A Synergistic Role of Myeloperoxidase and High Sensitivity Troponin T in the Early Diagnosis of Acute Coronary Syndrome.

Aim of this study was to evaluate the role of Myeloperoxidase (MPO) and high sensitive Troponin T in the early diagnosis of acute coronary syndrome (ACS). This was a cross sectional study that comprised of 120 individuals of which 75 were cases and 45 healthy controls. On the basis of clinical history and 12 lead electrocardiogram initial diagnosis of ACS was made in the cases. MPO and high sensitive Troponin T (hs-cTnT) was measured in all the individuals. Levels of MPO were significantly higher in patients of ACS as compared to those in control group [medians: 15.40 (95 % CI 11.06-20.84) vs 5.84 (95 % CI 5.50-6.44)]. By taking the cut off as >11.87 U/mL for MPO, its sensitivity was 87 % (95 % CI 73.7-95.1), specificity was 97.3 % (95 % CI 90.6-99.7), positive predictive value was 94.6 % and negative predictive value was 92.6 %. Positive likelihood ratio was 33.0 while negative likelihood ratio was 0.13, whereas the corresponding values in case of hs-cTnT were 95.6 % (95 % CI 85.2-99.5), 61.3 % (95 % CI 49.5-72.6), 59.7 %, 95.8 %, 2.47 and 0.07 by taking cut off as >14 pg/ml. The area under the ROC curves (AUC) of MPO and hscTnT at 0-6 h were 0.971 (95 % CI 0.92-0.99, P < 0.001) and 0.797 (95 % CI 0.71-0.86, P < 0.001) respectively. The logistic model combining the two markers yielded sensitivity, specificity, positive predictive value and negative predictive value of 95.7, 97.3, 98.2 and 93.7 % respectively. It was concluded that MPO and hs-cTnT may be useful tools for risk stratification of ACS and can be used together with better accuracy in the early diagnosis of ACS.

Gene polymorphisms, tobacco exposure and oral cancer susceptibility: a study from Gujarat, West India.

Polymorphic variability in the enzymes involved in biotransformation of tobacco-related pro-carcinogens plays an important role in modulating oral cancer susceptibility. CYP1A1*2A, CYP1A1*2C, GSTM1 and GSTT1 polymorphisms were determined in 122 oral carcinoma cases and 127 controls from Gujarat, West India using PCR-based methods. The results revealed that the polymorphic variants of CYP1A1 gene did not show association towards oral cancer risk. The GSTM1 and GSTT1 null genotypes were found to be over-represented in patients than controls, suggesting a moderate increase in risk of oral cancer. The oral cancer risk was significantly increased in the patients having either alone or concurrent deletion of GSTM1 and GSTT1. The results also suggested significant association between tobacco habits, especially chewing, variant genotypes of CYP1A1, GSTM1 and GSTT1 and oral cancer risk. Our data have provided evidence that GST polymorphism modified the susceptibility to oral cancer and individuals with variant genotypes of the three genes with tobacco habits are at significant risk of developing oral cancer.

Comparison of Mass Versus Activity of Creatine Kinase MB and Its Utility in the Early Diagnosis of Re-infarction.

Currently employed markers for the detection of acute coronary syndrome are Troponin T, CK (Creatine Kinase) and CKMB activity. CKMB activity measured by immunoinhibition method can give falsely elevated results due to the presence of atypical CK and CKBB and at times lead to the mis-diagnosis of acute coronary syndrome. Hence, CKMB mass (CKMB) measured by electrochemiluminence sandwich principle was employed. In this cross-sectional study 183 samples of 61 patients were analyzed within 6 h of diagnosis of acute coronary syndrome and followed up to 72 h. The correlation coefficient between CKMB activity and CKMBM at 4-6 h was 0.744, while at 12-24 h it was 0.909 and at 48-72 h it was 0.337. Thus there was good association between the two methods at 12-24 h but, statistically for method comparison studies and for replacing one method by another, the two methods need to be in agreement with one another. In this study the two methods are not in agreement with one another and thus analytically not replaceable. Another finding was obtained that CKMBM reached cut off levels prior to CKMB enzyme activity and hence, CKMBM is clinically better than CKMB activity to detect reinfarction.

Monitoring and root cause analysis of clinical biochemistry turn around time at an academic hospital.

Quality can be defined as the ability of a product or service to satisfy the needs and expectations of the customer. Laboratories are more focusing on technical and analytical quality for reliability and accuracy of test results. Patients and clinicians however are interested in rapid, reliable and efficient service from laboratory. Turn around time (TAT), the timeliness with which laboratory personnel deliver test results, is one of the most noticeable signs of laboratory service and is often used as a key performance indicator of laboratory performance. This study is aims to provide clue for laboratory TAT monitoring and root cause analysis. In a 2 year period a total of 75,499 specimens of outdoor patient department were monitor, of this a total of 4,142 specimens exceeded TAT. With consistent efforts to monitor, root cause analysis and corrective measures, we are able to decreased the specimens exceeding TAT from 7-8 to 3.7 %. Though it is difficult task to monitor TAT with the help of laboratory information system, real time documentation and authentic data retrievable, along with identification of causes for delays and its remedial measures, improve laboratory TAT and thus patient satisfaction.

A serial follow up study of cardiac marker enzymes during the week after acute myocardial infarction.

Laboratory infarction diagnostics are based on the detection of elevated serum activities of creatine kinase (CK) Creatine kinase Isoenzyme MB (CKMB) and Transaminases. Determination of these cardiac marker enzymes permits the diagnosis of transmural myocardial infarction. However in such patients the diagnosis of acute myocardial infarction can be confirmed by the clinical symptoms and changes in the ECG, in addition to the enzyme assays. The 50 AMI patients selected in the present study were those admitted to the ICCU of Shri Krishna Hospital, Karamsad. The blood samples were taken at Zero hours (i.e. at the time of admission of the patient). Within 6 hrs of the starting of chest pain, 1.5 million units of streptokinase were mixed with 100 to 150ml of normal saline and administered by infusion over a period of one hour. The blood samples were further collected at intervals of 6 hrs, 14hrs, 32hrs, 48hrs, 5(th) day and 7(th) day. The blood samples were analyzed for CK, CKMB, SGOT, α HBDH and Cardiac specific Troponin T. By 6hrs the CK and CKMB values had started rising, the rise continuing at 14hrs with peak values at 32hrs. The CK showed a slight decrease by 48 hrs. The cardiac Troponin T showed wide time window from 4 hrs to 7(th) day for detecting myocardial damage. The maximum cardiac Troponin T values were during the first 24hrs. Cardiac Troponin T in serum appears to be a more sensitive and early indicator of myocardial cell injury in comparison to CKMB.

A synergistic role of ischemia modified albumin and high-sensitivity troponin T in the early diagnosis of acute coronary syndrome.

AIM: The aim was to evaluate the role of high sensitivity troponin T and ischemia modified albumin (IMA) and in the early diagnosis of acute coronary syndrome (ACS). MATERIALS AND METHODS: This was a cross-sectional study that comprised of 120 individuals of which 75 were cases and 45 healthy controls. On the basis of clinical history and 12-lead electrocardiogram, initial diagnosis of ACS was made in the cases. High sensitive cardiac troponin T (hs-cTnT) and IMA were measured in all the individuals. RESULTS: Levels of IMA were significantly higher in patients of ACS as compared to those in control group (means: 101.83 [95% confidence interval (CI): 91.96-111.70] vs. 41.11 [95% CI: 38.55-43.67]). By taking the cut-off as >65.23 U/mL for IMA, which was obtained from receiver operating characteristic (ROC) curve, the sensitivity was 91.3%, specificity was 81.1%, positive predictive value (PPV) was 74.4%, and negative predictive value (NPV) was 93.9%. Positive likelihood ratio was 4.83 while negative likelihood ratio was 0.11, whereas the corresponding values in case of hs-cTnT were 95.6% (95% CI: 85.2-99.5), 61.3% (95% CI: 49.5-72.6), 59.7%, 95.8%, 2.47 and 0.07 by taking cut-off as >14 pg/mL. The area under the ROC curves (AUC) of IMA and hs-cTnT at 0-6 h were 0.932 (95% CI: 0.87-0.97, P < 0.001) and 0.797 (95% CI: 0.71-0.86, P < 0.001), respectively. The logistic model combining the two markers yielded sensitivity, specificity, PPV, and NPV of 95.7%, 81.1%, 88.6%, and 92.5% respectively. CONCLUSION: hs-cTnT and IMA may be useful tools for risk stratification of ACS and can be used together with better accuracy in the early diagnosis of ACS.

Utility of Heart-type Fatty Acid Binding Protein as a New Biochemical Marker for the Early Diagnosis of Acute Coronary Syndrome.

INTRODUCTION: Acute coronary syndrome (ACS) refers to a constellation of clinical symptoms caused by acute myocardial ischemia. Cardiovascular diseases (CVDs) are major and growing contributors to mortality and disability in India. AIMS AND OBJECTIVES: Especially patients with non-ACS-related troponin elevations have an adverse outcome and require careful patient management. So, we look forward for another marker Heart-type Fatty Acid Binding Protein (H-FABP) that reliably detects myocardial ischemia in the absence of necrosis and would be useful for initial identification and for differentiating patients with chest pain of aetiology other than coronary ischemia. MATERIALS AND METHODS: The study was done on 88 subjects of whom 34 subjects were with ischemic chest pain, 29 were with non-ischemic chest pain and 25 were normal subjects. RESULTS: Receiver operating characteristic (ROC) curve analysis was done which showed that area under the curve (AUC) for H-FABP was 0.885(0.79-0.94) and that of high-sensitive Troponin T (hs-TnT) in initial six hours was 0.805(0.70-0.88). The specificity of H-FABP was higher compare to hs-TnT while sensitivity was comparable during 0-6 h of presentation of chest pain. CONCLUSION: H-FABP can be used as an additional marker to hs-TnT in diagnosis of myocardial infarction (MI) and for exclusion of non-AMI (acute myocardial infarction) patients.

Electrolyte studies after intra-amniotic instillation of 20 per cent sodium chloride.

PIP: Electrolyte studies following intraamniotic instillation of 200 ml of 20% sodium chloride are reported. In 300 cases of second trimester termination of pregnancy, sodium, potassium, and chloride in the blood, urine, and liquor were analyzed over 24 hours. There was no marked difference in blood electrolytes though abnormally elevated serum sodium concentrations were occasionally noted but no adverse effects were observed. The excretion of sodium and chloride in the urine increased slowly and most was excreted in 24 hours. Urinary potassium increased in the 1st 2 hours, followed by a progressive fall to lower than baseline values at the end of 24 hours. The data showed rapid clearance of instilled hypertonic saline without adverse effects. It is suggested that this method is simple, sure, and safe when a careful assessment of patients is made before induction, and when precautions are taken for proper instillation of saline.^ieng

Evaluation of clinical utility of serum enzymes and troponin-T in the early stages of acute myocardial infarction.

Laboratory infarction diagnostics are based on the detection of elevated serum activities of total Creatine Kinase (CK), Creatine Kinase isoensyme MB, (CKMB), Lactate dehydrogenase (LDH), isoenzyme forms of LDH and transaminases. Determination of these cardiac marker enzymes permits a highly sensitive diagnosis of transmural myocardial infarction. In such patients the diagnosis of acute myocardial infarction can be confirmed by the clinical, symptoms, and changes in the ECG in addition to the enzyme assays. The 50 AMI patients selected in the present study were those admitted to the ICCU of Shri Krishna Hospital, Karamsad. The blood samples were taken at the time of admission (ie. within four hours of the start of chest pain). The samples were analyzed for CK, CKMB, SGOT, (Serum glutamate oxaloactate transaminase) αHBDH α-hydroxybutyrate dehydrogenase and troponin T. The serum CKMB activity in AMI showed an increase only 5-6 hours after the commencement of chest pain. The elevation in SGOT and αHBDH was still delayed. At the same time we could observe that the cardiac Troponin T (cTnT) was elevated at the time of admission of the patient itself. This increase of cTnT in AMI patients was 20 times higher than the normal blood donors. The controls included 25 normal blood donors and 25 patients with polytraumatic injuries with no chest contusion. The study shows that cTnT estimation could serve in the early diagnosis of AMI. The increase of cardiac troponin T in AMI patients was 20 times higher than the normal blood donors in AMI patients at the time of admission. Cardiac troponin T in serum appears to be a more sensitive indicator of myocardial cell injury than CKMB activity and its detection in the circulation may be a useful prognostic indicator in patients with unstable angina as well. When the blood of normal blood donors or that of patients with polytraumatic injury was analysed the troponin T values were well within the normal range in both the above categories showing that cardiac troponin T is highly specific for heart tissue. Although CKMB and cardiac troponin T are released soon after the myocardial injury, the release of cardiac troponin T is much earlier than CKMB thereby invalidating the important role of cardiac troponin T in diagnosing AMI. Cardiac troponin T has been shown to be highly sensitive for cardiac injury and not elevated in any other trauma, heavy exercise or skeletal muscle injury. Cardiac troponin T is ordinarily undetectable in healthy individuals, and so its measurement can serve as a powerful tool in the diagnosis of AMI.

A synthetic formulation, Dhanwantharam kashaya, delays senescence in stem cells.

OBJECTIVES: Mesenchymal stem cells (MSCs) derived from post-natal tissues offer a suitable source of MSCs for cellular therapy. Limitation of the use of MSCs for therapeutic purposes is attributed to the onset of senescence and slowing down of proliferation upon repeated passaging. Dhanwantram kashaya (DK), a synthetic herbal formulation, is widely used in Ayurvedic medicine as a growth stimulant in children and for nerve regeneration. In this study, we evaluated the effects of DK on the proliferation, viability and senescence of human Wharton jelly MSCs (WJMSCs) in vitro. RESULTS: Using the MTT proliferation assay and live/dead trypan blue analysis, we found that DK increased proliferation of WJMSCS up to three folds when supplemented in the culture media. The BrdU cell proliferation assay showed a substantial increase in WJMSCs treated with DK. Notably, the ß-galactosidase senescence assay revealed that drug treated WJMSCs at late passage still had intact and viable WJMSCs whereas the untreated cells exhibited profound senescence. CONCLUSION: These studies indicate that DK enhances the quality of WJMSCs by not only increasing the proliferation rate and decreasing their turnover time but also by delaying senescence. We have, thus, identified for the first time that a traditional Ayurvedic formulation, Dhanwantram kashaya, used as a growth enhancer, is able to improve the yield and quality of stem cells in vitro and could be an effective non-toxic supplement for culturing WJMSCs for clinical applications.

Inherent propensity of amnion-derived mesenchymal stem cells towards endothelial lineage: vascularization from an avascular tissue.

One of the most pressing problems in injury is wound healing and blood vessel formation. The amniotic membrane is important in clinical applications as it is pro-angiogenic, anti-fibrotic and anti-scarring and has low immunogenicity. In this study, we characterized amniotic membrane mesenchymal stem cells (AMMSCs) by their trademark mesenchymal stem cell (MSC) signature and profiled for embryonic pluripotency markers namely alkaline phosphatase, Oct4, Sox2, Nanog, SSEA3 and 4, and Klf4 by RT-PCR and nuclear localization of Oct4 and Nanog by immunocytochemistry. The amnion, although avascular, contains pro-angiogenic factors such as type I, III, IV and V collagen, laminin, and fibronectin in the extra cellular matrix. We, therefore, hypothesized that AMMSCs is pro-angiogenic. Thus, we demonstrate that MSCs derived from the amnion have a natural ability to initiate endothelialization and angiogenesis in vitro. Our results using a wound scratch assay and angiogenesis on Matrigel suggest a pro-angiogenic property of AMMSCs. We also show that native, uninduced AMMSCs are able to form endothelial rings in Matrigel. Further evidence was provided by RT-PCR showing the expression of pro-angiogenic factors such as Tie2, Ang1, VEGF, VEGFR, vWF, KDR and Flt4 in native AMMSCs. Taken together, our results suggest that MSCs from an avascular amnion have an inherent propensity for promoting angiogenesis and could be an ideal choice in wound healing, stroke and ischemic diseases that require rapid vascularization and tissue restoration.

Matrix metalloproteinases and their inhibitors: correlation with invasion and metastasis in oral cancer.

Matrix metalloproteinases (MMPs) have been implicated in invasion and metastasis of various malignancies. The study evaluated a comprehensive profile of MMP-2 and MMP-9 and their inhibitors, tissue inhibitor of metalloproteinases-2 (TIMP-2) and tissue inhibitor of metalloproteinases-1 (TIMP-1), respectively in 50 controls and 75 patients with oral squamous cell carcinoma (OSCC). Blood samples from controls and patients as well as malignant and adjacent normal tissues from the patients were collected. The study examined pro, active and total forms of MMP-2 and MMP-9 using zymography. Enzyme-linked immunoassay (ELISA) and reverse transcription polymerase chain reaction were carried out to evaluate protein levels and mRNA expression; respectively, for the MMPs and TIMPs. Plasma pro, active and total MMP-2, MMP-9 as well as TIMP-1 and TIMP-2 levels were significantly higher in oral cancer patients as compared to the controls. mRNA expression of the MMPs and TIMPs was significantly higher in malignant tissues as compared to adjacent normal tissues. A significant positive correlation was observed between levels of proMMP-9 and active MMP-9 with differentiation, stage and infiltration. ProMMP-2 and active MMP-2 exhibited significant positive correlation with differentiation and lymph node involvement. The multivariate analysis of ELISA results revealed a significant positive correlation between MMP-2, TIMP-1 and TIMP-2 levels with lymph node involvement, stage and differentiation. The receiver operating characteristic curve (ROC) analysis showed that the levels of MMPs and TIMPs have significant discriminatory efficacy to differentiate between controls and patients. The results indicate that MMP-2, MMP-9, TIMP-1 and TIMP-2 have significant clinical usefulness for oral cancer patients. Zymographic analysis is a simple, cost effective, rapid and sensitive alternative assay.