Comparison of Fecal Calprotectin and Myeloperoxidase in Predicting Outcomes in Inflammatory Bowel Disease.

BACKGROUND: Biomarkers have been proposed as surrogate treatment targets for the management of inflammatory bowel disease (IBD); however, their relationship with IBD-related complications remains unclear. This study investigated the utility of neutrophil biomarkers fecal calprotectin (fCal) and fecal myeloperoxidase (fMPO) in predicting a complicated IBD course. METHODS: Participants with IBD were followed for 24 months to assess for a complicated IBD course (incident corticosteroid use, medication escalation for clinical disease relapse, IBD-related hospitalizations/surgeries). Clinically active IBD was defined as Harvey-Bradshaw index >4 for Crohn's disease (CD) and simple clinical colitis activity index >5 for ulcerative colitis (UC). Area under the receiver-operating-characteristics curves (AUROC) and multivariable logistic regression assessed the performance of baseline symptom indices, fCal, and fMPO in predicting a complicated disease IBD course at 24 months. RESULTS: One hundred and seventy-one participants were included (CD, n = 99; female, n = 90; median disease duration 13 years [interquartile range, 5-22]). Baseline fCal (250 µg/g; AUROC = 0.77; 95% confidence interval [CI], 0.69-0.84) and fMPO (12 µg/g; AUROC = 0.77; 95% CI, 0.70-0.84) predicted a complicated IBD course. Fecal calprotectin (adjusted OR = 7.85; 95% CI, 3.38-18.26) and fMPO (adjusted OR = 4.43; 95% CI, 2.03-9.64) were associated with this end point after adjustment for other baseline variables including clinical disease activity. C-reactive protein (CRP) was inferior to fecal biomarkers and clinical symptoms (pdifference < .05) at predicting a complicated IBD course. A combination of baseline CRP, fCal/fMPO, and clinical symptoms provided the greatest precision at identifying a complicated IBD course. CONCLUSIONS: Fecal biomarkers are independent predictors of IBD-related outcomes and are useful adjuncts to routine clinical care.

An Open-Source Tool for Automated Human-Level Circling Behavior Detection.

Quantifying behavior and relating it to underlying biological states is of paramount importance in many life science fields. Although barriers to recording postural data have been reduced by progress in deep-learning-based computer vision tools for keypoint tracking, extracting specific behaviors from this data remains challenging. Manual behavior coding, the present gold standard, is labor-intensive and subject to intra- and inter-observer variability. Automatic methods are stymied by the difficulty of explicitly defining complex behaviors, even ones which appear obvious to the human eye. Here, we demonstrate an effective technique for detecting one such behavior, a form of locomotion characterized by stereotyped spinning, termed 'circling'. Though circling has an extensive history as a behavioral marker, at present there exists no standard automated detection method. Accordingly, we developed a technique to identify instances of the behavior by applying simple postprocessing to markerless keypoint data from videos of freely-exploring (Cib2-/-;Cib3-/-) mutant mice, a strain we previously found to exhibit circling. Our technique agrees with human consensus at the same level as do individual observers, and it achieves >90% accuracy in discriminating videos of wild type mice from videos of mutants. As using this technique requires no experience writing or modifying code, it also provides a convenient, noninvasive, quantitative tool for analyzing circling mouse models. Additionally, as our approach was agnostic to the underlying behavior, these results support the feasibility of algorithmically detecting specific, research-relevant behaviors using readily-interpretable parameters tuned on the basis of human consensus.

Partial enrichment of phospholipids by enzymatic hydrolysis and membrane filtration of whey protein phospholipid concentrate.

Whey protein phospholipid concentrate (WPPC) contains high amounts of phospholipids (PL; 4.5 ± 1%) but there is interest in further enriching the PL content for nutritional and functional applications. Chemical methods were unsuccessful in separating PL from proteins due to the presence of protein-fat aggregates. Instead, we explored hydrolysis of the proteins to peptides with the objective of removing peptides, thereby concentrating the PL fraction. We used microfiltration (MF) with a pore size of 0.1 µm to help reduce protein/peptide retention. Hydrolyzing proteins should facilitate passage of low molecular weight peptides through the MF membrane, while concentrating fat and PL in the MF retentate. Bench-top experiments were performed to select the proteolytic enzyme that resulted in the most extensive hydrolysis of proteins in WPPC from among 5 different commercial proteases. Sodium dodecyl sulfate-PAGE analysis was performed to measure the extent of protein hydrolysis over a period of 4 h. Alcalase enzyme was found to exhibit the highest proteolytic activity at conditions of pH 8 and temperature 55°C. The intensity of major protein bands (milkfat globule membrane proteins, caseins, ß-lactoglobulin) in WPPC decreased in sodium dodecyl sulfate-PAGE profiles as hydrolysis progressed, along with the appearance of low molecular weight bands. Pilot-scale MF production, coupled with diafiltration (DF), of the hydrolyzed sample aided in the removal of peptides that caused an ~18% reduction in protein content with the final retentate having a total PL content of 9.3% dry basis (db) with protein and fat contents at approximately 43.8 ± 0.4% (db) and 48.9 ± 1.2% (db), respectively. The MF permeate had minimal fat content, indicating that there was no transmission of lipids or PL through the membrane during the MF/DF process. Confocal laser scanning microscopy and particle size analysis of enzyme hydrolyzed solution revealed that protein aggregates were still present after 1 h of hydrolysis. Complete removal of proteins and peptides was not achieved by this process, suggesting that a combination of enzymes would be needed for further hydrolysis of protein aggregates in WPPC solution to further enrich the PL content.

A study of various chemical pretreatments to fractionate lipids from whey protein phospholipid concentrate.

Dairy-derived lipids such as phospholipids (PL) have been gaining interest due to their functional and nutritional properties. Our research goal was to develop a separation process (nonsolvent based) to produce an enriched dairy lipid fraction from whey protein phospholipid concentrate (WPPC). Various chemical pretreatments (i.e., adjustment of pH, calcium, or temperature) were applied to rehydrated commercial WPPC solutions. These treatments were done on a bench-top scale to aid in the precipitation of proteins or PL. The chemically treated solutions were centrifuged and fractionated into the following 3 layers: (1) top fat layer, (2) supernatant in the middle zone, and (3) sediment at the bottom of the centrifuge tubes. The thickness and size of the layers varied with the treatment parameters. Compositional analysis of each layer showed that the proteins, fat, and PL always appeared to fractionate in similar proportions. The proteins in each layer were characterized using sodium dodecyl sulfate-PAGE under reducing and nonreducing conditions. Different proteins including whey proteins, caseins, and milk fat globule membrane proteins and lipoproteins were identified, and no specific type of protein had an affinity for either the top or bottom layer. All types of proteins were present in each of the layers after centrifugation, and there were no major differences in fractionation of the proteins between layers with respect to the chemical treatment applied. The microstructure of protein and fat in WPPC was investigated using confocal laser scanning microscopy. Dual staining of the rehydrated WPPC solution with Fast Green FCF (proteins) and Nile Red (lipids) showed the presence of very large protein aggregates that varied in size from 20 to 150 µm, with fat trapped within these aggregates. The confocal laser scanning microscopy images of liquid WPPC revealed fine strands of a weak protein network surrounding the fat globules. This indicated that there were specific interactions between the proteins, as well as between the fat and proteins in WPPC. Sodium dodecyl sulfate treatment was performed to understand the nature of the interactions between protein and fat. We found that about 35% of the fat present in WPPC was in the form of free fat, which was only physically entrapped within the protein aggregates. The remaining fat had some form of association with the proteins in WPPC. Other fractionation techniques would be needed to obtain an enriched dairy lipid fraction.

Treating children for drug-resistant tuberculosis in Tajikistan with Group 5 medications.

BACKGROUND: Management of extensively drug-resistant tuberculosis (XDR-TB) and pre-XDR-TB is challenging, as effective drugs are lacking. Group 5 anti-tuberculosis drugs have an unclear role in the treatment of drug-resistant TB, and in children the efficacy, safety and effects of long-term use are not well described. We present clinical outcomes and adverse effects of a cohort of children with XDR-TB or pre-XDR-TB treated with Group 5 drugs in Tajikistan. METHODS: We conducted a retrospective analysis of eight children treated with one or more of the Group 5 drugs available under the Tajikistan National TB Programme-linezolid, amoxicillin-clavulanate, clofazimine and clarithromycin-given in combination with first- and second-line drugs. Time to sputum culture conversion, clinical outcomes and adverse effects were evaluated. RESULTS: Two children were cured, one completed treatment, four achieved favourable interim outcomes and one died. Adverse effects attributable to linezolid that required drug cessation occurred in one child; adverse effects of the other Group 5 drugs were insignificant or absent, requiring no regimen changes. CONCLUSION: Group 5 drugs can contribute to effective regimens in children with XDR and pre-XDR-TB. With proper monitoring and aggressive management of adverse effects, their safety profile might be acceptable, even in long-term use.

How do patients access the private sector in Chennai, India? An evaluation of delays in tuberculosis diagnosis.

SETTING: The diagnosis and treatment of tuberculosis (TB) in India are characterized by heavy private-sector involvement. Delays in treatment remain poorly characterized among patients seeking care in the Indian private sector. OBJECTIVE: To assess delays in TB diagnosis and treatment initiation among patients diagnosed in the private sector, and pathways to care in an urban setting. DESIGN: Cross-sectional survey of 289 consecutive patients diagnosed with TB in the private sector and referred for anti-tuberculosis treatment through a public-private mix program in Chennai from January 2014 to February 2015. RESULTS: Among 212 patients with pulmonary TB, 90% first contacted a formal private provider, and 78% were diagnosed by the first or second provider seen after a median of three visits per provider. Median total delay was 51 days (mean 68). Consulting an informal (rather than formally trained) provider first was associated with significant increases in total delay (absolute increase 22.8 days, 95%CI 6.2-39.5) and in the risk of prolonged delay >90 days (aRR 2.4, 95%CI 1.3-4.4). CONCLUSION: Even among patients seeking care in the formal (vs. informal) private sector in Chennai, diagnostic delays are substantial. Novel strategies are required to engage private providers, who often serve as the first point of contact.

An innovative spraying setup to obtain uniform salt(s) mixture deposition to investigate hot corrosion.

A hot corrosion study via molten salt deposition and its interaction with creep/fatigue play a critical role in predicting the life of gas turbine engine components. To do systematic hot corrosion studies, deposition of molten salts on specimens should be uniform with good adherence. Thus, the present study describes an in-house developed spraying setup that produces uniform and reliable molten salt deposition in a repeatable fashion. The efficacy of the present method was illustrated by depositing 90 wt. % Na2SO4 + 5 wt. % NaCl + 5 wt. % NaVO3 salt mixture on hot corrosion coupons and on creep specimens, and also by comparing with other deposition methods.

Challenges and solutions to implementing drug-resistant tuberculosis programmes for children in Central Asia.

Guidelines for children with drug-resistant tuberculosis (DR-TB) tend to focus on individual patient care; there is little guidance for national tuberculosis programmes (NTPs) on how to plan, implement and integrate DR-TB services for children. In 2013, through the paediatric tuberculosis (TB) programme started by the Tajikistan Ministry of Health and Médecins Sans Frontières in 2011, 21 children became the first to be treated for multidrug-resistant tuberculosis (MDR-TB) in Tajikistan. We describe the challenges encountered in establishing the programme and the solutions to these challenges, and propose a framework to guide the implementation of paediatric DR-TB care. This framework could prove useful for other NTPs in resource-limited settings.

Les directives relatives aux enfants atteints de tuberculose pharmacorésistante (TB-DR) ont tendance à se focaliser sur la prise en charge des patients individuels; il y a par contre peu de directives destinées aux programmes nationaux de lutte contre la TB (PNT) sur la manière de planifier, mettre en œuvre et intégrer les services de TB-DR destinés aux enfants. En 2013, dans un programme de prise en charge de la TB pédiatrique démarré par le Ministère de la Santé et Médecins Sans Frontières en 2011, 21 enfants ont été les premiers à être traités pour TB-MDR (TB multi-résistante) au Tadjikistan. Nous décrivons les défis de la mise en œuvre d'un programme et de leurs solutions et proposons un cadre conceptuel d'aide à la mise en œuvre de la prise en charge de la TB-DR pédiatrique. Notre cadre pourrait s'avérer utile pour d'autres PNT dans des contextes de ressources limitées.

Las directrices sobre el manejo de los niños con diagnóstico de tuberculosis drogorresistente (TB-MDR) suelen centrarse en la atención del paciente individual; existe poca orientación dirigida a los Programas Nacionales contra la Tuberculosis (PNT) en materia de planeamiento, ejecución e integración de los servicios que se ocupan de la TB-DR en los niños. El Ministerio de Salud y Médecins Sans Frontières iniciaron en el 2011 un programa de TB dirigido a los niños y en el 2013, por primera vez, 21 niños recibieron tratamiento contra la TB-MDR (multidrogorresistente) en Tayikistán. En el presente artículo se describen los obstáculos encontrados durante la introducción del programa, las soluciones que se aportaron y se propone un marco de trabajo encaminado a orientar la ejecución de la atención pediátrica de la TB-MDR. Este marco será útil a otros PNT en entornos con recursos limitados.

Engineering of yeast pyruvate decarboxylase for enhanced selectivity towards carboligation.

The aim of the study was to increase production of (R)-PAC by altering carboligation activity of Pdc in Saccharomyces cerevisiae. Pdc1 activity was modified by over-expression as well as changing the rate of decarboxylation and carboligation by site specific mutation in Pdc1. Over-expression of mutant Pdc1 resulted in 50 ± 2.5% increase in levels of (R)-PAC in wild-type and further 30-40% in pdc null background. The combination of mutant Pdc1 in pdc null background was successfully evaluated for production of (R)-PAC at industrial scale. This is the first report of enhancing (R)-PAC product in yeast by recombinant technology with capability of commercial production.

Fulminant methicillin-sensitive Staphylococcus aureus infection in a healthy adolescent, highlighting 'Panton-Valentine leucocidin syndrome'.

A 14-year-old immunocompetent adolescent presented systemically unwell with left knee septic arthritis. Within several days, disseminated bone and soft tissue collections became evident, associated with deep venous thrombosis and pulmonary involvement. Methicillin-sensitive Staphylococcus aureus was isolated, harbouring Panton-Valentine leucocidin genes. Aggressive antibiotic and surgical therapies eventually lead to recovery. Intrafamilial spread of the pathogenic isolate was shown by household screening. This presentation is consistent with 'PVL Syndrome' and is typical of severe S. aureus infection emerging in young populations globally.

Oliguric acute renal failure in mycosis fungoides with lymphomatous infiltrates in the kidneys.

OBJECTIVE: To present the clinical picture of acute renal failure in patients with mycosis fungoides (MF) and renal lymphomatous infiltrates. To analyze the pathogenesis of renal failure. METHODS: Correlation of clinical picture, urinary findings, imaging reports and autopsy findings in two patients with long-standing MF who died with renal failure. CASE SUMMARIES: Both subjects had sustained oliguria in the last 2 weeks. One patient had persistent hypotension, normal urinalysis, normal renal sonogram, and scarce interstitial lymphomatous infiltrates with preservation of renal parenchymal architecture. He was thought to have ischemic acute renal failure not directly linked to the lymphomatous infiltrates. The second patient developed hypertension one month prior to death, and had moderate proteinuria, hematuria, pyuria, grossly enlarged kidneys with hypoechoic masses, and extensive replacement of the renal parenchyma by lymphomatous infiltrates. This picture is typical of renal failure secondary to lymphomatous replacement of the kidneys. CONCLUSIONS: The development of oliguric renal failure in MF with renal lymphomatous infiltrates may have varying clinical and imaging manifestations and pathogeneses. Potentially reversible pathogenic mechanisms should be systematically investigated, particularly if the overall clinical picture is not characteristic of renal failure secondary to lymphomatous replacement of the parenchyma.

Cloning and functional expression of human retinal kir2.4, a pH-sensitive inwardly rectifying K(+) channel.

To identify novel potassium channel genes expressed in the retina, we screened a human retina cDNA library with an EST sequence showing partial homology to inwardly rectifying potassium (Kir) channel genes. The isolated cDNA yielded a 2,961-base pair sequence with the predicted open reading frame showing strong homology to the rat Kir2. 4 (rKir2.4). Northern analysis of mRNA from human and bovine tissues showed preferential expression of Kir2.4 in the neural retina. In situ hybridization to sections of monkey retina detected Kir2.4 transcript in most retinal neurons. Somatic hybridization analysis and dual-color in situ hybridization to metaphase chromosomes mapped Kir2.4 to human chromosome 19 q13.1-q13.3. Expression of human Kir2. 4 cRNA in Xenopus oocytes generated strong, inwardly rectifying K(+) currents that were enhanced by extracellular alkalinization. We conclude that human Kir2.4 encodes an inwardly rectifying K(+) channel that is preferentially expressed in the neural retina and that is sensitive to physiological changes in extracellular pH.

Rapidly progressive necrotizing fasciitis and gangrene due to Clostridium difficile: case report.

A case of rapidly progressive necrotizing fascitis and gas gangrene due to Clostridium difficile that responded very well to surgical intervention is described.

Mental health initiatives as peace initiatives in Sri Lankan schoolchildren affected by armed conflict.

The Health Reach Sri Lanka project (1993-96) is described. It was a school-based assessment of children's exposure to war-related events and the presence of psychological distress, undertaken in six communities in parts of Sri Lanka variously affected by armed conflict. Its objectives, methods and results are presented. The research project aimed to raise national awareness of the psychosocial effects of armed conflict on children, using a community-development approach to local capacity building, based on the 'health initiative as peace initiative' model. As a follow-up to the study, a locally run programme, based on creative play and trauma-healing, was established, initially for the children involved in the study. This was later extended to other children in the district affected by armed conflict.

Metabolism of tacrolimus (FK 506) in rat liver microsomes. Effect of rifampin and dexamethasone.

The in vitro metabolism of tacrolimus (TAC, FK 506) was investigated in the liver microsomes prepared from normal rats as well as rats treated with dexamethasone (DEX) and rifampin (RIF). The rate of tacrolimus metabolism was similar in control and RIF treated rat liver microsomes, whereas it significantly increased in microsomes obtained from dexamethasone treated rats. Seven different possible metabolites were identified in the microsomal preparations from rats treated with rifampin or dexamethasone whereas the microsomes from the control rats failed to produce the mono-demethylated and monohydroxylated metabolite of TAC (TAC+2, m/z = 805.5). There was an apparent difference in the amount of individual metabolites formed in different groups. This indicates quantitative differences in the induction of cytochrome P450 3A, an enzyme sub family known to be primarily responsible for tacrolimus metabolism. Lack of induction of tacrolimus metabolism by rifampin can be attributed to the lack of effect of rifampin in inducing cytochrome P450 3A in rats.

Clinical pharmacokinetics of tacrolimus.

Tacrolimus, a novel macrocyclic lactone with potent immunosuppressive properties, is currently available as an intravenous formulation and as a capsule for oral use, although other formulations are under investigation. Tacrolimus concentrations in biological fluids have been measured using a number of methods, which are reviewed and compared in the present article. The development of a simple, specific and sensitive assay method for measuring concentrations of tacrolimus is limited by the low absorptivity of the drug, low plasma and blood concentrations, and the presence of metabolites and other drugs which may interfere with the determination of tacrolimus concentrations. Currently, most of the pharmacokinetic data available for tacrolimus are based on an enzyme-linked immunosorbent assay method, which does not distinguish tacrolimus from its metabolites. The rate of absorption of tacrolimus is variable with peak blood or plasma concentrations being reached in 0.5 to 6 hours; approximately 25% of the oral dose is bioavailable. Tacrolimus is extensively bound to red blood cells, with a mean blood to plasma ratio of about 15; albumin and alpha 1-acid glycoprotein appear to primarily bind tacrolimus in plasma. Tacrolimus is completely metabolised prior to elimination. The mean disposition half-life is 12 hours and the total body clearance based on blood concentration is approximately 0.06 L/h/kg. The elimination of tacrolimus is decreased in the presence of liver impairment and in the presence of several drugs. Various factors that contribute to the large inter- and interindividual variability in the pharmacokinetics of tacrolimus are reviewed here. Because of this variability, the narrow therapeutic index of tacrolimus, and the potential for several drug interactions, monitoring of tacrolimus blood concentrations is useful for optimisation of therapy and dosage regimen design.

The use of a biodegradable mesh to prevent radiation-associated small-bowel injury.

Radiation-associated small bowel injury occurs in up to 50% of patients receiving postoperative radiotherapy following pelvic cancer surgery. We describe our experience using a biodegradable mesh that allows the small bowel to be supported above the pelvic inlet and is totally absorbed following radiation therapy. Between 1985 and 1989, 45 procedures were performed in patients with carcinoma of the rectum (anterior resection in 15 patients, abdominoperineal resection in 23 patients, pelvic exenteration in six patients, and proctocolectomy in one patient). In 30 patients a polyglycolic acid (Dexon) mesh was used, and in 15 patients a polyglactin 910 (Vicryl) mesh was used. Forty-four patients received postoperative radiotherapy. The mean (+/- SEM) dose was 56.8 +/- 18.4 Gy. There were no immediate complications related to the mesh. Follow-up ranged from 12 to 53 months (median follow-up, 34 months). With the exception of two patients who had a polyglactin 910 mesh and who developed bowel obstruction due to adhesions under the anterior abdominal wall, there has been no documented incidence of clinical radiation-associated small bowel injury. The use of the absorbable mesh may permit us to use higher doses of postoperative radiotherapy without the associated hazard of radiation-associated small bowel injury.