Prevalence, molecular characterization and antibiogram of Mycoplasma bovis isolated from milk in Pakistan

Mycoplasma bovis is a highly contagious pathogen that causes clinical or subclinical mastitis. The present study was aimed for the isolation, molecular characterization and antibiogram determination of M. bovis from raw milk samples. Milk samples were collected randomly from lactating cows and buffaloes from different tehsils of district Faisalabad, Pakistan. Samples were inoculated on modified Hayflick medium and biochemical tests were performed for further confirmation of isolated M. bovis. Out of total 400 milk samples, 184 (46%) samples were found positive for culture method. The 16S-rRNA gene polymerase chain reaction was performed for molecular characterization of isolated M. bovis strains. Out of total 400 milk samples, 240 (60%) positive for M. bovis through PCR method were examined. The 16S-rRNA gene PCR positive isolated M. bovis strains were sequenced and results were compared using Maximum-likelihood method and sequenced strains of M. bovis were aligned and analyzed by Clustal W software. Antibiogram of isolated M. bovis strains was analyzed by disc diffusion assay against eight commonly used antibiotics. Tylosin (30μg) and Tilmicosin (15ug) showed inhibition zones of 32.34 ± 1.10 mm and 17.12 ± 0.93 mm respectively against isolated M. bovis which were found sensitive. Isolated M. bovis was found resistant to other commonly used antibiotics. Statistical analysis revealed that p-value was < 0.05 and the odds ratio was >1.0 at 95% CI. This study complemented the lack of epidemiological knowledge of molecular characterization, comparative effectiveness and resistance trends of isolated M. bovis strains against commonly used antibiotics.

Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children

IMPORTANCE

Optimal agents and duration of primary treatment for multisystem inflammatory syndrome in children (MIS-C) remain unclear.

OBJECTIVE

To compare short-term patient outcomes based on initial treatment with corticosteroids, intravenous immunoglobulin (IVIG), or both.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients in a tertiary-care pediatric hospital system who had MIS-C per the Centers for Disease Control and Prevention case definition during the period March 2020 to February 2021.

EXPOSURES

Immunomodulatory therapy within the first 24 hours (patients in the intensive care unit [ICU]) or 48 hours (non-ICU patients): corticosteroids alone, IVIG alone, and IVIG plus corticosteroids.

MAIN OUTCOMES AND MEASURES

Primary outcome was failure of initial therapy, defined as therapy escalation due to fever or worsening or lack of improvement of laboratory, cardiac, or noncardiac clinical factors after 24 hours (ICU patients) or 48 hours (non-ICU patients) from time of therapy initiation, per clinician assessment. Secondary outcomes included presence of complications, cardiovascular outcomes, fever duration, length of hospital and ICU stays, corticosteroid use duration, and need for readmission.

RESULTS

Among 228 eligible patients, 215 patients were included in the univariate analysis; median age was 8 years, and 135 (62.8%) were boys. There were 69 patients in the corticosteroids group, 31 patients in the IVIG group, and 115 patients in the IVIG plus corticosteroids group. Patients in the corticosteroids group had milder disease at presentation. After propensity score weighting including 179 patients (68 in the corticosteroids group and 111 in the IVIG plus corticosteroids group), rates of initial treatment failure were similar between groups. Among patients whose initial treatment failed, treatment failure in the IVIG plus corticosteroids group was more likely to be based on laboratory parameters (odds ratio [OR], 1.96; 95% CI, 1.07-3.60) and less likely to be based on cardiovascular markers (OR, 0.39; 95% CI, 0.2-0.76), per clinician assessment. Patients in the IVIG plus corticosteroids group had a longer median inpatient stay (6 vs 5 days; P = .001) and longer median corticosteroid course duration (10 vs 5 days; P = .04) compared with the corticosteroids group. Forty-nine patients (71% of 69 in the corticosteroids group) recovered after receiving corticosteroid monotherapy for 10 days or less.

CONCLUSIONS AND RELEVANCE

Corticosteroid monotherapy is a reasonable management option for a subset of patients with MIS-C, particularly those with mild disease.

Distinguishing Multisystem Inflammatory Syndrome in Children From COVID-19, Kawasaki Disease and Toxic Shock Syndrome

BACKGROUND

Distinguishing multisystem inflammatory syndrome in children (MIS-C) from coronavirus disease 2019 (COVID-19), Kawasaki disease (KD), and toxic shock syndrome (TSS) can be challenging. Because clinical management of these conditions can vary, timely and accurate diagnosis is essential.

METHODS

Data were collected from patients <21 years of age hospitalized with MIS-C, COVID-19, KD, and TSS in 4 major health care institutions. Patient demographics and clinical and laboratory data were compared among the 4 conditions, and a diagnostic scoring tool was developed to assist in clinical diagnosis.

RESULTS

A total of 233 patients with MIS-C, 102 with COVID-19, 101 with KD, and 76 with TSS were included in the analysis. Patients with MIS-C had the highest prevalence of decreased cardiac function (38.6%), myocarditis (34.3%), pericardial effusion (38.2%), mitral regurgitation (31.8%) and pleural effusion (34.8%) compared with patients with the other conditions. Patients with MIS-C had increased peak levels of C-reactive protein and decreased platelets and lymphocyte nadir counts compared with patients with COVID-19 and KD and elevated levels of troponin, brain natriuretic peptide and pro-brain natriuretic peptide compared with COVID-19. Diagnostic scores utilizing clinical findings effectively distinguished MIS-C from COVID-19, KD, and TSS, with internal validation showing area under the curve ranging from 0.87 to 0.97.

CONCLUSIONS

Compared with COVID-19, KD, and TSS, patients with MIS-C had significantly higher prevalence of cardiac complications, elevated markers of inflammation and cardiac damage, thrombocytopenia, and lymphopenia. Diagnostic scores can be a useful tool for distinguishing MIS-C from COVID-19, KD, and TSS.

Adenoid basal carcinoma with adenoid cystic-like features—a rare diagnostic dilemma

Introduction/Objective

Adenoid basal carcinoma (ABC) of the cervix is a rare, indolent tumor with no known metastatic potential. The tumor is composed of small nests of bland, basaloid cells, which do not elicit a desmoplastic response within the surrounding stroma. Cystic and clear cell change, as well as glandular differentiation, are not unusual. As such, it is important to differentiate ABC from adenoid cystic carcinoma (ACC), particularly on account of the aggressive clinical course of the latter. We herein present a rare case of ABC with adenoid cystic-like features.

Methods/Case Report

A 74-year-old woman with an incidental ABC, diagnosed on an excisional procedure performed for a prior diagnosis of a high grade squamous intraepithelial lesion. Subsequent hysterectomy revealed a tumor composed of nests of basaloid cells, extending into the outer third of the cervical wall, but exhibiting no peri- tumoral desmoplasia. Cribriforming associated with increased mitotic activity was focally present and showed increased Ki-67 labeling compared to the solid nests of tumor. PAS special stain highlighted rare pseudolumina with basement membrane-like material. While these features were concerning for an ACC—the lack of any significant cytologic atypia, destructive stromal invasion, and a clinically apparent lesion—was consistent with an ABC with so- called adenoid cystic-like features.

Results (if a Case Study enter NA)

NA

Conclusion

Making an accurate diagnosis requires clinicopathologic correlation and awareness of histologic overlap. Additionally, adenoid cystic-like morphology in ABCs is a little-studied phenomenon, which necessitates further research to shed light on potential clinical implications.

Comparison of different diagnostic modalities for isolation of Mycobacterium Tuberculosis among suspected tuberculous lymphadenitis patients

Tuberculosis is a communicable disease with high morbidity and mortality rates in developing countries. The study's primary objective is to compare conventional methods such as acid-fast bacillus (AFB) culture and microscopy with rapid diagnostic methods. The secondary objective is to compare histopathological and microbiological findings in suspected patients with tubercular lymphadenitis. A total of 111 samples (August 2018 to September 2019) of lymph nodes were processed for AFB microscopy, AFB cultures, drug-susceptibility testing (DST), histopathology, and Xpert Mycobacterium Tuberculosis (MTB)/resistance to Rifampin (RIF) assays. Out of 111 lymph node samples, 6 (5.4%) were positive for AFB smear microscopy, 84 (75.6%) were positive for AFB culture, 80 (70.7%) were positive on Gene Xpert, and 102 (91.8%) were indicative of tuberculosis for histopathology studies. Mycobacteria growth indicator tube (MGIT) culture positivity was 84 (75.6%) higher than solid Lowenstein-Jensen (LJ) culture 74 (66.6%). Positive cultures underwent phenotypic DST. Two cases were Multidrug-resistant (MDR) on DST, while three cases were Rifampicin resistant on Gene Xpert. The sensitivity of Genexpert was (62%) against the conventional AFB culture method. The poor performance of conventional lymphadenitis diagnostic methods requires early and accurate diagnostic methodology. Xpert MTB/RIF test can help in the treatment of multidrug-resistant TB cases. Nonetheless, rapid and conventional methods should be used for complete isolation of Mycobacterium tuberculosis.

Prevalence, predictors and outcomes of thyroid dysfunction in patients with acute myocardial infarction: the ThyrAMI-1 study

PURPOSE

Thyroid dysfunction in patients with cardiac disease is associated with worse outcomes. This study aimed to evaluate the prevalence and analyse predictors and outcomes of thyroid dysfunction in patients presenting with an acute myocardial infarction (AMI).

METHODS

A prospective multicentre observational study of patients recruited from six acute hospitals within the North of England. Consecutive patients without previous thyroid disease presenting with both ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI) were recruited to the Thyroxine in Acute Myocardial Infarction 1 (ThyrAMI-1) cohort study between December 2014 and 2016. Thyroid profile, standard biochemistry measurements and demographic information were obtained within 12 h of admission to hospital. Multivariable logistic regression analyses were performed to assess the predictors of thyroid dysfunction and Cox proportional hazards analyses were utilised to compare all-cause mortality by categories of thyroid dysfunction up to June 2019.

RESULTS

Of the 1802 participants analysed, 1440 (79.9%) were euthyroid, 312 (17.3%) had subclinical hypothyroidism (SCH), 22 (1.2%) had subclinical hyperthyroidism (SHyper) and 25 (1.3%) had low T3 syndrome (LT3S). Predictors for SCH were increasing age, female sex, higher thyroid peroxidase antibody (TPOAb) levels, higher serum creatinine levels and early morning sampling time (between 00:01-06:00 h). The predictors of SHyper were lower body mass index and afternoon sampling time (between 12:01 and 18:00 h). Predictors of LT3S were increasing age, higher creatinine levels and presence of previous ischaemic heart disease. Compared to the euthyroid group, patients with LT3S had higher all-cause mortality; adjusted hazard ratio (95% CI) of 2.02 (1.03-3.95), p = 0.04, whereas those with SCH and SHyper did not exhibit significantly increased mortality; adjusted hazard ratios (95% CI) of 1.05 (0.74-1.49), p = 0.79 and 0.27 (0.04-1.95), p = 0.19, respectively.

CONCLUSIONS

Thyroid dysfunction is common in AMI patients on admission to hospital and our data provide an understanding regarding which factors might influence thyroid dysfunction in these patients. Furthermore, the negative association between LT3S and increased mortality post-AMI has once again been highlighted by this study. More research is required to assess if treatment of thyroid dysfunction improves clinical outcomes.

A Rare Presentation of Pseudomembranous Colitis in a COVID-19 patient

Introduction/Objective

Recent reports suggest that though COVID-19 is predominantly a respiratory pathogen, one of its presenting features can be gastrointestinal symptoms. We hereby present a case of a female with COVID-19 infection whose hospital course was complicated by colonic pseudo-obstruction caused by pseudomembranous colitis resulting in an emergent hemicolectomy.

Methods

A 59-Year-old female with history of hypertension, diabetes, and breast cancer post mastectomy presented with pneumonia and was confirmed to be COVID-19 positive. She was admitted to the hospital and was treated with Azithromycin for 6 days. Patient developed constipation on day six of hospitalization and started having abdominal pain on day eight with elevated WBC count. Imaging showed distension of cecum and proximal colon. She underwent exploratory laparotomy which revealed a necrotic appearing cecum that was massively dilated and had a serosal tear. These findings prompted emergent hemicolectomy with loop ileostomy. Grossly cecum was black/green, dilated, thin walled with a 5 x 5 cm yellow green raised plaques. Microscopy of the plaques revealed focal erosion of colonic mucosa with overlying acute inflammatory cells, fibrin deposits, mucus, and necrotic epithelial cells consistent with pseudomembranous colitis.

Conclusion

Review of literature shows no reported cases of intestinal pseudo-obstruction due to pseudomembranous colitis in a COVID-19 patient. Not only this, but there are also only a limited number of case studies of pseudomembranous colitis presenting as intestinal pseudo-obstruction without diarrhea. Though this patient’s presentation could be from Clostridium difficile infection secondary to Azithromycin, it is not a common antibiotic to cause this. Also, one of the known causes of pseudomembranous colitis is ischemia. Given that COVID-19 infection is a pro-thrombotic condition, possible ischemia secondary to COVID-19 infection related coagulopathy should also be a consideration.

A morphological and molecular phylogenetic analysis of relationships between genera of the nematode sub-family Cloacininae (Stossich) (Strongyloidea: Chabertiidae) parasitic in kangaroos, wallabies and rat-kangaroos (Marsupialia: Macropodoidea)

A phylogenetic analysis of the genera of the strongyloid sub-family Cloacininae from macropodoid marsupials in Australasia was undertaken based on morphological characteristics and analysis of concatenated sequences (ITS+) of the first (ITS-1) and second (ITS-2) internal transcribed spacers of nuclear ribosomal DNA. Neither approach provided a robust phylogeny, but similarities between the two methods in terms of generic groupings suggested that substantial revision is needed of the current phenetic classification, with some of the key morphological characteristics currently used to define genera and tribes proving to be homoplasious.

First characterization of immunogenic conjugates of Vi negative Salmonella Typhi O-specific polysaccharides with rEPA protein for vaccine development

Efficacious typhoid vaccines for young children will significantly reduce the disease burden in developing world. The Vi polysaccharide based conjugate vaccines (Vi-rEPA) against Salmonella Typhi Vi positive strains has shown high efficacy but may be ineffective against Vi negative S. Typhi. In this study, for the first time, we report the synthesis and evaluation of polysaccharide-protein conjugates of Vi negative S. Typhi as potential vaccine candidates. Four different conjugates were synthesized using recombinant exoprotein A of Pseudomonas aeruginosa (rEPA) and human serum albumin (HSA) as the carrier proteins, using either direct reductive amination or an intermediate linker molecule, adipic acid dihydrazide (ADH). Upon injection into mice, a significantly higher antibody titer was observed in mice administrated with conjugate-1 (OSP-HSA) (P=0.0001) and conjugate 2 (OSP-rEPA) (P≤0.0001) as compared to OSP alone. In contrast, the antibody titer elicited by conjugate 3 (OSPADH-HSA) and conjugate 4 (OSPADH-rEPA) were insignificant (P=0.1684 and P=0.3794, respectively). We conclude that reductive amination is the superior method to prepare the S. Typhi OSP glycoconjugate. Moreover, rEPA was a better carrier protein than HSA. Thus OSP-rEPA conjugate seems to be efficacious typhoid vaccines candidate, it may be evaluated further and recommended for the clinical trials.

Multi-country retrospective observational study of the management and outcomes of patients with Type 2 diabetes during Ramadan in 2010 (CREED)

AIM

To describe the characteristics and management of patients with diabetes who chose to fast during Ramadan in 2010.

METHODS

This was a multi-country, retrospective, observational study, supplemented with physician and patient questionnaires, with data captured before, during and after Ramadan. A total of 508 physicians in 13 countries enrolled 3777 patients and a total of 3394 evaluable cases were analysed. We report on the subset of patients with Type 2 diabetes, which included 3250 patients (95.8%).

RESULTS

Oral anti-hyperglycaemic therapy was the predominant pre-Ramadan therapy for most patients (76.6%). The treatment regimen was modified before Ramadan for 39.3% of all patients (34.9% for patients on oral drugs alone, 47.1% for patients on injectable drugs alone). Almost all physicians (96.2%) reported providing fasting-specific advice to patients and 62.6% report using guidelines or recommendations for the management of diabetes during Ramadan. In all, 64% of patients reported fasting everyday of Ramadan and 94.2% fasted for at least 15 days.

CONCLUSIONS

Physicians have increasingly adopted multiple approaches to the management of fasting during Ramadan, including the adoption of international and/or national guidelines, providing fasting-specific advice and adjusting treatment regimens, such that patients are able to fast for a greater number of days without acute complications. Additional research is needed to explore physician and patient beliefs and practices to inform the evidence-based management of diabetes while fasting, both during and outside of Ramadan, and to identify and address barriers to the universal uptake of techniques to facilitate that management.

Recurrence of morphea after successful ultraviolet A1 phototherapy: A cohort study

BACKGROUND

Studies support efficacy of ultraviolet (UV)A1 phototherapy, but little is known about recurrence after successful UVA1 treatment.

OBJECTIVE

We sought to determine the frequency of recurrent activity after UVA1 phototherapy and variables associated with recurrence.

METHODS

This was a case series and prospective cohort study of patients treated with UVA1 phototherapy with minimum 6 months of follow-up. Demographics, clinical features, and cumulative UVA1 dose were analyzed for association with recurrence.

RESULTS

Of 37 patients, 46% (n = 17) had recurrence of active morphea lesions after successful UVA1 phototherapy. Two-year and 3-year (after the last UVA1 phototherapy treatment) recurrence rates were 44.5% (95% confidence interval 30.1%-62.2%) and 48.4% (95% confidence interval 33.2%-66.1%), respectively. The only variable associated with recurrence was duration of morphea before UVA1 (P value = .02, hazard ratio 1.15, 95% confidence interval 1.06-1.27).

LIMITATIONS

The sample size limits conclusions.

CONCLUSION

With the exception of increased duration of morphea, risk of recurrence is no different in adults and children, or between morphea subtypes, skin types, and medium- to high-dose regimens. This indicates treatment doses in the medium-high UVA1 range are adequate with respect to frequency of recurrence.

No change in calcium absorption in adult Pakistani population before and after vitamin D administration using strontium as surrogate

Vitamin D, parathyroid hormone levels and calcium absorption was assessed before and after cholecalciferol using Strontium as a surrogate. Increase in 25OHD, lowering of iPTH with no effect on Sr absorption was seen, suggesting the possibility that maximal Ca absorption had already been achieved in these volunteers.

INTRODUCTION

This paper discusses the determination of calcium (Ca) absorption, using strontium (Sr) as a surrogate, before and after a single IM injection of vitamin D(3) (600,000 IU).

METHODS

Baseline serum 25-hydroxyvitamin D (25OHD), Sr, Ca, P, and intact parathyroid hormone (iPTH) were determined in 53 fasting volunteers, followed by administrating (PO) 0.03 mM (4.8 mg/kg) SrCl(2) and collecting blood at 0.5, 1 and 4 h to determine the absorption (AUC(0 → t )) of Sr. Following the initial absorption test, volunteers received a single IM injection of 600,000 IU vitamin D(3). Two months later, the fasting serum and the Sr absorption test were repeated, as described above.

RESULTS

The IM injection of vitamin D(3) caused a significant increase in fasting 25OHD (from 43.5 ± 19 to 66.1 ± 19.1 nmol/L (p < 0.001)) and a trend toward lower serum iPTH (from 59.8 ± 27.8 to 53 ± 31 ng/L). Fasting serum Ca and P remained unchanged. A higher 25OHD level failed (p = 0.32) to translate into a higher rate of Sr absorption. AUC(0 → 4 h) were almost identical before and after the IM injection of vitamin D(3).

CONCLUSION

A single vitamin D(3) injection of 600,000 IU significantly increase mean 25OHD concentration and tended to lower iPTH concentrations in volunteers with initially low 25OHD status, suggesting to utilize this simple form of treatment to improve vitamin D status and to have a possible biological effect on Ca homeostasis. However, we found no obvious effect on Sr absorption, suggesting the possibility that maximal vitamin D-dependent Ca absorption had already been achieved in these volunteers at a lower vitamin D status.

Radiological hazards due to naturally occurring radionuclides in the selected building materials used for the construction of dwellings in four districts of the Punjab Province, Pakistan

This paper presents the finding of a study undertaken to determine the naturally occurring radionuclides present in commonly used building materials for dwellings and workplaces in four districts of the Punjab Province, Pakistan. The concentrations of (226)Ra, (232)Th and (40)K were measured by using gamma-ray spectroscopy. A total of 80 samples of building materials were collected from various manufacturers and suppliers of the studied area. The specific activities of (226)Ra, (232)Th and (40)K were measured in building samples, and results ranged from minimum values of 9 ± 1, 9 ± 2 and 27 ± 8 Bq kg(-1) to maximum values of 106 ± 5, 133 ± 5 and 914 ± 21 Bq kg(-1) with mean values of 42 ± 3, 48 ± 3 and 376 ± 16 Bq kg(-1), respectively. From the measured activity concentrations, equivalent radium (Ra(eq)), terrestrial absorbed dose rate, annual effective dose as well as external and internal hazard indices were calculated and found to range from 52 ± 7 to 274 ± 15 Bq kg(-1), 23 ± 3 to 130 6 nGy h(-1), 0.15 ± 0.02 to 0.80 ± 0.03 mSv, 0.14 ± 0.02 to 0.75 ± 0.04 and 0.2 ± 0.02 to 0.98 ± 0.05, respectively. These results were comparable to the results of similar studies undertaken locally and in other countries. The samples considered were safe for use in construction of dwellings in the study area and do not pose any significant source of radiation hazard.

Contrasting views of animal healthcare providers on worm control practices for sheep and goats in an arid environment

A questionnaire survey was conducted to determine the worm control practices and anthelmintic usage of 150 key respondents involved in sheep and goat production in the arid Thal area of Pakistan. The information was collected by visiting farms, and interviewing the key respondents which included veterinary officers (n = 15), veterinary assistants (n = 51), traditional practitioners (n = 24), and small and large scale sheep/goat farm herders and owners (n = 60). Among all interviewed animal healthcare providers, the veterinary officers had the highest level of awareness of parasitic infection and advocated the use of modern available anthelmintics according to the predefined schedule. The farmers on the other hand, had the lowest level of knowledge about parasitic infections. They used modern anthelmintics at low frequencies (every six months) following an unusual practice of diluting the medicine. Veterinary assistants had a medium level of awareness about the parasitic infections using anthelmintic treatments when they deemed necessary rather than following a predefined treatment schedule. Traditional practitioners were also aware of parasitic infections and used traditional anthelmintics or a combination of the traditional and modern anthelmintics. The animal health providers had a different awareness and knowledge of parasitic infections which resulted in contrasting proposals for its' control. The farmers used worm control measures in accordance with their own views and those of animal healthcare advisors, combining modern and traditional treatments. This study provides the first insight into the differing views of those animal healthcare providers who form the basis for effective parasitic control within the sheep and goat industry of an arid region.

Variation in the cellular localization of host-protective oncospheral antigens in Taenia saginata and Taenia solium

Immunohistochemistry and immunofluorescence with confocal microscopy were used to localize the host-protective antigens of Taenia saginata (TSA9 and TSA18) and Taenia solium (TSOL16, TSOL18 and TSOL45). In nonactivated oncospheres, TSA9 and TSOL45 antigens were found primarily in the cytoplasm of the penetration gland type one (PG1) cell. A similar pattern of staining was seen for TSOL45 in oncospheres of T. solium that remained within the oncospheral membrane. In addition, there was less intense staining of TSA9 and TSOL45 in the quadri-nucleate penetration gland type 2 (PG2) cell. TSA18, TSOL16 and TSOL18 were predominantly found in the PG2 cell. In activated oncospheres that had escaped the oncospheral membrane, the antigens (other than TSA9) were seen both in the penetration gland cell locations and throughout the oncospheral parenchyma. Co-localization analyses revealed that only TSOL16 and TSOL18 antigens were co-localized in the PG2 cell of oncospheres that had not escaped the oncospheral membrane. However, in activated oncospheres that escaped the oncospheral membrane, all three antigens of T. solium were co-localized as they were present throughout the parenchyma. No positive staining was observed on the surface of nonactivated or recently activated oncospheres of T. saginata or T. solium.

Antimicrobial and cytotoxic activity of the alkaloids of Amlaki (Emblica officinalis)

Alkaloids are important sources of drug that's why we have conducted our research to find out the biological activity of the alkaloids of a plant that is the Amlaki. Alkaloids were extracted from the methanolic extract of the fresh ripe fruits of Amlaki (Emblica officinalis) through solvent-solvent partitioning method with n-hexane and chloroform. The chloroform soluble fraction of the crude methanolic extract of the ripe fruits of Amlaki containing alkaloids was subjected to antimicrobial activity and brine shrimp lethality bioassay for observing cytotoxic activity. The chloroform soluble fraction of the methanolic extract exhibited significant antimicrobial activity against some Gram positive and Gram negative pathogenic bacteria and strong cytotoxicity having a LC50 of 10.257 +/- 0.770 microg mL(-1). It is concluded that the chloroform soluble fraction of the ripe fruits of Amlaki containing alkaloids are biologically active.

Environmental gamma radiation measurement in district Swat, Pakistan

External exposure to environmental gamma ray sources is an important component of exposure to the public. A survey was carried out to determine activity concentration levels and associated doses from (226)Ra, (232)Th, (40)K and (137)Cs by means of high-resolution gamma ray spectrometry in the Swat district, famous for tourism. The mean concentrations for (226)Ra, (232)Th and (40)K were found to be 50.4 +/- 0.7, 34.8 +/- 0.7 and 434.5 +/- 7.4 Bq kg(-1), respectively, in soil samples, which are slightly more than the world average values. However, (137)Cs was only found in the soil sample of Barikot with an activity concentration of 34 +/- 1.2 Bq kg(-1). Only (40)K was determined in vegetation samples with an average activity of 172.2 +/- 1.7 Bq kg(-1), whereas in water samples, all radionuclides were found below lower limits of detection. The radium equivalent activity in all soil samples is lower than the limit set in the Organisation for Economic Cooperation and Development report (370 Bq kg(-1)). The value of the external exposure dose has been determined from the content of these radionuclides in soil. The average terrestrial gamma air absorbed dose rate was observed to be 62.4 nGy h(-1), which yields an annual effective dose of 0.08 mSv. The average value of the annual effective dose lies close to the global range of outdoor radiation exposure given in United Nations Scientific Committee on the Effects of Atomic Radiation. However, the main component of the radiation dose to the population residing in the study area arises from cosmic ray due to high altitude.

Metabolic risk factors, insulin-resistance and lifestyle in children of type 2 diabetes patients in Karachi, Pakistan

AIMS

To assess metabolic risk factors, insulin-resistance and lifestyle in children aged 8-20 years of patients with type 2 diabetes and to compare these with children aged 8-20 years of non-diabetic subjects.

METHODS

Case-control study. Data were collected from 37children/adolescents of type 2 diabetes patients and 37 controls from parents without diabetes. Variables included physical activity, diet, socioeconomic class, family history, ethnic background, anthropometric measures, blood pressure and fasting glucose and insulin.

RESULTS

Groups were comparable for age and gender. Differences between cases and controls were found for BMI (22.6 vs. 19.1kg/m(2), p=0.004), waist circumference (70.1 vs. 62.1cm, p=0.014), systolic blood pressure (104.5+/-15.1 vs. 97.9+/-13.4mmHg, p=0.05), diastolic blood pressure (66.2+/-10.9 vs. 60.7+/-10.1mmHg, p=0.025). Vegetable intake (3% of cases having two and 19% one full serving a day vs., respectively, 14% and 32% amongst controls, p=0.01) was less favourable in cases, and physical activity tended to be (5h vs. 9h/week, p=0.065).

CONCLUSIONS

Children of type 2 diabetes patients have higher BMI and blood pressure than controls but also lead a less healthy lifestyle. This suggests that both genetic and lifestyle factors contribute to the increased risk of metabolic syndrome in children and early preventive measures towards changing lifestyle could help in prevention.

Sixty-minute post-Synacthen serum cortisol level: a reliable and cost-effective screening test for excluding adrenal insufficiency compared to the conventional short Synacthen test

INTRODUCTION

Previous studies have indicated that most individuals reach peak cortisol levels in 60 minutes during the short Synacthen test (SST) done to exclude adrenal insufficiency. Therefore, measuring serum cortisol at only 60 minutes may suffice. This study was carried out to evaluate the significance of the 60-minute serum cortisol level in SST as a reliable and cost-effective screening test in comparison to the conventional SST.

METHODS

A cross-sectional study was conducted from January 2000 to September 2004, in which data was collected by reviewing medical records of all patients who underwent SST at the Aga Khan University Hospital, Karachi. A total of 236 patients suspected of having adrenal insufficiency were included. Values of serum cortisol at baseline, 30 and 60 minutes post-250 ug-injection Synacthen were recorded. The cortisol level was measured through fluorescence polarisation immunoassay. The cut-off value of 20 ug/dL was used to differentiate normal individuals from hypoadrenal individuals.

RESULTS

Out of 236 study participants, 93 (39 percent) were males and 143 (61 percent) were females. The mean age and standard deviation was 44.4 +/- 21 years. Cortisol concentration increased significantly from baseline to 30 minutes and 60 minutes after injecting Synacthen (p-value is less than 0.001 for each). The majority of the patients reached the cortisol peak of greater than 20 ug/dL (555 nmol/L) at 60 minutes. Normal responses were found in 148 patients (63.1 percent) at both 30 and 60 minutes, while 27 participants (12 percent) reached a peak greater than 20 ug/dL (555 nmol/L) at 60 minutes but were less than 20 ug/dL (555 nmol/L) at 30 minutes. In the deficient cases, SST showed abnormal responses in 60 cases (25 percent) at both 30 and 60 minutes. However, there was only one patient who reached a peak value of 21 ug/dL (589 nmol/L) at 30 minutes, which reduced to 17 ug/dL (485 nmol/L) at 60 minutes.

CONCLUSION

This study showed that a 60-minute cortisol value during SST was reliable enough in identifying normal subjects for excluding adrenal insufficiency, and was equally effective in identifying abnormal cases, as compared to values at both 30 and 60 minutes. It is therefore suggested that a single 60-minute post-Synacthen serum cortisol level may suffice, as compared to the conventional SST. This is also significant as a cost-effective measure, especially in third world countries where cost is a major issue for diagnosing and treating patients.

Effect of aniline coupling on kinetic and thermodynamic properties of Fusarium solani glucoamylase

Purified glucoamylase (GA) from Fusarium solani was chemically modified by cross-linking with aniline hydrochloride in the presence of 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) for 1 [aniline-coupled glucoamylase-1 (ACG-1)], 7 (ACG-7), and 13 min (ACG-13). The aniline coupling of GA had a profound enhancing effect on temperature, pH optima, and pK (a)'s of active site residues. The specificity constants (K (cat)/K (m)) of native, ACG-1, ACG-7, and ACG-13 were 136, 244, 262, and 208 at 55 degrees C for starch, respectively. The enthalpy of activation (DeltaH*) and free energy of activation (DeltaG*) for soluble starch hydrolysis were lower for the chemically modified forms compared to native GA. Proteolysis of ACGs by alpha-chymotrypsin and subtilisin resulted in activation.

Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients with co-existing diabetes mellitus

A review was made of the records of all patients with pulmonary tuberculosis and diabetes mellitus admitted over a 5-year period to a teaching hospital in Karachi, Pakistan. Among 42358 patients, the total number with both tuberculosis and diabetes was 173. The prevalence of tuberculosis in diabetic patients was 10-times higher than in non-diabetic patients and prevalence increased with duration of diabetes. The lower lung field was most frequently involved, followed by the upper and middle. Bilateral involvement was seen in half and an associated pleural effusion in one-third of the patients. Cavitating lesions were seen in 32% of men and 15% of women.

Needles and needleless devices for infusion of anti-haemophilic factor concentrate: impact on protein structure and function

A poor response to the infusion of anti-haemophilic factor (AHF) concentrates used to control acute bleeding or prevent haemorrhage during surgery may have many causes, including the lack of functional activity of the infused protein concentrate. It is generally recommended to follow the manufacturers' instructions when administering the factor intravenously. For convenience, infusion sets with 23 gauge butterfly needles are packaged with the major brands of AHF concentrate. In hospitals, blunt connectors for i.v. infusion are becoming more prevalent to reduce the risk of needle stick injuries to both patients and hospital staff. The integrity of AHF infused using such devices has not been examined. We examined the possibility that passage of complex proteins such as AHF through such devices may result in alteration of the protein, rendering it inactive. The results presented here suggest that this is not the case; neither the structure nor the function of AHF protein products was adversely affected by the use of the needleless transfer device (NTD) or the needle types and sizes commonly used in clinical practice. Samples of factor VIII and factor IX AHF concentrate were passed through the B-D Blunt Plastic Cannula or 23, 27 and 30 gauge needles. No significant changes in electrophoretic mobility or coagulation activity were detected. Samples generally showed slightly increased coagulation activity when compared with the control in which the sample was passed directly out of the syringe with no device attached. These data indicate that the NTD and various needle gauges are acceptable for the infusion of AHF concentrate in a clinical setting. Furthermore, the use of small gauge needles has advantages that may improve adherence to rigorous factor replacement programmes.

Stab to second intercostal space: a bubbling extrapleural wound

A 37 year old man was found collapsed at the roadside and taken to the emergency department. Communication was difficult, as the patient could not speak English. There was a wound in the left second intercostal space on the midclavicular line, which was bleeding and was bubbling air. A drain was inserted, bleeding controlled, and his wounds sutured. Chest x ray later confirmed satisfactory placement of the drain. The following day, swelling and discharge indicated oesophageal damage, which was later confirmed by gastrografin swallow. With conservative management in hospital for 2 weeks, he made a full recovery and was discharged.

Clinical presentation of thyroid cancer patients in Pakistan--AKUH experience

OBJECTIVE

To asses the clinical presentation of patients with thyroid cancer, their preferred diagnostic work-up and preferred surgical procedure.

METHODS

A retrospective chart review of patients that underwent partial or total thyroidectomy for thyroid cancer at AKUH between 1989 and 2002. SPSS was used to analyze data. Pearson's chi square and likelihood ratios used to calculate tests of significance.

RESULTS

A total of 97 patients were included in this review. Solitary thyroid nodule was the initial presentation in three. Majority (58.7%) presented with "neck swelling" or enlarging goiter. One out of every 3 patients showed evidence of lymph node involvement and 20% had distant metastases. The aggressiveness of the disease did not correlate with age, sex or histological subtype. There was no correlation between the size of the tumor and presence of local or distant metastases.

CONCLUSION

Thyroid cancer is a more aggressive disease in Pakistan, with majority of patients presenting with multinodular goiters, and a significant number have lymph node metastases. A higher degree of vigilance and a lower threshold for fine needle aspiration (FNA) is needed while evaluating patients with thyroid goiter.

Clinical characteristics and outcomes of diabetic ketoacidosis in Pakistani adults with Type 2 diabetes mellitus

AIMS

The aim of this study was to describe the clinical characteristics and outcomes of diabetic ketoacidosis (DKA) in Pakistani adult population with Type 2 diabetes mellitus.

METHODS

We reviewed the medical records of all adult patients admitted with a diagnosis of DKA and Type 2 diabetes mellitus (DM) and followed their clinical course and outcome. Follow-up data were obtained by chart review or telephone contact where necessary.

RESULTS

Fifty-seven patients fulfilled criteria for inclusion in the study. Their mean age was 48 +/- 7 years. The mean body mass index was 25.5 +/- 6.2 kg/m2. Forty-nine had a prior history of Type 2 DM but DKA was the initial presentation in 14%. Nine were on no treatment, 40 were using oral hypoglycaemic agents and eight were on insulin. A history of prior DKA was noted in eight patients. Infections were the most common precipitating factor (63%). There were 12 deaths. Follow-up after a period ranging between 12 and 43 months revealed that 30/45 patients remained on OHA without recurrence of DKA.

CONCLUSION

This report highlights the need for the growing recognition of DKA occurring in adults with Type 2 DM in the South Asian population. Mortality rates are unacceptably high but the majority of survivors remain insulin independent.

Clinical features and outcome of surgery in 30 patients with acromegaly

OBJECTIVE

To assess the surgical outcome of hypophysectomy in acromegalic patients, differences in response to surgery in micro and macroadenoma and the development of associated hormonal deficiency after surgery.

METHODS

Retrospective analysis of charts of acromegalic patients who were operated upon at Aga Khan University Hospital, Karachi, was done. Information regarding presentation, laboratory data, radiological assessment, details of surgery and postoperative outcome was recorded. Surgical outcome was classified depending on the degree of disease control after surgery as biochemical cure, remission and treatment failure.

RESULTS

Out of 30 patients, eighteen (60%) were males and 12 (40%) females with mean age at the time of diagnosis 35.6+/-10.4 years. The mean duration of symptoms was 3.2+/-2.4 years. Twenty-five patients had macroadenoma and five had microadenoma. Preoperative mean GH level was 42.4 ng/ml with range of 2.5 to 534 ng/ml. Following surgery, 13 had biochemical cure, 4 were in remission and 13 failed to respond. The outcome in microadenoma was better than in macroadenoma i.e. 100% vs. 32%. Preoperatively four patients had panhypopituitarism with additional six patients (20%) developing hypopituitarism postoperatively.

CONCLUSION

Our study showed that acromegaly was seen at a much earlier age, outcome of surgery was comparable to other international studies and postoperative panhypopituitarism was seen in significant number of patients. The outcome in microadenoma was better than in macroadenoma but the number of patients seen with microadenoma was small.

Kinetics of enhanced thermostability of an extracellular glucoamylase from Arachniotus sp

Purified extracelluar glucoamylase from Arachniotus sp. was used for kinetic and thermodynamic characterization. Thermal inactivation followed first order kinetics. The denaturation/activation energies of enzyme were 57 and 89 kJ mol(-1), respectively. Both enthalpy and entropy of activation for inactivation were lower than those for glucoamylases reported in literature. It is suggested that the enzyme is highly thermostable and is suitable for industrial applications.

Pharmacokinetics and tolerability of a bioadhesive buccal testosterone tablet in hypogonadal men

OBJECTIVE

A phase I single centre, open label study of the pharmacokinetics and tolerability of a buccal testosterone tablet (COL 1621) was carried out.

DESIGN

Twelve testosterone-deficient males were treated with the buccal tablet twice daily for 7 consecutive days. Multiple blood samples were drawn for testosterone, dihydrotestosterone (DHT), bioavailable testosterone and sex hormone-binding globulin (SHBG).

RESULTS

After COL 1621, means+/-S.D. serum testosterone level increased to a peak concentration of 26.6+/-5.8 nmol/l (7.7+/-1.7 ng/ml) at 4.8+/-5.8 h and stayed in the eugonadal range. Steady state was achieved within the first 24 h and was maintained in the normal range. The bioavailable testosterone, DHT and free testosterone index followed a pattern very similar to that of testosterone. The mean serum testosterone to DHT ratio was within the normal male range throughout treatment. There was only one treatment-related adverse event (headache). Two-thirds of patients indicated that treatment with COL 1621 was acceptable and that the tablet was convenient to use. Six patients (50.0%) preferred COL 1621 to their previous testosterone replacement therapy, two patients gave preference to their previous treatment and three patients found both treatments to be equally acceptable. Data for one patient was not available.

CONCLUSION

We conclude that COL 1621 can efficiently elevate serum testosterone and DHT levels in hypogonadal men within the first day of application, achieve a steady state within 24 h and maintain serum testosterone in the normal range with a twice-daily treatment regimen. COL 1621 provides an effective alternative oral testosterone replacement therapy that gives physiological levels of testosterone and is well tolerated by the patients.

Treatment of type 1 diabetes with insulin lispro during Ramadan

OBJECTIVE

To compare insulin lispro with regular human insulin with respect to blood glucose control and frequency of hypoglycaemia in patients with type 1 diabetes who wished to fast during the month of Ramadan.

RESEARCH DESIGN AND METHODS

Insulin lispro or regular human insulin was given together with NPH insulin, twice daily before the morning and evening meals, for two weeks each in an open-label, randomised, cross-over design, and 64 patients completed the protocol. Blood glucose was self-monitored at fasting morning and evening, and 1-h and 2-h after the post-sunset meal on three consecutive days at the end of each treatment period.

RESULTS

The 2-h blood glucose excursion after the post-sunset meal was significantly (p=0.026) lower with insulin lispro (2.50 +/- 0.46 mmol/l) than with regular human insulin (3.47 +/- 0.49 mmol/l). Daily insulin doses did not differ between treatments but compliance with recommended time of injection was better with insulin lispro. Hypoglycaemia incidence (insulin lispro, 15 (23.4%) patients; regular human insulin 31 (48.4%) patients; p=0.004) and frequency (insulin lispro, 0.70 +/- 0.19; regular human insulin 2.25 +/- 0.36 episodes/patient/30 days; p<0.001) were lower with insulin lispro. Five (22.7%) of the episodes during insulin lispro occurred during the nocturnal period compared with 27 (36.5%) of the episodes while on regular human insulin.

CONCLUSIONS

Glycaemic control, measured by postprandial glycemic excursions, was improved and hypoglycaemia was significantly reduced with insulin lispro compared with regular human insulin. Patients with type 1 diabetes who insist on fasting during Ramadan may be better managed with insulin lispro.

Standard of knowledge about their disease among patients with diabetes in Karachi, Pakistan

OBJECTIVE

The aim of this study was to determine the standard of knowledge among people with diabetes.

METHOD

Two hundred and thirty patients were randomly chosen from outpatient clinics and a 34-item multiple choice questionnaire administered to them. The questionnaire was structured to assess knowledge about the disease state, diagnostic tests, complications and management.

RESULTS

The average score of correct answers for the group was 40%. A significantly higher score correlated with younger age (16-30 years), educational status and regular follow-up with a diabetic clinic. There was no significant difference in the knowledge score between males and females or between those on oral hypoglycemic agents (OHA) and insulin. Fifty percent of the patients could correctly answers questions regarding food and nutrition and only 60% were aware of target blood glucose levels for optimal control. It was alarming to learn that 75% of those on insulin did not know that using U-40 or U-100 insulin does not change the dose required.

CONCLUSION

The study emphasizes the need for diabetes education at all levels, both for the patients as well as the health care providers to counter the pandemic of diabetes-related complications globally.

Antibacterial activity of Barringtonia racemosa

The antibacterial activity of the ethanol extract of Barringtonia racemosa roots, its chloroform soluble fraction and, a there from an isolated clerodane diterpenoid is reported.

Plastination of whole brain specimen and brain slices

BACKGROUND

The human dead body specimens are plastinated for teaching purposes in medical institutions, using silicone. The silicone impregnated whole brain specimens and brain slices do not give satisfactory results.

METHODS

In the present study the brain specimens were plastinated with another polymer known as Polyester-Copolymer. The brain specimens were first preserved and then fixed with 5% formalin. The specimens were then dehydrated and degreased in a volatile solvent acetone. The specimens were placed in Polyester-Copolymer solution which penetrated the brain tissue both intracellulary and intercelluraly. The specimens were then cured by gas method.

RESULTS

The whole brain specimens and brain slices plastinated with Polyester-Copolymer were dry, odorless, handy and durable. It also gives a clear visual contrast between grey and white matter in brain slices whereas the brain specimens plastinated with silicone are flexible and sticky. There was no color contrast between grey and white matter.

CONCLUSION

The polyester impregnated brain specimens and slices are non-toxic and ideal for teaching purposes and examinations. They require minimal aftercare. The whole organ serial sections of plastinated brain specimens will help 3-dimensional study of the normal brain and will improve the assessment of brain pathology.

Antiulcer activity of Mikania cordata

The alkaloidal fraction obtained from an ethanolic extract of the leaves of Mikania cordata exhibited significant in vivo antiulcer activity in diclofenac sodium-induced gastric erosions in Long Evans rats.