Ageing and Polypharmacy in Mesenchymal Stromal Cells: Metabolic Impact Assessed by Hyperspectral Imaging of Autofluorescence.

The impact of age on mesenchymal stromal cell (MSC) characteristics has been well researched. However, increased age is concomitant with increased prevalence of polypharmacy. This adjustable factor may have further implications for the functionality of MSCs and the effectiveness of autologous MSC procedures. We applied hyperspectral microscopy of cell autofluorescence-a non-invasive imaging technique used to characterise cytometabolic heterogeneity-to identify changes in the autofluorescence signals of MSCs from (1) young mice, (2) old mice, (3) young mice randomised to receive polypharmacy (9-10 weeks of oral therapeutic doses of simvastatin, metoprolol, oxycodone, oxybutynin and citalopram), and (4) old mice randomised to receive polypharmacy. Principal Component Analysis and Logistic Regression Analysis were used to assess alterations in spectral and associated metabolic characteristics. Modelling demonstrated that cells from young mice receiving polypharmacy had less NAD(P)H and increased porphyrin relative to cells from old control mice, allowing for effective separation of the two groups (AUC of ROC curve > 0.94). Similarly, cells from old polypharmacy mice were accurately separated from those from young controls due to lower levels of NAD(P)H (p < 0.001) and higher porphyrin (p < 0.001), allowing for an extremely accurate logistic regression (AUC of ROC curve = 0.99). This polypharmacy regimen may have a more profound impact on MSCs than ageing, and can simultaneously reduce optical redox ratio (ORR) and increase porphyrin levels. This has implications for the use of autologous MSCs for older patients with chronic disease.

Suspecting a fatal condition on a plain chest radiograph; Boerhaave syndrome.

Spontaneous oesophagus rupture, also known as Boerhaave syndrome, is a rare but near-fatal medical condition and despite recent medical advancements, it remains a diagnostic challenge for front-door clinicians. The authors describe a similar presentation in an elderly gentleman who presented to the emergency department with sudden chest pain post vomiting. His initial chest radiograph showed bilateral dense consolidations and pleural effusions, and was treated as sepsis secondary to bilateral pneumonia. He underwent computed tomography pulmonary angiogram to rule out pulmonary embolism because of his chest pain with elevated D-dimer which confirmed the diagnosis of oesophagus rupture. His care was transferred to Surgical and Intensive care colleagues with plans for radiological chest drain insertion to limit contamination of mediastinum, however the patient became hypoxic and hypotensive and despite maximal organ support passed away within 6 hours of admission. Retrospect review of chest radiograph revealed Peri-oesophageal air tracking, a sign of Boerhaave syndrome. The aim of this case is to emphasise the importance of raising the suspicion of Boerhaave syndrome in patients with sudden chest pain, unexplained pleural effusion or pneumothorax with a history of recent vomiting as early diagnosis holds the key to prompt lifesaving management.

Burnout among diabetes specialist registrars across the United Kingdom in the post-pandemic era.

Introduction: Burnout syndrome is a condition resulting from chronic work-related stress exposure and can be identified by the presence of one or more of the three classic dimensions of burnout, i.e., emotional exhaustion, depersonalization, and lack of personal accomplishment, which negatively impact physician health and productivity. Objective: This study aimed to identify burnout among Diabetes and Endocrinology Specialty Training Registrars (DStRs) across the United Kingdom. Design/setting: It was a Cross-sectional observational study after ethical approval ERSC_2022_1166, utilizing the gold standard Maslach Burnout Inventory to measure burnout syndrome, and to determine self-reported stressors and compare them with the results of our previous survey in 2018. Participants: Over 430 DStRs across the United Kingdom were invited electronically through their deanery representatives and specialty training bodies. Results: Using Google Forms™ to gather data, we were able to collect 104 completed surveys. Results revealed that 62.5% (n = 65) of participants have burnout (5% increase from the previous survey in 2018), 38.6% (n = 40) have high emotional exhaustion, and 44.2% (n = 46) feel a lack of personal accomplishment. "General Internal Medicine specific workload" was the most common self-reported stressor reported by 87.5% (n = 91) of participants, whereas bullying/harassment and discrimination at work were reported by 35.6% (n = 37) and 30.77% (n = 32) of participants, respectively. Using multivariable logistic regression model, personal stress (OR, 4.00; 95% CI, 1.48-10.86; p = 0.006) had significant, while Bullying/harassment (OR, 3.75; 95% CI, 0.93-15.12; p = 0.063) had marginal impact on the presence of burnout. Conclusion: Diabetes and Endocrinology Specialty Training Registrars frequently experience burnout syndrome, which has increased over the last 4 years. However, organizational changes can help identify, prevent, and treat physician burnout. Trial registration: NCT05481021 available at https://ichgcp.net/clinical-trials-registry/NCT05481021.

Label-Free Assessment of Key Biological Autofluorophores: Material Characteristics and Opportunities for Clinical Applications.

Autofluorophores are endogenous fluorescent compounds that naturally occur in the intra and extracellular spaces of all tissues and organs. Most have vital biological functions - like the metabolic cofactors NAD(P)H and FAD+, as well as the structural protein collagen. Others are considered to be waste products - like lipofuscin and advanced glycation end products - which accumulate with age and are associated with cellular dysfunction. Due to their natural fluorescence, these materials have great utility for enabling non-invasive, label-free assays with direct ties to biological function. Numerous technologies, with different advantages and drawbacks, are applied to their assessment, including fluorescence lifetime imaging microscopy, hyperspectral microscopy, and flow cytometry. Here, the applications of label-free autofluorophore assessment are reviewed for clinical and health-research applications, with specific attention to biomaterials, disease detection, surgical guidance, treatment monitoring, and tissue assessment - fields that greatly benefit from non-invasive methodologies capable of continuous, in vivo characterization.

Single cell, Label free Characterisation of Human Mesenchymal Stromal cell Stemness and Future Growth Potential by Autofluorescence Multispectral Imaging.

AIM: To use autofluorescence multispectral imaging (AFMI) to develop a non-invasive assay for the in-depth characterisation of human bone marrow derived mesenchymal stromal cells (hBM-MSCs). METHODS: hBM-MSCs were imaged by AFMI on gridded dishes, stained for endpoints of interest (STRO-1 positivity, alkaline phosphatase, beta galactosidase, DNA content) then relocated and results correlated. Intensity, texture and morphological features were used to characterise the colour distribution of regions of interest, and canonical discriminant analysis was used to separate groups. Additionally, hBM-MSC lines were cultured to arrest, with AFMI images taken after each passage to investigate whether an assay could be developed for growth potential. RESULTS: STRO-1 positivity could be predicted with a receiver operator characteristic area under the curve (AUC) of 0.67. For spontaneous differentiation this was 0.66, for entry to the cell-cycle it was 0.77 and for senescence it was 0.77. Growth potential (population doublings remaining) was estimated with an RMSPE = 2.296. The Mean Absolute Error of the final prediction model indicated that growth potential could be predicted with an error of ± 1.86 doublings remaining. CONCLUSIONS: This non-invasive methodology enabled the in-depth characterisation of hBM-MSCs from a single assay. This approach is advantageous for clinical applications as well as research and stands out for the characterisation of both present status as well as future behaviour. The use of data from five MSC lines with heterogenous AFMI profiles supports potential generalisability.

Looking Beyond What You See: A Rare Cause of Dysphagia.

Hypothyroidism is a common endocrine condition with typical symptoms such as cold intolerance, weight gain, fatigue, constipation, and coarse skin, as well as less common symptoms such as depression, difficulty in concentration, and hair thinning. It is usually diagnosed by combining clinical features and applying clinical judgment; however, the wide spectrum of presenting symptoms can sometimes lead to a diagnostic dilemma. Dysphagia secondary to hypothyroidism is a rarely reported symptom in the literature and is believed to be associated with a hormonal effect on esophageal and gastric motility with neuromuscular incoordination; however, the underlying mechanism remains unknown. The most common cause of hypothyroidism is Hashimoto's disease, which can rarely manifest as heartburn, possibly due to esophageal dysmotility. Herein, we describe an unusual presentation of severe hypothyroidism with dysphagia, for which we could not identify any obstructive cause despite extensive investigations This condition was resolved successfully with levothyroxine treatment. Through this report, we aimed to communicate to the audience the important learning message that hypothyroidism may cause symptoms of dysphagia and to inform practitioners regarding this possibility, which should be considered after ruling out any obstructive pathology.

Clinical applications of non-invasive multi and hyperspectral imaging of cell and tissue autofluorescence beyond oncology.

Hyperspectral and multispectral imaging of cell and tissue autofluorescence employs fluorescence imaging, without exogenous fluorophores, across multiple excitation/emission combinations (spectral channels). This produces an image stack where each pixel (matched by location) contains unique information about the sample's spectral properties. Analysis of this data enables access to a rich, molecularly specific data set from a broad range of cell-native fluorophores (autofluorophores) directly reflective of biochemical status, without use of fixation or stains. This non-invasive, non-destructive technology has great potential to spare the collection of biopsies from sensitive regions. As both staining and biopsy may be impossible, or undesirable, depending on the context, this technology great diagnostic potential for clinical decision making. The main research focus has been on the identification of neoplastic tissues. However, advances have been made in diverse applications-including ophthalmology, cardiovascular health, neurology, infection, assisted reproduction technology and organ transplantation.

Emerging clinical applications in oncology for non-invasive multi- and hyperspectral imaging of cell and tissue autofluorescence.

Hyperspectral and multispectral imaging of cell and tissue autofluorescence is an emerging technology in which fluorescence imaging is applied to biological materials across multiple spectral channels. This produces a stack of images where each matched pixel contains information about the sample's spectral properties at that location. This allows precise collection of molecularly specific data from a broad range of native fluorophores. Importantly, complex information, directly reflective of biological status, is collected without staining and tissues can be characterised in situ, without biopsy. For oncology, this can spare the collection of biopsies from sensitive regions and enable accurate tumour mapping. For in vivo tumour analysis, the greatest focus has been on oral cancer, whereas for ex vivo assessment head-and-neck cancers along with colon cancer have been the most studied, followed by oral and eye cancer. This review details the scope and progress of research undertaken towards clinical translation in oncology.

Benzimidazole and Benzoxazole Zinc Chelators as Inhibitors of Metallo-ß-Lactamase NDM-1.

Bacterial expression of ß-lactamases, which hydrolyze ß-lactam antibiotics, contributes to the growing threat of antibacterial drug resistance. Metallo-ß-lactamases, such as NDM-1, use catalytic zinc ions in their active sites and hydrolyze nearly all clinically available ß-lactam antibiotics. Inhibitors of metallo-ß-lactamases are urgently needed to overcome this resistance mechanism. Zinc-binding compounds are promising leads for inhibitor development, as many NDM-1 inhibitors contain zinc-binding pharmacophores. Here, we evaluated 13 chelating agents containing benzimidazole and benzoxazole scaffolds as NDM-1 inhibitors. Six of the compounds showed potent inhibitory activity with IC50 values as low as 0.38 µM, and several compounds restored the meropenem susceptibility of NDM-1-expressing E. coli. Spectroscopic and docking studies suggest ternary complex formation as the mechanism of inhibition, making these compounds promising for development as NDM-1 inhibitors.

Sporadic Fusobacterium Bacteremia as an Atypical Cause of Acute Hepatitis in a Young Caucasian Woman.

Fusobacterium species are gram-negative anaerobic non-spore-forming bacteria, which colonize mucous membranes in humans. Over the recent decade, the significance of these organisms has been increasingly recognized. We describe a rare case of acute hepatitis, which was found to be likely due to Fusobacterium nucleatum, grown on blood culture. In our case, the hepatitis caused by this microorganism resolved completely without any long-term sequelae to the liver, through conservative management namely intravenous antibiotics and supportive therapy only. This case highlights that early detection and prompt treatment in a case of acute hepatitis resulted in a good outcome. In addition, this case also illustrates that the differential diagnosis can be varied in cases of acute hepatitis.

External validation of the platelet count/spleen diameter ratio for the diagnosis of esophageal varices in hepatitis C virus-related cirrhosis.

BACKGROUND: Screening for esophageal varices (EV) is an important part of the diagnostic workup of cirrhotic patients. AIMS: To independently validate the use of the platelet count/spleen diameter ratio for the non-invasive diagnosis of EV in patients with HCV-related cirrhosis and in a sub-group of patients with compensated disease. METHODS: A platelet count/spleen diameter ratio cut-off value of 909 was evaluated for the diagnosis of EV in the whole population (n = 311) and in patients with compensated disease alone (n = 114). Compensated disease was defined as the absence of ascites as detected by abdominal ultrasound in patients who are not on diuretics and absence of hepatic encephalopathy. RESULTS: In the whole cohort (EV prevalence 49.5%), the platelet count/spleen diameter ratio 909 cut-off value had 96.9% positive predictive value, 100% negative predictive value, and 98.4% efficiency for EV diagnosis. In compensated cirrhotics (EV prevalence 26.3%), the platelet count/spleen diameter ratio 909 cut-off showed an excellent negative predictive value (100%) and a positive predictive value of 93.8%. for the diagnosis of EV. CONCLUSIONS: In patients with HCV-related cirrhosis, the platelet count/spleen diameter may be proposed as a non-invasive tool for EV diagnosis, especially in financially deprived developing countries.

Burnout among middle-grade doctors of tertiary care hospital in Saudi Arabia.

BACKGROUND: Burnout Syndrome is a mental condition caused by chronic exposure to work related stress and is identified by the presence of any of the three distinct elements of emotional exhaustion, depersonalization and lack of personal accomplishment. Middle grade doctors are the backbone of any tertiary care hospital / medical institution, partaking in unscheduled and inpatient care. OBJECTIVE: The aim of this study was to assess the presence of burnout syndrome in the middle grade doctors in a tertiary care hospital in Saudi Arabia. PARTICIPANTS: The study was conducted at the Armed Forces Hospital Southern Region, Khamis Mushyt, from August to October 2012 in departments with at least fifty inpatient admissions per month and with at least five middle grade (Resident, Registrar and Senior Registrar) doctors. The departments were Obstetrics and Gynecology, Internal Medicine, Pediatrics, Emergency, General Surgery and Nephrology. METHODS: This was a cross sectional descriptive and analytical study using the Maslach Burnout Inventory-Health Services Survey and a self-reported stressor-identifying questionnaire to ascertain possible precursors of, or contributing factors to, Burnout Syndrome. RESULTS: A total of 96 proformas/questionnaires were collected anonymously to maintain confidentiality and burnout syndrome was identified in as high as 88.5% of the respondents with high emotional exhaustion in 68.8%, high depersonalization in 63.6% and low personal accomplishment in 38.5%. CONCLUSION: The authors concluded that burnout syndrome is high among the middle-grade doctors in this medical facility and that urgent steps are needed to address this problem to ensure that these physicians remain physically and mentally healthy.

Vitamin d deficiency in patients with type-2 diabetes mellitus in southern region of saudi arabia.

INTRODUCTION: Type-2 diabetes mellitus and Vitamin D deficiency are both common in Saudi Arabian population. New roles of vitamin D have emerged recently especially in the prevention of cardiovascular disease, cancer and insulin resistance. OBJECTIVE: To estimate 25-OH vitamin D deficiency in patients with type-2 diabetes mellitus in comparison to normal age-matched non-diabetic control population. METHODS: A Randomized Case-Control study was done in three tertiary care hospitals in Southern Region, Saudi Arabia from June 2010 to June 2012 and 345 patients were selected; 172 in the diabetic group and 173 in the non-diabetic group. Biochemical workup and 25-OH vitamin D levels were done. RESULTS: The mean serum 25-OH vitamin D levels in the diabetic group were 15.7 + 7.5 ng/mL as compared healthy non-diabetic group having 11.1 + 5.9 ng/mL and a total of 340 patients (98.5%) from both groups were found to be deficient in 25-OH vitamin D which is the highest reported so far in Saudi Arabia. CONCLUSION: The population in our study was generally deficient in 25-OH vitamin D irrespective of diabetes mellitus indicating a greater need for vitamin D supplementation.

Peg-interfon alpha-2a and low-dose ribavirin for treatment of hepatitis C virus infection in patients with sickle-cell anemia in Saudi Arabia.

BACKGROUND AND OBJECTIVES: Data regarding the safety and efficacy of antiviral therapy with pegylated interferon (PEG-IFN) and ribavirin (RBV) in patients with sickle-cell disease (SCD) and hepatitis C virus (HCV) infection are scanty. In this study, our aim was to evaluate the safety and efficacy of antiviral therapy with PEG-IFN and low-dose RBV in patients with SCD and chronic HCV infection receiving hydroxyurea in Saudi Arabia. DESIGN AND SETTINGS: This was a prospective interventional study conducted between January 2009 and September 2012 at the outpatient departments of Haematology and Hepatology/Gastroenterology of a tertiary care hospital in Saudi Arabia. PATIENTS AND METHODS: We studied 8 treatment-naive patients (5 males, 63%) with chronic hepatitis C and SCD receiving hydroxyurea who were treated with PEG-IFN alpha-2a (180 micro g weekly) and low-dose RBV (200 mg daily). Early virological response (EVR) and sustained virological response (SVR) rates were assessed in all patients. RESULTS: All patients were infected with HCV genotype 1 (n=6.8%) or 4 (n=22%). EVR was obtained in 3 patients (38%) and SVR in 6 patients (7%). During the study, there was no increase in the number of blood units transfused and emergency visits due to painful crises. CONCLUSION: in Saudi Arabian patients with SCD and chronic HCV infection on hydroxyurea, PEG-IFN and low-dose RBV treatment proved to be efficacious and safe.

Factors predicting severe dengue in patients with dengue Fever.

INTRODUCTION: Dengue virus (DENV) affects over half the world's population in 112 countries, and dengue fever (DF) is the second largest arthropod borne infectious global hazard after malaria with complications like Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), accounting for significant morbidity and mortality world-over. Pakistan is significantly affected with DENV infection and to-date no study identifying risk factors associated with development of severe complications of DF has been done. METHODS: 997 confirmed cases of DF were collected from a tertiary care hospital in Lahore, Pakistan and their clinical and biochemical data were collected. Univariate, multivariate and logistics regression analysis was performed to identify risk factors associated with development of DHF and DSS. RESULTS: Bleeding OR 70.7 (CI 38.4-129.9), deranged liver function test OR 1.9 (CI 0.97-0.99), presence of urinary red blood cells OR 1.4 (95%CI 0.179-0.900) and presence of urinary protein OR 1.1 (95%CI 0.191-0.974) were related to development of DHF and DSS. DISCUSSION: Severe Dengue, like DHF and DSS can be predicted by the presence of clinical and biochemical factors like signs of bleeding, deranged liver function test, presence of urinary red blood cells and urinary protein; so that the patients at high risk for complication be identified early and started on treatment timely. CONCLUSION: Predictors of severe dengue are identified in this study but further large scale multi-centered studies are needed for better interpretation.

Feasibility of the cut-and-push method for removing large-caliber soft percutaneous endoscopic gastrostomy devices.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term nutrition in patients with longstanding eating difficulties due to pathological entities that impair swallowing. The feeding catheters are designed to be removed by external traction or by endoscopy. AIM: To evaluate the feasibility of the cut-and-push method as a possible safe alternative to the pullout method for removal of soft PEG devices with a large caliber. METHODS: Patients with 20 French (Fr) or larger soft PEG system were enrolled for PEG removal by the cut-and-push technique. The replacement catheters were 2 Fr larger than the original ones. Patients were observed at 24 and 72 hours via home nursing care and then weekly for 1 month for signs of intestinal obstruction, tube leakage, or blockage. RESULTS: Seventy-nine patients (52 men; mean age 67 years) underwent the procedure: 42 due to leakage and 37 due to blockage. Mean time before tube removal was 4.8 months (range, 3-8). PEG devices were 20 Fr and 24 Fr in 57 (72.2%) and 22 (27.8%) cases, respectively. Collection of the inner component from stool was reported within 48 hours in 63 cases (80%). No cases of intestinal obstruction or other severe adverse events due to the inner component being eliminated throughout the intestine were observed in any patient during the study. CONCLUSIONS: The cut-and-push method employed for removal of a soft PEG tube with a large caliber seems to be safe and can be performed when removal by external traction may determine the occurrence of peristomal complications or jeopardize PEG replacement.

Characteristics of Patients Hospitalized with 2009 H1N1 Influenza in a Tertiary Care Hospital in Southern Saudi Arabia.

BACKGROUND: Pandemic influenza A (H1N1) virus emerged and spread globally in the spring of 2009. We describe the clinical features of the patients who were hospitalized with 2009 H1N1 influenza July 2009 to June 2010 in a tertiary care hospital in Khamis Mushyt, Saudi Arabia. We analyzed the clinical and laboratory variables in order to determine predictors of poor outcome. METHODS: We performed a prospective study in all patients who were hospitalized for at least 48 hours and with a positive test for 2009 H1N1 virus through RT-PCR(real time polymerase chain reaction). Their epidemiological, clinical, biochemical characteristics were collected and the hospital course of the patients with eventual outcome (discharge or death) was observed. We applied a logistic regression analysis to determine the best predictor of death. RESULTS: A total of 52 patients (15 males) were adults and 65 were pediatrics (< 12 years of age) (19 males). The common presenting signs and/or symptoms associated with the disease was fever >38.5 ºC (n=85; 72.6%), dry cough (n=81; 69.2%), dyspnea (n=40; 34.5%), tachycardia (n=96; 83.5%) and saturation less than 90% in room air on pulse oximetry (n=65; 55.6%). The complications included pneumonia (40.2 %), intensive care unit admission (19.2%) and death (16.7%). CONCLUSIONS: We found that hypoxia at admission was the most important predictive factor of poor outcome (death) with area under curve of 0.768.

A case report of pseudo-subarachnoid hemorrhage.

BACKGROUND: The authors report an unusual case of the radiological appearance of diffuse subarachnoid hemorrhage on brain computed tomographic (CT) scan in a patient with post-resuscitation anoxic encephalopathy. CLINICAL PRESENTATION: A young man with chronic renal failure collapsed unconscious while starting hemodialysis and was revived after resuscitation for almost one hour. He was shifted to intensive care unit and subsequent CT scan after 3 days showed a picture compatible with diffuse subarachnoid hemorrhage. The subsequent lumbar puncture showed no evidence of subarchnoid hemorrhage while the attenuation at the basal cistern on CT brain was consistent with pseudosubarachnoid hemorrhage. A four vessel angiography done subsequently confirmed anoxic encephalopathy. CONCLUSION: Anoxic encephalopathy can mimic diffuse subarachnoid hemorrhage on CT.