Randomized, Double-Blind, Placebo-Controlled, Clinical Study of Passiflora incarnata in Participants With Stress and Sleep Problems.

Background and objectives SIVI is a standardized extract prepared using the aerial parts of Passiflora incarnata developed to enhance the quality of sleep. ​​​​​​The objective of the present study was to the evaluate efficacy and safety of SIVI (Passiflora incarnata extract) in the management of stress and sleep problems in Indian participants in a randomized, double-blind, placebo-controlled, clinical study. Materials and methods A total of 65 participants with stress and insomnia were randomized to two groups with 32 in the SIVI (Passiflora incarnata extract) group and 33 in the placebo group. Subjects were asked to take the test substance along with water at bedtime for 30 days. The Perceived Stress Scale, quality of life using the General Health Questionnaire (GHQ-12) scale, and Insomnia Severity Index were assessed on day 1, day 15, and day 30. Results Passiflora incarnata extract showed a statistically significant reduction in the mean score of stress on the Perceived Stress Scale and significantly increased the mean score of total sleep time compared to placebo. The general psychological health was found to be significantly improved in the SIVI (Passiflora incarnata extract) group compared to the placebo group on day 15 and day 30. SIVI (Passiflora incarnata extract) did not show any adverse effects. Conclusions The results of the current study indicate that Passiflora incarnata extract is beneficial in the management of stress and helps to improve sleep quality in subjects with stress and insomnia.

Nicotine Free Herbal Composition for Smoking De-Addiction - A Placebo Controlled, Double Blind, Randomized, Multicentric Clinical Study.

Background: Smoking is a major predisposing factor for many health problems including cancers, vascular disorders, etc., To quit smoking is the only solution to prevent them. Various medicinal and non-medicinal methods are used worldwide for the same. The present study evaluates the effect of a nicotine free herbal formulation containing ingredients like Mucuna pruriens, Withania somnifera, Bacopa monnieri, etc., for cessation of smoking and its effects on other health parameters related to smoking. Materials and Methods: The present study was a placebo controlled, double blind, randomized, and multi-centric clinical study conducted at three clinical sites in India. After ethical approval and informed consent, all participants were given Smotect Tablets or Placebo tablets in a dose of 2 tablets twice daily for 90 days. A total of 103 participants (52 in trial group and 51 in placebo group) completed the study. Evaluation of cessation of smoking was done along with other parameters like measurement of lung capacity, clinical assessment, and laboratory investigations before and after the study. Results: A significant reduction in smoking as well as in the alveolar Carbon monoxide (p < 0.05) and Carboxyhemoglobin levels (p < 0.05) were observed with the use of Smotect tablets as compared to placebo over a period of 90 days. Significant improvement was also observed in quality of life, energy and stamina levels, and reduction of stress level. Smotect tablets were found to be safe without causing any adverse effects. Conclusion: Smotect Tablets is an effective and safe remedy for cessation of smoking and reducing other effects related to smoking.

Targeting bioenergetics is key to counteracting the drug-tolerant state of biofilm-grown bacteria.

Embedded in an extracellular matrix, biofilm-residing bacteria are protected from diverse physicochemical insults. In accordance, in the human host the general recalcitrance of biofilm-grown bacteria hinders successful eradication of chronic, biofilm-associated infections. In this study, we demonstrate that upon addition of promethazine, an FDA approved drug, antibiotic tolerance of in vitro biofilm-grown bacteria can be abolished. We show that following the addition of promethazine, diverse antibiotics are capable of efficiently killing biofilm-residing cells at minimal inhibitory concentrations. Synergistic effects could also be observed in a murine in vivo model system. PMZ was shown to increase membrane potential and interfere with bacterial respiration. Of note, antibiotic killing activity was elevated when PMZ was added to cells grown under environmental conditions that induce low intracellular proton levels. Our results imply that biofilm-grown bacteria avoid antibiotic killing and become tolerant by counteracting intracellular alkalization through the adaptation of metabolic and transport functions. Abrogation of antibiotic tolerance by interfering with the cell's bioenergetics promises to pave the way for successful eradication of biofilm-associated infections. Repurposing promethazine as a biofilm-sensitizing drug has the potential to accelerate the introduction of new treatments for recalcitrant, biofilm-associated infections into the clinic.

Esophageal Mucosal Bridge of Unknown Etiology Causing Dysphagia in an Elderly Female: Endoscopic Management and Literature Review.

Esophageal mucosal bridge is an elastic stretchable structure, connecting across the lumen, extending either obliquely or horizontally, more commonly seen in the mid or lower esophagus. It can be either congenital or secondary (acquired). Acquired ones are secondary to reflux esophagitis, corrosive esophageal injury, drug-induced esophagitis, radiation esophagitis, Crohn's disease, Mallory-Weiss syndrome, malignant tumors, and infections like candidiasis, HSV, CMV, or tuberculosis. We present a case of an elderly female, who presented with progressive dysphagia for 3 months, more commonly to solids without any history of anorexia or weight loss. No history of corrosive ingestion, radiation exposure, or prior history of any surgical or endoscopic intervention was present. Upper gastrointestinal endoscopy revealed esophageal mucosal bridge at 20 and 25 cm from incisors and mucosal tag. Endoscopic resection was carried out successfully with hot biopsy forceps and needle knife after prophylactic application of hemoclips at two ends of each bridge, without any adverse event. Esophageal mucosal bridge, though rarely reported, should be kept in the differential diagnosis of patients presenting with dysphagia. Endoscopic resection with hot biopsy forceps or needle knife seems to be effective.

Uma ponte mucosa esofágica é uma estrutura elástica que se estende obliquamente ou horizontal mente através do lúmen esofágico, sendo a sua posição mais comum no esófago médio ou distal. Pode ser congénita ou secundária (adquirida). Estas geralmente são secundárias a esofagite de refluxo, lesão corrosiva, medicamentosa, rádica, doença de Crohn, síndroma de Mallory-Weiss, tumores malignos ou por infeções como candidiase, HSV, CMV ou tuberculose. Apresentamos um caso de uma mulher idosa com disfagia progressiva com 3 meses duração, mais para sólidos, sem história de anorexia ou emagrecimento, sem história de ingestáo de caústicos, radioterapia, cirurgia ou qualquer intervenção endoscópica prévia. A endoscopia digestiva alta revelou uma ponte mucosa aos 20 e 25 cm dos incisivos e uma prega mucosa. Procedeu-se a resseção endoscópica com pinça de hot-biopsy e com needle-knife após colocação profilática de hemoclips em ambas as extremidades de cada ponte, com sucesso e sem qualquer efeito adverso. Apesar de raramente reportadas as pontes mucosa esofágicas devem ser consideradas no diagnóstico diferencial de doentes com disfagia. A resseção endoscópica com pinça de hot-biopsy ou needle-knife parece ser eficaz nestes casos.

Host-induced spermidine production in motile Pseudomonas aeruginosa triggers phagocytic uptake.

Exploring the complexity of host-pathogen communication is vital to understand why microbes persist within a host, while others are cleared. Here, we employed a dual-sequencing approach to unravel conversational turn-taking of dynamic host-pathogen communications. We demonstrate that upon hitting a host cell, motile Pseudomonas aeruginosa induce a specific gene expression program. This results in the expression of spermidine on the surface, which specifically activates the PIP3-pathway to induce phagocytic uptake into primary or immortalized murine cells. Non-motile bacteria are more immunogenic due to a lower expression of arnT upon host-cell contact, but do not produce spermidine and are phagocytosed less. We demonstrate that not only the presence of pathogen inherent molecular patterns induces immune responses, but that bacterial motility is linked to a host-cell-induced expression of additional immune modulators. Our results emphasize on the value of integrating microbiological and immunological findings to unravel complex and dynamic host-pathogen interactions.

COMBINED NS5A & NS5B NUCLEOTIDE INHIBITOR THERAPY FOR PATIENTS WITH CHRONIC HEPATITIS C WITH STAGE 5 CHRONIC KIDNEY DISEASE ON HEMODIALYSIS.

BACKGROUND: Hepatitis C virus (HCV) infection is the most common hepatotropic viral infection affecting the patients on maintenance hemodialysis. Treatment of chronic HCV infection in stage 4 and 5 CKD includes a combination of elbasvir/grazoprevir and glecaprevir/pibrentasvir, which are not available in many countries. OBJECTIVE: Hence, we have conducted this study to look for the safety and efficacy of sofosbuvir combination therapy in this difficult to treat population. METHODS: We conducted a single-center, prospective, open-label study in which Stage 5 CKD patients on maintenance hemodialysis with HCV infection. Total of 18 patients was included. sofosbuvir with daclatasvir or ledipasvir was used according to genotype for 12 weeks. HCV RNA, genotype, transient elastography (TE) was considered for every patient. HCV RNA was quantified at 4th week, 12th week and 12 weeks post-treatment to look for sustained virologic response (SVR 12). RESULTS: Infection due to genotype 1 was seen in 12 (66.7%) patients followed by genotype 3 in 4 (22.3%) with each patient of genotype 2 and 5. The median value of HCV RNA was 2,35,000 IU/mL. On TE, all had liver stiffness of <9.4 KPa. All patients had HCV RNA of <15 IU/mL at 4th and 12th week of treatment and 12 weeks post-treatment. No significant change in hemoglobin, eGFR and liver stiffness was observed. CONCLUSION: Full dose sofosbuvir i.e. 400 mg, in combination with NS5A inhibitors daclatasvir or ledipasvir is found to be safe and effective in patients with end stage renal disease, who are on maintenance hemodialysis.

Clinical, serological, histopathological and treatment profile of autoimmune hepatitis in the elderly.

AIM OF THE STUDY: Autoimmune hepatitis (AIH), despite being uncommon, is on the rise in the elderly population. However, no study from India has described the natural history and treatment outcome of AIH in the elderly. The aim was to study the characteristics of AIH in the elderly population and compare them with the younger population. MATERIAL AND METHODS: Patients with a diagnosis of AIH based on the revised International Autoimmune Hepatitis Group (IAIHG) criteria were recruited from January 2011 to June 2018. Patients were defined as elderly when ≥ 60 years and young when < 60 years of age. Clinical, serological, histological characteristics and treatment outcome with follow-up until 12 months were analyzed and compared between the two groups. RESULTS: Out of 155 patients, 33 (21.29%) were elderly. Acute-on-chronic liver failure (ACLF) as the presentation was more common in elderly as compared to young AIH patients (39.4% vs. 13.9%, p = 0.0024). Serum alanine aminotransferases and serum creatinine levels were significantly higher in elderly patients as compared to the younger group (p < 0.05). On histology cirrhosis was significantly more common in the elderly group (75.7% vs. 56.6%, p = 0.045). Response to treatment at the end of 12 months was similar in both groups. Due to co-morbidities immunosuppressant could not be started in 18.2% of elderly and 6.5% of younger patients (p = 0.065). CONCLUSIONS: AIH is an important differential diagnosis among the elderly population presenting with ACLF and cirrhosis. When given appropriate immunosuppressants they have a similar outcome as compared to the youngest population.

Acute Pancreatitis: A Rare Post-Colonoscopy Sequela.

Abdominal pain is a common but benign symptom after colonoscopy. We report a case of acute pancreatitis that occurred just after an elective screening colonoscopy; this is a rare event with very few reported cases. A healthy, asymptomatic male underwent screening colonoscopy at our center and developed abdominal pain and emesis after the procedure. An abdominal X-ray ruled out perforation but laboratory tests revealed elevated levels of amylase and lipase. The patient had no etiological risk factors for pancreatitis. The presumed mechanism of pancreatitis in this case is mechanical and pressure trauma from excessive insufflation, external abdominal pressure, and repeated withdrawal of the colonoscope due to tight angulation of the splenic flexure, a structure that is in close proximity to the pancreatic tail. Acute pancreatitis should be considered in the differential diagnosis of patients who present with abdominal pain after colonoscopy once more common etiologies have been excluded.

Combined ns5a & ns5b nucleotide inhibitor therapy for patients with chronic hepatitis c with stage 5 chronic kidney disease on hemodialysis / Terapia inibidora de nucleotídeo NS5A& NS5B combinada para pacientes com hepatite C crônica com doença renal crônica em estágio 5, em hemodiálise

ABSTRACT BACKGROUND: Hepatitis C virus (HCV) infection is the most common hepatotropic viral infection affecting the patients on maintenance hemodialysis. Treatment of chronic HCV infection in stage 4 and 5 CKD includes a combination of elbasvir/grazoprevir and glecaprevir/pibrentasvir, which are not available in many countries. OBJECTIVE: Hence, we have conducted this study to look for the safety and efficacy of sofosbuvir combination therapy in this difficult to treat population. METHODS: We conducted a single-center, prospective, open-label study in which Stage 5 CKD patients on maintenance hemodialysis with HCV infection. Total of 18 patients was included. sofosbuvir with daclatasvir or ledipasvir was used according to genotype for 12 weeks. HCV RNA, genotype, transient elastography (TE) was considered for every patient. HCV RNA was quantified at 4th week, 12th week and 12 weeks post-treatment to look for sustained virologic response (SVR 12). RESULTS: Infection due to genotype 1 was seen in 12 (66.7%) patients followed by genotype 3 in 4 (22.3%) with each patient of genotype 2 and 5. The median value of HCV RNA was 2,35,000 IU/mL. On TE, all had liver stiffness of <9.4 KPa. All patients had HCV RNA of <15 IU/mL at 4th and 12th week of treatment and 12 weeks post-treatment. No significant change in hemoglobin, eGFR and liver stiffness was observed. CONCLUSION: Full dose sofosbuvir i.e. 400 mg, in combination with NS5A inhibitors daclatasvir or ledipasvir is found to be safe and effective in patients with end stage renal disease, who are on maintenance hemodialysis.

RESUMO CONTEXTO: A infecção pelo vírus da hepatite C (HCV) é a infecção viral hepática mais comum que afeta pacientes em hemodiálise de manutenção. O tratamento da infecção crônica por HCV no estágio 4 e 5 da doença renal crônica inclui uma combinação de elbasvir/grazoprevir e glecaprevir/pibrentasvir, que não estão disponíveis em muitos países. OBJETIVO: Portanto, realizamos este estudo para procurar a segurança e eficácia da terapia combinada de sofosbuvir nesta população de difícil tratamento. MÉTODOS: Realizamos um estudo de centro único, prospectivo e aberto, no qual pacientes com doença renal crônica em estágio 5 em hemodiálise de manutenção com infecção por HCV. Um total de 18 pacientes foi incluído. Sofosbuvir com daclatasvir ou ledipasvir foi usado de acordo com o genótipo por 12 semanas. O HCV RNA, genótipo, elastografia transitória foi considerado para cada paciente. O HCV RNA foi quantificado na 4ª semana, 12ª semana e 12 semanas após o tratamento para procurar uma resposta virológica sustentada. RESULTADOS: A infecção por genótipo 1 foi observada em 12 (66,7%) pacientes, seguido pelo genótipo 3 em 4 (22,3%), em um paciente do genótipo 2 e em outro, 5. O valor mediano do HCV RNA foi de 2.35.000 IU/mL. Na elastografia transitória, todos tinham rigidez hepática de <9.4 KPa. Todos os pacientes tinham RNA HCV <15 IU/mL na 4ª e 12ª semana de tratamento e 12 semanas após o tratamento. Não foi observada nenhuma alteração significativa na hemoglobina, eGFR e rigidez hepática. CONCLUSÃO: A dose completa sofosbuvir ou seja, 400 mg, em combinação com inibidores NS5A daclatasvir ou ledipasvir foi considerada segura e eficaz em pacientes com doença renal em estágio final, que estão em manutenção hemodiálise.

The immunogenic potential of bacterial flagella for Salmonella-mediated tumor therapy.

Genetically engineered Salmonella Typhimurium are potent vectors for prophylactic and therapeutic measures against pathogens as well as cancer. This is based on the potent adjuvanticity that supports strong immune responses. The physiology of Salmonella is well understood. It simplifies engineering of both enhanced immune-stimulatory properties as well as safety features, thus, resulting in an appropriate balance between attenuation and efficacy for clinical applications. A major virulence factor of Salmonella is the flagellum. It is also a strong pathogen-associated molecular pattern recognized by extracellular and intracellular receptors of immune cells of the host. At the same time, it represents a serious metabolic burden. Accordingly, the bacteria evolved tight regulatory mechanisms that control flagella synthesis in vivo. Here, we systematically investigated the immunogenicity and adjuvant properties of various flagella mutants of Salmonella in vitro and in a mouse cancer model in vivo. We found that mutants lacking the flagellum-specific ATPase FliHIJ or the inner membrane ring FliF displayed the greatest stimulatory capacity and strongest antitumor effects, while remaining safe in vivo. Scanning electron microscopy revealed the presence of outer membrane vesicles in the ΔfliF and ΔfliHIJ mutants. Finally, the combination of the ΔfliF and ΔfliHIJ mutations with our previously described attenuated and immunogenic background strain SF102 displayed strong efficacy against the highly resistant cancer cell line RenCa. We thus conclude that manipulating flagella biosynthesis has great potential for the construction of highly efficacious and versatile Salmonella vector strains.

Functional design of pH-responsive folate-targeted polymer-coated gold nanoparticles for drug delivery and in vivo therapy in breast cancer.

BACKGROUND: Curcumin has been widely used owing to its various medicinal properties including antitumor effects. However, its clinical application is limited by its instability, poor solubility and low bioavailability. Folic acid (FA)-functionalized nanoformulations may enhance the sustained release of an anticancer drug (curcumin) by tumor-specific targeting to improve therapeutic benefit. This study aims to design a nanoconjugate (NC) comprised of folate-curcumin-loaded gold-polyvinylpyrrolidone nanoparticles (FA-CurAu-PVP NPs) for targeted delivery in breast cancer model systems. METHODS: We developed curcumin-loaded FA-functionalized Au-PVP NCs by layer-by-layer assembly. The folic acid-curcumin Au-PVP NCs (FA-CurAu-PVP NCs) were characterized by ultraviolet-visible spectra, Fourier transform infrared spectroscopy, X-ray powder diffraction and thermogravimetric analysis. In vitro anticancer and antimigratory effects of NCs were examined by performing MTT and wound migration assays. The in vivo antitumor efficacy of NCs was investigated using a preclinical breast cancer orthotopic mouse model. RESULTS: Curcumin (40 µg/mL) was loaded along with conjugation of folate onto Au-PVP NPs to form FA-CurAu-PVP NCs. The size and charge of the NCs were increased gradually through layer-by-layer assembly and showed 80% release of curcumin at acidic pH. The NC did not show aggregation when incubated with human serum and mimicked an intrinsic peroxidase-like property in the presence of 3,3',5,5'-tetramethylbenzidine substrate. The MTT data using these NCs showed efficient anticancer activity at lower doses in estrogen/progesterone receptor (ER/PR)-negative cells compared with ER/PR-positive cells. Furthermore, the NCs did not show cytotoxicity at the investigated concentration in human breast epithelial and mouse fibroblast cell lines. They showed inhibitory effects on cell migration and high antitumor efficacy in in vivo analysis. CONCLUSION: These results suggest that folate-based tumor targeting using CurAu-PVP NCs is a promising approach for tumor-specific therapy of breast cancer without harming normal cells.

Dashavidha Parikshya Bhava (tenfold of investigation) according to Acharya Charaka - An ancient method of research.

Research follows a scientific way of establishing facts. All those methods which are used by the researcher during the course of studying the research problem are termed as research methods. The scientific method implies an objective, logical, and systematic method. Research is an organized endeavor. Like any other organized work, research requires proper planning, that systematizes the research work. It eliminates aimless intellectual wandering. Database of knowledge creation and its classification gives a definite structure to any literature. However, it needs a proper research methodology, without which the structure is incomplete. Ayurveda experts have followed certain research methods and methodology. The traditionally established truths need to be validated in scientific manner. Validation of ancient methods of investigation or research will ultimately lead to establishment of Ayurveda as a science which will contribute to broad domain of Indian research methodology. The critical scientific approach of Ayurveda is evident from various ancient methods. Proper planning before performance of any task is always advised by authoritative persons. Acharya Charaka has given Dashavidha Parikshya Bhava, i.e. tenfold of investigation which are necessary for accomplishment of task without intellectual wandering. The desired objectives can be achieved if proper planning is done beforehand. This study is an attempt to establish the applicability of Dashavidha Parikshya Bhava, i.e. tenfold of investigation in planning of research mentioned in Charaka Samhita.

Factors Differentiating Acute Hepatitis B from Acute Exacerbation of Chronic Hepatitis B in Prospective-retrospective Cohort.

INTRODUCTION AND AIM: It is difficult to distinguish acute hepatitis B (AVH-B) from chronic hepatitis B with an acute exacerbation (CHB-AE) in patients whose prior history of HBV infection is unknown. The present study aimed to screen laboratory parameters at presentation to discriminate between these two conditions. MATERIALS AND METHODS: A prospective study was conducted in patients presenting clinically as AVH-B without known previous chronic hepatitis B status. Patients were divided into AVH-B and CHB-AE at end of six months follow up. Clinical and laboratory profiles were compared between these two groups at presentation. RESULTS: There was no significant difference in clinical presentation and risk factors profile in patients of both the groups. Mean age of presentation in AVH-B was 31.8 ± 14.9 years while, 47.2 ±17.3 years in CHB-AE group (p=0.005). Mean IgM anti-HBc levels were higher in AVH-B than in the CHB-AE group (p=0.001). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IgM anti-HBc [>12.14 S/CO (Sample/Cut-off )] for diagnosis of AVH-B was 76.9%, 71.4%, 76.9% and 71.4 % respectively. Quantitative HBV DNA levels were significantly higher in CHB-AE group than in AVH-B group (p=0.015). Sensitivity, specificity, PPV and NPV of HBV DNA ( > 15390 IU/ml) for diagnosis of CHB-AE was 78.6%, 46.2%, 44% and 80% respectively. CONCLUSION: A high percentage of patients with apparent AVH-B might be cases of CHB-AE. Elderly patient (mean 47.2 years), high titers of HBV DNA (>15390 IU/ mL) and low IgM anti-HBc titer (<12.14 S/CO) favours CHB-AE over AVH-B.

An unusual case of obstructive jaundice: ampullary Burkitt lymphoma.

Primary lymphomas of the digestive tract are uncommon heterogenous group of neoplasms that primarily affects stomach. Lymphomatous involvement of small intestine is amongst the rare lymphomas; ampullary involvement is even rarer. It is important to recognize this entity early as it mimics periampullary neoplasms and its management is different. We present the case of a 14-year-old male who presented with rapidly progressive obstructive jaundice and weight loss and ultimately was diagnosed to have ampullary Burkitt's lymphoma. Early diagnosis of this aggressive tumor and prompt induction of chemotherapy dramatically improved the patient's condition. It is crucial to consider Burkitt's lymphoma as a differential diagnosis of obstructive jaundice as both the treatment and prognosis are markedly different.

Importance of flagella in acute and chronic Pseudomonas aeruginosa infections.

Pseudomonas aeruginosa is an environmental microorganism and a causative agent of diverse acute and chronic, biofilm-associated infections. Advancing research-based knowledge on its adaptation to conditions within the human host is bound to reveal novel strategies and targets for therapeutic intervention. Here, we investigated the traits that P. aeruginosa PA14 as well as a virulence attenuated ΔlasR mutant need to survive in selected murine infection models. Experimentally, the genetic programs that the bacteria use to adapt to biofilm-associated versus acute infections were dissected by passaging transposon mutant libraries through mouse lungs (acute) or mouse tumours (biofilm-infection). Adaptive metabolic changes of P. aeruginosa were generally required during both infection processes. Counter-selection against flagella expression was observed during acute lung infections. Obviously, avoidance of flagella-mediated activation of host immunity is advantageous for the wildtype bacteria. For the ΔlasR mutant, loss of flagella did not confer a selective advantage. Apparently, other pathogenesis mechanisms are active in this virulence attenuated strain. In contrast, the infective process of P. aeruginosa in the chronic biofilm model apparently required expression of flagellin. Together, our findings imply that the host immune reactions against the infectious agent are very decisive for acuteness and duration of the infectious disease. They direct disease outcome.

Minimal Hepatic Encephalopathy in Indians: Psychometric Hepatic Encephalopathy Score and Inhibitory Control Test for Diagnosis and Rifaximin or Lactulose for Its Reversal.

Background and Aims: Psychometric hepatic encephalopathy score (PHES) is used widely for diagnosis of minimal hepatic encephalopathy (MHE). This prospective study aimed to determine the utility of the inhibitory control test (ICT) for the diagnosis of MHE. Additionally, the efficacy of rifaximin and lactulose for reversal of MHE was evaluated. Methods: A total of 180 eligible cirrhotic patients underwent testing for MHE. When PHES was ≤ -5 and ICT lures were ≥ 14, MHE was diagnosed. The 108 patients with MHE were randomized to three groups for treatment with either lactulose, rifaximin, or placebo. Treatment outcomes were measured at the end of 3 months. Results: The 108 patients with MHE diagnosed by PHES and/or ICT accounted for 60%. The diagnosis of MHE was made by both ICT and PHES positivity in 56 patients, by abnormal ICT and normal PHES in 37 patients, and by abnormal PHES and normal ICT in 15 patients. For diagnosis of MHE, ICT had sensitivity of 78.87%, specificity of 66.06% with 60.22% positive predictive value and 82.76% negative predictive value. An area under the curve value of 0.724 (95% CI: 0.653-0.788) was obtained for diagnosis of MHE. Reversal of MHE was seen in 71.42%, 70.27% and 11.11% of patients in the rifaximin, lactulose and placebo arms (p < 0.001). Rifaximin showed better tolerability compared to lactulose. Conclusions: For the diagnosis of MHE, ICT is a simple tool but has lower sensitivity and better specificity than PHES. Rifaximin is as efficacious as lactulose in the treatment of MHE and better tolerated.

Presence of Infected Gr-1intCD11bhiCD11cint Monocytic Myeloid Derived Suppressor Cells Subverts T Cell Response and Is Associated With Impaired Dendritic Cell Function in Mycobacterium avium-Infected Mice.

Myeloid-derived suppressor cells (MDSC) are immature myeloid cells with immunomodulatory function. To study the mechanism by which MDSC affect antimicrobial immunity, we infected mice with two M. avium strains of differential virulence, highly virulent Mycobacterium avium subsp. avium strain 25291 (MAA) and low virulent Mycobacterium avium subsp. hominissuis strain 104 (MAH). Intraperitoneal infection with MAA, but not MAH, caused severe disease and massive splenic infiltration of monocytic MDSC (M-MDSC; Gr-1intCD11bhiCD11cint) expressing inducible NO synthase (Nos2) and bearing high numbers of mycobacteria. Depletion experiments demonstrated that M-MDSC were essential for disease progression. NO production by M-MDSC influenced antigen-uptake and processing by dendritic cells and proliferation of CD4+ T cells. M-MDSC were also induced in MAA-infected mice lacking Nos2. In these mice CD4+ T cell expansion and control of infection were restored. However, T cell inhibition was only partially relieved and arginase (Arg) 1-expressing M-MDSC were accumulated. Likewise, inhibition of Arg1 also partially rescued T cell proliferation. Thus, mycobacterial virulence results in the induction of M-MDSC that block the T cell response in a Nos2- and Arg1-dependent manner.

Breaking the Vicious Cycle of Antibiotic Killing and Regrowth of Biofilm-Residing Pseudomonas aeruginosa.

Biofilm-residing bacteria embedded in an extracellular matrix are protected from diverse physicochemical insults. In addition to the general recalcitrance of biofilm bacteria, high bacterial loads in biofilm-associated infections significantly diminish the efficacy of antimicrobials due to a low per-cell antibiotic concentration. Accordingly, present antimicrobial treatment protocols that have been established to serve the eradication of acute infections fail to clear biofilm-associated chronic infections. In the present study, we applied automated confocal microscopy on Pseudomonas aeruginosa to monitor dynamic killing of biofilm-grown bacteria by tobramycin and colistin in real time. We revealed that the time required for surviving bacteria to repopulate the biofilm could be taken as a measure for effectiveness of the antimicrobial treatment. It depends on the (i) nature and concentration of the antibiotic, (ii) duration of antibiotic treatment, (iii) application as monotherapy or combination therapy, and (iv) interval of drug administration. The vicious cycle of killing and repopulation of biofilm bacteria could also be broken in an in vivo model system by applying successive antibiotic dosages at intervals that do not allow full reconstitution of the biofilm communities. Treatment regimens that consider the important aspects of antimicrobial killing kinetics bear the potential to improve control of biofilm regrowth. This is an important and underestimated factor that is bound to ensure sustainable treatment success of chronic infections.

The Anaerobically Induced sRNA PaiI Affects Denitrification in Pseudomonas aeruginosa PA14.

Pseudomonas aeruginosa is an opportunistic pathogen that can thrive by anaerobic respiration in the lungs of cystic fibrosis patients using nitrate as terminal electron acceptor. Here, we report the identification and characterization of the small RNA PaiI in the P. aeruginosa strain 14 (PA14). PaiI is anaerobically induced in the presence of nitrate and depends on the two-component system NarXL. Our studies revealed that PaiI is required for efficient denitrification affecting the conversion of nitrite to nitric oxide. In the absence of PaiI anaerobic growth was impaired on glucose, which can be reconciled with a decreased uptake of the carbon source under these conditions. The importance of PaiI for anaerobic growth is further underlined by the observation that a paiI deletion mutant was impaired in growth in murine tumors.