Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India.

BACKGROUND: Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates. MAIN OBJECTIVES: To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India. METHODS: A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity. RESULTS: The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%). CONCLUSION: The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Impact of prepregnancy body mass index on adverse pregnancy outcomes: analysis from the Longitudinal Indian Family hEalth cohort study.

BACKGROUND: Both high and low maternal prepregnancy body mass index can lead to suboptimal fetal growth and risk of pregnancy complications. In developed countries, nearly half of all women of childbearing age are either overweight or obese, and most data linking maternal body mass index and adverse pregnancy complications are limited to these populations. OBJECTIVE: This study aimed to prospectively evaluate the relationships between prepregnancy body mass index and adverse pregnancy outcomes using the Longitudinal Indian Family hEalth (LIFE) study. STUDY DESIGN: We modeled the relationships between prepregnancy body mass index and adverse pregnancy outcomes such as low birthweight, preterm birth, cesarean delivery, intrauterine growth restriction, miscarriage, and fetal death among 675 women aged 15 to 35 years with singleton pregnancies in the Longitudinal Indian Family hEalth study, a population-based prospective pregnancy cohort study conducted in Telangana, India. Prepregnancy body mass index was calculated as weight in kilograms divided by height in meters squared and was classified into 4 categories using the World Health Organization recommendations for Asian adults. Prepregnancy body mass index was assessed at a mean of 12.3 months before pregnancy. Odds ratios and 95% confidence intervals of adverse pregnancy outcomes were modeled and adjusted for confounders. RESULTS: Obese women had a 3-fold increased risk of cesarean delivery (odds ratio, 3.13; 95% confidence interval, 1.56-6.29) compared with normal-weight women. Those who were overweight also had a marginally increased risk of cesarean delivery, albeit not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.61-2.24). Underweight women had a modestly increased risk of low birthweight, compared with normal-weight women (odds ratio, 1.12; 95% confidence interval, 0.71-1.77), although results were not significant. Conversely, obese (odds ratio, 0.71; 95% confidence interval, 0.28-1.77) and overweight (odds ratio, 0.61; 95% confidence interval, 0.24-1.51) women had a marginally decreased risk of low birthweight. CONCLUSION: Our data suggest that women with elevated prepregnancy body mass index may have a higher risk of adverse pregnancy outcomes, especially cesarean delivery. Although this study has limited generalizability, our findings are generalizable to rural to periurban regions of India. Further studies exploring the translatability of these findings to other populations are needed. In addition, targeted prepregnancy intervention studies and programs that include counseling on optimization of preconception health and lifestyle modification for improvement of subsequent pregnancy outcomes among overweight and obese women are needed.

Consanguineous Marriage and Early Pregnancy Loss in Rural to Peri-Urban India.

Background: Consanguineous marriage (CM) has been linked to spontaneous abortion (SAB), although studies have largely been cross-sectional and likely underestimated early loss. We aimed to determine the relationships between CM and SAB in a prospective pregnancy cohort study in Telangana State, India. Methods: Data from 661 participants aged 15-35 years in the Longitudinal Indian Family hEalth (LIFE) study actively followed for pregnancy and pregnancy loss were analyzed. SAB was classified as early (< 8) or late (8-22) weeks gestation. We used logistic regression to model the relationships between CM, defined by first-cousin marriage, and SAB, adjusted for maternal age. Results: Women in CM were at a modestly increased risk of any (ORadj 1.15, 95% CI 0.69, 1.91) and early (ORadj 2.03, 95% CI 0.85, 4.83) SAB compared to women in non-CM, although results were not statistically significant. There was no relationship between CM and late SAB. Conclusion: Among couples in southern India, there was a modest increase in early but not late SAB among CMs which may be explained by the expected influence of chromosomal abnormalities and lethal homozygous recessive disease on early loss. Pre- and Peri-marital Health Counseling that addresses this risk may be warranted. Supplementary Information: The online version contains supplementary material available at 10.1007/s13224-021-01498-7.

Which obesity index is a better predictor for cardiometabolic risk factors in a young adult rural population of Telangana State, India?

BACKGROUND: Waist-to-height ratio (WHtR) has recently been found to be a useful marker of cardiovascular disease (CVD) risk in populations in developed countries; the comparison of various obesity indices, particularly WHtR, has received little study in India and other developing countries. AIM: This study aimed to compare the associations of common obesity indices, body mass index (BMI), waist circumference, waist-hip ratio (WHR), and WHtR, with cardiometabolic risk factors in a young, rural Indian population. SUBJECTS AND METHODS: Anthropometric measurements and cardiometabolic risk factors (hypertension, diabetes, and dyslipidemia) were measured using standardized protocols at the baseline visit of the Longitudinal Indian Family hEalth Pilot Study, a population-based cohort study of child-bearing age women and their husbands in rural Telangana, India. RESULTS: In comparison with most previously studied populations, this population sample (642 males and 980 females) was younger; had lower BMI; and lower rates of diabetes, hypertension, and abnormal lipids (exception of high rates of low high-density lipoprotein). With regard to each of the cardiometabolic risk factors, the associations across the obesity indices tended to be significant, but weak, and similar to each other, whereas the association with WHR was less strong. CONCLUSION: Although WHtR was not a better predictor of cardiometabolic risk than conventional obesity indices, in this young adult Indian population, it was equally good. This raises the prospect of using WHtR as an alternative to BMI for assessing cardiometabolic risk in Indians considering the ease with which it can be easily done and interpreted.

Maternal Factors Associated with Mode of Delivery in a Population with a High Cesarean Section Rate.

We sought to identify factors associated with mode of delivery in a peri-urban Indian population with a high cesarean section rate. Poisson regression with robust error variance was applied to model factors associated with cesarean compared to vaginal delivery in a prospective, preconception pregnancy cohort study in Telangana State, India. Adjusted relative risks and 95% confidence intervals from multivariable models are presented. Among 1164 singleton births between 2010 and 2015, 46% were delivered by cesarean. In multiparous women (n = 674), prior cesarean delivery (4.2, 3.2-5.6), prior twin delivery (1.4, 1.1-1.9), diagnosis of hypertension (1.4, 1.0-2.0), or preeclampsia (3.5, 2.1-5.7) in a prior pregnancy independently increased the risk of cesarean. Prepregnancy overweight/obesity (1.4, 1.0-1.9), a composite of prenatal complications (1.3, 1.0-1.7), a composite of labor complications (1.5, 1.0-2.3), nonreassuring fetal heart rate (2.3, 1.3-4.1), and breech position (2.6, 1.4-5.0) also increased the cesarean risk. Among nulliparous women (n = 233), cephalo-pelvic disproportion (1.9, 1.2-3.0), a composite of labor complications (2.9, 1.8-4.9), and breech position (3.4, 1.9-6.2) increased the risk of cesarean. The high rate of cesarean delivery in this peri-urban Indian population is attributed to history of pregnancy complications, history of prior cesarean, prepregnancy body mass index, and medical indications at delivery.

Technology enabled non-physician health workers extending telemedicine to rural homes to control hypertension and diabetes (TETRA): A pre-post demonstration project in Telangana, India.

OBJECTIVES: We aimed to determine the feasibility and effectiveness of an intervention anchored on mHealth and task sharing strategy of involving non-physician health workers (NPHW) on population level detection, treatment and control of hypertension and diabetes in India. METHODS: Non-physician health workers (NPHWs) equipped with tablet computers that were linked with point-of-care devices for blood pressure (BP) and blood sugar measurements visited households, screened adult individuals for hypertension and diabetes from two randomly selected villages in the Medchal district, Telangana, India. Further, they digitally connected those individuals with hypertension and diabetes to a study physician via Skype, and handed over a printed e-prescription. Medication adherence checks, BP and fasting blood sugar measurements were done once a month and doctor consultations once in three months during follow-up. RESULTS: Among 2456 eligible individuals, 1751 and 1686 individuals were screened for hypertension and diabetes, respectively. Prevalence of hypertension was 23·6% (95% CI 21·6%-25·6%) and among them 38.9% were newly detected. Prevalence of diabetes was 11·2% (9·7%-12·7%) and 28.6% of them were newly detected. After 24 months of intervention, control of BP and blood sugar was achieved in 54.0% and 34·1% of individuals with hypertension and diabetes, respectively. Blood pressure control rate improved by 12% (7.9%-16.0%) in known hypertensive individuals over the intervention period. INTERPRETATION: This research demonstrates the feasibility and local acceptability of a mHealth intervention strategy anchored on NPHWs guided by physicians for detection, treatment and regular follow-up of individuals with hypertension and diabetes in a community setting in India.

Mode of delivery and short-term infant health outcomes: a prospective cohort study in a peri-urban Indian population.

BACKGROUND: Previous studies have found a relationship between cesarean section delivery and adverse outcomes in the offspring, partially attributing these findings to differential development of immunity in infants delivered by cesarean compared to vaginal delivery. The purpose of this study is to determine whether cesarean section delivery is associated with higher reports of adverse short-term infant health outcomes in a peri-urban Indian population. METHODS: Data from a prospective pregnancy cohort study in a peri-urban region of Telangana State, India, were analyzed to assess the association between mode of delivery, cesarean section or vaginal, and maternal report of recent infant diarrhea and/or respiratory symptoms at a 6 month follow-up visit. Inverse probability weights were applied to log-binomial regression models to account for maternal pre-pregnancy, prenatal, and labor and delivery factors. RESULTS: Of the 851 singleton infants delivered between 2010 and 2015, 46.7% were delivered by cesarean. Cesarean delivery was not associated with an increased report of infants having one or more of the outcomes (diarrhea, respiratory infection, or difficulty breathing) at 6 months (adjusted risk ratio 0.89, 95% confidence interval 0.76-1.03), nor was it associated with infants having a more severe outcome of comorbid diarrhea and respiratory infection (adjusted risk ratio 1.08, 95% confidence interval 0.58-2.04). CONCLUSION: Unlike findings in Western populations, in this peri-urban Indian population, cesarean delivery was not associated with higher reports of short-term adverse gastrointestinal or respiratory infant outcomes after accounting for pre-delivery maternal factors. Future research in this cohort could elucidate whether mode of delivery is associated with other adverse outcomes later in childhood.

Volumetric bone mineral density (vBMD), bone structure, and structural geometry among rural South Indian, US Caucasian, and Afro-Caribbean older men.

Peripheral quantitative computed tomography (pQCT) provides biomechanical estimates of bone strength. Rural South Indian men have reduced biomechanical indices of bone strength compared to US Caucasian and Afro-Caribbean men. This suggests an underlying higher risk of osteoporotic fractures and greater future fracture burden among the rural South Indian men. INTRODUCTION: Geographical and racial comparisons of bone mineral density (BMD) have largely focused on DXA measures of areal BMD. In contrast, peripheral quantitative computed tomography (pQCT) measures volumetric BMD (vBMD), bone structural geometry and provides estimates of biomechanical strength. To further understand potential geographical and racial differences in skeletal health, we compared pQCT measures among US Caucasian, Afro-Caribbean, and rural South Indian men. METHODS: We studied men aged ≥ 60 years enrolled in the Mobility and Independent Living among Elders Study (MILES) in rural south India (N = 245), Osteoporotic Fractures in Men Study (MrOS) in the US (N = 1148), and the Tobago Bone Health Study (N = 828). RESULTS: The BMI (kg/m2) of rural South Indian men (21.6) was significantly lower compared to the US Caucasians (28) and Afro-Caribbean men (26.9). Adjusting for age, height, body weight, and grip strength; rural South Indian men compared to US Caucasians had significantly lower trabecular vBMD [- 1.3 to - 1.5 standard deviation (SD)], cortical thickness [- 0.8 to - 1.2 SD]; significantly higher endosteal circumference [0.5 to 0.8 SD]; but similar cortical vBMD. Afro-Caribbean men compared to US Caucasians had similar trabecular vBMD but significantly higher cortical vBMD [0.9 to 1.2 SD], SSIp [0.2 to 1.4 SD], and tibial endosteal circumference [1 SD], CONCLUSIONS: In comparison to US Caucasians, rural South Indian men have reduced bone strength (lower trabecular vBMD) and Afro-Caribbean men have greater bone strength (higher cortical vBMD). These results suggest an underlying higher risk of osteoporotic fractures and greater future fracture burden among rural South Indian men.

Increasing Full Child Immunization Rates by Government Using an Innovative Computerized Immunization Due List in Rural India.

Increasing child vaccination coverage to 85% or more in rural India from the current level of 50% holds great promise for reducing infant and child mortality and improving health of children. We have tested a novel strategy called Rural Effective Affordable Comprehensive Health Care (REACH) in a rural population of more than 300 000 in Rajasthan and succeeded in achieving full immunization coverage of 88.7% among children aged 12 to 23 months in a short span of less than 2 years. The REACH strategy was first developed and successfully implemented in a demonstration project by SHARE INDIA in Medchal region of Andhra Pradesh, and was then replicated in Rajgarh block of Rajasthan in cooperation with Bhoruka Charitable Trust (private partners of Integrated Child Development Services and National Rural Health Mission health workers in Rajgarh). The success of the REACH strategy in both Andhra Pradesh and Rajasthan suggests that it could be successfully adopted as a model to enhance vaccination coverage dramatically in other areas of rural India.

Design of the Mobility and Independent Living in Elders Study: An older adult cohort in rural India.

AIM: The Mobility and Independent Living in Elders Study (MILES) was established in 2012 to estimate the prevalence, incidence, and risk factors for disability and age-related disease in rural older Indians. Here we describe the main goals of MILES, the essential elements of its design and examinations, and the initial findings from the baseline visit. METHODS: A random sample of 562 men and women aged ≥60 years was enrolled from the Medchal region in Telangana State. Baseline examination consisted of two separate clinical visits, and included measurements of blood pressure, anthropometry, physical function, peripheral artery disease, cognitive function, bone and muscle quality, knee osteoarthritis, carotid intima-media thickness, and blood biomarkers. A comprehensive interview was carried out for demographics, disability and disease history. Annual follow-up visits are ongoing to collect information on incident disability and disease. RESULTS: The median age of participants was 66 years (range 60-92 years); median body mass index 21.7 kg/m2 , median gait speed 0.67 m/s and 55% self-reported their health status as fair or poor. CONCLUSIONS: These findings suggest a more frail population in the MILES cohort compared with older adults in USA cohorts. MILES will provide estimates of burden of disease, and disability and risk factors in older adults. Findings will be used to identify potential interventions to prevent disability in this rural Indian population. Geriatr Gerontol Int 2017; 17: 31-40.

When is a South Indian Really Anemic?

To determine the normal range of Hemoglobin and cutoff values in healthy adults of Southern India, blood samples were analyzed for parameters of RBC and iron metabolism in 177 male and 203 female medical students. The data were compared with the American white population (NHANES III) and the WHO criteria for detection of anemia. The mean values for hemoglobin and hematocrit in male students differed minimally from American white males. However, values for parameters of iron metabolism were lower except total iron binding capacity (TIBC) which was higher. In female students, hemoglobin, hematocrit and parameters of iron metabolism were lower than American white females, except TIBC which was higher. Lower 5th percentile cutoff point (Mean - 1.645 SD) in males and females were 13.5 and 10 g/dl respectively. In conclusion, South Indian adult males have Hb values similar to American male adults, but South Indian females have considerably lower Hb levels than American females, raising the questions about appropriateness of WHO or US criteria for detection of anemia in Indian females.

Determinants of Infant Mortality in a Developing Region in Rural Andhra Pradesh.

BACKGROUND & OBJECTIVES: Despite several interventions implemented for the improvement of infant survival, the pace of decline in infant mortality in the State of Andhra Pradesh during the last two decades has been rather slow. This paper examines determinants of infant mortality in a rural population of about 45000 in Medchal region of Andhra Pradesh, India. METHODS: Data obtained through continuous (longitudinal) enumeration of household population and also from the cross-sectional survey of households carried out during 2008-09 in the study area were analyzed. A univariate analysis was carried out and followed by an application of binary logistic regression model to identify significant factors associated with infant mortality. RESULTS: Despite a substantial increase in institutional deliveries in the study area, infant mortality rate remained relatively constant at 43±1. Socioeconomic variables such as education and household economic status and environmental variables such as access to safe drinking water and sanitation facility and use of clean cooking fuel emerged as significant predictors of infant survival. INTERPRETATION & CONCLUSIONS: Promoting institutional deliveries by providing cash assistance to women by itself cannot be expected to bring down infant mortality to a low level in the absence of an improvement in socioeconomic and environmental conditions of the households.

Phytostabilisation potential of lemon grass (Cymbopogon flexuosus (Nees ex Stend) Wats) on iron ore tailings.

The present pot culture study was carried out for the potential phytostabilisation of iron ore tailings using lemon grass (Cymbopogon flexuosus) a drought tolerant, perennial, aromatic grass. Experiments have been conducted by varying the composition of garden soil (control) with iron ore tailings. The various parameters, viz. growth of plants, number of tillers, biomass and oil content of lemon grass are evaluated. The studies have indicated that growth parameters of lemon grass in 1:1 composition of garden soil and iron ore tailings are significantly more (-5% increase) compared to plants grown in control soil. However, the oil content of lemon grass in both the cases more or less remained same. The results also infer that at higher proportion of tailings the yield of biomass decreases. The studies indicate that lemongrass with its fibrous root system is proved to be an efficient soil binder by preventing soil erosion.

Differentiation of isomeric 2-aryldimethyltetrahydro-5-quinolinones by electron ionization and electrospray ionization mass spectrometry.

A series of isomeric 2-aryl-6,6-dimethyltetrahydro-5-quinolinones (set I) and 2-aryl-7,7-dimethyltetrahydro-5-quinolinones (set II) were studied under positive ion electron ionization (EI) and electrospray ionization (ESI) techniques. Under EI conditions, the molecular ions were found to be less stable in set I isomers, and they resulted in abundant fragment ions, i.e., [M-CH(3)](+), [M-CO](+.), [M-HCO](+), [M-(CH(3),CO)](+), and [M-(CH(3),CH(2)O)](+), when compared with set II isomers. In addition, the set I isomers showed specific fragment ions corresponding to [M-OH](+) and [M-OCH(3)](+). The retro-Diels-Alder (RDA) product ion was always higher in set II isomers. The ESI mass spectra produced [M + H](+) ions, and their decomposition showed favorable loss of CH(3) radical, CH(4) and C(2)H(6) molecules in set I isomers. The set II isomers, however, showed predominant RDA product ions, and specific loss of H(2)O. The selectivity in EI and ESI was attributed to the instability of set I isomers by the presence of a gem-dimethyl group at the α-position, and it was supported by the data from model compounds without a gem-dimethyl group. Density functional theory (DFT) calculations successfully corroborated the fragmentation pathways for diagnostic ions. This study revealed the effect of a gem-dimethyl group located at the α-position to the carbonyl having aromatic/unsaturated carbon on the other side of the carbonyl group.

Health metrics improve childhood immunisation coverage in a rural population of Andhra Pradesh.

Infant and child mortality, including deaths due to vaccine-preventable diseases, remains high in the rural areas of India. In Andhra Pradesh, the immunisation coverage of children in the 12-23 month age-group has progressively declined to 43%, indicating the immediate need for taking corrective steps. The Rural Effective Affordable Comprehensive Healthcare (REACH) project, based on the health metrics strategy was initiated to improve childhood immunisation coverage. Information on the immunisation status of children was recorded and each child was tracked with the help of a computerised database to provide timely immunisation. The health metrics strategy resulted in complete immunisation (96%) of all the 698 children in the 12-23 month age-group residing in the villages of the Medchal Mandal in the year 2007, as compared to 43% reported by the National Family Health Survey-3. Action oriented health metrics coupled with information technology can thereby improve childhood immunisation significantly.

Pyrimido[5,4-e][1,2,4]triazine-5,7(1H,6H)-dione derivatives: their cytoprotection effect from rotenone toxicity and preliminary DMPK properties.

Pyrimido[5,4-e][1,2,4]triazine-5,7(1H,6H)-dione derivatives exhibited potent cytoprotective effect from rotenone toxicity. Lead optimization focused on the CC50/EC50 ratio and DMPK properties led to the overall improvement of the compound profile of this series with high CC50/EC50 ratio (92 for 1f), good metabolic stability in rat microsomes and medium to high aqueous solubility.

Chloro-oxime derivatives as novel small molecule chaperone amplifiers.

Chloro-oxime derivatives were investigated as novel small molecule chaperone amplifiers. Lead optimization led to the discovery of compounds that displayed potent HSF1 activation activity, significant cytoprotection in MG-132 stress, ER stress and PolyQ stress cell models (EC(50)<10 microM).

Phylogenetic analysis, homology modelling, molecular dynamics and docking studies of caffeoyl-CoA-O- methyl transferase (CCoAOMT 1 and 2) isoforms isolated from subabul (Leucaena leucocephala).

Caffeoyl coenzyme A O-methyltransferase (CCoAOMT) is an important enzyme that participates in lignin biosynthesis especially in the formation of cell wall ferulic esters of plants. It plays a pivotal role in the methylation of the 3-hydroxyl group of caffeoyl CoA. Two cDNA clones that code CCoAOMT were isolated earlier from subabul and in the present study; 3D models of CCoAOMT1 and CCoAOMT2 enzymes were built using the MODELLER7v7 software to find out the substrate binding sites. These two proteins differed only in two amino acids and may have little or no functional redundancy. Refined models of the proteins were obtained after energy minimization and molecular dynamics in a solvated water layer. The models were further assessed by PROCHECK, WHATCHECK, Verify_3D and ERRAT programs and the results indicated that these models are reliable for further active site and docking analysis. The refined models showed that the two proteins have 9 and 10 alpha-helices, 6 and 7 beta-sheets respectively. The models were used for docking the substrates CoA, SAM, SAH, caffeoyl CoA, feruloyl CoA, 5-hydroxy feruloyl CoA and sinapyl CoA which showed that CoA and caffeoyl CoA are binding with high affinity with the enzymes in the presence and absence of SAM. It appears therefore that caffeoyl CoA is the substrate for both the isoenzymes. The results also indicated that CoA and caffeoyl CoA are binding with higher affinity to CCoAOMT2 than CCoAOMT1. Therefore, CCoAOMT2 conformation is thought to be the active form that exists in subabul. Docking studies indicated that conserved active site residues Met58, Thr60, Val63, Glu82, Gly84, Ser90, Asp160, Asp162, Thr169, Asn191 and Arg203 in CCoAOMT1 and CCoAOMT2 enzymes create the positive charge to balance the negatively charged caffeoyl CoA and play an important role in maintaining a functional conformation and are directly involved in donor-substrate binding.