Extracellular vesicle Cystatin C and CD14 are associated with both renal dysfunction and heart failure.

AIMS: Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients. METHODS AND RESULTS: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction. CONCLUSIONS: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment.

Twelve-hour fasting compared with expedited oral intake in the initial inpatient management of hyperemesis gravidarum: a randomised trial.

OBJECTIVE: To evaluate fasting for 12 hours compared with expedited oral feeding in hospitalised women with hyperemesis gravidarum (HG). DESIGN: Randomised trial. SETTING: University Hospital, Malaysia: April 2016-April 2017. POPULATION: One hundred and sixty women hospitalised for HG. METHOD: Women were randomised upon admission to fasting for 12 hours or expedited oral feeding. Standard HG care was instituted. MAIN OUTCOME MEASURE: Primary outcome was satisfaction score with overall treatment at 24 hours (0-10 Visual Numerical Rating Scale VNRS), vomiting episodes within 24 hours and nausea VNRS score at enrolment, and at 8, 16 and 24 hours. RESULTS: Satisfaction score, median (interquartile range) 8 (5-9) versus 8 (7-9) (P = 0.08) and 24-hour vomiting episodes were 1 (0-4) versus 1 (0-5) (P = 0.24) for 12-hour fasting versus expedited feeding, respectively. Repeated measures analysis of variance of nausea scores over 24 hours showed no difference (P = 0.11) between trial arms. Participants randomised to 12-hour fasting compared with expedited feeding were less likely to prefer their feeding regimen in future hospitalisation (41% versus 65%, P = 0.001), to recommend to a friend (65% versus 84%, P = 0.01; RR 0.8, 95% CI 0.6-0.9) and to adhere to protocol (85% versus 95%, P = 0.04; RR 0.9, 95% CI 0.8-1.0). Symptoms profile, ketonuria status at 24 hours and length of hospital stay were not different. CONCLUSION: Advisory of 12-hour fasting compared with immediate oral feeding resulted in a non-significant difference in satisfaction score but adherence to protocol and fidelity to and recommendation of immediate oral feeding to a friend were lower. The 24-hour nausea scores and vomiting episodes were similar. TWEETABLE ABSTRACT: Women hospitalised for hyperemesis gravidarum could feed as soon, as much and as often as can be tolerated compared with initial fasting.

A randomised trial of caesarean wound coverage: exposed versus dressed.

OBJECTIVE: To evaluate the superficial surgical site infection (SSI) rate to 28 days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure. DESIGN: Randomised trial. SETTING: University Hospital, Malaysia: April 2016-October 2016. POPULATION: 331 women delivered by caesarean section. METHOD: Participants were randomised to leaving their wound entirely exposed (n = 165) or dressed (n = 166) with a low adhesive dressing (next day removal). MAIN OUTCOME MEASURES: Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge. RESULTS: The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P = 0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P = 0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups. CONCLUSION: The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken. TWEETABLE ABSTRACT: An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

Get with the guidelines: management of chronic obstructive pulmonary disease in emergency departments in Europe and Australasia is sub-optimal.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are common in emergency departments (ED). Guidelines recommend administration of inhaled bronchodilators, systemic corticosteroids and antibiotics along with non-invasive ventilation (NIV) for patients with respiratory acidosis. AIM: To determine compliance with guideline recommendations for patients treated for COPD in ED in Europe (EUR) and South East Asia/Australasia (SEA) and to compare management and outcomes. METHODS: In each region, an observational prospective cohort study was performed that included patients presenting to ED with the main complaint of dyspnoea during three 72-h periods. This planned sub-study included those with an ED primary discharge diagnosis of COPD. Data were collected on demographics, clinical features, treatment, disposition and in-hospital mortality. We determined overall compliance with guideline recommendations and compared treatments and outcome between regions. RESULTS: A total of 801 patients was included from 122 ED (66 EUR and 46 SEA). Inhaled bronchodilators were administered to 80.3% of patients, systemic corticosteroids to 59.5%, antibiotics to 44 and 60.6% of patients with pH <7.3 received NIV. The proportion administered systemic corticosteroids was higher in SEA (EUR vs SEA for all comparisons; 52 vs 66%, P < 0.001) as was administration of antibiotics (40 vs 49%, P = 0.02). Rates of NIV and mechanical ventilation were similar. Overall in-hospital mortality was 4.2% (SEA 3.9% vs EUR 4.5%, P = 0.77). CONCLUSION: Compliance with guideline recommended treatments, in particular administration of corticosteroids and NIV, was sub-optimal in both regions. Improved compliance has the potential to improve patient outcome.

Extensively drug-resistant tuberculosis in Myanmar: burden and mutations causing second-line drug resistance.

SETTING: Two tuberculosis (TB) reference laboratories in Myanmar. OBJECTIVES: To determine the proportion of extensively drug-resistant TB (XDR-TB) cases among multidrug-resistant TB (MDR-TB) cases and the mutations that cause resistance to second-line drugs in Myanmar. DESIGN: This was a cross-sectional, retrospective study. Multidrug-resistant Mycobacterium tuberculosis isolates were collected during 2015-2016. Phenotypic drug susceptibility testing (DST) was performed and drug-resistant mutations identified by sequencing. Genotypes were determined to explain relationships between drug resistance patterns and genotypes. RESULTS: Of 89 MDR-TB isolates, 12 were XDR-TB and 24 were pre-XDR-TB, with 21 resistant to fluoroquinolones (FQs) and 3 to second-line injectable agents (SLIDs). High rates of cross-resistance among second-line drugs were observed. Correlations between phenotypic and molecular DST against FQs and SLIDs were 91% in both cases. The most frequent mutation in FQ-resistant isolates was D94G (8/21) in gyrA and A1401G (11/15) in rrs in those resistant to SLIDs. The dominant genotype was the Beijing type (76/89). CONCLUSION: There were high proportions of XDR-TB and pre-XDR-TB among MDR-TB cases; cross-resistance among second-line drugs was high, with various types of genetic mutations. These data suggest that resistance to second-line anti-tuberculosis drugs should be monitored intensively, and molecular DST should be employed.

JNK interaction with Sab mediates ER stress induced inhibition of mitochondrial respiration and cell death.

Our aim was to better understand the mechanism and importance of sustained c-Jun N-terminal kinase (JNK) activation in endoplasmic reticulum (ER) stress and effects of ER stress on mitochondria by determining the role of mitochondrial JNK binding protein, Sab. Tunicamycin or brefeldin A induced a rapid and marked decline in basal mitochondrial respiration and reserve-capacity followed by delayed mitochondrial-mediated apoptosis. Knockdown of mitochondrial Sab prevented ER stress-induced sustained JNK activation, impaired respiration, and apoptosis, but did not alter the magnitude or time course of activation of ER stress pathways. P-JNK plus adenosine 5'-triphosphate (ATP) added to isolated liver mitochondria promoted superoxide production, which was amplified by addition of calcium and inhibited by a blocking peptide corresponding to the JNK binding site on Sab (KIM1). This peptide also blocked tunicamycin-induced inhibition of cellular respiration. In conclusion, ER stress triggers an interaction of JNK with mitochondrial Sab, which leads to impaired respiration and increased mitochondrial reactive oxygen species, sustaining JNK activation culminating in apoptosis.

Prevalence of overweight and obesity among children six to ten years of age in the north-east health region of Jamaica.

OBJECTIVE: To estimate the prevalence and correlates of overweight and obesity among children six to ten years old in the North-East Health Region (NEHR) ofJamaica. METHODS: Weights and heights were measured in a representative sample of 5710 children between the ages of six and ten years in 34 schools between October 2008 and March 2009. Overweight and obesity were defined as body mass index (BMI) Z-score > 1SD and >2SD, respectively based on the World Health Organization (WHO)-endorsed age and gender-specific growth standards for children. Point prevalence estimates of overweight and obesity were calculated. Odds ratios (OR) and 95% confidence intervals (CI) were used to estimate associations between overweight and obesity and age, gender and school location. RESULTS: Overweight and obesity prevalence among children six to ten years old in NEHR, Jamaica, was 10.6% and 7.1%, respectively. Overweight (OR = 1.11, 95% CI: 1.04, 1.18) and obesity (OR = 1.17, 95% CI: 1.08, 1.26) prevalence increased significantly with age. Overweight (OR = 1.51, 95% CI: 1.27, 1.80) and obesity (OR = 1.36, 95% CI: 1.11, 1.67) prevalence was significantly higher among girls than boys. Children attending rural-public schools had less risk of being overweight (OR = 0.57, 95% CI: 0.46, 0.70) and obese (OR = 0.35, 95% CI: 0.28, 0.44) when compared with urban-public schools and private schools. Both overweight (OR = 2.11, 95% CI: 1.60, 2.78) and obesity (OR = 1.68, 95% CI: 1.24, 2.28) were significantly more common among children attending private schools. After adjusting for age and gender the results still remained statistically significant. CONCLUSIONS: Overweight/obesity prevalence among children six to ten years old in NEHR of Jamaica is 17.7% with older children and girls having higher rates. Children attending urban-public and private schools have higher prevalence than those attending rural schools. Appropriately targeted interventions are needed to combat this problem.

Risk factors and impact of proximal fixation on acute and chronic renal dysfunction after endovascular aortic aneurysm repair using glomerular filtration rate criteria.

BACKGROUND: The incidence of renal impairment relevant to proximal fixation of aortic endograft devices remains unclear. METHODS: Retrospective cohort of 208 consecutive patients that underwent EVAR from 2006 to 2011. Estimated glomerular filtration rate (eGFR) was based on MDRD study equation. Acute kidney injury (AKI) and chronic kidney disease (CKD) were classified with ADIQ/RIFLE criteria and National Kidney Foundation criteria, respectively. Kaplan-Meier curve was applied to evaluate progression to CKD. Multivariate regression model was fit to identify predictors for developing AKI and CKD. RESULTS: Suprarenal fixation group (SF) included 110 patients and infrarenal fixation group (IF) included 98 patients. Both groups had similar demographics, baseline eGFR, and renal-protection protocols. There was a trend for decreased use of contrast in IF group (median: 93.5 vs. 103 cc, P = 0.07). AKI occurred in 15% of patients in SF group and 19% of patients in IF group (RR: 1.24, P = 0.47). The freedom from progression to stage 3 or 4 CKD in the SF group was 0.76, 0.72, and 0.49 at 6, 12, and 18 months, respectively, while for IF group was 0.8, 0.73, and 0.68, respectively (P = 0.4). Increasing age (P = 0.07), lengthy procedures (P < 0.001), and baseline renal dysfunction (P < 0.001) were significant predictors for developing CKD. Contrast volume (P < 0.001) and ace-inhibitors (P = 0.07) were predictors for AKI. CONCLUSION: Proximal fixation type has no significant effect on both acute and chronic renal function. Identification of modifiable perioperative risk factors may be used to improve renal function outcomes.

Enhancing the immunogenicity of tumour lysate-loaded dendritic cell vaccines by conjugation to virus-like particles.

BACKGROUND: Tumour cell lysates are an excellent source of many defined and undefined tumour antigens and have been used clinically in immunotherapeutic regimes but with limited success. METHODS: We conjugated Mel888 melanoma lysates to rabbit haemorrhagic disease virus virus-like particles (VLP), which can act as vehicles to deliver multiple tumour epitopes to dendritic cells (DC) to effectively activate antitumour responses. RESULTS: Virus-like particles did not stimulate the phenotypic maturation of DC although, the conjugation of lysates to VLP (VLP-lysate) did overcome lysate-induced suppression of DC activation. Lysate-conjugated VLP enhanced delivery of antigenic proteins to DC, while the co-delivery of VLP-lysates with OK432 resulted in cross-priming of naïve T cells, with expansion of a MART1(+) population of CD8(+) T cells and generation of a specific cytotoxic response against Mel888 tumour cell targets. The responses generated with VLP-lysate and OK432 were superior to those stimulated by unconjugated lysate with OK432. CONCLUSION: Collectively, these results show that the combination of VLP-lysate with OK432 delivered to DC overcomes the suppressive effects of lysates, and enables priming of naïve T cells with superior ability to specifically kill their target tumour cells.

A clinical audit of the quality of care of hypertension in general practice.

Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from "best practice" can then be examined, and causes can be determined and acted upon. The Ministry of Health (MOH), Jamaica, has recently published standards of care for hypertension. The medical records of a convenience sample of 125 hypertensive patients being managed by five current family medicine residents in their respective primary care practices were audited Initial results showed limited adherence to the MOH recommended hypertension management guidelines. The same practices were re-audited after an interval of six months, during which time the physicians were sensitized to the results of the preliminary audit. Marked improvements were noted in the second audit. Assessment for co-risk factors for hypertension-related diseases improved: nutritional advice (33% to 74%), smoking and alcohol intake history (40% to 65%) and history taking of physical activity (30% to 47%). Assessment for target organ damage also improved: fundoscopy done (11% to 54%), foot examination done (30% to 58%) and yearly electrolytes done (28% to 62%). There are clear gaps between current practice and standards that exist internationally and locally for management of hypertension. The MOH needs to disseminate and educate general practitioners about the standards of care guidelines.

A clinical audit of the quality of care of hypertension in general practice / Una Auditoría Clínica de la Calidad del Cuidado de la Hipertensión en la Práctica Médica General

Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from [quot ]best practice[quot ] can then be examined, and causes can be determined and acted upon. The Ministry of Health (MOH), Jamaica, has recently published standards of care for hypertension. The medical records of a convenience sample of 125 hypertensive patients being managed by five current family medicine residents in their respective primary care practices were audited Initial results showed limited adherence to the MOH recommended hypertension management guidelines. The same practices were re-audited after an interval of six months, during which time the physicians were sensitized to the results of the preliminary audit. Marked improvements were noted in the second audit. Assessment for co-risk factors for hypertension-related diseases improved: nutritional advice (33% to 74%), smoking and alcohol intake history (40% to 65%) and history taking of physical activity (30% to 47%). Assessment for target organ damage also improved: fundoscopy done (11% to 54%), foot examination done (30% to 58%) and yearly electrolytes done (28% to 62%). There are clear gaps between current practice and standards that exist internationally and locally for management of hypertension. The MOH needs to disseminate and educate general practitioners about the standards of care guidelines

Los auditores clínicos monitorean el uso de intervenciones particulares, o la atención recibida por los pacientes, a fin de verificar si se cumplen las normas establecidas. Cualquier desviación de "la práctica estándar" puede ser entonces analizada, determinándose de ese modo las causas, y empren-diéndose las correspondientes acciones sobre ellas. El Ministerio de Salud (MS) de Jamaica, ha publicado recientemente las normas del cuidado de la hipertensión. A las historias clínicas de una muestra de conveniencia de 125 pacientes hipertensos tratados por cinco residentes de medicina familiar en sus respectivas consultas de atención primaria, se les practicó una auditoría. Los resul-tados iniciales mostraron una correspondencia limitada con las pautas para el tratamiento de la hipertensión recomendadas por el MS. Las mismas prácticas fueron sometidas de nuevo a auditoría, luego de un intervalo de seis meses, durante el cual se sensibilizó a los médicos con los resultados de la auditoría preliminar. En la segunda auditoría se observaron mejorías considerables. Mejoró la evaluación de los factores de co-riesgo por enfermedades relacionadas con la hipertensión: consejo nutricional (33% a 74%), historia de hábito de fumar y consumo de alcohol (40% a 65%), confección de historia de la actividad física (30% a 47%). También mejoró la evaluación de daños dirigida a órganos predeterminados: fondoscopia realizada (11% a 54%), examen de pies realizado (30% a 58%) y electrólitos anuales hechos (28% a 62%). Evidentemente hay lagunas entre la práctica común y las normas existentes internacional y localmente para el tratamiento de hipertensión. El MS necesita diseminar y educar médicos generales versados en las normas de cuidado establecidas.

ELISPOT cloning of tumor antigens recognized by cytotoxic T-lymphocytes from a cDNA expression library.

The methodology of cloning genes coding for antigens recognized by T-cells from cDNA expression libraries was improved technically by using enzyme-linked immunospot (ELISPOT) assays instead of enzyme-linked immunosorbent assays (ELISA) or bioassays to detect cytokines produced by T-cells in response to antigens. Combining large and small scale ELISPOT assays for expression cloning has the following advantages compared to conventional cDNA expression cloning: i) the number of recombinant plasmids which can be screened is greater than 10,000 per well in a 24-well plate in a large scale ELISPOT assay compared to fewer than 100 per well in a 96-well plate in an IFN-gamma ELISA or a TNF-alpha bioassay; ii) the total number of recombinant plasmids which can be screened in a routine assay is 2 x 10 (5) in only one 24-well plate in a large scale ELISPOT assay compared to 1 x 10 (5) in ten 96-well plates in an IFN-gamma ELISA or a TNF-alpha bioassay. Thus the screening efficiency of large scale ELISPOT cloning is approximately 200 times that of conventional expression cloning approaches. The efficiency of the method was confirmed by detecting the model gene RLakt from a cDNA library of a murine leukemia RL male 1.

Growth kinetics of Saccharomyces cerevisiae in batch and fed-batch cultivation using sugarcane molasses and glucose syrup from cassava starch.

Growth kinetics of Saccharomyces cerevisiae in glucose syrup from cassava starch and sugarcane molasses were studied using batch and fed-batch cultivation. The optimum temperature and pH required for growth were 30 degrees C and pH 5.5, respectively. In batch culture the productivity and overall cell yield were 0.31 g L-1 h-1 and 0.23 g cells g-1 sugar, respectively, on glucose syrup and 0.22 g L-1 h-1 and 0.18 g cells g-1 sugar, respectively, on molasses. In fed-batch cultivation, a productivity of 3.12 g L-1 h-1 and an overall cell yield of 0.52 g cells g-1 sugar were achieved in glucose syrup cultivation and a productivity of 2.33 g L-1 h-1 and an overall cell yield of 0.46 g cells g-1 sugar were achieved in molasses cultivation by controlling the reducing sugar concentration at its optimum level obtained from the fermentation model. By using an on-line ethanol sensor combined with a porous Teflon tubing method in automating the feeding of substrate in the fed-batch culture, a productivity of 2.15 g L-1 h-1 with a yield of 0.47 g cells g-1 sugar was achieved using glucose syrup as substrate when ethanol concentration was kept at a constant level by automatic control.

The impact of national measles immunization programme on measles admissions to the major children's hospital in Yangon.

To ascertain whether measles vaccination was associated with reduced measles associated mortality and morbidity in the Yangon Children's Hospital (YCH), the hospital records of children admitted to YCH in 1985 and 1989 with the diagnosis of measles or measles associated conditions, were analysed retrospectively. Measles vaccination was associated with a 90.7% reduction of deaths directly attributed to measles or ascribed to diarrhoea, respiratory illness, malnutrition or fits. An 85% reduction in the percentage of medical admissions related to measles and measles associated conditions was also seen. The case-fatality rate from measles declined from 25.3% to 15.6%. We conclude that measles immunization has been associated with a marked reduction in morbidity and mortality.

Double-blind trial to find dose range using a fixed combination of mefloquine, sulfadoxine and pyrimethamine in falciparum malaria: a field study on adults in Burma.

In a field study conducted in Burma, 60 semi-immune adults were randomly assigned to 2 treatment groups. The first (mean parasite count, 12717/mm3) received a single dose of a fixed combination of 500 mg mefloquine base, 1000 mg sulfadoxine and 50 mg pyrimethamine (2 tablets of 'Fansimef') plus 1 tablet placebo. The second group (mean parasite count, 11 863/mm3) were given 3 tablets of the same medication. The study was double-blind. Parasite count was checked daily for the first week and weekly for a further 3 weeks. Average times for parasite clearance were 1.47 d in patients receiving 2 tablets, and 1.87 d in those given 3 tablets. Asexual parasites reappeared on day 28 in one patient in each group, although they had been free of parasites during the previous 4 weeks; this could be due to reinfection. The drugs were generally well tolerated, though mild and transient giddiness was seen in 80% of patients in the first group and 96% in the second. Nausea was reported by 33% and 43% of patients respectively. No vomiting occurred in the first group but 8 patients vomited in the second (P less than 0.01). In conclusion it seems possible to treat falciparum malaria in semi-immune adults, weighing less than 60 kg, with a single dose of 500 mg mefloquine base, 1000 mg sulfadoxine and 50 mg pyrimethamine (2 tablets), instead of the higher dose (3 tablets) currently recommended. This reduces treatment cost and improves tolerance of the drugs.

Falciparum malaria treated with a fixed combination of mefloquine, sulfadoxine and pyrimethamine: a field study in adults in Burma.

In a field study conducted in Burma, 54 semi-immune adults suffering from falciparum malaria (mean parasite count, 15 328/mm(3) before treatment) were given a single dose of a fixed combination of 750 mg mefloquine base, 1500 mg sulfadoxine, and 75 mg pyrimethamine (3 tablets of Fansimef). All these patients were cleared of asexual parasites by day 7, giving a cure rate of 100%; the mean clearance time was 2.6 days. Reappearance of parasitaemia occurred in 10 patients on or before day 7 and persisted for one day in 8 of them and for two days in 2 patients. It eventually disappeared without further treatment. No recrudescence occurred during the follow-up time of four weeks despite the fact that there was active transmission of Plasmodium falciparum in the area throughout the whole of the study period. The drug was generally well tolerated, though mild to moderate giddiness was reported by 49 patients (90.7%) and severe giddiness by 3 patients (5.5%). Nausea occurred in 25 patients (46.3%) and vomiting in 17 (31.5%).