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Biomedical subjects

H Patel

Publications and source records attributed to H Patel.

At least 19 recordsLinked to original sources

Expression of recombinant human serum amyloid A in mammalian cells and demonstration of the region necessary for high-density lipoprotein binding and amyloid fibril formation by site-directed mutagenesis.

Site-directed mutagenesis of the acute-phase human serum amyloid A (SAA1 alpha) protein was used to evaluate the importance of the N-terminal amino acid residues, namely RSFFSFLGEAF The full-length cDNA clone of SAA1 alpha (pA1.mod.) was used to create two mutations, namely Gly-8 to Asp-8 and an 11 amino acid truncation between Arg-1 and Phe-11 respectively. Wild-type and mutant cDNAs were expressed in Chinese hamster ovary (CHO) cells under the control of the human cytomegalovirus promoter, which resulted in the secretion of the processed proteins into the culture media. Wild-type recombinant human SAA (rSAA) protein was shown to have pI values of 6.0 and 6.4, similar to the human SAA isoform SAA1 alpha and SAA1 alpha desArg found in acute-phase plasma. N-terminal sequencing of 56 residues confirmed its identity with human SAA1 alpha. The total yield of wild-type rSAA measured by ELISA was between 3.5 and 30 mg/l. The two mutations resulted in reduced expression levels of the mutant SAA proteins (3-10 mg/l). Further measurements of rSAA concentration in lipid fractions of culture medium collected at a density of 1.21 g/ml (high-density liporotein; HDL) and 1.063-1.18 g/ml (very-low-density lipoprotein/low-density lipoprotein; VLDL/LDL) showed that 76% of the wild-type protein was found in the HDL fraction and the remaining 24% in the infranatant non-lipid fraction. In contrast the relative concentration of mutant rSAA in HDL and infranatant fractions was reversed. This is consistent with the previously proposed involvement of the 11 amino acid peptide in anchoring. SAA protein on to HDL3 [Turnell, Sarra, Glover, Baum, Caspi, Baltz and Pepys (1986) Mol. Biol. Med. 3, 387-407]. Wild-type rSAA protein was shown to from amyloid fibrils in vitro under acidic conditions as shown by electron microscopy, and stained positive with Congo Red and exhibited apple-green birefringence when viewed under polarized light. Under the same conditions mutSAA(G8D) and mutSAA delta 1-11 did not form amyloid fibrils. In conclusion, replacement of Gly-8 by Asp-8 or deletion of the first 11 amino acid residues at the N-terminus of rSAA diminishes its capacity to bind to HDL and decreases amyloid fibril formation.

Amyloid

Characterization of the electrostatic perturbation of a catalytic site (Cys)-S-/(His)-Im+H ion-pair in one type of serine proteinase architecture by kinetic and computational studies on chemically mutated subtilisin variants.

We have used two structurally well-characterized serine proteinase variants, subtilisins Carlsberg and BPN', to produce (Cys)-S-/(His)-Im+H ion-pairs by chemical mutation in well defined, different, electrostatic microenvironments. These ion-pairs have been characterized by pH-dependent rapid reaction kinetics using, as reactivity probes, thiol-specific time dependent inhibitors, 2,2'-dipyridyl disulfide and 4,4'-dipyrimidyl disulfide, that differ in the protonation states of their leaving groups in acidic media, computer modelling and electrostatic potential calculations. Both ion-pairs possess nucleophilic character, identified by the striking rate maxima in their reactions with 2,2'-dipyridyl disulfide in acid media. In the Carlsberg enzyme, the (Cys220)-S-/(His63)-Im+H ion-pair is produced by protonic dissociation with pKa 4.1 and its reactivity is not perturbed by any detectable electrostatic influence other than the deprotonation of His63 (pKa 10.2). In the BPN' enzyme, the analogous, (Cys221)-S-/(His64)-Im+H ion-pair is produced by protonic dissociation with pKa 5.1 and its reactivity is affected by an ionization with pKa 3.5 in addition to the deprotonation of His64 (pKa > or = 10.35). It is a striking result that calculations using finite difference solutions of the Poisson-Boltzmann equation provide a value of the pKa difference between the two enzyme catalytic sites (0.97) in close agreement with the value (1.0) determined by reactivity probe kinetics when a protein dielectric constant of 2 is assumed and water molecules within 5 A of the catalytic site His residue are included. The pKa difference is calculated to be 0.84 when the water molecules are not included and a protein dielectric constant of 20 is assumed. The calculations also identify Glu156 in the BPN' enzyme (which is Ser in the Carlsberg enzyme) as the main individual source of the pKa shift. The additional kinetically influential pKa of 3.5 is assigned to Glu156 by examining the non-covalent interactions between the 2-pyridyl disulfide reactivity probe and the enzyme active centre region.

2,2'-Dipyridyl

Failure of implementation of the National Heart Foundation of New Zealand guidelines for the management of dyslipidaemia.

AIMS: We examined the outcome of patients at high absolute risk of coronary events who had been discharged from the Green Lane Hospital risk factor clinic before publication of the 1993 National Heart Foundation of New Zealand (NHF) guidelines for management of dyslipidaemia. METHODS: Consecutive patients who had been discharged >12 months previously were followed up by general practitioner and patient questionnaires. Patients were categorised according to risk of a coronary event over 10 years. Ideal lipid levels (cholesterol <5.2 mmol/L, high-density lipoprotein (HDL) cholesterol >1 mmol/L, total:HDL cholesterol ratio <5) and 'acceptable' lipid levels (cholesterol <6.5 mmol/L for high risk, <7.5 for moderate risk, <8 in men and <8.5 in women at mild or low risk) were defined according to the NHF guidelines. RESULTS: Of the 270 patients, 55.6% were at very high risk, 25.5% at high risk, 10.4% at moderate risk, 3.8% at mild risk and 0.7% at low risk. Twenty-four percent of patients were managed on diet alone at clinic discharge and 18% at follow up of 32+/-12 months. Total cholesterol (6.39 mmol/L), HDL cholesterol (1.22 mmol/L) and the total:HDL cholesterol ratio (5.71) were unchanged from discharge. In the very high risk group ideal lipid levels were achieved in only 12% at discharge and 7% at follow up. The corresponding figures for achievement of acceptable lipids at discharge compared with follow up were 48% and 39% for the high risk group, 88% and 79% for the moderate risk group and 93% and 93% for the mild risk group. The corresponding figures for achievement of ideal lipids were 4% and 8% for the high risk group, 0% and 5% for the moderate risk group and 7% and 7% for the mild risk group. CONCLUSIONS: Lipid levels achieved during clinic visits were maintained long term, but there were no improvements following publication of the NHF guidelines. Continued efforts are needed to increase awareness and implementation of the guidelines, particularly in patients at high risk. Removal of the restrictions on prescription of lipid modifying agents by general practitioners and improved interchange between general practitioners and specialists should greatly improve these outcomes.

Family Practice

Recent corticosteroid use and the risk of complicated varicella in otherwise immunocompetent children.

OBJECTIVE: To determine whether recent corticosteroid use was associated with an increased risk of complicated varicella-zoster virus infection in otherwise immunocompetent children. STUDY DESIGN: A case-control study design was used because the outcome of interest, complicated varicella-zoster virus infection, is rare. SETTING: Cases and controls were selected from the population of children aged 2 months to 18 years admitted to two hospitals, between January 1979 and July 1994 in one and between January 1974 and July 1994 in the other, with diagnosis codes that indicated chickenpox. POPULATION: Cases were defined as children with invasive varicella-zoster virus infection or associated invasive bacterial infection. Controls were defined as children with uncomplicated varicella admitted for elective surgery, fracture or burn management, psychiatric or social evaluation, treatment of simple dehydration, or evaluation of fever or rash not yet diagnosed. Exclusions included varicella-zoster virus infection in neonates and immunocompromised children. METHODS: A priori criteria were formulated on the basis of a comprehensive literature review to define complicated varicella-zoster virus infection. Recent corticosteroid exposure was defined as corticosteroid use of any sort within 30 days of onset of the chickenpox rash. Data were abstracted by medical chart review. RESULTS: In total, 167 cases and 134 controls were identified. Only three children (two cases and one control) had a history of recent corticosteroid therapy. Recent corticosteroid exposure was therefore not statistically associated with an increased risk of complicated varicella-zoster virus infection (odds ratio, 1.6; 95% confidence interval, 0.2 to 16.9). No differences between cases and controls were found in sex, history of asthma, or length of hospital stay. The mean age of cases was greater than that of controls (6.0 vs 4.7 years; P<.01). CONCLUSIONS: Recent corticosteroid therapy in otherwise immunocompetent children does not appear to be associated with a statistically increased risk of complicated varicella. A conservative estimate of risk, using the upper limit of the 95% confidence interval, is markedly lower than previously published risk estimates.

Adolescent

Procarbazine, lomustine, and vincristine (PCV) chemotherapy for grade III and grade IV oligoastrocytomas.

The authors provided procarbazine, lomustine (CCNU), and vincristine (PCV) chemotherapy to 32 patients whose tumors contained varying mixtures of oligodendroglial and astrocytic cells. Twenty-five patients had oligodendroglioma-astrocytoma (oligoastrocytoma) with a histological Grade of III (19 patients) or IV (six patients); seven had anaplastic oligodendroglioma. The PCV therapy was administered every 6 weeks for a total of at least 124 cycles. The median duration of follow-up review from the start of chemotherapy was 19.3 months. Nineteen patients were treated before receiving radiation therapy and 12 after receiving it (one patient received concurrent radiotherapy and chemotherapy). Grade 3 or 4 hematological toxicity was experienced by nine (31%) of 29 patients. Ten patients had delayed treatment due to treatment-related toxicities (34.5%). Ninety-one percent of the 32 patients responded to the therapy. These included 10 patients with a complete response and 19 with a partial response. The median time to progression was 15.4 months for all patients and 23.2 months for those with Grade III tumors. The median time to progression for patients with Grade III oligoastrocytomas was 13.8 months; for those with Grade IV oligoastrocytoma it was 12.4 months and for those with anaplastic oligodendrogliomas it was 63.4 months (p = 0.0348). These patients survived a median of 49.8 months, 16 months, and 76 or more months, respectively, from the start of chemotherapy (p = 0.0154). The PCV therapy provides durable responses in patients with Grade III or IV oligoastrocytomas.

Adult

Diabetes insipidus, acute myelogenous leukemia, and monosomy 7.

Diabetes insipidus together with acute myelogenous leukemia has rarely been seen. Still rarer is the occurrence of monosomy 7 with the two diseases (only six cases reported). A patient who had diabetes insipidus develop before the diagnosis of acute myelogenous leukemia was found at karyotyping to have monosomy 7. Although a specific mechanism whereby monosomy 7 would cause diabetes insipidus has been proposed, some have suggested that monosomy 7 may have its effect by altering cell wall membranes. Others have suggested that acute myelogenous leukemia causes diabetes insipidus by causing infiltrates in the hypothalamus or posterior lobe of the pituitary gland. Magnetic resonance imaging of the patient's brain showed no abnormalities of the hypothalamus or pituitary gland. Lumbar puncture revealed no leukocytes in the cerebrospinal fluid. The authors believe that the cause of diabetes insipidus can be explained in patients with acute myelogenous leukemia by checking for monosomy 7 during karyotyping. Because karyotyping is now more frequently performed in evaluation of patients for chemotherapy or bone marrow transplantation, genetic abnormalities such as monosomy 7 will become increasingly apparent.

Anti-Bacterial Agents

Physiologic definitions of obliterative bronchiolitis in heart-lung and double lung transplantation: a comparison of the forced expiratory flow between 25% and 75% of the forced vital capacity and forced expiratory volume in one second.

BACKGROUND AND METHODS: A comparison of the forced expiratory flow between 25% and 75% of the forced vital capacity (FEF25-75) and forced expiratory volume in 1 second (FEV1) was conducted for the detection of obstructive airway disease as an early manifestation of obliterative bronchiolitis. Pulmonary function tests performed on heart-lung and double lung transplant recipients between March 1981 and March 1983 were reviewed. Thirty patients were identified who showed progressive deterioration in pulmonary function after transplantation. Ratios determining proportionate decreases were calculated from measurements of absolute values for the FEF25-75 and FEV1 at the point when the FEF25-75 reached < 70% and < or = 30% of predicted, divided by baseline values obtained before the decline in function. Similar ratios were obtained for FEV1 and FEF25-75 at the point the FEV1 declined > or = 20% from its baseline value. RESULTS: Comparison of the ratios for the FEF25-75 and FEV1 at FEF25-75 values < 70% and < or = 30% of predicted and a similar comparison when the FEV1 declined > or = 20% from baseline showed a greater proportional decrease in FEF25-75 than FEV1 (p < 0.01). With the use of the FEF25-75, declines in airway function were detected earlier. After transplantation a decline in FEF25-75 to < 70% of predicted occurred approximately 112 days before a 20% decline a FEV1. CONCLUSION: The FEF25-75 is more sensitive than the FEV1 for the early detection of obliterative bronchiolitis. A presumptive diagnosis of obliterative bronchiolitis can be made with physiologic criteria, providing infection or acute rejection has been ruled out. When conducting epidemiologic studies or for vital statistics we propose that a decline in FEF25-75 to < 70% be used to define the onset of obliterative bronchiolitis.

Adult

Efficacy of combination therapy with insulin and oral hypoglycemic agents in patients with type II diabetes during a 1-year period.

In this retrospective study, the authors assess the efficacy of combined insulin and oral hypoglycemic agents (OHAs) in controlling glycemic levels, as well as lipid levels and insulin requirements, in 48 patients with type II diabetes mellitus during a 1-year period. Thirty-two of these patients had secondary failure to an OHA (group 1). Sixteen patients (group 2) were taking high doses of insulin alone. Overall, 64.6% of all the patients responded to the combination therapy and insulin at 6 months. Response was defined as a decrease in hemoglobin A1c of more than 0.5%. At 12 months, 50% of these patients continued to respond to this regimen. No significant differences were seen in the patients' total cholesterol and triglyceride levels between responders and nonresponders in each group. After 1 year of combination OHA and insulin therapy, 50% of the patients showed a 21.4% reduction in their daily insulin dose.

Administration, Oral

Squamous cell carcinoma of the head and neck in the elderly.

OBJECTIVE: While squamous cell carcinoma of the head and neck (HNSCC) most commonly affects individuals in the fifth to seventh decades of life, it occasionally arises in older patients. Biologic and epidemiologic factors of HNSCC in elderly patients have been investigated to shed light on the process of neoplastic transformation in that population. DESIGN: The medical records of patients with new onset of HNSCC presenting between 1988 and 1993 were reviewed retrospectively. SETTING: Tertiary-care hospital-based clinic. PATIENTS: Eighty-one individuals who developed HNSCC of the upper aerodigestive tract after their 75th birthday constituted the study group. A control group consisting of 102 patients who developed HNSCC between the ages of 40 and 70 years was also analyzed. MAIN OUTCOME MEASURE: Information about each individual's tobacco and ethanol exposure, family history of cancer, history of second primary cancer, treatment provided, and current disease status were derived from the medical record. The presence or absence of p53 gene mutation was tabulated for a subset of individuals in both the elderly and the middle-aged groups. RESULTS: The elderly patients had a significantly lower degree of alcohol and tobacco exposure, but a significantly higher rate of second primary cancers, especially in sites outside the upper aerodigestive tract. There was no difference in the incidence of cancer in first-degree relatives in the two groups. These findings were interpreted in light of results from our laboratory examining the incidence of p53 gene mutation in a large number of patients with HNSCC. A significantly higher percentage of tumors from the younger group contained a p53 gene mutation. Major surgery was an integral part of the treatment plan for most of the older patient group despite their advanced age. CONCLUSIONS: These findings suggest that HNSCC arising after the seventh decade of life less frequently involves a genetic change commonly found in younger patients. Heavy carcinogen exposure and p53 gene mutations are present less often in elderly individuals, whereas this group appears to be more susceptible to multiple cancers. The precise biologic factors involved in neoplastic transformation in this older population await discovery. Since aggressive therapy can be successfully tolerated by many elderly patients, an individualized approach to treatment is advocated.

Adult

Effects of K+, pH and glutamate on 45Ca kinetics in hippocampal brain slices.

Altered calcium homeostasis is likely to play a pathogenetic role in cerebral ischemia. In order to further understand which factors associated with ischemia contribute to disturbances of calcium metabolism, the influence of 3 isolated insults, 8 mM K+, pH 6.1 and 1 mM glutamate, on total tissue calcium were studied by analysis of steady-state kinetics of 45Ca in 500 microns hippocampal brain slices. 45Ca kinetics were analyzed with 2 bi-exponential models by non-linear least-squares analysis. Tissue wet weight/protein was measured simultaneously. Each experimental condition produced a unique tissue response. Raising K+ had no effect on tissue water but increased the rate of uptake of Ca2+ into the larger, rapidly equilibrating tissue Ca2+ space. Acidosis reduced tissue water and the amount of Ca2+ in the slowly equilibrating compartment due to enhanced efflux from that space. Glutamate increased tissue water in a time-dependent manner and increased the influx and amount of Ca2+ in the slowly equilibrating space. Combined insults revealed minimal interaction between K+ and acidosis or glutamate, but glutamate with acidosis worsened tissue injury. We discuss the relationship of this technique to other methods for studying tissue calcium and the significance of the observations regarding ischemia.

Animals

Clinical correlation of periodic lateralized epileptiform discharges in children.

Fifteen children with periodic lateralized epileptiform discharges are reported and clinical and radiologic features and outcome are presented. Both structural cerebral lesions and metabolic factors were associated with periodic lateralized epileptiform discharges. Although all patients had seizures, 8 had status epilepticus. Seven patients survived and 8 patients died. Six of the 7 survivors had residual seizures. Periodic lateralized epileptiform discharges in children are associated with acute encephalopathies and there is a high incidence of subsequent epilepsy.

Adolescent

Spontaneous extracranial carotid artery dissection in children.

Dissection of cerebral arteries as a cause of stroke is rarely recognized in children. Two patients with stroke due to extracranial carotid artery dissection are reported. A 7-year-old girl with a 2-week history of right arm chorea had a left basal ganglia infarct and is receiving haloperidol for persistent chorea. The second patient, a 15-year-old boy, developed aphasia and right hemiparesis a day before admission during a football game without obvious trauma. He had a large left middle cerebral artery infarct and died of cerebral edema and herniation. We believe that strokes due to arterial dissection are more common than currently recognized, partly because of a lack of history of trauma, and suggest that cerebral artery dissection be considered as an etiology of childhood strokes. Greater awareness of arterial dissection as a cause of stroke and availability of noninvasive techniques like magnetic resonance angiography should result in a more accurate diagnosis and improved prognosis in these patients.

Adolescent

Special considerations in the endourologic management of stones in continent urinary reservoirs.

To various degrees, all continent pouch designs are subject to stones, which often are infected. We report on the endourologic management of large stone burdens in three types of continent reservoirs. Stone in a UCLA and a Kock pouch were managed endoscopically, and stones in an augmented pouch with a Mitrofanoff valve were managed percutaneously. Recommendations are made with regard to the optimal endourologic management of significant stone burdens in each of the common continent urinary reservoirs.

Adult

Variability of intrinsic positive end-expiratory pressure in patients receiving mechanical ventilation.

OBJECTIVE: Since variations in breathing pattern may affect the level of intrinsic positive end-expiratory pressure (PEEP), breath-to-breath variation of intrinsic PEEP was assessed. DESIGN: Descriptive and prospective study. SETTING: Medical intensive care unit of a university teaching hospital. PATIENTS: Thirty-four patients requiring mechanical ventilation for a period of time due to respiratory failure. MEASUREMENTS AND MAIN RESULTS: Intrinsic PEEP was determined using simultaneous recordings of the esophageal pressure and airflow. The breath-to-breath intrinsic PEEP, respiratory rate, tidal volume, inspiratory time, and fractional inspiratory time were measured. Intrinsic PEEP was noted in 33 of 34 patients. For all patients, the mean intrinsic PEEP was 3.59 cm H2O. The group mean standard deviation (SD) of the intrinsic PEEP over 35 breaths was 2.68 cm H2O. In 17 chronic obstructive pulmonary disease patients, the mean intrinsic PEEP was 4.69 cm H2O and the group mean SD of the intrinsic PEEP was 3.19 cm H2O. In the subgroup of patients with significant intrinsic PEEP, the mean intrinsic PEEP was 6.69 cm H2O and the group mean SD was 4.29 cm H2O. The group mean coefficient of variation of intrinsic PEEP for all 34 patients was 123%. Among the 15 patients with clinically significant intrinsic PEEP, the coefficient of variation was smaller (74%). We did not find significant correlation between the coefficients of variation of breathing pattern parameters and the coefficients of variation of intrinsic PEEP. CONCLUSIONS: We conclude that the occurrence rate of intrinsic PEEP in mechanically ventilated patients is high. The degree of variability in intrinsic PEEP on a breath-to-breath basis is also high. It may be difficult to find a specific level of intrinsic PEEP. Addition of external positive end-expiratory pressure without considering the breath-to-breath variability may lead to overdistention of the lung.

Adult

Three-dimensional structure of the platelet integrin recognition segment of the fibrinogen gamma chain obtained by carrier protein-driven crystallization.

We have developed a method for crystallizing small functional protein segments so that their three-dimensional structure can be determined by x-ray diffraction analysis. This method consists of linking a small protein segment of unknown tertiary structure to either the amino or carboxyl terminus of a larger carrier protein of known tertiary structure. Crystallization of the small segment is then driven by crystallization of the carrier protein. Using this approach, we have obtained crystals of the human fibrinogen gamma-chain carboxyl-terminal segment linked to the carboxyl terminus of chicken egg white lysozyme. The three-dimensional structure of the carboxyl-terminal segment of the fibrinogen gamma chain was determined by x-ray diffraction analysis at a resolution of 2.4 A. This segment encompasses the recognition site for the integrin alpha IIb beta 3 receptor on activated platelets and for the clumping receptor on pathogenic staphylococci and also bears donor and acceptor sites for factor XIIIa-catalyzed crosslinking of fibrin. Therefore, the structural information derived from our analysis will provide a rational basis for the design of inhibitors of these important functions of fibrinogen. Moreover, carrier protein-driven crystallization will facilitate the determination of the three-dimensional structure of functional segments of other proteins that are, like fibrinogen, difficult to crystallize in toto.

Amino Acid Sequence