Uropathogens and their antimicrobial susceptibility pattern in Bharatpur, Nepal

Urinary tract infection is one of the common clinical condition in the patients presenting to the clinics and hospitals. Detection of common pathogens and their antimicrobial susceptibility pattern is mandatory for effective treatment. The present study was conducted to detect common pathogens of urinary tract infection (UTI) and their susceptibility pattern to the commonly used antimicrobial agents in local scenario. We conducted a retrospective study on bacteria isolated from the urine samples submitted in microbiology unit from May 2009 to October 2009 at Chitwan Medical College. Study included total 950 clean catched midstream urine samples which were processed to identify the causative agents and their susceptibility pattern to commonly used antimicrobial agents according to the CLSI guidelines. This study showed UTI is more common in young females. Out of total 950 samples, 237 (24.94%) samples grew potential pathogens causing UTI. Escherichia coli were the predominant 163 (68.77%) isolates followed by Enterobacter spp 33 (13.92%). Most of the urinary isolates showed hundred percent resistant to Ampicillin and high degree of resistance to Nalidixic acid, Nitrofurantoin, Cotrimoxazole followed by Ciprofloxacin and Gentamicin. More than 50% of common pathogens were resistant to Ceftriaxone. Uropathogens were more sensitive to Cephotaxim, Amikacin, Ofloxacin and Norfloxacin. Uropathogens resistant to 3rd generation cephalosporin are increasing. Irrational and repeated use of antibiotics is the main cause of increasing resistant organism of UTI.

Antimicrobial Resistant Streptococcus pneumoniae

Introduction: Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy.  Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against  commonly used antimicrobials with special reference to determination of minimum inhibitory  concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal. Methods: Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by  disk diffusion method. MIC of penicillin was tested by broth dilution method. Results: Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant. Conclusions: S. pneumoniaeisolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future. Keywords: antimicrobial susceptibility pattern, penicillin, Streptococcus pneumoniae.

Properties of Composite Specimens of Old and New Bone Cement

The most common cause of failure of a total hip replacement is aseptic loosening of an implant. In a number of cases, the cement—bone interface of at least one component is not compromised. In cases of aseptic cup loosening, removal of a well-fixed femoral stem may be undertaken to facilitate exposure of the acetabulum for cup revision, and the surgeon may choose to leave the functional cement—bone interfaces in the femur undisturbed. After cup revision, new cement is pressurized within the old cement mantle and a stem is cemented into this ‘old—new cement’ composite. Retaining the old cement mantle is an attractive option as it reduces the duration of surgery, minimizes bleeding, and preserves the bone stock. Excellent results have been shown with this technique of ‘in-cement femoral revision’ using a double-tapered polished stem. While considerable literature is available on the short- and long-term properties of PMMA bone cement, very little is known about the mechanical properties of old—new composite cement specimens where the old cement is more than a few days old. This paper tests the properties of such old—new composite specimens where the ‘old’ cement is aged between 3.3 and 17.7 years, better reflecting clinical situations.

Antimicrobial resistant Streptococcus pneumoniae

INTRODUCTION

Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy. Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against commonly used antimicrobials with special reference to determination of minimum inhibitory concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal.

METHODS

Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by disk diffusion method. MIC of penicillin was tested by broth dilution method.

RESULTS

Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant.

CONCLUSIONS

S. pneumoniae isolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis

INTRODUCTION: Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing. METHODS: All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared. RESULTS: A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus. CONCLUSION: Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.  KEYWORDS: continuous ambulatory peritoneal dialysis, Peritonitis, Peritonitis rate.

Bacteriology and Antibiotic Susceptibility Pattern of Peitonsillar Abscess

INTRODUCTION: Peritonsillar abscess is a common complication of acute tonsillitis. Its management consists of aspiration or surgical drainage followed by appropriate antibiotics. Appropriate antibiotic treatment depends on the common organisms associated with infection and their antibioticsensitivity pattern in local scenario. METHODS: Pus samples aspirated from diagnosed cases of peritonsillar abscess and submitted for culture and sensitivity in last two years were included in this study. Identification of different microorganisms was made on the basis of the microscopic findings, observation of their colony morphology and standard biochemical reactions. Susceptibility pattern to commonly used antibiotics were determined by Clinical Laboratory Standards Institute (CLSI) guidelines. RESULTS: Altogether 24 pus samples were included in the study. Positive culture was obtained from 18 samples. Among them one organism was isolated from 13 samples whereas from five samples multiple organisms were isolated. From six samples no organisms could be cultured. Altogether Streptococcus pyogenes was isolated from 12 samples and Staphylococcus aureus from five samples. Other isolated organisms included Haemophlilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Enterococcus species. Penicillin was effective for Streptococcus pyogenes whereas Staphylococcus aureus was resistant to it. Cloxacillin was found to be effective for Staphylococcus aureus. Ciprofloxacin and Ceftazidime were found to be effective for both organisms. CONCLUSIONS: Streptococcus pyogenes and Staphylococcus aureus were more commonly associated with peritonsillar abscess. Streptococcus pyogenes were sensitive to penicillin but all Staphylococcus aureus were resistant to it. This fact should be considered in clinical practice for management of peritonsillar abscess. KEYWORDS: Bacteriology, Peritonsillar abscess, Susceptibility pattern.

Peritonitis in Continuous ambulatory peritoneal dialysis

INTRODUCTION

Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing.

METHODS

All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared.

RESULTS

A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus.

CONCLUSION

Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.

Bacteriology and antibiotic susceptibility pattern of peritonsillar abscess

INTRODUCTION

Peritonsillar abscess is a common complication of acute tonsillitis. Its management consists of aspiration or surgical drainage followed by appropriate antibiotics. Appropriate antibiotic treatment depends on the common organisms associated with infection and their antibiotic sensitivity pattern in local scenario.

METHODS

Pus samples aspirated from diagnosed cases of peritonsillar abscess and submitted for culture and sensitivity in last two years were included in this study. Identification of different microorganisms was made on the basis of the microscopic findings, observation of their colony morphology and standard biochemical reactions. Susceptibility pattern to commonly used antibiotics were determined by Clinical Laboratory Standards Institute (CLSI) guidelines.

RESULTS

Altogether 24 pus samples were included in the study. Positive culture was obtained from 18 samples. Among them one organism was isolated from 13 samples whereas from five samples multiple organisms were isolated. From six samples no organisms could be cultured. Altogether Streptococcus pyogenes was isolated from 12 samples and Staphylococcus aureus from five samples. Other isolated organisms included Haemophlilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Enterococcus species. Penicillin was effective for Streptococcus pyogenes whereas Staphylococcus aureus was resistant to it. Cloxacillin was found to be effective for Staphylococcus aureus. Ciprofloxacin and Ceftazidime were found to be effective for both organisms.

CONCLUSIONS

Streptococcus pyogenes and Staphylococcus aureus were more commonly associated with peritonsillar abscess. Streptococcus pyogenes were sensitive to penicillin but all Staphylococcus aureus were resistant to it. This fact should be considered in clinical practice for management of peritonsillar abscess.

Gender variation in interleukin-13 production: a possible mechanism of differential in vivo growth of a T-cell lymphoma

Interleukin (IL)-13 is a T(H)2 type of cytokine that plays a crucial role in the pathophysiology of different type of infections, autoimmune diseases and malignancies. It has been shown to dampen the T(H)1 type of immune responses and favours tumour growth. In the present investigation, we have determined IL-13 level in serum and ascitic fluid in both the sexes of BALB/c strain of mice bearing a T-cell lymphoma of spontaneous origin, designated as Dalton's Lymphoma (DL). Further, we have studied the involvement of gender hormones on the IL-13 level and NKT-cell production of IL-13. It has been observed that there exists a gender variation or gender dimorphism in the IL-13 production. IL-13 level in serum is directly correlated with in vivo progressive growth of DL cells. We observed a tendency in female DL-bearing mice to have higher serum IL-13 level and faster growth of DL cells. This study, therefore, indicates that sex hormones are directly involved in the differential production of IL-13 that may be a factor responsible, at least in part, for the differential in vivo progressive growth of a T-cell lymphoma.

Unusual cause of unilateral epistaxis: nasal leech infestation

Common causes for unilateral nasal bleeding in adults are benign or malignant tumors and deviated nasal septum. Here we present two cases of recurrent unilateral nasal bleeding due to leech infestation. Though it is not a common cause for nasal bleeding, a clinician should suspect leech infestation for a recurrent nasal bleeding specially in tropical countries like Nepal.

Characterization and susceptibility patterns of clinically important Enterococcus species in eastern Nepal

Life threatening infections caused by enterococcus species with multidrug resistance has emerged as a threat to medical care in the present era. This study was conducted to characterize enterococcus species isolated from different clinical samples and to detect the pattern of susceptibility to some of the commonly used antibiotics in B.P Koirala Institute of Health Sciences (BPKIHS), a tertiary care hospital in eastern Nepal. Clinical samples submitted to the microbiology unit of Central Laboratory Service (CLS) for culture and sensitivity during March 2002 - February 2003 was analyzed. Enterococcus species were identified by colony characteristics, gram staining and relevant biochemical tests. Antibiotic susceptibility test was done by the Kirby Bauer disc diffusion technique. Of 50 Enterococcus species isolated, E. faecalis was the predominant isolate (48.0%) followed by E. faecium (32.0%) and E. avium (20.0%). Eighty-eight percent of E. faecalis showed sensitivity to cephotaxime and 87.0% to vancomycin. Multiple drug resistance was observed most commonly in E. faecium. Seventeen percent of E. faecium were resistant to vancomycin and 63.0% to ciprofloxacin and 44.0% to ampicillin. On the contrary E. avium rarely showed resistance to the antimicrobials tested including vancomycin. Enterococcal infections are common nowadays specially in hospitalized patients. Inappropriate use of antibiotics in clinical practice and poultry should be discouraged to prevent the emergence of multidrug resistant species.

IL-13 Ralpha2-mediated interleukin-13 neutralization represses in vivo progressive growth of a T-cell lymphoma

Dalton's lymphoma (DL) is a T-cell lymphoma of spontaneous origin, characterized by highly invasive and malignant nature, killing the host in a very short period of life span. DL-bearing host is reflected by very high titer of IL-13 in serum. Therefore, we hypothesized that over expression of IL-13 may greatly affect the growth of DL-cells in a tumor-bearing host. In this study, to assess the involvement of IL-13 in DL-cell progression, we have blocked the IL-13 activity/signalling by the systemic delivery of non-signaling decoy receptor IL-13 Ralpha2, and IL-13 level vs DL-cell proliferation were measured. We observed that systemic delivery of IL-13 Ralpha2 inhibits the DL-cell progression in much extent and enhances the survival and longevity of DL-bearing mice. Further, this study re-inforce the therapeutic advantage of IL-13 Ralpha2 in a T-cell lymphoma tumor system.

Interleukin-13-induced type II polarization of inflammatory macrophages is mediated through suppression of nuclear factor-kappaB and preservation of IkappaBalpha in a T cell lymphoma

Spontaneously arising transplantable T cell lymphoma, designated as Dalton's lymphoma (DL), is characterized by a highly invasive and deleterious nature almost completely paralysing the host immune system. The level of interleukin (IL)-13 is elevated in serum and ascitic fluid of the DL-bearing host. IL-13 is a potent immunosuppressive cytokine and is an alternative activator of macrophages that suppresses the production of nitric oxide (NO) and expression of inducible nitric oxide synthase (iNOS), and proinflammatory cytokines. The expression of iNOS and proinflammatory cytokines are dependent largely upon the activation of nuclear factor-kappaB (NF-kappaB). Activation of NF-kappaB involves the degradation of cytoplasmic inhibitor IkappaBalpha, allowing the nuclear translocation of NF-kappaB and thereby transcription of the iNOS gene. Therefore, in this study we sought to determine whether the alternative activation or type II polarization of macrophages induced by IL-13 is mediated by the suppression of NF-kappaB and cytoplasmic preservation of IkappaBalpha. Western blot analysis and electrophoretic mobility shift assay (EMSA) indicate that tumour-associated macrophages (TAM) or polarized type II macrophages are due to preserved protein expression of IkappaBalpha, and therefore suppressed NF-kappaB nuclear translocation. These findings suggest that IL-13 may operate through the suppression of NF-kappaB activation and preservation of IkappaBalpha.

Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy

INTRODUCTION

Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy.

AIMS

To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional.

METHODS

We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature.

RESULTS

We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell-Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent.

CONCLUSION

Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.

Hsp70 induces Th1 polarization through tumor-associated macrophages in a T-cell lymphoma

Tumor progression produces immunoregulatory phenotype of macrophages in tumor bearing host (TBH), that mediate immunosuppression through increased production of soluble factors. These factors obviously suppress the T-cell responsiveness and underproduction of Th1-polarizing cytokines. Here, we reported that in vitro treatment of TAMs with autologous Hsp70 purified from DL-bearing mice reverse back the tumor induced macrophage suppressor activity, suggesting that Hsp70 can restore TAMs production of Th1-polarizing cytokines. LPS stimulation failed to overcome tumor-induced dysregulation of IL-1, IL-12, IL-15 and IFN-gamma production. In contrary, Hsp70 significantly enhanced IL12, IL-15, IL-1 and IFN-gamma production by TAMs in vitro and in vivo, but also enhanced the LPS and IFN-gamma responsiveness of TAMs. These Th1 polarizing effects of cytokines of TAMs are dose dependent and reach the maximal values at 24 hrs of incubation. Though, we found a significant release of IFN-gamma in TAMs without T-cells, and increased level of IFN-gamma with T-cells suggests that Hsp70 stimulates T-cells. Summarizing, these data demonstrates that Hsp70 restore Th1 polarizing cytokines production in the TBH and thus ascribe a possibility to develop a novel immunotherapeutic regime by using TAMs that could contribute well to the correction of tumor induced immune dysfunction.

Brain abscess due to Scedosporium apiospermum in a non immunocompromised child

Scedosporium apiospermum is a filamentous fungi that commonly causes cutaneous infection. In certain circumstances, S. apiospermum can also cause invasive disease, which can involve the central nervous system (CNS). When the CNS becomes involved, treatment is difficult, therapeutic options are limited and the prognosis is poor. Early identification and treatment can decrease the mortality rate. Here we present a case of brain abscess with chronic suppurative otitis media, caused by S. apiospermum. This is the first such case report from Nepal. We could identify the organism only post mortem. We could not save the patient, probably due to delay in diagnosis.

Anaesthesia-related maternal mortality

Complications of anaesthesia leading to death in young pregnant women might be prevented if more experienced personnel could be entrusted with the job. The contribution of anaesthesia to maternal mortality in the United Kingdom is 1.7 per million pregnancies with almost similar incidence from United States. The commonest single factor responsible for anaesthesia-related death is difficult or failed intubation. A pregnant woman with a potentially difficult airway should receive aspiration prophylaxis (mechanical or pharmacological) as soon as operative delivery is anticipated. Anaesthetists should make a plan that comes into effect as soon as failure to view the larynx or to intubate the trachea becomes evident. Unsuspected difficult airway can be managed if the skill of the anaesthetists is of high standard. Pulmonary aspiration is one cause of death in obstetric anaesthesia. Regurgitation and vomiting prevention can minimise pulmonary aspiration. In regional anaesthesia, local anaesthetics toxicity is another cause of concern. This should be tackled with some safe local anaesthetics. Preventing a high spinal or epidural block involves ways to detect inadvertent injection of local anaesthetic into the cerebrospinal fluid. Postoperative care after anaesthesia in obstetric cases is very important.

Intestinal trematode infection in North Bihar

Reports of intestinal trematode infections are not common from Bihar, India. However, we herewith report one case of fasciolopsiasis from North Bihar, India. A 14 years old girl presented with diarrhea, vomiting, generalized pain abdomen and loss of weight. Routine stool examination and upper gastrointestinal endoscopy revealed fasciolopsis buski in large numbers. Her rural life style and food habit (ingestion of raw vegetables- caltrops and water chest nuts) supported the cause of infestation. Despite treatment with praziquantel, the patient died after two days. Mild infestations of Fasciolopsis buski may pass on unnoticed. However, heavy infestations may cause considerable prostration, illness and even death in younger age groups. Awareness regarding this parasitic infestation (endemic in some regions), especially in the rural set up is still a much needed entity.

Caudal Additives in Pediatrics: A Comparison Among Midazolam, Ketamine, and Neostigmine Coadministered with Bupivacaine

Single-shot "kiddie caudal" with bupivacaine alone is losing popularity because of its duration of 4-8 h. In a prospective randomized double-blind clinical study, we assessed and compared the efficacy of ketamine, midazolam, and neostigmine coadministered with bupivacaine in a caudal epidural to provide intraoperative and postoperative pain relief. Eighty children (ASA status I) aged 5-10 yr undergoing unilateral inguinal herniotomy were allocated randomly in equal numbers (n = 20) into 4 groups to receive a caudal injection of 0.25% bupivacaine (1 mL/kg) with or without ketamine (0.5 mg/kg), midazolam (50 microg/kg), and neostig-mine (2 microg/kg), after the induction of standardized general anesthesia without premedication. Monitoring for pain, sedation, postoperative nausea/vomiting, dizziness, and pruritus was performed by anesthesiologists blinded to the study allocation. The time to first analgesic administration (paracetamol syrup) was longer (P < 0.05) in the bupivacaine-neostigmine group and the bupivacaine-midazolam group than in the other groups. Undesirable effects, such as emesis, pruritus, and dizziness, were comparable in all groups. However, the incidence of hallucination was more frequent in the bupivacaine-ketamine group compared with the other groups. This study shows that single-shot caudal coadministration of bupivacaine-neostigmine and bupivacaine-midazolam was associated with an extended duration of postoperative pain relief.

Novel Peptide Treated Macrophage Induces Apoptosis in Tumor Cell Line P815

In vitro macrophages treated with novel peptides have been shown to develop enhanced tumoricidal activity against tumor target cell (P815), though the exact mechanism is not known. In the present study, we have investigated the mechanism involved in the tumor cell cytotoxicity mediated by novel peptides treated macrophage and involvement of possible effectors molecule. Peritoneal exudated macrophages treated with LPS, peptides, and LPS plus peptides and when cocultured with tumor cell P815 caused tumor cell death by induction of apoptosis. The results of our experiment reveal a specific pattern of intranucleosomal DNA fragmentation detected by agarose gel electrophoresis and also with microscopic examination of the cells revealed nuclear alteration characteristic of apoptosis. Viability studies showed that most of the cells undergoing apoptosis were found to be non-viable even after 24 h coculture. Macrophage induced apoptosis in tumor target cells even in the absence of cell to cell contact through diffusible effectors molecule. The study thus shows that the novel peptide treated macrophage can kill tumor cell P815 by extracellular release of effectors molecule NO (nitric oxide) that act by inducing apoptosis in a target cell-specific manner.

Management of intracapsular femoral neck fractures in the elderly; is it time to rethink our strategy?

We reviewed 100 adult patients who had a traumatic intracapsular femoral fracture internally fixed prior to 1998, with full clinical and radiological data available. End points were complete clinical and radiological union of the fracture, non-union, avascular necrosis or fixation failure. The incidence of non-union and avascular necrosis was found to be 13 and 11%, respectively. The following factors did not influence the development of avascular necrosis or non-union; fracture displacement, screws inserted (two or three), osteoporosis, parallelism of screws, presence of screws in each "quadrant" and the experience or seniority of the surgeon. The factors influencing a poor outcome were the age of the patient at injury, reduction gap at the fracture site, alignment after reduction of the fracture especially on AP view and having all screw threads crossing beyond the fracture site. We conclude that the incidence of non-union and avascular necrosis following fixation of femoral neck fractures in our study is less than generally reported with no statistical difference between displaced and undisplaced fractures. Traditional fixation factors such as screw position and number do not seem to significantly affect the outcome with the quality of reduction being most important. Thus, the majority of patients under the age of 70 with displaced intracapsular fracture should be considered for internal fixation.

N(2)O(2)-induced apoptosis of thymocytes involves mobilization of divalent cations

More than 90% of thymocytes undergo apoptosis while undergoing differentiation in the thymus. Although several factors act in concert to induce thymocyte apoptosis, it remains speculative if reactive oxygen intermediates produced by thymic macrophages may play a role in this process. The present investigation was carried out to determine if H(2)O(2) is capable of inducing apoptosis of thymocytes in vitro. It was observed that H(2)O(2) could induce apoptosis of thymocytes in vitro in a dose and time dependent manner. It was further found that H(2)O(2)-induced thymocyte apoptosis was dependent on the mobilization of divalent cations. The result of this study will help further in the understanding of the mechanism of H(2)O(2)-induced apoptosis

Physicochemical Investigations of Microemulsification of Coconut Oil and Water Using Polyoxyethylene 2-Cetyl Ether (Brij 52) and Isopropanol or Ethanol

The microemulsification of coconut oil/polyoxyethylene 2-cetyl ether/2-propanol or ethanol/water was investigated. The phase behaviors of the mixed system were examined. The shear viscosity at different temperatures was measured to derive activation parameters for the viscous flow. The diffusion coefficient of the microemulsions at different compositions was determined by the DLS method. The energetics of solubilization of water into oil + Brij + alkanol as well as of oil into water + Brij + alkanol forming w/o and o/w microemulsions, respectively, were calorimetrically determined.

Diarrhea and gallbladder hydrops in an immunocompetent child with Cryptosporidium infection

We report a case of an immunocompetent child who developed gallbladder hydrops during a concurrent diarrheal illness caused by Cryptosporidium parvum. Hepatobiliary disease and chronic cryptosporidial diarrhea is an accepted association in adults with HIV infection but has only once previously been reported in a child, also with HIV.

Physicochemical investigations on microemulsification of eucalyptol and water in presence of polyoxyethylene (4) lauryl ether (Brij-30) and ethanol

The microemulsification of eucalyptol/polyoxyethylene(4)lauryl ether (Brij-30)/ethanol/water has been investigated. The phase behaviours of the mixed system in pseudoternary and tetrahedral representations have been examined to understand the topological nature of the multicomponent mixtures. Phase volumes of the heterogeneous combinations have been estimated to understand the mixing efficacy of the combinations. Shear viscosities of different monophasic compositions have been measured at different shear rates and temperatures, and the activation parameters for the viscous flow have been evaluated. The dimensions of the nanodispersions of w/o and o/w types, their diffusion coefficients and the polydispersity have been determined by the DLS method. The energetics of solubilisation (dissolution) of water in oil+Brij-30+ethanol as well as oil in water+Brij-30+ethanol forming w/o and o/w microemulsions, respectively, have been calorimetrically determined. Considering the phase separation point to be the point of maximum solubility, the energetic parameters (enthalpy, free energy and entropy) of the microemulsification process have been estimated.

S-adenosyl-L-methionine is required for DNA cleavage by type III restriction enzymes

The requirement of S-adenosyl-L-methionine (AdoMet) in the cleavage reaction carried out by type III restriction-modification enzymes has been investigated. We show that DNA restriction by EcoPI restriction enzyme does not take place in the absence of exogenously added AdoMet. Interestingly, the closely related EcoP15I enzyme has endogenously bound AdoMet and therefore does not require the addition of the cofactor for DNA cleavage. By employing a variety of AdoMet analogs, which differ structurally from AdoMet, this study demonstrates that the carboxyl group and any substitution at the epsilon carbon of methionine is absolutely essential for DNA cleavage. Such analogs could bring about the necessary conformational change(s) in the enzyme, which make the enzyme proficient in DNA cleavage. Our studies, which include native polyacrylamide gel electrophoresis, molecular size exclusion chromatography, UV, fluorescence and circular dichroism spectroscopy, clearly demonstrate that the holoenzyme and apoenzyme forms of EcoP15I restriction enzyme have different conformations. Furthermore, the Res and Mod subunits of the EcoP15I restriction enzyme can be separated by gel filtration chromatography in the presence of 2 M NaCl. Reconstitution experiments, which involve mixing of the isolated subunits, result in an apoenzyme form, which is restriction proficient in the presence of AdoMet. However, mixing the Res subunit with Mod subunit deficient in AdoMet binding does not result in a functional restriction enzyme. These observations are consistent with the fact that AdoMet is required for DNA cleavage. In vivo complementation of the defective mod allele with a wild-type mod allele showed that an active restriction enzyme could be formed. Furthermore, we show that while the purified c2-134 mutant restriction enzyme is unable to cleave DNA, the c2-440 mutant enzyme is able to cleave DNA albeit poorly. Taken together, these results suggest that AdoMet binding causes conformational changes in the restriction enzyme and is necessary to bring about DNA cleavage.

Treatment of chronic anal fissure with topical glyceryl trinitrate: a double-blind, placebo-controlled trial

BACKGROUND

Topical glyceryl trinitrate (GTN) may produce healing of anal fissure by decreasing the high resting anal sphincter pressure in these patients. The present study assessed the efficacy of GTN in chronic anal fissure in a double-blind placebo-controlled trial.

METHOD

Patients with chronic anal fissure (for more than 8 weeks) underwent measurement of maximum anal resting pressure (MARP) before and 12 minutes after application of either 0.2% GTN or placebo ointment in a randomized manner. They then received twice-daily local application of their respective ointment for 6 weeks. Symptoms and healing of fissure were assessed; patients were evaluated at 3 months for evidence of relapse.

RESULTS

19 adult patients (12 men) were studied; 10 received GTN and 9 placebo. Mean (SD) MARP decreased from 131.0 (32.3) cm H2O to 93.5 (28.4) cm H2O (p<0.05) with GTN and from 150.5 (36.9) cm H2O to 142.8 (35.0) cm H2O (p=ns) with placebo. Fissure healed in 7 of 10 patients treated with GTN and 2 of 9 patients treated with placebo (p<0.05). There was no relapse of fissure in either group.

CONCLUSION

Local application of GTN was effective in healing chronic anal fissure.

Effect of TNF-alpha on the induction of apoptosis in murine macrophages: role of interleukin-1 beta converting enzyme

Tumor necrosis factor-alpha (TNF-alpha) is a cytokine that induces apoptosis in various cell types via its binding to TNF-receptors (TNF-R). Involvement of ICE-like protease in the induction of TNF-alpha mediated apoptosis in murine macrophage was investigated using ICE inhibitor YVAD-cmk (Tetrapeptide-Acetyl-Try-Val Ala-Asp-Chloromethyl ketone). Macrophages treated with TNF showed a time dependent decrease in cell viability with a simultaneous increase in the percent of cells showing apoptotic morphology and an increase in percent DNA fragmentation, a quantitative measure of apoptosis. However, incubation of macrophage in medium containing TNF and YVAD-cmk had inhibitory effect on the TNF-induced apoptosis of macrophage. This finding suggests that ICE-like protease may be involved in the induction of apoptosis in macrophage by TNF-alpha.

Selective estrogen receptor modulators suppress mesangial cell collagen synthesis

Estrogen receptor modulators (SERMs) are "designer drugs" that exert estrogen-like actions in some cells but not in others. We examined the effects of the SERMs LY-117018 (an analog of raloxifene) and tamoxifen on mesangial cells synthesis of type I and type IV collagen. We found that LY-117018 and tamoxifen suppressed mesangial cell type IV collagen gene transcription and type IV collagen protein synthesis in a dose-dependent manner, with a potency identical to that of estradiol. Type I collagen synthesis was also suppressed by LY-117018 in a dose-dependent manner with a potency identical to that of estradiol but greater than that of tamoxifen. Genistein, which selectively binds to estrogen receptor-beta in nanomolar concentrations, suppressed type I and type IV collagen synthesis, suggesting that estrogen receptor-beta mediates the effects of estrogen on collagen synthesis. Because matrix accumulation is central to the development of glomerulosclerosis, second-generation SERMs may prove clinically useful in ameliorating progressive renal disease without the adverse effects of estrogen on reproductive tissues.