The effect of the different waves of COVID-19 pandemic on the outcome of diabetic foot ulcers.

AIMS: COVID-19 pandemic has massively impacted human health. We studied the effect of COVID-19 on outcome of Diabetic foot ulcers (DFUs). OBJECTIVES AND METHODS: We recruited 483 people with DFUs from June 2020 to April 2022 (pandemic) together with a matched group of 226 people with DFU from March 2019 to March 2020 (pre-pandemic). Primary endpoint was outcome of ulcers-healed or amputation (major/minor). It was sub-analysed into 3 waves of COVID-19. Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data included site and type of ulcer (ischemic or neuropathic), duration, presence or absence of infection and Wagner's grading of DFUs was collected for all patients. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ankle brachial index (ABI). Standardized treatment protocol was provided. All patients were monitored for 6 months. RESULTS: In the pandemic group 323 (66.9%) patients in whom ulcers healed, 70 (14.5%) underwent minor amputation, 11 (2.2%) major amputation, 29 (6%) were lost to follow up, 22 (4.6%) were not healed. Rate of healing of DFU was higher (66.9% vs 53.5%) and rate of amputation was lower (16.7% vs 23.4%) in the pandemic group than in the pre-pandemic group (P = 0.001 and 0.037 respectively). Rate of healing in first, second and third wave was 65.4%, 75.2%, 58.3% respectively (P = 0.001). Neuropathic ulcers though less prevalent (49.8% vs 57.8%) in the first two waves than in the third wave, healing was better (79.3% vs 75.6%) in the first two waves than in the third wave (P = 0.085 and 0.488 respectively). Similarly, amputation rates in ischemic and neuro-ischemic ulcers were greater in the third wave than first two waves (46.7% vs 15.7%, P = 0.049). CONCLUSION: During the COVID-19 pandemic, healing of neuropathic ulcers was better, especially in the first and second waves and travel restriction may have accounted for this. However, worsening of ischemic and neuro-ischemic ulcers was observed with more amputation in these two groups. Conversely, in the third wave withdrawal of lockdown led to worsening of DFUs resulting in less healing and more amputation.

DNA synthesis inhibition in response to benzo[a]pyrene dihydrodiol epoxide is associated with attenuation of p(34)cdc2: Role of p53.

Our previous findings demonstrated that DNA damage by polynuclear aromatic hydrocarbons (PAHs) triggers a cellular protective response of growth inhibition (G1-S cell cycle arrest and inhibition of DNA synthesis) in human fibroblasts associated with accumulation of p53 protein, a growth-inhibitory transcription factor. Here, we report that BPDE (the ultimate carcinogenic metabolite of the PAH benzo[a]pyrene) treatment triggers a variable extent of inhibition of DNA synthesis/cell growth, which does not correspond to the extent of increased p53 accumulation. BPDE treatment of cells significantly attenuates expression of p(34)cdc2, a cell cycle activating protein. Although the role of cdc2 down-regulation in inhibition of cell cycle progression is well known, cdc2 down-regulation in response to cellular insult by PAHs has not been reported. Unlike p53 accumulation, there is a correspondence between DNA synthesis/cell growth inhibition and cdc2 down-regulation by BPDE. BPDE-induced cdc2 down-regulation is p53 dependent, although there is no correspondence between p53 accumulation and cdc2 down-regulation. BPDE-induced cdc2 down-regulation corresponded with accumulation of the cell cycle inhibitor protein p21 (transactivation product of p53). DNA synthesis/cell growth inhibition in response to DNA-damaging PAHs may involve down-regulation of cdc2 protein mediated by p53 activation (transactivation ability), and the extent of p53 accumulation is not the sole determining factor in this regard.

Phenolic fraction of tobacco smoke inhibits BPDE-induced apoptosis response and potentiates cell transformation: role of attenuation of p53 response.

Polynuclear aromatic hydrocarbons (PAHs) present in tobacco smoke are regarded as chemical carcinogens. Previously, we observed that a weakly acidic phenolic fraction of tobacco smoke condensate (TSCPhFr), which is devoid of PAHs, significantly potentiates (±)-anti-BP-7,8-diol-9,10-epoxide (BPDE)-induced anchorage-independent cell growth of promotion-sensitive JB6 cell, indicating its tumor-promoting potential. In the present article, we report that further fractionation of phenolic components from TSCPhFr did not show any significant potentiation of BPDE-induced cell transformation by any of the HPLC-purified phenolic fractions, indicating several phenolic components as a whole are needed for observed activity. Although the tumor-promoting activity of weakly acidic phenolic fraction of tobacco smoke had been indicated long before, no studies have been pursued to understand the mechanism(s) underlying the tumor-promoting activity of TSCPhFr. We observed that BPDE, an ultimate carcinogenic metabolite of tobacco smoke carcinogen benzo[a]pyrene, elicits apoptosis induction, which is significantly inhibited by TSCPhFr. Increased cell transformation and decreased apoptosis by TSCPhFr were associated with attenuation of BPDE-induced p53 accumulation. JB6 cells transfected with p53 siRNA showed significantly less apoptosis induction by BPDE as compared to control cells. In p53 impaired cells (which are observed to have a faster growth rate as compared to normal cells), TSCPhFr has a practically negligible effect on apoptosis induction in response to BPDE. Also, in p53 null HCT116 p53(-/-) cells, BPDE-induced apoptosis is unresponsive to TSCPhFr. Inhibition of BPDE-induced NF-κB activation was also observed by us previously. Interestingly, treatment of cells with NF-κB-specific inhibitor IKK-NBD peptide showed no effect on BPDE-induced apoptosis, whereas TSCPhFr showed moderate inhibition of apoptosis in NF-κB inhibited cells as compared to control cells. Our observations indicate that attenuation of BPDE-induced p53 response has a role in apoptosis inhibition and increased cell transformation by TSCPhFr. These findings have implication with regard to the underlying mechanism of tumor-promoting activity of TSCPhFr in PAH-induced carcinogenesis. Although p53-mediated NF-κB activation has a role in apoptosis induction, the role of NF-κB in TSCPhFr-mediated potentiation of PAH-induced cell transformation is not clear from our studies.

Pharyngoesophageal diverticulum resembling a thyroid nodule on ultrasound.

BACKGROUND: Ultrasound is routinely used in evaluating thyroid nodules and performing fine-needle aspiration cytology (FNAC). Occasionally, nonthyroidal lesions can mimic thyroid nodules on imaging and get wrongly aspirated. METHODS: A 63-year-old woman was reported to have an incidental left thyroid "nodule" on neck ultrasound scan. It was isoechoic with a surrounding hypoechoic rim and contained tiny foci of echogenicity. Similar findings were noted in a second surgeon-performed ultrasound scan. RESULTS: An ultrasound-guided FNAC showed abundant squamous cells, bacteria, and vegetable cells with no evidence of thyroid cells or colloid. The suspicion of a pharyngoesophageal diverticulum was confirmed on barium swallow. She remained asymptomatic with no increase in size at 6 months follow-up. CONCLUSION: A pharyngoesophageal diverticulum can be mistaken for a posteriorly placed "thyroid nodule" on ultrasound scan if the subtle differentiating signs are missed. An awareness of this condition is important to avoid unnecessary needle biopsies.

Phenolic fraction of tobacco smoke condensate potentiates benzo[a]pyerene diol epoxide-induced cell transformation: role of protein kinase C.

In this study we separated weakly acidic phenolic components from other neutral, acidic and basic components of tobacco smoke condensate (TSC) and observed that phenolic fraction of TSC significantly increased the number of colonies of promotion-sensitive JB6 Cl41 cells that showed anchorage-independent growth on soft agar in response to BPDE (an ultimate carcinogen produced by metabolic activation of the PAH benzo[a]pyrene). Anchorage-independent cell growth is indicative of cell transformation resulting in acquisition of tumorigenic potential. In order to understand the underlying mechanism by which TSC phenolic fraction potentiates BPDE-induced tumorigenicity, we examined its effect on the activation of two transcription factors AP-1 and NF-kappaB which are known to be influenced by established tumor promoter TPA. BPDE treatment caused induction of both AP-1 and NF-kappaB activity as determined by luciferase reporter assay and only NF-kappaB induction in response to BPDE was significantly attenuated by TSC phenolic fraction whereas AP-1 induction remains unaltered. Attenuation of NF-kappaB activation by TSC phenolic fraction was associated with significant decrease of intracellular PKC substrate phosphorylation in BPDE treated cells. Non-specific PKC inhibitors staurosporine and bisindolylmaleimide II as well as inhibitors specific to conventional PKCs (Go6976) and PKC-delta (rottlerin) attenuated NF-kappaB activation in BPDE treated cells to a varying degree indicating a possible link between PKC down-regulation and the attenuation of NF-kappaB activity by TSC phenolic fraction. Treatment of cells with PKC inhibitors also potentiated anchorage-independent growth of BPDE treated cells on soft agar. Our data suggest a possible role of PKC down-regulation in potentiation of BPDE-induced tumorogenicity by TSC phenolic fraction.

Acute abdominal pain secondary to retroperitoneal bleeding from a giant adrenal lipoma with review of literature.

Adrenal lipomas are rare, non-functioning benign tumours, which are primarily detected during autopsy or imaging, as asymptomatic incidentalomas. Occasionally, they can present with abdominal pain due to their large size. Imaging studies help to determine the origin, volume, composition of the lesion and presence of bleeding. Histopathology, however, is necessary to differentiate an adrenal lipoma from other fatty tumours such as myelolipoma, angiomyolipomas, teratomas and liposarcomas. We report a case of spontaneous bleeding from a giant adrenal lipoma that presented as an acute abdomen, and was initially mistaken on imaging for the more common myelolipoma. The literature is reviewed to discuss the clinical, pathological and radiological features, and the optimum therapeutic management.

Inhibition of benzopyrene-diol-epoxide (BPDE)-induced bax and caspase-9 by cadmium: role of mitogen activated protein kinase.

Cadmium, a major metal constituent of tobacco smoke, elicits synergistic enhancement of cell transformation when combined with benzo[a]pyrene (BP) or other polynuclear aromatic hydrocarbons (PAHs). The mechanism underlying this synergism is not clearly understood. Present study demonstrates that (+/-)-anti-benzo[a]pyrene-7,8-diol-9,10-epoxide (BPDE), an ultimate carcinogen of BP, induces apoptosis in human leukemic HL-60 cells and others, and cadmium at non-cytotoxic concentration inhibits BPDE-induced apoptosis. We observed that BPDE treatment also activates all three MAP kinases e.g. ERK1/2, p38 and JNK in HL-60 cells, and inhibition of BPDE-induced apoptosis by cadmium is associated with down-regulation of pro-apoptotic bax induction/caspase-9 activation and up-regulation of ERK phosphorylation, whereas p38 MAP kinase and c-Jun phosphorylation (indicative of JNK activation) remain unaffected. Inhibition of ERKs by prior treatment of cells with 10muM U0126 relieves cadmium-mediated inhibition of apoptosis/bax induction/caspase-9 activation. Our results suggest that cadmium inhibits BPDE-induced apoptosis by modulating apoptotic signaling through up-regulation of ERK, which is known to promote cell survival.

Inhibition of benzopyrene diol epoxide-induced apoptosis by cadmium(II) is AP-1-independent: role of extracelluler signal related kinase.

Cadmium, a major metal constituent of tobacco smoke, elicits synergistic enhancement of cell transformation when combined with benzo[a]pyrene (BP) or other PAHs. The mechanism underlying this synergism is not clearly understood. We observed that (+/-)-anti-benzo[a]pyrene-7,8-diol-9,10-epoxide (BPDE), an ultimate carcinogen of BP, induces apoptosis in promotion sensitive mouse epidermal JB6 Cl41 cells at non-cytotoxic concentrations. BPDE also activates AP-1 several folds in AP-1 reporter JB6 cells. Cadmium at non-cytotoxic concentrations inhibits both AP-1 activation and apoptosis in response to BPDE. Since AP-1 is known to be involved in stress-induced apoptosis we investigated whether inhibition of AP-1 by cadmium has any role in the inhibition of BPDE-induced apoptosis. MAP kinases (particularly ERKs, p38 and JNKs) are known to have important role in DNA damage-induced AP-1 activation. We observed that ERK and JNK, but not p38 MAP kinase, are involved in BPDE-induced AP-1 activation. Effect of cadmium on MAP kinases and the effect of inhibition of above three MAP kinases on BPDE-induced AP-1 activation and apoptosis indicate that AP-1 is probably not involved in BPDE-induced apoptosis. Cadmium up-regulates BPDE-activated ERKs and ERK inhibition by U0126 relieves cadmium-mediated inhibition of BPDE-induced apoptosis. We suggest that cadmium inhibits BPDE-induced apoptosis not involving AP-1 but probably through a different mechanism by up-regulating ERK which is known to promote cell survival.

Attenuation of BPDE-induced p53 accumulation by TPA is associated with a decrease in stability and phosphorylation of p53 and downregulation of NFkappaB activation: role of p38 MAP kinase.

DNA damage caused by benzo[a]pyrene (B[a]P) or other polynuclear hydrocarbons (PAHs) induce p53 protein as a protective measure to eliminate the possibility of mutagenic fixation of the DNA damage. 12-O-tetradecanoylphorbol-13-acetate (TPA) inhibits p53 response induced by B[a]P and other DNA-damaging agents and may cause tumor promotion. The molecular mechanism of attenuation of B[a]P-induced p53 response by TPA is not known. We investigated the effect of TPA on p53 response in (+/-)-anti-benzo[a]pyrene-7,8-diol-9,10-epoxide (BPDE)-treated mouse epidermal JB6(P(+)) Cl 41 cells. BPDE treatment induced p53 accumulation which was attenuated significantly by TPA. Cells treated with BPDE and TPA showed increased ratio of Mdm2 to p53 proteins in p53 immunoprecipitate and decreased p53 life span compared to BPDE-treated cells indicating p53 destabilization by TPA. TPA also inhibited BPDE-induced p53 phosphorylation at serine15. Activation of both ERKs and p38 MAPK by BPDE and attenuation of BPDE-induced p53 accumulation by U0126 or SB202190, specific inhibitor of MEK1/2 or p38 MAPK, indicate the role of ERKs and p38 MAPK in p53 accumulation. Interestingly, TPA potentiated BPDE-induced activation of ERKs whereas p38 MAPK activation was significantly inhibited by TPA, suggesting that inhibition of p38 MAPK is involved in p53 attenuation by TPA. Furthermore, SB202190 treatment caused decreased p53 stability and inhibition of phosphorylation of p53 at serine15 in BPDE-treated cells. We also observed that TPA or SB202190 attenuated BPDE-induced nuclear factor kappa B (NFkappaB) activation in JB6 Cl 41 cells harboring NFkappaB reporter plasmid. To our knowledge this is the first report that TPA inhibits chemical carcinogen-induced NFkappaB activation. Interference of TPA with BPDE-induced NFkappaB activation implicates abrogation of p53 function which has been discussed. Overall, our data suggest that abrogation of BPDE-induced p53 response and of NFkappaB activation by TPA is mediated by impairment of the signaling pathway involving p38 MAPK.

Effects of cadmium(II) on (+/-)-anti-benzo[a]pyrene-7,8-diol-9,10-epoxide-induced DNA damage response in human fibroblasts and DNA repair: a possible mechanism of cadmium's cogenotoxicity.

Cadmium, a widespread environmental pollutant and a cigarette smoke constituent, enhances the genotoxicity of benzo[a]pyrene (BP). The mechanism(s) underlying the potentiation of BP-induced genotoxicity by Cd2+ is not clearly understood. Our studies of the effects of noncytotoxic concentrations of Cd2+ on the levels of p53 and p21 in (+/-)-anti-benzo[a]pyrene-7,8-diol-9,10-epoxide (BPDE)-treated human fibroblasts showed that Cd2+ decreased BPDE-induced p21 levels in a dose-dependent manner whereas p53 accumulation is attenuated only at higher noncytotoxic concentrations of cadmium. These findings suggest that both the activity and the accumulation of p53 in response of BPDE treatment are inhibited by Cd2+ although the possibility of p53-independent p21 transactivation cannot be ruled out. Exposure of synchronized human fibroblast cells to 0.5 microM of BPDE caused 72% of the cells remaining in G1 phase as compared to 52% in the case of untreated cells. Treatment of the cells with CdCl2 prior to exposing them to BPDE caused a decrease in the G1 population (72 to 54%) in a dose-dependent manner. An in vitro repair assay of BPDE-damaged pUC18 plasmid DNA using untreated and cadmium-treated nucleotide excision repair (NER) proficient HeLa extract showed that cadmium impaired the ability of HeLa cell extract to repair BPDE-damaged pUC18 DNA. Our findings indicate that cadmium not only inhibits NER pathway-dependent repair of BPDE-damaged DNA but also impairs p53 and p21 responses and overrides BPDE-induced G1-S cell cycle arrest. The effect of cadmium on these processes may explain, at least partly, the potentiating effect of the metal on the genotoxicity of BP.