Biomedical subjects
Publications and source records attributed to N Singh.
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CONTEXT: The effect of calcium carbonate on the absorption of levothyroxine has not been studied systematically. Such a potential drug interaction merits investigation because concurrent treatment with both drugs is common, particularly in postmenopausal women. OBJECTIVE: To investigate the potential interference of calcium carbonate in the absorption of levothyroxine. DESIGN: Prospective cohort study conducted from November 1998 to June 1999, supplemented with an in vitro study of thyroxine (T(4)) binding to calcium carbonate. SETTING: Veterans Affairs Medical Center in West Los Angeles, Calif. PATIENTS: Twenty patients (age range, 27-78 years; n=11 men) with hypothyroidism who were taking a stable long-term regimen of levothyroxine were included in the study. All patients had serum free T(4) and thyrotropin values in the normal range before beginning the study. INTERVENTION: Subjects were instructed to take 1200 mg/d of elemental calcium as calcium carbonate, ingested with their levothyroxine, for 3 months. MAIN OUTCOME MEASURES: Levels of free T(4), total T(4), total triiodothyronine (T(3)), and thyrotropin, measured in all subjects at baseline (while taking levothyroxine alone), at 2 and 3 months (while taking calcium carbonate and levothyroxine), and 2 months after calcium carbonate discontinuation (while continuing to take levothyroxine). RESULTS: Mean free T(4) and total T(4) levels were significantly reduced during the calcium period and increased after calcium discontinuation. Mean free T(4) levels were 17 pmol/L (1.3 ng/dL) at baseline, 15 pmol/L (1.2 ng/dL) during the calcium period, and 18 pmol/L (1.4 ng/dL) after calcium discontinuation (overall P<.001); mean total T(4) levels were 118 nmol/L (9.2 microg/dL) at baseline, 111 nmol/L (8.6 microg/dL) during the calcium period, and 120 nmol/L (9.3 microg/dL) after calcium discontinuation (overall P=.03). Mean thyrotropin levels increased significantly, from 1.6 mIU/L at baseline to 2.7 mIU/L during the calcium period, and decreased to 1. 4 mIU/L after calcium discontinuation (P=.008). Twenty percent of patients had serum thyrotropin levels higher than the normal range during the calcium period; the highest observed level was 7.8 mIU/L. Mean T(3) levels did not change during the calcium period. The in vitro study of T(4) binding to calcium showed that adsorption of T(4) to calcium carbonate occurs at acidic pH levels. CONCLUSIONS: This study of 20 patients receiving long-term levothyroxine replacement therapy indicates that calcium carbonate reduces T(4) absorption and increases serum thyrotropin levels. Levothyroxine adsorbs to calcium carbonate in an acidic environment, which may reduce its bioavailability. JAMA. 2000;283:2822-2825
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Immunosuppressive-associated leukoencephalopathy is a significant complication of cyclosporine (CsA) or tacrolimus therapy. However, the precise time of onset, role of putative risk factors, differences, if any, in presentation in various types of organ transplantation and outcome of this entity, remain poorly defined. Fifty cases of immunosuppressive-associated leukoencephalopathy reported in the literature in organ transplant recipients, were reviewed. Of 50 cases, 31 occurred in liver, 8 in renal, 6 in lung, and 5 in heart transplant recipients. Median time to onset was 28 days (range 3-1512 days); 82% occurred within 90 days of transplantation. Lesions tended to occur earlier in the liver transplant recipients, compared with other organ transplant recipients (median 9 vs. 29 days, P=.19). Seizures 74%, altered mental status 50%, and visual abnormalities 28% were the most frequently presenting features. Ten percent of the patients had fever with no documented source of infection. Systemic hypertension (P=.001), and lesions in the presence of therapeutic drug levels (P=.11) were more likely to occur with CsA than tacrolimus. Neuroimaging and clinical abnormalities were reversible on cessation or reduction of CsA or tacrolimus in all but two cases. Resolution of neurologic signs/symptoms occurred a median of 4 days and neuroimaging abnormalities in a median of 20 days on reduction/cessation of the drug. Immunosuppressive-associated leukoencephalopathy is a unique entity that can usually be diagnosed on the basis of its distinctive time of onset, and clinical and neuroimaging characteristics, and it is potentially reversible if promptly diagnosed. Despite identical clinical presentation of this syndrome in the recipients of CsA and tacrolimus, above noted variations in risk factors suggest that a difference in pathophysiologic mechanism may exist.
BACKGROUND: Late-onset renal failure is being increasingly recognized as a complication in patients undergoing liver transplantation for hepatitis C virus (HCV). However, its precise incidence, predisposing risk factors, and impact on outcome after liver transplantation, have not been defined. METHODS: The development of late-onset renal failure (defined as serum creatinine persistently >2.0 mg/dl, occurring more than 6 months posttransplant) was assessed in 120 consecutive liver transplant recipients who survived at least 6 months after transplantation. Fifty-seven percent (68/120) of the patients had undergone transplantation for liver disease due to HCV. The median follow-up was 5 years. RESULTS: Late-onset renal failure developed in 28% (33/120)of the patients. Posttransplant alcohol use (P=0.0001), posttransplant diabetes (P=0.0042), and recurrent HCV hepatitis (P=0.019) were significantly associated with late onset renal failure. In multivariate analysis, alcohol use (O.R. 10.7, 95%; CI 2.4-35.9, P=0.001) and diabetes (O.R. 2.1, 95%; CI 1.1-9.9, P=.03) were independently significant predictors of late onset renal failure. When only patients transplanted for HCV were analyzed, posttransplant alcohol use (P=0.004) was the only significant independent predictor of late-onset renal failure. HCV genotype 1b, as compared with other HCV genotypes, was associated with a higher rate of late-onset renal failure in patients with HCV; 70% of the patients with genotype 1b versus 32% of those with 1a and 33% of those with 2b, developed late onset renal failure (P=0.03). At a median follow up of 5 years, mortality in patients with HCV with late-onset renal failure was 52% as compared with 2% in those without renal failure (P=.0001). CONCLUSION: Late-onset renal failure in patients with HCV portended a grave outcome. Alcohol use was an independent predictor of late-onset renal failure in patients with HCV and represents a potentially modifiable risk factor for late-onset renal failure in these patients.
Experiments were conducted to define the spectra of mutations occurring in Hprt exon 3 of T-cells isolated from spleens of female B6C3F1 mice and F344 rats exposed by inhalation to 1,3-butadiene (BD) or its reactive metabolite, (+/-)-diepoxybutane (DEB). Hprt mutant frequencies (Mfs) in BD-exposed (1250 ppm for 2 weeks or 625 ppm for 4 weeks; 6 h/day, 5 days/week) and DEB-exposed (2 or 4 ppm for 4 weeks or 5 ppm for 6 weeks; 6 h/day, 5 days/week) mice and rats were significantly increased over concurrent control values. Mutant T-cell colonies from control and treated animals were screened for mutations in Hprt exon 3 using PCR amplification of genomic DNA and denaturing gradient gel electrophoresis, followed by sequence analysis. Exon 3 mutations were found at the following frequencies: 20/394 (5%) in control mice, 56/712 (8%) in BD-exposed mice, 59/1178 (5%) in BD-exposed rats, 66/642 (10%) in DEB-exposed mice, and 51/732 (7%) in DEB-exposed rats. Mutations in exposed animals included base substitutions, small deletions (1 to 74 bp), and small insertions (1 to 8 bp), with base substitutions predominating. Among the types of base substitutions observed in mice, the proportions of G.C-->A.T transitions (p=0.035, Fisher's Exact Test) and G.C-->C.G transversions (p=0.05) were significantly different in control vs. BD-exposed animals. Given the small number of exon 3 mutants analyzed, there was a high degree of overlap in the mutational spectra between BD-exposed mice and rats, between BD- and DEB-exposed mice, and between BD- and DEB-exposed rats in terms of the sites with base substitutions, the mutations found at those mutated sites, the relative occurrence of the most frequently observed base substitutions, and the occurrence of a consistent strand bias for the most frequently observed base substitutions. The spectra data suggest that adduction of both G.C and A.T bps is important in the induction of in vivo mutations by BD metabolites in exposed mice and rats.
BACKGROUND: Thrombocytopenia is a frequent and potentially serious complication in liver transplant recipients. The role of endogenous thrombopoietin level in posttransplant thrombocytopenia, has not been fully defined in liver transplant recipients. Additionally, there is accumulating evidence to suggest that platelets play a important role in antimicrobial host defense. METHODS: There were 50 consecutive liver transplant recipients studied. Variables predictive of thrombocytopenia, its impact on infectious morbidity and outcome, and serial thrombopoietin (TPO) serum concentration were assessed. RESULTS: The median pretransplant platelet count was 67 x 10(3)/cmm. After the liver transplantation, the median nadir platelet count was 33 x 10(3)/cmm and was reached a mean of 6 days after the transplant. A lower pretransplant platelet count (r= +.068, P=.0001), lower serum albumin before the transplants (r=+0.39, P=.014), longer operation time (r=0.27, P=.05), higher intraoperative packed red cells (r=0.28, P=.049) and fresh frozen plasma transfusions (r=0.42, P=.004), higher bilirubin at Day 7 (r=-.386, P=.005), and higher serum creatinine at Day 7 after the transplants (r=-.031, P=.025) correlated significantly with a lower nadir in platelets after the transplant. Nadir in platelet count was significantly lower in nonsurvivors compared with survivors (16 vs. 36 x 10(3)/cmm, P=.0001). Forty-three percent (9 of 21) of the patients with nadir platelet counts of < or =30 x 10(3)/cmm had a major infection within 30 days of the transplant compared with 17% (5 of 29) with nadir platelet counts > 30 x 10(3)/cmm (P=.04). Fungal infections occurred in 14% of the patients with nadir platelet counts of < or =30 x 10(3)/cmm versus 0% in those with nadir platelet counts of > 30 x 10(3)/cmm (P=.06); all patients with fungal infections had nadir platelet counts of < or =30 x 10(3)/cmm before fungal infection. Nadir in platelet count preceded the first major infection by a median of 7 days. Pretransplant TPO level did not differ between survivors (mean 103 pg/ml) or nonsurvivors (mean 144 pg/ml). After the transplantation, TPO levels increased in both groups. TPO level peaked at Day 7 and subsequently declined in survivors. Nonsurvivors had persistent thrombocytopenia despite a progressive rise in TPO level; TPO level was significantly higher at Day 7 (P=.02), Day 9 (P=.0019), and Day 14 (P=.04) in nonsurvivors compared with survivors. CONCLUSION: Persistent thrombocytopenia portended a poor outcome in liver transplant recipients and was not related to low TPO levels. Thrombocytopenia preceded infections and identified a subgroup of liver transplant patients susceptible to early major infections; its precise role in fungal infections warrants validation in larger studies.
Predictors of bacteremia and mortality in bacteremic liver transplant recipients were prospectively assessed. One hundred eleven consecutive episodes of fever or infections were documented in 59 patients over a 4-year period. Forty-nine percent (29 of 59 patients) of the patients had bacteremia, 39% (23 of 59 patients) had nonbacteremic infections, and 12% (7 of 59 patients) had fever of noninfectious cause. Primary (catheter-related) bacteremia (31%; 9 of 29 patients), pneumonia (24%; 7 of 29 patients), abdominal and/or biliary infections (14%; 4 of 29 patients), and wound infections (10%; 3 of 29 patients) were the predominant sources of bacteremia. Diabetes mellitus (odds ratio, 6.9; P =.03) and serum albumin level less than 3.0 mg/dL (odds ratio, 0.14; P =.02) were independently significant predictors of bacteremia compared with nonbacteremic infections. Mortality at 14 days was 28% (8 of 29 patients) in those with bacteremia compared with 4% (1 of 23 patients) in those with nonbacteremic infections and 0% (0 of 7) in patients with fever of noninfectious cause (P =.03). Intensive care unit stay at the time of bacteremia (100% v 47%; P =.005), absence of chills (0% v 53%; P =.005), lower temperature at the onset of bacteremia (99.2 degrees F v 101.5 degrees F; P =.009), lower maximum temperature during the course of bacteremia (99.3 degrees F v 102 degrees F, P =.008), greater serum bilirubin level (7.6 v 1.5 mg/dL; P =.024), presence of abnormal blood pressure (80% v 16%; P =. 0013), and greater prothrombin time (15.6 v 13.3 seconds; P =.013) were significantly predictive of greater mortality in the bacteremic patients. These data have implications for discerning the likelihood of bacteremia and initiation of empiric antibiotics pending cultures. Lack of febrile response in bacteremic liver transplant recipients portended a poorer outcome.
The spectrum of antimalarial activity of the new macrolide antibiotic azithromycin was evaluated against blood- and sporozoite-induced infections with a chloroquine-resistant strain of Plasmodium yoelii nigeriensis (N-67) in Swiss mice and with simian parasite Plasmodium cynomolgi B in rhesus monkeys. Against experimental rodent malaria, a 70 mg/kg/day dose showed curative blood-schizontocidal activity in a four-dose regimen administered orally from day 0 to day 3 or from day 2 to day 5 to mice harboring established infection. The curative response was also obtained with a 40 mg/kg/day dose administered in an extended seven-dose (days 0-6) regimen. Azithromycin was also effective in the causal prophylactic test, since a 50 mg/kg dose from day -1 to day +2 protected mice against P. y. nigeriensis (N-67) sporozoite challenge. In comparison, erythromycin did not show either of the above activities up to a 405 mg/kg/day dose in identical regimens. Comparison of the ED(90) values showed that azithromycin was 31-fold more effective than erythromycin as a blood schizontocide. In the simian model, trophozoite-induced infections of P. cynomolgi B were cured with 25 mg/kg/day azithromycin administered for 7 days. In the causal prophylactic test, the prepatent period was significantly extended in monkeys challenged with P. cynomolgi B sporozoites, presumably because of the growth inhibition of preerythrocytic schizonts in hepatocytes. Azithromycin did not exhibit any hypnozoitocidal (dormant exoerythrocytic stages) activity at 25 mg/kg/day in a seven-dose regimen.
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PURPOSE: To report an unusual case of pulmonary edema following intramuscular ketamine administration. CLINICAL FEATURES: An eight-year-old, healthy girl presented for dressing of first degree burns on dorsum of hand. Ten minutes after administration of 125 mg ketamine im, she developed laboured breathing, cyanosis, and bilateral crepitations and arterial blood gas analysis showed PaO2 55 mmHg. There was no evidence of upper airway obstruction. On intubating the trachea, pink frothy fluid emerged from the tube. She was diagnosed as a case of neurogenic pulmonary edema. She was managed with positive pressure ventilation with positive end expiratory pressure, morphine and furosemide. With this treatment she showed a favourable recovery. CONCLUSION: Ketamine was given im to aid burns dressing in this case because it has distinct advantages above the other anesthetic agents including that of being a good analgesic which is absorbed by im route. Its use led to the development of pulmonary edema.
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High light stress (40 W/m(2))-induced alterations in the nitrogen assimilatory enzymes in Spirulina platensis were studied under the Ca(2+) and phosphate (Pi)-supplemented as well as starved conditions. Results revealed that activities of nitrate reductase (NR), amino acid transferases (AST/GOT and ALT/GPT), and protease enzymes in the high-light-incubated cells were relatively higher under the Ca(2+)- and Pi-starved conditions. On the contrary, relative rates of glutamine synthetase (GS) and ATPase activities were lower in the Ca(2+)- and Pi-starved cells. But the Spirulina cells under the Ca(2+)- and Pi-added conditions showed enhanced activity of both GS and ATPase enzymes. During the high-light stress, a decline in the GS activity, particularly under the Ca(2+)- and Pi-starved conditions, was indicative of a nitrogen starvation-like condition. This could be one of the reasons for induction of the NR and protease enzymes. A higher rate of GS activity was recorded under both the Ca(2+)- and Pi-supplemented conditions, perhaps owing to the enhanced rate of ATPase activity in such conditions. But a declining pattern of both NR and protease activities in the presence of Ca(2+) and Pi, despite the higher rate of ATPase activity, might involve some other mechanism like the protein-kinase system.
Recent in vivo and in vitro data of patients analyzed for genetic susceptibility to radiation during cancer therapy have shown structural changes in the chromosomes to be prevalent both in the patients being treated and in their immediate family members. As structural changes in chromosomes frequently lead to activation of proto-oncogenes and elimination of tumor-suppressor genes, they represent important mechanisms for the initiation of DNA repair processes and tumorigenesis. With the exception of rare genetic syndromes such as AT (Ataxia telangiectasia) or NBS (Nijmegen Breakage Syndrome), the background for the inheritance of genetic susceptibility to radiation is unknown. Recently, a large-scale genetic screen of mouse mutants has been established within the German Human Genome Project (Hrabè de Angelis and Balling 1998). The goal of this ENU (ENU: ethylnitrosourea) mutagenesis screen is the generation of mutant mice that will serve as animal models for human diseases and genetic susceptibility. In order to fully utilize the potential of a genetic screen of this magnitude, in which exploration for genes responsible for genomic instability and radiation sensitivity is to occur, it is necessary to establish a simple assay system that is amenable to automation. Hence, we are using the single-cell gel electrophoresis (comet assay) to detect mouse mutants that display a genetic susceptibility to ionizing radiation. We have established the analysis parameters in the comet assay which are currently used to detect radiation-sensitive mouse mutants and to control the variance within the mouse population in the ENU screen. The assay can be used to isolate genes that are responsible for DNA repair and radiation sensitivity in mouse and human.
OBJECTIVE: Hematopoiesis is the process by which mature blood cell types are generated from a small population of pluripotent hematopoietic stem cells. How these cells undergo fate selection, however, is not fully understood. The Notch signaling system is known to mediate cell fate decisions of multipotent precursors in a wide range of complex animals throughout development. As Notch signaling involves cell-cell interactions, we sought to determine the expression of Notch receptors, ligands, and regulators in individual cell populations along the hematopoietic differentiation pathway. MATERIALS: Described here is a single cell RT-PCR analysis of Notch1, Notch3, Notch4, Notch ligands (Dll1 and Jagged1), and Fringe gene expression in cells of the blood system. As previously described, single cell globally amplified cDNA was generated by RT-PCR from various hematopoietic precursor cells whose potential was known from sibling analysis. A precursor hierarchy slot blot was created containing these cDNAs as well as samples from maturing blood cell populations and two fibroblast cell lines. The precursor slot blot was screened with probes for each of the candidate genes. RESULTS: Macrophage precursors expressed high levels of Notch1 transcript, while maturing macrophages expressed high levels of both Notch1 and Notch4. The Jagged 1 ligand transcript was highly expressed in terminally maturing cells including mast cells and megakaryocytes. In contrast, the Manic Fringe gene was highly expressed in uncommitted bi- and tri-potential precursors as well as in committed neutrophil and macrophage precursors. CONCLUSIONS: Distinct expression patterns of Jagged1 and Manic Fringe suggest that their corresponding proteins could regulate cell fate choices during hematopoiesis and may be responsible for regulating communication between lineage compartments during hematopoietic development.
The spectrum of major infections after transplantation has undergone a striking evolution. The epidemiologic trends in infectious diseases through the last decade have been most notable for a dramatic decrease in the incidence of several opportunistic infections, largely because of advances in prophylaxis against these pathogens. Paralleling these trends has been an exponential rise in the proportion of infections caused by antimicrobial-resistant bacteria. These multiresistant organisms have now emerged as leading pathogens at many transplant centers, and their management is a daunting challenge.