The artificial pancreas: two alternative approaches to achieve a fully closed-loop system with optimal glucose control

INTRODUCTION

Diabetes mellitus type 1 is a chronic disease that implies mandatory external insulin delivery. The patients must monitor their blood glucose levels and administer appropriate insulin boluses to keep their blood glucose within the desired range. It requires a lot of time and endeavour, and many patients struggle with suboptimal glucose control despite all their efforts.

MATERIALS AND METHODS

This narrative review combines existing knowledge with new discoveries from animal experiments.

DISCUSSION

In the last decade, artificial pancreas (AP) devices have been developed to improve glucose control and relieve patients of the constant burden of managing their disease. However, a feasible and fully automated AP is yet to be developed. The main challenges preventing the development of a true, subcutaneous (SC) AP system are the slow dynamics of SC glucose sensing and particularly the delay in effect on glucose levels after SC insulin infusions. We have previously published studies on using the intraperitoneal space for an AP; however, we further propose a novel and potentially disruptive way to utilize the vasodilative properties of glucagon in SC AP systems.

CONCLUSION

This narrative review presents two lesser-explored viable solutions for AP systems and discusses the potential for improvement toward a fully automated system: A) using the intraperitoneal approach for more rapid insulin absorption, and B) besides using glucagon to treat and prevent hypoglycemia, also administering micro-boluses of glucagon to increase the local SC blood flow, thereby accelerating SC insulin absorption and SC glucose sensor site dynamics.

Abnormal cell wall structure caused by boron nutrient imbalance in orchards could affect psyllid feeding behaviour, resulting in epidemic variation of Asian citrus psyllid

The control of Huanglongbing (HLB), one of the most destructive pests of citrus, relies heavily on the reduction of Asian citrus psyllid (ACP), Diaphorina citri Kuwayama. An in-depth understanding of ACP feeding behaviours among citrus plants is urgent for comprehensive management of orchards. An investigation was conducted in 37 citrus orchards in HLB epidemic areas, sampling shoots in the area with aggregation feeding of ACP (ACPf) and shoots in a neighbouring area without ACP feeding (CK), to study the interaction between leaf chemical composition and ACP psyllid feeding behaviours. Results of FTIR showed a strong absorption peak intensity, mainly representing functional groups originating from cell wall components in the leaf with ACP feeding. As compared with the control, cell wall components, such as alkali-soluble pectin, water-soluble pectin, total soluble pectin, cellulose, and hemicellulose, of the cell wall of ACPf increased by 134.0%, 14.0%, 18.0%, 12.5%, and 20.35%, respectively. These results suggest that cell wall mechanical properties significantly decreased in the term of decreases in pectin performance and cellulose mechanical properties. In addition, there was a remarkably lower boron (B) content in leaves and cell wall components with ACP feeding. Further analysis indicated that leaf B content significantly affected leaf cell wall components. Taken together, we provide evidence to demonstrate that the regional distribution of nutrient imbalance in orchards could affect psyllid feeding behaviour by weakening the cell wall structure, resulting in epidemic variation in ACP. This could help us to understand the management of psyllid infections in orchards with unbalanced nutrition.

Demographic and clinical correlates of suicidal ideation in individuals with at-risk mental state (ARMS): A study from Pakistan

BACKGROUND

Suicide is a major public health concern and one of the leading causes of mortality worldwide. People with an at-risk-mental-state (ARMS) for psychosis are more vulnerable to psychiatric co-morbidity and suicide, however, there are limited data from low-middle-income countries. The present study aimed to identify the prevalence of depressive symptoms and suicidal ideation along with sociodemographic and clinical correlates of suicidal ideation in individuals with ARMS from Pakistan.

METHOD

Participants between the age of 16 and 35 years who met the criteria for ARMS based on the Comprehensive Assessment of At-Risk Mental State (CAARMS), were recruited from the community, general practitioner clinics and psychiatric units across Pakistan (n = 326). Montgomery and Asberg Depression Rating Scale (MADRS) and Social-Occupational-Functional-Assessment-Scale (SOFAS) were administered to participants.

RESULTS

The prevalence of depressive symptoms and suicidal thoughts in the sample at baseline were 91.1% (n = 297) and 61.0% (n = 199), respectively. There were significant mean differences between groups (mean difference [95% CI]; p-value) without suicidal ideation and with suicidal ideation on measures of MADRS (-5.47 [-7.14, -3.81]; p < .001), CAARMS non-bizarre ideas (-0.29 [-0.47, -0.11]; p = .002) and perceptual abnormalities (-0.23 [-0.41, -0.04]; p = .015).

CONCLUSION

These findings indicate that suicidal ideation and depressive symptoms are highly prevalent in individuals with ARMS in Pakistan. Given the pivotal developmental stages that ARMS presents, and the poor outcomes associated with co-morbid depression, there is an urgent need to prioritize the development of low-cost and scalable evidence-based interventions to address psychiatric comorbidity and suicidality in the ARMS population in Pakistan.

Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report

INTRODUCTION

Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management.

CASE PRESENTATION

A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.

Increased health risk assessment in different vegetables grown under untreated sewerage irrigation regime due to higher heavy metals accumulation

Heavy metals are environmental pollutants and carcinogenic for human health if ingested. In developing countries, including Pakistan, untreated sewerage water is one of the major sources of irrigation for vegetable production in the vicinities of urban areas which might be toxic to human health due to heavy metals contamination. The present study was conducted to investigate the uptake of heavy metals by sewage water application and its impact on human health. The experiment consisted of five vegetable crops (Raphanus sativus L, Daucus carota, Brassica rapa, Spinacia oleracea, and Trigonella foenum-graecum L.) and two irrigation sources (clean water irrigation and sewage water irrigation). Each treatment was three time replicated for all five vegetables, and standard agronomic practices were applied. The results demonstrated that shoot and root growth in radish, carrot, turnip, spinach, and fenugreek was enhanced significantly with sewerage water, probably due to enhanced organic matter. However, pithiness was observed in the root of radish under sewerage water treatment. Very high concentrations of Cd, up to 7.08 ppm in turnip roots while up to 5.10 ppm in fenugreek shoot, were observed, and other vegetables also contained higher concentrations of Cd. Zn concentrations in the edible parts of carrot (control (C) = 129.17 ppm, sewerage (S) = 164.10 ppm), radish (C = 173.73 ppm, S = 253.03), turnip (C = 109.77 ppm, S = 149.67 ppm), and fenugreek (C = 131.87 ppm, S = 186.36 ppm) were increased by sewerage water treatment but a decrease in Zn concentration in spinach (C = 262.17 ppm, S = 226.97 ppm) was observed. Fe concentration in edible parts of carrot (C = 888.00 ppm, S = 524.80 ppm), radish (C = 139.69 ppm, S = 123.60 ppm), turnip (C = 195.00 ppm, S = 121.37 ppm), and fenugreek (C = 1054.93 ppm, S = 461.77 ppm) were also decreased by sewerage water treatment while spinach leaves had accumulated higher Fe (C = 1560.33 ppm, S = 1682.67 ppm) in sewerage water treatment. The highest bioaccumulation factor value was 4.17 for Cd in carrots irrigated with sewerage water. The maximum value of bioconcentration factor was 3.11 for Cd in turnip under control, and the highest value of translocation factor was 4.82 in fenugreek irrigated with sewerage water. Daily intake of metals and health risk index (HRI) calculation indicated that HRI for Cd was more than 1, suggesting toxicity in these vegetables while HRI for Fe and Zn is still under safe limit. Correlation analysis among different traits of all vegetables under both treatments revealed valuable information for selecting traits in the next crop breeding programs. It is concluded that untreated sewerage-irrigated vegetables, highly contaminated with Cd, are potentially toxic for human consumption and should be banned in Pakistan. Furthermore, it is suggested that the sewerage water should be treated to eliminate toxic compounds, particularly Cd, before irrigation usage and non-edible/phytoremediation crops might be grown in contaminated soils.

A study of non small cell lung cancer (NSCLC) patients with brain metastasis: A single centre experience

BACKGROUND

Lung cancer is the leading cause of cancer death with the majority of cases being non-small cell lung cancer (NSCLC) [1]. A common complication of NSCLC is brain metastasis (BM) [2, 3], where the prognosis remains poor despite new treatments. Real world data complements data gained from clinical trials, providing information on patients excluded from prospective research [4]. However, information from patient notes may prove incomplete and difficult to extract. We developed an algorithm to identify patients in our clinical database with brain metastasis from the electronic health record (EHR).

METHODS

We retrospectively extracted data from the EHR of patients managed at a large teaching hospital between 2007 and 2018. Using the ICD-10 code C34, for lung cancer, our algorithm used phrases associated with BMs to search the unstructured text of radiology reports. Summary statistics and univariant analysis was performed for overall survival.

RESULTS

818 patients were identified as potentially having BM and 453 patients were confirmed on clinical review of their records. The median age of patients was 69 years, 50% were female and 66% had a performance status of >2. 12.2% had an identifiable mutation and 11.5% were identified as PD-L1 positive. In the first line setting, 65% of patients received symptomatic treatment, 23% received systemic anticancer therapy (SACT), 6.1% surgery and 10% radiotherapy, of which 6.5% had external beam and 3.5% stereotactic radiosurgery. Regarding those treated with SACT, 35% had an intracranial response to treatment (3% had complete response, 32% had a partial response). Median survival was 2 months (1.9 - 2.4 months 95% CI).

CONCLUSION

The real-world prognosis for NSCLC patients with BMs is poor. By using an algorithm, we have reported outcomes on a comprehensive cohort of patients which helps identify those for whom an active treatment approach is appropriate.

Comparative Analysis of the Efficacies of the GeneXpert and Solid Culture Media Techniques in the Diagnosis of Mycobacterium Tuberculosis

Tuberculosis is one of the predominant infectious diseases causing significant deaths worldwide. Detection of Mycobacterium tuberculosis bacilli (MTB) using culture media was officially recognized by World Health Organization. However, there is a significant limitation in the authenticity of evaluation for its effectiveness on clinically important attributes. GeneXpert detects the presence of Mycobacterium tuberculosis (M. tuberculosis) based on the detection of nucleic acid and is able to identify the resistance of both isoniazid (INH) and Rifampicin (RIF) drugs. In this technique, DNA amplification is done using the GeneXpert instrument in the suspected sample with a specific reagent cartridge. Although GeneXpert is a rapid technique compared to other diagnostic tools for MTB identification due to false-negative results, the culture media technique is still considered the gold standard in detecting M. tuberculosis. The current study was designed to evaluate the comparative efficacies of GeneXpert and the solid culture media technique in identifying MTB. Sputum samples of 250 (n=250) suspected tuberculosis (TB) patients were investigated using both diagnostic techniques. The results revealed that out of the 250 suspected patients, 30 (12%) samples were positive with the culture media technique, while only 17 (6.8%) samples showed positive results with GeneXpert. Culture tests and GeneXpert are not equally efficient in detecting M. tuberculosis. The current study's findings showed that the culture-based detection method for M. tuberculosis is more efficient and reliable than GeneXpert.

Association between plant nutrients, the development of Huanglongbing and abnormal growth symptoms in navel orange

Huanglongbing (HLB) causes extensive damage in citrus orchards worldwide. Symptoms include blotchy mottle leaf (BML) and little leaf chlorosis (LLC), and nutrient deficiency usually occurs concurrently. However, the relationship between plant mineral content and infection with Candidatus Liberibacter asiaticus (CLas) is not clearly established. We sampled 7-month-old autumn shoots with three characteristic phenotypes, asymptomatic leaf (AL), BML and LLC, representing HLB disease progression, and further divided samples into CLas-infected and uninfected based on PCR analysis. HLB infection decreased transfer coefficients of Mg and K from leaf to phloem tissues through regulation of the transporter genes Cs3g03790.1 and PtrMGT5, increasing the content of leaf Mg and K. HLB infection also decreased leaf Zn, xylem Ca and phloem Ca and Zn content. Leaf Ca, Mg, Zn and B content decreased while leaf K content increased significantly as symptoms progressed from AL to LLC. The transport of P from leaf to phloem tissue, as evaluated by the transfer coefficient, was regulated by the transporter CsiPT2, resulting in irregular levels of leaf P. Our results provide insights into the nutrient dynamics in Citrus in response to CLas infection and the progression of HLB symptoms.

Population genomic screening of all young adults in Australia to detect familial hypercholesterolemia: a cost-effectiveness analysis

Background

Heterozygous familial hypercholesterolemia (FH) is a highly-penetrant, autosomal dominant monogenic disorder that causes elevated plasma low-density cholesterol (LDL-C) levels and risk of premature coronary heart disease (CHD). To date, the cost-effectiveness of the emerging strategy of genomic screening of adult populations for FH has not been investigated.

Purpose

To assess the impact and cost-effectiveness of offering population genomic screening to all young adults in Australia to detect heterozygous familial hypercholesterolemia (FH).

Methods

We designed a decision analysis model to compare the current standard of care for heterozygous FH diagnosis in Australia (opportunistic cholesterol screening and genetic cascade testing) with population genomic screening of adults aged 18–40 years to detect pathogenic variants in the LDLR/APOB/PCSK9 genes. The model captured morbidity/mortality due to coronary heart disease (CHD) over a lifetime horizon, from a healthcare perspective. Risk of CHD, treatment effects, prevalence, and healthcare costs were estimated from published studies. Outcomes included quality adjusted life years (QALYs), costs and incremental cost-effectiveness ratio (ICER), discounted 5% annually. Sensitivity analyses were undertaken to explore the impact of key input parameters on the robustness of the model. The model structure was designed to be transferable to countries with different healthcare systems.

Results

Over the lifetime of the population (4,167,768 men; 4,129,961 women), the model estimated a gain of 62,722 years of life lived and 73,959 QALYs due to CHD prevention. Population genomic screening for FH would be cost-effective from a healthcare perspective if the cost per test was ≤AU$300 (∼US$233) which would yield an ICER AU$28,000 cost-saving.

Conclusion

Based on our model, offering population genomic screening to all young adults to detect FH could be cost-effective in the Australian healthcare system, at testing costs that are currently feasible.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This work was supported by the Australian National Heart Foundation and Monash University Faculty of Medicine, Nursing and Health Sciences Results from scenario analysesResults from Monte Carlo simulations

Antibiotic Resistance in Diarrheagenic Escherichia coli Isolated from Broiler Chickens in Pakistan

Background: Diarrheagenic Escherichia coli (DEC) strains are predominant cause of gastrointestinal tract illnesses. The main objective of the study was to determine antibiotic resistance in various types of DEC isolated from chicken broilers farmed in Pakistan. Methods: A total of 200 feces and 200 meat samples from broiler chickens were collected from the slaughtering shops in Southern Punjab, Pakistan. The confirmed fecal (n=150) and meat (n=150) E. coli isolates were investigated against 16 antibiotics. Fourteen virulence genes specific for Enteropathogenic (EPEC), Shiga Toxin-producing (STEC), Enteroinvasive (EIEC), Enteroaggregative (EAEC), and Enterotoxigenic (ETEC) E. coli were identified using Polymerase Chain Reaction. Results: EPEC was the most detected pathotype in both feces (76%) and meat (90%) samples, followed by STEC, EIEC, and ETEC. The highest resistance (40-90%) was observed against penicillin, oxytetracycline, and nalidixic acid in fecal isolates. More than 50% EPEC and EAEC fecal isolates, and 60% EAEC meat isolates were simultaneously resistant to 6 or more antibiotics. Conclusion: Conclusively, the broiler meat sold in open markets of Pakistan was considerably contaminated with multi-drug resistant DEC. To mitigate the issue, the gov- ernment should regulate the use of antibiotics at poultry farms and monitor slaughtering practices in slaughterer houses.

OP0015 GENOMIC RISK SCORE FOR ADVANCED OSTEOARTHRITIS IN OLDER ADULTS

Background:

Osteoarthritis (OA) is a major cause of disability, with treatment options mostly limited to advanced disease when joint replacement is indicated. Recent genome-wide association analysis more than doubled the number of OA-associated variants identified (1, 2), extending the feasibility of identification of high-risk individuals.

Objectives:

Including these variants, we calculated polygenic risk scores (PRSs) and performed validation in a well-characterised population of older individuals.

Methods:

We calculated PRSs for knee and hip OA respectively, using joint replacement surgeries as markers of advanced disease in 12,724 older individuals of European descent in the ASPREE trial. We considered in-trial joint replacement (hospitalizations during median 4.7 years follow-up) and pre-trial joint replacement from self-reported medical history. Multivariable models examined the effect of PRS as a continuous variable (per standard deviation [SD]) and categorical variable (low-risk [0-20%], medium-risk [21-80%], high-risk [81-100%] groups), adjusting for age, sex and BMI.

Results:

Mean population age at baseline was 75 years and 54.9% of participants were female. In total, 1478 (11.6%) participants had knee replacements and 1324 (10.4%) had hip replacements. Female sex, higher BMI and age were associated with higher risk of knee and hip replacements. PRSs as continuous variables per SD were associated with knee (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.04-1.17) and hip (OR 1.18, 95% CI 1.11-1.25) replacements. We found meaningfully different rates of knee or hip joint replacement occurring between low-, medium- and high-risk PRS groups. Participants in the high-risk PRS group, compared with the low, had a higher risk of knee replacements (OR=1.35, CI 1.12-1.62), and hip replacements (OR 1.66, 95% CI 1.37-2.02). We found no interaction between PRS and sex, and no collinearity between PRS and BMI, suggesting PRS is an independent risk factor for OA.

Conclusion:

Joint-specific genomic risk scores predict advanced OA in older adults, independent of age, sex and BMI. Stronger associations are observed for hip versus knee OA. Our study provides some of the first evidence of potential clinical utility of genomic risk prediction for OA, which may help identify individuals who would benefit most from targeted clinical management and preventive intervention.

References:

[1]Tachmazidou I, Hatzikotoulas K, Southam L, et al. 2019. Identification of new therapeutic targets for osteoarthritis through genome-wide analyses of UK Biobank data. Nat Genet, 51, 230-236

[2]Zengini E, Hatzikotoulas K, Tachmazidou I, et al. 2018. Genome-wide analyses using UK Biobank data provide insights into the genetic architecture of osteoarthritis. Nat Genet, 50, 549-558

Disclosure of Interests:

None declared

The governance of overseas surgical collaborations - BFIRST/BSSH

Clinical governance is the structured approach to maintaining and improving the quality of patient care and is a vital part of global surgery. BFIRST and BSSH closely collaborate with local doctors on a number of overseas projects, seeking to strengthen and develop local knowledge and skills, aiming for an independent local practice in reconstructive and upper limb surgery. Thoughts on essential requirements, improvements and pitfalls in the ethical approach to global collaboratives are presented.

Do community mental health teams caring for severely mentally ill patients adjust treatments and services based on patients’ antisocial or criminal behaviours?

Background

Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation.

Aim

To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour.

Method

A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files.

Results

Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits.

Conclusions

While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.

Abstract P4-13-14: “Real world” characteristics, treatment patterns and outcomes of patients with hormone receptor positive (HR+), human epidermal growth factor 2 negative (HER2-) metastatic breast cancer (MBC)

OBJECTIVES: Outcomes for patients with MBC vary according to disease phenotype and treatment history. We present UK real-world patient characteristics, treatment patterns and outcomes for patients with HR+/HER2- BC treated at a single cancer center.

METHODS: A retrospective review of health records including coded data, unstructured text and clinical review of patients treated from January 2012 to March 2018 identified females ≥ 18 years with metastatic or locally advanced HR+/HER2- BC. Those enrolled in clinical trials, with operable local recurrence as only disease site, incomplete treatment records or significant secondary malignancy were excluded. Patient characteristics, systemic, local (radiotherapy/surgery) and supportive treatments, health care resource use (HRU) and overall survival (OS) are presented. OS was estimated using the Kaplan-Meier method, censoring patients alive at study end.

RESULTS: 253 patients meeting study inclusion criteria were identified (median age 67, IQR 56,76; 84% post-menopausal), of whom 47 (19%) had locally advanced disease (T4 and/or N3), 75 (30%) had MBC at initial presentation and 131 (52%) had metastatic disease at first recurrence. Among patients with MBC at initial presentation, all received systemic treatment following diagnosis, including chemotherapy (35%), endocrine (93%) and targeted therapy (i.e. everolimus 7%). Among those recurring with MBC, 97% subsequently received systemic treatment, including chemotherapy (50%), endocrine (93%) and targeted therapy (27%). For patients recurring with MBC, the most common first line therapies (LoT) were letrozole (20%), exemestane (single agent, 15%), anastrozole (14%), everolimus (with exemestane, 11%) and paclitaxel (9%). For patients diagnosed with MBC, the most common first LoT were letrozole (47%), anastrozole (23%) and EC (11%). At second LoT, the most commonly used regimen for patients recurring with MBC was fulvestrant (13%) and for patients with MBC at initial diagnosis, it was exemestane (19%). Median OS for patients recurring with MBC was estimated to be 2.11 years (IQR 1.80,3.05), compared with 2.65 years (IQR 2.24,2.95) for those with metastatic disease at initial diagnosis. Median available follow-up time for the whole cohort was 2.85 years (IQR 1.42,4.82).

CONCLUSIONS: Patients with overt metastatic disease at presentation comprise a substantial proportion of those treated for MBC. With the follow-up time available, estimated median OS for patients with metastatic disease at initial presentation appears somewhat better than for those recurring with metastatic disease. Real world analysis demonstrates diverse treatment pathways for patients with HR+, HER2- MBC, reflecting the individualized care they receive.

Citation Format: Twelves C, Cheeseman S, Thompson M, Riaz M, Perren T, Ahat-Donker N, Sopwith W, Myland M, Lee A, Turner S, Hall G. “Real world” characteristics, treatment patterns and outcomes of patients with hormone receptor positive (HR+), human epidermal growth factor 2 negative (HER2-) metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-14.

Phenolics, tocopherols and fatty acid profiling of wild and commercial mushrooms from Pakistan

Mushrooms can be used as nutraceutical or functional foods to maintain and promote good health. In the present study, wild Ganoderma lucidum and four commercial mushrooms, Pleurotus ostreatus, Volvariella volvacea, Hericium erinaceus and Lentinus edodes, collected from Pakistan were screened for phenolics, tocopherols and fatty acid contents. High performance liquid chromatography analysis of phenolic acids showed that chlorogenic acid, ferulic acid, gallic acid, p-Coumaric and caffeic acids were observed in selected mushrooms. H. erinaceus contained high amounts of chlorogenic acid (11.49±0.1 µ/g of dry weight) and ferulic acid (7.84±0.7 µg/g of dry weight). γ-tocopherol and lutein were present in all studied mushrooms. Lutein contents were higher in H. erinaceus (2.42±0.087 µg/g of DW) followed by V. volvacea> P. ostreatus> L. edodes. γ-tocopherol was observed in the range of 74.25±3.01 to 29.65±1.2 µg/g of dry weight. GC/MS analysis of fatty acids showed that linoleic acid (18’:2n6c), oleic acid (18’:1n9c), palmitic acid (C16:0), stearic acid (C18:0), linolenic acid (18’:3n3) and nonadecanoic acid (C19-0), were the main fatty acids found in selected mushrooms. The unsaturated fatty acids were predominated over saturated fatty acids. It is concluded that selected mushrooms are good sources of antioxidant compounds and unsaturated fatty acids.

Effects of household bleach on sputum smear microscopy to concentrate acid fast bacilli for the diagnosis of pulmonary tuberculosis

Tuberculosis (TB) is one of the major public health problem among contagious diseases in Pakistan. TB diagnosis mainly depends on sputum smear microscopy. The main objective of this study was to evaluate the effects of household bleach on sputum smear microscopy to concentrate acid fast bacilli for the diagnosis of pulmonary tuberculosis. Sputum specimens of 200 suspected TB patients were collected for the study. Smears were prepared from the purulent part of sputum sample before and after bleach treatment, heat fixed and stained with the ZN technique. The obtained data were analyzed by chi-squared test using SPSS software. Out of 200 isolates, 22 (11%) patients had positive smears for acid fast bacilli (AFB) by direct ZN staining. After treatment with household bleach (NaOCL) and centrifugation, the number of AFB positive patients were increased from 22 (11%) to 37 (18.5%). The bleach-concentration method for sputum samples significantly increased the TB detection rate as compared to direct sputum smear microscopy. Thus, a shift from direct sputum microscopy to bleach-concentration technique should be considered a better method for detection of AFB in sputum through smear microscopy.

Role of fungal-induced stress in biochemical and phytochemical profiling of Peganum harmala

The current study was designed to evaluate bioactive compounds under the influence of biotic stress on seedlings of Peganum harmala. Biologically active compounds were determined by using different techniques. The HPLC and GC-MS analyses detected the significant amount of phenolic acids and active biological compound. Total protein content, activity of proteases, α-amylases, catalases and peroxidases were observed to be accelerated under fungal stress. The seedling extracts exhibited prominent antifungal and antimicrobial activity against selected strains. The present study showed that P. harmala is a good candidate to be used in natural therapies and medicine.

An insight into nutritional profile of selected Pleurotus species

The global demand for good quality food indicates that consumers are more concerned about a particular diet associated with good health and lower risk for certain ailments. Mushrooms are widely used as healthy nutritious food. In the present study, the nutritional composition of four different Pleurotus sp. was determined. Prior to extraction, all the selected mushrooms were subjected for proximate composition analysis. The protein, fat, ash, total carbohydrate, fiber and energy contents were in the range of (16.07- 25.15%), (0.64-2.02%), (2.1-9.14%), (65.66-82.47%), (6.21-54.12%) and (342.20-394.30Kcal/100g), respectively. The spectrophotometric analysis showed that the concentration of protein was in the range of 45.78-33.47 mg/g in all Pleurotus sp. High performance liquid chromatographic analysis of sugars showed six different mono and disaccharides in all the selected mushrooms. The fatty acid profile by gas chromatography-mass spectrometry revealed that the main fatty acids in selected mushrooms were present in the order linoliec acid> oleic acid> palmitic acid. The results suggested that all the Pleurotus sp. could be considered as a rich source of nutrients.

Buccinator Sandwich Pushback: A New Technique for Treatment of Secondary Velopharyngeal Incompetence

Objective

A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich.

Patients

In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length.

Design

The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist.

Results

Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication.

Conclusion

The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

BACKGROUND

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

AIM

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

METHODS

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

RESULTS

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

CONCLUSION

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

In vitro antioxidant potential of selected aphrodisiac medicinal plants

The present study aimed to evaluate the antioxidant activity of six selected aphrodisiac medicinal plants. Useful parts of the selected medicinal plants were collected and extracted in methanolic solvent. The antioxidant activity of selected plant extract was determined through different antioxidant assays, namely DPPH radical scavenging assay and ferric reducing antioxidant assay. Moreover, antioxidant compounds, like total phenolics and total flavonoids contents, were also determined. Results showed that Mucuna pruriens seed extract displayed high contents of phenolic compounds with total phenolic content of 683.15±4.28 mg GAE/g dry plant material while the least phenolic content was observed in Asparagus racemosus (195.5±3.02 mg GAE/g dry plant material). Highest total flavonoids content was found in Anacyclus pyrethrum roots (156.58±4.01 μg CE/g) and the least content was found in Asparagus racemosus roots. Among the studied plant extracts, the highest radical scavenging activity was shown by Mucuna pruriens seed extract (82.05±0.55%) and the least percent scavenging activity was observed in Tribulus terrestris extract (36.40±2.01%). Vitamin C was used as positive control for antioxidant assays showing 93.54±0.9% radical scavenging activity. The plant extract also exhibited a strong reducing potential against free radicals. Therefore, the present study concluded that all the studied medicinal plants possess varying concentrations of secondary active metabolites responsible for the antioxidant properties of the tested plant extracts.

Immunomodulatory potential of Anacyclus pyrethrum (L.) and Mucuna pruriens (L.) In male albino rats

The present study was designed to investigate the immunomodulatory potential of Anacyclus pyrethrum roots and Mucuna pruriens seeds in male albino rats. The roots of A. pyrethrum and seeds of M. pruriens were extracted with methanolic solvent (70:30) and administered at dose concentrations of 50, 100 and 200 mg/Kg body weight to healthy male rats. The immune system of rats was suppressed by injecting carbon tetrachloride to animals in the toxic control group and test group animals. Cell-mediated immune response of animals was examined by performing neutrophil adhesion test and the humoral immune response was evaluated by determining serum immunoglobulin levels of the animals under study. The administration of methanolic extracts of A. pyrethrum roots and M. pruriens seeds significantly (p less than 0.05) increased the neutrophil adhesion to the nylon fiber. Increase in % neutrophil adhesion was observed in animals treated with 200 mg of each plant extract. Significant (p less than 0.05) improvement in immunoglobulin levels was recorded in the extract treated group animals, showing that the root extract of A. pyrethrum and seed extract of M. pruriens have immunomodulatory potential. We therefore conclude that the tested extracts can be used as immunomodulatory agents to stimulate the immune system.

Phytopharmacology of Tribulus terrestris

Tribulus terrestris is an annual herb which belongs to the Zygophyllaceae family. This plant has been used in traditional medicine for the treatment of various diseases for hundreds of decades. The main active phytoconstituents of this plant include flavonoids, alkaloids, saponins, lignin, amides, and glycosides. The plant parts have different pharmacological activities including aphrodisiac, antiinflammatory, antimicrobial and antioxidant potential. T. terrestris is most often used for infertility and loss of libido. It has potential application as immunomodulatory, hepatoprotective, hypolipidemic, anthelmintic and anticarcinogenic activities. The aim of the present article is to create a database for further investigation of the phytopharmacological properties of this plant to promote research. This study will definitely help to confirm its traditional use along with its value-added utility, eventually leading to higher revenues from the plant.

Effect of acetaminophen on sulfamethazine acetylation in male volunteers

The effect of acetaminophen on sulfamethazine N-acetylation by human N-acetyltrasferase-2 (NAT2) was studied in 19 (n=19) healthy male volunteers in two different phases. In the first phase of the study the volunteers were given an oral dose of sulfamethazine 500 mg alone and blood and urine samples were collected. After the 10-day washout period the same selected volunteers were again administered sulfamethazine 500 mg along with 1000 mg acetaminophen. The acetylation of sulfamethazine by human NAT2 in both phases with and without acetaminophen was determined by HPLC to establish their respective phenotypes. In conclusion obtained statistics of present study revealed that acetaminophen significantly (P<0.0001) decreased sulfamethazine acetylation in plasma of both slow and fast acetylator male volunteers. A highly significant (P<0.0001) decrease in plasma-free and total sulfamethazine concentration was also observed when acetaminophen was co-administered. Urine acetylation status in both phases of the study was found not to be in complete concordance with that of plasma. Acetaminophen significantly (P<0.0001) increased the acetyl, free and total sulfamethazine concentration in urine of both slow and fast acetylators. Urine acetylation analysis has not been found to be a suitable approach for phenotypic studies.

Genotypic variability for root/shoot parameters under water stress in some advanced lines of cotton (Gossypium hirsutum L.)

Research pertaining to genetic variability parameters, heritability, and genotypic, phenotypic, simple, and environmental correlations for various seedling traits in five elite advanced cotton (Gossypium hirsutum L.) lines (FH-113, FH-114, FH-941, FH-942, and FH-2015) and one check (CIM-496) was carried out during October and November 2010 under greenhouse conditions at the Cotton Research Institute (Faisalabad, Pakistan). Material was raised in plastic tubes with a randomized complete block design replicated three times. Three drought shocks were applied by withholding water from the tube-sown plants for 8-, 10-, and 12-day intervals. After 60 days of sowing, data on root/shoot traits like root length (cm), shoot length (cm), root weight (g), shoot fresh weight (g), lateral root number, root dry weight (g) shoot dry weight (g), and total plant weight (g) were recorded. Considerable genotypic variations existed between genotypes for all seedling characters. Higher broad-sense heritability estimates were found for all traits studied. Maximum broad-sense heritability coupled with high genetic advance in root length (0.99, 17.34), lateral root number (0.91, 2.89), and shoot length (0.90, 4.35) suggested a potential for genetic improvement through breeding and selection. The correlation coefficients among root length, shoot length, root dry weight, fresh shoot weight, and total plant weight were positively and significantly correlated; thus, they can be selected simultaneously as drought tolerance selection indexes owing to the absence of undesired relationships. Genotypes FH-942 and FH-113 had the lowest excised leaf water loss during the first 4 h and also for the next 4 h. Therefore, these two advanced lines (FH-942 and FH-113) with high initial water content and lower excised leaf water loss had better adaptation to water stress.

Simultaneous determination of nitrite and nitrate by normal phase ion-pair liquid chromatography

Normal phase ion-pair high performance liquid chromatography has been used for simultaneous separation of nitrite and nitrate using tetraethylammonium (TEA)(+) as ion-pairing reagent. The concentration effect of (TEA)(+), buffer salt and pH of the eluent on separation is investigated. The UV detector response at various wavelengths has been optimized. The performance of the proposed method is compared with ion chromatography for quantification of the anions in potable water, wastewater and in food samples, such as spinach and lettuce.

Combining ability analysis for within-boll yield components in upland cotton (Gossypium hirsutum L.)

Cotton is an important cash crop worldwide, accounting for a large percentage of world agricultural exports; however, yield per acre is still poor in many countries, including Pakistan. Diallel mating system was used to identify parents for improving within-boll yield and fiber quality parameters. Combining ability analysis was employed to obtain suitable parents for this purpose. The parental genotypes CP-15/2, NIAB Krishma, CIM-482, MS-39, and S-12 were crossed in complete diallel mating under green house conditions during 2009. The F₀ seed of 20 hybrids and five parents were planted in the field in randomized complete block design with three replications during 2010. There were highly significant differences among all F₁ hybrids and their parents. Specific combining ability (SCA) variance was greater than general combining ability (GCA) variance for bolls per plant (9.987), seeds per boll (0.635), seed density (5.672), lint per seed (4.174), boll size (3.69), seed cotton yield (0.315), and lint percentage (0.470), showing predominance of non-additive genes; while seed volume (3.84) was controlled by additive gene action based on maximum GCA variance. Cultivar MS-39 was found to be the best general combiner for seed volume (0.102), seeds per boll (0.448), and lint per seed (0.038) and its utilization produced valuable hybrids, including MS-39 x NIAB Krishma and MS-39 x S-12. The parental line CIM-482 had high GCA effects for boll size (0.33) and seeds per boll (0.90). It also showed good SCA with S-12 and NIAB Krishma for bolls per plant, with CP- 15/2 for boll size, and with MS-39 for seeds per boll. The hybrids, namely, CP-15/2 x NIAB Krishma, NIAB Krishma x S-12, NIAB Krishma x CIM-482, MS-39 x NIAB Krishma, MS-39 x CP-15/2, and S-12 x MS-39 showed promising results. Correlation analysis revealed that seed cotton yield showed significant positive correlation with bolls per plant, boll size and seeds per boll while it showed negative correlation with lint percentage and lint per seed. Seed volume showed significant negative correlation with seed density. Seeds per boll were positively correlated with boll size and negatively correlated with bolls per plant lint percentage and lint per seed. Similarly, lint per seed exhibited positive correlation with lint percentage and boll size showed significantly negative correlation with bolls per plant. Presence of non-additive genetic effects in traits like bolls per plant, seeds per boll, lint per seed, seed cotton yield, and lint percentage is indicative of later generation selection or heterosis breeding may be adopted. For boll size, seed volume and seed density early generation selection may be followed because of the presence of additive gene action. The parental material used in this study and cross combinations obtained from these parents may be exploited in future breeding endeavors.

Movement abnormalities and psychotic-like experiences in childhood: markers of developing schizophrenia?

BACKGROUND

Both involuntary dyskinetic movements and psychotic-like experiences (PLEs) are reported to be antecedents of schizophrenia that may reflect dysfunctional dopaminergic activity in the striatum. The present study compared dyskinetic movement abnormalities displayed by children with multiple antecedents of schizophrenia (ASz), including speech and/or motor developmental lags or problems, internalising/externalising problems in the clinical range, and PLEs, with those displayed by children with no antecedents (noASz).

METHOD

The sample included 21 ASz and 31 noASz children, aged 9-12 years old. None had taken psychotropic medication or had relatives with psychosis. The antecedents of schizophrenia were assessed using questionnaires completed by children and caregivers. A trained rater, blind to group status, coded dyskinetic movement abnormalities using a validated tool from videotapes of interviews with the children.

RESULTS

ASz children reported, on average, 'certain experience' of 2.5 PLEs, while noASz children, by definition, reported none. The ASz children, as compared with noASz children, displayed significantly more dyskinetic movement abnormalities in total, and in the facial and the upper-body regions, after controlling for sex and age. Receiver operator characteristics analyses yielded high area under the curve values for the total score (0.94), facial score (0.91) and upper-body score (0.86), indicating that these scores distinguished between the ASz and noASz children with great accuracy.

CONCLUSIONS

Brief questionnaires identified children with multiple antecedents of schizophrenia who displayed significantly more involuntary dyskinetic movement abnormalities than children without antecedents. The presence of PLEs and dyskinesias could reflect early disruption of striatal dopamine circuits.

Effect of zinc and iron fortification of the feed on liver and thyroid function in rats

Changes in plasma glutamate oxaloacetate transaminase (GOT), glutamate pyruvate transaminase (GPT), triiodothyronine (T3), and thyroxin (T4) of male rats, following 8 weeks of administration of different concentrations of elemental iron (EI), sodium iron ethylenediaminetetraacetate (NaFeEDTA), zinc sulfate (ZnSO(4)), and zinc oxide (ZnO) in whole wheat flour were investigated. Liver enzymes and thyroid hormones were determined using colorimetric methods and enzyme immune assay, respectively. Ingestion of fortified diets by the male rats did not show a marked effect on GOT and GPT, the exception being NaFeEDTA fed alone and EI with ZnO-fortified diets indicating a significant (p < 0.05) decrease in GOT levels in rats. Similarly, only NaFeEDTA significantly (p < 0.05) increased thyroxin, while EI, ZnSO(4), and ZnO either alone or in any combination did not alter thyroid secretions. Changes in GOT, GPT, T3, and T4 levels, as a result of ingesting iron and zinc-fortified diets by rats, ranged in the safe limits.

Effectiveness of educational interventions in improving clinical competence of residents in an internal medicine residency program in Pakistan

INTRODUCTION

Medical education is a continuously evolving field. Training institutes and programs should have a process in place to gather continuous feedback and then make appropriate modifications in order to provide education and training effectively. Our study aimed to assess the effect of a quality improvement cycle approach in using various educational interventions within a residency. Effects were measured on the key educational outcomes of residents; medical knowledge, skills and professional attitudes using results of postgraduate examination with both written and clinical skills components.

METHODOLOGY

A number of educational interventions were implemented which included changes in work hours with increased time for self-study, new educational activities including a Residents Hour, a Residents Slide Session, Grand Rounds and Journal Clubs, Clinico-pathological conferences, and a two- week postgraduate course for senior residents. Newer and improved assessment tools were also implemented, including an annual in-training mock exam based on the format of the postgraduate examination. Pass rates in postgraduate examinations (Fellow of College of Physicians and Surgeons exam and Member of Royal College of Physicians exam) were compared before and after the interventions to assess the effectiveness of the interventions.

RESULTS

The first group of residents after introduction of the educational interventions completed residency training in 2001. Postgraduate exam pass rates (sometimes after two or more attempts) were 59.2% (42 of 71 graduates) before 2001 and 86.4% (38 of 44 graduates after 2001 (p = 0.002). The number of candidates passing the examinations in either their first or second attempts before 2001 was 17 of 42 (40.5%), which increased to 33 of 38 (86.8%) after 2001 (p = <0.001).

CONCLUSIONS

Our study describes a number of interventions that were successful in bringing about an improvement in the performance of our residents. These can serve as a guide for postgraduate training programs, particularly those of Internal Medicine, in implementing strategies to strengthen training and enhance the performance of trainees.

Abstract P4-07-01: Correlation of Breast Cancer Susceptibility Loci with Patient Characteristics, Metastasis-Free Survival and Expression of the Nearest Genes

Background: Genome-wide association studies has identified single nucleotide polymorphisms (SNPs) in several loci being associated with breast cancer risk: fibroblast growth factor receptor 2 (FGFR2), trinucleotide repeat containing 9 (TNRC9 or TOX3), mitogen-activated protein kinase kinase kinase 1 (MAP3K1), lymphocyte-specific protein 1 (LSP1) and the imprinted maternally expressed H19, and loci in gene deserts at 8q24 and 2q35. However, the mechanism by which these loci confer breast cancer risk in patients is still largely unknown. Here, we addressed this question by associating these SNPs with the mRNA expression of the genes located at or nearest to the SNP in the same linkage disequilibrium region. In addition, we associated the SNPs with clinical, pathological and patient characteristics and prognosis. Material and Methods : SNPs tagging breast cancer loci were genotyped in genomic tumor DNA samples of 2,480 breast cancer patients. All samples were collected between 1978-2004. The mean age was 55.6 years and median follow-up up was 106 months. The SNPs were correlated with patients and tumor characteristics. Of the 1,262 patients with lymph-node negative disease and who did not receive any adjuvant systemic therapy, SNP status was associated with distant metastasis-free survival (MFS) using Cox regression analysis. Finally, in a subset of 1,400 of the 2,480 patients, the mRNA expression of FGFR2, TNRC9, MAP3K1, LSP1 and H19 genes was determined by quantitative RT-PCR and correlated with SNP genotypes.

Results: The SNP rs2981582 in FGFR2 was significantly associated with ER and PgR status of the tumors (both p=0.001). Besides weak associations with tumor grade (FGFR2, p=0.01), ER (MAP3K1, p=0.03; LSP1, p=0.03), and PgR (LSP1, p=0.05), no other association with any clinical or pathological variable for any of the SNPs was observed. Of the SNPs analyzed, only rs2107425 near H19 was significantly linked in uni-and multivariable analysis with MFS (Hazard ratio [HR]=1.44, 95% Confidence interval [CI]: 1.04-1.98; p=0.026; HR=1.53; 95% CI: 1.09-2.14; p=0.013, respectively) with the more aggressive minor allele displaying a recessive trade. Interestingly, the minor allele of SNP rs3803662 was significantly associated with lower mRNA expression of the 8 kb downstream TNRC9 gene (p=0.0019). However, none of the other risk alleles, including the one in FGFR2, had an association with mRNA expression of the nearest located gene.

Conclusions: In agreement with previous studies, a clear correlation of the SNPs in FGFR2 with ER and PR status of tumors was observed. The lower level of TNRC9 mRNA in tumors having the minor allele genotype suggests that TNRC9 may act as a tumor suppressor gene and its expression might have a protective effect. A significant association of the SNP near H19 with poor outcome without apparent effect on H19 mRNA expression suggests that this prognostic SNP in a well-known imprinted region is not linked to prognosis through altering H19 gene expression. This study indicates that most of the studied SNPs that confer breast cancer risk are not linked to prognosis nor do they effect, in primary tumors mRNA expression of the nearest gene.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-07-01.

Medical mortality in Pakistan: experience at a tertiary care hospital

AIM

To acquire systematic data on the causes of hospital mortality in Pakistan, a developing country with scant mortality records.

STUDY DESIGN

Retrospective review of death certificates and hospital charts of patients dying on general and specialty medical services at our hospital during one calendar year.

RESULTS

Of a total 10,590 admissions, 657 (6.2%) died in hospital. The deceased included 357 (54.4%) males and 299 (45.6%) females, with a collective median age of 63 years and mean length of stay 6.71 days (median 4 days, range 1-56 days). Primary cause of death was categorised as infectious (21.2%), pulmonary (17.2%), cancer related (15.7%), cardiovascular (12.6%), gastrointestinal and hepatic (10.8%), neurological (11.4%) and miscellaneous (11.1%). Within each category, the most common diagnoses were septicaemia (76.9% of infectious cases), pneumonia (55.7% of pulmonary cases), myocardial infarction (40.9% of cardiovascular), intracranial haemorrhage (37.3% of neurological), and cirrhosis (45.0% of gastrointestinal). There were multiple causes among malignant disorders with no single cause dominating. Patients with cardiovascular and pulmonary deaths tended to be older than the median age (p = 0.001), while patients with gastrointestinal and cancer related deaths tended to be younger than the median age (p = 0.001). Length of stay did not differ significantly among the various subgroups. About a quarter (26.4%) deaths occurred within 24 h of admission.

CONCLUSIONS

Infections, including septicaemia and pneumonia, are the leading causes of hospital mortality in our setting, followed by malignancy and cardiovascular causes. The overall mortality rate is comparable to published mortality data from other hospital settings.

Buckling and mechanical instability of ZnO nanorods grown on different substrates under uniaxial compression

Mechanical instability and buckling characterization of vertically aligned single-crystal ZnO nanorods grown on different substrates including Si, SiC and sapphire (α-Al(2)O(3)) was done quantitatively by the nanoindentation technique. The nanorods were grown on these substrates by the vapor-liquid-solid (VLS) method. The critical load for the ZnO nanorods grown on the Si, SiC and Al(2)O(3) substrates was found to be 188, 205 and 130 µN, respectively. These observed critical loads were for nanorods with 280 nm diameters and 900 nm length using Si as a substrate, while the corresponding values were 330 nm, 3300 nm, and 780 nm, 3000 nm in the case of SiC and Al(2)O(3) substrates, respectively. The corresponding buckling energies calculated from the force displacement curves were 8.46 × 10(-12), 1.158 × 10(-11) and 1.092 × 10(-11) J, respectively. Based on the Euler model for long nanorods and the J B Johnson model (which is an extension of the Euler model) for intermediate nanorods, the modulus of elasticity of a single rod was calculated for each sample. Finally, the critical buckling stress and strain were also calculated for all samples. We found that the buckling characteristic is strongly dependent on the quality, lattice mismatch and adhesion of the nanorods with the substrate.

Glycaemic trend during Ramadan in fasting diabetic subjects: a study from Pakistan

The aim of this questionnaire based survey was to assess the glycaemic control care and management of our fasting diabetic subjects. This retrospective study was carried out at Baqai Institute of Diabetology and Endocrinology, its affiliated centers and Memon Diabetic Centre of Karachi. Data was collected by a questionnaire including socio-demographic data, duration of diabetes, life style, diet and treatment during and preceding Ramadan of year 2004. All Known diabetic Muslim subjects except children below 10 years were included. The subjects were asked if they had observed any of the hypoglycemic or hyperglycemic symptoms. The major severity of the symptoms was assessed depending upon the assistance needed. The plasma glucose level during these episodes was recorded where it was available. During the month of Ramadan 327 out of 453 subjects (72.5%) fasted. Mean age of subjects was 50.3 +/- 12.6 years. Average duration of diabetes was 9.3 +/- 7.3 years. Majority of the subjects (96.3%) fasted with type 2 diabetes while only 3.7% fasted with type I diabetes. Subjects fasted for an average of 25 days. Overall prevalence of hypoglycemia and hyperglycemia was 21.7 and 19.8%, respectively. Only 4.0% had major hypoglycemic episodes, while 8% had major hyperglycemic episodes. The present study suggests that all diabetic subjects who intend to fast should be counseled before Ramadan about change in medication timings and dose, dietary changes and pattern of physical activity and about role of self-monitoring of blood glucose especially during acute symptoms.