SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB

BACKGROUND

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.

METHODS

Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).

RESULTS

SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.

CONCLUSION

This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Punicalagin improves inflammation and oxidative stress in rat model of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is one of the major public health concerns accounting for 30% of infertility and 50% of ectopic pregnancy cases due to severe inflammation and fibrosis. Punicalagin® are known to exhibit potent anti-inflammatory activity. The aim of this study was to demonstrate the anti-inflammatory and antioxidant effects of Punicalagin®, against pelvic inflammatory disease in rats. Female Sprague Dawley rats (n = 24) were divided into 6 groups (n = 4) as control, PID, prophylactic (low dose and high dose) and therapeutic group (low dose and high dose). PID model was constructed by implanting the rat cervix with mixed microbe (Escherichia Coli and Staphylococcus Aureus) solution. Prophylactic group was gavaged with 3 mg/kg (low dose) and 6 mg/kg (high dose) Punicalagin® daily starting one day before PID induction and therapeutic group was gavaged with 3 mg/kg (low dose) and 6 mg/kg (high dose) Punicalagin® daily starting 1 day after confirmation of PID model. Rats were sacrificed at the end of experiment and samples from upper genital tract were collected for ELISA, antioxidant assay and histopathological examination. According to results, obvious signs of inflammation and oxidative stress including infiltration of neutrophils and significantly raised levels of cytokines, and oxidative stress markers were observed in PID group when compared to control group. Punicalagin® significantly decreased the levels of IL-1β, catalase and lipid peroxidation in both prophylactic and therapeutic groups when compared to PID group. Punicalagin® also decreased the infiltration of leucocytes in uterus of prophylactic and therapeutic group when compared to PID group, as determined by histological examination. On basis of these results, we concluded that Punicalagin® showed anti-inflammatory and antioxidant potential in rat model of pelvic inflammatory disease and could be used as possible therapeutic agent in treatment of PID.

Salivary Oxidative Stress and Antioxidant Capacity in Smokeless Tobacco (Naswar) Users

Background

Naswar, a smokeless tobacco product, commonly consumed in Pakistan, is associated with a 10-fold increase in the risk of oral cancer. However, little is known about Naswar's underlying toxicity mechanisms.

Objective

The current study aimed to investigate the effects of Naswar use on oral health and salivary parameters.

Methods

A case-control study was conducted among Naswar users (n=42) and age-matched healthy controls (n=42) in Pakistan in 2019. Participant data were collected using questionnaires. Decayed, missing, and filled teeth (DMFT) scores were computed during clinical examinations. Unstimulated whole saliva was collected to assess salivary flow rate, pH, and salivary total oxidative stress (TOS)/total antioxidant capacity (TAC) using commercially available kits. Participants' oral health parameters were compared between cases and controls using ANOVA.

Results

No significant differences were observed between the two groups in terms of age, oral health, and hygiene practices and mean DMFT score. Mean salivary pH and the salivary flow rate was significantly (p<0.001) higher in Naswar users (7.7 and 0.71 mL/minute, respectively) than in non-users (6.95 and 0.52 mL/minute, respectively). Although TOS and TAC were not significantly different between the groups, Naswar users generally had a higher TOS (51.6±42 µmol/L) and lower TAC (0.55±0.18 mmol/L) than non-users (TOS 45.5±38.2 µmol/L and TAC 0.57±0.17 mmol/L). Correlational analysis also revealed a significant positive correlation between DMFT score and Naswar use duration (r=0.796, p<0.001) and the number of dips/units consumed each day (r=0.515; p<0.001).

Conclusion

Habitual Naswar use is associated with increased salivary flow rate, pH, and TOS, and reduced TAC levels in Pakistani adults compared to non-users. The pro-oxidant changes may contribute toward deleterious effects of Naswar use including oral cancer.

The effects of tobacco and cannabis use on semen and endocrine parameters in infertile males

Substances such as tobacco and cannabis can negatively modulate seminal parameters and sex hormones and lead to fertility problems in males. The present study aimed to determine the effect of cigarettes, dipping tobacco, and cannabis on semen parameters and sex hormones in infertile males. A total of 160 infertile healthy participants (cigarette smokers n = 40, dipping tobacco users n = 40, cannabis users n = 40 and infertile controls n = 40) were included in the study. Fasting blood samples were collected from all the participants using the aseptic technique, and semen samples were collected by masturbation following sexual abstinence of 2-7 days. The levels of serum testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were determined using ELISA. The serum level of FSH was significantly higher in cannabis users relative to the control group (p = 0.043). A mild non-significant decrease in sperm count, serum LH and testosterone levels were observed in all drug users compared to controls. In conclusion, chronic use of tobacco and cannabis mildly modulates semen and hormonal parameters in infertile males.

Delineating the Spectrum of Genetic Variants Associated with Bardet-Biedl Syndrome in Consanguineous Pakistani Pedigrees

This study aimed to find the molecular basis of Bardet-Biedl syndrome (BBS) in Pakistani consanguineous families. A total of 12 affected families were enrolled. Clinical investigations were performed to access the BBS-associated phenotypes. Whole exome sequencing was conducted on one affected individual from each family. The computational functional analysis predicted the variants' pathogenic effects and modeled the mutated proteins. Whole-exome sequencing revealed 9 pathogenic variants in six genes associated with BBS in 12 families. The BBS6/MKS was the most common BBS causative gene identified in five families (5/12, 41.6%), with one novel (c.1226G>A, p.Gly409Glu) and two reported variants. c.774G>A, Thr259LeuTer21 was the most frequent BBS6/MMKS allele in three families 3/5 (60%). Two variants, c.223C>T, p.Arg75Ter and a novel, c. 252delA, p.Lys85STer39 were detected in the BBS9 gene. A novel 8bp deletion c.387_394delAAATAAAA, p. Asn130GlyfsTer3 was found in BBS3 gene. Three known variants were detected in the BBS1, BBS2, and BBS7 genes. Identification of novel likely pathogenic variants in three genes reaffirms the allelic and genetic heterogeneity of BBS in Pakistani patients. The clinical differences among patients carrying the same pathogenic variant may be due to other factors influencing the phenotype, including variants in other modifier genes.

Effects of Oral Lipid-Based nutritional supplements on appetite, energy intake, and lipid profile of moderately underweight children

Oral lipid-based nutritional supplements (LNS) are designed to ensure dietary adequacy and to improve malnourishment in children. Therefore, this study investigated the effects of 4 weeks of LNS on appetite, energy intake, and lipid profile of moderately underweight children (5-10 years old) with BMI-Z score between -2 and - 3 SDS, recruited in a single-blind randomized control trial. In addition to the regular dietary intake, fasting blood samples, anthropometric measurements, energy intake, and appetite responses were obtained before and after 4 weeks of LNS (535 kcal) or PLACEBO (92 kcal). After 4 weeks of supplementation mean energy intake (kcal) (p < .001), body weight (kg) (p < .001), BMI (kg/m2) (p < .01), mid-upper arm circumference (cm) (p < .01), total cholesterol (mg/dl) (p < .01) and fasting glucose (mg/dl) (p < .01) were raised significantly in the LNS group as compared to the PLACEBO group. No significant changes were detected in appetite responses (p > 0.05). In conclusion, LNS increases the overall energy intake, but does not affect the appetite but may induce hyperglycemia and hyperlipidemia.

Mixed reality model for learning and teaching in anatomy using peer assisted learning approach

The objective of this study was to evaluate the effectiveness of mixed reality models in anatomy teaching and learning at Kirkpatrick’s level I, using Peer Assisted Learning approach. This study was based on a single group, post-test study design and was carried out at three affiliated medical schools of Khyber Medical University, Peshawar, over four months. A total of 97 first- and secondyear medical students from three medical schools were enrolled. All students received a basic introduction to the use of Hololens (Microsoft), the mixed-reality simulator-based course on the anatomy of the heart and liver via peer-assisted learning (PAL) method. Student satisfaction was evaluated at Kirkpatrick Level I of program evaluation using a validated and structured PAL questionnaire. Most students agreed or strongly agreed to the effectiveness of questions (mean ± SD 4.3±0.2, percentage 86±4.4%). There was no difference between the satisfaction scores of male and female students (p=0.34), whereas a slight difference was seen between 2nd- and 1st-year students’ satisfaction scores (88% versus 85%, p=0.03). There was also a statistically significant difference of perceptions between different medical schools’ students’ scores (p=.000). Students appear to be satisfied with the use of the mixed reality model for learning anatomy. A randomized trial to directly compare the satisfaction levels between traditional methods and mixed-reality model may be conducted and the effects of mixed-reality models on learning should be assessed.

Evaluating structure-based activity in a high-throughput assay for steroid biosynthesis

Data from a high-throughput human adrenocortical carcinoma assay (HT-H295R) for steroid hormone biosynthesis are available for >2000 chemicals in single concentration and 654 chemicals in multi-concentration (mc). Previously, a metric describing the effect size of a chemical on the biosynthesis of 11 hormones was derived using mc data referred to as the maximum mean Mahalanobis distance (maxmMd). However, mc HT-H295R assay data remain unavailable for many chemicals. This work leverages existing HT-H295R assay data by constructing structure-activity relationships to make predictions for data-poor chemicals, including: (1) identification of individual structural descriptors, known as ToxPrint chemotypes, associated with increased odds of affecting estrogen or androgen synthesis; (2) a random forest (RF) classifier using physicochemical property descriptors to predict HT-H295R maxmMd binary (positive or negative) outcomes; and, (3) a local approach to predict maxmMd binary outcomes using nearest neighbors (NNs) based on two types of chemical fingerprints (chemotype or Morgan). Individual chemotypes demonstrated high specificity (85-98%) for modulators of estrogen and androgen synthesis but with low sensitivity. The best RF model for maxmMd classification included 13 predicted physicochemical descriptors, yielding a balanced accuracy (BA) of 71% with only modest improvement when hundreds of structural features were added. The best two NN models for binary maxmMd prediction demonstrated BAs of 85 and 81% using chemotype and Morgan fingerprints, respectively. Using an external test set of 6302 chemicals (lacking HT-H295R data), 1241 were identified as putative estrogen and androgen modulators. Combined results across the three classification models (global RF model and two local NN models) predict that 1033 of the 6302 chemicals would be more likely to affect HT-H295R bioactivity. Together, these in silico approaches can efficiently prioritize thousands of untested chemicals for screening to further evaluate their effects on steroid biosynthesis.

Outcomes of Endoscopic Third Ventriculostomy in Pediatric Patients With Hydrocephalus

Background

Endoscopic third ventriculostomy (ETV) is used to treat patients with obstructive hydrocephalus in infants. This study evaluated the postoperative outcomes of ETV among pediatric patients.

Methodology

A retrospective study was undertaken at the Mardan Medical Complex between June 2018 and June 2021. All pediatric patients who underwent the procedure of ETV in both the absence and presence of choroid plexus cauterization (CPC) at our center were included in the study. Using medical history data, a comprehensive survey questionnaire was designed. The findings and effects were evaluated either as a success or failure.

Results

A total of 90 cases were reviewed during the study. The rate of in-hospital mortality was 1.1% while the most commonly identified causes of hydrocephalus were myelomeningocele and aqueductal stenosis. A total of 39 (43.33%) patients had a successful surgery. In patients where hydrocephalus was secondary to aqueductal stenosis, the success rate was the highest, while the success rate was quite low for post-infectious hydrocephalus and intraventricular hemorrhage (p < 0.0001). The postoperative complication rate was 55.56% in our study. The rate of in-hospital mortality was 1.1%.

Conclusions

We found that the success rate of ETV was dependent upon factors such as the cause of hydrocephalus, type of hydrocephalus, and the age of the patient. Therefore, ETV is not suitable for all patients, and vigilance must be undertaken in selecting patients for the procedure. The rate of postoperative infections in our institution was alarmingly high which is a concerning matter for the institution.

Efficacy Of Multiple Micronutrients Supplementation On Energy Intake, Calcium And Vitamin D Levels In Underweight Children

BACKGROUND

Under-nutrition is a major public health problem worldwide. Several studies have documented the effects of vitamin D and calcium supplements in healthy children and in children with bone abnormalities but the effects of multiple micronutrients supplementation in underweight children is limited in literature.

METHODS

In this randomized controlled trial 38 participants were recruited and divided into two groups of 19 subjects. On the first day of experimental trial, in fasting state 5cc blood samples were collected from all subjects followed by their anthropometric measurements, and serum levels of calcium and vitamin D. All subjects of one group were given Lipid-based nutritional supplement (LNS) and whereas the other group was given the placebo. After one month of compliance the same measurements were repeated and compared.

RESULTS

After one month of supplementation mid-upper arm circumference (p=0.005), weight (p<0.001), height (p=0.000), and BMI-Z score (p=0.002) the energy intake (p<0.001), were significantly increased in LNS as compared to Placebo. However, no improvement was observed in the plasma vitamin D (p=0.44) and calcium levels (p=0.46) of underweight children in both groups.

CONCLUSION

Multi micronutrient supplementations are effective in improving anthropometry in the short duration of time. They also improve the energy intake of underweight children. However, no improvement is observed in levels of vitamin D and calcium in LNS group even after a one-month use.

Differing radiation exposure in scrub technicians and rotating staff in cardiac catheterization laboratory: occupation matters

Funding Acknowledgements

Type of funding sources: None.

Background

Radiation exposure of cardiac catheterization lab personnel is an evolving area of concern, due to long term, repetitive exposure causing deterministic and stochastic effects(1,2). Current radiation protection measures are based on increasing distance, shielding from fluoroscopy source and depend on primary operator behavior(3)

Effective dose(ED) in micro Sieverts( μSv) as a measure of individual absorbed radiation dose provides feedback as to occupational exposure and risks. Dosimeter badges worn over equipment measure ED correlating with radiation exposure of areas unprotected by standard lead apron such as head, neck, lens and upper limbs. (4)

Most studies focus on primary operator exposure (5,6,7), overlooking non physician staff comprising scrub technicians working as assistants to primary operator physicians, and rotating staff involved in peri-procedural care of patients.

Purpose

This study aimed to find out ED acquired by scrub technicians(ED.S) and rotating staff(ED.R) in interventional cardiology and invasive electrophysiology procedures, utilizing external dosimeters worn over lead aprons.

Methods

We prospectively collected radiation data over forty six invasive Cardiology procedures from 15th March 2021 to 1st June 2021 comprising fourteen diagnostic coronary and graft angiograms, seventeen combined diagnostic and interventional cardiology procedures, nine sole percutaneous coronary interventions and six electrophysiology procedures. Nine staff members: two female and seven male members participated as scrub technicians and rotating staff, provided with external dosimeter badges. ED was obtained by logging in dosimeter badges into pre calibrated monitors.

Results

Significantly high mean ED was acquired by rotating staff as compared to scrub technicians, mean ED.R:21.04 μSv( SD: +/-39.64) and mean ED.S: 7.54 μSv( SD:+/- 17.23), this three fold difference in radiation exposure was statistically significant with a p-value of 0.03.

This was consistent across procedure groups, with rotating staff acquiring higher ED compared to their scrub technician colleagues in diagnostic, interventional and electrophysiology cases. Statistically significant differences in radiation exposure of both staff groups were demonstrated in diagnostic and interventional cardiology procedures, with p-values of 0.04 and 0.01 respectively.(See Table)

Conclusion

This small, single center study highlights occupational role as a significant factor in varying radiation exposure amongst non-physician staff . Higher ED was attributed to rotating staff duties involving proximity and mobility around fluoroscopy source and patient, devoid of protective lead shields.

Based on these findings, avoiding fluoroscopy use while staff performs duties involving proximity to patient such is mandatory. Other essential measures should include accessory left sided leads shields, mandatory protective lens and head shields for rotating staff. Abstract Table

The family planning "know-do" gap among married women of reproductive age in urban Pakistan

OBJECTIVE

To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.

DESIGN

This was a cross-sectional survey of randomly selected 7288 MWRA (16-49 years) to identify predictors of the know-do gap in FP using a logistic regression model.

RESULTS

More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25-35 years: OR 1.45, 95% CI 1.09-1.94; >35 years: OR 3.02, 95% CI 1.90-4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11-2.42; Saraiki: OR 1.66, 95% CI 1.01-2.71; other minorities: OR 2.37, 95% CI 1.63-3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13-1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06-1.98). Conversely, women were more likely to use contraceptives if they had >10 years of schooling (OR 0.66, 95% CI 0.46-0.94), with each increasing number of a living child (OR 0.68, 95% CI 0.62-0.75) and each increasing number of contraceptive method known (OR 0.93, 95% CI 0.88-0.98).

CONCLUSION

The predictors associated with the FP know-do gap among MWRA should be considered when planning future strategies to improve the contraceptive prevalence rate in Pakistan.

Effect of short duration moderate intensity physical activity on glycemic control and antioxidant status of prediabetic population

OBJECTIVES

To determine the effect of moderate-intensity physical activity on glycemic control and antioxidant status in the prediabetic population.

METHODS

This experimental study was carried out in the Physiology Department, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan. A total of 50 adult prediabetic subjects having 22 females and 28 males with the age range of 18 to 35 years were included. Diagnosis of prediabetes was made by glycated hemoglobin falling in the range of 5.7-6.4%, and impaired fasting glucose (100-125 mg/dL). Anthropometric measurements and biochemical assays were carried out at pre and post-exercise intervention. The participants performed moderate exercise of 30 min with heart rate max 7% ± 5% for 5 days a week for 8 weeks, monitored with pedometer. Enzyme-linked immunosorbent assay was carried out for individual and total antioxidants.

RESULTS

Anthropometric parameters showed a significant decrease at post-exercise analysis. Similar changes were observed for fasting glucose (p<0.001) and glycated hemoglobin (p<0.001). Slight increase in uric acid (p<0.005) and total antioxidant concentration (p<0.001) were found. However, superoxide dismutase, glutathione peroxidase, vitamin C, and nitric oxide decreased (p<0.001).

CONCLUSION

Moderate physical activity for 8 weeks significantly reduced the individual antioxidant levels, nominal increase in total antioxidant capacity and uric acid, and there was an explicit decline in the anthropometric and diabetic profile of prediabetic population.

New TB drugs for the treatment of children and adolescents with rifampicin-resistant TB in Mumbai, India

SETTING: Médecins Sans Frontières (MSF) clinic in Mumbai, India.OBJECTIVE: To determine the final treatment outcomes, culture conversion and adverse events (AEs) during treatment among children and adolescents (0-19 years) with rifampicin-resistant tuberculosis (RR-TB) who received ambulatory injectable-free treatment, including bedaquiline (BDQ) and/or delamanid (DLM) during September 2014-January 2020.DESIGN: This was a retrospective cohort study based on review of routinely collected programme data.RESULTS: Twenty-four patients were included; the median age was 15.5 years (min-max 3-19) and 15 (63%) were females. None were HIV-coinfected. All had fluoroquinolone resistance. Twelve received treatment, including BDQ and DLM, 11 received DLM and one BDQ. The median exposure to BDQ (n = 13) and DLM (n = 23) was 82 (IQR 80-93) and 82 (IQR 77-96) weeks, respectively. Seventeen (94%) patients with positive culture at baseline (n = 18) had negative culture during treatment; median time for culture-conversion was 7 weeks (IQR 5-11). Twenty-three (96%) had successful treatment outcomes: cured (n = 16) or completed treatment (n = 7); one died. Eleven (46%) had 17 episodes of AEs. Two of 12 serious AEs were associated with new drugs (QTcF >500 ms).CONCLUSION: Based on one of the largest global cohorts of children and adolescents to receive new TB drugs, this study has shown that injectable-free regimens containing BDQ and/or DLM on ambulatory basis were effective and well-tolerated among children and adolescents and should be made routinely accessible to these vulnerable groups.

The Effect of Different Exercise Intensities on Plasma Endostatin in Healthy Volunteers

Background: Physical activity decreases the risk and development of many angiogenesis related health problems including atherosclerosis. Physiological influence of different physical activities on plasma endostatin concentration is contradictory. This study aimed to determine the effects of mild, moderate and vigorous exercise on the concentration of endostatin. Methodology: 22 participants, 16 males (age = 30.6 ± 7.8 years) and 6 females (age = 26.5 ± 5 years) were recruited. Weekly session of different intensities exercise based on predicted maximum heart (60% (low), 70% (moderate) and 80% (vigorous)] were carried out. One pre and two post exercise samples were taken at 10 and 60 minutes. Results: Low intensity exercise insignificantly decreased the endostatin concentration at 10 and 60 minutes (P = 0.5 and 0.8). However, moderate (P values = 0.022. 0.004) and vigorous intensities (P= < 0.001, 0.02) increased the endostatin concentrations significantly at both intervals respectively. The effects were not significantly influenced by gender, exercise mode (walking vs running), components of exercise (HR, Speed, Gradients, distance, duration) or metabolism during exercise (VO2 max, VCO2, RER, Energy expenditure). Conclusion: Low intensity exercises did not influence endostatin concentration. However, moderate to high intensity exercises significantly increase endostatin concentration and may have potential benefits.

Profile of osteoarticular tuberculosis in children

OBJECTIVE

To determine clinical profile of osteoarticular tuberculosis (TB) in children.

METHODS

Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included.

RESULTS

Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient.

CONCLUSION

Drug resistant osteoarticular TB is an emerging problem in children.

Association Of Risk Factors With Spontaneous Preterm Labour With Intact Foetal Membranes

BACKGROUND

Spontaneous preterm labour refers to the onset of uterine contractions of sufficient strength and frequency to effect progressive dilatation between 24 and 37 weeks of gestation. The objective of the study was to determine an association between risk factors and spontaneous preterm labour with intact foetal membranes.

METHODS

A case control study was designed which was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital, Abbottabad. Sample size of 262 subjects was equally divided into two equal groups (131 cases and control each). Non-probability consecutive sampling was used collection of samples. Pregnant women presenting after 24 weeks of gestation with spontaneous preterm labour with intact membranes were considered as cases. While, pregnant women presenting after 37 complete weeks of gestation with normal pregnancy were considered as controls. The diagnosis of bacterial vaginosis was established by Amsel criteria. Asymptomatic bacteriuria was diagnosed by microscopy. Odds ratios were calculated as measure of association with calculation at 95% confidence interval. Level of 5% (p<0.05) was used to test for significant difference.

RESULTS

Mean±SD age of cases was 26.97±7.072. Subjects with young maternal age (<20 years) were 27 (10.3%) from cases and 12 (4.6%) from controls (OR=2.575, 95% CI: 1.242, 5.338). The subjects with advanced maternal age (>35 years) were 26 (9.9%) from cases and 15 (5.7%) from controls (OR=0.522, 95% CI: 0.262, 1.039). 25 (19.1%) cases and 6 (4.6%) controls had bacterial vaginosis (OR=4.914, 95% CI: 1.943, 12.426). Asymptomatic bacteriuria was present in 03 (2.3%) subjects from cases and 2 (1.5%) from controls (OR=1.512, 95% CI: 0.248, 9.199).

CONCLUSIONS

The study concluded that risk factors like young maternal age and bacterial vaginosis are significantly associated with spontaneous preterm labour with intact foetal membranes. While, association of other risk factors like advanced maternal age and asymptomatic bacteriuria with spontaneous preterm labour is still debatable.

Quantitative prediction of repeat dose toxicity values using GenRA

Computational approaches have recently gained popularity in the field of read-across to automatically fill data-gaps for untested chemicals. Previously, we developed the generalized read-across (GenRA) tool, which utilizes in vitro bioactivity data in conjunction with chemical descriptor information to derive local validity domains to predict hazards observed in in vivo toxicity studies. Here, we modified GenRA to quantitatively predict point of departure (POD) values obtained from US EPA's Toxicity Reference Database (ToxRefDB) version 2.0. To evaluate GenRA predictions, we first aggregated oral Lowest Observed Adverse Effect Levels (LOAEL) for 1,014 chemicals by systemic, developmental, reproductive, and cholinesterase effects. The mean LOAEL values for each chemical were converted to log molar equivalents. Applying GenRA to all chemicals with a minimum Jaccard similarity threshold of 0.05 for Morgan fingerprints and a maximum of 10 nearest neighbors predicted systemic, developmental, reproductive, and cholinesterase inhibition min aggregated LOAEL values with R² values of 0.23, 0.22, 0.14, and 0.43, respectively. However, when evaluating GenRA locally to clusters of structurally-similar chemicals (containing 2 to 362 chemicals), average R² values for systemic, developmental, reproductive, and cholinesterase LOAEL predictions improved to 0.73, 0.66, 0.60 and 0.79, respectively. Our findings highlight the complexity of the chemical-toxicity landscape and the importance of identifying local domains where GenRA can be used most effectively for predicting PODs.

Impact of Conventional Beliefs and Social Stigma on Attitude Towards Access to Mental Health Services in Pakistan

This study aims to explore the role of conventional beliefs and social stigma on attitude towards access to mental health services. From 50 caregivers data were collected by Perceived Public Stigma Scale and an in-depth semi-structured interview. The majority (86%) of patients having significant symptoms of major mental illness visited traditional healer prior to engagement with the mental health services. However a significant positive finding, related to carers predominantly perceiving that individuals with mental health difficulties were trustworthy, capable of engagement in employment and were comfortable with having them as their friends were identified.

Changes In Learning Style Preferences Of Postgraduates After Entering A New Learning Environment

BACKGROUND

The aim of this study was to investigate whether the learning style preferences of post-graduate medical students change with time when they enter a new learning environment. The learning styles of post-graduate medical students from Pakistan were assessed on Kolb's Learning style inventory and prospectively monitored for any change when the students entered a degree program at the University of Glasgow.

METHODS

Medical doctors from Pakistan who joined post graduate program in Evidence Based Medicine and Health Professions Education participated in the study. Kolb's learning style inventory was used to evaluate the learning preferences. Learning styles were evaluated twice in the study, in the first term of the course and then at the end, with a time span of 7 months.

RESULTS

The predominant learning style preferences of students were 'Assimilating' type, both at the beginning and at follow up. Some change in the learning style preferences of students was noted as 2/10 students moved to a different learning grid at follow-up. These results were assessed against gender, clinical and teaching experience using linear regression however no significant correlation was found.

CONCLUSIONS

There was not enough evidence to suggest that learning style preferences of students change in a meaningful way after coming to a new learning environment. This study however, leads to a suggestion that further large sized longitudinal study should be done with enough statistical power to accept or reject the null hypothesis.

Evaluation Of Peer Assisted Learning In Evidence Based Medicine Course: A Pilot Study At University Of Glasgow

BACKGROUND

Peer Assisted Learning (PAL) is a well-established approach in learning and is increasingly being utilized in the medical education system. It is a process where active help of peer group members is taken for learning. This study aimed to look at the impact of peer assisted learning on the students at the end of the session.

METHODS

Sixteen Postgraduate students attending Evidence Based Medicine (EBM) course spanning over two semesters (6 months each) were recruited. It was a cross sectional study and non-probability convenience sampling technique was used for gathering data. All students enrolled in EBM course conducted an hour-long PAL session during the coursework. At the end of the semester a link to an online questionnaire was sent to all the participants. A set of both open and closed ended questions were included in the questionnaire.

RESULTS

Response rate was 87.5%, 14 out of the 16 students completed the questionnaire. The results showed an affirmative change in the behaviour and attitude of the participants' after the workshops. Majority of the respondents were of the opinion that it was a valuable experience and they benefitted through involvement in the process. Most of the postgraduate students suggested that it should be implemented in post graduate studies especially medical education.

CONCLUSIONS

PAL is more interactive and informal way of teaching and it helps in the professional development, if peers from different specialties are gathered. However, study with a larger sample size are suggested to prove the generalizability of this assertion.

Factors associated with psychotic relapse in patients with schizophrenia in a Pakistani cohort

Despite a large body of research evaluating factors associated with the relapse of psychosis in schizophrenia, no studies in Pakistan have been undertaken to date to identify any such factors, including specific cultural factors pertinent to Pakistan. Semistructured interviews and psychometric measures were undertaken with 60 patients diagnosed with schizophrenia (49 male and 11 female) and their caregivers at four psychiatric hospitals in the Peshawar region in Pakistan. Factors significantly associated with psychotic relapse included treatment non-adherence, comorbid active psychiatric illnesses, poor social support, and high expressed emotion in living environments (P < 0.05). The attribution of symptoms to social and cultural values (97%) and a poor knowledge of psychosis by family members (88%) was also prevalent. In addition to many well-documented factors associated with psychotic relapse, beliefs in social and cultural myths and values were found to be an important, and perhaps treatable, factor associated with relapse of psychosis in Pakistan. The provision of evidence-based psychotherapeutic interventions, such as behaviour and family therapy and cognitive behaviour therapy for psychosis, could potentially ameliorate the relapse rate of psychosis in Pakistan.

Endostatin Concentration In Plasma Of Healthy Human Volunteers

BACKGROUND

Angiogenesis is involved in many cardiovascular and cancerous diseases, including atherosclerosis and is controlled by a fine balance between angiogenic and angiostatic mediators. Endostatin is one of the main angiostatic mediators, and inhibits angiogenesis and prevents progression of atherosclerosis. The available literature shows a broad range of concentrations in relatively small samples of healthy controls and is calculated by using different techniques. This study was aimed to determine the basal endostatin concentration in plasma of healthy volunteers, to fully understand its physiological role.

METHODS

Fifty healthy adult volunteers were recruited to the study. Participants were advised not to participate in any physical activity on the day before the blood sampling. The volunteers' physical activity, height, weight, heart rate and blood pressure were recorded. The samples were analysed for plasma endostatin concentration, using ELISA. The participants were divided by gender and ethnic groups to calculate any difference.

RESULTS

Endostatin and other variables were normally distributed. Most of the participants had a moderate level of physical activity with no gender related difference (p=0.370). The mean value for plasma endostatin in all samples was 105±12 ng/ml with range of 81-132 ng/ml. For males, it was 107±13 ng/ml, while for females; 102±12 ng/ml. There were no significant gender or ethnicity related differences in endostatin concentration. Moreover, endostatin was not significantly related with any anthropometric and physical variable.

CONCLUSIONS

This study gives endostatin levels in normal healthy people and show no gender and ethnicity related differences in endostatin levels. Endostatin was not related with any anthropometric and physical variable.

Eosinophilic meningitis: a case series and review of literature of Angiostrongylus cantonensis and Gnathostoma spinigerum

Eosinophilic meningitis is defined as the presence of >10 eosinophils/μL in cerebrospinal fluid (CSF) or at least 10% eosinophils in the total CSF leukocyte count. Eosinophilic meningitis has been reported in two case series and two case reports in India till date and has not been reported in children below 15 years of age. We present two children with eosinophilic meningitis with peripheral eosinophilia and the proposed etiologic agents based on the clinical setting and their response to antihelminthic agents.

Adolescent conduct problems and premature mortality: follow-up to age 65 years in a national birth cohort

BACKGROUND

Severe youth antisocial behaviour has been associated with increased risk of premature mortality in high-risk samples for many years, and some evidence now points to similar effects in representative samples. We set out to assess the prospective association between adolescent conduct problems and premature mortality in a population-based sample of men and women followed to the age of 65 years.

METHOD

A total of 4158 members of the Medical Research Council National Survey of Health and Development (the British 1946 birth cohort) were assessed for conduct problems at the ages of 13 and 15 years. Follow-up to the age of 65 years via the UK National Health Service Central Register provided data on date and cause of death.

RESULTS

Dimensional measures of teacher-rated adolescent conduct problems were associated with increased hazards of death from cardiovascular disease by the age of 65 years in men [hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.04-1.32], and of all-cause and cancer mortality by the age of 65 years in women (all-cause HR 1.16, 95% CI 1.07-1.25). Adjustment for childhood cognition and family social class did little to attenuate these risks. Adolescent conduct problems were not associated with increased risks of unnatural/substance-related deaths in men or women in this representative sample.

CONCLUSIONS

Whereas previous studies of high-risk delinquent or offender samples have highlighted increased risks of unnatural and alcohol- or substance abuse-related deaths in early adulthood, we found marked differences in mortality risk from other causes emerging later in the life course among women as well as men.

Using a birth cohort to study ageing: representativeness and response rates in the National Survey of Health and Development

Britain's oldest birth cohort study, the MRC National Survey of Health and Development (NSHD) provides data to explore life time influences on ageing. The latest data collection was undertaken between 2006 and 2011 when study members were aged 60-64 and consisted of postal and pre-assessment questionnaires to eligible study members, followed by invitation to attend one of six clinical research facilities (CRFs) across the UK for clinical assessments, and dietary diaries and activity monitors in the days following the CRF visit. The option of a home visit for clinical assessments was provided if the study member refused or was unable to attend the CRF. We examined response and attrition, here describing rates overall and for postal and clinical assessment modes of data collection, identifying socioeconomic and health-related predictors of response, and assessing the continued representativeness of the sample. In total, 2,661 (84 % of the target sample) responded. Lower educational attainment, lower childhood cognition and lifelong smoking independently predicted lower likelihood of both overall response and CRF cooperation. At 53 years, not owning one's home and not being married predicted lower likelihood of overall response whereas manual social class and obesity predicted lower likelihood of CRF cooperation. Providing for collection of biomedical data in the home and use of assessment instruments and modes to retain study members with lower education attainment, lower cognition and poorer health behaviours should be priorities for helping reduce attrition amongst vulnerable ageing study members.

Kawasaki's disease: An unusual presentation

Atypical presentations of Kawasaki's disease have been described in the form of intestinal pseudo-obstruction, tonsillitis, hemorrhagic serous effusions, thrombocytopenia, and non-fulfillment of all criteria for diagnosis of Kawasaki's disease. However, presentation of Kawasaki's disease with shock and need for ionotropic support have been rarely described. We present a 4-year-old girl with Kawasaki's disease who presented with anasarca, oliguria, shock, and presence of dilated coronary arteries within 5 days of fever and responded to intravenous immunoglobulin (IVIG) and inotropic support.

Reliability of absolute lymphocyte count as a marker to assess the need to initiate antiretroviral therapy in HIV-infected children

BACKGROUND

CD4 counts are a standard laboratory measure of disease progression in HIV-infected children. However, CD4 counting is done by flow cytometry and may not always be possible in every centre treating HIV-infected children in resource-limited countries. Absolute Lymphocyte Count (ALC) can be derived easily by performing a routine white blood cell count. The World Health Organization (WHO) in 2006 had recommended ALC to identify HIV-infected children in need of ART in resource-limited settings, when CD4 cell count is not available.

AIMS

This study aims to assess the reliability of using ALC as a marker for starting antiretroviral therapy (ART) in HIV-infected children in a tertiary hospital setting.

SETTINGS AND DESIGN

Retrospective analysis of 46 HIV-infected children who presented at a pediatric HIV clinic at a tertiary referral centre from 2002-2005.

MATERIALS AND METHODS

Using WHO 2006 guidelines for cutoff values of ALC and 2008 guidelines for CD4% as a comparative standard, a retrospective analysis was done on ART-naοve HIV-infected children who underwent baseline CD4% and ALC, and sensitivity and specificity of ALC was calculated.

STATISTICAL ANALYSIS

Fischer exact two-tailed analysis was used to correlate ALC and CD4 and need for starting ART.

RESULTS

Sensitivity of ALC was 27.6% (72.4% were false negatives), specificity was 70.6%, with positive predictive value of 61.5%. On comparison across all clinical stages of disease, only 13/46 children (28.2%) would have been started on ART according to ALC cutoffs versus 29/46 children (63.04%) using CD4 criteria (P value=0.0015). In children with WHO clinical Stage 1 or 2 of disease, only 1/11 (9.1%) children were identified by ALC as requiring ART as opposed to 6/11 (54.5%) children by CD4% (P=0.0635).

CONCLUSIONS

ALC is an unreliable marker to determine the need for starting ART in HIV-infected children.

Budd-Chiari disease in infancy: three cases

Budd-Chiari syndrome (BCS) is rare in infancy. Three cases are presented. Case 1, an 8-month-old boy, presented with abdominal distension and oliguria. Doppler study of the abdomen showed ascites, hepatomegaly and normal hepatic veins. However, a CT scan demonstrated hepatic vein thrombosis. Case 2, a 5-month-old boy, presented with abdominal distension and diarrhoea. Ultrasound of the abdomen showed hepatic vein thrombosis and hepatomegaly. Case 3, a 7-month-old girl, presented with abdominal distension, diarrhoea and oliguria. Ultrasound of the abdomen showed hepatomegaly and obstructed hepatic veins. None of the cases had fever or jaundice before presentation. Case 1 developed fungal septicaemia and was lost to follow-up. Cases 2 and 3 succumbed to the disease before further intervention.

Preliminary Phytochemical Screening and Antispasmodic Activity of Artemisia macrocephala Jacquem

The current work describes the antispasmodic action of Artemisia macrocephala, which is achieved via blocking of the calcium channels. This explains its traditional use as an antispasmodic.The crude methanolic extract of A. macrocephala was studied for possible relaxant effect(s) on spontaneous rabbits' jejunum preparations. Analytical-grade chemicals were used in the experimental protocols. A. macrocephala gave positive tests for flavonoids, saponins, glycosides, alkaloids, and terpenes. A. macrocephala caused relaxation of spontaneous rabbits' jejunum preparations (n=6) at a dose of 10.0 mg/mL (EC(50) = 6.95 ± 0.20 mg/mL; 95% CI: 6.2 to 7.5). Contractions induced by 80 mM potassium chloride (KCl) were also relaxed by the A. macrocephala at dose of 10.0 mg/mL. Attempting to find an explanation for the possible mode of action, we found that, A. macrocephala at concentration of 1.0 mg/mL produced rightward shift in the calcium chloride curves, with EC(50) value of -1.65 ± 0.02 log [Ca(++)] M vs control with EC(50) value of -2.44 ± 0.043 for calcium chloride curves. At a concentration of 1.0 mg/mL it could produce 52.4% of the control response at log [Ca(++)] M = -1.6. Similarly, verapamil at a concentration of 0.1 μM produced a rightward shift, with EC(50) value of -1.74 ± 0.026 log [Ca(++)] M (95% CI: -1.66 to -1.82; n=6) vs control with EC(50) value of -2.45 ± 0.05 log [Ca(++)] M (95% CI: - 2.23 to -2.91; n=6). The right shift of the EC(50) values is justification for the folkloric use of A. macrocephala as an antispasmodic, suggesting that the possible mode of action is through calcium channel blockade.

Ileal perforation in a child with abdominal tuberculosis

A 6-year-old boy presented with a 1-month history of fever followed by abdominal distension, constipation and bilious vomiting for 2 days. The clinical impression was of intestinal obstruction. At exploratory laparotomy, there was an ileal perforation secondary to tuberculosis. There are many case reports of tubercular ileal perforation in adults but in children it is very rare.

Maternal and biochemical predictors of antepartum stillbirth among nulliparous women in relation to gestational age of fetal death

OBJECTIVE

To determine whether maternal serum levels of alphafetoprotein (alpha-FP) and human chorionic gonadotrophin (hCG) at 15-21 weeks provided clinically useful prediction of stillbirth in first pregnancies.

DESIGN

Retrospective study of record linkage of a regional serum screening laboratory to national registries of pregnancy outcome and perinatal death.

SETTING

West of Scotland, 1992-2001.

POPULATION

A total of 84,769 eligible primigravid women delivering an infant at or beyond 24 weeks of gestation.

METHODS

The risk of stillbirth between 24 and 43 weeks was assessed using the Cox proportional hazards model. Logistic regression models within gestational windows were then used to estimate predicted probability. Screening performance was assessed as area under the receiver operating characteristic (ROC) curve.

MAIN OUTCOME MEASURE

Antepartum stillbirth unrelated to congenital abnormality.

RESULTS

The odds ratio (95% CI) for stillbirth at 24-28 weeks for women in the top 1% were 11.97 (5.34-26.83) for alpha-FP and 5.80 (2.19-15.40) for hCG. The corresponding odds ratios for stillbirth at or after 37 weeks were 2.44 (0.74-8.10) and 0.79 (0.11-5.86), respectively. Adding biochemical to maternal data increased the area under the ROC curve from 0.66 to 0.75 for stillbirth between 24 and 28 weeks but only increased it from 0.64 to 0.65 for stillbirth at term and post-term. Women in the top 5% of predicted risk had a positive likelihood ratio of 7.8 at 24-28 weeks, 3.7 at 29-32 weeks, 5.1 at 33-36 weeks and 3.4 at 37-43 weeks, and the corresponding positive predictive values were 0.97, 0.33, 0.47 and 0.63%, respectively.

CONCLUSIONS

Maternal serum levels of alpha-FP and hCG were statistically associated with stillbirth risk. However, the predictive ability was generally poor except for losses at extreme preterm gestations, where prevention may be difficult and interventions have the potential to cause significant harm.

Seroprevalence of HIV infection in hospitalized paediatric patients at a tertiary care centre in western India

The prevalence of HIV infection in children in India is not known. In this study, a total of 270 children admitted to paediatric wards in Mumbai were screened for HIV infection by enzyme-linked immunosorbent assay (ELISA). Eight patients (2.96%) had a positive HIV ELISA. Of these two patients (25%) were less than 15 months of old and hence HIV infection in them could not be confirmed. The prevalence of HIV was 2.3%. Three out of 11 patients with tuberculosis (27.3%) and four out of 15 patients with nutritional anaemia (26.7%) had HIV infection (P<0.0001 in each case). Vertical transmission was the cause in all children, suggesting that implementation of Prevention of Parent to Child Transmission of HIV (PPTCT) is required to reduce the rate of paediatric HIV infection.