Human amniotic epithelial cells (HAECS); a potential cell type for the hepatic disorders.

OBJECTIVE: To isolate a homogenous population of human amniotic epithelial cells (hAECs) from the amniotic membrane of the human placenta and differentiate them into hepatic-like cells with the help of small molecules. METHODS: hAECs were isolated by using the enzymatic digestion method and characterized for the presence of specific stem cell markers. In-vitro, hepatic differentiation of hAECs was carried out by using a combination of small molecules. Differentiated cells were observed under a live cell imaging microscope for morphological changes followed by gene and protein expression analysis by qPCR and immunocytochemistry respectively. RESULTS: The isolated hAECs attained characteristic cuboid epithelial shape and express stem cells marker. The hepatic differentiation method was optimized based on soluble chemical compounds supplied in the culture medium. The differentiated hAECs phenotypically acquire hepatic-like cell features and expressed hepatic markers as well as hepatic protein albumin at immature levels. CONCLUSIONS: The isolated population of hAECs is highly proliferative. Moreover, hepatic markers expression in the isolated hAECs makes them an exclusive source for the treatment of chronic liver diseases.

PTPN3 in cancer: unveiling its immune-mediated impact on prognosis and dysregulated signaling pathways.

OBJECTIVES: Oncogenic processes in cancer are frequently marked by the dysregulation of critical genes, and PTPN3 (Protein Tyrosine Phosphatase, Non-Receptor Type 3) has emerged as a gene of interest due to its potential involvement in various cellular processes. This study delves into the diagnostic and prognostic implications of PTPN3 in a pan-cancer context. METHODS: Leveraging comprehensive genomic datasets and experimental validation, we aimed to shed light on the role of PTPN3 in cancer. RESULTS: Our findings revealed the pervasive up-regulation of PTPN3 across 33 cancer types, making it a ubiquitous player in tumorigenesis. Of particular note, PTPN3 up-regulation exhibited a strong association with reduced overall survival in breast cancer (BRCA) and lung adenocarcinoma (LUAD). This underscores PTPN3's potential as a valuable prognostic marker in these cancers. While genetic mutations often drive oncogenic processes, our mutational analysis demonstrated the relative stability of PTPN3 in BRCA and LUAD. Promoter methylation analysis showed that hypomethylation plays a predominant role in PTPN3 dysregulation in BRCA and LUAD. Furthermore, our study unveiled positive correlations between PTPN3 expression and CD8+ T cell infiltration, offering insights into the gene's influence on the tumor immune microenvironment. Pathway enrichment analysis highlighted the involvement of PTPN3-associated genes in crucial signaling pathways. In addition, drug prediction analysis pinpointed potential drugs capable of modulating PTPN3 expression, opening avenues for personalized treatment strategies. CONCLUSION: In summary, our study elucidates the multifaceted roles of PTPN3 in BRCA and LUAD, underlining its significant up-regulation, prognostic relevance, epigenetic regulation, and its impact on the tumor immune microenvironment.

Clinical Outcomes of Ustekinumab in Inflammatory Bowel Disease.

Inflammatory bowel diseases including Crohn's disease (CD) and ulcerative colitis (UC) are characterized by abdominal pain, diarrhea, blood in stools, weight loss, and fatigue. It presents in patients with varying severity from mild to severe depending on the inflammation. Detailed analysis and guidelines are required for the safe usage of biological therapies in the treatment of inflammatory bowel diseases as surgery is reserved for more complex cases. There is also geographical variation in inflammatory bowel disease (IBD) incidence and prevalence based on environmental and climate changes, and socio-demographics. Studies also show that there is more hospitalization and reduced health-related quality of life in IBD patients when compared to normal people. We conducted an extensive literature database search for articles with keywords within the last 10 years on adults >18 years of age with IBD and its treatment, especially with ustekinumab. Ustekinumab is a human immunoglobulin G1 (IgG1) kappa monoclonal antibody, that blocks IL-12 and IL-23 and was approved by the FDA for the treatment of moderate to severe IBD, especially in patients who are intolerant to immunomodulators or corticosteroids treatment. There are several retrospective studies that show the effectiveness of ustekinumab dosage escalation every four weeks in IBD patients. This escalation of dose not only improved the clinical outcome but also reduced the worsening of the disease. Previous studies also show the importance of considering dosage escalation before switching biological agents in the IBD treatment. Ustekinumab has also demonstrated both efficacy and safety in the induction and maintenance of the treatment of this disease. There are certain challenges and opportunities associated with ustekinumab usage in IBD patients that require further research. Ustekinumab seems to be more cost-effective in the tumor necrosis factor (TNF)-alpha-inhibitor failure population when compared to previously used biological treatment regimes.

Validation of the Short Version of the 10/66 Dementia Diagnosis in Urdu in Karachi, Pakistan.

The standard 10/66 battery has been translated and validated in Pakistan; however, it takes long to administer it with specialized training for the staff. This study was performed to validate a shorter version of the 10/66. The data for validation of the short version was extracted from the full version study. Ethical approval was taken from the Institutional Review Board of the Aga Khan University. The study was funded by the Aga Khan University, University Research Council Grant. The total number of participants was 257, equally divided between people with dementia and normal cognition. The sensitivity of the short version was 95.7% and 80.5%; specificity was 83.5% and 90.7%; κ was 0.751 and 0.712; and the area under the curve was 0.89 and 0.85 against the standard 10/66 diagnosis and clinician diagnosis, respectively. The short version of 10/66 battery is a valid instrument for diagnosing dementia in the Urdu-speaking Pakistani population.

Morphological Spectrum of Vesiculobullous Skin Lesions: An Institutional Perspective.

Introduction A vesiculobullous lesion of the skin encompasses a group of dermatological disorders with protean clinicopathological features. They usually occur as a part of the spectrum of various infectious, inflammatory, drug-induced, genetic, and autoimmune disorders. Therefore, accurate diagnosis of these lesions is essential for appropriate management and to reduce the associated morbidity and mortality. The conventional skin punch biopsy is the mainstay in the diagnosis of dermatological diseases, especially when combined with confirmatory tests, such as direct immunofluorescence (DIF). Our study evaluated the clinicopathological spectrum of vesiculobullous lesions. Methods We studied 150 cases of vesiculobullous lesions at the Department of Histopathology, Liaquat National Hospital and Medical College Karachi, Pakistan. Written and informed consent was taken from the patients followed by skin punch procedure in which three biopsies were obtained, which included one biopsy from the lesion and two peri-lesional biopsies. One peri-lesional biopsy was sent in cryomatrix for DIF studies, whereas the other two were sent in formalin to follow the standard tissue-processing protocol. Results Our results showed that most patients belonged to the geriatric age group of more than 50 years (44.7%), and 54.7% of the patients were females. Total 74.7% of the patients had generalized lesions, followed by lower limbs (9.3%) and trunk (7.3%) involvement. Most patients were diagnosed with bullous pemphigoid (31.3%), followed by pemphigus vulgaris (27.3%), dermatitis herpetiformis (15.3%), Darier's disease (14.7%), pemphigus foliaceus (4.7%), epidermolysis bullosa (2%), linear immunoglobulin A dermatosis (2%), paraneoplastic pemphigus (0.7%), and drug reactions (0.7%). DIF studies were applied on 60 cases, out of which complement protein C3c was the most commonly deposited protein (53.3%). Conclusion Our study emphasized the diagnostic role of skin punch biopsy in the proper evaluation of vesiculobullous skin lesions. Histopathology is the cornerstone diagnostic tool in this regard, with DIF being a useful adjunct.

Association of Pulmonary Hypertension With End-Stage Renal Disease Among the Obese Population.

Introduction Pulmonary hypertension (PH) is a known complication that occurs in patients of end-stage renal disease (ESRD) that have an arteriovenous fistula (AVF) for hemodialysis (HD). It is defined as pulmonary artery pressure (PAP) of greater than 30 mmHg on echocardiography. The presence of PH in ESRD is an independent risk factor and decreases the survival likelihood among HD patients. Unexplained PH is frequently seen in ESRD following AVF. Obesity can lead to various complications, such as sleep apnea, cardiac complications, pulmonary hypertension, and mortality. Data on the prevalence of coexisting PH and obesity are scarce. Obese patients often have increased albumin excretion rates (AER) that can lead to early renal impairment and an increase in intraglomerular pressure, which may increase the risk of cardiovascular (CV) morbidity and mortality. Therefore, the study aimed to evaluate and compare the associated PH and obesity separately and collectively among ESRD patients. Methods This comparative cross-sectional study was conducted in a tertiary care public sector hospital with the approval of the medical ethics review board committee. The study enrolled all consecutive patients with ESRD as defined by having an estimated glomerular filtration rate (GFR) of <15 mL/min/1.7 3 m2 from April 2017 till March 2019, who presented to our facility. These patients underwent dialysis twice or thrice a week, each session lasting three to four hours approximately. On initial encounter, trans-thoracic echocardiography (TTE) was done by the cardiologist to diagnose pulmonary hypertension. In addition, body mass index (BMI) was calculated for all patients, and the patients were categorized into underweight, normal, overweight, or obese. All patients underwent post-dialysis TTE at one hour or when patients were at the optimal dry weight. Systolic PAP and ejection fraction were measured, and pulmonary hypertension was defined as a PAP of 30 mmHg or greater on TTE. ESRD patients that were diagnosed with PH prior to hemodialysis or had primary PH were excluded from the study. Only ESRD patients developing secondary PH after hemodialysis were included in the study. The chi-square test was used to see the correlation of gender, ambulation status, smoking status, obesity, pulmonary hypertension, body mass index (BMI), and pulmonary hypertension and obesity combined on the final outcome. A p-value of 0.05 was considered significant. Odds ratio (OR) and relative risk (RR) were calculated for pulmonary hypertension and obesity combined, obesity, and pulmonary hypertension in the final outcome. Results The study enrolled 204 patients with a mean age of 46.23 (±20.45 SD) having higher female participation of 108 (52.9%), whereas 96 (47.1%) were males. The average weight of the cohort was 66.78 kg (±22.98 SD) with a mean BMI of 29.91 kg/m2 (±13.29SD), 52 (25.5%) patients were underweight, 40 (19.6%) had a normal BMI, 29 (14.2%) were overweight, and 83 (40.7%) patients were obese. Pulmonary hypertension and obesity combined were observed in 48 (23.5%) of the cases and there was a 4.60 relative risk of death among these individuals, with an odds ratio of 13.35 and a p-value of 0.00. Conclusion The study shows a strong synergistic effect of pulmonary hypertension and obesity towards the final survival outcome in ESRD patients who are on hemodialysis.

Echocardiographic Changes in Chronic Kidney Disease Patients on Maintenance Hemodialysis.

Introduction Chronic kidney disease (CKD) carries a significant association with cardiac diseases, which suggests a minor reduction in the glomerular filtration rate (GFR) can act as an independent risk factor for causing cardiovascular abnormalities. Patients of CKD having cardiovascular disease (CVD) had three to thirty times higher risk of mortality as compared to the general population. In addition, mortality among cardiovascular patients has been found to be twofold higher in CKD stage 2 patients and three-fold higher in patients with stage 3 CKD, when collated to patients with normal renal function. Furthermore, cardiomyopathy among hemodialysis (HD) is due to the presence of coronary artery obstruction, reduction in coronary reserves, and left ventricular (LV) physiological-structural abnormalities secondary volume and pressure overload. Echocardiography is a gold standard diagnostic modality for the identification of cardiac structural and functional abnormalities. Therefore, the evaluation of echocardiographic parameters in patients of CKD can help to determine the risk and prognosis of CVD in patients of CKD. In the present study, we evaluated the echocardiographic findings in patients of CKD on maintenance hemodialysis. Methods This cross-sectional study was conducted in the nephrology unit of Jinnah Postgraduate Medical Center between March 2019 to October 2019. A total of 100 patients who were on maintenance for more than one year were included in the analysis. Two-dimensional transthoracic echocardiography was done in each patient for the determination of cardiac structural and functional parameters such as LV hypertrophy, LV systolic dysfunction, and LV diastolic dysfunction. Results The mean age of the patients was 46.9±12.8 years. There was male dominance with male/female ratio 63/37. There were 39% hypertensive and 62% anemic patients. LV dysfunction was diagnosed in 31% of patients, LV diastolic dysfunction in 47% patients, and left ventricular hypertrophy (LVH) in 55% of patients. LVH was found in 74.3% hypertensive patients versus only 42.6% non-hypertensive patients (p-value 0.001). LV systolic dysfunction was also high in hypertensive patients, 46.1% versus 21.3% patients in non-hypertensive patients (p-value 0.008).  Conclusion There is a high frequency of cardiac functional and structural abnormalities in CKD patients on HD especially in patients having concomitant hypertension. LVH is the most common structural defect and LV diastolic dysfunction is the most common functional cardiac defect in CKD patients on hemodialysis.

Serious Inadequacies in High Alert Medication-Related Knowledge Among Pakistani Nurses: Findings of a Large, Multicenter, Cross-sectional Survey.

INTRODUCTION: Deaths-related to medications errors are common in Pakistan but these are not accurately reported. Recently, the death of a 9 months old baby due to abrupt administration of 15% potassium chloride injection sparked the issue of high alert medications (HAMs) related errors in the country. Since drug administration is the prime responsibility of the nurses, it is pivotal that they possess good knowledge of HAMs. Since there is no published data regarding the knowledge of HAMs among Pakistani nurses, we aimed to assess knowledge of HAMs among registered nurses of Pakistan. METHODS: A cross-sectional study was conducted among registered nurses, recruited using a convenient sampling technique, from 29 hospitals all over the Punjab Province. Data were collected using a validated self-administered instrument. All data were entered and analyzed using SPSS version 22. RESULTS: The study sample was comprised of 2,363 registered nurses (staff nurses = 94.8%, head nurses = 5.2%). Around 63% were working in tertiary hospitals whereas almost 25 and 12% were from district headquarter hospitals and tehsil headquarter hospitals, respectively. Around 84% of the study participants achieved scores <70%, indicating majority of Pakistani nurses having poor knowledge of HAMs administration as well as regulation. There was no significant difference of overall knowledge among age, hospitals, departments, training, designations, qualification, and experience categories. Major obstacles encountered during HAMs administration were "getting uncertain answers from colleagues" (72.9%), "unavailability of suitable person to consult" (61.1%) and "receiving verbal orders" (55.6%). CONCLUSION: Our study revealed the serious inadequacies in HAMs knowledge among Pakistani nurses which may lead to adverse patient outcomes. Nurses should receive comprehensive pharmacology knowledge not only during in-school nursing education but also as hospital-based continuing education. Moreover, it is of immense importance to bridge the gaps between physicians, clinical pharmacists, and nurses through effective communication as this will help reduce medication errors and improve patient care.

Translation and Validation of 10/66 Dementia Diagnostic Battery in Urdu in Karachi, Pakistan.

PURPOSE: The 10/66 dementia research group (DRG) diagnostic tool was devised to diagnose dementia in people with low education in low and middle-income countries. This study aimed to validate the 10/66 DRG tool in Urdu in Pakistan. METHODOLOGY: People older than or equal to 60 years were included: (1) With normal cognition: no/low education, high education, and depression; (2) People with mild and moderate dementia. The diagnostic and statistical manual IV-TR clinician diagnosis was used as the gold standard for dementia. The Clinician Dementia Rating scale was used to rate dementia severity. The geriatric mental status AGECAT stage I output was used to diagnose depression. The 10/66 battery was comprised of CSI-D (cognitive screening instrument for dementia), CERAD (consortium to establish a registry of Alzheimer disease), and animal naming test. RESULT: The sensitivity and specificity of CSI-D COG score for diagnosing dementia was 86.7% and 72.1%, for CSI-D DF score was 71.1% and 96.1%, for CERAD-10 word list delayed recall was 85.9% and 62.2% at a cut point of ≥5 words, and 70.3% and 97.7% for 10/66 diagnostic algorithm. CONCLUSIONS: The 10/66 DRG tool is a valid instrument for diagnosing dementia in the Urdu-speaking population, including with low education and depression, in Pakistan.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care.

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.

Genetic risk factors for the posterior cortical atrophy variant of Alzheimer's disease.

INTRODUCTION: The genetics underlying posterior cortical atrophy (PCA), typically a rare variant of Alzheimer's disease (AD), remain uncertain. METHODS: We genotyped 302 PCA patients from 11 centers, calculated risk at 24 loci for AD/DLB and performed an exploratory genome-wide association study. RESULTS: We confirm that variation in/near APOE/TOMM40 (P = 6 × 10(-14)) alters PCA risk, but with smaller effect than for typical AD (PCA: odds ratio [OR] = 2.03, typical AD: OR = 2.83, P = .0007). We found evidence for risk in/near CR1 (P = 7 × 10(-4)), ABCA7 (P = .02) and BIN1 (P = .04). ORs at variants near INPP5D and NME8 did not overlap between PCA and typical AD. Exploratory genome-wide association studies confirmed APOE and identified three novel loci: rs76854344 near CNTNAP5 (P = 8 × 10(-10) OR = 1.9 [1.5-2.3]); rs72907046 near FAM46A (P = 1 × 10(-9) OR = 3.2 [2.1-4.9]); and rs2525776 near SEMA3C (P = 1 × 10(-8), OR = 3.3 [2.1-5.1]). DISCUSSION: We provide evidence for genetic risk factors specifically related to PCA. We identify three candidate loci that, if replicated, may provide insights into selective vulnerability and phenotypic diversity in AD.

Evaluating pathogenic dementia variants in posterior cortical atrophy.

Posterior cortical atrophy (PCA) is an understudied visual impairment syndrome most often due to "posterior Alzheimer's disease (AD)" pathology. Case studies detected mutations in PSEN1, PSEN2, GRN, MAPT, and PRNP in subjects with clinical PCA. To detect the frequency and spectrum of mutations in known dementia genes in PCA, we screened 124 European-American subjects with clinical PCA (n = 67) or posterior AD neuropathology (n = 57) for variants in genes implicated in AD, frontotemporal dementia, and prion disease using NeuroX, a customized exome array. Frequencies in PCA of the variants annotated as pathogenic or potentially pathogenic were compared against ∼ 4300 European-American population controls from the NHLBI Exome Sequencing Project. We identified 2 rare variants not previously reported in PCA, TREM2 Arg47His, and PSEN2 Ser130Leu. No other pathogenic or potentially pathogenic variants were detected in the screened dementia genes. In this first systematic variant screen of a PCA cohort, we report 2 rare mutations in TREM2 and PSEN2, validate our previously reported APOE ε4 association, and demonstrate the utility of NeuroX.

Late-onset Alzheimer disease genetic variants in posterior cortical atrophy and posterior AD.

OBJECTIVE: To investigate association of genetic risk factors for late-onset Alzheimer disease (LOAD) with risk of posterior cortical atrophy (PCA), a syndrome of visual impairment with predominant Alzheimer disease (AD) pathology in posterior cortical regions, and with risk of "posterior AD" neuropathology. METHODS: We assessed 81 participants with PCA diagnosed clinically and 54 with neuropathologic diagnosis of posterior AD vs 2,523 controls for association with 11 significant single nucleotide polymorphisms (SNPs) from published LOAD risk genome-wide association studies. RESULTS: There was highly significant association with APOE ε4 and increased risk of PCA (p = 0.0003, odds ratio [OR] = 3.17) and posterior AD (p = 1.11 × 10(-17), OR = 6.43). No other locus was significant after corrections for multiple testing, although rs11136000 near CLU (p = 0.019, OR = 0.60) and rs744373 near BIN1 (p = 0.025, OR = 1. 63) associated nominally significantly with posterior AD, and rs3851179 at the PICALM locus had significant association with PCA (p = 0.0003, OR = 2.84). ABCA7 locus SNP rs3764650, which was also tested under the recessive model because of Hardy-Weinberg disequilibrium, also had nominally significant association with PCA risk. The direction of association at APOE, CLU, and BIN1 loci was the same for participants with PCA and posterior AD. The effects for all SNPs, except rs3851179, were consistent with those for LOAD risk. CONCLUSIONS: We identified a significant effect for APOE and nominate CLU, BIN1, and ABCA7 as additional risk loci for PCA and posterior AD. Our findings suggest that at least some of the genetic risk factors for LOAD are shared with these atypical conditions and provide effect-size estimates for their future genetic studies.

Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure.

OBJECT: Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable-shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). METHODS: The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. RESULTS: Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs. 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs. 27.0, respectively; p = 0.005). CONCLUSIONS: Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.