Advance Directive Utilization Is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation (HCT) is associated with significant morbidity and mortality, making advance care planning (ACP) and management especially important in this patient population. A paucity of data exists on the utilization of ACP among allogeneic HCT recipients and the relationship between ACP and intensity of healthcare utilization in these patients. We performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died after HCT. Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record. Outcomes of interest included use of intensive care unit (ICU) level of care at any time point after HCT, within 30 days of death, and within 14 days of death; use of mechanical ventilation at any time after HCT; and location of death. Univariate logistic regression was performed to explore associations between AD completion and each outcome. Of the 1031 patients who received allogeneic HCT during the study period, 422 decedents (41%) were included in the analysis. Forty-four percent had AD documentation prior to death. Most patients (69%) indicated that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with non-Hispanic white patients documenting ADs more frequently (51%) compared with Hispanic (22%) or Asian patients (35%; P?=?.0007). Patients with ADs were less likely to use the ICU during the transplant course (41% for patients with ADs versus 52% of patients without ADs; P?=?.03) and also were less likely to receive mechanical ventilation at any point after transplantation (21% versus 37%, P?<?.001). AD documentation was also associated with decreased ICU use at the end of life; relative to patients without ADs, patients with ADs were more likely to die at home or in hospital as opposed to in the ICU (odds ratio, .44; 95% confidence interval, .27 to .72). ACP remains underused in allogeneic HCT. Adoption of a systematic practice to standardize AD documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU use and mechanical ventilation while improving quality of care at end of life in HCT recipients.     

Characterization of a robust serine protease from Bacillus subtilis K‐1

Process apt microbial proteases due to their wide range industrial applications have become the focus of intense scientific research during recent years. Considering the hostile process milieu, the proteases intended for application must be robust enough to withstand the extremes of temperature and pH, and presence of organic solvents and other potential enzyme inhibitors. Current study presents the characterization of a robust protease from a previously isolated bacterium Bacillus subtilis K‐1 (BSK‐1). Purification of BSK‐1 protease (5.21‐fold) was achieved to homogeneity by salt (ammonium sulfate) precipitation, and ion‐exchange (diethyl‐aminoethyl‐sephadex) and size exclusion chromatography (Sephadex G‐100). Molecular weight of BSK‐1 protease was determined by SDS‐PAGE analysis (42 kDa). Though the optimum temperature and pH for BSK‐1 protease activity was 50 °C and 10, respectively, but, the protease exhibited remarkable activity and stability over elevated temperatures (60–80 °C) and a broad pH range (pH 7–11). Protease showed resistance towards several organic solvents/other potential enzyme inhibitors. Drastic activity loss in presence of phenylmethylsulfonyl fluoride indicated that the enzyme is a serine protease. Kinetic parameters (K_m and V_max) for BSK‐1 protease were found to be 0.14 mg ml^?1 and 1176 mg min^?1, respectively. Putative amino acid sequence of BSK‐1 protease (derived from nucleotide sequence of protease gene) suggested that the enzyme belonged to peptidases S8/S53 super family with multidomain of S8. BSK‐1 protease being stable under harsh conditions may serve a model system for understanding the molecular basis of stability, and may help designing novel proteases that are suitable for industrial applications.     

Argininosuccinate Synthetase-1 (ASS1) Loss in High-Grade Neuroendocrine Carcinomas of the Urinary Bladder: Implications for Targeted Therapy with ADI-PEG 20

High-grade neuroendocrine carcinomas (HGNECs) of the urinary bladder encompass small cell (SCNEC) and large cell neuroendocrine carcinomas (LCNEC). Currently, recommended initial management is with systemic chemotherapy, followed by consolidative therapy with either radical cystectomy or radiotherapy in patients with localized disease. Nevertheless, survival in this setting remains poor. We therefore evaluated the potential to modify arginine metabolism as an alternative, targeted therapy approach in these carcinomas. In humans, arginine is a semi-essential amino acid and its synthesis enzyme argininosuccinate synthetase (ASS1) represents the rate-limiting step in arginine biosynthesis. Neoplasms that show low to absent ASS1 expression require extracellular arginine for cancer cell survival, and thus can be targeted using arginine-degrading enzymes such as pegylated arginine deiminase (ADI-PEG 20). An initial study by our group of 19 patients demonstrated that a high percentage of SCNEC lack ASS1 expression. Herein, we evaluated an expanded cohort of 74 radical cystectomy patients with HGNEC, including 63 SCNEC, 5 LCNEC, and 6 mixed morphology HGNEC patients. ASS1 expression was assessed through immunohistochemistry. Fifty-eight (of 74, 78%) patients with HGNEC showed absent ASS1 expression, including all patients with LCNEC and mixed morphology (11 of 11, 100%). Ten-year survival from disease-specific death was not statistically significant between ASS1-expressing and ASS1-deficient cases (p?=?0.75). Our results show that HGNEC of the bladder may be candidates for arginine deprivation therapy using drugs such as ADI-PEG 20. Further studies are needed to validate these findings and to determine the therapeutic efficacy of such agents.     

Immune Profiling of T Cells Infiltrating Vitreous Humor in Tubercular Uveitis

Purpose: To assess cellular composition and local cytokine response in vitreous humor of tubercular uveitis.

Methods: Cells were collected from vitreous cassettes and peripheral blood of 8 tubercular uveitis and 5 control subjects, undergoing vitrectomy and analyzed by flow cytometry for cellular composition, activation status, proinflammatory cytokine expression, and uptake of TLR9 ligand, CpG ODN 2216.

Results: CD3 + T cells with equal proportion of CD4+ and CD8 + T cells formed major fraction of infiltrating cells. The vitreous humor showed higher expression of recent activation marker, CD69, and proinflammatory cytokines, IFN-γ and IL-17A, in CD4 + T cells as compared to peripheral blood. Lastly, intraocular CD4 + T cells showed reduced uptake of ODN 2216 than peripheral blood.

Conclusions: Our results indicate that local antigenic stimuli trigger T cell infiltration and activation of CD4 + T cells that are hyporesponsive to TLR9 stimulation. These infiltrating T cells might be responsible in further aggravating ocular inflammation.     

Role of granulosa cell mitogen-activated protein kinase 3/1 in gonadotropin-mediated meiotic resumption from diplotene arrest of mammalian oocytes

In mammals, preovulatory oocytes are encircled by several layers of granulosa cells (GCs) in follicular microenvironment. These follicular oocytes are arrested at diplotene arrest due to high level of cyclic nucleotides from encircling GCs. Pituitary gonadotropin acts at the level of encircling GCs and increases adenosine 3′,5′-cyclic monophosphate (cAMP) and guanosine 3′,5′-cyclic monophosphate (cGMP) and activates mitogen-activated protein kinase 3/1 (MAPK3/1) signaling pathway. The MAPK3/1 disrupts the gap junctions between encircling GCs and oocyte. The disruption of gap junctions interrupts the transfer of cyclic nucleotides to the oocyte that results a drop in intraoocyte cAMP level. A transient decrease in oocyte cAMP level triggers maturation promoting factor (MPF) destabilization. The destabilized MPF finally triggers meiotic resumption from diplotene arrest in follicular oocyte. Thus, MAPK3/1 from GCs origin plays important role in gonadotropin-mediated meiotic resumption from diplotene arrest in follicular oocyte of mammals.     

Evaluation of test results of microbiology laboratories of North India for standard tests for syphilis under an external quality assurance scheme

Test results of syphilis serology are critical due to inter- and intralaboratory variability. The accuracy of results is crucial in the control of the disease. This study was aimed to compare results of laboratories and performance of methods for syphilis serology. Results of Veneral Disease Reference Laboratory (VDRL) or rapid plasma reagin (RPR) tests of 25 microbiology laboratories were compared in six proficiency testing sentinel surveys. The performance of laboratories was compared with the results of a hypothetical average laboratory. Of the 141 participants, 104 (73.8%) responded. The inter-laboratory variability was exhibited by 62.2% of samples tested by VDRL and 58.7% by RPR test. Intralaboratory variability was observed in 46.7% samples. There was an insignificant improvement in proficiency testing (PT) performance over the years with a significant improvement in 2007. The common errors involved departure from testing protocols. Syphilis serology proficiency testing is needed in India for reliability in test results.     

Zona pellucida-based contraceptive vaccines for human and animal utility

Contraceptive vaccines can be designed to inhibit (i) production of the gametes (sperm and oocyte), (ii) functions of gametes leading to block in fertilization, and (iii) the gamete outcome (pregnancy). The zona pellucida (ZP) glycoproteins have been proposed as candidates for developing contraceptive vaccines by virtue of their critical role in fertilization. Immunization of non-human primates with either native or recombinant ZP proteins leads to curtailment of fertility, which however is invariably associated with ovarian pathology. To avoid oophoritis, immunogens corresponding to mapped B cell epitopes of ZP proteins that are devoid of 'oophoritogenic' T cell epitopes have been proposed. However, ways to overcome the observed oophoritis associated with the ZP-based contraceptive vaccines are yet to be fully defined. This is essential if their use for control of human fertility is to be considered. Nonetheless, contraceptive vaccines based on ZP proteins have shown very promising results in controlling wildlife population such as wild horses, white-tailed deers, elephants, marsupials, grey seals and dogs, where long term infertility or even permanent sterility is desirable.     

Comparison of bone mineral density and its variables between premenopausal and postmenopausal women

Objectives

To compare the bone mineral density (BMD) and its variables in premenopausal and postmenopausal women.

Methods

In this cross sectional study, 62 premenopausal and 62 postmenopausal apparently healthy women were evaluated by a questionnaire. The dietary intake of calcium was evaluated by 24 hours recall method and using table for proximate principle of common Indian food by Indian Council of Medical Research (ICMR). BMD at lumbar spine, femoral neck and Ward’s triangle were measured by dual energy X-ray absorptiometry (DXA). A correlation between BMD and various variables were calculated for each of the two groups.

Results

The mean age of premenopausal and postmenopausal women was 32.46±7.8 and 51.74±7.1 years respectively. The body mass index (BMI), height and weight were comparable in both the groups. The daily intake of calcium was significantly higher in premenopausal women (p<0.01). Approximately, 17% of the postmenopausal women and 9.6% of the premenopausal women were having osteoporosis; 28.56% of the postmenopausal women and 43.54% of the premenopausal women were having osteopenia at the lumbar spine. The BMD at lumber spine was found to be statistically significantly higher in premenopausal women than that in postmenopausal women (p=0.03). BMD at lumbar spine, femoral neck and Ward’s triangle were positively correlated with height, weight, BMI in premenopausal as well in postmenopausal women.

Conclusion

A significant number of women had osteopenia during premenopausal period and osteoporosis in postmenopausal phase. By increasing awareness towards bone health in second and third decade, morbidity of osteoporosis can be reduced.     

Evaluation of Oxidative Stress and Antioxidant Defence in Subjects of Preeclampsia

Objectives

To evaluate the parameters of oxidative stress and anti oxidant defense in preeclampsia and thereby find any etiological correlation.

Methods

Study was carried out on pregnant and non pregnant women attending or admitted in the Obstetrics and Gynecology Department of SSG Hospital, Baroda between 1st June 2007 to 31st May 2008. Each serum sample from different groups was evaluated for malondialdehyde (MDA), a product of lipid peroxidation process as a marker for oxidative stress and reduced Glutathione, Superoxide Dismutase, and Catalase for antioxidant enzyme activity and a comparison drawn and analyzed using t-test and χ² test.

Results

The levels of MDA (a lipid peroxidation product) increased significantly in pregnancy compared to non-pregnant females and further significantly increased in preeclampsia compared to normal pregnant females. The superoxide dismutase levels, catalase levels and vit-E levels were found to be increased in preeclamptic females as compared to normal pregnant females.

Conclusion

Preeclampsia is found to be a condition with markedly increased oxidative stress as is evidenced by highly significantly increased levels of MDA, a marker of lipid peroxidation. Levels of antioxidant enzymes, viz. reduced glutathione, superoxide dismutase, catalase and vitamin E have been found to be increased in preeclampsia as compared to normal pregnant females. This may be a compensatory mechanism for handling the increased oxidative stress.