Sickle red blood cell-derived extracellular vesicles activate endothelial cells and enhance sickle red cell adhesion mediated by von Willebrand factor.

Endothelial activation and sickle red blood cell (RBC) adhesion are central to the pathogenesis of sickle cell disease (SCD). Quantitatively, RBC-derived extracellular vesicles (REVs) are more abundant from SS RBCs compared with healthy RBCs (AA RBCs). Sickle RBC-derived REVs (SS REVs) are known to promote endothelial cell (EC) activation through cell signalling and transcriptional regulation at longer terms. However, the SS REV-mediated short-term non-transcriptional response of EC is unclear. Here, we examined the impact of SS REVs on acute microvascular EC activation and RBC adhesion at 2 h. Compared with AA REVs, SS REVs promoted human pulmonary microvascular ECs (HPMEC) activation indicated by increased von Willebrand factor (VWF) expression. Under microfluidic conditions, we found abnormal SS RBC adhesion to HPMECs exposed to SS REVs. This enhanced SS RBC adhesion was reduced by haeme binding protein haemopexin or VWF cleaving protease ADAMTS13 to a level similar to HPMECs treated with AA REVs. Consistent with these observations, haemin- or SS REV-induced microvascular stasis in SS mice with implanted dorsal skin-fold chambers that was inhibited by ADAMTS13. The adhesion induced by SS REVs was variable and was higher with SS RBCs from patients with increased markers of haemolysis (lactate dehydrogenase and reticulocyte count) or a concomitant clinical diagnosis of deep vein thrombosis. Our results emphasise the critical contribution made by REVs to the pathophysiology of SCD by triggering acute microvascular EC activation and abnormal RBC adhesion. These findings may help to better understand acute pathophysiological mechanism of SCD and thereby the development of new treatment strategies using VWF as a potential target.

An Umbrella Converse for Data Exchange: Applied to Caching, Computing, and Shuffling.

The problem of data exchange between multiple nodes with storage and communication capabilities models several current multi-user communication problems like Coded Caching, Data Shuffling, Coded Computing, etc. The goal in such problems is to design communication schemes which accomplish the desired data exchange between the nodes with the optimal (minimum) amount of communication load. In this work, we present a converse to such a general data exchange problem. The expression of the converse depends only on the number of bits to be moved between different subsets of nodes, and does not assume anything further specific about the parameters in the problem. Specific problem formulations, such as those in Coded Caching, Coded Data Shuffling, and Coded Distributed Computing, can be seen as instances of this generic data exchange problem. Applying our generic converse, we can efficiently recover known important converses in these formulations. Further, for a generic coded caching problem with heterogeneous cache sizes at the clients with or without a central server, we obtain a new general converse, which subsumes some existing results. Finally we relate a "centralized" version of our bound to the known generalized independence number bound in index coding and discuss our bound's tightness in this context.

Leukocyte adhesion to P-selectin and the inhibitory role of Crizanlizumab in sickle cell disease: A standardized microfluidic assessment.

Upregulated expression of P-selectin on activated endothelium and platelets significantly contributes to the initiation and progression of vaso-occlusive crises (VOC), a major cause of morbidity in sickle cell disease (SCD). Crizanlizumab (ADAKVEO®), a humanized monoclonal antibody against P-selectin, primarily inhibits the interaction between leukocytes and P-selectin, and has been shown to decrease the frequency of VOCs in clinical trials. However, the lack of reliable in vitro assays that objectively measure leukocyte adhesion to P-selectin remains a critical barrier to evaluating and improving the therapeutic treatment in SCD. Here, we present a standardized microfluidic BioChip whole blood adhesion assay to assess leukocyte adhesion to P-selectin under physiologic flow conditions. Our results demonstrated heterogeneous adhesion by leukocytes to immobilized P-selectin, and dose-dependent inhibition of this adhesion following pre-exposure to Crizanlizumab. Importantly, treatment with Crizanlizumab following adhesion to P-selectin promoted detachment of rolling, but not of firmly adherent leukocytes. Taken together, our results suggest that the microfluidic BioChip system is a promising in vitro assay with which to screen patients, monitor treatment response, and guide current and emerging anti-adhesive therapies in SCD.

The Anesthesia Records of Harvey Cushing and Ernest Codman.

Hundreds of thousands of anesthesia records are created each day. The earliest records were prepared by 2 medical students in late 19th-century Boston. Ernest Codman and Harvey Cushing went on to become prominent surgeons and contributed much to the safety of the surgical patient. Cushing's career is celebrated due to his associations with William Stewart Halsted, Peter Bent Brigham Hospital, Yale University, in New Haven, Connecticut, and his biography of Sir William Osler. Codman is remembered for introducing the morbidity and mortality conference as well as his drive to improve outcomes and patient safety. We analyze every anesthetic record created by Codman and Cushing and provide both a historical context and perspective on many ways in which their doggedness, brilliance, and insight anticipated many advances that enhanced safety for patients undergoing surgical procedures.

EXTRA CORPOREAL MEMBRANE OXYGENATION IN ACUTE RESPIRATORY DISTRESS SYNDROME.

A young female presented with pneumonitis and worsened acute respiratory distress syndrome (ARDS) failed all the conservative ventilator management, was managed with extra corporeal life support technology, and was successfully discharged.

Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients.

Background: Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5-120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5-120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results: The RSBI 5-120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5-120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5-120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5-120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion: The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome.

The stereoselective sulfate conjugation of 4'-methoxyfenoterol stereoisomers by sulfotransferase enzymes.

The presystemic sulfate conjugation of the stereoisomers of 4'-methoxyfenoterol, (R,R')-MF, (S,S')-MF, (R,S')-MF, and (S,R')-MF, was investigated using commercially available human intestinal S9 fractions, a mixture of sulfotransferase (SULT) enzymes. The results indicate that the sulfation was stereospecific and that an S-configuration at the ß-OH carbon of the MF molecule enhanced the maximal formation rates with (S,R')-MF (S,S')-MF (R,S')-MF ≈ (R,R')-MF, and competition studies demonstrated that (S,R')-MF is an effective inhibitor of (R,R')-MF sulfation (IC(50) = 60 µM). In addition, the results from a cDNA-expressed human SULT isoform screen indicated that SULT1A1, SULT1A3, and SULT1E1 can mediate the sulfation of all four MF stereoisomers. Previously published molecular models of SULT1A3 and SULT1A1 were used in docking simulations of the MF stereoisomers using Molegro Virtual Docker. The models of the MF-SULT1A3 and MF-SULT1A1 complexes indicate that each of the two chiral centers of MF molecule plays a role in the observed relative stabilities. The observed stereoselectivity is the result of multiple hydrogen bonding interactions and induced conformational changes within the substrate-enzyme complex. In conclusion, the results suggest that a formulation developed from a mixture of (R,R')-MF and (S,R')-MF may increase the oral bioavailability of (R,R')-MF.

Cancer-selective antiproliferative activity is a general property of some G-rich oligodeoxynucleotides.

Oligodeoxynucleotide libraries containing randomly incorporated bases are used to generate DNA aptamers by systematic evolution of ligands by exponential enrichment (SELEX). We predicted that combinatorial libraries with alternative base compositions might have innate properties different from the standard library containing equimolar A + C + G + T bases. In particular, we hypothesized that G-rich libraries would contain a higher proportion of quadruplex-forming sequences, which may impart desirable qualities, such as increased nuclease resistance and enhanced cellular uptake. Here, we report on 11 synthetic oligodeoxynucleotide libraries of various base combinations and lengths, with regard to their circular dichroism, stability in serum-containing medium, cellular uptake, protein binding and antiproliferative activity. Unexpectedly, we found that some G-rich libraries (composed of G + T or G + C nucleotides) strongly inhibited cancer cell growth while sparing non-malignant cells. These libraries had spectral features consistent with G-quadruplex formation, were significantly more stable in serum than inactive libraries and showed enhanced cellular uptake. Active libraries generally had strong protein binding, while the pattern of protein binding suggested that G/T and G/C libraries have distinct mechanisms of action. In conclusion, cancer-selective antiproliferative activity may be a general feature of certain G-rich oligodeoxynucleotides and is associated with quadruplex formation, nuclease resistance, efficient cellular uptake and protein binding.

Role of ventromedial hypothalamus on energy homeostasis in albino rats: effect of gender.

Various brain areas like the ventromedial hypothalamus (VMH) are known to influence food intake and body weight. Though obesity is more common in females, the reports on gender difference in the neural regulation of energy homeostasis are not adequate. Therefore, the present study was conducted to assess the gender difference in the effect of VMH lesion on food intake (FI), body weight (BW), serum lipid profile, thyroid profile, glucose and insulin levels and glucose-insulin ratio (GIR) in Wistar albino rats. Twenty-four Wistar albino rats were divided equally into control and experimental groups with 6 male and 6 female rats in each. In the experimental group, bilateral electrolytic lesion of VMH was performed by stereotaxy and post-lesion parameters were recorded. In the control group, VMH sham lesion was made. Male-female difference in each parameter was determined. Following VMH lesion, FI was increased (females, P < 0.01) and BW (males, P < 0.05) and GIR decreased in males (P < 0.001), which was significantly correlated with BW. T3 was more significantly correlated with FI and BW in females (P < 0.000 and P < 0.001). Following VMH lesion, male rats exhibited significant weight gain in the absence of proportionate hyperphagia indicating that weight-gain was mainly metabolic in nature. Also, the male rats developed more susceptibility to insulin resistance. The female rats developed resistance to weight-gain inspite of hyperphagia, which could be due to the higher T3 level.

Effect of lesion of nucleus septal medialis on energy homeostasis in Wistar rats.

Mesolimbic areas such as nucleus accumbens, amygdala and septal nuclei are known to influence food intake and body weight. However, the reports on gender difference in the neural regulation of obesity and energy homeostasis are incomplete. Therefore, the present study was conducted to assess the effect of lesions of nucleus septal medialis (NSM) and the gender difference of lesion on food intake (FI), body weight (BW), serum lipid profile, thyroid profile, glucose and insulin levels and glucose-insulin ratio (GIR) in Wistar albino rats. Twenty-four rats were divided equally into control and experimental groups having 6 male and 6 female rats in each group. In the experimental group, bilateral electrolytic lesion of NSM was performed by stereotaxy and post-lesion parameters were recorded. In the control group, sham-lesions of NSM were produced. Following lesion, blood glucose and serum insulin levels were decreased and GIR was increased significantly in female rats, but not in male rats. It was concluded that NSM is involved in energy homeostasis, especially in female rats.

Study of sympathovagal imbalance by spectral analysis of heart rate variability in young prehypertensives.

Though prehypertension has recently been considered as a risk factor for cardiovascular accidents, the pathophysiological mechanism that causes the development of prehypertension in normotensive subjects has not been fully elucidated. Therefore, the present study was conducted to assess the sympathovagal imbalance in prehypertensives and normotensives by spectral analysis of heart rate variability (HRV) to understand the nature of change in autonomic balance in this dysfunction. Body mass index (BMI), waist-hip ratio (WHR), basal heart rate (BHR), blood pressure (BP), rate-pressure product (RPP) and spectral indices of HRV such as total power (TP), normalized low frequency power (LFnu), normalized high frequency power (HFnu), ratio of low frequency power to high frequency power (LF-HF ratio), mean heart rate (mean RR), square root of the mean squared differences of successive normal to normal intervals; (RMSSD), the number of interval differences of successive NN intervals greater than 50 ms (NN50) and the proportion derived by dividing NN50 by the total number of NN intervals (pNN50) were assessed in two groups of young subjects: normotensives (n=68) and prehypertensives (n=66). Sympathovagal balance (SVB) was analyzed and correlated with BMI, WHR, BHR, BP and RPP in both the groups. It was observed that autonomic imbalance in prehypertensives was due to increase in both sympathetic activity and vagal inhibition. LF-HF ratio, the sensitive indicator of SVB was significantly correlated with BMI, WHR, BHR, BP and RPP in prehypertensive subjects. It was concluded that vagal inhibition might be important in the critical alteration of sympathovagal balance in the development of prehypertension in young normotensive subjects.

Evaluation of diuretic efficacy and antiurolithiatic potential of ethanolic leaf extract of Annona squamosa Linn. in experimental animal models.

OBJECTIVE: The study is to investigate the diuretic and antiurolithiatic activities of ethanolic leaf extract of Annona squamosa Linn. in experimental animals. MATERIALS AND METHODS: For both studies, Wistar albino rats and two doses of extract (250 and 500 mg/kg) were used. Diuretic activity was evaluated by Lipschitz model. Urine volume and urine pH were noted, the concentration of sodium and potassium was estimated by flame photometry, and diuretic index, natriuretic index, and Lipschitz values were calculated from the results. Furosemide was used as a positive control. Ethylene glycol-induced urolithiasis model was used for antiurolithiatic study. Urine volume, urine pH, body weight, and biochemical parameters such as calcium, urea, uric acid, and creatine both from serum and urine were estimated. Antioxidant parameters and histopathological analysis of the kidney were evaluated. Cystone was used as a positive control in this study. Results were expressed as mean ± standard error of mean. Statistical analysis was carried out using one-way analysis of variance, followed by Dunnett's multiple comparison tests. RESULTS: In both diuretic and antiurolithiatic studies, both doses of the extract showed efficacy, and the dose of 500 mg/kg has shown a significant effect compared to positive control and negative control. CONCLUSION: The dose of 500 mg/kg showed a promising diuretic and antiurolithiatic activity.

G-rich oligonucleotides for cancer treatment.

Oligonucleotides with guanosine-rich (G-rich) sequences often have unusual physical and biological properties, including resistance to nucleases, enhanced cellular uptake, and high affinity for particular proteins. Furthermore, we have found that certain G-rich oligonucleotides (GROs) have antiproliferative activity against a range of cancer cells, while having minimal toxic effects on normal cells. We have investigated the mechanism of this activity and studied the relationship between oligonucleotide structural features and biological activity. Our results indicate that the antiproliferative effects of GROs depend on two properties: the ability to form quadruplex structures stabilized by G-quartets and binding affinity for nucleolin protein. Thus, it appears that the antiproliferative GROs are acting as nucleolin aptamers. Because nucleolin is expressed at high levels on the surface of cancer cells, where it mediates the endocytosis of various ligands, it seems likely that nucleolin-dependent uptake of GROs plays a role in their activity. One of the GROs that we have developed, a 26-nucleotide phosphodiester oligodeoxynucleotide now named AS1411 (formerly AGRO100 or GRO26B-OH), is currently being tested as an anticancer agent in Phase II clinical trials.

Lung Ultrasound: The Emerging Role of Respiratory Therapists.

Lung ultrasound is a point-of-care imaging tool that is routinely used in acute care medicine. Traditionally, radiology physicians were the primary practitioners of diagnostic ultrasound, but with the recognition of its importance in intensive care medicine, critical care physicians have also adopted this practice. Within the intensive care unit inter-professional team is the respiratory therapist, who participates actively in the care of ventilated patients. Their scope of responsibility is expanding with newer technologies being brought into clinical use on a regular basis. This review focuses on the scope and benefits of ultrasound training within respiratory care-related areas.

Effect of resveratrol on 17beta-estradiol sulfation by human hepatic and jejunal S9 and recombinant sulfotransferase 1E1.

The purpose of this study was to investigate the sulfation of resveratrol (3,5,4'-trihydroxystilbene) and its potential to exhibit drug-drug interactions via sulfation. The possible interaction of resveratrol with 17beta-estradiol (E2), a major estrogen hormone and prototypic substrate for sulfate conjugation, was studied. Resveratrol and E2 are both known to undergo sulfate conjugation catalyzed by human sulfotransferases (SULTs). Resveratrol is a phytoestrogen with mixed estrogen agonist/antagonist properties that is being developed as a chemopreventive agent. The sulfate conjugation of E2 and resveratrol were studied individually using S9 fractions from human liver and jejunum as well as recombinant human SULT isoforms. The sulfation of E2 (3-20 nM) was then investigated in the presence of various concentrations (0, 0.5, 1, and 2 microM) of resveratrol using the two S9 preparations as well as recombinant SULT1E1, the major isoform responsible for E2 sulfation. Resveratrol inhibited E2 sulfation with estimated K(i) values of 1.1 microM (liver), 0.6 microM (jejunum), and 2.3 microM (SULT1E1), concentrations that could be pharmacologically relevant. The results suggest that these phytoestrogens can potentially alter the homeostasis of estrogen levels. These findings also imply that resveratrol may inhibit the metabolism of other estrogen analogs or therapeutic agents such as ethinylestradiol or dietary components that are also substrates for SULT1E1.

Acute respiratory failure as a manifestation of an arachnoid cyst.

Arachnoid cysts are the most common congenital cystic lesions in the brain occurring in the middle fossa, suprasellar region and occasionally in the posterior fossa. Conventionally all cysts are considered as benign and symptoms are attributed to expansion of cysts causing compression of adjacent neurological structures, bleeds within the cyst or due to the development of acute hydrocephalus. We are reporting this case of a 15-year-old female patient with non-progressive weakness in the limbs since the age of seven years who presented with acute onset syncopal attacks and respiratory failure. She was intubated and ventilated. An magnetic resonance imaging scan showed large posterior fossa cyst extending up to mid second cervical vertebra causing compression of the medulla and pons, with mild hydrocephalus. After a failed attempt to wean her from the ventilator a cysto peritoneal shunt surgery was performed following which she was weaned from the ventilator successfully. Weakness in the upper and lower limbs, which had increased in the preceding month, also improved following the surgery.

Variability of serum phenytoin levels in critically ill head injured patients in intensive care unit.

Patients with large variations in phenytoin levels despite standard doses may prove to become difficult clinical problems. Our study of 34 head injury patients whose serum phenytoin levels were measured on day one and day five following intravenous loading and maintenance dose of phenytoin, showed 38.24% patients, to have therapeutic phenytoin levels on day one, while 20% were in toxic range. On day five, 23% patients were in toxic and 29.41% were in therapeutic range. Only 21% patients remained in the therapeutic range during the monitoring period. This study shows that there is a wide variability of phenytoin levels in the ICU patients with a difference of more than 100% between the highest and lowest phenytoin level in individual cases (in four patients the difference exceeded 500%) raising concern about the safety of the drug. Hence it is recommended that intensive care unit patients receiving phenytoin therapy should have periodic serum phenytoin obtained even in absence of seizures or classic signs phenytoin toxicity.

Structure-based lead optimization to improve antiviral potency and ADMET properties of phenyl-1H-pyrrole-carboxamide entry inhibitors targeted to HIV-1 gp120.

We are continuing our concerted effort to optimize our first lead entry antagonist, NBD-11021, which targets the Phe43 cavity of the HIV-1 envelope glycoprotein gp120, to improve antiviral potency and ADMET properties. In this report, we present a structure-based approach that helped us to generate working hypotheses to modify further a recently reported advanced lead entry antagonist, NBD-14107, which showed significant improvement in antiviral potency when tested in a single-cycle assay against a large panel of Env-pseudotyped viruses. We report here the synthesis of twenty-nine new compounds and evaluation of their antiviral activity in a single-cycle and multi-cycle assay to derive a comprehensive structure-activity relationship (SAR). We have selected three inhibitors with the high selectivity index for testing against a large panel of 55 Env-pseudotyped viruses representing a diverse set of clinical isolates of different subtypes. The antiviral activity of one of these potent inhibitors, 55 (NBD-14189), against some clinical isolates was as low as 63 nM. We determined the sensitivity of CD4-binding site mutated-pseudoviruses to these inhibitors to confirm that they target HIV-1 gp120. Furthermore, we assessed their ADMET properties and compared them to the clinical candidate attachment inhibitor, BMS-626529. The ADMET data indicate that some of these new inhibitors have comparable ADMET properties to BMS-626529 and can be optimized further to potential clinical candidates.

Integration of Mobile Health Technology in the Treatment of Chronic Pain: A Critical Review.

This article provides a critical overview and best-evidence synthesis of the use of mobile health (mHealth) technology among persons with chronic pain and their health care providers and examines the future benefits and barriers of implementing mHealth technology in clinical care. We critically review articles about electronic pain diaries, pain assessment programs, text messaging, and smartphone pain apps for management of persons with pain. Also presented are findings on the utility of activity trackers and use of telehealth to deliver cognitive behavioral therapy. Finally, barriers, study gaps, and future challenges of incorporating mobile technology for chronic pain are discussed. Although the future of mHealth technology and telemedicine in clinical practice is promising, this critical review highlights the need for rigorous studies to establish an association of the use of mHealth technology with improved quality of life, functional autonomy, and decreased hospital use.

Glucuronidation of trans-resveratrol by human liver and intestinal microsomes and UGT isoforms.

Resveratrol (trans-resveratrol, trans-3,5,4'-trihydroxystilbene) is a naturally occurring stilbene analogue found in high concentrations in red wine. There is considerable research interest to determine the therapeutic potential of resveratrol, as it has been shown to have tumour inhibitory and antioxidant properties. This study was performed to investigate the glucuronidation of resveratrol and possible drug interactions via glucuronidation. Two glucuronide conjugates, resveratrol 3-O-glucuronide and resveratrol 4'-O-glucuronide, were formed by human liver and intestinal microsomes. UGT1A1 and UGT1A9 were predominantly responsible for the formation of the 3-O-glucuronide (Km = 149 microM) and 4'-O-glucuronide (Km = 365 microM), respectively. The glucuronide conjugates were formed at higher levels (up to 10-fold) by intestinal rather than liver microsomes. Resveratrol was co-incubated with substrates of UGT1A1 (bilirubin and 7-ethyl-10-hydroxycamptothecin (SN-38)) and UGT1A9 (7-hydroxytrifluoromethyl coumarin (7-HFC)). No major changes were noted in bilirubin glucuronidation in the presence of resveratrol. Resveratrol significantly inhibited the glucuronidation of SN-38 (Ki = 6.2 +/- 2.1 microM) and 7-HFC (Ki = 0.6 +/- 0.2 microM). Hence, resveratrol has the potential to inhibit the glucuronidation of concomitantly administered therapeutic drugs or dietary components that are substrates of UGT1A1 and UGT1A9.