Invasive candidiasis in Pakistan: clinical characteristics, species distribution and antifungal susceptibility

This study reports for the first time, to our knowledge, descriptive epidemiological data for 188 invasive Candida isolates from Pakistan, including species identification and antifungal susceptibility against fluconazole, itraconazole, voriconazole, caspofungin, micafungin, anidulafungin and amphotericin. Risk factors for invasive candidiasis (IC) were determined for 96 patients from Karachi, Pakistan. In adults and neonates, Candida tropicalis (38 and 36 %, respectively) was the most common species, followed in adults by Candida parapsilosis (17.8 %), Candida glabrata (15.9 %) and Candida albicans (12.3 %). C. albicans (21 %) was the second most common in neonates. In children, C. albicans (31.9 %), C. tropicalis (26.4 %) and C. parapsilosis (19.4 %) were the most common. C. albicans IC was significantly associated with paediatric age [crude odds ratio (COR) 3.46, 95 % confidence interval (CI) 1.63-7.32]. Rare species made up 17.5 % of the total isolates studied. Resistance to fluconazole was seen in C. glabrata (15 .0%) and Candida krusei (100 .0%). Only one isolate (C. glabrata) was resistant to all three echinocandins. Low MICs of fluconazole for 98 % (184/188) of isolates tested support its continued use as an empiric therapy for IC. Non-C. albicans IC was associated with the use of β-lactam inhibitor combinations (COR 3.16, 95 % CI 1.05-9.57). Use of healthcare devices was documented in 85.4 % of IC patients, whilst 75 .0% had been admitted to special care units. Surprisingly, 66.7 % of patients with IC were not obviously immunosuppressed. The high frequency of modifiable risk factors in this population indicates that candidaemia can be reduced with stringent antibiotic and infection control measures. These data will be useful for empiric selection of antifungals in Karachi, and contribute to global assessments of antifungal resistance.

The 2-week wait referral system does not improve 5-year colorectal cancer survival

AIM

The aim of this study was to compare 5-year survival rates in colorectal cancer (CRC) patients who underwent potentially curative surgery before and after the introduction of the 2-week wait (2WW) referral system.

METHOD

Data were collected retrospectively from a prospectively maintained cancer database for CRC patients who underwent surgery in 1999 (pre-2WW group, n = 150) and 2002 (post-2WW group, n = 126). Patients who presented as an emergency, those who died within 30 days of surgery and those who presented with incurable CRC were excluded. We used the Kaplan-Meier method to plot survival curves and the log rank test to compare survival rates between the two groups.

RESULTS

The 5-year survival rates in the pre-2WW and post-2WW groups did not differ significantly (71%vs 72%, respectively; P = 0.880). The number of CRC patients who presented via urgent pathways was higher in the post-2WW group than in the pre-2WW group (77%vs 38%, P < 0.001). Further, owing to this change in the referral pattern, the overall delay between referral and treatment was significantly lower in the post-2WW group than in the pre-2WW group (median 76 days vs 115, P = 0.009).

CONCLUSION

The 2WW referral system for patients with symptoms of CRC does not translate into improved survival. However, more patients with symptomatic CRC are being referred via urgent pathways.

Pattern of magnetic resonance imaging and magnetic resonance venography changes in cerebral venous sinus thrombosis

BACKGROUND

Cerebral venous sinus thrombosis is a common but highly under-recognised condition, which is missed not only by general practitioners but also by neurologists. Computerised tomography (CT) or magnetic resonance imaging (MRI) of brain alone is not sufficient to diagnose this condition. Objective of this study was to explore the pattern of magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) changes in cerebral venous sinus thrombosis (CVST).

METHODS

This was a descriptive study in which 52 cases of cerebral venous sinus thrombosis with special emphasis on their MRI and MRV findings were included. The study was conducted in Neurology Unit, Lady Reading Hospital, Peshawar, Pakistan, from January 2010 to July 2011. All patients suffering from cerebral venous sinus thrombosis were included in the study. Multi-planar/multi-sequential, Tesla 1.5 MRI/MRV time of flight images were done in all cases where there was suspicion of cerebral venous sinus thrombosis.

RESULTS

Out of 52 patients with cerebral venous sinus thrombosis 41 (78.84%) were female and 11 (21.15%) were male. Mean age was 37 +/- 5 years. Definite risk factors were found in 38 (73.076%) patients with pregnancy, use of oral contraceptives or puerperium being the most frequently found risk factor in 20 (73.076%) patients. Most common complaint was headache found in 41 (78.84%) patients, followed by focal neurological deficits, and altered mental status and seizures. Papilloedema was seen in 20 (38.46%) patients. The cerebral venous sinuses most frequently involved were transverse and sigmoid sinuses in 17 patients (32.69%) while superior sagittal sinus alone in 10 (19.23%) patients. Overall CT brain was normal in 30% and MRI brain in 23.07% patients; however, MRV of these patients revealed CVST.

CONCLUSION

Imaging plays a primary role in the diagnosis of cerebral venous sinus thrombosis because the clinical picture of CVST is non-specific and highly variable. Thrombosis of cerebral venous system is readily picked-up on MRV even if it is missed by CT scan or MRI.

Molecular and epidemiological characterisation of clinical isolates of carbapenem-resistant Acinetobacter baumannii from public and private sector intensive care units in Karachi, Pakistan

The purpose of this study was to identify molecular and epidemiological characteristics of hospital-acquired carbapenem-resistant Acinetobacter baumannii (CRAB) from two different intensive care unit (ICU) settings in Karachi, Pakistan. A cross-sectional study was performed in the adult ICUs of a private sector tertiary care hospital (PS-ICU) and of a government sector hospital (GS-ICU) between November 2007 and August 2008. Deduplicated CRAB isolates from clinical specimens were examined for carbapenemase and class 1 integrase genes. Isolates were typed using sequence-based multiplex polymerase chain reaction, pulsed-field gel electrophoresis (PFGE) and variable number tandem repeat (VNTR). A total of 50 patients (33 from PS-ICU and 17 from GS-ICU) were recruited. There were statistically significant differences between patients in the two ICUs in terms of mean age, comorbidities, the presence of central venous pressure lines, urinary catheters, and average length of stay. bla(OxA-23-like) acquired-oxacillinase genes were found in 47/50 isolates. Class 1 integrase genes were found in 50% (25/50) of the organisms. The majority of isolates belonged to strains of European clones I and II. PFGE typing grouped the isolates into eight distinct clusters, three of which were found in both hospitals. Most of the isolates within each PFGE cluster shared identical or highly similar VNTR profiles, suggesting close epidemiological association. Irrespective of differences in risk factors and infection control policies and practices, the extent of clonality among CRAB isolates was very similar in both ICU settings.

Burden of disease associated with cervical cancer in malaysia and potential costs and consequences of HPV vaccination

BACKGROUND

An estimated 70% of cervical cancers worldwide are attributable to persistent infection with human papillomaviruses (HPV) 16 and 18. Vaccination against HPV 16/18 has been shown to dramatically reduce the incidence of associated precancerous and cancerous lesions. The aims of the present analyses were, firstly, to estimate the clinical and economic burden of disease attributable to HPV in Malaysia and secondly, to estimate long-term outcomes associated with HPV vaccination using a prevalence-based modeling approach.

METHODS

In the first part of the analysis costs attributable to cervical cancer and precancerous lesions were estimated; epidemiologic data were sourced from the WHO GLOBOCAN database and Malaysian national data sources. In the second part, a prevalence-based model was used to estimate the potential annual number of cases of cervical cancer and precancerous lesions that could be prevented and subsequent HPV-related treatment costs averted with the bivalent (HPV 16/18) and the quadrivalent (HPV 16/18/6/11) vaccines, at the population level, at steady state. A vaccine efficacy of 98% was assumed against HPV types included in both vaccines. Effectiveness against other oncogenic HPV types was based on the latest results from each vaccine's respective clinical trials.

RESULTS

In Malaysia there are an estimated 4,696 prevalent cases of cervical cancer annually and 1,372 prevalent cases of precancerous lesions, which are associated with a total direct cost of RM 39.2 million with a further RM 12.4 million in indirect costs owing to lost productivity. At steady state, vaccination with the bivalent vaccine was estimated to prevent 4,199 cervical cancer cases per year versus 3,804 cases for the quadrivalent vaccine. Vaccination with the quadrivalent vaccine was projected to prevent 1,721 cases of genital warts annually, whereas the annual number of cases remained unchanged with the bivalent vaccine. Furthermore, vaccination with the bivalent vaccine was estimated to avert RM 45.4 million in annual HPV-related treatment costs (direct+indirect) compared with RM 42.9 million for the quadrivalent vaccine.

CONCLUSION

This analysis showed that vaccination against HPV 16/18 can reduce the clinical and economic burden of cervical cancer and precancerous lesions in Malaysia. The greatest potential economic benefit was observed using the bivalent vaccine in preference to the quadrivalent vaccine.

Essential medicines management during emergencies in Pakistan

This paper illustrates the experiences of essential medicine management in providing cure and care to victims of Pakistan's 2005 earthquake in a safe, rational and effective mode. The health interventions assured access to essential medicine, sustained supply, inventory control through a computerized logistic support system and rational use of medicines. World Health Organization Pakistan outlined modalities for acceptance of donated medicines, assisted in speedy procurement of medicines and designed customized kits. Proper storage of medicines at controlled temperature was ensured in warehousing facilities in 12 locations. A steady supply of medicines and their consumption without stock-outs in the 56 first-level care facilities of calamity-hit areas helped to ascertain the average consumption and cost of essential medicines and supplies for the catchment population. Tools for quantification and forecasting of medicines and supplies were developed and shared. Medicines and medical supplies were efficiently used resulting in minimum wastage.

Breast cancer screening practices and awareness in women admitted to a tertiary care hospital of Lahore, Pakistan

OBJECTIVE

To assess the awareness and practices of women with regard to breast cancer and its different methods of screening.

METHODS

A descriptive cross-sectional study was carried out in the inpatient wards of Fatima Memorial Hospital, Lahore. By convenience sampling, 200 female inpatients were selected. An interviewer based pre-tested questionnaire was used to ask questions regarding knowledge and practices about breast self-examination, clinical breast examination, and mammography.

RESULTS

A total of 189 patients gave consent to be interviewed. One hundred and sixty one (84%) patients had heard of breast cancer, 35% were aware of one or two major risk factors while 65% knew at least one major sign or symptom of breast cancer. Eighty five percent of respondents believed that early detection of cancer improved survival. Of the 101 participants > 40 years of age, 36.9% practiced Breast Self Examination, 6.9% Clinical Breast Examination and only 4.9% had had a mammogram at some point in their life. Most patients did not practice breast cancer screening because they had either never heard of the screening tests, or did not feel the need to perform them.

CONCLUSIONS

The results of this study revealed lack of awareness regarding breast cancer and its screening practices. Most women did not practice breast cancer screening. Increased awareness should be made through health education and doctors' encouragement of BSE, CBE and Mammography practice.

Infection control education: impact on ventilator-associated pneumonia rates in a public sector intensive care unit in Pakistan

We describe efforts towards introducing infection control (IC) practices and establishment of antimicrobial resistance (AMR) surveillance in a public sector hospital in Pakistan. The study was conducted in an eight-bed intensive care unit. IC principles, introduced through interactive sessions, were used as an intervention and their impact was observed by conducting surveillance for ventilator-associated pneumonia (VAP) before and after the intervention. Respiratory isolates of VAP patients in the period after intervention were screened for AMR, and empiric antibiotic at the time of admission was compared with the antimicrobial sensitivity pattern reported. VAP rates were high in general and declined in the period after intervention, although the difference was not significant. Of 37 VAP patients in the period after intervention, 68% had more than one clinically significant organism isolated from the respiratory specimen. Acinetobacter spp. were isolated from 76% of patients and Pseudomonas aeruginosa from 43%. All Acinetobacter spp. and 72% P. aeruginosa were multidrug resistant. The mean stay of the nosocomially infected patients was significantly higher than for the uninfected group (6.5 vs. 2.1 days, P<0.001). Our study suggests IC education needs to be supplemented by a hospital system that facilitates IC practices and development of surveillance programmes.

Metallo-beta-lactamase-producing clinical isolates of Acinetobacter species and Pseudomonas aeruginosa from intensive care unit patients of a tertiary care hospital

Prompt detection of metallo-beta-lactamase (MBL) producing isolates is necessary to prevent their dissemination. Frequency of MBLs producing strains among multidrug resistant (MDR) Acinetobacter species and Pseudomonas aeruginosa was evaluated in critical care patients using imipenem-EDTA disk method. One hundred MDR Acinetobacter spp. and 42 Pseudomonas aeruginosa were checked for MBL production, from January to June 2001. MBL was produced by 96.6 % of imipenem-resistant Acinetobacter isolates, whereas 100% imipenem-resistant Pseudomonas aeroginosa isolates were MBL producers. Carbapenem resistance in MDR Acinetobacter spp. and Pseudomonas aeruginosa isolates in this study was due to MBLs. This calls for strict infection control measures to prevent further dissemination.

Increased isolation of Vibrio cholerae O1 serotype Inaba over serotype Ogawa in Pakistan

Although the predominant Vibrio cholerae serotype in Pakistan is Ogawa and serotype Inaba is rare, there has been a significant increase in the isolation of Inaba in our referral laboratory in Karachi. This paper reports this observation and further analysis of previous cholera data from 1993 to 2005 to assess the trend of occurrence and resistance pattern of V. cholerae strains. From January to September 2005, 245/3292 (7.4%) specimens yielded growth of V. cholerae. Of these, 243 were serotype Inaba, outnumbering serotype Ogawa. This recent Inaba strain is 100% resistant to cotrimoxazole, 3% resistant to chloramphenicol and not resistant to ampicillin, tetracycline and ofloxacin. This sensitivity pattern is almost similar to that of the previous predominant serotype Ogawa.

Prevalence of primary multidrug resistance to anti-tuberculosis drugs in Pakistan

SETTING

Pakistan ranks sixth in the world in terms of tuberculosis (TB) burden, with a World Health Organization estimated incidence of 181 per 100000, or 286000 new cases annually. Hospital-based data indicate a significant problem of multidrug-resistant TB (MDR-TB) in the country and highlight the need to assess its extent at community level. In this cross-sectional study, sputum samples from 742 untreated newly diagnosed pulmonary TB patients from all over the country were used.

OBJECTIVE

To assess the prevalence of primary drug resistance in Pakistan.

RESULTS

Of 672 culture-positive patients, 76 (11.3%) showed resistance to one or more drugs. Resistance to streptomycin (10 microg/ml) was found in 36 (5.4%) patients, isoniazid (INH) (1 microg/ml) in 51 (7.6%), rifampicin (RMP) (5 microg/ml) in 15 (2.2%), ethambutol (10 microg/ml) in 12 (1.8%) and pyrazinamide in 22 (3.3%) samples. Forty-six (6.8%) of the isolates tested were resistant to a single drug, 10 (1.5%) to two drugs, 12 (1.8%) to three drugs, and 6 (0.9%) to four drugs, while 2 (0.3%) isolates were resistant to all five first-line agents. Primary MDR-TB was 1.8% (n=12) (INH 1 microg/ml, RMP 5 microg/ml).

CONCLUSION

The results of this study show a prevalence of primary MDR-TB in Pakistan of <2%, which needs to be addressed through an effective DOTS strategy.

Reducing ventilator-associated pneumonia rates through a staff education programme

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in patients on mechanical ventilation and results in increases in mortality, prolonged hospitalization and costs. Preventive measures for VAP are well-documented and evidence-based, yet remain poorly implemented in most intensive care units. We undertook an observational pre and post-intervention study to assess whether an educational programme focusing on preventive practices for VAP could reduce the incidence. Six hundred and seventy-seven adult patients, mechanically ventilated for >48 h were included in the study population. An evidence-based guideline for preventive practices at the bedside was developed and disseminated to the intensive care unit staff. VAP incidence rates before and after implementation of the educational programme were compared. VAP infection rates reduced by 51%, from a mean of 13.2+/-1.2 in the pre-intervention period to 6.5+/-1.5/1000 device days in the post-intervention period (mean difference 6.7; 95% CI: 2.9-10.4, P =0.02). A multidisciplinary educational programme geared towards intensive care unit staff can successfully reduce the incidence rates of VAP. Further studies will be needed to assess the impact on broader outcome measures such as costs or mortality.

Evaluation of frequency of isolation and trends in antibiotic resistance among Campylobacter isolates over 11 year period

OBJECTIVE

To analyze frequency of isolation and trends in antibiotic resistance among Campylobacter isolates over 11 year period in Microbiology Laboratory, Aga Khan University from the year 1992-2002.

METHODS

Total 52,777 stool specimens were processed during the study period. Enteric pathogens isolated from 8,483 stool samples were further analyzed for frequency of isolation and antimicrobial resistance. Statistical Analysis was done by using descriptive statistics of SPSS version 10. Values were expressed as percentages, mean and rates.

RESULTS

Campylobacter species were third in frequency of isolation with an isolation rate of 24.8%. C. jejuni was the predominant pathogen followed by C.coli. Isolation rate of Campylobacter was higher (45.7%) among children under 2 years of age as compared to other age groups. A steady rise in resistance among Campylobacter isolates against ampicillin; tetracycline and ofloxacin has been noted whereas resistance against erythromycin remained fairly low.

CONCLUSION

The isolation of Campylobacter is higher from stool specimens of children of less than two years of age rendering Campylobacteriosis to be an important cause of gastroenteritis in pediatric population. This study also demonstrates a steady rise in antibiotic resistance in Campylobacter isolates especially against quinolones with fall in resistance against erythromycin throughout the study period.

Induction therapy with interleukin-2 receptor antagonist after intestinal transplantation is associated with reduced acute cellular rejection and improved renal function

PURPOSE

To determine the effectiveness of induction immunotherapy with interleukin-2 receptor antagonists (IL2RA) after intestinal transplantation (IT).

METHODS

A single-center, retrospective study was undertaken of all patients undergoing IT using existing medical records and database. Immunotherapy was either triple (standard maintenance triple therapy [SMTT]) or IL2RA [induction IL2RA plus SMTTx] or OKT3 [induction antilymphocyte preparations plus SMTTx]). Data was collected for the first 175 postoperative days. Outcomes included pretransplant renal function, posttransplant serum creatinine normalized to age (nl-sCR), rejection (ACR), and survival. Standard statistical analysis was undertaken.

RESULTS

There were no significant differences in the groups: triple (n = 10, median age 3.5 years, cGFR 106 +/- 44 mL/min), IL2RA (n = 13, median age 3.2 years, cGFR 101 +/- 61 mL/min), OKT3 (n = 4, median age 7.7 years, cGFR 104 +/- 27 mL/min). nl-sCR was significantly (P <.01) lower in IL2RA at most postoperative weeks. IL2RA had significantly fewer rejection and infectious episodes than the other two groups. Three-year patient survival was 92% in IL2RA versus 50% triple and OKT3.

CONCLUSIONS

IL2RA immunotherapy after IT is associated with a lower incidence of renal dysfunction as compared with historical controls. Furthermore, IL2RA therapy resulted in a lower incidence of rejection and improved survival. IL2RA should be considered in select patients undergoing IT.

Improved outcome after intestinal transplantation at a single institution over 12 years

PURPOSE

To evaluate the outcomes of patients undergoing intestinal transplantation (IT).

METHODS

Retrospective review was undertaken using existing medical records and database.

RESULTS

Between November 1991 and May 2003, 114 patients were referred for consideration for IT, of which 33 patients received 37 intestinal allografts. All patients had intestinal failure and all patients had significant complications from total parenteral nutrition (TPN). TPN was the predominant cause of liver failure (63%). Combined liver intestinal grafts were used in the majority of patients. Overall 1- and 3-year patient survival is 77% and 52% with patients transplanted since 1999 having a 1- and 3-year survival of 94% and 73%, respectively. The most common cause of death was sepsis. No graft or patient was lost to cytomegalovirus or Epstein-Barr virus disease. Twenty-seven percent of allografts were lost to rejection. Long-term TPN independence is 82% for grafts more than 30 days after IT. Statistical analysis revealed several important factors impacting outcome.

CONCLUSIONS

Successful IT defined as prolonged patient and graft survival and TPN independence can be readily achieved in select patients with IF and complications related to TPN therapy. Outcomes have improved with experience gained and control of viral infections and rejection.

Comparison of double disc and combined disc method for the detection of extended spectrum beta lactamases in enterobacteriaceae

OBJECTIVE

To compare double disc approximation and combined disc method for their ability to detect extended spectrum b lactamase (ESBL) production in enterobacteriaceae and determine the percentage of isolates which are falsely reported as sensitive in absence of ESBL detection, in a clinical microbiology laboratory of a tertiary care hospital between September-October 2002.

METHODS

Selected isolates were identified according to standard biochemical tests. Disc susceptibility tests were performed according to NCCLS. ESBL detection by combined disc [cefotaxime (30 ug) versus cefotaxime plus clavulanate (30+10 ug)] was compared with detection using double discs [amoxy-clavulanic acid (20+10 ug) and aztreonam (30 ug) applied 10 mm apart]. Results were interpreted according to NCCLS and analysed on SPSS version 10.

RESULTS

ESBL production was detected in 140 (30%) isolates by combined disc method and 139 (29.5%) by double disc method. There was no significant difference between two methods. Of the ESBL positive isolates 41 (29%) gave zone diameters that were within the sensitivity range cutoff and would have been falsely reported as being beta lactam sensitive in absence of ESBL detection.

CONCLUSION

ESBL detection should be routinely performed in clinical laboratories as false reporting would result in treatment failure despite in vitro sensitivity. No difference was found between the combined disc and double disc methods hence either of two could be used.

Seasonal variation in bacterial pathogens isolated from stool samples in Karachi, Pakistan

OBJECTIVE

To determine the seasonal variation of the commonly isolated bacterial pathogens in stool samples.

MATERIAL AND METHODS

A retrospective descriptive study was undertaken of all the stool samples submitted from within Karachi to the Aga Khan University Hospital Laboratory over a period of five years (January 1997- December 2001) in order to determine the commonly isolated bacterial pathogens and to predict their seasonal variation.

RESULTS

A total of 16379 stool samples were included in this review. Bacterial isolates were found in 6670 stool samples (culture detection rate=40.7%). The mean age at the time of culture of each sub-group was < or = 1 year group (6.58 +/- 3.1 months), 1-5 years (2.13 +/- 0.94 years), 5-14 years (8.3 +/- 2.6 yrs) and adults (43.2 +/- 18.5 years). Male: Female ratio was 1.2:1. Vibrio cholera 01 Ogawa (32.8%), Campylobacter jejuni (17.3%), Enteropathogenic Escherichia coli (9.9%), Salmonella paratyphi b (6.6%) and Shigella flexneri (6.2%) were the most common organisms isolated. These organisms show a distinct seasonal variation with summer predilection.

CONCLUSION

In contrast to the previous studies from South Asia, which have identified E. coil, followed by Vibrio cholerae as the most common enteric isolates, we found Vibrio cholera 01 Ogawa followed by Campylobacter jejuni as the most common enteric pathogens isolated in an urban setting. It is important to consider seasonal variation when empirically treating diarrheal diseases in our region.

Management of diabetic foot--two years experience

BACKGROUND

Diabetic foot is a serious complication of diabetes mellitus and may be the initial presentation of undiagnosed diabetes mellitus. A study of 48 patients with diabetic foot admitted in Surgical B Unit of Ayub Teaching Hospital over a period of two years is presented here.

METHODS

This study was done to identify the risk factors and causative organisms in diabetic foot. This will help to lay down important principles of management of diabetic foot and highlight problems faced in the management of diabetic foot in our set up.

RESULTS

There were 32 (66.6%) males and 16 (33.3%) females. The age incidence ranged from 30-70 years. Average length of hospital stay was 26 days. 2 patients had cellulitis, 6 patients had gangrene, 10 patients had ulcers and 15 patients had abscesses. 31 (64%) patients were cured by drainage of abscess and debridements alone. 17(36%) patients needed amputations. Peripheral neuropathy was the commonest risk factor. Staphylococcus aureus was the most common organism isolated from cultures (54%).

CONCLUSIONS

Early hospitalization, effective glycaemic control, aggressive debridements and patient education in foot care can minimize diabetic foot diseases.

In-vitro antimicrobial activity of Cefpirome: a new fourth-generation cephalosporin against clinically significant bacteria

OBJECTIVE

To study the in-vitro antimicrobial activity of Cefpirome: A new fourth generation Cephalosporin in comparison with other agents against clinically significant Gram-negative and Gram-positive bacteria.

SETTING

A multi-center in-vitro study was conducted in 13 centers.

MATERIALS AND METHODS

Bacterial isolates--A total of 1300 isolates were collected from different clinical laboratories and hospitals at 13 centers. Organisms were identified by the API identification systems (API systems, SA Vericeu, France). The age and sex of each patient, type of hospital unit, source of the isolate and genus and species of the bacteria were recorded on standardized report forms. The sensitivity testing was carried out by the "NCCLS (modified Kirby-Bauer) method"--using Mueller-Hinton agar.

RESULTS

The results suggest that Cefpirome has a potential clinical advantage against gram-positive and gram-negative bacteria resistant to other third generation cephalosporins.

CONCLUSION

Cefpirome was active against both gram-negative and gram-positive organisms. Cefpirome was more active than ceftazidime, cefoperazone, ceftizoxime and ceftriaxone against E. coli, Klebsiella spp, Enterobacter spp, Proteus spp, Salmonella typhi, Enterococci, methicillin sensitive Staphylococci and Betahemolytic Streptococci. The activity of Cefpirome was comparable with ceftazidime against pseudomonas aeruginosa. Cefpirome had the smallest numbers of resistant isolates. Cefpirome was more active than other third generation cephalosporins compared in this study against E. coli (87% vs 61%), Klebsiella spp (84% vs 56%), Enterobacter spp (88% vs 59%), Proteus spp (97% vs 92%), Salmonella typhi (98% vs 96%), methicillin sensitive Staphylococci (86% vs 59%) and Enterococci spp (82% vs 72%).

Cholesterol inhibits the nuclear entry of estrogen receptor activation factor (E-RAF) and its dimerization with the nonactivated estrogen receptor (naER) in goat uterus

An alternative form of estrogen receptor isolated from goat uterus, the nonactivated estrogen receptor (naER), has no DNA-binding function, although it is closely similar to the classical estrogen receptor (ER) in its hormone binding affinity and specificity. The naER dimerizes with a DNA binding protein, estrogen receptor activation factor (E-RAF). The heterodimer binds to the DNA. Assays carried out during the purification of E-RAF showed that an endogenous inhibitor that is heat stable and dialyzable bound to the E-RAF and prevented the formation of the heterodimer. The inhibitor has been isolated and purified. GC-MS analysis identifies this molecule to be cholesterol. Circular dichroism measurement has shown that the high-affinity binding of cholesterol to E-RAF results in subtle changes in the secondary and the tertiary structure of the protein. The E-RAF with altered conformation fails to dimerize with the naER. Instead of facilitating E-RAF entry into the nucleus, dimerization with the naER prevents it. Similarly, cholesterol binding blocks the nuclear entry of the protein, showing that E-RAF with altered conformation is incapable of interaction with the nuclear pore complex/membrane proteins. The naER-E-RAF heterodimer remains at the nuclear periphery, incapable of further transport. These results indicate the possibility that the dimerization between naER and the E-RAF takes place only within the nuclear compartment. The observation that cholesterol binding prevents nuclear entry of the E-RAF reflects the similarity of E-RAF with the sterol regulatory element (SRE) binding protein that enters the nucleus and binds to SRE only when the intracellular level of cholesterol remains low.

Synthesis and characterization of nickel(II) bis(alkylthio)salen complexes

NiX2(2-RSC6H4CH=NCH2CH2N=CHC6H4SR-2) (NiX2L; L = 5) (1a, X = Br, R = C6H13; 1b, X = Cl, R = C12H25) and NiX2(2-C6H13SC6H4CH2NHCH2CH2NHCH2C6H4SC6H13-2) (NiX2L; L = 6) (2a, X = Br; 2b, X = Cl; 2c, X = OClO3) were prepared from ligands 5 and 6, respectively. The 1:2 metal-ligand complex Ni(OClO3)2(2-RSC6H4CH2NHCH2CH2NHCH2C6H4SR-2)2 3, was obtained from an EtOH solution of 2c. The characterization of paramagnetic 1-3 included single-crystal X-ray diffraction studies of 1a and 3. Complex 2c converted into 3 in the presence of excess ligand 6 in CHCl3.

Prevalent nosocomial gram negative aerobic bacilli and their antimicrobial susceptibility pattern in intensive care unit

OBJECTIVE

To determine the type of prevalent aerobic gram-negative bacilli and their sensitivity pattern among nosocomial isolates.

DESIGN

Prospective collection of clinically significant nosocomial gram negative bacilli.

SETTING

Tertiary care hospital in Karachi.

METHOD

One hundred isolates were identified by standard methods and minimum inhibitory concentration was checked by epsilometer test.

RESULTS

The most frequent isolates were Eschericia coli (43%) followed by Klebsiella pneumoniae (18%) Acinetobacter spp. (7%) Enterobacter spp. (7%) and Klebsiella spp. other than pneumoniae (7%). Most of the isolates of dominant species (E. coli and Klebsiella pneumoniae) were multiresistant including third generation cephalosporins.

CONCLUSION

This study indicates that most effective antibiotics imipenem and amikacin inhibited most of the isolates. Imipenem alone or amikacin in combination with one broad spectrum beta-lactam drug should be used in initial empiric therapy in any life threatening nosocomial infection.

The Regenstrief Medical Record System: a quarter century experience

Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

Continuous speech recognition for clinicians

The current generation of continuous speech recognition systems claims to offer high accuracy (greater than 95 percent) speech recognition at natural speech rates (150 words per minute) on low-cost (under $2000) platforms. This paper presents a state-of-the-technology summary, along with insights the authors have gained through testing one such product extensively and other products superficially. The authors have identified a number of issues that are important in managing accuracy and usability. First, for efficient recognition users must start with a dictionary containing the phonetic spellings of all words they anticipate using. The authors dictated 50 discharge summaries using one inexpensive internal medicine dictionary ($30) and found that they needed to add an additional 400 terms to get recognition rates of 98 percent. However, if they used either of two more expensive and extensive commercial medical vocabularies ($349 and $695), they did not need to add terms to get a 98 percent recognition rate. Second, users must speak clearly and continuously, distinctly pronouncing all syllables. Users must also correct errors as they occur, because accuracy improves with error correction by at least 5 percent over two weeks. Users may find it difficult to train the system to recognize certain terms, regardless of the amount of training, and appropriate substitutions must be created. For example, the authors had to substitute "twice a day" for "bid" when using the less expensive dictionary, but not when using the other two dictionaries. From trials they conducted in settings ranging from an emergency room to hospital wards and clinicians' offices, they learned that ambient noise has minimal effect. Finally, they found that a minimal "usable" hardware configuration (which keeps up with dictation) comprises a 300-MHz Pentium processor with 128 MB of RAM and a "speech quality" sound card (e.g., SoundBlaster, $99). Anything less powerful will result in the system lagging behind the speaking rate. The authors obtained 97 percent accuracy with just 30 minutes of training when using the latest edition of one of the speech recognition systems supplemented by a commercial medical dictionary. This technology has advanced considerably in recent years and is now a serious contender to replace some or all of the increasingly expensive alternative methods of dictation with human transcription.

The temporal order judgment paradigm: subcortical attentional contribution under exogenous and endogenous cueing conditions

The role of subcortical attentional processing was investigated under exogenous and endogenous cueing conditions. As retinotectal projections arise predominantly from the nasal retina i.e., temporal hemifield, subcortical attention should be distributed asymmetrically under monocular viewing conditions with a temporal hemifield advantage. We compared the results of monocular and binocular viewing conditions using a temporal order judgment (TOJ) paradigm. Subjects fixated a centrally located cross and two stimuli were presented with a variable onset asynchrony. Three experiments were conducted: no cue, exogenous cue and endogenous cue. Subjects reported which stimulus seemed to appear first. An effect consistent with subcortical processing was found under exogenous cueing conditions. No such effect was found under endogenous cueing conditions. We believe that subcortical attentional processing in response to an exogenous cue facilitates rapid shifts in attention towards environmental stimuli. We found no evidence for subcortical processing in voluntary directed attention and believe this process to be cortical in nature.

Isolation and identification of Aeromonas species from human stools

One thousand and three diarrhoeal stool samples were processed in our laboratory during the period 1996/1997 for the presence of enteric pathogens especially Aeromonas spp., which has emerged as a new agent causing diarrhoea. Ampicillin sheep blood agar was found to be the best medium for the isolation of Aeromonas spp. from stool specimens. Enteric pathogens were found in 200 (20%) stools, of which Aeromonas spp. was the second commonest pathogen isolated amounting to 21% of isolates. This study clearly indicates that Aeromonas spp. must be looked for in every diarrhoeal stool samples, specially in children below 10 years of age. Isolation and identification is cost effective and easy, if the given protocol is observed.

Fine needle aspiration cytology in parotid lumps

Over a period of two years, Fine Needle Aspiration Cytology (FNAC) was performed on 33 patients presenting with a parotid lump. Five patients were excluded as they were treated medically after FNAC report. The FNAC results of 28 cases were compared with histopathological diagnoses of surgically resected specimens. There were 8 true positive, 17 true negative, 1 false positive and 2 false negative cases. Sensitivity was 80%, specificity 94.4% and diagnostic accuracy 89.3%. FNAC is a simple quick, accurate and virtually complications free investigative modality. It is also helpful adjunct to assess preoperatively the suitability and extent of the surgical treatment.

Conduction disturbances in acute myocardial infarction: incidence, site-wise relationship and the influence on in-hospital prognosis

The study was designed to assess the incidence of conduction disturbances, the relationship of the site of infarction with the type of conduction disturbances and the influence of conduction disturbances on the in-hospital prognosis. One hundred consecutive patients (M:F = 89:11) with a age range of 35-60 years with the history of first attack of acute myocardial infarction were included in the study. There were 45 anterior, 43 inferior and 12 combined anterior and inferior myocardial infarction patients. 44 of the patients had some type of conduction disturbances (Group A) and 56 had none (Group B). Inferior myocardial infarction patients showed higher incidence of conduction disturbances than anterior myocardial infarction (56.8% and 31.8% respectively) (Odd's ratio 2.98, 95% ci 1.14 to 7.9). Conduction disturbances were mostly (92%) atrio-ventricular in inferior myocardial infarction and mostly (72%) intraventricular in anterior myocardial infarction. Of the 13 cases of complete atrioventricular block, 8 had inferior, 2 anterior and 3 combined anterior and inferior infarction. In inferior infarction, complete atrioventricular block developed gradually through 1 degree and 2 degrees atrioventricular block but in the anterior infarction it developed suddenly. Patients with conduction disturbances developed more complications (84%) than those without conduction disturbances (54%). Mortality rate was higher in Group A (25%) than in Group B (3.6%) (Odd's ratio 9.0, 95% ci 1.76 to 86.73) with a overall rate of 13%. Mortality rate was higher in anterior myocardial infarction (50%) than in inferior myocardial infarction (25%) when complicated by complete atrioventricular block. It was concluded that conduction disturbances are predominantly atrioventricular in inferior and intra-ventricular in anterior MI; conduction disturbances are associated with increased risk of complications and death. Anterior location of MI may have an independent risk attribute.

Ruptured aneurysm of the sinus of Valsalva

The objective of the present study was to assess the value of imaging techniques in the diagnosis of ruptured aneurysm of sinus of Valsalva (RASV). 38 patients were included in the study. 30 were male and 8 female. Their age ranged from 7 to 55 years (mean 25.8 years). Echocardiographic and doppler studies were done in all cases and 20 patients underwent catheterization and angiography. Two patients were asymptomatic, 20 (53%) had acute onset of symptoms and in the remaining 16 (42%) patients symptoms developed gradually. Twenty two (58%) patients were in NYHA functional class III or IV when first seen. Predominant symptoms were dyspnea (79%), palpitation (55%) and chest pain (52%). A continuous machinery murmur was detected in all the patients with associated thrill in 34 patients. Right coronary sinus (RCS) was the most common sinus involved (89%) followed by the noncoronary sinus (NCS) which was involved in 11% of patients. None of the patients in our series had aneurysm of the left coronary sinus. Twenty eight of the 34 RCS aneurysms ruptured into the right ventricular outflow tract (RVOT), 4 into right ventricular cavity (RVC), one into right atrium (RA) and one dissected into the ventricular septum and subsequently ruptured into the left ventricle. Of the 4 NCS aneurysms, 2 ruptured into RVC, one into RA and one into both the RA and RVC. Associated ventricular septal defect (VSD) was found in 10 (26%) patients and all of these patients had RCS aneurysm that ruptured into the RVOT. Aortic regurgitation (AR) was detected in 16 (42%) cases. Discrete subaortic stenosis was detected in one patient who also had associated VSD and AR. Vegetation of the aortic valve was detected in one patient who had RCS aneurysm. Twelve patients (11 male and one female) underwent surgical correction, 10 with and 2 without prior catheterization. Localization of the involved sinus, site of rupture and associated cardiac lesions by echocardiography and doppler study were found accurate at surgery and/or angiography in 22 cases of our series. Imaging techniques, thus appeared to be reliable tools for the diagnosis of RASV.

The detection of verocytotoxins in bacterial cultures from human diarrhoeal samples with monoclonal antibody-based ELISAs

Bacterial cultures from 1801 human diarrhoeal faecal specimens were examined for verocytotoxins I and II by monoclonal antibody-based sandwich ELISAs. Of the 68 ELISA-positive cultures selected from initial screening, 32 were positive by ELISA on repeat or from freshly grown cultures. ELISA-positive pure cultures were obtained from 13 of these, of which seven were confirmed as verocytotoxin positive by cytotoxicity assay. These seven strains were typed as O26 (5) and O146 (2). The six false positive results were from isolates of Enterobacter sp. (1), Citrobacter Freundii (1) and Escherichia coli (4), one each of types O1, O18ac and O98 and an untypable strain. Despite the occurrence of false positive reactions, sandwich ELISA was a useful method for the rapid screening of samples, and detected verocytotoxin-positive E. coli strains, other than O157, from patients with clinical conditions in which they could be implicated.

24h withdrawal following repeated administration of caffeine attenuates brain serotonin but not tryptophan in rat brain: implications for caffeine-induced depression

Caffeine injected at doses of 20, 40 and 80 mg/kg increased brain levels of tryptophan, 5-hydroxytryptamine (5-HT) and 5-hydroxyindole acetic acid (5-HIAA) in rat brain. In view of a possible role of 5-HT in caffeine-induced depression the effects of repeated administration of high doses of caffeine on brain 5-HT metabolism are investigated in rats. Caffeine was injected at doses of 80 mg/kg daily for five days. Control animals were injected with saline daily for five days. On the 6th day caffeine (80 mg/kg) injected to 5 day saline injected rats increased brain levels of tryptophan, 5-HT and 5-HIAA. Plasma total tryptophan levels were not affected and free tryptophan increased. Brain levels of 5-HT and 5-HIAA but not tryptophan decreased in 5 day caffeine injected rats injected with saline on the 6th day. Plasma total and free tryptophan were not altered in these rats. Caffeine-induced increases of brain tryptophan but not 5-HT and 5-HIAA were greater in 5 day caffeine than 5 day saline injected rats. The findings are discussed as repeated caffeine administration producing adaptive changes in the serotonergic neurons to decrease the conversion of tryptophan to 5-HT and this may precipitate depression particularly in conditions of caffeine withdrawal.

Association of cytoskeletal proteins with estrogen receptor in rat uterine cytosol: possible role in receptor movement into the nucleus

Evidence is presented to demonstrate a close association between an estrogen receptor or an estrogen receptor activation factor and the cytoskeletal proteins, tubulin and actin in rat uterine cytosol. Exposure of uterine cytosol to protein kinase assay medium resulted in the phosphorylation of three proteins, of molecular mass 55, 50 and 45 kDa. These 55 and 50 kDa proteins apparently represent tubulin, while the 45 kDa protein, is presumed to be actin. Phosphorylation of these proteins is under the regulatory influence of estradiol and the cyclic nucleotides, cAMP and cGMP. It is proposed that the protein kinase involved in this process may be the non-activated estrogen receptor (naER).

Characterization of biofilm and encrustation on ureteric stents in vivo

OBJECTIVE

To examine the relationship between encrustation and microbial biofilm formation on indwelling ureteric stents.

PATIENTS AND METHODS

Ureteric stents from 40 patients were examined for the presence of a microbial biofilm and encrustations. Bacteria in stent biofilms were isolated and identified.

RESULTS

A profuse biofilm (> 10(4) c.f.u. cm-3) was identified on 11 (28%) stents. Enterococcus faecalis was the most common biofilm organism identified and Proteus spp. were not present. Encrustation was seen in 23 (58%) of stents and was not associated with the level of urinary calcium. The major risk factor for stent encrustation was the presence of urolithiasis. Importantly, there was no causative link between stent biofilm formation and encrustation. Both biofilm formation and encrustation increased with the duration of stenting.

CONCLUSION

The results indicate that polyurethane is readily encrusted and colonized by bacteria in vivo despite antibiotic prophylaxis. Newer materials must be sought if effective long-term stenting is to be achieved.

Tolerance to diacetyl morphine antinociception: effects on brain serotonin

The effects of 5 mg kg-1 diacetyl morphine (DAM) on brain serotonin metabolism of rats were investigated following tolerance to the antinociceptive effects of 2.5 mg kg-1 DAM. Brain levels of tryptophan and 5-hydroxy indoleacetic acid (5-HIAA) were higher in the DAM-tolerant rats killed 24 h after last daily administration of 2.5 mg kg-1 DAM. Administration of 5 mg kg-1 DAM produced less antinociception in DAM-tolerant than DAM-naive rats and increased brain tryptophan concentration in both tolerant and naive rats. 5-HIAA concentrations increased only in naive rats. Combined use of drugs interfering with brain 5-HT turnover along with opiates may be of future benefit for the treatment of chronic pain.

Enhancement of hepatic tryptophan pyrrolase activity and decreases of open field locomotion following single and repeated administration of high doses of caffeine in rats

In view of a possible role of kynurenine in caffeine-induced anxiety syndrome, the effects of single and repeated administration of caffeine on hepatic tryptophan (T)-pyrrolase activity are investigated. Single administration of caffeine at doses of 80 mg/kg decreased open field locomotion and increased hepatic T-pyrrolase activity. Locomotor stimulating effects of 80 mg/kg caffeine, monitored in the home cages of rats, were attenuated following daily administration of caffeine for 5 days. Open field locomotor activity of rats and its caffeine-induced decrement were also attenuated following 5 daily administrations of caffeine on the 6th day. Basal levels of hepatic T-pyrrolase activity increased after 5 daily administrations of caffeine on the 6th day. Acute administration of caffeine did not further elevate hepatic T-pyrrolase activity in 5 day caffeine injected rats. Drug adjuvants decreasing hepatic T-pyrrolase activity may prove valuable for extending the clinical utility of caffeine.

Primary pulmonary hypertension: clinical, echocardiographic and haemodynamic features in 14 patients

Clinical, echocardiographic and haemodynamic features in 14 patients (8 male and 6 females) with primary pulmonary hypertension, diagnosed by strict clinical and haemodynamic criteria are described. Age of the patients at diagnosis ranged from 11 years to 40 years with a mean of 23 years. The mean interval from onset of symptoms to diagnosis was 2.6 years. Common symptoms included dyspnoea on exertion (86%), fatigue (78%) and palpitation (78%). Raynaud's phenomenon was not encountered but one patient had signs and symptoms of left recurrent laryngeal nerve palsy. Pulmonary function studies showed mild restrictive ventilatory impairment (mean forced vital capacity 80% of predicted) with hypoxaemia and hypocapnea. The M-mode tracing of the pulmonary valve showed flat or negative E-F slope, a small or absent 'a' wave, and midsystolic notching in all the patients. Two-dimensional echocardiographic images showed a thickened right ventricular wall in 12(86%) patients; a normal to small left ventricular end-diastolic internal dimension in all the patients and right ventricular and right atrial enlargement in 78% of patients. Significant tricuspid regurgitation and pulmonary regurgitation was documented by Doppler interogation in 87% and 62% of patients examined respectively. Haemodynamic findings consisted of a marked rise of pulmonary artery pressure and pulmonary vascular resistance, low cardiac index and normal pulmonary artery wedge pressure. At cardiac catheterisation the mean right atrial pressure (mean +/- SD) was 9.8 +/- 4.8 mmHg; mean pulmonary artery pressure, 63.2 +/- 14.3 mmHg; cardiac index, 2.2 +/- 0.9 L/min. m2; and pulmonary vascular resistance index, 22.3 +/- 10.6 mmHg/L/min. m2; in these patients. No, death nor any sustained morbid events occurred during the diagnostic evaluation of the patients.

A four-step, inexpensive protocol for large-scale purification of goat uterine estrogen receptor

A relatively inexpensive yet highly efficient and extremely rapid procedure has been developed for the isolation and purification of estrogen receptor from the goat uterine cytosol. Greater than 1 mg of purified receptor protein could be obtained from 75 g of uterine tissue within a period of < 24 h, following this protocol. The procedure does not require the use of an ultracentrifuge, a cold room, or a column chromatography setup. The entire isolation procedure, which involves adsorption to and selective elution from different chromatography matrices, is carried out at the laboratory bench using beakers kept in an ice bath. Antibodies raised against this receptor cross-react with the goat uterine estrogen receptor activation factor, a DNA binding protein having no capacity to bind estradiol but which dimerizes with the nonactivated estrogen receptor, an estrogen receptor incapable of binding to DNA on its own.

Acute leukaemia in children--French-American-British (FAB) classification and its relation to clinical features

A retrospective study of 45 patients of acute leukaemia in children (15 years age), in relation to FAB classification, is presented. Acute lymphoblastic leukaemias (ALL) were commoner than acute myeloid leukaemias (AML), with an ALL:AML ratio of 4.63:1. Amongst ALL, L1 was the most frequent type (59%), followed by L2 (35%) and L3 (5.4%), respectively. FAB types M2, M3, M4 and M5 were diagnosed in 2 patients each. An analysis of clinical features in relation to FAB classification is also presented.