Two Cases of Early Morning Neuroparalytic Syndrome (EMNS) in the Tropics - Masquerading as Brain Death.

Neurotoxicity from elapid bite may masquerade as early morning neuroparalytic syndrome (EMNS). We are reporting a series of two cases who presented as EMNS with absent brain stem reflexes, mimicking brain death. The first case was being considered for potential organ retrieval when the diagnosis was revised, and he recovered completely with Anti-snake venom (ASV). The second patient developed severe anaphylaxis to ASV, which made continuation of the empirical therapy in a comatose patient very tricky. She gradually tolerated a low dose ASV infusion under steroid and adrenaline cover, with reversal of paralysis and coma. Both the patients showed excellent recovery post ASV treatment. A simple bedside Neostigmine challenge test and timely ASV therapy can save many helpless patients of EMNS from certain death.

Randomized trial to assess safety and clinical efficacy of intensive blood pressure reduction in acute spontaneous intracerebral haemorrhage.

BACKGROUND: Haematoma expansion due to raised blood pressure in spontaneous intracerebral haemorrhage may determine outcome. The aim of this study was to determine safety and efficacy of lowering blood pressure in acute spontaneous intracerebral haemorrhage. METHODS: This open label, multicentric trial randomized patients ≥18 years with spontaneous intracerebral haemorrhage with no secondary cause within 72 h of onset to tight BP control arm where treatment was initiated if mean arterial pressure (MAP) was ≥115 mm of Hg and conventional BP control arm where treatment was initiated if MAP was ≥130 mm of Hg. The MAP was maintained in the respective arm for another 72 h after which both arms had MAP below 115 mm of Hg. Primary outcome was modified Rankin Scale at 90 days. RESULTS: 118 patients, 59 in each arm were included. Follow up was available for all. Baseline characteristics were similar. At 90 days there was no significant difference between median mRS between the two arms. Odds Ratio for "poor outcome" (mRS 3-6) in the tight control arm (safety of the intervention) against "good outcome" (mRS 0-2) was not significant (OR 0.70 [95% CI 0.34-1.47] p = 0.35). Efficacy of the intervention in the form of Odds Ratio for "good outcome" in the tight control arm was not significant (OR 1.43 [95% CI 0.68-2.99], p = 0.35). CONCLUSION: In patients with spontaneous intracerebral haemorrhage who present within 72 h of the onset of symptoms, MAP can be safely lowered if it crosses 115 mm of Hg but it does not improve clinical outcome.

Antithyroid drugs in Graves' disease: Are we stretching it too far?

INTRODUCTION: Early and durable achievement of euthyroid or hypothyroid status with low likelihood of relapse is the key to effective treatment of Graves' disease (GD). Although antithyroid drugs (ATDs) are commonly used first-line agents, likelihood of remission remains highest with radioactive iodine (RAI) therapy and surgery. Data regarding efficacy and economical superiority of RAI therapy over ATDs are lacking from India. This study was designed to study the response to long-term (>12 months) use of ATDs in GD with respect to attainment of remission and to compare the cost of treatment with ATDs versus RAI therapy beyond 12 months. SETTINGS: The study was conducted in a tertiary care center. STUDY DESIGN: This was a retrospective analysis. MATERIALS AND METHODS: Patients of GD in our follow-up from February 2009 to March 2016 who had received ATDs for a duration exceeding 12 months were retrospectively analyzed. Patients who underwent radioablation after a period of at least 12 months on ATDs were analyzed and their status was recorded after a minimum of 6 months after radioablation. Patients who remained hyperthyroid beyond 12 months and received RAI therapy were further compared with those who continued on ATDs, for achievement of euthyroid or hypothyroid status. Cost analysis was done for follow-ups and treatment and compared. STATISTICAL ANALYSIS USED: All analyses were done using Fisher's exact test for categorical and descriptive statistics for numerical data. RESULTS: Use of ATDs leading to euthyroid and hypothyroid status in GD patients was only significant beyond 24 years when compared to those at <12-18 months therapy (P = 0.0262 and P = 0.0217, respectively). The patients who ended up with hypothyroid status were significantly greater in RAI group compared to ATD group (P = 0.0003). Cost of therapy per patient beyond 12 months was lower in the RAI group compared to the ATD group (cost difference Rs. 5435.00). CONCLUSIONS: Within limitations, our study demonstrates that RAI is effective and economical option in GD.

Diabetes mellitus in the young: Gliptins or sulfonylurea after metformin?

INTRODUCTION: Diagnosis and initial management of diabetes mellitus (DM) in the young are clinical dilemma. Gliptins may be a safer and more effective option than sulfonylureas. Few Indian studies have addressed this issue of clinical relevance. AIM: To compare the use of sitagliptin and glimepiride as early add-on drugs along with metformin in young patients with DM to achieve optimum glycemic targets. METHODS: This was a prospective, open-label, cohort study set in a tertiary care hospital in North India. Newly diagnosed patients of DM ≤35 year of age were initially treated to pre-defined glycemic goals (Fasting plasma glucose (FPG) 70-130, post prandial glucose (PPG) < 180 mg/dl) with insulin and metformin 1 g for 8 weeks. Insulin was discontinued and metformin increased to 2 g daily for next 4 weeks. Thereafter, glimepiride 1 mg or sitagliptin 100 mg was randomly added to those who were not maintaining the set glucose targets. Dose of glimepiride was uptitrated every 4 weeks upto a maximum of 4 mg. Three groups (Gp A: Metfromin 2 g/d, Gp B: Metformin 2 g + Glimepiride 1-4 mg/d, and Gp C: Metformin 2 g + sitagliptin 100 mg/d) were followed up over next 24 weeks. They were compared for glycemic control and weight change. Those failing therapy on these drugs (FPG > 180, PPG > 250 mg/dl with/without catabolic symptoms/ketosis) were withdrawn. RESULTS: Sitagliptin with metfromin and metfromin alone group fared better than the glimepiride group for glycemic control, lesser treatment failures, and less weight gain. CONCLUSION: In this limited study, we found that sitagliptin is a safer and more effective option in young, newly diagnosed patients with DM. Findings of this study are relevant for clinical practice in Indian setting.

cAMP increases the expression of human angiotensinogen gene through a combination of cyclic AMP responsive element binding protein and a liver specific transcription factor.

Angiotensinogen is the glycoprotein precursor of one of the most potent vasoactive hormones angiotensin-II which plays an important role in the regulation of blood pressure. We show here that the promoter activity of reporter constructs containing human angiotensinogen promoter is increased by cAMP treatment on transient transfection in HepG2 cells. We have identified a composite cAMP responsive element, located around 840 bases upstream from the transcriptional initiation site, in the promoter of human angiotensinogen gene. This element is recognized by members of CREB/ATF as well as C/EBP family of transcription factors. Another C/EBP binding site that is not recognized by CREB is located 10 bases upstream from this site. We show that co-transfection of CREB increases the promoter activity of reporter constructs containing human angiotensinogen gene promoter attached to the CAT gene. We also show that co-transfection of DBP (which is a member of C/EBP family of transcription factors) increases promoter activity of these reporter constructs.

Orphan receptor Arp-1 binds to the nucleotide sequence located between TATA box and transcriptional initiation site of the human angiotensinogen gene and reduces estrogen induced promoter activity.

Human angiotensinogen gene contains a C/A polymorphism at 20 bases upstream from the transcriptional initiation site. This sequence binds to the estrogen receptor when nucleoside A is present at this site and reporter constructs containing human angiotensinogen gene promoter with nucleoside A at -20 are transactivated on co-transfection of estrogen receptor in HepG2 cells followed by estrogen treatment. We show here that orphan receptor, Arp-1, which belongs to the COUP family of transcription factors also binds to this sequence. Co-transfection of Arp-1 reduces estrogen induced promoter activity of reporter constructs containing human angiotensinogen gene promoter. On the other hand co-transfection of Arp-1 does not have a significant effect on estrogen induced promoter activity of reporter constructs containing rat angiotensinogen gene promoter. Our data suggests that human and rat angiotensinogen genes are regulated in a different manner by estrogens.

Role of C/A polymorphism at -20 on the expression of human angiotensinogen gene.

-Angiotensinogen is the glycoprotein precursor of 1 of the most potent vasoactive hormones, angiotensin II. Human angiotensinogen gene contains a C/A polymorphism at -20 located between the TATA box and transcriptional initiation site. We show here that when nucleoside A is present at -20, this sequence binds to the estrogen receptor. We also show that transcriptional activity of reporter constructs containing human angiotensinogen gene promoter with nucleoside A at -20 is increased on cotransfection of an expression vector containing human estrogen receptor-alpha coding sequence in human hepatoma cells (HepG2) followed by estrogen treatment. On the other hand, adenoviral major late transcription factor binds preferentially to this region of the promoter when nucleoside C is present at -20. We also show that reporter constructs containing human angiotensinogen gene promoter with nucleoside C at -20 have increased basal promoter activity on transient transfection in HepG2 cells as compared with reporter constructs with nucleoside A at -20. Our data suggest that C/A polymorphism at -20 may modulate the expression of human angiotensinogen gene in a sex-specific manner.

DBP binds to the proximal promoter and regulates liver-specific expression of the human angiotensinogen gene.

Angiotensinogen is the glycoprotein precursor of one of the most potent vasoactive hormones, angiotensin-II. It has been shown recently that an ATF like element (ALE) located between bases -102 and -87 of the human angiotensinogen gene plays an important role in liver specific expression of this gene and binds to CREB/ATF family of transcription factors and a novel factor (ALF). We show here that this sequence binds to the liver enriched transcription factor DBP and cotransfection of expression vector CMV-DBP increases the expression of reporter constructs containing this sequence. In addition, we show that transcription factor C/EBP-delta binds to this sequence and an expression vector containing C/EBP-delta coding region increases the expression of reporter constructs containing this sequence. Since DBP is involved in circadian rhythm, our studies suggest that this sequence may be involved in circadian expression of the human angiotensinogen gene.

Exon-I is involved in positive as well as negative regulation of human angiotensinogen gene expression.

Angiotensinogen is the glycoprotein precursor of one of the most potent vasoactive hormones, angiotensin-II. Angiotensinogen gene is primarily expressed in the liver, and this gene locus is linked with human essential hypertension. We show here that a mutation in exon-I reduces the basal expression of the human angiotensinogen gene in liver cells. We also show that a nucleotide sequence in exon-I binds to liver-enriched transcription factor HNF-3 and a ubiquitous factor AP4. Our studies also show that transient transfection of an expression vector containing AP4 coding sequence downregulates the expression of reporter constructs containing human angiotensinogen gene promoter. By contrast, co-transfection of an expression vector containing HNF-3beta coding sequence increases the expression of these reporter constructs. The human angiotensinogen gene has a C/A polymorphism located at -20, and we have shown that estrogen receptor-alpha binds to this sequence when nucleoside A is present at this site. We show here that co-transfection of an expression vector containing AP4 coding sequence reduces estrogen-induced promoter activity of reporter constructs containing human angiotensinogen gene promoter (with nucleoside A at -20) attached to the CAT gene. These studies partly explain the molecular mechanisms involved in tissue-specific expression of the human angiotensinogen gene.

Phorbol myristate acetate enhances degradation of TRH receptor mRNA in a pituitary cell type-specific manner.

Regulation of the level of thyrotropin-releasing hormone (TRH) receptor (TRH-R) mRNA appears to involve both modulation of gene transcription and of mRNA degradation. To study regulation of TRH-R mRNA degradation and circumvent any physiological effect on transcription, we use cells stably transfected with mouse TRH-R cDNA under control of the constitutively active cytomegalovirus promoter. In stably transfected GH pituitary cells, we find that phorbol 12-myristate 13-acetate (PMA), like TRH, down-regulates TRH-R mRNA by increasing the rate of TRH-R mRNA degradation. In contrast, in stably transfected AtT-20 pituitary cells and in nonpituitary cell lines, neither TRH nor PMA decreased TRH-R mRNA levels. These findings are consistent with the idea that activation of protein kinase C leads to enhanced degradation of TRH-R mRNA in a cell-type-specific manner.

Extraction equilibria of rare earths by a new reagent (2-ethylhexyl-3-pentadecylphenyl) phosphoric acid.

A new reagent (2-ethylhexyl-3-pentadecylphenyl) phosphoric acid (EPPA = HR) was synthesized from cardanol (I, 37300-39-5) and was used to investigate the extraction behaviour of lanthanum(III), europium(III) and lutetium(III) from hydrochloric acid solutions. The species extracted were found to be Ln(HR(2))(3) (where Ln = La(III) or Eu(III) or Lu(III)). The extraction behaviour of the above lanthanides has also been compared with yttrium and other rare earths. It was observed that the extraction increases with increase in atomic number of rare earths. In addition, the extraction efficiency of EPPA has also been compared with well known acidic organophosphorus extractants like di-2-ethylhexyl phosphoric acid (DEHPA), 2-ethylhexyl-mono-2-ethylhexyl phosphoric acid (EHEHPA).

Posttranscriptional up-regulation of thyrotropin-releasing hormone (TRH) receptor messenger ribonucleic acid by TRH in COS-1 cells transfected with mouse pituitary TRH receptor complementary deoxyribonucleic acid.

We found previously that the level of endogenous TRH receptor (TRH-R) mRNA in pituitary (GH3) cells and the level of mouse TRH-R mRNA in GH3 cells stably transfected with mouse pituitary TRH-R cDNA are down-regulated by TRH. This down-regulation is caused by TRH stimulation of TRH-R mRNA degradation via a mechanism that appears to involve protein kinase-C. In this report we study regulation of TRH-R mRNA in monkey kidney (COS-1) cells transiently transfected with mouse pituitary TRH-R cDNA. In transfected COS-1 cells, TRH and phorbol 12-myristate 13-acetate (PMA) caused increases in the level of TRH-R mRNA. In contrast, TRH caused only a small transient increase in the level of the mRNA for the neomycin resistance gene, which was cotransfected with TRH-R, and did not affect the level of the mRNA for glyceraldehyde phosphate dehydrogenase, an endogenous gene. The increases in TRH-R mRNA caused by TRH and PMA were inhibited to similar extents by H-7 (1-[5-isoquinolinesulfonyl]2-methyl piperazine dihydrochloride), an inhibitor of protein kinases. The effect of TRH was observed in cells transfected with expression vectors in which TRH-R cDNA was controlled by cytomegalovirus or Rous sarcoma virus promoters. There was no effect of TRH or PMA on the rate of transcription of the transfected TRH-R cDNA. In contrast, TRH caused the rate of degradation of TRH-R mRNA to decrease from 8.0% to 5.1%/h. Hence, TRH, most likely via a protein kinase-C-mediated mechanism, up-regulates TRH-R mRNA levels in transfected COS-1 cells by decreasing the rate of TRH-R mRNA degradation. Since TRH and PMA down-regulate TRH-R mRNA in GH3 cells, posttranscriptional regulation of TRH-R mRNA is a cell-type specific process.

Regulation by thyrotropin-releasing hormone (TRH) of TRH receptor mRNA degradation in rat pituitary GH3 cells.

In rat pituitary GH3 cells, thyrotropin-releasing hormone (TRH) down-regulates TRH receptor (TRH-R) mRNA (Fujimoto, J., Straub, R.E., and Gershengorn, M.C. (1991) Mol. Endocrinol. 5, 1527-1532), at least in part, by stimulating its degradation (Fujimoto, J., Narayanan, C.S., Benjamin, J.E., Heinflink, M., and Gershengorn, M.C. (1992) Endocrinology 130, 1879-1884). Here we show that TRH regulates RNase activity in GH3 cells and that specific mRNA sequences are needed for in vivo regulation of TRH-R mRNA by TRH. TRH affected RNase activity in a biphasic manner with rapid stimulation (by 10 min) followed by a decrease to a rate slower than in control lysates within 6 h. This time course paralleled the effects of TRH on degradation of TRH-R mRNA in vivo. The regulated RNase activity was in a polysome-free fraction of the lysates and was not specific for TRH-R RNA. A truncated form of TRH-R RNA that was missing the entire 3'-untranslated region (TRHR-R5) was more stable than full-length TRH-R RNA (TRHR-WT). In contrast to TRHR-WT mRNA, TRHR-R5 mRNA and TRHR-D9 mRNA, which was missing the 143 nucleotides 5' of the poly(A) tail, were not down-regulated by TRH in stably transfected GH3 cells as their rates of degradation were not increased. These data show that TRH regulates RNase activity in GH3 cells, that the 3'-untranslated region bestows decreased stability on TRH-R mRNA and that the 3' end of the mRNA is necessary for regulation by TRH of TRH-R mRNA degradation. We present an hypothesis that explains specific regulation of TRH-R mRNA degradation by TRH in GH3 pituitary cells.

Mechanism of regulation of thyrotropin-releasing hormone receptor messenger ribonucleic acid in stably transfected rat pituitary cells.

We showed previously that the level of TRH receptor (TRH-R) mRNA in rat pituitary GH3 cells is down-regulated by TRH. Here, we study the mechanism of regulation of TRH-R mRNA in a line of GH3 cells that are stably transfected with mouse pituitary TRH-R cDNA (GH-mTRHR-1 cells). GH-mTRHR-1 cells were found to have 2.4 times the number of TRH-Rs and to stimulate a 2.5-fold greater increase in inositol phosphates in response to TRH than the parent cell line and to show TRH-induced down-regulation of TRH-R number. GH-mTRHR-1 cells contained 26 +/- 1.6 molecules of mouse TRH-R mRNA/cell and 230 +/- 31 molecules of mRNA for the neomycin resistance gene (NEO) with which it was cotransfected. In GH-mTRHR-1 cells, TRH caused a dose-dependent transient decrease in mouse TRH-R mRNA, with a nadir to 20% of control levels after 6 h. In contrast, TRH did not affect NEO mRNA or glyceraldehyde phosphate dehydrogenase (GAPDH) mRNA, an endogenous gene product. TRH stimulated the rate of transcription of mouse TRH-R DNA by approximately 2-fold, but did not affect total poly(A) RNA synthesis. Most importantly, TRH caused a 4-fold increase in the rate of degradation of mouse TRH-R mRNA, but did not affect degradation of GAPDH mRNA. The half-lives of mouse TRH-R and GAPDH mRNAs were 3 and more than 20 h in control cells and 0.75 and more than 20 h in cells treated with 1 microM TRH for 1.5 h, respectively. These data show that the predominant effect of TRH on mouse TRH-R mRNA in GH-mTRHR-1 cells is to enhance the rate of its degradation. We suggest, therefore, that down-regulation of TRH-R mRNA caused by TRH in the parent GH3 cell line is secondary to increased TRH-R mRNA degradation.

Cassava starch effluent treatment with concomitant SCP production.

Yeasts and yeast-like organisms were chosen for the aerobic treatment of cassava starch factory effluent. A mixed culture of Candida utills and Endomycopsis fibuliger efficiently and rapidly utilized both starch and free sugars. After 28 h fermentation the protein content of the biomass was 22% (w/w), which remained unchanged during the remainder of the fermentation (60 h). This treatment removed 94% of the COD and 91% of the BOD.

Anaerobic digestion of cassava starch factory effluent.

Biomethanation of cassava starch factory effluent in a batch digester produced 130 l biogas/kg dry matter with an average melthane content of 59%. About 63% COD was removed during 60 days. In semicontinuous digesters, gas production was 3251/kg dry matter with a retention time of 33,3 days giving a COD reduction of 50%. Size of starter inoculum was important for good biogasification of the effluent.

Replication properties of pIM13, a naturally occurring plasmid found in Bacillus subtilis, and of its close relative pE5, a plasmid native to Staphylococcus aureus.

A naturally occurring plasmid from Bacillus subtilis, pIM13, codes for constitutively expressed macrolide-lincosamide-streptogramin B (MLS) resistance, is stably maintained at a high copy number, and exists as a series of covalent multimers. The complete sequence of pIM13 has been reported (M. Monod, C. Denoya, and D. Dubnau, J. Bacteriol. 167:138-147, 1986) and two long open reading frames have been identified, one of which (ermC') is greater than 90% homologous to the ermC MLS resistance determinant of the Staphylococcus aureus plasmid pE194. The second reading frame (repL) shares homology with the only long open reading frame of the cryptic S. aureus plasmid pSN2 and is probably involved in plasmid replication. The map of pIM13 is almost a precise match with that of pE5, a naturally occurring, stable, low-copy-number, inducible MLS resistance plasmid found in S. aureus. pIM13 is unstable in S. aureus but still multimerizes in that host, while pE5 is unstable in B. subtilis and does not form multimers in either host. The complete sequence of pE5 is presented, and comparison between pIM13 and pE5 revealed two stretches of sequence present in pE5 that were missing from pIM13. It is likely that a 107-base-pair segment in the ermC' leader region missing from pIM13 accounts for the constitutive nature of the pIM13 MLS resistance and that the lack of an additional 120-base-pair segment in pIM13 that is present on pE5 gives rise to the high copy number, stability, and multimerization in B. subtilis. The missing 120 base pairs occur at the carboxyl-terminal end of the putative replication protein coding sequence and results in truncation of that protein. It is suggested either that the missing segment contains a site involved in resolution of multimers into monomers or that the smaller replication protein causes defective termination of replication. It is concluded that pIM13 and pE5 are coancestral plasmids and it is probable that pIM13 arose from pE5.