Scrub typhus among hospitalised patients with febrile illness in South India: magnitude and clinical predictors

OBJECTIVES

To derive a clinical algorithm for diagnosis of scrub typhus among patients hospitalized with febrile illness and to determine predictors of bad prognosis.

METHODS

Patients hospitalized with febrile illness of 5-30 days duration were evaluated for common aetiologies. Sera were tested for antibodies (IgM and IgG) to Orientia tsutsugamushi using ELISA kit.

RESULTS

Among 207 patients, 50 had elevated levels of IgM antibodies. The data of these patients were compared with that of 16 controls having febrile illnesses in whom rickettsial infection was ruled out. Transaminase elevation (>twice normal) was present in 90% and was significantly (P=0.004) more common in those with scrub typhus. If a combination of elevated transaminases, thrombocytopenia and leukocytosis is used, the specificity and positive predictive value are about 80%. Case fatality rate was 14%. Univariate analysis showed that hyperbilirubinemia (>1.5mg%) has a RR of 9 (95% CI=1.48-58.5) and elevated creatinine level (>1.4 mg%) had a RR of 43.99 (95% CI=3.65-530.5) for death. Elevated creatinine level was found to be an independent predictor of mortality (P=0.02).

CONCLUSION

In developing countries with limited diagnostic facilities, it is prudent to recommend empiric therapy in patients with undifferentiated febrile illness having evidence of multiple system involvement especially if there is transaminase elevation. Elevated creatinine may predict bad outcome.

Clinical pharmacokinetics (PK) of AMN107, a novel inhibitor of Bcr-Abl, in healthy subjects and patients with imatinib resistant or intolerant chronic myelogenous leukemia (CML) or relapsed/refractory Ph+ acute lymphocytic leukemia (Ph+ALL)

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Background: AMN107, a selective and potent inhibitor of Bcr-Abl tyrosine kinase, has demonstrated activity against imatinib resistant forms of Bcr-Abl in patients with CML or Ph+ALL in a phase I study. This study characterizes clinical PK of AMN107 for the safe and effective use of the drug. Methods: Serum samples were collected in 119 patients with CML or Ph+ALL treated with once (QD) or twice daily (BID) oral AMN107 (doses of 50 to 1200 mg/day). PK parameters were derived from serum concentration-time data by non-compartmental methods. In separate multi-period crossover studies 92 healthy subjects were treated with single doses of AMN107 to assess the food effect on PK, and to assess the potential for drug-drug interactions with medications which inhibit (ketoconazole) or are metabolized by CYP3A4 (midazolam). Results: Steady-state AMN107 PK in patients were stable over time, and showed a dose-dependency with less than dose-proportional increases in systemic exposure at dose levels higher than 400 mg QD. Daily exposure at 400 mg BID, which maintains serum AMN107 levels at least 30 times higher than the IC50 of cellular phosphorylation of Bcr-Abl, was greater than at 800 mg QD. The effective half-life was 15 hours. Bioavailability of AMN107 administered with a high-fat meal was increased by 82% compared to fasting. CYP3A4 inhibition by concomitantly administered ketoconazole produced 3-fold increases in systemic exposure to AMN107, whereas AMN107 appeared a weak inhibitor of CYP3A4 with 30% increase in systemic exposure of midazolam given concomitantly. Conclusions: Systemic AMN107 levels at an oral AMN107 dose of 400 mg BID in patients with CML or Ph+ALL were well above the IC50 of Bcr-Abl. The food/drug interaction results provide further guidance for the safe use of AMN107 in the clinical setting.

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Predictors of mortality in mechanically ventilated patients

OBJECTIVES

There are scarce data from India validating scoring systems used to predict outcome in patients requiring mechanical ventilation. This study prospectively compared the organ system failure (OSF), the acute physiology and chronic health evaluation (APACHE) II, and the APACHE III, scores on patients requiring mechanical ventilation in the medical intensive care unit, to predict outcome.

METHODS

200 consecutive patients requiring mechanical ventilation in a medical intensive care unit were recruited. OSF, APACHE II, and APCHE III scores were calculated at admission and daily for one week or until discharge in all patients. Other variables recorded include age, sex, diagnosis, oxygen therapy before ventilation, complications on ventilation, duration in hospital before ventilation, duration of ventilation, type of respiratory failure, alveolar arterial oxygen gradient, P/F ratio, use of tracheostomy, time on ventilator before tracheostomy, muscle relaxant used, fluid balance, inotrope support. Logistic regression analysis and area under the curve were computed to determine which variables independently predict outcome.

RESULTS

Of the 200 patients, at discharge 143 patients (71.5%) had died. The factors that independently predicted outcome among these patients on mechanical ventilation were the type of respiratory failure (type I) OR = 2.7 (p = 0.02), the use of inotropes OR 2.4 (p = 0.04), and the APACHE II score OR = 1.8 (p = 0.008) for every five point increase in APACHE II score.

CONCLUSIONS

Type 1 respiratory failure, the use of inotropes, and the APACHE II score measured at admission are significant independent predictors of mortality in the patients on mechanical ventilation.

Assessment of the dispensing practices of drug retail outlets in selected towns, north west Ethiopia

OBJECTIVES

Ethical dispensing of drugs and medicinal products is an integral component of rational drug therapy. Nevertheless, this essential health issue apparently has a large commercial aspect. This study was conducted to assess the dispensing practices of pharmacies and rural drug vendor shops in selected towns of northwest Ethiopia.

MATERIALS AND METHODS

In this cross-sectional study, all private pharmacies (totally 3) and rural drug vendor shops (totally 9) were included in the study. The dispensing activities, condition of the dispensing environment, dispensed drugs and other relevant information were recorded on a structured protocol. In total, the dispensing procedures for 74 clients in pharmacies and 194 clients in rural drug vendor shops were observed (each premise was visited only once).

RESULTS

The results demonstrated that all premises possessed clean dispensing environment. The average dispensing time was 1,86 minutes in Pharmacies and 1.7 minutes in rural drug vendor shops. The dispensing of prescription-only medications without a medical prescription was higher in rural drug vendor shops (68.8%) than in Pharmacies (7.3%). The provision of verbal (about 87%) and written (about 66%) instructions was similar in both pharmacies and rural drug vendor shops.

CONCLUSION

The dispensing environment and storage conditions are satisfactory. However, the dispensing of prescription-only-medications without medical prescription was more frequent particularly in rural drug vendor shops. The provision of drug-related information especially labeling of the dispensed medications was not satisfactory in both types of drug retail outlets. Implementation of training programs and supervisory visits are recommended for the improvement of dispensing practices and application of code of Ethics.

Renal vasoconstrictor responses to static exercise during orthostatic stress in humans: effects of the muscle mechano- and the baroreflexes

Renal circulatory adjustments to stress contribute to blood pressure and volume regulation. Both handgrip (HG) and disengagement of baroreflexes with lower body negative pressure (LBNP) can engage the sympathetic nervous system (SNS). However, the effect of simultaneous HG and LBNP on the renal circulation in humans is not known. Eighteen young healthy volunteers were studied. Beat-to-beat changes in renal blood flow velocity (RBV; Duplex Ultrasound), mean arterial pressure (MAP; Finapres) and heart rate (ECG) were monitored during (a) 15 s HG at 30% maximum voluntary contraction (MVC); (b) LBNP at -10 and -30 mmHg (each level for 5 min); and (c) 15 s HG (at 30% MVC) during LBNP at both levels. Renal vascular resistance index (RVR units) was calculated by dividing MAP by RBV. The increases in RVR during HG alone (12 +/- 6%) were not different from the responses noted during combined HG and LBNP (17 +/- 6% at -10 mmHg and 25 +/- 8% at -30 mmHg). These results suggest occlusion occurs between a neural circuit engaged during 15 s of HG (central command and/or the muscle mechanoreflex) and a circuit activated by LBNP. In additional experiments (n = 6), similar non-algebraic summation of RVR was seen during 15 s involuntary biceps contractions (engages only muscle reflexes) and LBNP. With respect to RVR, neural occlusion occurs between baroreflexes and the muscle mechanoreflex. Muscle mechanoreflex mediated renal vasoconstriction during short bouts of HG is not influenced by baroreflex disengagement.

Febrile convulsions: development and validation of a questionnaire to measure parental knowledge, attitudes, concerns and practices

BACKGROUND

The best medicine for febrile convulsions (FCs) is not prescription medications but effective communication of related information to parents. Therefore, a quick assessment tool for obtaining information about parental responses to FCs is essential for educating parents, clinical practice and research. This paper describes the development and psychometric testing of a questionnaire on parental knowledge, attitudes, concerns and practices (KACP) toward FC.

METHODS

Questionnaire items were created via literature review, interview, and expert consultation. Ten parents were interviewed to develop the questionnaire contents. Nine experts and seven parents were consulted to review the content and face validity of the questionnaire. Of the 326 parents of children with FC visiting 11 emergency departments in southern Taiwan, 216 parents completed the questionnaire, and 64 completed the questionnaire again 2 weeks later. Content validity, internal consistency, test-retest reliability, and item analysis were evaluated.

RESULTS

Cronbach's alpha exceeded 0.72 for the knowledge, attitudes and concerns domains. The item-total correlations in the knowledge and concerns domains ranged from 0.40 to 0.73, but were lower in the attitudes domain (only 4 in 10 items were within 0.40-0.70). The intraclass correlation coefficients (ICC) for the test-retest reliability of the knowledge, attitudes and concerns domains were 0.65, 0.68 and 0.58, respectively. The correlation coefficients between KACP domains were tested and significantly supported the theoretical basis of the questionnaire.

CONCLUSION

For research purposes, the KACP questionnaire measures parental responses with a moderate level of reliability and validity. Cross-cultural investigation of the questionnaire is needed to facilitate its use in other countries.

The role of the interferon regulatory factors, IRF-1 and IRF-2, in LPS-induced cyclooxygenase-2 (COX-2) expression in vivo and in vitro

Cyclooxygenase (COX) exists as two isoforms: COX-1, which is constitutively expressed in most cell types; and COX-2, which is inducible by lipopolysaccharide (LPS) and cytokines in a variety of cell types. Although previous studies have implicated two DNA binding proteins, interferon regulatory factor (IRF)-1 and IRF-2, in the regulation of LPS- and IFN-gamma-induced COX-2, their effects in vivo and in vitro are not well-defined. Using real-time PCR, COX-2 gene expression in the livers and lungs of mice challenged in vivo and in macrophages stimulated with LPS in vitro was investigated in wild-type and in IRF-1 and IRF-2 knockout mice. In response to 35 mg/kg LPS, IRF-1-, but not IRF-2-deficient mice, exhibited much poorer induction of COX-2 gene expression in both the livers and lungs. In vitro, COX-2 mRNA levels were also poorly induced in IRF-1-deficient macrophages, while IRF-2- deficient macrophages exhibited higher levels than in normal macrophages. IRF-1 and IRF-2 were confirmed to activate and repress expression of the COX-2 promoter, respectively, in a transient transfection system and the role of specific DNA binding sites confirmed by site-specific mutagenesis. Collectively, these data provide evidence for an important role for IRF-1 in vivo and in vitro and for IRF-2 in vitro in the regulation of COX-2 expression by LPS.

Crohn's disease in rheumatology clinic--an Indian experience

BACKGROUND

Prevalence of Crohn's disease (CD) among patients with rheumatic illnesses in India is grossly under estimated, especially when it has overtaken that of Ulcerative Colitis in the West.

AIM

To study the frequency of histologically unequivocal CD amongst clinically suspected patients with enteropathic arthropathy and to ascertain if the arthritics with CD have any independent clinical predictor.

SETTINGS AND DESIGNS

Retrospective datasheet analysis from a Rheumatology clinic of a large tertiary care centre.

MATERIALS AND METHODS

Patients of suspected enteropathic arthropathy were studied by ileocolonoscopy and segmental colonic biopsy for histological evidence of Crohn's disease and followed up.

STATISTICAL ANALYSIS

Logistic regression analysis was done to find out any clinical predictor of histologically proven CD.

RESULTS

Fourteen of the twenty-nine patients studied had histologically confirmed CD. Those with CD were younger than those without (34.7 yr vs 41.6 yrs, p=0.057). The CD group also had significantly higher number of people with loss of weight (12 vs 1), fever (11 vs 0), perianal fistula (4 vs 0), abdominal pain (8 vs 2), history of dysentery (4 vs 0) and uveitis (6 vs 1) (p=0.00002, 0.00001, 0.026, 0.013, 0.026 & 0.01 respectively). However logistic regression analysis of the most relevant ones among these, namely, loss of weight, fever, and perianal fistula showed loss of weight as only independent predictor of CD in this subset of patients (p=0.03 with odds ratio of 28).

CONCLUSION

Presence of significant loss of weight in an Indian patient with clinically suspected enteropathic arthropathy is an independent predictor of CD.

Cutting edge: expression of IL-1 receptor-associated kinase-4 (IRAK-4) proteins with mutations identified in a patient with recurrent bacterial infections alters normal IRAK-4 interaction with components of the IL-1 receptor complex

In a patient with recurrent bacterial infections and profound hyporesponsiveness to LPS and IL-1, we previously identified two mutations in IL-1R-associated kinase-4 (IRAK-4) that encoded proteins with truncated kinase domains. Overexpression of either of these mutant IRAK-4 variants in HEK293 cells failed to activate endogenous IRAK-1 and suppressed IL-1-induced IRAK-1 kinase activity, in contrast to wild-type (WT) IRAK-4. In this study, interactions of WT and mutant IRAK-4 species with IL-1R, IRAK-1, and MyD88 in HEK293 transfectants were compared. IL-1 induced a strong interaction among the IL-1R, activated IRAK-1, MyD88, and WT, but not mutant, IRAK-4. Truncated IRAK-4 proteins constitutively interacted more strongly with MyD88 and blunted IL-1-induced recruitment of IRAK-1 and MyD88 to the IL-1R. Thus, decreased IL-1-induced association of IRAK-1 and MyD88 with the IL-1RI may result from sequestration of cytoplasmic MyD88 by IRAK-4 mutant proteins. Therefore, mimetics of these truncated IRAK-4 proteins may represent a novel approach to mitigating hyperinflammatory states.

Predictors of multi-organ dysfunction in heatstroke

BACKGROUND

Heatstroke is a medical emergency that results from failure of thermoregulatory mechanism coupled with an exaggerated acute phase response, causing an elevation in core body temperature that rises above 40 degrees C, producing multi-organ dysfunction. It carries a high mortality rate, and in survivors, a risk of permanent neurological damage.

OBJECTIVE

To investigate predictors of multiple organ dysfunction syndrome in patients presenting with heatstroke.

METHODS

We investigated 28 patients admitted to a hospital in southern India during the period January 1998 to December 2001. Using a standard form, we collected data on the patients' characteristics, laboratory data, and outcome, and compared those with multiple organ dysfunction with those without such dysfunction.

RESULTS

We found that more than three quarters of the studied patients developed multiple organ dysfunction, with the most common dysfunction being respiratory failure. Among the selected predictors, metabolic acidosis 14 of 16 patients, 87.5%; p = 0.011, elevated CPK 17 of 19 patients, 89.5%; p = 0.005, and liver enzymes elevated more than twice the normal (11 of 18 patients, 61%; p = 0.02) had the highest correlation with dysfunction of two or more organs.

CONCLUSIONS

The high mortality observed in heatstroke is secondary to multi-organ dysfunction, and among the various parameters assessed, high levels of CPK (>1000 IU/l), metabolic acidosis, and elevated liver enzymes are predictive. Aggressive measures to lower the body temperature with other supportive therapy could substantially reduce the mortality.

Disease and injury among participants in the Agricultural Health Study

The Agricultural Health Study (www.aghealth.org) is a cohort of 89,658 pesticide applicators and their spouses from Iowa and North Carolina assembled between 1993 and 1997 to evaluate riskfactorsfor disease in ruralfarm populations. This prospective study is just now reaching sufficient maturity for analysis of many disease endpoints. Nonetheless, several analyses have already provided interesting and important leads regarding disease patterns in agricultural populations and etiologic clues for the general population. Compared to the mortality experience of the general population in the two states (adjusted for race, gender, age and calendar time), the cohort experienced a very low mortality rate overall and for many specific causes and a low rate of overall cancer incidence. A few cancers, however, appear elevated, including multiple myeloma and cancers of the lip, gallbladder, ovary, prostate, and thyroid, but numbers are small for many cancers. A study of prostate cancer found associations with exposure to several pesticides, particularly among individuals with a family history of prostate cancer. Links to pesticides and other agricultural factors have been found for injuries, retinal degeneration, and respiratory wheeze. Methodological studies have determined that information collected by interview is unbiased and reliable. A third round of interviews scheduled to begin in 2005 will collect additional information on agricultural exposures and health outcomes. The study can provide data to address many health issues in the agricultural community. The study investigators welcome collaboration with interested scientists.

Quantification of 2,4-D on Solid-Phase Exposure Sampling Media by LC-MS-MS

Three types of solid-phase chemical exposure sampling media: cellulose, polyurethane foam, and XAD-2, were analyzed for 2,4-dichlorophenoxyacetic acid (2,4-D) and the amine salts of 2,4-D. Individual samples were extracted into acidified methanol, and the extracts were analyzed via liquid chromatography-tandem mass spectrometry using electrospray ionization and a C(8) reversed-phase LC column. (13)C 2,4-D and a labeled benzoic acid (13)C or d5) were employed as the surrogate and internal standard, respectively. Over a three-year study of pesticide exposure among agricultural workers involving a high volume of analyses, values of average % recovery for (13)C 2,4-D on personal exposure samples ranged from 87 to 98 with a % relative standard deviation ranging from 7 to 12. The performance of the method compares favorably with that of the current National Institute for Occupational Safety and Health-recommended approach for the analysis of 2,4-D on these types of exposure sampling matrices.

Popliteal artery entrapment syndrome in a young girl

Popliteal artery entrapment syndrome (PAES) is well-described in adults, but is an uncommon cause of lower-limb pain in children. We present an 11.5-year-old girl with thrombosed aneurysm of the right popliteal artery, subsequently diagnosed with bilateral type I PAES. Multimodality illustration of the radiological findings is presented.

The DNA sequence of the human X chromosome

The human X chromosome has a unique biology that was shaped by its evolution as the sex chromosome shared by males and females. We have determined 99.3% of the euchromatic sequence of the X chromosome. Our analysis illustrates the autosomal origin of the mammalian sex chromosomes, the stepwise process that led to the progressive loss of recombination between X and Y, and the extent of subsequent degradation of the Y chromosome. LINE1 repeat elements cover one-third of the X chromosome, with a distribution that is consistent with their proposed role as way stations in the process of X-chromosome inactivation. We found 1,098 genes in the sequence, of which 99 encode proteins expressed in testis and in various tumour types. A disproportionately high number of mendelian diseases are documented for the X chromosome. Of this number, 168 have been explained by mutations in 113 X-linked genes, which in many cases were characterized with the aid of the DNA sequence.