Symptom-based diagnosis of urinary tract infection in women: are we over-prescribing antibiotics?

BACKGROUND

Current clinical guidelines for the management of symptoms suggesting urinary tract infection recommend empiric antibiotic therapy.

OBJECTIVE

To determine the diagnostic accuracy of urinary tract symptoms for early identification of urinary tract infection (UTI) in sexually active women when culture results are not available.

METHOD

This was a cross-sectional observational study conducted in a tertiary care hospital between July 2009 and May 2011. Subjects comprised 312 women ≥ 18 year of age who reported to the physician with symptoms suggestive of UTI. A predesigned questionnaire was filled and urine was analysed by microscopic examination and culture. Diagnostic values were calculated against gold standard urine culture results (> 10(2) CFU/ml) and 95% CIs and likelihood ratios are reported.

RESULTS

A total of 312 women were enrolled, as culture was contaminated in 36 only 276 women were included in final analysis. Prevalence of UTI was 46.01% amongst symptomatic women. Urgency (p = 0.001), burning sensation during micturition (p = 0.035), dysuria (p = 0.004), frequency of sexual intercourse > 5 per month (p = 0.010) and pyuria (p = 0.000) were significantly associated with culture positivity. Absence of pyuria emerged as best predictor for ruling out UTI even if the woman had symptoms (sensitivity 93.70%, NPV 91.84%, AUC 77.07%, LR- 0.1). The combination of urgency, burning during micturition and pyuria was the best predictor of UTI in our study (sensitivity 85.83%, PPV 71.71%, AUC 78.48%, LR+ 2.97)

CONCLUSION

Symptoms alone have low accuracy when assessed against the reference standard for diagnosing UTI. Empiric treatment of UTI based on symptoms may expose large number of patients to unnecessary antibiotics. Wet mount microscopy for presence of pyuria as a 'near patient test' before starting antibiotics seems a rational approach for management of UTI in symptomatic women.

Expression of extracellular matrix metalloproteinase inducer (EMMPRIN) and its expected roles in the bovine endometrium during gestation

Extracellular matrix metalloproteinase inducer (EMMPRIN) and its induced matrix metalloproteinases (MMPs) play a crucial role in tissue remodeling during the peri-implantation period. However, the role of EMMPRIN in the bovine placenta is still unclear. We have postulated that EMMPRIN might play a regulatory role in trophoblastic cell functions during gestation by itself or through the regulation of MMP expression. In this study, EMMPRIN mRNA was detected in the bovine placentome and interplacentome throughout gestation, and its expression was significantly higher in the cotyledon during late gestation. In situ hybridization showed that EMMPRIN mRNA was expressed in the caruncular epithelium and the cotyledonary epithelium, including binucleate cells. Western blot analysis detected a band representing a protein of approximately 65 kDa in the caruncular and cotyledonary tissues, and the intensity of its expression was increased in both of these tissues during late gestation. The expression levels of MMP-2 and MMP-14 in the bovine placenta were higher during late gestation, as was observed for EMMPRIN. Therefore, EMMPRIN might regulate trophoblastic cell functions, especially those of binucleate cells, through MMP expression in the bovine placenta.

Identification and fine-mapping of Xa33, a novel gene for resistance to Xanthomonas oryzae pv. oryzae

Broadening of the genetic base for identification and transfer of genes for resistance to insect pests and diseases from wild relatives of rice is an important strategy in resistance breeding programs across the world. An accession of Oryza nivara, International Rice Germplasm Collection (IRGC) accession number 105710, was identified to exhibit high level and broad-spectrum resistance to Xanthomonas oryzae pv. oryzae. In order to study the genetics of resistance and to tag and map the resistance gene or genes present in IRGC 105710, it was crossed with the bacterial blight (BB)-susceptible varieties 'TN1' and 'Samba Mahsuri' (SM) and then backcrossed to generate backcross mapping populations. Analysis of these populations and their progeny testing revealed that a single dominant gene controls resistance in IRGC 105710. The BC(1)F(2) population derived from the cross IRGC 105710/TN1//TN1 was screened with a set of 72 polymorphic simple-sequence repeat (SSR) markers distributed across the rice genome and the resistance gene was coarse mapped on chromosome 7 between the SSR markers RM5711 and RM6728 at a genetic distance of 17.0 and 19.3 centimorgans (cM), respectively. After analysis involving 49 SSR markers located between the genomic interval spanned by RM5711 and RM6728, and BC(2)F(2) population consisting of 2,011 individuals derived from the cross IRGC 105710/TN1//TN1, the gene was fine mapped between two SSR markers (RMWR7.1 and RMWR7.6) located at a genetic distance of 0.9 and 1.2 cM, respectively, from the gene and flanking it. The linkage distances were validated in a BC(1)F(2) mapping population derived from the cross IRGC 105710/SM//2 × SM. The BB resistance gene present in the O. nivara accession was identified to be novel based on its unique map location on chromosome 7 and wider spectrum of BB resistance; this gene has been named Xa33. The genomic region between the two closely flanking SSR markers was in silico analyzed for putatively expressed candidate genes. In total, eight genes were identified in the region and a putative gene encoding serinethreonine kinase appears to be a candidate for the Xa33 gene.

Determination of genetic relationships among elite thermosensitive genic male sterile lines (TGMS) of rice (Oryza sativa L.) employing morphological and simple sequence repeat (SSR) markers

A set of morphological traits and SSR markers were used to determine the genetic relationship among 12 elite thermosensitive genic male sterile (TGMS) lines developed at three different research institutions of India. Agro-morphological data recorded on 20 morphological traits revealed a wide base of genetic variation and a set of four morphological traits could distinguish most of the TGMS lines. Analysis with 30 SSR markers (20 EST-SSRs and 10 genomic SSRs) revealed 27 markers to be polymorphic, amplifying a total of 83 alleles. Each SSR marker amplified 2-6 alleles with an average of 2.76 alleles per marker and a PIC value varying from 0.54 to 0.96. Cluster analysis based on SSR and morphological data clearly differentiated the lines according to their source of origin. Correlation analysis between morphological and molecular data revealed a very poor association (r = 0.06), which could be attributed to selection pressure, genetic drift, sampling error and unknown relationship among related lines. The SSR markers discriminated the genotypes distinctly and quantified the genetic diversity precisely among the TGMS lines. Data on the yield per plant indicated that the genotypes grouping under a similar cluster showed same heterotic behaviour as compared to the genotypes from different clusters when crossed to similar pollinators.

Povidone-iodine as a corrosion inhibitor towards a low modulus beta Ti-45Nb implant alloy in a simulated body fluid

Povidone-iodine and various bactericidal agents used in dental procedures may affect the corrosion response of an implant/prosthesis in the oral environment. The effect of various concentrations of povidone-iodine (PI) on the corrosion behavior of a low modulus beta titanium alloy, Ti-45Nb, has been investigated in normal saline solution. The open circuit potential, electrochemical impedance spectroscopy and potentiodynamic polarization measurements have been used to assess the electrochemical response of the alloy surface on PI addition so as to effectively predict the prosthetic treatment outcome. As the concentration of PI is increased, the corrosion rate decreases, suggested by decreased R(p) values. Povidone-iodine acts as an anodic inhibitor by adsorbing on the anodic sites of the alloy. Addition of PI to a simulated body fluid such as normal saline leads to a decrease in corrosion rate of Ti-45Nb alloy.

Multilayered membrane-controlled microcapsules for controlled delivery of isoniazid

BACKGROUND AND THE PURPOSE OF THE STUDY

Layer-by-layer (LbL) deposition of polyelectrolytes (PEs) has received a great attention in the area of drug delivery due to its simplicity and versatility. This research was aimed to develop multilayered microcapsules through LbL deposition of chitosan (CHI) and sodium alginate (NaALG) and utilize them as vehicle for controlled delivery of isoniazid (INH).

METHODS

CaCO(3) particles, prepared by colloidal crystallization of CaCl(2) and Na(2)CO(3) solutions, were used as micro-templates for LbL deposition of CHI and NaALG. Subsequent to the deposition, templates were decomposed to obtain hollow microcapsules. Prepared microcapsules were subjected to physicochemical evaluations, drug release and stability studies.

RESULTS AND MAJOR CONCLUSION

Though CaCO(3) particles possessed a rough and irregular surface, prepared hollow microcapsules were spherical in shape, having smooth surface and regular thickness. Following deposition of each layer, alternating values of zeta potential were observed, indicating the formation of multilayered films. Microcapsules with 5 bilayers, i.e. (CHI/NaALG)(5) provided 39% entrapment efficiency and exhibited a controlled release behavior, lasting up to 24 hrs. An improvement in drug release rate and stability profile of the formulation was observed by increasing the number of deposition steps and performing the crosslinking of polyelectrolytes. This study showed that the prepared formulation could promisingly be utilized as controlled delivery vehicle for INH.

Design of a controlled release liquid formulation of lamotrigine

BACKGROUND AND THE PURPOSE OF THE STUDY

Lamotrigine is a broad spectrum anticonvulsant drug widely used as mono- or adjunct- therapy in adults and children. The aim of this study was to develop controlled release liquid formulation of lamotrigine to improve bioavailability and compliance of pediatric and geriatric epileptic patients.

METHODS

Multiple (w/o/w) emulsion was prepared using one step emulsification technique. It was evaluated for entrapment efficiency (EE), morphology, zeta potential (ZP), polydispersity index (PI), rheology, thermal property, in vitro drug release behavior and stability. In vivo studies in albino mice were carried out using maximal electroshock seizure (MES) test and strychnine induced seizure (SIS) pattern test and results were compared with marketed formulation.

RESULTS

The EE of the formulations varied from 84.37% to 98.11%. The ZP and PI values of the prepared batches were in the range of +23.46 to +28.07 and 0.256 and 0.365, respectively. Microscopic observation clearly indicated the stability of the emulsions during the storage period. All batches exhibited controlled in vitro drug release up to 12 hrs. Batch C11 exhibited significantly longer duration of protection of seizure in mice against MES and exhibited comparable efficacy in SIS as compared to the marketed formulation.

MAJOR CONCLUSION

Multiple emulsion of lamotrigine compared to the marketed tablet showed plasma drug concentration within therapeutic range for longer time and comparable efficacy.

Use of antimicrobial agents and granulocyte colony stimulating factors for febrile neutropenia in cancer patients in a tertiary care hospital in India

BACKGROUND

Use of antimicrobials (AM) and granulocyte colony stimulating factors (G-CSF) affect the outcome and cost of treatment of febrile neutropenia (FN). There are no studies describing the AM utilization pattern or the use of G-CSF and cost incurred on them in cancer patients with FN from India.

MATERIALS AND METHODS

A study was conducted in a tertiary care, teaching hospital in New Delhi, India, with the objectives of describing the utilization pattern of AM and G-CSF in cancer patients with FN. The efficacy and costs of AM and G-CSF prescribed were also assessed.

RESULTS

A total of 211 patients with FN were enrolled in the study. A majority of 207 (98.1%) were in the low-risk category. The average number of AM used per patient was 2.45 ± 0.02 and the AM exposure density was 1.19. All patients were administered five different combinations of AM regimens and G-CSF, irrespective of the risk category. No difference in the time to defervesence or in the recovery of ANC counts were observed with the different AM regimens. The average drug cost per febrile neutropenia episode (FNE) was Rs 4694.45 ± 296.35 (113.95 ± 7.19$). G-CSF accounted for 76.14 - 97.58% of the total costs.

CONCLUSION

Large variations in the pattern of AM prescribed with routine use of G-CSF, irrespective of the risk status, was observed. Guidelines for the rational and cost-effective use of AM and G-CSF in patients with FN needed to be prepared. This was especially important as treatment was given free of cost to all patients admitted in the government health facility.

Study of polymorphs of progesterone by novel melt sonocrystallization technique: a technical note

A large number of pharmaceuticals exhibit polymorphism; 23% steroids, 60% sulfonamides, and 70% of barbiturates have shown this property. In this study, we have investigated and compared a new technique termed as melt sonocrystallization (MSC) with melt and sonocrystallization (SC) for induction of polymorphism in progesterone (PRG). Polymorphs were characterized by DSC, XRD, FT-IR, and FT Raman spectroscopy. Melt sonocrystallized progesterone (MSC-PRG) contained both the polymorphs, more soluble form II along with less soluble form I, whereas melt progesterone (M-PRG) and sonocrystallized progesterone (SC-PRG) contained only form I. Improvement in dissolution characteristics of both the polymorphs were compared and form II was found to be more readily soluble than form I in deionized water. Reduction in mean particle size of PRG during SC was also determined using laser diffractometer. During stability testing (40°C/75% RH) for 1 month, metastable form II of MSC-PRG was found to be transformed into its more stable state. MSC technique was thus found as a useful tool for induction of polymorphism.

Novel reactions of one-electron oxidized radicals of selenomethionine in comparison with methionine

Pulse radiolysis studies on hydroxyl (*OH) radical reactions of selenomethionine (SeM), a selenium analogue of methionine, were carried out, and the resultant transient radical cations and their subsequent reactions have been reported. At pH<3, the >Se*-OH radical adducts produced on reaction of SeM with *OH radical were converted to selenium centered radical cations (Se*+M), which react with another molecule of SeM to form dimer radical cation M(Se therefore Se)M+. At pH 7, the >Se*-OH radical adducts were converted to a monomer radical of the type (Se therefore N)M+ that acquires intramolecular stability through interaction with the lone pair of the N atom and this radical is denoted as SeM*+. SeM*+ decayed by first order kinetics, and the reduction potential of the couple SeM*+/SeM was determined to be 1.21+/-0.05 V vs NHE at pH 7. SeM*+ oxidized ABTS2- and TMPD with rate constants of (2.5+/-0.1)x10(8) and (6.1+/-0.2)x10(8) M(-1) s(-1), respectively, and reacted with hydroxide ion with a rate constant of (3.8+/-0.9)x10(5) M(-1) s(-1). SeM*+ reacts with molecular oxygen, and the rate constant for this reaction was determined to be (4.3+/-0.2)x10(8) M(-1) s(-1); similar reaction with methionine could not be observed experimentally. Like methionine radical cations, SeM*+ undergoes decarboxylation, although with lesser yield, to produce reducing 3-methyl-selenopropyl amino radicals (referred as alpha-amino radicals). The formation of these radicals was confirmed both by the estimation of the liberated CO2 and by one-electron reduction of MV2+, thionine, and PNAP. These results have been supported by quantum chemical calculations. Implications of these results in the biological role of SeM have also been briefly discussed.

L(9) orthogonal design assisted formulation and evaluation of chitosan-based buccoadhesive films of miconazole nitrate

The present study was aimed to prepare and evaluate buccoadhesive films of miconazole nitrate (MCZ). The films based on chitosan were prepared by solvent casting method using L(9) orthogonal array design to release the drug above its minimum inhibitory concentration (MIC) for a prolonged period of time so as to reduce its frequency of administration. As per the experimental design, guar gum, HPMC K15M and HEC were added at three different levels to control the drug release. Films showed smooth, uniform and non-sticky surface with good flexibility and folding endurance. Thickness and weight-variation data showed no significant difference among the batches, indicating that the polymeric blend possessed a good film forming ability and its desired properties could easily be achieved by varying the composition of the casting solution. Films composed of chitosan with guar gum appeared to be tougher; comparatively more bioadhesive in vitro, resided to an appropriate time interval and swelled at a more reasonable rate than those containing HPMC and HEC, suggesting the superiority of guar gum over other polymers. In vitro drug release studies conducted on all batches and microbiological studies done on the statistically optimized formulation demonstrated that the films had ability to sustain the drug concentration above its MIC for 6 hrs, despite the incorporation of a smaller dose (2.5 mg/cm(2) of the film). Films, except CF2 and CF3, followed Fickian diffusion of release mechanism. FT-IR spectra revealed no interactions between the drug and polymers.

Colloidal nanocarriers: a review on formulation technology, types and applications toward targeted drug delivery

Colloidal nanocarriers, in their various forms, have the possibility of providing endless opportunities in the area of drug delivery. The current communication embodies an in-depth discussion of colloidal nanocarriers with respect to formulation aspects, types, and site-specific drug targeting using various forms of colloidal nanocarriers with special insights to the field of oncology. Specialized nanotechnological approaches like quantum dots, dendrimers, integrins, monoclonal antibodies, and so forth, which have been extensively researched for targeted delivery of therapeutic and diagnostic agents, are also discussed. Nanotechnological patents, issued by the U.S. Patent and Trademark Office in the area of drug delivery, are also included in this review to emphasize the importance of nanotechnology in the current research scenario.

FROM THE CLINICAL EDITOR

Colloidal nanocarriers provide almost endless opportunities in the area of drug delivery. While the review mainly addresses potential oncological applications, similar approaches may be applicable in other conditions with a requirement for targeted drug delivery. Technologies including quantum dots, dendrimers, integrins, monoclonal antibodies are discussed, along with US-based patents related to these methods.

Efficient and robust prediction algorithms for protein complexes using Gomory-Hu trees

Two-Hybrid (Y2H) Protein-Protein interaction (PPI) data suffer from high False Positive and False Negative rates, thus making searching for protein complexes in PPI networks a challenge. To overcome these limitations, we propose an efficient approach which measures connectivity between proteins not by edges, but by edge-disjoint paths. We model the number of edge-disjoint paths as a network flow and efficiently represent it in a Gomory-Hu tree. By manipulating the tree, we are able to isolate groups of nodes sharing more edge-disjoint paths with each other than with the rest of the network, which are our putative protein complexes. We examine the performance of our algorithm with Variation of Information and Separation measures and show that it belongs to a group of techniques which are robust against increased false positive and false negative rates. We apply our approach to yeast , mouse, worm, and human Y2H PPI networks, where it shows promising results. On yeast network, we identify 38 statistically significant protein clusters, 20 of which correspond to protein complexes and 16 to functional modules.

Gastroretentive drug delivery system of Ranitidine hydrochloride based on osmotic technology: development and evaluation

Gastroretentive drug delivery systems (GRDDS) of Ranitidine hydrochloride (RHC) has been designed based on the osmotic technology, with the floating and swelling features in order to prolong the gastric retention time. The developed system consisted of osmotic core (containing drug, osmotic agent and hydrophilic polymers), coated with semipermeable membrane (SPM) which is then further coated with compression coating of gelling agent (HPMC K4M) containing gas generating agent (citric acid). All the developed formulations were evaluated for floating lag time, duration of floating, drug content and in-vitro drug release profile. Formulation variables like levels of hydrophilic polymer (0-18.26%w/w), type of plasticizer (PEG-400, Dibutyl phthalate), coat thickness of SPM (60-100 microm), were found to affect the drug release from the developed formulations. Drug release was directly proportional to hydrophilic nature of plasticizer but inversely proportional to the levels of hydrophilic polymer and coat thickness of SPM. Drug release from developed formulations was independent of level of gas generating agent in compression coat, pH and agitation intensities of release media but dependent on osmotic pressure of the release media. All the developed formulation showed floating lag time of less than 2 min (desired) and were floated for more than 12 hr. Floating lag time was inversely related to level of citric acid in compression coat and directly related to the density of the developed formulations. The manufacturing procedure was found to be reproducible and formulations were stable after 3 months accelerated stability study. Prediction of steady state levels showed the plasma concentrations of RHC to be within desired range.

Formulation and Biopharmaceutical Evaluation of Osmotic Matrix Tablets of Diclofenac Sodium

The objective of our study was to prepare and evaluate osmotic matrix (OM) tablets of diclofenac sodium (DS). In vitro studies were done on USPXXIV dissolution apparatus II in different release medium. Surface characteristics of coating films and osmotic contribution of OM tablets also were studied. In vivo evaluation was carried out in 6 healthy human volunteers using HPLC method to assay plasma samples, and the results were compared with the performance of fabricated matrix and two commercial tablets of DS. Through in vitro drug release kinetics, using regression coefficient analysis and Peppas equation, different pharmacokinetic parameters and relative bioavailability were determined. OM tablets were found to provide more prolonged and controlled therapeutic plasma DS levels and also showed improved bioavailability in comparison to fabricated matrix and commercial tablets studied.

Colon targeted drug delivery systems--an overview

In the last two decades colon targeted drug delivery has gained increased importance not just for the deliver drugs for the treatment of various colonic diseases but also for its potential for delivery of proteins and therapeutic peptides. In the past various traditional approaches used for colon targeted delivery like prodrugs, pH, time dependent, and microflora activated systems, have achieved limited success. For successful colon targeted drug delivery, the drug needs to be protected from absorption and/or the environment of the upper gastrointestinal tract and then be abruptly released into the colon. Hence continuous efforts have been made on designing colon targeted drug delivery systems with improved site specificity and versatile drug release kinetics to fulfill different therapeutic needs. In last couple of years few new systems have been developed for colon targeted drug delivery such as pressure dependent systems, CODES technology, microsponges, pectin and galactomannan coating, microbially triggered osmotic systems, lectins and neoglyconjugated etc. which are reported to have better in-vivo site specificity and design rationale than the earlier approaches. This review article gives an overview of various approaches for colonic targeted drug delivery with emphasis on newer systems, their merits and demerits, in vitro/ in-vivo evaluation and market status of such delivery systems.