Potentiation of antibiotic against Pseudomonas aeruginosa biofilm: a study with plumbagin and gentamicin.

AIMS: Pseudomonas aeruginosa is one of the fatal biofilm-forming pathogens which pose to be a problem in clinical infections, contamination of food and marine ecosystems. In this report, a naphthoquinone-plumbagin has been explored for its antimicrobial (antibacterial and antibiofilm) activity against P. aeruginosa biofilm. The ability of plumbagin to enhance the bioactivity of a known broad-spectrum antibiotic was further assayed by combining the sub-MIC doses of plumbagin with sub-MIC doses of gentamicin against P. aeruginosa biofilm. METHODS AND RESULTS: This combinatorial approach was used for a series of experiments for understanding the mechanism of action for antibiofilm activity against P. aeruginosa (MTCC 424, MTCC 2488). Antibiofilm activity was studied by safranin staining, estimating total protein, visualization of biofilms and extra polymeric substances quantification. Antivirulent activity of these doses was studied by azocasein degradation, expression of virulent factors and molecular docking. Expression of quorum sensing (QS) phenotypes was studied by motility assessment and mRNA expression pattern of virulence genes. It was observed that plumbagin alone and the combinatorial doses of plumbagin and gentamicin exhibit significant antibiofilm and antivirulent activity coupled with the reduction in the expression of QS phenotypes and virulence genes. Molecular docking study revealed that plumbagin had variable affinity for different QS proteins. CONCLUSION: Low doses of plumbagin and gentamicin exhibit synergistic activity against P. aeruginosa biofilm while maintaining their effectiveness. SIGNIFICANCE AND IMPACT OF THE STUDY: As the P. aeruginosa biofilms are reservoir of persister bacteria, thus, the increasing concern of antibiotic tolerance has to be dealt with combinatorial approaches. In this report, plumbagin has been explored in potentiating the antibiofilm effect of a broad-spectrum antibiotic gentamicin for better therapeutic efficacy.

A multicentre retrospective study to understand anti-platelet treatment patterns and outcomes of acute coronary syndrome patients in India (TRACE).

BACKGROUND: There is limited available information for treatment of acute coronary syndrome (ACS) with respect to outcomes, therapeutic agents and treatment practices. Our retrospective registry study collected and evaluated varying anti-platelet treatment strategies and outcomes of ACS patients who were admitted to 9 different tertiary care hospitals in India. This study was carried out to provide an insight to anti-platelet treatment patterns and analyze outcomes of ACS patients in India. METHODS: All the relevant data, including anti-platelet treatment strategies, outcomes and patient treatment compliance were collected from 500 ACS (defined as STEMI, NSTEMI and unstable angina [UA]) cases from January 2007 to December 2009. These ACS cases were randomly collected from the hospital records and included in the analysis. The patient follow up data was acquired either from the hospital records or via telephonic contact for a period of one year following the event. RESULTS: Out of 500 ACS patients, 59.8% had UA/NSTEMI and 40.2% had STEMI. On hospital admission, aspirin, clopidogrel, statins, beta-blockers and angiotensin converting enzyme inhibitors (ACE-Is) were used by 83%, 83%, 68%, 43.2% and 31.6% patients, respectively. On discharge, aspirin, clopidogrel, statins and beta-blockers were used by 90.2%, 88%, 80.6%, and 59% patients, respectively. The average patient compliance to statins, clopidogrel and aspirin was recorded as 74.28%, 69.7% and 68.66%, respectively during discharge and follow-up visits. Greater than 50% of ACS patients after discharge were lost to follow-up and as a result there was significant drop in the number of clinical events reported. CONCLUSION: This pilot study conducted in tertiary care centers in India showed that patients with ACS were more often diagnosed with UA/NSTEMI as compared to STEMI and reported maximum compliance to statins, clopidogrel and aspirin after discharge over 1 year follow-up. More ACS patients were lost to follow up that resulted in low reporting of clinical outcomes, following discharge upto 1 year.

The paclitaxel-eluting PTCA-balloon in combination with a cobalt-chromium stent in two different sequences to treat de novo coronary artery lesions: an angiographic follow up study.

INTRODUCTION: The paclitaxel-coated balloon catheter (DCB) based on the PACCOCATH(®) technology has yielded angiographic and clinical results superior to drug-eluting stents (DES) in situations like in-stent restenosis (ISR) and a trend towards superior results in small coronary vessels and side branches of coronary bifurcations. Using the DCB followed by cobalt-chromium stent (CoCr) deployment or with a reverse sequence may yield different outcomes in terms of late loss. METHODS: 97 patients with de-novo coronary stenosis (55.6 ± 10.7 years, 79.4% male, ≥70%, length: ≤25 mm, vessel diameter: 2.5-4.0 mm) were randomly treated with the DCB (3 µg/mm²) followed by a CoCr-stent or stent first and DCB later. Six-month angiographic and one-year clinical follow-up intention-to-treat analyses were performed. RESULTS: Angiographic and demographic baseline data was comparable between the two groups. When comparing balloon first versus stent first technique, the primary outcome variables were not statistically different for mean in-segment (0.51 ± 0.56 mm vs. 0.36 ± 0.55 mm, p = 0.23) and in-stent (0.52 ± 0.55 mm vs. 0.46 ± 0.52 mm, p = 0.65) late lumen loss. The lesion related 12-month MACE rates were 5/49 (10.2%) and 2/48 (4.2%) (p = 0.44). Lesion related thrombotic events occurred in three patients in balloon first and in one patient in stent first group, two of which were associated with early discontinuation of continuous dual anti-platelet therapy, two with suboptimal PCI, and one each were performed in a thrombotic lesion and a bifurcation type 1.1.0. CONCLUSION: Drug-coated balloon first followed by cobalt chromium stent deployment versus a reverse sequence is not associated with statistically significantly different 6-month angiographic or 12-month clinical outcomes.

Fractional flow reserve: intracoronary versus intravenous adenosine induced maximal coronary hyperemia.

BACKGROUND: Fractional Flow Reserve (FFR), a measure of coronary stenosis severity is based on the achievement of maximal hyperemia of coronary microcirculation. The most widely used pharmacological agent is adenosine which is administered either by intra coronary or intra venous routes. IV route is time consuming, has more side effects and expensive. This study is undertaken to compare the two routes of administration. METHODS: FFR was assessed in 50 patients with 56 intermediate focal lesions using both IV and intracoronary (IC) adenosine. FFR was calculated as the ratio of the distal coronary pressure to the aortic pressure at maximal hyperemia. RESULTS: A total of 25 left anterior descending, 8 right, 21 circumflex, and 2 left main coronary arteries were evaluated. The mean percent stenosis was 63.91 ± 13.13 SD and, the mean FFR was 0.831 ± 0.0738 SD for IV and 0.832 ± 0.0707 SD for IC adenosine. There was a strong and linear correlation between 2 sets of observations with IV dose and IC adenosine dose (R = 0.964, y = 0.065 + 0.923x; p < 0.001) (y = IV dose, x = IC dose). The agreement between the two sets of measurements was also high, with a mean difference of: 0.001 ± 0.0197. The changes in heart rate and blood pressure were significantly higher in IV adenosine group. Different incremental doses were well tolerated, with fewer systemic adverse events with IC adenosine. Transient AV blocks were observed with both IV and IC adenosine. CONCLUSIONS: This study suggests that IC adenosine is equivalent to IV infusion for the determination of FFR. The administration of IC adenosine is easy to use, cost effective, safe and associated with fewer systemic events.

Tuberous sclerosis--a multi system disease.

Tuberous sclerosis is a genetic disease with autosomal dominant inheritance, associated with hamartomas in several organs and various skin findings. A case of a ten year old boy is presented here to highlight the multisystem involvement in tuberous sclerosis. The child had seizures, facial papular naevi and peri-ungual fibromas. MRI revealed cortical tubers, white matter lesions and subependymal nodules. Orbital ultrasound showed retinal hamartoma on the left side. Ultrasound of the abdomen revealed a soft tissue mass at the upper pole of left kidney with a small cyst in right kidney.

Hemodynamic effects of arteriovenous fistula in end-stage renal failure.

Hemodynamic parameters using Swan Ganz catheter were studied in 17 patients with end stage renal disease. The acute effects of radiocephalic AV fistula on the hemodynamic parameters were studied at 24 hours of surgery. The chronic effects were studied in 8 of these patients at 6 weeks of arteriovenous (AV) fistula. The AV fistula matured in 3 to 4 weeks time and blood flow was sufficient for hemodialysis (400 mL/min). Patients with chronic renal failure had normal or high normal hemodynamic parameters. Six weeks after the AV fistula, the cardiac index and the stroke volume index slightly increased along with a significant increase in systolic and mean systemic arterial pressure. None of the patients had significant increase in cardiac filling pressures. Although there was some fall in systemic vascular resistance index and rise in cardiac index and stroke volume index, these changes were physically small and unlikely to put any extra hemodynamic load. Thus, AV fistula in dialysis patients is not an appreciable cause of circulatory or pulmonary congestion.

Plasma homocysteine and insulin in diabetic nephropathy: relationship to body mass index.

The data on plasma homocysteine and endogenous insulin in type 2 diabetes mellitus with nephropathy and relationship to body mass index (BMI) is particularly from the Indian subcontinent. A prospective study was carried out in 50 patients of type 2 diabetes mellitus with overt nephropathy (Group A). The results were compared with 25 diabetics without nephropathy (Group B), and 25 age and sex matched healthy controls (Group C). Microenzyme immunoassay and ELISA estimated the plasma homocysteine and insulin, respectively. The mean values of plasma homocysteine were significantly elevated in diabetic nephropathy (21.3+/-7.2 micromol/L) and diabetics without nephropathy (19.4+/-7.1) when compared to healthy control (11.5+/-2.3). The insulin levels and BMI were significantly higher in diabetics as compared to controls. There was no correlation between homocysteine and insulin, homocysteine and BMI, and homocysteine with the degree of renal failure.

Sonographic evaluation of renal allograft.

Sonography has become an integral part of the care of renal allograft recipients. It is a simple, inexpensive and readily available non-invasive imaging modality. It is indicated as the initial investigation in patients presenting with decreased urine output, pain, infection and hematuria and for doing a percutaneous allograft biopsy. While sonography confirms the diagnosis of obstructive nephropathy and perinephric fluid collections, Doppler is an effective screening modality for the detection of post-transplant vascular complications.

In-vitro metabolism of celecoxib, a cyclooxygenase-2 inhibitor, by allelic variant forms of human liver microsomal cytochrome P450 2C9: correlation with CYP2C9 genotype and in-vivo pharmacokinetics.

In-vitro studies were conducted to assess the impact of CYP2C9 genotype on the metabolism (methyl hydroxylation) and pharmacokinetics of celecoxib, a novel cyclooxygenase-2 inhibitor and CYP2C9 substrate. When compared to cDNA-expressed wild-type CYP2C9 (CYP2C9*1), the Vmax/Km ratio for celecoxib methyl hydroxylation was reduced by 34% and 90% in the presence of recombinant CYP2C9*2 and CYP2C9*3, respectively. These data indicated that the amino acid substitution at position 359 (Ile to Leu) elicited a more pronounced effect on the metabolism of celecoxib than did a substitution at position 144 (Arg to Cys). The Vmax/Km ratio was also decreased in microsomes of livers genotyped CYP2C9*1/*2 (47% decrease, mean of two livers), or CYP2C9*1/*3 (59% decrease, one liver). In all cases, these changes were largely reflective of a decrease in Vmax, with a minimal change in Km. Based on simulations of the in-vitro data obtained with the recombinant CYP2C9 proteins, it was anticipated that the pharmacokinetics of celecoxib (as a much as a five-fold increase in plasma AUC) would be altered (versus CYP2C9*1/*1 subjects) in subjects genotyped heterozygous or homozygous for the CYP2C9*2 (Cys144) or CYP2C9*3 (Leu359) allele. In a subsequent clinical study, the AUC of celecoxib was increased (versus CYP2C9*1/*1 subjects) approximately 2.2-fold (range, 1.6-3-fold) in two CYP2C9*1/*3 subjects and one CYP2C9*3/*3 subject receiving a single oral dose (200 mg) of the drug. In contrast, there was no significant change in celecoxib AUC in two subjects genotyped CYP2C9*1/*2.

Nonpeptide tachykinin receptor antagonists. II. Pharmacological and pharmacokinetic profile of SB-222200, a central nervous system penetrant, potent and selective NK-3 receptor antagonist.

The pharmacological and pharmacokinetic profile of SB-222200 [(S)-(-)-N-(alpha-ethylbenzyl)-3-methyl-2-phenylquinoline-4-car boxami de], a human NK-3 receptor (hNK-3R) antagonist, was determined. SB-222200 inhibited (125)I-[MePhe(7)]neurokinin B (NKB) binding to Chinese hamster ovary (CHO) cell membranes stably expressing the hNK-3 receptor (CHO-hNK-3R) with a K(i) = 4.4 nM and antagonized NKB-induced Ca(2+) mobilization in HEK 293 cells stably expressing the hNK-3 receptor (HEK 293-hNK-3R) with an IC(50) = 18.4 nM. SB-222200 was selective for hNK-3 receptors compared with hNK-1 (K(i) > 100,000 nM) and hNK-2 receptors (K(i) = 250 nM). In HEK 293 cells transiently expressing murine NK-3 receptors (HEK 293-mNK-3R), SB-222200 inhibited binding of (125)I-[MePhe(7)]NKB (K(i) = 174 nM) and antagonized NKB (1 nM)-induced calcium mobilization (IC(50) = 265 nM). In mice oral administration of SB-222200 produced dose-dependent inhibition of behavioral responses induced by i.p. or intracerebral ventricular administration of the NK-3 receptor-selective agonist, senktide, with ED(50) values of approximately 5 mg/kg. SB-222200 effectively crossed the blood-brain barrier in the mouse and rat. The inhibitory effect of SB-222200 against senktide-induced behavioral responses in the mouse correlated significantly with brain, but not plasma, concentrations of the compound. Pharmacokinetic evaluation of SB-222200 in rat after oral administration (8 mg/kg) indicated sustained plasma concentrations (C(max) = about 400 ng/ml) and bioavailability of 46%. The preclinical profile of SB-222200, demonstrating high affinity, selectivity, reversibility, oral activity, and central nervous system penetration, suggests that it will be a useful tool compound to define the physiological and pathophysiological roles of NK-3 receptors, in particular in the central nervous system.

Non-traumatic rhabdomyolysis with acute renal failure.

A clinical profile of non-traumatic rhabdomyolysis with acute renal failure is presented. Myoglobinuric renal failure is treatable and hence a high index of suspicion is warranted in the etiologies discussed.

Mobility challenges and solutions for fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by progressive soft tissue ossification. Although signs may be present at birth, the first appearance of ectopic bone typically occurs in early childhood. The primary target is the axial musculature. Eventually ectopic bone also occurs in ligaments, fascia, aponeurosis, tendons, and joint capsules of the appendicular skeleton with a proximal to distal predilection. As the disease advances, mobility becomes restricted, and affected individuals are typically limited to bed or chair by their early 30s. This report describes a 30-year-old woman with advanced FOP. She had a fused spine and a fixed pelvis, with hips and knees locked in flexion and feet in plantarflexion. Her upper limb mobility was similarly restricted. She was not able to stand upright or sit independently. The modification of a commercially available power wheelchair that allowed the patient to maintain her employment as a preschool teacher and custom shoes are described. Creative physiatric intervention is essential to liberate human potential for people with FOP.

Metabolic transition in the development of Hymenolepis diminuta (Cestoda).

Cysticercoids as well as 6-, 10-, and 14-day Hymenolepis diminuta were evaluated in terms of enzymatic activities related to phosphoenolpyruvate (PEP) utilization and mitochondrial succinate accumulation. The data obtained support a transition toward anaerobic electron-transport-dependent succinate accumulation, characteristic of adult H. diminuta, with development from cysticercoid to adult. This transition was reflected most prominently in the increasing activities of PEP carboxykinase (PEPCK), malate dehydrogenase, NADPH-->NAD+ transhydrogenase, and fumarate reductase. Developmental increases in PEPCK/pyruvate kinase (PK), fumarate reductase (FR)/NADH oxidase (NO), and FR/succinate dehydrogenase (SDH) activity ratios were also apparent. Evaluations of "egg-free" immature, mature, and pregravid-gravid segments of adult H. diminuta revealed that in general the greater levels of activity were associated with the immature and mature segments. Whereas FR/NO and FR/SDH ratios remained relatively constant in segment comparisons, the greatest PEPCK/PK ratio was associated with the pregravid-gravid segment.

Helicobacter pylori infection and upper gastrointestinal patholgy in a British immigrant Indian community.

OBJECTIVES: To assess the pattern of upper gastrointestinal pathology and the prevalence of Helicobacter pylori infection in the Southall Indian community. DESIGN: A prospective study of endoscopic findings in 124 Indian and 107 whites from the Southall area. In a separate study blood samples were taken from 100 Indian subjects presenting to a single general practitioner in Southall. METHODS: The presence of gastritis and H. pylori infection was assessed histologically in Indian and white patients undergoing endoscopy. Serum samples were analysed using a specific enzyme-linked immunosorbent assay (ELISA) for anti-H. pylori immunoglobulin G. RESULTS: In the endoscopic study, Indian and white patients had the same rate of H. pylori infection (52% vs. 43%, respectively) (P= NS). The pattern of upper gastrointestinal pathology was similar in whites and Indians. In the general practice based study 41 subjects were H. pylori seropositive. Seropositivity increased with age (P<0.05). CONCLUSION: There is no excess of H. pylori-related pathology in Southall immigrant Indians. The similarity of upper gastrointestinal pathology in UK Indian and white patients presenting for endoscopy suggests that the high rates of duodenal ulceration, gastritis and H. pylori infection in India are environmentally rather than racially determined.

Giant cavernous hemangiomas of liver mimicking metastasis.

Most hepatic hemangiomas are small and symptomless. These are now being increasingly diagnosed with the greater use of scanning procedures. Hemangiomas can occasionally grow to a large size and become manifest to the patient and the clinician. Giant hemangiomas can produce symptoms including awareness of abdominal mass, pain due to thrombosis, and very rarely, rupture. Though ultrasound is known to be quite suggestive of the diagnosis, large hemangiomas may be mistaken for liver metastases due to their enormous size and variegated picture on the scanning procedure. Dynamic CT scan and at times MRI may be required for confirmation of the diagnosis. Needle biopsy is contraindicated if the diagnosis is suspected.