OP0154 COMORBIDITY CLUSTERS IN ANKYLOSING SPONDYLITIS AND THEIR ASSOCIATION WITH DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT: DATA FROM THE PSOAS COHORT

Background

Comorbidities in ankylosing spondylitis (AS) occur more frequently than in the general population and are associated with higher morbidity and mortality. Some comorbidities may occur together, making one more likely in the presence of another, and different combinations of comorbidities may have differential considerations for AS management and outcomes.

Objectives

To examine the association of baseline comorbidities with disease activity and functional status in AS.

Methods

We used baseline data from the Prospective Study Of Ankylosing Spondylitis (PSOAS) cohort, a multicenter, prospective cohort from five centers (4 in the US, 1 in Australia). AS patients ≥ 18 years fulfilling mNY criteria for AS (2002-20) were included. Patient-reported AS comorbidities (N=28) and extra-musculoskeletal manifestations (EMMs, N=2) within 3 years of enrollment (prespecified on the baseline case-report form) and only those occurring in ≥1% were included. Undocumented comorbidities were assumed to be absent if missing in <15% of patients, and those missing in >50% of patients were excluded. Comorbidity clusters were identified using K-median clustering. The optimal number of clusters was determined using scree plot of the sum of squared errors and “elbow” on the graph line. Baseline characteristics of the clusters were compared, and associations of with disease activity and functional status measures (primary outcomes: ASDAS-CRP and BASFI) were examined using linear regression adjusted for age and sex.

Results

There were 1,270 AS patients included with a mean age of 44.6 ±14.3 years, 74.4% males, and 81.2% whites. Mean AS symptom duration was 20.6±5.6 years, 81.6% HLA-B27 positive, and CRP elevated in 27.5% of patients at baseline. Depression was the most prevalent comorbidity (31.4%) followed by hypertension (26.1%); uveitis was the most common EMM (30.4%). The five clusters identified included depression (27%), no comorbidities (22%), hypertension (21%), uveitis (20%), and asthma/low bone mass (10%) (Figure 1). The cluster with no comorbidities was significantly younger, with lower symptom duration (p<0.001). Females had higher odds of being in the depression (OR=2.00, 95% CI 1.38- 2.90) and uveitis (OR=2.09, 95% CI 1.41-3.11) clusters compared to the cluster with no comorbidities. The number of comorbidities and clusters with depression and hypertension were significantly associated with worse disease activity and functional status (Table 1).

Table 1.

Age and sex adjusted associations between comorbidity clusters, compared to cluster 3, and baseline disease activity/ functional status measures in ankylosing spondylitis based on Linear regression models.

Cluster 1 (depression)Cluster 3 (hypertension)Cluster 4 (uveitis)Cluster 5 (asthma, low bone mass)OutcomesCoef (95% CI)Coef (95% CI)Coef (95% CI)Coef (95% CI)ASDAS-CRP0.98 (0.78-1.18)0.43 (0.18-0.68)0.04 (-0.19-0.27)0.16 (-0.12-0.44)BASFI (0-10)1.92 (1.51-2.34)1.00 (0.53-1.48)-0.03 (-0.49-0.42)0.64 (0.076-1.20)Enthesitis count1.17 (0.73-1.61)0.73 (0.19-1.26)0.18 (-0.32-0.68)0.48 (-0.13-1.08)Swollen joint count (0-44)0.27 (-0.08-0.62)0.43 (-0.01-0.86)0.31 (-0.09-0.71)-0.95 (-0.58-0.39)Tender joint count (0-46)1.24 (0.59-1.88)0.44 (-0.34-1.23)0.56 (-0.18-1.29)0.34 (-0.55-1.23)BASDAI (0-10)2.30 (1.88-2.71)0.88 (0.36-1.40)0.30 (-0.17-0.78)0.61 (0.03-1.19)Patient Global (0-10)2.25 (1.82-2.68)0.76 (0.21-1.30)-0.22 (-0.71-0.27)0.29 (-0.31-0.89)Patient Pain (0-10)2.45 (1.95-2.94)1.00 (0.37-1.62)0.19 (-0.38-0.75)0.16 (-0.54-0.85)Spinal pain (0-10)2.40 (1.89-2.91)1.05 (0.41-1.70)0.43 (-0.16-1.01)0.76 (0.04-1.47)Figure 1.

Comorbidity clusters in PSOAS cohort at baseline

Conclusion

Distinct comorbidity clusters were identified in AS patients in the PSOAS cohort. In addition to the number of comorbidities, the type of comorbidity seems to be important. Depression and hypertension clusters seem to be associated with worse disease activity and function.

Disclosure of Interests

Paras Karmacharya: None declared, Cynthia S. Crowson: None declared, Dilli Poudel: None declared, John M Davis III Consultant of: Dr. Davis has received consulting fees and/or honoraria from AbbVie and Sanofi-Genzyme (less than $10,000 each), Grant/research support from: Dr. Davis has received research support from Pfizer., Alexis Ogdie Consultant of: Dr. Ogdie has served as a consultant for AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB (less than 10,000 each), Grant/research support from: Dr. Ogdie has received grants from Novartis and Pfizer to Penn and from Amgen to Forward (grants more than 10,000)., Jean Liew Grant/research support from: Dr. Liew received grant/research support from Pfizer (> $10,000), Michael Ward: None declared, Mariko Ishimori: None declared, Michael Weisman Consultant of: Dr. Weisman received consulting fees for Novartis, UCB, Gilead, and GSK (< $10,000)., Matthew Brown: None declared, Mohammad Rahbar: None declared, Mark Hwang: None declared, John D Reveille Consultant of: JDR received consulting fees for UCB (< $10,000), Grant/research support from: Dr. Reveille received research support from Lilly and Janssen unrelated to this work., Lianne S. Gensler Consultant of: Dr. Gensler has received consulting fees for AbbVie, Eli Lilly, GSK, Gilead, Pfizer (< $10,000)., Grant/research support from: Dr. Gensler received grant/research support from UCB and Novartis (> $10,000).

Sonodynamic therapy and common head and neck cancers: in vitro and in vivo studies

Carcinogenesis is a complex multi-stage process associated with abnormal oncogenic signals in various signaling pathways. HNSCC (Head and neck squamous cell carcinoma) includes the majority of head and neck cancers (HNC). Also, HNSCC indicates a tumors heterogeneous group that derives from the squamous epithelium of the oropharynx, hypopharynx, oral cavity, and larynx. The main cancer management approach contains chemotherapy, radiation, and surgery separately or in combination. Each therapeutic approach has a limitation that influences cancer therapy procedures. Different treatment manners, stimuli-responsive therapeutic methods can improve on-target responses and reduce side effects. Sonodynamic therapy (ST) shows promising potential as an alternative treatment for cancer in the last few years. There is a hypothesis that shows ST using sonosenitizer in combination with low-intensity ultrasound (LIUS) could be useful in all kinds of cancer without focusing on specific target proteins, molecules, and/or genes. This review study discussed the application of ST for the treatment, ST mechanisms, and also, advances in the treatment of HNCs approaches in the recent decades.

POS0904 FACTORS ASSOCIATED WITH SWITCHING FROM ONE ANTI-TNF AGENT TO ANOTHER ANTI-TNF, OR IL17 AGENT IN PATIENT WITH ANKYLOSING SPONDYLITIS

Background:

A recent study examining Commercial Claims Insurance database found that many patients with ankylosing spondylitis (AS) do not remain on their initial TNF inhibitor two years after initiation, particularly women and those taking opioids.

Objectives:

To examine factors associated with switching from one TNF inhibitor (i)agent to either another TNFi, IL-17i or JAKi over time (at <2years and >2 years) in a longitudinal cohort of AS patients.

Methods:

Patients enrolled in the Prospective Study of Outcomes in AS (PSOAS), an observational longitudinal study of predictors of AS severity operative since 2002-2020 including over 1250 patients meeting modified New York criteria. Data collected included age, gender, ethnicity, HLA-B27 status, disease activity (BASDAI or ASDAS), erythocyte sedimentation rate (ESR), C-reactive protein (CRP), disease severity,(functional (BASFI) or radiographic (mSASSS)), comorbidities, smoking, exercise, disease duration, depression (either by self report or by the Center for Epidemiologic Studies Depression Scale (CES-D) and other medication usage (NSAIDs, including the NSAID index, nonbiologic DMARDs, opioids, anti-depressants, anxiolytics and hypnotics). Logistic regression models were built to identify clinical and sociodemographic characterstics associated with medication switching to another TNFi, IL-17i, or other biologic therapy (another TNFi, Il-17i, or JAKi) within 2 years and after 2 years of initiation).

Results:

Of those patients in PSOAS who had at least two years of follow-up, 496 were prescribed anti-TNF, 34 anti-IL-17 and 3 anti-JAK agents. According to the multinomial logistic regression analysis, patients who switched from their original TNFito another TNFi, IL-17i or JAKi within two years after initiating their original TNFi were more likely to be older, have higher baseline subjective disease activity (BASDAI), less radiographic severity by MSASSS, exercise > 120 minutes/week and less likely to be currently smoking. Patients who switched after two years were less likely be depressed, had shorter disease duration, had greater subjective disease activity, were more likely to be exercising > 120 minutes/week, and had more comorbidities.

Conclusion:

Different factors were encountered in AS patients who switched from their initial TNFi to another TNFi, IL-17i or JAKi within 2 years versus after 2 years of treatment.

Table 1.

Factors Associated With Switching From One TNFi To A Second TNFi or IL-17i or JAKi Before or After Two Years Based On Multinomial Logistic Regression Model (N=496 Patients)

VariableSwitched within 2 years vs. not switchedp-value*Switched after 2 years vs. not switchedp-value*Gender (Male vs. Female)0.99(0.637, 1.549)0.980.95 (0.528, 1.719)0.87HLA-B27_(+ vs. -)0.99 (0.639, 1.523)0.950.66 (0.365, 1.192)0.17Depression (CESD≥ 16 or self-report)(Yes vs. No)0.99 (0.676, 1.445)0.950.35 (0.182, 0.672)0.002Disease duration at baseline (≥20 vs. <20 years)0.72 (0.485, 1.062)0.100.27 (0.146, 0.491)<0.001Age at baseline (≥40 vs. <40) (years)2.00 (1.291, 3.101)0.0021.23 (0.693, 2.193)0.48CRP (≥0.8 vs. <0.8)1.94 (1.230, 3.056)0.0040.90 (0.454, 1.789)0.77BASFI (≥40 vs. <40)1.34 0.852, 2.118)0.200.87 (0.450, 1.688)0.68BASDAI (≥4 vs. <4)1.73 (1.064, 2.797)0.032.31 (1.202, 4.427)0.01NSAID index (≥50 vs. <50)1.32 (0.822, 2.128)0.250.83 (0.437, 1.586)0.58NSAIDs used (Yes vs. No)0.84 (0.534, 1.309)0.430.85 (0.479, 1.510)0.58Exercise (≥120 vs. <120) (minutes/week)1.95 (1.396, 2.731)<0.0011.66(1.057, 2.613)0.03ASDAS (≥3 vs. <3)0.78 (0.454, 1.356)0.391.07 (0.478, 2.399)0.87Number of comorbidities (≥2 vs. <2)1.40 (0.997, 1.951)0.051.63 (1.029, 2.575)0.04mSASSS (≥4, vs. <4)0.63 (0.421, 0.957)0.030.81(0.474, 1.392)0.03Current smoker (Yes vs No)0.69 (0.385, 1.225)<0.0010.79 (0.297, 2.076)0.20

*p-values calculated based on multinomial logistic regression model when switching is defined as being prescribed a second TNFi or taking IL-17i or JAKi before or after 2 years from first TNFi initiation

Disclosure of Interests:

Mark Hwang Consultant of: UCB, Novartis, Michael Weisman Consultant of: Novartis, GSK, UCB, Lilly, Lianne S. Gensler Consultant of: AbbVie, GlaxoSmithKline, Eli Lilly, Novartis, Pfizer, UCB Pharma, Amirali Tahanan: None declared, Mariko Ishimori: None declared, Theresa Hunter Employee of: Eli Lilly, Rebecca Bolce Employee of: Eli Lilly, Jeffrey Lisse Employee of: Eli Lilly, Mohammad Rahbar: None declared, Minyang Shan Employee of: Eli Lilly, John D Reveille Consultant of: UCB, Grant/research support from: Eli Lilly

Intra-hospital dissemination of clinical and environmental isolates of Stenotrophomonas maltophilia from Tehran

Stenotrophomonas maltophilia isolates are responsible for various hospital-acquired infections and are particularly increasing in the immunocompromised patients. The aim of this study was to determine the clonal relatedness between S. maltophilia isolates originating from the clinic and environment. A total of 150 S. maltophilia isolates from patients and 1108 environmental samples obtained in three hospitals from Tehran. Following molecular identification targeting 23S rRNA gene, the clonal relatedness of the environmental and clinical isolates was determined using pulsed field gel electrophoresis (PFGE). Of the 150 clinical and 18 environmental isolates identified using phenotypic tests, the speciation of 120 and 15 was confirmed by targeting the 23S rRNA gene. The 24 common pulsotypes (PTs) and 32 single PTs were identified by PFGE. Only a small cluster was shared among the clinic and environment within a hospital; therefore, the intra-hospital dissemination of certain isolates of S. maltophilia among the clinic and environment was demonstrated.

Serogroups, and drug resistance of nontyphoidal Salmonella in symptomatic patients with community-acquired diarrhea and chicken meat samples in Tehran

BACKGROUND

Salmonella is considered as a main cause of community-acquired diarrhea in humans, however, sources of the multi-drug resistant (MDR) strains and their link with the disease are not well known.

AIMS

This study aimed to investigate the frequency, serogroup diversity, and antimicrobial susceptibility patterns of Salmonella strains in poultry meat and stool samples of patients with community acquired diarrhea in Tehran.

METHODS

We compared the frequency of non-typhoidal Salmonella serogroups, the similarities of their resistance patterns to 10 antimicrobial compounds, the prevalence of extended spectrum β-lactamase (ESBL) and ampicillinase C (AmpC) genetic determinants, and class 1 and 2 integrons in 100 chicken meat and 400 stool samples of symptomatic patients in Tehran during June 2018 to March 2019.

RESULTS

Salmonella was isolated from 75% and 5.5% of the chicken meats and human stool samples, respectively. The chicken meat isolates mainly belonged to serogroup C (88%, 66/75), while the human stool isolates were mainly related to serogroup D (59.1%, 13/22). The MDR phenotype and the most common rates of resistance to antibiotics, including tetracycline, trimethoprim/sulfamethoxazole (TS) and azithromycin, were detected in 4.5% and 45.3%, 59% and 13.6%, 43% and 9.1%, 42% and 9.1% of the human stool and chicken meat samples, respectively. Carriage of bla _CTX, bla _SHV, and bla _PER genes in the meat isolate with ESBL resistance phenotype and bla _ACC, bla _FOX, and bla _CMY-2 among the 7 meat strains with AmpC resistance phenotype was not confirmed using polymerase chain reaction (PCR). High prevalence of class 1 and 2 integrons was characterized and showed a correlation with resistance to TS and chloramphenicol.

CONCLUSION

These findings showed a lack of association between chicken meats and human isolates due to discrepancy between the characterized serogroups and resistance phenotypes.

The Effect of Educational Program Based on the Extended Theory of Reasoned Action on Self-Care Behaviors in Women with Type 2 Diabetes

BACKGROUND AND OBJECTIVE

The aim of this study is to determine the effect of educational program based on the extended theory of reasoned action on self-care behaviours in women with type 2 diabetes in Fasa. This quasi-experimental study was performed on 100 women with type 2 diabetes who referred to diabetes clinics in Fasa.

MATERIALS AND METHODS

Samples were randomly divided into experimental and control groups. The data were collected using a questionnaire based on the extended theory of reasoned action and self-care behaviours that were completed by both the control and experimental groups before and 3 months after the educational intervention. Data were analysed by SPSS software version 22, descriptive statistics tests, Chi-square test, independent T-test, and paired T-test.

RESULTS

The results of the study showed that after the educational intervention, the mean scores of all constructs of the extended theory of reasoned action in the experimental group were significantly increased compared to the control group (P <0.05).

CONCLUSION

Also, the educational intervention had a significant effect on the promotion of patient's self-care behaviours in the experimental group and the HbA1c level decreased in the experimental group compared to the control group (P <0.05). In addition, it was found that the extended theory of reasoned action could be a suitable framework for designing educational interventions for promoting self-care behaviours in diabetic patients.

The Effect of Educational Intervention Based on BASNEF Model on Self-Medication Behavior of Type 2 Diabetic Patients

BACKGROUND

Diabetes is one of the main reasons of the increase of morbidity and mortality around the world. Considering the burden of disease, self-medication can result in irrecoverable consequences. The aim of this study is to investigate the effect of educational intervention based on Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model on self-medication behaviors of type 2 diabetic patients in Fasa, Fars province, Iran, in 2017-2018.

MATERIALS AND METHODS

In this quasi-experimental study, 200 type 2 diabetic patients under cover of the diabetes center of Fasa were investigated (100 patients for experimental group and 100 patients for control group). A questionnaire investigating demographic information and BASNEF Model constructs (knowledge, attitude, enabling factors, subjective norms, and behavioral intention) was used for evaluating self-medication behaviors of patients before and 3 months after intervention.

RESULTS

The average age of experimental group was 53.25 ± 8.42 and the average age of control group was 54.18 ± 8.13. Three months after intervention, experimental group showed significant enhancement in knowledge, attitude, enabling factors, subjective norms, and behavioral intention and their self-medication behaviors reduced, while control group showed no significant changes in mentioned factors.

CONCLUSION

The present study indicated the efficiency of BASNEF model on reduction of self-medication behaviors of diabetic patients. Hence, this model can act as a framework for designing and implementing educational interventions in this field.

Molecular serotyping and genotyping of penicillin non-susceptible pneumococci: the introduction of new sequence types, Tehran, Iran

The emergence of penicillin non-susceptible Streptococcus pneumoniae (PNSP) isolates can pose significant challenges to today's health-care system. Resistant clonal isolates are disseminated in different regions and countries, and this study was focused on the description of the epidemiological spread of these strains. Clinical samples were collected from individuals admitted to hospitals affiliated to the Tehran University of Medical Sciences, Iran. To investigate the molecular characteristics of PNSP isolates, they were subjected to molecular typing using multi-locus sequence typing (MLST). Serotype distributions of S. pneumoniae isolates were also evaluated by multiplex PCR assay. The most prevalent serotypes in the PNSP isolates were 23F, 19F, 14, 3 and 9V. Two isolates were considered as a non-vaccine serotype. The MLST analysis showed that PNSP isolates belonged to five different clonal complexes (CC180, CC217, CC81, CC63 and CC320) and 42% (5/12) of the sequence types were novel (12936, 12937, 12938, 12939 and 12940). This study indicates the high level of heterogeneity that is present among PNSP isolates. Unexpected high genetic diversity in small populations indicates consecutive diversification of resistant strains.

Severity of Mitral Regurgitation before and after Kidney Transplantation

BACKGROUND

Perivalvular and valve involvement are prevalent in patients with end-stage renal disease (ESRD), especially in younger patients compared with normal population. Kidney transplantation improves the prognosis of these patients. Patients with cardiac valvular disease is also be improved following kidney transplantation.

OBJECTIVE

To evaluate the impact of renal transplantation on the severity of mitral regurgitation (MR).

METHODS

We studied 95 kidney transplantation candidates in Sina Hospital. The patients underwent echocardiography preoperatively and at the 3^rd, 6^th, and 12^th months post-operatively.

RESULTS

Pre-operatively, the average MR fraction was 30%; MR volume 30 mL/beat; mitral valve mean gradient 1.8 mm Hg; mitral valve area 4.6 cm²; and mitral annular size 3 cm. No significant difference was observed among the measurements made at the 3^rd, 6^th, and 12^th months post-operatively.

CONCLUSION

There was no significant association between the variables measured pre- and post-operatively. The reason might be the fact that patients with ESRD in Iran do not have to expect long transplant waiting lists and dialysis cannot affect their heart adversely.

Comparative in vitro activity of carbapenems against clinical isolates of Acinetobacter baumannii

AIMS

The aim of this multi-hospital study was to assess the in vitro activity of doripenem and its comparators, imipenem and meropenem, using the new CLSI breakpoints against a large population of a frequently isolated nosocomial pathogen, Acinetobacter baumannii.

METHODS AND RESULTS

During a 2-year period, four referral or tertiary hospitals submitted 400 isolates of Ac. baumannii for susceptibility testing using imipenem, meropenem and doripenem via disc diffusion and E-test methods. A subset of 390 isolates was resistant to all three tested carbapenems. Doripenem and meropenem (MIC50 , 32 μg ml(-1) ) had comparable activity, albeit doripenem's activity was greater than imipenem (MIC50 , >32 μg ml(-1) ). A significantly higher proportion of the isolates were inhibited by doripenem than by imipenem at MIC values of 12, 16, 24 and 32 μg ml(-1) (P < 0·05). The cumulative percentage of imipenem MICs was lower compared to its comparators. The comparison of resistance rate to imipenem and meropenem based on old and new breakpoints showed <1% difference. The overall agreement between the two susceptibility testing methods was ≥95%.

CONCLUSION

Doripenem has a slightly greater in vitro activity than imipenem in terms of zone breakpoints and MIC values, but its activity is comparable to meropenem.

SIGNIFICANCE AND IMPACT OF THE STUDY

Doripenem should be considered as a therapeutic option for monotherapy or combination therapy, particularly when the therapeutic options are limited.

The impact of primer sets on detection of the gene encoding biofilm-associated protein (Bap) in Acinetobacter baumannii: in silico and in vitro analysis

The Acinetobacter baumannii virulence protein Bap is encoded by a large gene and contains both variable sequence and repetitive modules. To date, four primer sets targeting different regions of bap have been designed, but no study has evaluated all these primers simultaneously for detection of bap. Here, we assessed the effect of primer sets Bap I-IV, on detection of bap both in silico and in vitro. Using the primer set Bap II, all 143 tested strains yielded an amplicon corresponding to the bap gene. This primer set showed the highest sensitivity (100, 95% CI: 97·9-100%) compared to the other primer sets. This study demonstrates that primer set Bap II performs with optimal efficiency for detection of the bap gene among different strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study investigated the effect of nucleotide variation on PCR detection of the bap gene in various Acinetobacter baumannii strains. Since bap is the target gene for many detection assays, this variation can affect the detection efficiency. Here we present a primer set Bap II with optimal detection efficiency amongst 143 different strains, as shown by in silico and in vitro evidence.

Trend of extensively drug-resistant Acinetobacter baumannii and the remaining therapeutic options: a multicenter study in Tehran, Iran over a 3-year period

Comprehensive data on drug-resistant patterns of Acinetobacter baumannii isolates in developing countries is limited. We conducted a multihospital study to assess the rate and trend of drug-resistant phenotypes in Ac. baumannii using standardized definitions and to determine the remaining therapeutic options against resistant phenotypes. The 401 nonduplicate isolates were collected from six hospitals which are geographically distributed across Tehran, Iran over a 3-year period. Following PCR of bla_OXA-51-like gene, susceptibility testing was performed against nine antimicrobial agent categories. Three hundred and ninety (97%) isolates were resistant to least two carbapenems; carbapenem-resistant Ac. baumannii. The majority of isolates (366, 91·3%) were extensively drug resistant (XDR) and the rest of the isolates were classified as multidrug resistant (26, 6·8%) and susceptible (9, 2·2%). The rate of XDR-AB slightly decreased from 93·8% in 2011 to 89·8% in 2013. A considerable decrease in resistance to doxycycline, minocycline and tigecycline was demonstrated. The XDR-AB isolates showed susceptibility to gentamicin (10·4%), tobramycin (23%), ampicilin-sulbactam (30·1%), minocycline (32·8%), tigecycline (10·7%), doxycycline (21·6%), colistin (100%) and polymixin B (100%). We demonstrated the rising trend of resistance to all antibiotic categories except tetracyclines and folate pathway inhibitors. We found that the treatment options against XDR-AB are extremely limited and each treatment alternative including even old, but safe, antibiotics might be considered.

SIGNIFICANCE AND IMPACT OF THE STUDY

The high frequency of drug-resistant phenotypes including carbapenem-resistant Acinetobacter baumannii, multidrug-resistant, and extensively resistant has been demonstrated in Ac. baumannii isolates tested here. As the antibiotic resistance pattern of isolates varies in different geographical regions, this study can provide comprehensive information about the antibiotic resistance profile of Ac. baumannii isolates in Tehran. In addition, the resistance profiles could be effectively considered by clinicians to manage antibiotic therapy. This work also emphasizes on the prudent use of antibiotics and the monitoring of antibiotic susceptibility trend and rate.

InvasiveVibrio cholerae01 E1 Tor Inaba in a 3-day-old neonate: case report

A 3-day-old girl with invasive V. cholerae infection is described. Her mother had cholera in the perinatal period. Because of retracted nipples, she expressed milk and fed her infant by bottle. The infant died on the 2nd day of admission.

Intraperitoneal inoculation of Haemophilus influenzae local isolates in BALB/c mice model in the presence and absence of virulence enhancement agents

PURPOSE

Haemophilus influenzae (Hi), predominantly type b accounts for approximately 4% of cases of community-acquired and nosocomial meningitis, in adults. The objective of this study was to evaluate the pathogenicity of local Hi isolates (type b, f and non-typable) in BALB/c mice in the presence of virulence enhancement agents.

MATERIALS AND METHODS

Three different concentrations of the Hi isolates were inoculated intraperitoneally in BALB/c mice in the presence of 2% hemoglobin and 4% mucin as virulence enhancing agents (VEA). The ability of the isolates to produce bacteremia, the percent survival and lethal dose (LD50) were recorded in different challenge groups.

RESULTS

The 3 Haemophilus influenzae type b (Hib) isolates used in study were able to show virulence in BALB/c mice model only in the presence of VEA and their LD50 decreased significantly when 2% hemoglobin and 4% mucin were used. All survived animals showed bacteremia within 4 h of inoculation which was cleared within 18 h. Significant differences (P<0.01) in the virulence and survival percentage of Hib challenge groups were observed based on their dose of inoculation and VEA. None of the isolates were able to induce infection in the absence of VEA. Non-type b isolates failed to produce disease in the mice models even at the highest inoculated dose (10⁸ cfu) and in the presence of VEA.

CONCLUSIONS

BALB/c mice appeared suitable for evaluating the virulence of Hib strains, and 2% hemoglobin with 4% mucin an appropriate concentration for inducing infection in this animal model.

Mortality causes in children 1-59 months in iran

BACKGROUND

Mortality rate indicator for children under 5 years old is one of the important indicators in countries' development. Identifying the most common causes of mortality is one of the most important attempts to reduce mortality in children less than 5 years. The purpose of this study was to identify distribution of the mortality causes in Iranian children less than 5 years.

METHODS

This cross-sectional study has been carried out based on the results of data from the Child Mortality Surveillance System since 2007 to 2008. To determine the causes of death questionnaires have been designed which include personal data of the deceased child, medical history, and information on procedures at the time of hospitalization or death.

RESULTS

Of 5926 deaths on children under 5 years which the questionnaires were filled out, 63.2% were postneonatal deaths (1-11 month). Totally 60% of mortalities occurred in the rural areas and 52% of them had been among boys. The most common causes of mortality were the congenital and chromosomal abnormalities with 23.4%. The most incidences among diseases were respiratory system diseases.

CONCLUSIONS

Carrying out more epidemiologic studies, providing health programs to control and prevent diseases with high incidences and delivering more specialized health facilities and services could be the proper strategies to reduce under 5 mortality rates in Iran.

KPC-producer gram negative bacteria among burned infants in Motahari Hospital, Tehran: first report from Iran

To the best of our knowledge, this is the first report of Klebsiella, Acinetobacter and Pseudomonas-producing Klebsiella pneumoniae Carbapenemase (KPC) among burn infants in Iran. The objective of this study was to determine the phenotypic detection of these KPC among isolated Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella spp. A cross-sectional study was performed (February to September 2011) at a tertiary burn hospital in Tehran, Iran. Sixty-four strains were isolated from 20 patients. Strain and genus of isolates were confirmed, antibiotic susceptibility testing was implemented, and KPC determined by Modified Hodge Test. Fifteen of 36 strains (six Pseudomonas aeruginosa, six Acinetobacter baumannii, and three Klebsiella pneumoniae) were resistant to imipenem. Ten strains of 36 Gram negative isolates were resistant to all tested antibiotics except for Colistin. Thirteen of 15 resistant imipenem strains were confirmed as KPC-producer bacteria that isolated from nine patients. Six of 36 isolated strains were extended-spectrum β-lactamase (ESBL)-producing bacteria, of which four strains were both KPC and ESBL. A high percentage of multidrug resistant (MDR) strains in our centre with positive KPC have created a major challenge in terms of mortality and morbidity. The findings of this study highlight the importance of implementing an effective infection control strategy to prevent and decrease the prevalence of KPC-producing organisms.

Effect of tannin extract against Pseudomonas aeruginosa producing metallo beta-lactamase

Carbapenems are the most potent beta-lactam agents with a broad-spectrum activity against Gram-negative and Gram-positive bacteria. They are stable in the presence of penicillinases and cephalosporinases. This study was focused on frequency of metallo beta- lactamase (MBL) among Pesudomonas aeruginosa strains isolated in patients with urinary tract infection, effect of tannin against PA positive strains which produced blaVIM or blaIMP and both of these genes (Species). Detection of MBL was performed by phonotypic and genotypic methods. Tannin extract was tested against P. aeruginosa producing MBL. During the study period, 240 P. aeruginosa isolates were identified. Among them 64 (26.6 percent) isolates were imipenem non-susceptible and confirmed by imipenem/EDTA. Our results revealed that the growth of blaVIM positive P. aeruginosa inhibited at 15 microg/ml concentration. The experiment repeated for blaIMP-positive P. aeruginosa and P. aeruginosa which harbored blaIMP and blaVIM, the results showed 35 microg/ml was the best concentration for inhibition of P. aeruginosa-positive blaIMP and also P. aeruginosa blaIMP and blaVIM. In conclusion, tannin was effective against P. aeruginosa producing blaVIM and blaIMP and both of them so it can be substituted with common antibiotics. The result showed significantly P. aeruginosa-harbored blaIMP was more responsible for imipenem resistance than P. aeruginosa-positive blaVIM. Interestingly, tannin was more effective against MBL-P. aeruginosa in comparison with current antibiotics.

Specific PCR Assay for Rapid and Direct Detection of Neisseria meningitidis in Cerebrospinal Fluid Specimens

BACKGROUND

Neisseria meninigitidis is one of the most frequently encountered microorganisms associated with central nervous system infections. The aim of this study was to evaluate a PCR-based assay for specific and rapid detection of N. meninigitidis in CSF specimens.

METHODS

Since April 2002 to July 2006, 130 CSF specimens were collected from patients suspected of having bacterial meningitis. Bacterial isolation and identification was carried out according to the standard bacteriological methods. The PCR was used to amplify a 101bp fragment of capsular transport gene A (ctrA) of N. meningitidis.

RESULTS

PCR yielded an amplified product with the expected size of 101 base pair fragment. Sensitivity test proved 500 ng of N. meningitidis DNA as the final detection limit and specificity test revealed no cross-reaction for a wide range of respiratory pathogenic organisms.

CONCLUSION

The PCR assay was more sensitive than the bacterial culturing. It might be possible to apply this procedure for rapid diagnosis of meningococci in clinical samples.

Should post kidney transplantation hyperlipidemia considered a risk factor for graft function?

BACKGROUND

Hyperlipidemia is a common problem after kidney transplantation.

OBJECTIVE

To uncover the real impact of post kidney transplantation hyperlipidemia on graft function and survival, and to determine whether it is just a biochemical phenomenon after using immunosuppressant or a part of disease pathology.

METHODS

330 kidney transplants were managed in Sina Hospital Kidney Transplantation Unit affiliated to Tehran University of Medical Sciences, Tehran, Iran from September 1994 till February 2010. The demographic characteristics of the patients, causes of chronic kidney diseases, history of pretransplantation dialysis, pretransplantation comorbidities (e.g., hypertension, diabetes mellitus [DM], hyperlipidemia and coronary artery disease), rejection episodes, status of infection with cytomegalous virus [CMV], post-transplantation DM, hyperlipidemia, ischemic heart disease [IHD], and graft and patient survival were recorded. A serum creatinine level >2 mg/dL was considered as "graft deterioration," and return to dialysis as "graft loss." According to the presence or absence of post kidney transplantation hypercholesterolemia (>200 mg/dL) or hypertriglyceridemia (>200 mg/dL), the patients were classified into "hyperlipidemic" or "non-hyperlipidemic." The presence of clinical or paraclinical coronary artery disease was also determined in both groups.

RESULTS

The incidence of hyperlipidemia elevated from 8% to 50% before and after transplantation. 2.7% developed clinical IHD. 13% of hyperlipidemics and 22% of non-hyperlipidemics developed graft deterioration. Among hyperlipidemics with deteriorated grafts 40% had premorbid diseases, 68% had CMV infection and 82% had hypertension. Only 22% had previous acute rejection and 27% received deceased kidney transplant.

CONCLUSIONS

post kidney transplantation hyperlipidemia is just an associated phenomenon secondary to the use of immunosuppressant medications, which have no obvious impact on renal graft function and can be easily controlled by instituting dietary modifications and use of modern antilipid medications. Post kidney transplantation CMV infection and hypertension are considered as the main threatening risk for renal graft-even more dangerous than acute or chronic rejections.

Relationship of pharmacist interaction with patient knowledge of dispensed drugs and patient satisfaction

A prospective survey of pharmacists' tasks and patients' knowledge and satisfaction was conducted in 35 randomly selected community pharmacies in Tabriz, Islamic Republic of Iran. The total pharmacist interaction received a mean score of 3.05 out of 5. Providing written directions for use attained the highest score of 0.98 out of 1. Patients scored 3.18 out of 5 for knowledge about their medicines. There was a close correlation between patients' knowledge of dispensed drugs and pharmacist interaction (r = 0.95). Mean total prescription filling time was 7.6 min, but only 1.4 min was spent on pharmacist-patient counselling. The interaction between pharmacist and patient increases patients' knowledge about dispensed medicines and their satisfaction with the pharmacist's activities.

Kidney biopsy in west of Iran: Complications and histopathological findings

In this retrospective study, we reviewed the medical records and histopathology findings of 135 patients who underwent renal biopsies at two special hospitals affiliated to Kermanshah medical university during a six-year period (2003-2007). All were performed using Tru-Cut needle under ultrasound guidance. Twenty four specimens were unsatisfactory. There were 38 males (34.2%) and 73 females (65.7%) in 111 patients with adequate specimens (each specimen has more than 5 glomeruli); the mean age was 16.5 years (range 2-64 years). Side effects of the renal biopsies included pain at the site of biopsy in 2 (2.7%), gross hematuria in 1 (0.9%). Nephrotic syndrome was the most common indication for biopsy followed by acute renal failure of unknown etiology and nephritic syndrome. Primary glomerular disease was reported in 78 patients (70.2%) and also secondary glomerular disease in 33 patients (29.7%). Among the primary glomerulonephritis disease, minimal change disease and membranous glomerulonephritis were the commonest findings in children below the age of 16 years. Minimal change disease ranked first in adults whole membranous glomerular disease and focal segmental glomerulosclerosis were more common in the elderly. In all patients lupus glomerular disease was the commonest secondary glomerular disease. We conclude that study on renal biopsy makes final diagnosis which is associated with an acceptably low rate of complications in our practice, and in all, the patterns of renal histology in our study vary slightly from those reported from other countries.

Evaluation of the 10th External Quality Assessment Scheme results in clinical microbiology laboratories in Tehran and districts

We evaluated the performance of microbiology laboratories in the 10th run of the external quality assessment scheme (EQAS) in Tehran and districts. Each laboratory was sent 2 species of bacteria for identification. Of the 487 laboratories that participated, 437 returned their findings. While 77.0% and 69.9% correctly identified Staphylococcus saprophyticus and Citrobacter freundii respectively, only 29.8% correctly identified Acinetobacter baumanii, 25.3% identified Enterococcus faecalis and 35.6% identified Enterobacter agglomerans. However 78.7% and 79.5% of the laboratories reported correct -results for susceptibility testing for S. saprophyticus and C. freundii respectively.

Nosocomial blood stream infections in Imam Khomeini Hospital, Urmia, Islamic Republic of Iran, 1999-2001

Ina 2-year retrospective study, the database of the microbiology laboratory of the Imam Khomeini Hospital was reviewed to identify patients who had nosocomial bacteraemia between 1 May 1999 and 31 May 2001 and identify the pathogen responsible and its resisitance to antibiotics. Of 6492 patients in various wards, 593 [9.1%] had positive blood cultures; 85 of those [14.3%] had signs of potential skin contamination. Gram-positive cocci, including coagulase-negative staphylococci, Staphylococcus aureus, Streptococcus pneumoniae and other Gram-positive cocci, accounted for 42.3% of isolates. Gram-negative bacilli were responsible for another 42.3% of isolates; Pseudomonas aeruginosa was the predominant isolate. Patterns of drug resistance varied according to species of bacteria but were generally quite high

Nosocomial blood stream infections in Imam Khomeini Hospital, Urmia, Islamic Republic of Iran, 1999-2001

In a 2-year retrospective study, the database of the microbiology laboratory of the Imam Khomeini Hospital was reviewed to identify patients who had nosocomial bacteraemia between 1 May 1999 and 31 May 2001 and identify the pathogen responsible and its resisitance to antibiotics. Of 6492 patients in various wards, 593 (9.1%) had positive blood cultures; 85 of those (14.3%) had signs of potential skin contamination. Gram-positive cocci, including coagulase-negative staphylococci, Staphylococcus aureus, Streptococcus pneumoniae and other Gram-positive cocci, accounted for 42.3% of isolates. Gram-negative bacilli were responsible for another 42.3% of isolates; Pseudomonas aeruginosa was the predominant isolate. Patterns of drug resistance varied according to species of bacteria but were generally quite high.

Immunohistochemical cathepsin-D expression in breast cancer: correlation with established pathological parameters and survival

Breast cancer is an increasingly important cause of illness and death among women. In recent years, several novel prognostic determinants of breast cancer have been identified, including Cathepsin-D (CD) protein. CD protein expression was analyzed immunohistochemically (IHC) in tumor specimens (315 patients) of infiltrating ductal breast carcinoma. These patients also had axillary lymph node sampling. Overexpression of CD was observed in 39% of the tumors. IHC results were compared with the histological grade. Seventy nine percent (n = 95; 79%) tumor positivity was seen in grade II tumors, followed by grade I (n = 13; 11%) and grade III tumors (n = 12; 10%). Axillary lymph node metastasis had no significant correlation with CD positivity (p > 0.05). Bone metastases were significantly correlated with CD positivity (p < 0.05). CD positivity showed no significant correlation with disease-free and overall survival (p > 0.05). At a median follow-up of 48 (4 years) months in CD-positive patients, overall survival was 3.17 years, and disease-free survival 2.67 years. The overall survival of CD-negative tumor patients was 3.50 years, and disease-free survival was 2.93 years. We conclude that in comparison with cytosol-based quantitative studies, CD expression is not a good prognostic marker when, as in all ICH studies, only the expression in the tumor is considered.

A low-cost intervention for cleaner drinking water in Karachi, Pakistan

OBJECTIVE

To pilot test an inexpensive, home-based water decontamination and storage system in a low-income neighborhood of Karachi.

METHODS

Fifty households received a 20-L plastic water storage vessel with a high-quality spout and a regular supply of diluted hypochlorite solution. Twenty-five control households were recruited. Water samples were collected at baseline and during unannounced follow-up visits 1, 3, 6, and 10 weeks later.

RESULTS

Baseline drinking water samples among intervention households were contaminated with a mean 9397 colony-forming units (cfu)/100 mL of thermotolerant coliforms compared with a mean 10,990 cfu/100 mL from controls. After intervention the mean concentration of thermotolerant coliforms decreased by 99.8% among the intervention households compared with an 8% reduction among controls. Two years after vessel distribution, 34 (68%) of the families were still using the vessel. Thirteen of the households had stopped using their vessel because it had broken after more than 6 months of use, a pattern most consistent with ultraviolet radiation-induced degradation of the plastic.

CONCLUSIONS

In a highly contaminated environment, a specifically designed water storage container and in-home water chlorination was acceptable and markedly improved water quality. Where plastic water vessels will be exposed to substantial sunlight, ultraviolet light stabilizers should be incorporated into the plastic.

Hypertension and its determinants among adults in high mountain villages of the Northern Areas of Pakistan

We studied the prevalence and determinants of hypertension among adults in mountainous rural villages in the Ghizar district Northern Areas of Pakistan, an area that recently has undergone substantial economic development. We selected a stratified random sample of 4203 adults (age > 18 years) from 16 villages in Punial Valley of Ghizar district where the number of study subjects from each village was proportionate to the size of the village. We obtained blood pressure (BP) records by taking the mean of the second and third BP measurement, using a standard mercury sphygmomanometer, and assessed risk factors for hypertension in the study subjects. The mean +/- s.d. blood pressures (mm Hg) were 125 +/- 19 systolic and 80 +/- 12 diastolic in men and 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The mm Hg, or systolic BP > or = 140 mm Hg or currently taking antihypertensive medication) was 15%, increasing from 4% in the 18-29 year age group to 36% among persons 60 years of age or older. The age-standardised prevalence of hypertension was 14% (12.5% among men and 14% among women). There was no significant difference in prevalence of hypertension in males, and in females. Multivariate analysis revealed that age, and higher body mass index (overweight and obesity) were independently associated with higher prevalence of hypertension. People with hypertension were more likely to have a first-degree relative with physician-diagnosed hypertension (OR = 1.90, 95% CI 1.49, 2). Hypertension is a significant health problem in rural northern Pakistan. The primary health care programme in the Northern Areas of Pakistan needs to address this problem, especially identifying people at risk.