[Beers-Criteria: Translation of the recent update]

The Beers criteria are an important instrument to improve medication safety in geriatrics. In 2015, the American Geriatrics Society (AGS) updated the Beers criteria and extended the list regarding important aspects. Our translation into German aims to simplify the application in German health care and to improve medication safety. The list was adapted to the German health care market to ensure its suitability for daily clinical use. The updated Beers lists is extended regarding clinical relevant drug-drug interactions and advice for dose titration in patients with renal insufficiency. Thereby, we hope that the updated Beers criteria will help to optimize geriatric pharmacotherapy.

MRI Appearance of Intracerebral Iodinated Contrast Agents: Is It Possible to Distinguish Extravasated Contrast Agent from Hemorrhage?

BACKGROUND AND PURPOSE

Hyperattenuated cerebral areas on postinterventional CT are a common finding after endovascular stroke treatment. There is uncertainty about the extent to which these hyperattenuated areas correspond to hemorrhage or contrast agent that extravasated into infarcted parenchyma during angiography. We evaluated whether it is possible to distinguish contrast extravasation from blood on MR imaging.

MATERIALS AND METHODS

We examined the influence of iodinated contrast agents on T1, T2, and T2* and magnetic susceptibility in a phantom model and an ex vivo animal model. We determined T1, T2, and T2* relaxation times and magnetic susceptibility of iopamidol and iopromide in dilutions of 1:1; 1:2; 1:4; 1:10; and 1:100 with physiologic saline solution. We then examined the appearance of intracerebral iopamidol on MR imaging in an ex vivo animal model. To this end, we injected iopamidol into the brain of a deceased swine.

RESULTS

Iopamidol and iopromide cause a negative susceptibility shift and T1, T2, and T2* shortening. The effects, however, become very small in dilutions of 1:10 and higher. Undiluted iopamidol, injected directly into the brain parenchyma, did not cause visually distinctive signal changes on T1-weighted spin-echo, T2-weighted turbo spin-echo, and T2*-weighted gradient recalled-echo imaging.

CONCLUSIONS

It is unlikely that iodinated contrast agents extravasated into infarcted brain parenchyma cause signal changes that mimic hemorrhage on T1WI, T2WI, and T2*WI. Our results imply that extravasated contrast agents can be distinguished from hemorrhage on MR imaging.

Comparison of biopsy-based methods for the detection of Helicobacter pylori infection

Various biopsy-based methods for the detection of Helicobacter pylori are evaluated to determine their sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), followed by polymerase chain reaction (PCR) for the 16S ribosomal RNA (rRNA) gene of H. pylori (16S PCR) to confirm the results. Seventyfive patients (65% [49] males, age range: 17-77 years, mean 42+/-14.6 years) with dyspeptic symptoms are included in the study. Gastric antrum biopsy specimens collected during endoscopy are tested using a urea agar base enriched with 40% urea solution (eUAB, Oxoid)), a commercial rapid urease test (Pronto Dry, Medical Instrument Corp, Switzerland), histopathology and 16S PCR. The eUAB test showed 97% sensitivity, 86% specificity, 84% PPV, 97% NPV and 91% accuracy when the diagnosis of H. pylori infection was made with positive Pronto Dry and histopathology. Pronto Dry showed 100% sensitivity, 82% specificity, 80% PPV, 100% NPV and 89% accuracy when the diagnosis of H. pylori infection was made on positive histopathology and eUAB. Thus, the eUAB can be used as a rapid urease test. It is economical and has a sensitivity and specificity comparable to a commercially available rapid urease test to detect urease activity of H. pylori in gastric biopsy.

Dielectric Behavior of OPEFB Reinforced Polycaprolactone Composites at X-Band Frequency

Short fibres are often used as reinforcing materials with thermoplastic polymers to improve the dielectric properties of the composites. In this work, the effects of oil palm empty fruit bunch (OPEFB)-fibre loading on polycaprolactone (PCL) polymer were extensively studied. The synthesis of OPEFB-PCL composites were prepared via melt blend method. Theoretical and experimental analysis of electromagnetic (EMI) propagation, absorption and shielding effectiveness (SE) properties of the composite were also studied. The magnitudes of S-parameters for OPEFB fiber-reinforced PCL composites with different percentages of filler were measured by a rectangular waveguide connected with a microwave vector network analyzer (VNA) at (8 – 12) GHz frequency. Whilst the dielectric properties were studied using an open ended coaxial probe. The morphological characterization of the OPEFB-PCL composite was carried out using X-ray diffraction and scanning electron microscopy (SEM). This work showed that XRD profile patterns slightly changed duo to the filler loading increment which result a reduction in both dielectric constant and loss factor. However, the relative permittivity of pure oil palm fibre and PCL was measured as (1.8-j*0.08) and (2.929-j*0.3242) respectively. In addition, the composition of 12.5 wt% filler gave the highest dielectric constant and loss factor values. However, the reflection loss increases to filler content increments at the maximum frequency of 12 GHz. The excellent behavior of these polymer composites makes them superior nominees for microwave low absorption materials.

Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update

Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Helicobacter pylori: correlation of the virulence marker iceA allele with clinical outcome in a high prevalence area

The association of Helicobacter pylori virulence marker 'induced by contact with epithelium A' (iceA) allele types was determined in H. pylori-related diseases and virulence markers. Gastric biopsies were obtained at EGD from patients for culture, histopathology and polymerase chain reaction (PCR) for iceA types, cagA and vacA alleles. Two hundred and eighty-four H. pylori isolates were examined. iceA type 1 was positive in 177 (62%) and iceA type 2 in 158 (56%). In iceA type 2, gastric ulcer was present in 34 (21%) (P < 0.001) and carcinoma in 28 (25%) (P = 0.002), compared to nine (8%) and 2 (2%) in iceA type 2-negative cases. For iceA type 2, 139 (88%) were associated with chronic active gastritis compared to 95 (75%) (P = 0.006) in iceA type 2-negative. H. pylori cagA was positive in 101 (64%) iceA type 2 strains compared to 57 (45%) in negative strains (P = 0.002). H. pylori iceA type 2 was dominant and associated with cagA, chronic active inflammation, gastric ulcer and carcinoma.

The Effect of ZnO Nanoparticle Filler on the Attenuation of ZnO/PCL Nanocomposites Using Microstrip Line at Microwave Frequency

This paper describes attenuation measurement using the modified micrsotrip line technique from new microwave substrate material. The magnitudes of the transmission coefficient (S21) from the microstrip measurement were used to determine the attenuation of the ZnO/PCL nanocomposites substrate with respect to different percentages of ZnO nanoparticles filler. Result from the measurement showed amongst others that as the filler content increases, the attenuation increases. The highest magnitude for attenuation was calculated for the 70% ZnO nano filler with a value of 14.92 dB and the least attenuation was calculated for the 25% ZnO nano filler, which value gave 6.72 dB which is very good for shielding applications. Transmission electron microscope (TEM) was used to analyse the average particle size of the ZnO powder used as filler in the study. The analysis showed that the average partcile size was 52.7 nm.

A pilot behavioural and biological surveillance survey for HIV and other bloodborne infections among Aboriginal people in Regina, Saskatchewan

BACKGROUND

Aboriginal people in Canada are disproportionately affected by HIV and other blood-borne infections. A-Track is a national public health surveillance system designed to monitor HIV and related infections, behaviours and socio-demographic factors among Aboriginal populations in Canada. The pilot survey for the A-Track surveillance system, the first of its kind in Canada, was conducted in Regina, Saskatchewan and implemented via a community and public health partnership.

OBJECTIVE

To assess the prevalence of HIV, hepatitis C, syphilis and associated risk behaviours and socio-demographic factors among Aboriginal people in Regina, Saskatchewan. This focus of the pilot survey was to provide this surveillance information for public health action and to determine whether this type of public health surveillance activity could be conducted in an urban setting across Canada.

METHODS

Survey participants were self-identified Aboriginal people (First Nations, Inuit or Métis) or those who claimed Aboriginal ancestry and between the ages of 16 and 60 years. These individuals were also asked to provide a blood sample for HIV, hepatitis C and syphilis antibody testing. Descriptive analyses were performed with sex-based comparisons.

RESULTS

There were 1064 people who participated in the survey. Their average age was 33 years and 51% were male. The majority of participants (93%) lived in urban Regina at the time of the survey. Just over half (53.2%) of all participants had been removed from their families during childhood; 29.9% had lived in a residential or boarding school during childhood; and 57.7% had lived at some point in a correctional facility. Among the 1,045 participants who provided a blood sample of sufficient quantity for testing, 5.2% were HIV seropositive and 55.8% of these were aware of their HIV status. The lifetime exposure to hepatitis C was 41.6%, with significantly higher proportions of males than females testing positive for hepatitis C exposure. Syphilis seroprevalence was very low (<1%). Almost three-quarters (71.5%) of participants reported being tested for HIV at least once in their lifetime and among those ever tested, 67.6% had been tested during the 12 months prior to the interview.

CONCLUSION

Aboriginal people are disproportionately affected by the HIV/AIDS epidemic in Canada. The findings from the A-Track pilot survey can be used to inform and evaluate prevention and treatment services for HIV and other related infections among Aboriginal people. Lessons learned from the pilot survey could also be used to guide the possible implementation of A-Track in other urban and/or reserve locations in Canada.

Preparation and in vitro characterization of mucoadhesive hydroxypropyl guar microspheres containing amlodipine besylate for nasal administration

Amlodipine besylate microspheres for intranasal administration were prepared with an aim to avoid first-pass metabolism, to achieve controlled blood level profiles and to improve therapeutic efficacy. Hydroxypropyl Guar, a biodegradable polymer, was used in the preparation of microspheres by employing water in oil emulsification solvent evaporation technique. The formulation variables were drug concentration, emulsifier concentration, temperature, agitation speed and polymer concentration. All the formulations were evaluated for particle size, particle shape and surface morphology by scanning electron microscopy, percentage yield, drug entrapment efficiency, in vitro mucoadhesion test, degree of swelling and in vitro drug diffusion through sheep nasal mucosa. The microspheres obtained were free flowing, spherical and the particles ranged in size from 13.4±2.38 μm to 43.4±1.92 μm very much suitable for nasal delivery. Increasing polymer concentration resulted in increased drug entrapment efficiency and increased particle size. Amlodipine besylate was entrapped into the microspheres with an efficiency of 67.2±1.18 % to 81.8±0.64 %. The prepared microspheres showed good mucoadhesion properties, swellability and sustained the release of the drug over a period of 8 h. The data obtained were analysed by fitment into various kinetic models; it was observed that the drug release was matrix diffusion controlled and the release mechanism was found to be non-Fickian. Stability studies were carried out on selected formulations at 5±3°, 25±2°/60±5% RH and 40±2°/75±5% RH for 90 days. The drug content was observed to be within permissible limits and there were no significant deviations in the in vitro mucoadhesion and in vitro drug diffusion characteristics.

Experience of fibrosing cholestatic hepatitis with hepatitis C virus in kidney transplant recipients

BACKGROUND

Fibrosing cholestatic hepatitis C (FCH-C) is a rare entity that occurs among immune-compromised patients resulting from the direct hepatotoxicity of a high intracellular viral load along with an ineffective immune system ultimately leading to a fatal outcome. We have describes herein 4 renal transplant recipients who were diagnosed with FCH-C at our institution in the last 8 months.

METHODS

Four renal transplant recipients presented with jaundice and deteriorating liver function tests. They were diagnosed to display FCH-C based on the presence of hepatitis C virus (HCV) RNA and characteristic liver biopsy findings; there was no evidence of any other cause of cholestasis or biliary obstruction.

RESULTS

The patients were men of ages 40, 25, 20, and 27 years. The durations after transplantation were 1.5, 10, 1.5 and 2.0 years, respectively. In all cases pretransplantation screening was negative for HCV antibody, HCV RNA, and hepatitis B surface antigen (HBsAg). All 4 patients were infected with genotype 1, whereas case 2 had coinfection with type 3. Cases 1 and 2 who were treated with interferon and ribavirin, showed improvement in cholestasis but did not achieve a rapid virological response. Case 1 developed graft dysfunction secondary to acute cellular rejection at 4 months after initiation of interferon treatment, which was treated with pulse steroids. Interferon-based therapy was stopped prematurely in both cases due to pancytopenia. Case 3 developed florid pyelonephritis and died without receiving therapy for hepatitis C. Case 4 was managed conservatively by decreasing the immunosuppression with regular monitoring.

CONCLUSION

FCH-C is difficult to treat and shows high morbidity and mortality rates. Treatment is associated with a risk of graft rejection.

Virulence markers of Helicobacter pylori in patients with diarrhoea-dominant irritable bowel syndrome

Recent studies suggest that irritable bowel syndrome (IBS) is associated with low-grade inflammation. This study aims to determine the distribution of Helicobacter pylori cytotoxin-associated gene A (cagA) and vacuolating cytotoxin A (vacA) alleles (e.g., s1 and s2) in patients with diarrhoea-dominant IBS (IBS-D) as the latter causes vacuolation in colonic epithelial cells in vitro. One hundred and seventy patients meeting Rome III criteria for IBS-D (mean age: 40 +/- 15 years) were enrolled. Gastric biopsy was assessed histologically and DNA extraction was performed by polymerase chain reaction (PCR) for H. pylori genus 16S ribosomal DNA (16S rDNA), cagA and vacA allele s1 and s2. There was no age- or gender-related difference in H. pylori positivity in IBS-D compared to the control group. H. pylori was positive in 116 (68%) with IBS-D compared to 88 (55%) in the control group (P=0.01). cagA was positive in 73 (63%) with IBS-D compared to 42 (48%) in the control group (P=0.03). vacA s1 was positive in 61 (53%) with IBS-D compared to 32 (36%) in the control group (P=0.02). cagA s1 was positive in 39 (34%) with IBS-D compared to 13 (15%) in the control group (P=0.002).

Antibiotic susceptibility patterns of Helicobacter pylori and triple therapy in a high-prevalence area

This study aims to determine primary Helicobacter pylori resistance and its effect on eradication of the organism. Ninety-two patients with dyspeptic symptoms were enrolled. H. pylori was cultured and antibiotic sensitivity was determined by the Epsilometer test (Etest) for clarithromycin (CLR), amoxicillin (AMX) and metronidazole (MTR). 23S ribosomal RNA (rRNA) point mutations associated with clarithromycin resistance were also detected. Patients were treated with omeprazole (40 mg daily), CLR (500 mg) and AMX (1g twice a day) for 14 days. A 14C-urea breath test (14C-UBT) was repeated four weeks after completion of treatment to confirm eradication. Triple therapy failure was seen in 30 (33%) patients. The resistance rates were: CLR 33% (30/92), MTR 48% (44/92) and AMX 2% (2/92). Clarithromycin resistance (CLR-R) was present in the 16-39 age group in 21 (47%) (P = 0.007) compared to nine (19%) in the 40-79 age group. CLR resistance was seen in 30 H. pylori isolates, 20 (67%) from patients with non-ulcer dyspepsia (NUD), six (20%) with gastric ulcer (GU) and four (13%) with duodenal ulcer (DU). Triple therapy failure was associated with CLR-R in 28 (93%) (P < 0.001). CLR-R mutations were present in 30 (33%) and were associated with treatment failure in 27 (90%; P < 0.001). They were present in 20 (44%) isolates obtained from patients in the 16-39 age group (P = 0.018). Treatment failure was associated with A2142G mutation in 20 (67%; P < 0.001), A2143G mutation in 12 (40%; P < 0.001) and A2142C mutation in five (17%; P = 0.003). In conclusion, triple therapy failure was associated with CLR-R. Metronidazole resistance exceeded that of CLR, hence it cannot be substituted for CLR in a triple therapy.

Prevalences of Giardia lamblia and Cryptosporidium parvum infection in adults presenting with chronic diarrhoea

Giardia lamblia and Cryptosporidium parvum are both waterborne pathogens associated with diarrhoea in developing countries. In a recent study based at the Aga Khan University in Karachi, 334 adults aged 16-83 years (178 patients with chronic diarrhoea and 156 diarrhoea-free volunteers who acted as controls) were checked for infection with these parasites, using stool microscopy and/or PCR. Overall, 21 (6.3%) and 29 (8.7%) of the subjects were found positive for G. lamblia by microscopy and PCR, respectively, while the corresponding values for C. parvum were 13 (3.9%) and 14 (4.2%). Although, compared with the diarrhoea-free controls, the patients with diarrhoea were not significantly more likely to be found infected with Giardia, either by microscopy [15 (8.4%) v. six (3.8%); P=0.085] or PCR [19 (10.7%) v. 10 (6.4%); P=0.167], they were significantly more likely to be found infected with C. parvum, both by microscopy [11 (6.2%) v. two (1.3%); P=0.024] and by PCR [12 (6.7%) v. two (1.3%); P=0.014]. The 19 patients found PCR-positive for Giardia comprised 10 (67%) of the 15 found smear-positive for the same parasite but only nine (5%) of the 163 found smear-negative (k=0.545; P<0.001). Similarly, the 12 patients found PCR-positive for Cryptosporidium comprised all 11 (100%) patients found smear-positive for the same parasite but only one (0.6%) of the 167 found smear-negative (k=0.954; P<0.001). Although C. parvum was associated with chronic diarrhoea in the present study, the carriage of G. lamblia often appeared asymptomatic.