Prescribing Patterns for Long-Acting Inhaled Bronchodilators Among Rural Adults With Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) is prevalent in rural areas of the USA. Long-acting inhaled bronchodilators (LABDs) are a key tool in COPD management and are underutilized. The purpose of this study was to determine whether rates of prescriptions for LABD differed by payer among patients with COPD in a rural healthcare network. Methods: In analysis 1, a random sample of patients with spirometry- and symptom-confirmed COPD over April 1, 2017 to December 31, 2019 was identified. Patient characteristics, including payer status, extracted from medical records were compared for those who did and did not have any prescriptions for LABD during the study window. In analysis 2, patients with one or more COPD-related hospitalizations during the same time period were identified and similar comparisons were made by LABD prescription status. Results: Among a random sample of patients with spirometry-confirmed COPD, 93.0% had been prescribed LABD during the study window with no difference in proportion by payer. Among the 461 patients with a COPD-related hospitalization, 388 (84.2%) had been prescribed LABD, again with no difference in prescriptions by payer. Those with a COPD-related hospitalization who had been prescribed LABD were younger, had lower body mass index, were more likely to be current smokers and had higher rates of hospitalizations for COPD during the study period than those not prescribed LABD. Conclusion: While disparities in LABD utilization may occur due to cost or other barriers to filling prescriptions, in our study, prescriptions for LABD were common and did not differ by payer status.

Aberrant STAT1 methylation as a non-invasive biomarker in blood of HCV induced hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common types of cancer in the world and a reason behind different oncogenes activation and tumor suppressor genes inactivation. Hyper-methylation of tumor suppressor genes including RASSF1a, GSTP1, p16, and APC cause gene silencing as well as tumor cell invasion. STAT 1 gene is a part of signaling cascade of JAK/STAT and any dysregulation in signaling has been implicated in tumor formation. OBJECTIVE: The current investigation focus on the methylation role of STAT1 gene as a non-invasive biomarker in the progression and diagnosis of hepatocellular carcinoma. METHODS: STAT1 gene methylation status in 46 HCV induced hepatocellular carcinoma patients and 40 non-HCC controls were examined by methylation specific PCR. STAT1 gene expression was examined by real time PCR and further validated by various bioinformatics tools. RESULTS: STAT1 methylation in HCV-induced HCC (67.4%) was significantly higher compared to the non-HCC controls (p< 0.01). However, mRNA expression of STAT1 gene in methylated groups was significantly lower compared to unmethylated groups (p< 0.05). Furthermore, insilco analysis of STAT1 validated our results and shown expression of STAT1 mRNA was lower in liver cancer with the median 24.3 (p= 0.085). CONCLUSION: After using peripheral blood samples we observed that STAT1 silencing caused by aberrant methylation could be used as potential non-invasive biomarker for the diagnosis of HCV induced hepatocellular carcinoma. We conclude that blood as a sample source could be used instead of biopsy for early detection of HCC.

Biosynthesis of silver nanoparticles for the fabrication of non cytotoxic and antibacterial metallic polymer based nanocomposite system.

Nanomaterials have significantly contributed in the field of nanomedicine as this subject matter has combined the usefulness of natural macromolecules with organic and inorganic nanomaterials. In this respect, various types of nanocomposites are increasingly being explored in order to discover an effective approach in controlling high morbidity and mortality rate that had triggered by the evolution and emergence of multidrug resistant microorganisms. Current research is focused towards the production of biogenic silver nanoparticles for the fabrication of antimicrobial metallic-polymer-based non-cytotoxic nanocomposite system. An ecofriendly approach was adapted for the production of silver nanoparticles using fungal biomass (Aspergillus fumigatus KIBGE-IB33). The biologically synthesized nanoparticles were further layered with a biodegradable macromolecule (chitosan) to improve and augment the properties of the developed nanocomposite system. Both nanostructures were characterized using different spectrographic analyses including UV-visible and scanning electron microscopy, energy dispersive X-ray analysis, dynamic light scattering, and Fourier transform infrared spectroscopic technique. The biologically mediated approach adapted in this study resulted in the formation of highly dispersed silver nanoparticles that exhibited an average nano size and zeta potential value of 05 nm (77.0%) and - 22.1 mV, respectively with a polydispersity index of 0.4. Correspondingly, fabricated silver-chitosan nanocomposites revealed a size of 941 nm with a zeta potential and polydispersity index of + 63.2 mV and 0.57, respectively. The successful capping of chitosan on silver nanoparticles prevented the agglomeration of nanomaterial and also facilitated the stabilization of the nano system. Both nanoscopic entities exhibited antimicrobial potential against some pathogenic bacterial species but did not displayed any antifungal activity. The lowest minimal inhibitory concentration of nanocomposite system (1.56 µg ml-1) was noticed against Enterococcus faecalis ATCC 29212. Fractional inhibitory concentration index of the developed nanocomposite system confirmed its improved synergistic behavior against various bacterial species with no cytotoxic effect on NIH/3T3 cell lines. Both nanostructures, developed in the present study, could be utilized in the form of nanomedicines or nanocarrier system after some quantifiable trials as both of them are nonhazardous and have substantial antibacterial properties.

Structural elucidation and cytotoxic analysis of a fructan based biopolymer produced extracellularly by Zymomonas mobilis KIBGE-IB14.

Fructan based biopolymers have been extensively characterized and explored for their potential applications. Linear chained biopolymers, like levan-type fructan, have gained attention because they have exhibited unconventional stretchable and unbendable properties along with biodegradable and biocompatible nature. Current study deals with the chemical characterization and cytotoxic analysis of fructose based exopolysaccharide that was extracellularly produced by an indigenously isolated bacterial species (Zymomonas mobilis KIBGE-IB14). Maximum yield of exopolysaccharide (44.7 gL-1) was attained after 72 h of incubation at 30 °C under shaking conditions (180 rpm) when the culture medium was supplemented with 150.0 gL-1 of sucrose as a sole carbon source. This exopolysaccharide displayed high water solubility index (96.0%) with low water holding capacity (17.0%) and an intrinsic viscosity of about 0.447 dL g-1. This biopolymer exhibited a characteristic linear homopolysaccharide structure of levan when characterized using Fourier Transform Infrared (FTIR), Nuclear Magnetic Resonance (NMR) spectroscopy (1H, 13C, TOCSY and NOESY) while, Atomic Force Microscopy (AFM) revealed its pointed and thorny structure. The decomposition temperature of levan was approximately 245 °C as revealed by Thermal Gravimetric Analysis (TGA). X-Ray Diffraction (XRD) results revealed its amorphous nature with crystalline phase. Cytotoxicity of different concentrations of levan was investigated against mouse fibroblast cell lines by measuring their cellular metabolic activity and it was noticed that a higher concentration of levan (2.0 mg ml-1) permitted the normal cell growth of NIH/3T3 cell lines. This non-cytotoxic and biocompatible nature suggests that this levan has the capability to be utilized in food and drug-based formulations as it exhibited biomedical potential.

Habit Mimics the Illness: EVALI During the Era of the COVID-19 Pandemic.

Globally, health care providers have been challenged to provide adequate care during the coronavirus disease-2019 (COVID-19) pandemic. Due to the ever changing and rapidly evolving nature of the novel coronavirus, there is increased public anxiety and knowledge gaps that have created major dilemmas in health care delivery. In this environment, there is tremendous pressure on clinicians to diagnose each and every case of COVID-19. This has led to a situation in which clinicians are primed to suspect all respiratory illness is due to COVID-19 infection until proven otherwise. Because of this, providers may misdiagnose patients who have illnesses that are distinct from COVID-19 but present in a similar manner. In the current article, we present the case of e-cigarette- and vaping-associated acute lung injury (EVALI) mimicking pneumonia secondary to the novel coronavirus. It is unknown if vaping puts patients at higher risk of respiratory failure if coinfected with COVID-19. Therefore, exposure history in patients presenting with pneumonia-like syndrome is important. Physicians should be aware of the overlap between these conditions and should pay particular attention during history taking to distinguish EVALI from COVID-19 pneumonia.

Pulmonary blastomycosis in rural Upstate New York: A case series and review of literature.

In a rural medical center in Upstate New York, we observed an increase in pulmonary blastomycosis cases. Herein, we highlight the increased prevalence of blastomycosis in our region, and our experience with the diagnostic dilemma resulting in delayed diagnosis. This delay may have resulted in an increased mortality. A high index of suspicion may help hasten the diagnosis in an otherwise nonendemic area. A single-center retrospective case series of all patients diagnosed with culture-proven blastomycosis is reported at the Bassett Medical Center from 2007 to 2019. Eight cases of confirmed pulmonary blastomycosis were identified. All patients resided in a rural area along the Susquehanna River Basin. Only one case had a travel history to an endemic state. Males accounted for 100% of cases. There was a 50% mortality rate from acute respiratory distress syndrome. Bronchoalveolar lavage (BAL) reliably made the diagnosis. About 40% of patients had a false-negative blastomycosis serology. There was an average delay of 2.5 months from presentation to correct diagnosis due to a lack of consideration for blastomycosis. BAL resulted in a correct diagnosis, while serology was not reliable to exclude the diagnosis. Physicians should include blastomycosis in the diagnostic differential cases of nonresolving pneumonia in Upstate New York, an area not previously considered as endemic. Bronchoalveolar remains the evaluation method of choice if blastomycosis is suspected.

Incidence and Risk of Thyroid Dysfunction in Advanced or Metastatic Non-small Cell Lung Cancer Patients Treated with Pembrolizumab: A Meta-analysis.

Thyroid dysfunction is one of the major side effects associated with Pembrolizumab in the treatment of advanced or metastatic non-small cell lung cancer (NSCLC). We performed a systematic review and meta-analysis of randomized clinical trials to determine its overall incidence. A literature search was conducted using the electronic database engines PubMed and Google Scholar from inception to March 2019. Eligible studies were prospective randomized clinical trials with advanced or metastatic NSCLC. The pooled incidence, risk ratio (RR), and 95% confidence interval (CI) of thyroid dysfunction were calculated using the random-effect model. Given the possibility of a between-study variance, we used the random-effect model rather than the fixed-effect model. A total of four studies, including 1603 patients, were selected for analysis. Among patients receiving Pembrolizumab, the overall incidence of all-grade thyroid dysfunction was 19.8% (95% CI: 16.6-23.3%). Pembrolizumab was associated with a significantly increased risk of thyroid dysfunction of all grades, with a relative risk of 3.9 (95% CI: 2.08-7.42%, p= 0.084) in comparison with the controls. Therefore, there is a significant increase in developing thyroid dysfunction in advanced or metastatic NSCLC patients treated with Pembrolizumab.

A Rare Case of Necrotizing Sarcoid Granulomatosis Involving Liver.

Sarcoidosis is a multi-system inflammatory disease, characterized by formation of non-caseating epithelioid granulomas. It usually involves lungs, lymph nodes, skin, joints, eyes and uncommonly liver. Necrotizing sarcoid granuloma is a rare entity. We are presenting a case of necrotizing sarcoid granuloma of liver which is extremely rare.

Systemic Air Embolism Following Computed Tomography-Guided Lung Biopsy.

A 61-year-old male with a history of poorly differentiated squamous cell carcinoma of tongue who completed chemo-radiation was found to have bilateral lung nodules on follow-up positron emission tomography (PET) scan. He underwent computed tomography (CT)-guided lung biopsy. Sequential chest scans done during the procedure showed air-fluid level in the left ventricle, suggestive of air embolism. He was hemodynamically stable during the procedure, however at the end of the procedure he developed right-sided face and arm weakness with aphasia. Emergent CT scans including angiography of head and neck were done which did not show any bleed and was also negative for any air in intracranial vasculature. Patient was treated with 100% oxygen. His neurological symptoms resolved in 30 minutes and he was subsequently admitted to intensive care unit (ICU) for further management. Six hours later, repeat CT of chest was done which showed resolution of air embolism.

Severe Hyponatremia Due to Cisplatin-induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone.

We report a rare case of severe hyponatremia due to cisplatin-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in a 74-year-old male with a history of squamous cell carcinoma of the tongue who presented with a five days history of worsening confusion. He was found to have severe hyponatremia. His clinical and laboratory findings were consistent with hyponatremia due to SIADH. He was treated with fluid restriction and salt tablets after which his serum sodium markedly improved. Drugs including diuretics, antidepressants, antipsychotics are well known to cause hyponatremia. Cisplatin is a very common antineoplastic drug for solid tumors. Clinicians need to have prompt recognition of this rare side effect of cisplatin to prevent life-threatening hyponatremia.

A case of Avascular Necrosis in a patient with Adrenocortical Carcinoma and Disseminated Metastasis.

28 years old, male patient was diagnosed with Metastatic Adrenocortical Carcinoma after extensive investigation. Patient's primary concern was only his right hip and right shoulder pain. On imaging investigations, the patient was diagnosed with Avascular Necrosis of the right hip joint. Further laboratory work-up for avascular necrosis showed Primary Hypercortisolism and eventually patient was found to have Adrenocortical Carcinoma base on CT and bone scan results, Avascular Necrosis usually presents with pain in the affected area, mostly involving shoulder, knee or hip joint. Among many of the causes of Avascular necrosis, one rare cause is hormone secreting Adreno cortical Carcinoma, a rare and a highly malignant tumour. Patients can present with Cushing's syndrome or can have atypical presentation like this patient. This patient did not have any symptoms related to malignancy such as loss of appetite and weight loss.

Bioprospecting of indigenous resources for the exploration of exopolysaccharide producing lactic acid bacteria.

Exploration of biodiversity lead towards the discovery of novel exopolysaccharide (EPS) producing microbes that have multiple applications. The safety compatibility status of lactic acid bacteria (LAB) makes it an attractive candidate for the production of EPS in industries. Therefore, new bacterial isolates are continuously being identified from different habitats. Current research was conducted to explore indigenous biodiversity for the production of dextransucrase, which is involved in the synthesis of dextran. Dextran is an EPS which is used in different industries. In this study, thirty-nine LAB were isolated from different food samples. The isolates were identified as genus Leuconostoc, Weissella and Streptococcus based on genotypic and phenotypic characteristics. Screening revealed that only eight isolates can produce dextransucrase in high titres. Fermentation conditions of dextran producing LAB was optimized. The results indicated that Weissella confusa exhibited maximum specific activity (1.50 DSU mg-1) in 8 h at 25 °C with pH 7.5. Dextran produced from Weissella proved to be a useful alternative to commercially used dextran produced by Leuconostoc mesenteroides in industries for various applications.

Hyper-production of levansucrase from Zymomonas mobilis KIBGEIB14 using submerged fermentation technique.

The industrial utilization of enzymes requires the high yield of enzyme production for the synthesis of polymers by microorganisms. Therefore, it is necessary to optimize different production parameters of levansucrase in order to increase its industrial applications. Zymomonas mobilis KIBGE-IB14 was considered as a promising candidate for the large scale production of levan among wide range of microorganisms. The current investigation is aimed to optimize the production parameters of levansucrase by Z. mobilis KIBGE-IB14 isolated from molasses. The results indicated that bacterial growth as well as enzyme production was greatly influenced by both physical and chemical conditions. It was revealed that high enzyme titers were achieved at 30°C with pH 6.5 after 24 hours of incubation in a modified medium. Moreover, the enzyme exhibited its induction in the presence of sucrose used as a substrate. Thus, the present study demonstrated that newly isolated Z. mobilis KIBGE-IB14 can be used as a plausible producer of levansucrase for industrial applications.

A case of hypotriploid chromosome in a patient with acute lymphoblastic leukaemia.

TA 58-61, XXXX, hypotriploid chromosome was detected in the cytogenetics report of a 28 years old female patient, known case of B-cell Acute Lymphoblastic Leukaemia. On admission, the patient had normal physical examination findings and mental status, except history of fever spikes and generalized bone pains. The patient was admitted for induction of chemotherapy. Bone Marrow/Trephine biopsy report showed diffuse infiltration with blast cells with overall cellularity around 80-85% and suppressed normal haematopoiesis. Hypotriploid chromosome number in patients with B-cell Acute Lymphoblastic Leukaemia is a unique finding which, according to WHO classification of ALL, is an important prognostic factor itself and these cases have a favourable prognosis. There are only a few medical reports published about cases with similar presentations in Pakistan. Therefore, this case is very unique and further work should be done for better understanding of similar presentations and to find out more about its epidemiology.

A case report of acute myelogenous leukemia with Turner Syndrome.

Turner Syndrome was diagnosed in a 45 years old female, known case of Acute Myeloid Leukaemia (AML) with maturation, on Bone Marrow biopsy. She presented with blurred vision, vertigo, exertional dyspnoea and insomnia. She did not show the typical features of Turner syndrome, but her cytogenetis confirmed the diagnosis. Bone marrow biopsy showed diffuse infiltration of blast cells with cellularity around 80-85% and haematopoietic suppression. Karyotype analysis showed: 45 X, -X, t (8; 21) (q22; q22) [According to The International System for Human Cytogenetic Nomenclature (ISCN)]. Turner syndrome is caused by partial or complete absence of second X chromosome in a female. It is known to have Cardiovascular and Reproductive complications but it is rare to find haematologic malignancies. There are few similar reported cases of AML associated with Turner syndrome, therefore this is a unique case presented to Jinnah Postgraduate Medical Center, Karachi, Pakistan and further research should be done to identify more similar cases to explore the prognostic significance of this association.

DNA methyltransferase 1, 3a, and 3b expression in hepatitis C associated human hepatocellular carcinoma and their clinicopathological association.

Identification of biomarker will obligate a substantial influence on various cancer management and treatment. We hypothesize that genetic/proteomic and epigenetic studies should be uncovering modifications which may be independently or jointly affect the expression of the genes that are involved in the progression of liver cancer (LC). For this purpose, we examined the effect of expressional changes of DNMTs on HCV infected LC of different genotypes. We found that both mRNA and protein expression levels of DNMT1, 3a, and 3b were upregulated in genotype 1b and 3a HCV infected patients as compared to control. However, DNMT3b mRNA levels did not change in genotypes 2a, 3, and 4, but were upregulated at the protein level by genotype 1b, 2a, and 3a. Furthermore, no significant changes were observed for DNMTs investigated in sample expressing the genotypes 5 and 6. Our findings suggest that HCV at least in part by altering DNMTs expression may play a significant role in HCC progression.