Wernicke Encephalopathy Associated With Semaglutide Use.

A patient presenting to the emergency room with neurological symptoms is more commonly found to have manifestations of stroke, transient ischemic attack, or nervous system injury. Alcoholic Wernicke encephalopathy (WE) is also another common manifestation of neurological dysfunction; however, the prevalence of non-alcoholic WE is relatively uncommon. We discuss a 37-year-old male who presented to the ED with dysphagia, slurred speech, word-finding difficulty, and restricted extraocular movements from non-alcoholic WE in the setting of semaglutide use.

An Uncommon Side Effect of Baclofen Withdrawal in End Stage Renal Disease.

Baclofen is a commonly prescribed muscle relaxant that functions to reduce spasticity associated with a variety of musculoskeletal and neurological conditions. Patients with decreased renal function, however, are at an increased risk of suffering from baclofen withdrawal symptoms. We discuss the case of a 77-year-old male who presented to the emergency room with altered mental status and was admitted for acute metabolic encephalopathy found to be from abrupt cessation of baclofen. The presence of kidney disease in this patient further increased his susceptibility to the withdrawal symptoms that began after cessation of the normal medication regimen. This case further illustrates the importance of both comprehensive history and a high index of suspicion when it comes to patient presentation of baclofen withdrawal.

The Importance of Clinically Correlating Tuberculosis With Indeterminate QuantiFERON Gold Test.

Tuberculosis (TB) is a highly contagious airborne infection of the lungs. It can present in active form, as well as latent form. The clinical manifestations of tuberculosis can present as either subacute or chronic. Some symptoms include weight loss, night sweats, fevers, and hemoptysis. This case highlights the importance of clinical judgment and follow-up testing when patient presentation does not correlate with initial results. We share a perplexing encounter where a 34-year-old male presented with hemoptysis, fevers of unclear origin, and an indeterminate QuantiFERON Gold result and was empirically started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy. RIPE therapy includes the gold standard medications used to treat tuberculosis.

A Novel Inactive Isoform with a Restored Reading Frame Is Expressed from the Human Interferon Lambda 4 TT Allele at rs368234815.

The TT allele of the dinucleotide variant rs368234815 (TT/ΔG) abolishes the open reading frame (ORF) created by the ancestral ΔG allele of the human interferon lambda 4 (IFNL4) gene, thus preventing the expression of a functional IFN-λ4 protein. While probing the expression of IFN-λ4 in human peripheral blood mononuclear cells (PBMCs), using a monoclonal antibody that binds to the C-terminus of IFN-λ4, surprisingly, we observed that PBMCs obtained from TT/TT genotype individuals could also express proteins that reacted with the IFN-λ4-specific antibody. We confirmed that these products did not emanate from the IFNL4 paralog, IF1IC2 gene. Using cell lines and overexpressing human IFNL4 gene constructs, we obtained evidence from Western blots to show that the TT allele could express a protein that reacted with the IFN-λ4 C-terminal-specific antibody. It had a molecular weight similar if not identical to IFN-λ4 expressed from the ΔG allele. Furthermore, the same start and stop codons used by the ΔG allele were used to express the novel isoform from the TT allele suggesting that a restoration of the ORF had occurred in the body of the mRNA. However, this TT allele isoform did not induce any IFN-stimulated gene expression. Our data do not support a ribosomal frameshift that leads to the expression of this new isoform, implying that an alternate splicing event may be responsible. An N-terminal-specific monoclonal antibody did not react with the novel protein isoform suggesting that the alternate splicing event likely occurs beyond exon 2. The new isoform is glycosylated similar to the functional IFN-λ4 and is also secreted. Furthermore, we show that the ΔG allele can also potentially express a similarly frameshifted isoform. The splicing event that leads to the generation of these novel isoforms and their functional significance remains to be elucidated.

Treatment of COVID-19 Pneumonia and Acute Respiratory Distress With Ramatroban, a Thromboxane A2 and Prostaglandin D2 Receptor Antagonist: A Four-Patient Case Series Report.

Hypoxemia in COVID-19 pneumonia is associated with hospitalization, mechanical ventilation, and mortality. COVID-19 patients exhibit marked increases in fatty acid levels and inflammatory lipid mediators, predominantly arachidonic acid metabolites, notably thromboxane B2 >> prostaglandin E2 > prostaglandin D2. Thromboxane A2 increases pulmonary capillary pressure and microvascular permeability, leading to pulmonary edema, and causes bronchoconstriction contributing to ventilation/perfusion mismatch. Prostaglandin D2-stimulated IL-13 production is associated with respiratory failure, possibly due to hyaluronan accumulation in the lungs. Ramatroban is an orally bioavailable, dual thromboxane A2/TP and prostaglandin D2/DP2 receptor antagonist used in Japan for allergic rhinitis. Four consecutive outpatients with COVID-19 pneumonia treated with ramatroban exhibited rapid relief of dyspnea and hypoxemia within 12-36 h and complete resolution over 5 days, thereby avoiding hospitalization. Therefore, ramatroban as an antivasospastic, broncho-relaxant, antithrombotic, and immunomodulatory agent merits study in randomized clinical trials that might offer hope for a cost-effective pandemic treatment.

First study on detection of cryptic resistance to linezolid among clinical isolates of methicillin resistant Staphylococcus aureus from India.

PURPOSE: Linezolid is an oral antibiotic which is widely used for serious infections caused by Methicillin Resistant Staphylococcus aureus (MRSA). With emergence of vancomycin MIC creep among clinical strains of MRSA, it is essential to know the possible emergence of subclinical resistance against linezolid as well. With this background, we aimed to detect evident (phenotypic) and cryptic (hidden or genotypic) linezolid resistance among MRSA isolates. METHODS: 250 clinical isolates of MRSA were collected and their susceptibility patterns were determined. Every third MRSA isolate was subjected to PCR for domain V of the 23S rRNA for the mutation hotspot in the 746bp segment which harbors the classical mutation for linezolid resistance. Restriction Fragment Length Polymorphism was done to confirm presence of the G2576U mutation. RESULTS: Six isolates (2.4%) were phenotypically resistant to linezolid. Among these six LRSA isolates, 5 demonstrated the G2576U mutation by PCR - RFLP. Cryptic resistance to Linezolid was identified in two isolates among linezolid susceptible isolates. CONCLUSIONS: In the present study, hidden resistance to linezolid was observed in linezolid susceptible clinical isolates. Emergence of resistance against over-the-counter drugs like linezolid is major challenge. Identification of cryptic resistance among patients implies impending resistance to linezolid. Judicious use of antimicrobials, application of strict infection control practices and prescription audit needs to be made mandatory to preserve such drugs.

Virus-Induced Silencing of Key Genes Leads to Differential Impact on Withanolide Biosynthesis in the Medicinal Plant, Withania somnifera.

Withanolides are a collection of naturally occurring, pharmacologically active, secondary metabolites synthesized in the medicinally important plant, Withania somnifera. These bioactive molecules are C28-steroidal lactone triterpenoids and their synthesis is proposed to take place via the mevalonate (MVA) and 2-C-methyl-d-erythritol-4-phosphate (MEP) pathways through the sterol pathway using 24-methylene cholesterol as substrate flux. Although the phytochemical profiles as well as pharmaceutical activities of Withania extracts have been well studied, limited genomic information and difficult genetic transformation have been a major bottleneck towards understanding the participation of specific genes in withanolide biosynthesis. In this study, we used the Tobacco rattle virus (TRV)-mediated virus-induced gene silencing (VIGS) approach to study the participation of key genes from MVA, MEP and triterpenoid biosynthesis for their involvement in withanolide biosynthesis. TRV-infected W. somnifera plants displayed unique phenotypic characteristics and differential accumulation of total Chl as well as carotenoid content for each silenced gene suggesting a reduction in overall isoprenoid synthesis. Comprehensive expression analysis of putative genes of withanolide biosynthesis revealed transcriptional modulations conferring the presence of complex regulatory mechanisms leading to withanolide biosynthesis. In addition, silencing of genes exhibited modulated total and specific withanolide accumulation at different levels as compared with control plants. Comparative analysis also suggests a major role for the MVA pathway as compared with the MEP pathway in providing substrate flux for withanolide biosynthesis. These results demonstrate that transcriptional regulation of selected Withania genes of the triterpenoid biosynthetic pathway critically affects withanolide biosynthesis, providing new horizons to explore this process further, in planta.

Comprehensive assessment of the genes involved in withanolide biosynthesis from Withania somnifera: chemotype-specific and elicitor-responsive expression.

Withania somnifera (L.) Dunal (Family, Solanaceae), is among the most valuable medicinal plants used in Ayurveda owing to its rich reservoir of pharmaceutically active secondary metabolites known as withanolides. Withanolides are C28-steroidal lactones having a triterpenoidal metabolic origin synthesised via mevalonate (MVA) pathway and methyl-D-erythritol-4-phosphate (MEP) pathway involving metabolic intermediacy of 24-methylene (C30-terpenoid) cholesterol. Phytochemical studies suggest differences in the content and/or nature of withanolides in different tissues of different chemotypes. Though development of genomic resources has provided information about putative genes encoding enzymes for biosynthesis of intermediate steps of terpenoid backbone, not much is known about their regulation and response to elicitation. In this study, we generated detailed molecular information about genes catalysing key regulatory steps of withanolide biosynthetic pathway. The full-length sequences of genes encoding enzymes for intermediate steps of terpenoid backbone biosynthesis and their paralogs have been characterized for their functional and structural properties as well as phylogeny using bioinformatics approach. The expression analysis suggests that these genes are differentially expressed in different tissues (with maximal expression in young leaf), chemotypes and in response to salicylic acid (SA) and methyl jasmonate (MJ) treatments. Sub-cellular localization studies suggest that both paralogs of sterol ∆-7 reductase (WsDWF5-1 and WsDWF5-2) are localized in the endoplasmic reticulum (ER) thus supporting their indispensible role in withanolide biosynthesis. Comprehensive information developed, in this study, will lead to elucidation of chemotype- as well as tissue-specific withanolide biosynthesis and development of new tools for functional genomics in this important medicinal plant.

Split-dose bowel preparation with polyethylene glycol for colonoscopy performed under propofol sedation. Is there an optimal timing?

OBJECTIVE: Aspiration risk, especially with propofol sedation, remains a concern after split-dose bowel preparation of up to 1 L polyethylene glycol for the procedure. We aimed to identify the ideal timing of bowel preparation to achieve optimal colon cleansing with no increased risk of aspiration. METHODS: A total of 892 consecutive patients undergoing simultaneous esophagogastroduodenoscopy (EGD) and colonoscopy were prospectively recruited. Residual gastric volume (RGV) and pH of gastric contents were measured at EGD, and patients' characteristics, runway time (duration between completion of the final liter of bowel preparation and colonoscopy commencement), and cleansing quality were recorded. RESULTS: A shorter runway time resulted in better colon cleansing (r = -0.124, P < 0.001). No correlation between runway time and RGV or pH was found (r = -0.017, P = 0.62 and r = -0.030, P = 0.47, respectively). RGV and pH did not differ significantly with runway time of 4 or 5 h. RGV with runway time ≤3 h was 35.9 ± 11.8 mL and 17.4 ± 0.6 mL after runway time >3 h (P < 0.001). No aspiration pneumonia occurred. The only factors independently related to higher RGV were younger age and male sex. CONCLUSIONS: The consumption of bowel preparation agent within 3-4 h before propofol sedation resulted in a similar RGV and pH as those achieved by more prolonged fasting, with no increased risk of aspiration even in patients perceived to be at high risk.

The Difficult Paediatric Airway: Two Cases of large Cystic Hygroma.

This is a report of a two cases of difficult intubation experienced in paediatric surgical cases. Both the infants, aged one and three-month-old respectively, had very large cystic hygroma of the neck area. Prior hematological and radiological investigations (USG and CT scan of the swelling) and preanaesthesia check up was done and cases were posted for surgical excision. Case I had difficult airway due to pressure of the tumour/cystic hygroma over the airway and posed difficulty for intubation, but was managed well. Case II had respiratory distress during preoperative period. She had been postponed for surgical excision of the cystic hygroma of neck twice due to the difficulties experienced during intubation. Needle aspiration of hygroma fluid helped to reduce the respiratory distress, and the size of the tumour as well, which further helped in the smooth intubation after a week. The postoperative period was uneventful in both the infants.

Comparative transcriptome analysis of different chemotypes elucidates withanolide biosynthesis pathway from medicinal plant Withania somnifera.

Withania somnifera is one of the most valuable medicinal plants synthesizing secondary metabolites known as withanolides. Despite pharmaceutical importance, limited information is available about the biosynthesis of withanolides. Chemo-profiling of leaf and root tissues of Withania suggest differences in the content and/or nature of withanolides in different chemotypes. To identify genes involved in chemotype and/or tissue-specific withanolide biosynthesis, we established transcriptomes of leaf and root tissues of distinct chemotypes. Genes encoding enzymes for intermediate steps of terpenoid backbone biosynthesis with their alternatively spliced forms and paralogous have been identified. Analysis suggests differential expression of large number genes among leaf and root tissues of different chemotypes. Study also identified differentially expressing transcripts encoding cytochrome P450s, glycosyltransferases, methyltransferases and transcription factors which might be involved in chemodiversity in Withania. Virus induced gene silencing of the sterol ∆7-reductase (WsDWF5) involved in the synthesis of 24-methylene cholesterol, withanolide backbone, suggests role of this enzyme in biosynthesis of withanolides. Information generated, in this study, provides a rich resource for functional analysis of withanolide-specific genes to elucidate chemotype- as well as tissue-specific withanolide biosynthesis. This genomic resource will also help in development of new tools for functional genomics and breeding in Withania.

Congenital fibroepithelial polyp: a case report of difficult airway.

A 9 month old child presented with a growth in the oropharynx for removal. Only complaint was distressed breathing on crying. It turned out to be a case of difficult paediatric airway that was managed well. A diagnoses of oesophageal fibro-epithelial polyp was made after histopathological examination.

Cloning and characterization of 2-C-methyl-D-erythritol-4-phosphate pathway genes for isoprenoid biosynthesis from Indian ginseng, Withania somnifera.

Withania somnifera (L.) is one of the most valuable medicinal plants used in Ayurvedic and other indigenous medicines. Pharmaceutical activities of this herb are associated with presence of secondary metabolites known as withanolides, a class of phytosteroids synthesized via mevalonate (MVA) and 2-C-methyl-D-erythritol-4-phosphate pathways. Though the plant has been well characterized in terms of phytochemical profiles as well as pharmaceutical activities, not much is known about the genes responsible for biosynthesis of these compounds. In this study, we have characterized two genes encoding 1-deoxy-D-xylulose-5-phosphate synthase (DXS; EC 2.2.1.7) and 1-deoxy-D-xylulose-5-phosphate reductase (DXR; EC 1.1.1.267) enzymes involved in the biosynthesis of isoprenoids. The full-length cDNAs of W. somnifera DXS (WsDXS) and DXR (WsDXR) of 2,154 and 1,428 bps encode polypeptides of 717 and 475 amino acids residues, respectively. The expression analysis suggests that WsDXS and WsDXR are differentially expressed in different tissues (with maximal expression in flower and young leaf), chemotypes of Withania, and in response to salicylic acid, methyl jasmonate, as well as in mechanical injury. Analysis of genomic organization of WsDXS shows close similarity with tomato DXS in terms of exon-intron arrangements. This is the first report on characterization of isoprenoid biosynthesis pathway genes from Withania.

Correlation of serology with morphological changes in gastric biopsy in Helicobacter pylori infection and evaluation of immunohistochemistry for H. pylori identification.

BACKGROUND/AIM: Helicobacter pylori is implicated in various gastroduodenal diseases and many tests are available for its detection. The present study attempted to document the morphological changes in the gastric mucosa induced by H. pylori colonization and correlate them with the severity of the infection. The study also compared various diagnostic tests and evaluated the different staining methods used for H. pylori detection, especially immunohistochemical identification. PATIENTS AND METHODS: One hundred and two patients with dyspepsia were included. Enzyme-linked immunosorbent assay (ELISA) for H. pylori-specific immunoglobulin G (IgG), immunoglobulin A (IgA), and immunoglobulin M (IgM) was used. Rapid urease test was performed on endoscopic biopsy and it was stained with hematoxylin and eosin (H and E), modified Giemsa, and immunohistochemical stains. RESULTS: A significant correlation was found between the density of H. pylori and severity of gastritis. A significant correlation was observed between serology (especially when used in combination, IgG and IgA) and status of H. pylori. Immunohistochemical staining enhanced the diagnostic yield of H. pylori detection. CONCLUSIONS: Immunohistochemistry (IHC) should be used judiciously, whereas simple and economical tests like modified Giemsa should be used routinely for the detection of H. pylori. Combined ELISA (IgG and IgA) should be preferred over single ELISA. Simultaneous morphological and serological detection of H. pylori is preferable as H. pylori may not be detected on morphology alone due to its patchy distribution in the stomach.

Broken safety pin in bronchus - Anaesthetic considerations.

Safety pins are not commonly aspirated objects in infants and form only a small fraction of all the metallic foreign body (FB) which accounts for 4.4% of all foreign bodies found in tracheobronchial tree. Bronchoscopy procedure has various complications, in addition to failure to remove FB due to its impaction, especially with metallic pointed objects ending up in open surgical removal. Infant with inhaled foreign body are always a challenge to anaesthetist. We had one such case of broken safety pin impacted in the wall of right bronchus of an infant with failure to remove on repeated attempts at rigid bronchoscopy.