevalence of Organic Colonic Lesions by Colonoscopy in Patients Fulfilling ROME IV Criteria of Irritable Bowel Syndrome

Introduction: Irritable bowel syndrome occurs as recurrent abdominal pain that is related to defecation and associated with change in frequency and/or form of stool. Few Patients with IBS may have organic lesions detectable at colonoscopy. Methods: A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria. The study was conducted in Gastroenterology unit, Department of Medicine, Bir hospital, Kathmandu from July 2016 to September 2017. All patients underwent full colonoscopy along with biopsy from sigmoid colon and any visibly abnormal areas. Results: The average age of patients was 37.5 years with 76 (52.8%) males. Forty-two (30%) had IBS-D, 36 (26%) had IBS-C, 31 (22%) had IBS-M and 31 (22%) had IBS-U. Dyspepsia was seen in 16 (11.4%) and fear of TB/Malignancy/IBD was seen in 27 (19.2%). Organic lesions were seen in 39 (27.85%) patients. Nonspecific colitis was seen in 10 (7.1%) followed by ileal erosions in 7 (5%), polyps in 8 (5.7%), hemorrhoids in 6 (4.2%) and diverticula in 3 (2.1%). Only one (0.71%) patient had microscopic colitis and one (0.71%) had malignant lesion seen at histopathological examination. Females with IBS-D had more organic findings than males (P=0.03, RR=4.13, 95% CI=1.21-15.71). Conclusions: The prevalence of organic lesions in patients with IBS fulfilling ROME IV criteria is 27%. Dyspepsia is the most common comorbidity and fear of TB/malignancy/IBD is the most common reason for seeking health care. Females with IBS-D have a higher risk of detecting organic lesions by colonoscopy and histopathology examination.

Prevalence of Organic Colonic Lesions by Colonoscopy in Patients Fulfilling ROME IV Criteria of Irritable Bowel Syndrome

INTRODUCTION

Irritable bowel syndrome occurs as recurrent abdominal pain that is related to defecation and associated with change in frequency and/or form of stool. Few Patients with IBS may have organic lesions detectable at colonoscopy.

METHODS

A cross sectional study was carried out in 140 consecutive patients of IBS fulfilling the ROME IV criteria. The study was conducted in Gastroenterology unit, Department of Medicine, Bir hospital, Kathmandu from July 2016 to September 2017. All patients underwent full colonoscopy along with biopsy from sigmoid colon and any visibly abnormal areas.

RESULTS

The average age of patients was 37.5 years with 76 (52.8%) males. Forty-two (30%) had IBS-D, 36 (26%) had IBS-C, 31 (22%) had IBS-M and 31 (22%) had IBS-U. Dyspepsia was seen in 16 (11.4%) and fear of TB/Malignancy/IBD was seen in 27 (19.2%). Organic lesions were seen in 39 (27.85%) patients. Nonspecific colitis was seen in 10 (7.1%) followed by ileal erosions in 7 (5%), polyps in 8 (5.7%), hemorrhoids in 6 (4.2%) and diverticula in 3 (2.1%). Only one (0.71%) patient had microscopic colitis and one (0.71%) had malignant lesion seen at histopathological examination. Females with IBS-D had more organic findings than males (P=0.03, RR=4.13, 95% CI=1.21-15.71).

CONCLUSIONS

The prevalence of organic lesions in patients with IBS fulfilling ROME IV criteria is 27%. Dyspepsia is the most common comorbidity and fear of TB/malignancy/IBD is the most common reason for seeking health care. Females with IBS-D have a higher risk of detecting organic lesions by colonoscopy and histopathology examination.

Supracrestal Non-Surgical Therapy in Periodontal Diseases

Periodontal diseases are the complex disease with a dynamic relationship between biofilm and the host immunoinflammatory response. The goal of periodontal therapy is to preserve the natural dentition and increase their longevity by creation of a favorable environment around the teeth. The mainstay to achieve this is by the non-surgical periodontal therapy, followed by surgical and other recent treatment modalities. However, there seems no sure indication to choose amongst them that are clinically significant and offer long term predictability. We report here two cases that had supracrestal defects and were treated with less invasive instrumentation and repeated full mouth scaling and root planing. This avoided a surgical intervention and was more cost-effective in treating moderate to severe young chronic periodontitis patients. The decision for the type of treatment needs to be critically assessed with a better understanding of the outcome, morphology of the defects, and type of teeth involved. Fundamentals like positive reinforcements, compliance and self-performed plaque control will always remain an integral component regardless of nonsurgical or surgical periodontal therapy.

Atypical Presentation of Traumatic Neuroma: A case report

Congenital Traumatic neuroma is a rare disorder that represents a reactive proliferation of neural tissue followingdamage to an adjacent nerve. Rarely these lesions appear in the oral cavity with certain predilection for the mental foramen and the tongue area. However, its presentation on lip is more unusual with only few cases being reported in the literature. Typically diagnosed in middle-aged women, patient complains of pain as a frequent symptom. Clinically, the lip lesions appear as a normal or grayish white nodule with a smooth surface that typically resembles a mucocele. We report here a case of a 37-year old female who presented with similar signs and symptoms and was diagnosed clinically as a mucocele. However, histopathological examination revealed it as a traumatic neuroma that was surgically excised. The patient is under follow-up with no signs of recurrence for 18 months. 

Effects of nonsurgical periodontal therapy in patients with moderately controlled type 2 diabetes mellitus and chronic periodontitis in Nepalese population

Objectives

Despite several investigations, evidence is still controversial regarding the effect of periodontal treatment on diabetes. This study evaluates and compares the effect on glycemic control and periodontal status with or without nonsurgical periodontal therapy in patients with type 2 diabetes mellitus and chronic periodontitis in a Nepalese population.

Materials and methods

A total of 82 patients attending the diabetes clinic and fulfilling enrollment criteria with moderate to severe periodontitis were selected. They were assigned in an alternative sequence, into test and control group. Both groups were instructed to continue with their medical treatment without modifications. Scaling and root surface debridement were performed in the test group whereas the control group received oral hygiene instructions with no treatment during the 3-month study period.

Results

There were 41 participants in each group with the mean age of 50.66±7.70 and 53.80±9.16 years, average diabetes duration of 6.32±4.21 and 6.24±4.00 years, mean body mass index of 24.78±1.85 and 24.6±1.79 kg/m², and glycated hemoglobin (HbA1c) level of 6.71±0.50% and 6.80±0.45%, in the test and control group, respectively. After 3 months, there was significant reduction in HbA1c levels in the test group compared to the control group (p=0.029). Clinical periodontal parameters of gingival index, probing depth (PD), and clinical attachment level (CAL) significantly improved in the test group (p<0.001) with PD reduction by 0.9 mm and gain in CAL by 0.3 mm compared to the control group (p>0.001) who showed an increase by 0.05 mm.

Conclusion

This study showed that nonsurgical periodontal therapy may have a beneficial effect on HbA1c level in moderately controlled type 2 diabetic patients.

Patient with Small Cell Lung Carcinoma and Suspected Right Upper Lobe Abscess Presenting with a Purulent Pericardial Effusion

Patient: Male, 61

Final Diagnosis: Streptococcus pneumoniae pericarditis

Symptoms: —

Medication: —

Clinical Procedure: Pericardiocentesis

Specialty: Critical Care Medicine

Unusual Presentation of Necrotic Erythema Nodosum Leprosum on Scalp: A Case Report

Lepra reactions are acute episodes occurring during the disease process of leprosy and are of 2 types: type 1 or reversal reaction and type 2 reaction or erythema odosumleprosum (ENL). In the episodes of lepra reaction several parts are affected including face and extremities like oral cavity. In the present case report we reported a rare case of lepromatous leprosy with necrotic ENL involving scalp apart from the usual sites. A 58 year old married male presented to us with complaints of spontaneous onset, recurrent eruption of multiple reddish raised painful lesions. Biopsy from the infiltrated skin over the back showed atrophic epidermis, free Grenz zone, diffuse and periadnexal macrophage granulomas with predominant mononuclear infiltrate, appandageal atrophy, fibrosis around the neural structures and leukocytoclastic vasculitis. Fites stain showed strong positivity for M. leprae. His routine blood investigations showed anemia (Hb = 7.8 gm%), neutrophil leukocytosis (TLC = 17,600, DLC = P66L28M4E2) and raised ESR (80 mm in the first hour). These bullous and necrotic lesions in leprosy may be a manifestation of severe type II reactions in patients with very high bacillary load.

A microRNA processing defect in smokers' macrophages is linked to SUMOylation of the endonuclease DICER

Despite the fact that alveolar macrophages play an important role in smoking-related disease, little is known about what regulates their pathophysiologic phenotype. Evaluating smoker macrophages, we found significant down-regulation of multiple microRNAs (miRNAs). This work investigates the hypothesis that cigarette smoke alters mature miRNA expression in lung macrophages by inhibiting processing of primary miRNA transcripts. Studies on smoker alveolar macrophages showed a defect in miRNA maturation. Studies on the miRNA biogenesis machinery led us to focus on the cytosolic RNA endonuclease, DICER. DICER cleaves the stem-loop structure from pre-miRNAs, allowing them to dissociate into their mature 20-22-nucleotide single-stranded form. DICER activity assays confirmed impaired DICER activity following cigarette smoke exposure. Further protein studies demonstrated a decreased expression of the native 217-kDa form of DICER and an accumulation of high molecular weight forms with cigarette smoke exposure. This molecular mass shift was shown to contain SUMO moieties and could be blocked by silencing RNA directed at the primary SUMOylating ligase, Ubc9. In determining the cigarette smoke components responsible for changes in DICER, we found that N-acetylcysteine, an antioxidant and anti-aldehyde, protected DICER protein and activity from cigarette smoke extract. This massive down-regulation of miRNAs (driven in part by alterations in DICER) may be an important regulator of the disease-promoting macrophage phenotype found in the lungs of smokers.

Lepromatous leprosy with an uncommon presentation: a case report

28 yr old male presented with asymptomatic nodules and few well to ill defined papules on ears, asymmetrical nerve enlargement and evanescent tender nodules on the extremities without any infiltration of the skin and madarosis. Slit skin smear done from normal skin was BI 6+. Skin biopsy showed features of lepromatous leprosy.

Interrelationship between Diabetes and Periodontitis- A Review

Evidence for the link between periodontal disease and several systemic diseases is growing rapidly. Diabetes mellitus is a systemic disease with several major complications affecting both the quality and length of life causing morbidity and mortality. Periodontitis, one of these complications, is a chronic infection associated with substantial morbidity in the form of tooth loss and that affects the quality of life directly. The association between diabetes and inflammatory periodontal disease has been studied extensively. The relationship between these two conditions appears bidirectional. The presence of one condition tends to promote the other and the meticulous management of either may assist treatment of the other. It also provides a perfect example of a cyclical association, whereby a systemic disease predisposes the individual to oral infections, and once the oral infection is established, it exacerbates the systemic disease. This review focuses to explain the interrelationship between the two based on information in the literature and the potential common immunoregulatory connections involved, exploring the mechanisms through which periodontal infection can contribute to the low-grade general inflammation associated with diabetes. Keywords: Diabetes mellitus; inflammation; insulin resistance; periodontitis.

Interrelationship between diabetes and periodontitis: a review

Evidence for the link between periodontal disease and several systemic diseases is growing rapidly. Diabetes mellitus is a systemic disease with several major complications affecting both the quality and length of life causing morbidity and mortality. Periodontitis, one of these complications, is a chronic infection associated with substantial morbidity in the form of tooth loss and that affects the quality of life directly. The association between diabetes and inflammatory periodontal disease has been studied extensively. The relationship between these two conditions appears bidirectional. The presence of one condition tends to promote the other and the meticulous management of either may assist treatment of the other. It also provides a perfect example of a cyclical association, whereby a systemic disease predisposes the individual to oral infections, and once the oral infection is established, it exacerbates the systemic disease. This review focuses to explain the interrelationship between the two based on information in the literature and the potential common immunoregulatory connections involved, exploring the mechanisms through which periodontal infection can contribute to the low-grade general inflammation associated with diabetes.

Knowledge, attitude, and practice of sugarcane crushers towards hand injury prevention strategies in India

INTRODUCTION

Injuries of the hand have an enormous impact on hand function and on quality of life. Occupational injuries are a major cause of morbidity and mortality in India and their incidence has been steadily increasing. Sugarcane crushers produce juice using dangerous procedures.

OBJECTIVE

The objective of this study was to determine the knowledge, attitudes, and practices among sugarcane crushers in India and thus assist in the formulation of effective preventive strategies.

SETTING

A block (area) in the Vellore District, South India (population 100 000).

SUBJECTS AND METHODS

All sugarcane crushers living in this area (n = 32) were included. A single observer, using a questionnaire, conducted personal on-site interviews.

RESULTS

Carelessness was involved in 63% of injuries. Sixteen per cent felt that machines with improved safety features are required; 40% supported the use of special gloves, although 19% considered them a hindrance. Eighty eight per cent did not consider the long duration of work as a risk factor and 38% were fatalistic (God's will); 50% thought the injuries were due to "bad luck".

CONCLUSION

Sugarcane crushers do not perceive the need for safer equipment. To overcome fatalistic views, and persuade this group to take other safety measures, safety education will need to take into consideration their socioeconomic and educational status.

Antimicrobial activity of extracts of eastern North American hardwood trees and relation to traditional medicine

Wood and bark extracts of 14 eastern North American hardwood tree species which were used traditionally as medicine by First Nation's people were screened for antimicrobial activities with eight strains of bacteria and six strains of fungi. Eighty-six percent of the bark extracts were active against methicillin sensitive Staphylococcus aureus; 71% against Bacillus subtilus and 79% against Mycobacterium phlei. The bark extract of Juglans cinerea was active against Pseudomonas aeruginosa 187, Salmonella typhiumurium, and Klebsiella pneumoniae. The wood extracts were less active: 72% were active against S. aureus (methicillin-sensitive), 36% against B. subtilus and 43% against M. phlei. Results from antifungal tests indicated that 36% of the extracts were active against at least one fungal strain and that bark extracts were more active than wood extracts. The bark extract from Juglans cinerea had the broadest spectrum of activities against Candida albicans, Saccharomyces cerevisiae, Cryptococcus neoformans, Trichophyton mentagrophytes, Microsporum gypseum, and Aspergillus fumigatus. In general, the extracts were more active against gram positive bacteria than gram negative bacteria and against filamentous fungi than yeast-like fungi. The study also demonstrated a correlation between frequency of traditional medicinal use by the First Nations people and antimicrobial activity of extracts indicating that the traditional knowledge encompasses an understanding of aspects of chemical ecology.

Effects of single and repeated electroconvulsive therapy sessions on plasma ACTH, prolactin, growth hormone and cortisol concentrations

To study the effects of electroconvulsive therapy (ECT) on hormone release, we measured circulating concentrations of adrenocorticotropic hormone (ACTH), prolactin (PRL), growth hormone (GH) and cortisol (CORT) immediately before and at 2 min, 5 min, 15 min, and 30 min following ECT. Compared to pre-ECT concentrations, there were significant increases in post-ECT plasma ACTH, PRL and CORT. GH did not change consistently. No significant difference between unilateral and bilateral ECT was observed. Compared to the first ECT, repeated treatments were associated with a significant decrease in the magnitude of hormone surge. These hormonal changes induced by ECT may reflect changes at the neurotransmitter level.