Epidemiology of candidemia in a tertiary care centre of north India: 5-year study

BACKGROUND

To determine the distribution of species of Candida and the risk factors associated with candidemia in Indian population for which we conducted a retrospective study for 5 years in a tertiary care centre of North India.

MATERIALS AND METHODS

Blood samples from 7,297 patients aged from 3 days to 85 years, suspected with candidemia, were collected and tested for Candida. The susceptibility patterns toward fluconazole for the year 2005 isolates were tested by micro-dilution assay as described in the CLSI (M27A-2 method).

RESULTS

Most of the episodes have been caused by species other than C. albicans. Non-albicans candidemia was 79%-80% in both female and male populations. The most frequent species isolated from 275 patients in 5 years (January 2001-December 2005) was C. tropicalis (35.3%), followed by C. albicans (21.5%), C. parapsilosis (20%), C. glabrata (17.5%), C. krusei (3.3%), C. haemulonii (1.5%), and C. guilliermondii (1%). C. parapsilosis was the predominant in the fifth year of the study (2004-2005). Dose-dependent susceptibility to fluconazole was observed in 5% (n = 3) of the strains. Antifungal resistance was found in 11.7% (n = 7), which includes only C. glabrata.

CONCLUSION

These results were comparable to those derived from other regions of India. C. tropicalis has been reported as the predominant species involved in the cases of candidemia. But in 2005 it has moved toward C. parapsilosis. No true antifungal resistance is reported. Further epidemiological surveillance is needed.

Biofilm formation by and antifungal susceptibility of Candida isolates from urine

Biofilm formation (BF) in the setting of candiduria has not been well studied. We determined BF and MIC to antifungals in Candida spp. isolates grown from urine samples of patients and performed a retrospective chart review to examine the correlation with risk factors. A total of 67 Candida spp. isolates were grown from urine samples from 55 patients. The species distribution was C. albicans (54%), C. glabrata (36%), and C. tropicalis (10%). BF varied greatly among individual Candida isolates but was stable in sequential isolates during chronic infection. BF also depended on the growth medium and especially in C. albicans was significantly enhanced in artificial urine (AU) compared to RPMI medium. In nine of the C. albicans strains BF was 4- to 10-fold higher in AU, whereas in three of the C. albicans strains and two of the C. glabrata strains higher BF was measured in RPMI medium than in AU. Determination of the MICs showed that planktonic cells of all strains were susceptible to amphotericin B (AMB) and caspofungin (CASPO) and that three of the C. glabrata strains and two of the C. albicans strains were resistant to fluconazole (FLU). In contrast, all biofilm-associated adherent cells were resistant to CASPO and FLU. The biofilms of 14 strains (28%) were sensitive to AMB (MIC(50) of <1 mug/ml). Correlation between degree of BF and MIC of AMB was not seen in RPMI grown biofilms but was present when grown in AU. A retrospective chart review demonstrated no correlation of known risk factors of candiduria with BF in AU or RPMI. We conclude that BF is a stable characteristic of Candida strains that varies greatly among clinical strains and is dependent on the growth medium. Resistance to AMB is associated with higher BF in AU, which may represent the more physiologic medium to test BF. Future studies should address whether in vitro BF can predict treatment failure in vivo.

Treatment of idiopathic hypereosinophilic syndrome with imatinib mesylate

Patients with idiopathic hypereosinophilic syndrome (HES) show persistent hypereosinophilia of unknown etiology that is associated with end-organ damage. Different treatments, including the use of corticosteroids and cytotoxics, have been investigated for HES with modest success. We report a young patient with HES who developed stroke and remained refractory to conventional therapy. Therapy with imatinib mesylate, a selective tyrosine kinase inhibitor that is highly effective in treating patients with BCR-ABL-positive chronic myeloid leukemia, was tried with the patient. The result was impressive, with hematologic remission achieved rapidly. Our finding concurs with recent reports that imatinib mesylate may be a promising agent in the treatment of some cases of HES.

Management of minor head injuries according to NICE guidelines and changes in the number of patients requiring computerised tomography imaging in a district general hospital: a retrospective study

The objective of this study was to investigate how many patients with minor head injury would have required computerised tomography (CT) imaging if they were to be managed according to the National Institute of Clinical Excellence (NICE) guidelines (June 2003) and the difference in workload for patients presenting out of hours at Calderdale Royal Hospital, Halifax. The study was a retrospective cohort analysis of patient's notes presenting with head injury at Calderdale Royal Hospital, Halifax. The data set comprised case notes of 844 patients with head injuries, 400 adults and 444 children attending the Accident and Emergency department from January to June 2003. The case notes were evaluated according to the NICE guidelines for the indications for CT imaging for the time that they presented to the Accident and Emergency department, and how many of them actually underwent CT imaging. The number of patients who required CT imaging and how many of them presented out of hours (between 17:00 and 21:00 hours on weekdays and at any time on weekends). Ten patients underwent CT imaging for minor head injuries from January to June 2003. Eighty-eight patients required CT imaging if they were to be managed according to the NICE guidelines. Sixty-three per cent of these patients presented out of hours when a radiologist was not available in the hospital. Adhering to the NICE guidelines would significantly increase the number of patients requiring CT imaging. A significant proportion of these patients would present out of hours.

Autologous stem cell transplantation (ASCT) in AL amyloidosis: Feasibility outside national amyloidosis referral centers and proposal for simpler pre-transplant staging

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Background: Single center data from national amyloidosis referral centers suggest that high dose melphalan based ASCT is an effective upfront treatment strategy for AL amyloidosis. Absence of published randomized control trials, referral bias and center experience make generalizability of this data difficult since data from outside of major referrals centers is limited. Pre-transplant staging is complicated by the profusion of articles describing various adverse risk factors. Methods: Retrospective review of bone marrow transplant database at our institution was conducted. All patients with AL amyloidosis who underwent ASCT were included in the study. We stratified patients based on International Staging System (ISS) for multiple myeloma. Organ and hematological response were assessed using 2005 consensus guidelines. Results: 13 patients (6 males) underwent ASCT for AL amyloidosis with risk adapted high dose melphalan dosing (melphalan mg/m2 100 (n = 1), 150 (n = 8) and 200 (n = 4)). Median age of the patient population was 53 years (range 31–75 years). Organ involvement was as follows - single organ = 6, 2 organs = 4 and 3 organs = 3. 4 patients had cardiac amyloidosis. 100 day transplant related mortality (TRM) was 15.3%. Overall survival was 84 % (95 % CI 51–96%) @ 1 yr and 75% (95% CI 38–91%) @ 2 yrs. Median follow up was 18 months. No deaths were observed >17 months post-transplant. 45 % patients had organ response. Complete hematological response was observed in 45 % patients. Mean duration of peri-transplant hospital stay for ISS stage I, II and III were 20.5 days (n = 2), 23.3 days (n = 9) and 29 days (n = 1) respectively. Number of deaths observed in ISS stage I, II and III were 0 (0/2), 2 (2/9) and 1 (1/1) respectively. Conclusions: Autologous stem cell transplant (ASCT) for AL amyloidosis is a feasible, effective and safe procedure outside of major national referral centers. Pretransplant stratification of amyloidosis patients using ISS for multiple myeloma indicated a trend towards longer peri-transplant hospital stay and mortality with increasing ISS stage. This hypothesis needs to be tested in larger studies.

No significant financial relationships to disclose.

Phenotypic switching in Cryptococcus neoformans

Phenotypic switching has been described in serotype A and D strains of Cryptococcus neoformans. It occurs in vivo during chronic infection and is associated with differential gene expression and changes in virulence. The switch involves changes in the polysaccharide capsule and cell wall that affect the yeast's ability to resist phagocytosis. In addition, the phenotypic switch variants elicit qualitatively different inflammatory responses in the host. In animal models of chronic cryptococosis, the immune response of the host ultimately determines which of the switch variants are selected and maintained. The importance of phenotypic switching is further underscored by several findings that are relevant in the setting of human disease. These include the ability of the mucoid colony variant of RC-2 (RC-2 MC) but not the smooth variant (RC-2 SM) to promote increased intracerebral pressure in a rat model of cryptococcal meningitis. Furthermore, chemotherapeutic and immunological antifungal interventions can promote the selection of the RC-2 MC variant during chronic murine infection.

Phenotypic switching in a Cryptococcus neoformans variety gattii strain is associated with changes in virulence and promotes dissemination to the central nervous system

This is the first report of a Cryptococcus neoformans var. gattii strain (serotype B) that switches reversibly between its parent mucoid (NP1-MC) colony morphology and a smooth (NP1-SM) colony morphology. Similar to C. neoformans var. grubii and C. neoformans var. neoformans strains, the switch is associated with changes in the polysaccharide capsule and virulence in animal models. In murine infection models, NP1-MC is significantly more virulent than NP1-SM (P < 0.021). In contrast to the serotype A and D strains, the serotype B strain switches in vivo reversibly between both colony morphologies. The polysaccharide of NP1-MC exhibits a thicker capsule, and thus NP1-MC exhibits enhanced intracellular survival in macrophages. Consistent with this finding, switching to the mucoid variant is observed in pulmonary infection with NP1-SM. In contrast, the thin polysaccharide capsule of NP1-SM permits better crossing of the blood-brain barrier. In this regard, only smooth colonies were grown from brain homogenates of NP1-MC-infected mice. Our findings have important implications for the pathogenesis of cryptococcosis and suggest that phenotypic switching affects host-pathogen interactions in the local microenvironment. This altered interaction then selects for specific colony variants to arise in a pathogen population.

Maintaining standards in surgical training

In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years.

There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%.

Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards.

Salt wasting disorder in the newborn

The clinical presentation of pseudohypoaldosteronism (PHA) mimics congenital adrenal hyperplasia (CAH). Poor response of the dehydration and electrolyte abnormalities to steroid therapy should make one suspect PHA. The treatment is supportive in the form of salt replacement and sodium resonium. We report a case of PHA that presented as salt wasting on the second day of life, initially appearing like CAH. The baby responded well to sodium resonium and salt replacement.

Molecular epidemiology of clinical Cryptococcus neoformans strains from India

Little is known about the molecular epidemiology of the human pathogenic fungus Cryptococcus neoformans in India, a country now in the midst of an epidemic of AIDS-related cryptococcosis. We studied 57 clinical isolates from several regions in India, of which 51 were C. neoformans var. grubii, 1 was C. neoformans var. neoformans, and 5 were C. neoformans var. gattii. This strain set included 18 additional sequential isolates from 14 patients. Strains were characterized phenotypically by measuring the polysaccharide capsule and by determining the MICs of standard antifungals. Molecular typing was performed by a PCR-based method using the minisatellite-specific core sequence (M13), by electrophoretic karyotyping, by restriction fragment length polymorphisms with the C. neoformans transposon 1 (TCN-1), and by URA5 DNA sequence analysis. Overall, Indian isolates were less heterogeneous than isolates from other regions and included a subset that clustered into one group based on URA5 DNA sequence analysis. In summary, our results demonstrate (i) differences in genetic diversity of C. neoformans isolates from India compared to isolates from other regions in the world; (ii) that DNA typing with the TCN-1 probe can adequately distinguish C. neoformans var. grubii strains; (iii) that TCN-1 sequences are absent in many C. neoformans var. gattii strains, supporting previous studies indicating that these strains have a limited geographical dispersal; and (iv) that human cryptococcal infection can be associated with microevolution of the infecting strain and by simultaneous coinfection with two distinct C. neoformans strains.

Impact of post-methanation distillery effluent irrigation on groundwater quality

Molasses-based distilleries generate large quantities of effluent, which is used for irrigation in many countries including India. The effluent is rich in organic and inorganic ions, which may leach down and pollute the groundwater. An on-farm experiment was conducted to assess the impact of long-term irrigation with post-methanation distillery effluent (PMDE) on nitrate, sulphate, chloride, sodium, potassium, and magnesium contents in the groundwater of two sites in northwest India. Electrical conductivity (EC), pH, total dissolved solids (TDS), sodium adsorption ratio (SAR) and colour were also determined to assess the chemical load in the groundwater. Nitrate content in the groundwater samples ranged from 16.95 mg L(-1) in the unamended fields to 59.81 mg L(-1) in the PMDE-amended fields during the 2-year study (2001-2002). Concentrations of TDS in water samples from tubewell of the amended field was higher by 40.4% over the tubewell water of the unamended field. Colour of the water samples of the amended fields was also darker than that of the unamended fields. The study indicated that the organic and inorganic ions added through the effluent could pose a serious threat to the groundwater quality if applied without proper monitoring.

Cutaneous metastasis from glioblastoma

A rare case of glioblastoma with isolated cutaneous metastasis adjacent to the scar site is described. Its pathogenesis and clinical significance are discussed.

Transdermal Delivery of An Analgesic Agent Using Elastic Liposomes: Preparation, Characterization and Performance Evaluation

The aim of the present study was to prepare and characterize novel vesicular carrier elastic liposomes, of most commonly used non-steroidal anti-inflammatory agent diclofenac for its sustained and targeted delivery. Elastic liposomes of diclofenac were prepared and characterized in vitro and in vivo. The effect of different formulation variables like type of surfactant, concentration of surfactant and dose of drug on transdermal flux, amount of drug deposited into the skin, muscle and plasma concentration was investigated. The biological activity of optimized formulation was evaluated using carrageenan induced rat paw edema model and results were compared with commercial hydrogel formulation. The elastic liposomal formulations achieved muscle drug concentration between 2.2+/-0.14 to 5.3+/-0.22 microg/g at 12 hr. The same dose of commercial hydrogel formulation produced drug levels between 0.41+/-0.07 to 1.1+/-0.09 microg/g in the muscle. Plasma concentration study showed regiospecificity of elastic liposomal formulation. The results of in vivo study revealed that incorporation of diclofenac in elastic liposomes increased its biological activity two fold as compared to commercial hydrogel formulation. The results of the present study demonstrated greater effectiveness of dermaly applied diclofenac elastic liposomal formulation in comparison to conventional delivery system. The optimized elastic liposomal formulation offers a promising means for the non-invasive treatment of local pain and inflammation by topical application.

Impact of a “Direct Approach” to Live Kidney Donation in the British Indo-Asian Community

Although a general imbalance exists between the demand for renal transplants and the supply of suitable organs, the shortfall is particularly severe for patients from the Indo-Asian (I-A) community. It seems unlikely that this will be remedied by any increase in cadaveric donation. Our aim was to increase the rate of live donor transplantation (LDT) in the I-A population through a direct approach to patients and their families, in a culturally acceptable environment by an Asian transplant coordinator. Whereas an increase in LDT was seen in the I-A population over the period of review, 1997 to 2003, 15 compared with none prior to 1997, significant attrition was seen within the program, with only 10% of the original cohort coming to donation. There are multiple reasons for this including medical, social and psychological.

Infantile cortical hyperostosis

Infantile cortical hyperostosis (Caffey disease) is characterized by radiological evidence of cortical hyperostosis, soft tissue swellings, fever and irritability. We report a case of Caffey disease highlighting its presentation as pyrexia of unknown origin, appearance on radionuclide bone scintigraphy and our unsatisfactory experience of treating it with Ibuprofen, a prostaglandin inhibitor.

VON RECKLINGHAUSEN'S DISEASE

Von Recklinghausen's disease (VRD) is a rare genetic autosomal dominant disorder that affects the ectodermaltissues (nerve and skin). The cardinal features of this disorder are spots of increase pigmentation (cafe-au-lait spot, CAL), peripheral nerve tumours (neurofibromatosis) and iris hamartoma (Lisch nodule). Clinicaldiagnosis of VRD is based on the criteria given by National Institute of Health (NIH) because the mutationanalysis is laborious. Here, we are reporting a case of a family with VRD.Key Words: VonRecklinghausen's disease (VRD), Cafe-au-lait (CAL) spot, Lisch nodule,Neurofibromatosis (NF)

Third generation cephalosporins versus conventional antibiotics for treating acute bacterial meningitis

BACKGROUND

Antibiotic therapy for suspected acute bacterial meningitis (ABM) needs to be started immediately, even before the results of cerebrospinal fluid culture and antibiotic sensitivity are available. It is not clear whether the available evidence supports the choice of third generation cephalosporins over the conventional antibiotic combination of ampicillin and chloramphenicol. Immediate institution of effective treatment through intravenous route may reduce death and disability in survivors.

OBJECTIVES

The objective of this review is to determine the effectiveness and safety of the third generation cephalosporins and conventional treatment with penicillin/ampicillin-chloramphenicol in patients with community-acquired acute bacterial meningitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2003) which contains the Cochrane Acute Respiratory Infections Group trials register, MEDLINE (January 1966 to November 2003), and EMBASE (January 1990 to November 2003). We also searched the reference list of review articles and textbook chapters and contacted experts for any unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing ceftriaxone or cefotaxime with conventional antibiotics as empirical therapy of acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

Two independent reviewers applied the study selection criteria, assessed methodological quality and extracted data.

MAIN RESULTS

Eighteen trials included 993 patients in the analysis. The kappa (chance-corrected agreement) between the observers in study selection and data extraction was substantial. There was no heterogeneity of results among the studies in any outcome except diarrhoea. There was no statistically significant difference between the groups in the risk of death (risk difference -1%; 95% confidence interval (CI) -4% to +3%), risk of deafness (risk difference -4%; 95% CI -9% to +1%), risk of treatment failure (risk difference -2%; 95% CI -5% to +2%). However, there were significantly decreased risk of culture positivity of CSF after 10-48 hours (risk difference -6%; 95% CI -11% to 0%) and statistically significant increased in the risk of diarrhoea between the groups (risk difference +8%; 95% CI +3% to +13%) with the third generation cephalosporins. The risk of neutropenia and skin rash were not significantly different between the two groups. However, all the studies have been conducted in the eighties except two, which have been conducted in 1993 and 1996.

REVIEWERS' CONCLUSIONS

Although the review shows no clinically important difference between ceftriaxone or cefotaxime and conventional antibiotics, the studies are done decades ago and may not apply to current routine practice. However, in situations where ceftriaxone or cefotaxime are not available or affordable, ampicillin-chloramphenicol combination may be used as an alternative. The antimicrobial resistance pattern against various antibiotics needs to be closely monitored in developing as well as developed countries. The factors determining overuse of antibiotics in developing countries and educational interventions to limit such practice are priority area for research in developing countries.

Fluconazole and itraconazole susceptibility of clinical isolates of Cryptococcus neoformans at a tertiary care centre in India: a need for care

OBJECTIVES

In cryptococcosis, fluconazole is a standard prophylactic, therapeutic and maintenance option, particularly in the expanding HIV/AIDS group. However, its excessive use may lead to resistance in Cryptococcus neoformans. Variations in clinical response to fluconazole have already been noted elsewhere, and cases of post-therapy relapse are not uncommon. To assess azole antifungal susceptibility profiles of clinical cryptococcal isolates in India, the All India Institute of Medical Sciences (AIIMS) has recently initiated preliminary studies using NCCLS M27-A.

MATERIALS AND METHODS

Twenty-eight randomly chosen AIIMS clinical isolates (spanning 1997-2000), 16 isolates from other institutions in North India, and six reference strains of C. neoformans were subjected to susceptibility testing to fluconazole and itraconazole.

RESULTS

Among clinical isolates, susceptibilities to fluconazole and itraconazole were 84.1% and 93.2%, respectively. MICs for all clinical isolates were 0.25-32 mg/L for fluconazole and <0.03-0.25 mg/L for itraconazole. MIC50 and MIC90 values for fluconazole were 4 and 16 mg/L, respectively, and those for itraconazole were 0.032 and 0.125 mg/L, respectively. Out of 28 AIIMS clinical isolates, 22 had minimum fungicidal concentrations (MFCs) of fluconazole at 128 mg/L. Moderately high fluconazole MICs (16-32 mg/L) were observed in 16% of clinical isolates--probably the first such report from India. MIC/MFC ratios for fluconazole and itraconazole were 1:32 or more in 16 AIIMS clinical isolates, indicating possible azole tolerance. There was good agreement between MIC values obtained by the micro- and macro-broth dilution techniques of M27-A compared in this study.

CONCLUSIONS

The observed MIC data warrant continued surveillance of susceptibility values of clinical cryptococcal isolates in India.

Non-ligation of the hernial sac during herniotomy: a prospective study

Herniotomy is performed for the surgical repair of hernia and along with orchiopexy for the closure of associated patent processus vaginalis. Ligation of the hernial sac has been considered mandatory for a successful repair. The present report was designed to study the results of non-ligation of the hernial sac before excision at the neck. It was found that non-ligation has no untoward effect on early complications and recurrence rate on long-term follow-up. It is suggested that it is not necessary to ligate the hernial sac during herniotomy in children.

Pulmonary arteriovenous fistula presenting as multiple brain abscess

Pulmonary arteriovenous fisula is a rare condition in which there is abnormal connection between pulmonary arteries and veins. We describe this condition is an 18-year-old male who presented with cyanosis, clubbing, polycythemia and multiple brain abscesses. The patient was diagnosed as pulmonary arteriovenous fistula based on CT scan and on pulmonary angiography. The patient had a complete recovery after surgical drainage of brain abscess and excision of right upper lobe. After one year of follow up, there are no symptoms and there is complete reversal of cyanosis and polycythemia.

Nosocomial outbreak of diarrhoea by enterotoxigenic Escherichia coli among preterm neonates in a tertiary care hospital in India: pitfalls in healthcare

An outbreak of watery diarrhoea accompanied by low-grade fever and weight loss in 16 preterm neonates (age range 2-20 days) admitted to a neonatal intensive care unit (NICU) over four days in August 2000 is reported. Escherichia coli having similar antibiograms were identified on routine bacterial stool cultures in 14 (87.5%) neonates and none of the other known enteropathogens were detected. An investigation was undertaken to trace the source of infection. Surveillance cultures of swabs from the utensils used to prepare milk feed, culture of the formula feed and all items handled by one particular cook yielded growth of E. coli as did culture of his hand swabs and faecal sample. The causative agent was identified as enterotoxigenic E. coli (ETEC) as toxin production could be demonstrated by reverse passive latex agglutination in all the strains of E. coli isolated both from the infected neonates and the source of infection. The outbreak was effectively controlled by appropriate therapy and institution of proper measures of hygiene after identification of the source of infection.

Sodium valproate in the management of painful neuropathy in type 2 diabetes - a randomized placebo controlled study

OBJECTIVE

To study the effectiveness and safety aspects of sodium valproate in the management of painful neuropathy in patients of type 2 diabetes mellitus.

MATERIAL AND METHODS

A randomized double-blind placebo controlled trial of sodium valproate was done in type 2 diabetic patients to assess its efficacy and safety in the management of painful neuropathy. We screened 60 patients but eight patients could not complete the study; hence, the present study was done on 52 patients. Each patient was assessed by clinical examination, pain score by short form of the McGill pain questionnaire (SF-MPQ) and electrophysiological examination, which included motor and sensory nerve conduction velocity, amplitude and H-reflex initially and at the end of 1 month of treatment.

RESULTS

Significant improvement was noticed in the pain score of patients receiving sodium valproate in comparison to patients receiving placebo at the end of 1 month (P < 0.05). The changes in electrophysiological data were not significant. The drug was well tolerated by all patients except one who developed a raised aspartate transaminase (AST)/alanine transaminase (ALT) level after 15 days of treatment.

CONCLUSION

Sodium valproate is a well-tolerated drug and provides significant subjective improvement in painful diabetic neuropathy. These data provide a basis for future trials of longer duration in a larger group of patients.

Liquid crystalline pharmacogel based enhanced transdermal delivery of propranolol hydrochloride

A novel pharmacogel was developed for the enhanced transdermal delivery of propranolol hydrochloride (PH). The synthesized prodrugs, propranolol palmitate hydrochloride (PPH) and propranolol stearate hydrochloride (PSH) self-assembled to form gel simply upon mixing alcoholic solution of prodrug with an aqueous solution in a specified ratio. By varying the ratio of prodrug, alcohol and water, three-component phase diagram was constructed which revealed isotropic-gel-vesicular dispersion regions, respectively concomitant to increasing the ratio of water. The gel phase is termed 'Pharmacogel' and exhibits birefringence under plane-polarized light corroborating the presence of lamellar liquid crystals. The pharmacogel by virtue of high chemical potential gradient and improved physicochemical properties showed the enhanced in-vitro skin permeation flux of 51.5+/-3.7 and 42.5+/-3.1 microg/cm(2)/h from PPH and PSH gel, respectively, as compared to 1.9+/-0.1 microg/cm(2)/h for control; and decrease in lag time (1.8 and 2.8 h for PPH and PSH gel, respectively) compared to control (7.6 h) was observed. The admixing of egg lecithin (EL) in increasing ratio concomitantly decreased the flux values to 31.7+/-2.1 microg/cm(2)/h (at a mole ratio of 50:50 PPH:EL) and increased the lag time. In the gel containing 50% EL, the addition of span 40 and cholesterol slightly reduced the permeation while sodium deoxycholate and Tween-80 improved it. The plasma drug levels following transdermal application of control were low (C(max)=23 ng/ml) while in PPH gel, it increased with time reaching C(max) of 94 ng/ml at 8 h post-application of PPH gel (C(max) of 75 ng/ml at 12 h post application of PL5 gel) and maintained for longer times. The AUC(0-32 h) for PPH gel was much higher (1968 ng h/ml) than control (AUC(0-18 h) was 239 ng h/ml), while EL mixed gel also showed better absorption (AUC(0-32 h) was 1707 ng h/ml). The gel formulations also caused less irritation than control, while mixed gel showed least irritation. This novel self-assembled pharmacogel providing high transdermal permeation with many variables to regulate the delivery is therefore having a great potential in percutaneous delivery.

Tassier cleft no 30 (median cleft from lower lip to manubrium)

One-year-old female presented with cleft of lower lip, mandible, fissured tongue, absent hyoid bone, cleft of manubrium sterni, later is detected clinically by suprasternal bulge at suprasternal region while crying. It is radiologically detected by wide apart medial end of clavicle. This is extremely rare anomaly known as Tassier Cleft no 30.

Biosorption of chromium(VI) from aqueous solutions by green algae Spirogyra species

Biosorption of heavy metals is an effective technology for the treatment of industrial wastewaters. Results are presented showing the sorption of Cr(VI) from solutions by biomass of filamentous algae Spirogyra species. Batch experiments were conducted to determine the adsorption properties of the biomass and it was observed that the adsorption capacity of the biomass strongly depends on equilibrium pH. Equilibrium isotherms were also obtained and maximum removal of Cr(VI) was around 14.7 x 10(3) mg metal, kg of dry weight biomass at a pH of 2.0 in 120 min with 5 mg/l of initial concentration. The results indicated that the biomass of Spirogyra species is suitable for the development of efficient biosorbent for the removal and recovery of Cr(VI) from wastewater.

Barriers to acceptance: an exploratory study of complementary/alternative medicine disuse

BACKGROUND

Previous research indicates wide use of complementary and alternative medicine (CAM). While understanding this trend is certainly important, an equally meaningful although largely unexamined research question is: why do the majority of patients and individuals fail to avail themselves of such therapies? Understanding these factors may be particularly important given the increasing evidence suggesting that certain of these therapies may be efficacious.

METHODS

A two-page survey that examined demographic characteristics, attitudes toward CAM, and rates of use of specific CAM therapies was mailed to a randomly selected sample of 1680 Stanford University alumni. A total of 601 responses were received (response rate, 35.8%). Multiple regression analyses were carried out to examine predictors of general CAM disuse and disuse of specific therapies.

RESULTS

The following variables predicted disuse of CAM in general (p < 0.05): (1) being male (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.44-0.98); (2) being healthy (OR 0.95; 95% CI 0.91-0.99); (3) lack of physician support for CAM use (OR 1.82; 95% CI 1.42-2.29); and (4) believing CAM treatments are ineffective or inferior (OR 0.27; 95% CI 0.19-0.38). Lack of knowledge about CAM approached significance (p = 0.068). With regards to specific therapies, the following patterns were seen: disuse of massage was associated with being male and younger; lack of physician support predicted disuse for all treatments except acupuncture and homeopathy; the belief that CAM treatments in general are ineffective predicted disuse of all therapies except chiropractic while the belief that chiropractic was ineffective predicted its disuse; the perception that CAM produced negative side-effects predicted disuse of chiropractic; lack of knowledge of CAM predicted disuse of herbs, chiropractic, and homeopathy; positive health status was associated with disuse of chiropractic; and finally, the perception that providers were not in accessible locations predicted disuse of all CAM therapies except homeopathy and meditation.

CONCLUSIONS

Study findings indicate people are less likely to use CAM if they are male, are in good health, believe that the therapies are in general ineffective or inferior to conventional methods, perceive that conventional medical doctors are not supportive, and to a lesser extent feel they do not have adequate knowledge of CAM. Specifically, avoidance of chiropractic is associated with concerns for safety and side-effects. For treatments that are more provider-based as opposed to self-care based, lack of accessibility-to providers may explain disuse. As researchers continue to demonstrate the clinical efficacy of CAM therapies, these preliminary findings deserve attention because they highlight potential reasons why patients and physicians may be biased against or unable to avail themselves of such therapies.

Effect of electroconvulsive therapy on hematological parameters

Although a complete blood count is part of the evaluation before the use of electroconvulsive therapy (ECT), there are no known hematological contraindications for the procedure. A preliminary study was done on 31 randomly selected psychiatric patients (chronic schizophrenia, n=10; acute depression, n=8; acute mania, n=6; acute psychosis, n=6; delusional disorder, n=1) receiving ECT to study its hematological effects. Blood samples were drawn just before and 0, 1 and 2 h after ECT. Hemoglobin (Hb%), total and differential leukocyte count (TLC and DLC), red blood cell (RBC) count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) and platelet count were measured on a fully automated hematology analyzer (Sysmex K-1000). Significant changes were found in TLC, percentage of polymorphs and lymphocytes, and Hb%. Changes in other parameters were not statistically significant. More such studies are needed to substantiate these observations and to understand the mechanism and implication of these effects.

Evaluation of semi-quantitative methods for protein and sugar estimation in urine

OBJECTIVES

To compare the accuracy of semi quantitative methods for estimation of protein and sugar in urine as shown by their agreement with the quantitative estimation. Hundred randomly collected samples of urine were analysed for levels of protein and sugar. Protein estimation was dine by dipstick and sulphosalicylic acid method (SSA) and sugar by dipstick and Benedict's semi-quantitative methods. Kappa analysis was done on Epi Info 6.03 software to assess the agreement of these semi quantitative methods with the quantitative estimation. Neither of the two tests for urine protein, dipstick or SSA, showed good agreement with the quantitative estimation (Kappa coefficient: 0.26 and 0.07 respectively). However, the dipstick was significantly better than SSA (p < 0.05). For urine sugar, both dipstick and Benedict's tests showed good agreement with the quantitative estimation (Kappa coefficient: 0.78 and 0.84 respectively). The difference between them was insignificant. Results demonstrate that for urine protein, dipstick or SSA show poor agreement with quantitative values. For urine sugar estimation, Benedict's semi-quantitative test shows good agreement with the quantitative values and is as good as the dipstick method.

Long-term management of asthma

Long-term management of asthma includes identification and avoidance of precipitating factors of asthma, pharmacotherapy and home management plan. Common precipitating factors include viral upper respiratory infections, exposure to smoke, dust, cold food and cold air. Avoidance of common precipitating factors has been shown to help in better control of asthma. Pharmacotherapy is the main stay of treatment of asthma. Commonly used drugs for better control of asthma are long and short acting bronchodilators, mast cell stabilizers, inhaled steroids, theophylline and steroid sparing agents. After assessment of severity most appropriate medications are selected. For mild episodic asthma the medications are short acting beta agonists as and when required. For mild persistent asthma: as and when required bronchodilators along with a daily maintenance treatment in form of low dose inhaled steroids or cromolyn or oral theophylline or ketotifen are required. Moderate persistent asthma should be treated with inhaled steroids along with long acting beta agonists for symptom control. For severe persistent asthma the recommended treatment includes inhaled steroids, long acting beta agonists with or without theophylline. If symptoms are not well controlled, a minimal dose of oral prednisolone preferably on alternate days may be needed in few patients. Newer drugs like leukotriene antagonists may find a place in control of exercise-induced bronchoconstriction and mild and moderate persistent asthma. Patients should be followed up every 8-12 weeks. On each follow up visit patients should be examined by a doctor, compliance to medications should be checked and actual inhalation technique is observed. Depending on the assessment, medications may be decreased or stepped up. For exercise induced bronchoconstriction: cromolyn, short or long acting beta agonists may be used. In children with seasonal asthma, maintenance treatment according to assessed severity should be started 2 weeks in advance and continued throughout the season. These patients should be reassessed after discontinuing the treatment. Parents should be given a written plan for management of acute exacerbation at home.

Prediction of aqueous solubility of organic compounds by the general solubility equation (GSE)

The revised general solubility equation (GSE) is used along with four different methods including Huuskonen's artificial neural network (ANN) and three multiple linear regression (MLR) methods to estimate the aqueous solubility of a test set of the 21 pharmaceutically and environmentally interesting compounds. For the selected test sets, it is clear that the GSE and ANN predictions are more accurate than MLR methods. The GSE has the advantages of being simple and thermodynamically sound. The only two inputs used in the GSE are the Celsius melting point (MP) and the octanol water partition coefficient (K(ow)). No fitted parameters and no training data are used in the GSE, whereas other methods utilize a large number of parameters and require a training set. The GSE is also applied to a test set of 413 organic nonelectrolytes that were studied by Huuskonen. Although the GSE uses only two parameters and no training set, its average absolute errors is only 0.1 log units larger than that of the ANN, which requires many parameters and a large training set. The average absolute error AAE is 0.54 log units using the GSE and 0.43 log units using Huuskonen's ANN modeling. This study provides evidence for the GSE being a convenient and reliable method to predict aqueous solubilities of organic compounds.

Solubilization of NSC-639829

Solubilization using pH combined with cosolvents, surfactants, and complexants are investigated for NSC-639829, an investigational anti-tumor agent. The intrinsic solubility of the drug is approximately 30 ng/ml and it has an ionizable dimethyl aniline group with an approximate base pK(a) of 5. Samples buffered at pH 1.0, 2.0, and 7.0 with various concentrations of the solubilizing agents were used to study the solubilization of NSC-629829 when present as charged and uncharged species. The solubilization of NSC-639829 was found to be much more effective when the drug was present primarily in ionized form. At pH values 1.0 and 2.0 where the surfactant (SLS) and complexant (SBEbetaCD) carried a negative charge enhanced solubilities of more than a million-fold were observed for the drug.

Modes of granular segregation in a noncircular rotating cylinder

Axial segregation is a well-known example of segregation of granular materials. However, at present, there is no conclusive explanation as to why it occurs. Most studies of axial segregation to date are based on cylinders with circular cross sections, and models focus on the character of the surface flow without accounting explicitly for the influence of any subsurface detail. The present experiments demonstrate that the cross section of the mixer has a significant influence on axial segregation and that subsurface dynamics are, in fact, important. Unlike circular mixers, in square mixers the subsurface segregation patterns change with filling level, as does the time dependence of axial segregation. Furthermore, when radial segregation patterns in noncircular mixers most closely resemble that observed for circular cylinders, the time dependence for axial band formation deviates the most. These results challenge segregation theories of axial segregation that ignore subsurface effects.

Effects of light intensity, n-alcohols, water-soluble colorants, and solution viscosity on photoisomerization of sorivudine

Effects of various factors, such as light intensity, polarizability of n-alcohol solvents, addition of colorants, and viscosity of solutions on the kinetics of the photoisomerization of therapeutically effective E-isomer of sorivudine to its less effective Z-isomer were studied. Solutions of known concentrations of E-isomer or Z-isomer in water or in a series of n-alcohols were directly exposed to ultraviolet (UV) A light, or visible light of 400 or 900 foot candles (fc). E-isomer solutions containing various colorants at 1% w/v, or in a series of poloxamer solutions of different viscosities, were also exposed to 400 or 900 fc light. Using the stability-indicating HPLC assay, which showed mass-balance between the starting isomer and the converting isomer, the kinetics of photoisomerization were monitored. The photoisomerization reaction, which takes place on the vinyl side chain, was found to be a first-order reversible reaction. In water, the rate of conversion of E-isomer to Z-isomer was faster than that of Z-isomer to E-isomer, since, E-isomer with higher extinction coefficient absorbed substantially more light than Z-isomer. The rate of photoisomerization increased with the intensity of the visible light and was very rapid in the presence of UV A light (300 to 400 nm), which is to be expected based on the 239 nm and 283 nm absorption maxima of sorivudine. Addition of water-soluble colorants retarded the photoisomerization process significantly, especially as the maximum absorption wavelengths (lambda max) of the colorants approached the UV region. The rate of photoisomerization increased with increasing polarizability (alpha s) of the n-alcohol solvents. Polarizable solvents such as alcohols could compensate for the electron density built up in the excited state, and thus facilitated the photoisomerization process. The rate of photoisomerization decreased as the viscosity of solution increased. This may be attributed to the fact that the twisting of the C=C bond in the excited state can be inhibited by the friction imposed by the viscous medium.

Clinical characteristics of familial B-CLL in the National Cancer Institute Familial Registry

In an ongoing study, families with two or more living cases of B-CLL in first-degree relatives have been recruited through physician and self-referral. Since 1967, 28 kindreds with 73 cases of B-CLL have been enrolled within the National Cancer Institute (NCI) Familial B-CLL Registry. Medical, clinical, and demographic information have been obtained from private physicians, patient interview, hospital records, and death certificates. We used SEER Registry data to compare characteristics of sporadic B-CLL to familial B-CLL. The mean age at diagnosis was approximately 10 years younger among familial cases (57.9 +/- 12.1) than that observed in sporadic cases (70.1 +/- 11.9). A higher percentage of second primary tumors among familial CLL cases compared to reports in sporadic was also observed (16% vs. 8.8%). However, the transformation rate to non-Hodgkin's lymphoma does not appear to be different from that reported for sporadic cases. In conclusion, we observed some differences between familial and sporadic cases; whether any of these characteristics affect survival time or severity of disease is unknown. The study of families with multiple B-CLL cases will aid in delineating the genes and environmental factors that may play a role in the development of both forms of B-CLL.