Reno protective role of amlodipine in patients with hypertensive chronic kidney disease

Chronic kidney disease (CKD) and hypertension (HTN) are closely associated with an overlapping and intermingled cause and effect relationship. Decline in renal functions are usually associated with a rise in blood pressure (BP), and prolonged elevations in BP hasten the progression of kidney function decline. Regulation of HTN by normalizing the BP in an individual, thereby slowing the progression of kidney disease and reducing the risk of cardiovascular disease, can be effectively achieved by the anti-hypertensive use of calcium channel blockers (CCBs). Use of dihydropyridine CCBs such as amlodipine (ALM) in patients with CKD is an attractive option not only for controlling BP but also for safely improving patient outcomes. Vast clinical experiences with its use as monotherapy and/or in combination with other anti-hypertensives in varied conditions have demonstrated its superior qualities in effectively managing HTN in patients with CKD with minimal adverse effects. In comparison to other counterparts, ALM displays robust reduction in risk of cardiovascular endpoints, particularly stroke, and in patients with renal impairment. ALM with its longer half-life displays effective BP control over 24-h, thereby reducing the progression of end-stage-renal disease. In conclusion, compared to other classes of CCBs, ALM is an attractive choice for effectively managing HTN in CKD patients and improving the overall quality of life.

Evaluation of Effectiveness and Tolerability of Fondaparinux in the Management of Symptomatic Acute Coronary Syndrome: A Real-World Evidence-Based Study on an Indian Population

INTRODUCTION

Fondaparinux is a low molecular weight heparin anticoagulant used to manage the full spectrum of acute coronary syndrome (ACS) patients and has proved its efficacy and safety in multiple clinical trials. However, there are limited data available showing whether the same results could be reproduced in real-world practice on an Indian population. Our objective was to determine the effectiveness and tolerability of fondaparinux in the management of symptomatic ACS in real-world clinical practice.

METHODS

The EMR data of hospitalized ACS patients (n = 611), from January 2015 to January 2020, representing UA or NSTEMI or STEMI and were prescribed fondaparinux (2.5 mg once daily) to manage ACS were analyzed. The effectiveness was analyzed as recurrence of ACS and tolerability as total incidence of major bleeding during hospitalization, at 30 days and 180 days. Appropriate statistical analysis was used with a statistically significance of p value < 0.05.

RESULTS

The incidence of recurrent ACS was not seen during hospitalization and in the first 30 days, while in only 0.65% (n = 4) patients, ACS reoccurred within 180 days. In a mean duration of 172.75 ± 3.20 days, UA was reported in 0.49% (n = 3) patients, NSTEMI in 0.16% (n = 1) of patients, and STEMI was not documented. None of the major bleeding events occurred during the entire study period, whereas minor bleeding events were reported during hospitalization 0.98% (n = 6) and at 30 days 0.16% (n = 1). The bleeding events were statistically insignificant (p value > 0.05). No incidences of stent thrombosis were reported during the entire study period.

CONCLUSIONS

In the real world, fondaparinux was found to be effective and tolerable when used to manage symptomatic ACS patients regardless of revascularization procedure with no incidence of stent thrombosis, and minimal recurrent ACS and insignificant increase in bleeding events.

Fondaparinux: A cornerstone drug in acute coronary syndromes

In acute coronary syndrome (ACS), the use of anticoagulants in conjunction with antiplatelet agents in the acute phase has resulted in reduced ischemic events and is more effective than either class of drug used alone. Though parenteral anticoagulation is essential at the time of diagnosis, a balance must be made between ischemic benefit and the increased risk of bleeding when prescribing anticoagulants. Adverse events associated with anticoagulants, such as heparin-induced thrombocytopenia, bleeding problems, and the need for close monitoring of anticoagulant activity, have contributed to finding agents that reduce these limitations. Studies like the Organization to Assess Strategies in Ischemic Syndromes 5 and 6 and their meta-analysis have proven the efficacy of Fondaparinux over the entire ACS spectrum. The convenience of administration (once daily), lack of monitoring, reduction in mortality, and better safety profile make Fondaparinux a simple and effective anti-coagulant for the management of ACS.

Molecular detection and prevalence of Rotavirus with acute gastroenteritis among the children of rural and urban areas

Rotavirus is the main infective agent of acute gastroenteritis (AGE) in children under the age of five years and causing significant morbidity as well as mortality throughout the world. The study was carried out to detect the prevalence rate, genotypes strain and risk factors of Rotavirus among the children of rural and urban areas of district Bannu Khyber Pakhtunkhwa Pakistan. A total of 180 stool samples were collected from children under the age of 5 years from two major hospitals of Bannu from January to December (2015). The samples were analyzed by Reverse-transcriptase Polymerase Chain Reaction (RT-PCR) for the detection of Rotavirus, positive samples were further processed for genotyping (G and P type) through specific PCR. Of the total, 41 (23%) samples were positive for Rotavirus. The most prevalent G genotypes found were: G3, G8, G9 (each 29%), followed by G10 (15%), and G11 (10%). Whereas the prevalent P genotypes were: P-8 (25%), P-4 and P-10 (each 20%), P-9 (15%), followed by P-6 and P-11 (each 10%). Moreover, Rotavirus infection was more prevalent in summer (23.73%) and winter (22.7%) than spring (20%) and autumn (21.4%). Rotavirus infection exhibited high frequency in June (14%), October (8%) and November (6%). It is concluded that Rotavirus is more prevalent in children and various genotypes (G and P) of Rotavirus are present in the study area. Lack of studies, awareness and rarer testing of Rotavirus are the principal reasons of virus prevalence in district Bannu, Pakistan.

Effect of Amlodipine in Stroke and Myocardial infarction: A Systematic Review and Meta-analysis

INTRODUCTION

Hypertension is a progressive cardiovascular condition arising from complex aetiologies. Progression is strongly associated with functional and structural abnormalities that lead to multi-organ dysfunction. Stroke and myocardial infarction are two of the major complications of hypertension in India. Various anti-hypertensive drugs, such as calcium channel blockers (CCBs), beta-blockers, diuretics, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been the medications of choice for disease management and are known to be effective in reducing the complications of hypertension. CCBs, such as amlodipine, are also currently being used and proven to be effective, although their beneficial effects in the management of complications of hypertension like stroke and myocardial infarction (MI) have yet to be proven. Therefore, the aim of this systematic review was to evaluate the effect of amlodipine on stroke and MI in hypertensive patients.

METHODS

A systematic search of English electronic databases was performed for studies with sufficient statistical power that were published between 2000 andl 30 August 2020, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. A total of 676 papers were screened, and 13 were found eligible to be included in the meta-analysis. Studies that included patients who suffered from MI or stroke and were under amlodipine treatment were included in the analysis. The odds ratio and the risk ratio of amlodipine compared to active control/placebo were noted from the studies and statistically analyzed.

RESULTS

Amlodipine had a significant effect in reducing stroke and MI in hypertensive patients. Similar to results published in reports, this systematic review proved that the hazard ratio for amlodipine was < 1 for stroke (0.69-1.04) and MI (0.77-0.98), showing that amlodipine accounted for better prevention of stroke and MI.

CONCLUSION

In the pooled analysis of data from 12 randomised controlled trials and one double-blinded cohort study measuring the effect of CCBs, we found that the CCB amlodipine reduced the risk of stroke and MI in hypertensive patients. Superior results for amlodipine were found in ten of the 13 studies included in this meta-analysis.

Demographic profile, clinical characteristics and medical management patterns of Indian coronary artery disease patients: a nationwide urban-based, real-world, retrospective, observational electronic medical record study- report of baseline data

Background: This is the first detailed Indian electronic medical record (EMR)-based real-world observational study to understand the clinical characteristics, associated comorbidities/risk factors and treatment(s) of CAD patients across India.Methods: EMR data of adult Indians (aged ≥ 18 years) diagnosed with CAD was retrospectively analyzed.Results: The majority of the participants had stable IHD (93%), were men (68.5% in ACS, 59.8% in stable IHD), most common age group was 40-64 years in ACS (56.6%) and stable IHD (51.4%). Both are common in metros (ACS 52%, 62% stable IHD). There is a high frequency of hypertension (38.2% in ACS, 59% in stable IHD) and diabetes mellitus (32.3% in ACS, 57.6% in stable IHD). Most common treatments are antiplatelet drugs and lipid-lowering drugs (96%).Conclusions: In India, stable IHD is the most prevalent form in vast majority of patients. The patients with CAD are mostly males, are mainly located in metros and majority fall between the age group of 40-64. The major comorbidities are hypertension and diabetes mellitus. Sociodemographic and clinical characteristics for CAD in India may not be similar to what is reported from the west. There is a significant difference in drug usage and adherence to guidelines in India for CAD.

Effectiveness and Effect on Renal Parameters of Amlodipine vs. Other Dihydropyridine Calcium Channel Blockers in Patients with Essential Hypertension: Retrospective Observational Study Based on Real-World Evidence from Electronic Medical Records

Introduction

The renoprotective effects of dihydropyridine calcium channel blockers (CCBs) have been established as non-inferior to other classes of antihypertensive drugs. Studying their effect on renal outcome parameters, specifically for amlodipine as monotherapy, in real-world settings can further help in expanding its usage among Indian patients. This study was performed to assess the effects of amlodipine and other dihydropyridine CCBs (cilnidipine, benidipine and azelnidipine) on renal parameters and effectiveness in blood pressure reduction in Indian patients.

Methods

The retrospective data of adult patients (> 18 years) with essential hypertensive who were prescribed amlodipine (n = 92), cilnidipine (n = 91), benidipine (n = 70) or azelnidipine (n = 71) as monotherapy were analyzed. The renal outcomes, serum creatinine, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), microalbumin, urine albumin-to-creatinine ratio (UACR), sodium and potassium levels, and mean changes in BP were analyzed from baseline to 12 months. Appropriate statistical methods were used to determine the significance (p value < 0.05).

Results

From baseline to the end of the study, mean serum creatinine changed from 0.98 ± 0.17 to 1.07 ± 0.28 mg/dL with amlodipine, 0.97 ± 0.18 to 1.13 ± 0.50 mg/dL with cilnidipine, 0.98 ± 0.30 to 0.97 ± 0.27 mg/dL wi th benidipine, and 0.99 ± 0.23 to 0.98 ± 0.25 mg/dL with azelnidipine (p = 0.01). The mean microalbumin and UACR were reduced from baseline to the end of the study (p = 0.06 and p > 0.05). No significant changes were observed in BUN, sodium or potassium levels. Overall, for all CCBs, the mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) values were reduced from baseline to the end of the study (p = 0.002). At the end of the study, the average dose of amlodipine was 7.25 mg, and the average reduction in SBP and DBP per mg dose was 1.54 and 0.57 mmHg. The corresponding numbers for the other CCBs were as follows: cilnidipine, 14.28 mg, 0.26 and 0.01; benidipine, 5.71 mg, 0.41 and 0.11; azelnidipine, 15.88 mg, 0.13 and 0.06.

Conclusion

Amlodipine and other CCBs demonstrated good efficacy and similar effects on renal parameters from baseline to end of study. Amlodipine also showed higher potency by demonstrating greater BP reduction at a lower dose. Thus, amlodipine can remain a preferred choice among CCBs, even with the advent of the newer CCBs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-021-00224-8.

Retrospective, Observational Study to Determine the Choice of Antihypertensive agent According to Stage of Hypertension, Risk factors and Co-morbidities in Real World Setting in India: A Report of Baseline Data

BACKGROUND

The present study intended to estimate the comorbidities and risk factors among patients with hypertension in India. Further, the current practice of hypertension management was evaluated and the choice of therapy was assessed based on hypertension grade, risk factors, and comorbidities.

METHODS

Electronic medical record data (June 2017-June 2019) of Indian adult hypertensive patients (≥140/90 mmHg) who had two blood pressure (BP) readings were retrospectively analyzed. Demographic characteristics, BP readings, comorbidities, medications and co-medications, and laboratory data were collected at baseline. Grids based on hypertension grade (I, II, and III), demographic factors, risk factors, and comorbidities were created and prescribed antihypertensive drugs (AHDs) in each grid were evaluated.

RESULTS

Among 100,075 patients, the proportion of patients in 18-40 year, 40-65 year, and &gt;65 year age groups were 11.4%, 65.1%, and 23.4%, respectively. Proportion of men and women was similar (52.0% vs 47.9%). Proportion of patients with BMI &lt;25 Kg/m2 was 8.1%, 25-29.9 Kg/m2 was 11.9%, and &gt;30 Kg/m2 was 8.8%. Mean BP of patients with hypertension was: grade I (145.05/90.73 mmHg), grade II (160.07/95.64 mmHg), and grade III (180.82/102.76 mmHg). Mean low density lipoprotein (113.26 mg/dL), serum creatinine (2.28 mg/dL), mean HbA1c (8.7%) levels were highest among patients with grade III hypertension. Commonly observed comorbidities were type 2 diabetes mellitus (T2DM: 51.5%), dyslipidemia (36.4%), and chronic kidney disease (CKD: 4.4%). Top concomitant medications included anti-diabetic therapies (34.6%), drugs for dyslipidemia (30.0%), and anti-platelet therapies (6.9%).

CONCLUSION

Most prescribed AHD monotherapies were angiotensin receptor II blockers (ARBs) and calcium channel blockers (CCBs) and most prescribed combination therapies were ARBs + diuretics and ARBs + CCBs. Telmisartan and amlodipine+telmisartan for patients with comorbid T2DM or dyslipidemia and metoprolol for those with coronary artery disease were the commonly prescribed AHDs.

Effectiveness of Telmisartan on Blood Pressure Control in Hypertensive Patients in India: A Real-World Retrospective Study from Electronic Medical Records

INTRODUCTION

The effectiveness of telmisartan has been reported in Indian clinical trials; however, real-world data are limited. We aimed to provide real-world evidence regarding the effectiveness of telmisartan as monotherapy or in combination with other antihypertensive drugs (AHDs) in Indian patients with essential hypertension.

METHODS

Electronic medical record data of adult patients diagnosed with essential hypertension (≥ 140/90 mmHg) and who were prescribed telmisartan as mono- or add-on therapy were retrospectively analyzed. Patients were classified according to the number of AHD classes prescribed on initiating telmisartan. Change in systolic and diastolic blood pressure (SBP and DBP) after a month of treatment and the proportion of patients who achieved treatment goals according to the 2018 European Society of Cardiology/European Society of Hypertension guidelines were evaluated.

RESULTS

A majority (90.6%) of the 1304 patients included in the study were on telmisartan monotherapy or telmisartan + 1 AHD. The mean (95% confidence interval [CI]) change in the telmisartan monotherapy group was SBP (-13.3 [-14.6, -12.0] mmHg) and DBP (-7.2 [-7.9, -6.5] mmHg), and the mean (95% CI) change in the telmisartan + 1 AHD group was SBP (-10.8 [-13.1, -8.5] mmHg) and DBP (-6.5 [-7.7, -5.3] mmHg) (P < 0.001 for all). SBP and DBP goals were achieved by 35.9% and 47.3% of patients on telmisartan monotherapy and by 35.9% and 46.8% of patients on telmisartan + 1 AHD. Among patients with comorbid diabetes, the mean (95% CI) change in the telmisartan monotherapy group was SBP (-13.3 [-15.0, -11.6] mmHg) and DBP (-7.3 [-8.2, -6.5] mmHg), and the mean (95% CI) change in the telmisartan + 1 AHD group was SBP (-13.0 [-16.5, -9.5] mmHg) and DBP (-6.9 [-8.7, -5.1] mmHg) (P < 0.001 for all). SBP and DBP goals were achieved by 31.7% and 39.7% of patients on telmisartan monotherapy and by 31.9% and 41.8% of patients on telmisartan + 1 AHD.

CONCLUSION

Telmisartan may be a good candidate for blood pressure control in Indian patients with essential hypertension and comorbidities.

Quality Improvement Project Demonstrate that Prolonged Pre-Analytical Time Does Not Lead to False Negative Blood Cultures

Introduction/Objective

Bacterial infection is a significant cause of morbidity and mortality. Prompt identification of microorganisms and their susceptibilities to antimicrobial therapies is critical in the management of patients with bloodstream infections. Blood cultures are collected in paired aerobic and anaerobic bottles. However, transport delays might allow some organisms to grow extensively prior to incubation in the blood culture instruments, leading to false-negative culture results. The Detroit Medical Center utilizes the BD Bactec™ instruments for blood culture incubation and the Verigene DNA-based molecular assay for the identification of bacteria and major resistance genes. It has a core microbiology lab that serves 6 hospitals, however, 2 of the hospitals are remotely located.

The aim of this project was to determine if transportation delays led to significant false-negative culture results. If significant false negativity occurred, additional Bactec™ instruments would need to be purchased.

Methods

For one month, we tracked the collection of blood cultures to incubation time at one of the remote hospitals. All blood cultures that remain negative after 164 hours of incubation are routinely discarded. However, in this case, they were subcultured to a Petri plate containing chocolate agar for 30 days. Any organisms that grew were identified by standard lab techniques.

Results

Of the 547 negative culture bottles that were subcultured for possible false-negative results, only 3 (0.5%) bottles grew bacteria. All three were isolated from different patients. The mean time from blood collection to incubation in the instrument was 4-8 hours. The isolates either met criteria for contaminated cultures, or they grew the same pathogen that had previously been identified in the paired bottle from the same culture. The organisms isolated include coagulase negative Staphylococcus species, Staphylococcus pettenkoferi, and Pseudomonas aeruginosa. No unexpected pathogenic organisms were detected.

Conclusion

Our results demonstrate that prolonged pre-analytical time does not lead to false-negative blood culture results. The patients’ diagnoses were not changed, therefore, the purchase of additional blood culture instruments was not necessary. However, transportation time from the patient floors to the main microbiology lab needs to be improved to meet the recommended 2 hours pre-analytical time.

Effectiveness of Amlodipine on Blood Pressure Control in Hypertensive Patients in India: A Real-World, Retrospective Study from Electronic Medical Records

BACKGROUND

The effectiveness of amlodipine has been reported in clinical trials in India. However, real-world data on the effectiveness of amlodipine in India is limited.

OBJECTIVE

To provide real-world evidence regarding the effectiveness of amlodipine as monotherapy or in combination with other antihypertensive drugs (AHDs) in Indian patients with essential hypertension.

METHODS

Electronic medical record data of adult patients who were diagnosed with essential hypertension (≥ 140/90 mmHg) and were prescribed amlodipine as monotherapy or add-on therapy were retrospectively analyzed. Patients were classified based on the number of AHD classes prescribed on initiation of amlodipine. Change in systolic (SBP) and diastolic (DBP) blood pressure from baseline was the primary endpoint. Evaluation of proportion of patients who achieved treatment goals as per 2018 European Society of Cardiology/European Society of Hypertension guidelines was the secondary endpoint. Readings were obtained before initiating amlodipine and after at least a month of therapy with amlodipine.

RESULTS

Among the 462 included patients, the majority (90.7%) were on amlodipine monotherapy or amlodipine + 1AHD. Mean (95% confidence interval [CI]) change in the amlodipine monotherapy group was: SBP (- 12.1 [- 14.9, - 9.3] mmHg) and DBP (- 7.5 [- 8.9, - 6.1] mmHg) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 17.8 [- 21.0, - 14.6] mmHg) and DBP (- 9.5 [- 11.0, - 8.0] mmHg) (P < 0.001 for all). SBP and DBP goals were achieved by 31.4% and 42.9% of patients on amlodipine monotherapy and by 38.9% and 51.8% of patients on amlodipine + 1AHD, respectively. Among patients aged ≤ 45 years, mean (95% CI) change in the amlodipine monotherapy group was: SBP (- 11.7 [- 16.0, - 7.4] mmHg; P < 0.001) and DBP (- 7.2 [- 9.7, - 4.7] mmHg; P < 0.001) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 14.6 [- 21.9, - 7.3] mmHg; P < 0.05) and DBP (- 10.6 [- 14.8, - 6.4] mmHg; P < 0.01). SBP and DBP goals were achieved by 35.4% and 33.8% of patients on amlodipine monotherapy and by 48.0% and 56.0% of patients on amlodipine + 1AHD, respectively. Among patients aged ≥ 65 years, mean (95% CI) change in the amlodipine monotherapy group was: SBP (- 13.9 [- 20.2, - 7.6] mmHg; P < 0.01) and DBP (- 8.5 [- 11.4, - 5.7] mmHg; P < 0.001) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 22.4 [- - 28.8, - 16.0] mmHg; P < 0.001) and DBP (- 10.8 [- 14.0, - 7.6] mmHg; P < 0.001). SBP and DBP goals were achieved by 25.5% and 13.7% of patients on amlodipine monotherapy and by 29.8% and 14.0% of patients on amlodipine + 1AHD.

CONCLUSION

Amlodipine prescribed as monotherapy or add-on therapy during routine clinical practice significantly reduced BP in ≤ 45- and ≥ 65-year-old Indian patients with mild to moderate hypertension, emphasizing that amlodipine may be a good candidate for BP control in Indian patients with essential hypertension in these age groups.

Effectiveness of Olmesartan on Blood Pressure Control in Hypertensive Patients in India: A Real World, Retrospective, Observational Study from Electronic Medical Records

BACKGROUND

Real-world data on the effectiveness of antihypertensive drugs (AHDs) in India is limited. The present study aims to provide updated evidence regarding the effectiveness of olmesartan as monotherapy or in combination with other AHDs in Indian patients with essential hypertension.

METHODS

Electronic medical record data of adult patients who were diagnosed with essential hypertension (≥140/90 mmHg) and were prescribed olmesartan as mono- or add-on therapy were retrospectively analyzed. Patients were classified based on the number of AHD classes prescribed on initiation of olmesartan. Change in systolic and diastolic blood pressure (SBP and DBP) from baseline was the primary endpoint. Secondary endpoint was evaluation of proportion of patients who achieved treatment goals as per 2018 European Society of Cardiology/European Society of Hypertension guidelines. Readings were obtained before initiating olmesartan and after at least a month of therapy with olmesartan.

RESULTS

Among the 459 included patients, majority were on olmesartan monotherapy or olmesartan+1AHD (91.7%). Mean (95% confidence interval [CI]) change in olmesartan monotherapy group was: SBP (-13.4 [-15.7, -11.1] mmHg) and DBP (-8.3 [-9.5, -7.1] mmHg) and mean (95% CI) change in olmesartan+1AHD group was: SBP (-11.7 [-15.1, -8.3] mmHg) and DBP (-6.6 [-8.3, -4.9] mmHg) (P<0.001 for all). SBP and DBP goals were achieved by 40.4% and 50.3% of patients on olmesartan monotherapy and by 36.1% and 46.2% of patients on olmesartan+1AHD. Among patients with comorbid diabetes, mean (95% CI) change in olmesartan monotherapy group was: SBP (-15.5 [-18.6, -12.4] mmHg) and DBP (-8.7 [-10.2, -7.2] mmHg) and mean (95% CI) change in olmesartan+1AHD group was: SBP (-13.5 [-18.3, -8.7] mmHg) and DBP (-7.6 [-9.8, -5.4] mmHg) (P<0.001 for all). SBP and DBP goals were achieved by 38.5% and 49.4% of patients on olmesartan monotherapy and by 31.7% and 42.9% of patients on olmesartan+1AHD.

CONCLUSION

Olmesartan prescribed as mono- or add-on therapy during routine clinical practice significantly reduced blood pressure in Indian patients with essential hypertension as well as in patients with comorbid diabetes.

1H NMR based serum metabolic profiling reveals differentiating biomarkers in patients with diabetes and diabetes-related complication

BACKGROUND

Diabetes is among the most prevalent diseases worldwide, of all the affected individuals a significant proportion of the population remains undiagnosed due to lack of specific symptoms early in this disorder and inadequate diagnostics. Diabetes and its associated sequela, i.e., comorbidity are associated with microvascular and macrovascular complications. As diabetes is characterized by an altered metabolism of key metabolites and regulatory pathways. Metabolic phenotyping can provide us with a better understanding of the unique set of regulatory perturbations that predispose to diabetes and its associated complication/comorbidities.

METHODOLOGY

The present study utilizes the analytical platform NMR spectroscopy coupled with Random Forest statistical analysis to identify the discriminatory metabolites in diabetes (DB = 38) vs. diabetes-related complication (DC = 35) along with the healthy control (HC = 50) subjects. A combined and pairwise analysis was performed to identify the discriminatory metabolites responsible for class separation. The perturbed metabolites were further rigorously validated using t-test, AUROC analysis to examine the statistical significance of the identified metabolites.

RESULTS

The DB and DC patients were well discriminated from HC. However, 15 metabolites were found to be significantly perturbed in DC patients compared to DB, the identified panel of metabolites are TCA cycle (succinate, citrate), methylamine metabolism (trimethylamine, methylamine, betaine), -intermediates; energy metabolites (glucose, lactate, pyruvate); and amino acids (valine, arginine, glutamate, methionine, proline, and threonine).

CONCLUSION

The ¹H NMR metabolomics may prove a promising technique to differentiate and predict diabetes and its complication on their onset or progression by determining the altered levels of the metabolites in serum.

A Mesopore-Dependent Catalytic Cracking of n-Hexane Over Mesoporous Nanostructured ZSM-5

Herein, pore size, crystalinity, and Si/Al ratio of mesoporous ZSM-5 (MFI) nanocrystals was controlled by synthesis parameters, such as surfactant concentration ([3-(trimethoxysilyl)propyl] hexa-decyl dimethyl ammonium chloride), sodium hydroxide concentrations, synthesis temperature and time. The morphology, surface structure and composition of the MFI particles was systematically investigated. More notably, the mesopore-dependent catalytic activity of ZSM-5 was evaluated by studying the cracking of n-hexane. The findings suggest the porosity has pronounced impact on the catalytic activity, selectivity and stability of ZSM-5 nanocrystals. Critical surface attributes such as nature of acid sites (Brønsted and Lewis), concentration, and strength are obtained by the infrared study of adsorbed probe molecules (pyridine) and the temperature programmed desorption. In spite of being weaker in Si/Al ratio or acidic strength, mesoporous catalysts showed more stable and efficient cracking of n-hexane suggesting that acidity seems not the predominant factor operative in the activity, selectivity and stability.

Do Human Papilloma Viruses Play Any Role in Oral Squamous Cell Carcinoma in North Indians?

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy among males in India. While tobacco and alcohol are main aetiological factors, human papilloma virus (HPV) presence has surprisingly increased in head and neck Squamous Cell Carcinoma (HNSCC) in the past two decade but its frequency in OSCCS is still uncertain. We aim to explore the frequency of HPV and its major genotypes in North Indian patients and their association with clinicopathological and histopathological features and p16 expression pattern.

MATERIALS AND METHODS

The study group comprised 250 histologically proven cases of OSCC. HPV was detected by real time PCR in tumor biopsy specimens and confirmed by conventional PCR with PGMY09/ PGMY11 primers. Genotyping for high-risk types 16/ 18 was conducted by type specific PCR. p16 expression was assessed by immunohistochemsitry.

RESULTS

HPV presence was confirmed in 23/250 (9.2%) OSCC cases, of which 30.4% had HPV 16 infection, 17.4%were positive for HPV 18 and 26.1% had co-infections. HPV presence was significantly associated with male gender (p=0.02) and habit of pan masala chewing (p=0.01). HPV positive cases also had a history of tobacco consumption in 91.3% cases. p16 over expression was observed in 39.1% of HPV positive cases but this was not significantly different from negative cases (p=0.54).

CONCLUSIONS

The frequency of HPV in OSCC is low in North-India and majority of cases are associated with a tobacco habit. It appears that tobacco shows a confounding effect in HPV positive cases and use of p16 protein as a reliable marker to assess the potential etiological role of HPV in OSCC in our population is not suggested.

Prevention of acute cadmium toxicity by Picroliv

The potential of Picroliv, a herbal extract against acute cadmium (Cd) intoxication, was evaluated in male rats. Biochemical and histopathological profile in rats pretreated with Picroliv (12 mg/kg, oral) followed by a single dose of Cd as cadmium chloride (CdCl2) (3 mg/kg, ip) revealed marked suppression of oxidative stress in liver and testes. The Cd-induced enhanced levels of lipid peroxidation, membrane fluidity and reduced levels of nonprotein sulphydryls and Na+K+ATPase were significantly restored to near normal by Picroliv pretreatment. In addition, the Cd-induced serum levels of glutamate oxaloacetate transaminase, glutamate pyruvate transaminase, gamma glutamyl transpeptidase and lactate dehydrogenase were restored to near basal levels. Hepatic and testicular histopathological damage was also minimized. The results strongly suggest definite hepatoand testicular protection by Picroliv. The antioxidant potential of the herbal extract in the major part, and not its chelating property, seems to be responsible for its ameliorative action.

Impact of genetic variations in C-C chemokine receptors and ligands on infectious diseases

Chemokine receptors and ligands are crucial for extensive immune response against infectious diseases such as malaria, leishmaniasis, HIV and tuberculosis and a wide variety of other diseases. Role of chemokines are evidenced in the activation and regulation of immune cell migration which is important for immune response against diseases. Outcome of disease is determined by complex interaction among pathogen, host genetic variability and surrounding milieu. Variation in expression or function of chemokines caused by genetic polymorphisms could be associated with attenuated immune responses. Exploration of chemokine genetic polymorphisms in therapeutic response, gene regulation and disease outcome is important. Infectious agents in human host alter the expression of chemokines via epigenetic alterations and thus contribute to disease pathogenesis. Although some fragmentary data are available on chemokine genetic variations and their contribution in diseases, no unequivocal conclusion has been arrived as yet. We therefore, aim to investigate the association of CCR5-CCL5 and CCR2-CCL2 genetic polymorphisms with different infectious diseases, transcriptional regulation of gene, disease severity and response to therapy. Furthermore, the role of epigenetics in genes related to chemokines and infectious disease are also discussed.

Isolation and characterization of head kidney derived macrophages of Labeo rohita

Macrophages play a significant role in non-specific defense mechanisms of all vertebrates against pathogens. One critical element in the area of fish immunology is the unavailability of in-vitro model of immune cells. Therefore, it is essential to develop methods for harvesting and culture of macrophages for assessing innate immune functions of rohu, Labeo rohita, an important culture fish of India. Head kidney leukocytes from were isolated by density gradient sedimentation, so as to exclude other cells. Among isolated leukocytes, only macrophages showed the unique property of sustained adherence on plastic surfaces. These cells exhibited optimum growth at 28 degrees C in L-15 containing 20% FBS. Cultured head kidney macrophages (HKM) demonstrated the property of phagocytosis as evidenced by engulfment of yeast cells. Bacterial lipopolysaccharide (20 microg/ml) resulted in functional activation of macrophages as seen by enhanced reactive oxygen and nitrite production; and lysosomal enzyme activity. These results show that in-vitro model of HKM cells can be used to study the role of macrophages in innate immune responses against various immunomodulators.

Establishment of a leukocyte cell line derived from peritoneal macrophages of fish, Labeo rohita (Hamilton, 1822)

A continuous leukocyte cell line with phagocytic activity was established from peritoneal macrophages of rohu, Labeo rohita (LRPM). LRPM was initiated from adherent mononuclear leukocytes isolated from peritoneal cavity of rohu, without use of any growth factors or feeder cells. These cells exhibited maximum growth at 30 °C in L-15 medium containing 20 % foetal bovine serum, and has been subcultured for more than 60 passages till date. The cells showed 85 % viability after 6 months of storage in liquid nitrogen. The species of origin of the LRPM was confirmed by the amplification and sequencing of 655 bp fragment of cytochrome oxidase subunit I of mitochondrial DNA. Functionally, LRPM showed phagocytic activity of yeast cells and fluorescent latex beads as evaluated by phase contrast and scanning electron microscopy, respectively. Immuno-modulators such as bacterial lipopolysaccharide and phorbol myristate acetate resulted in functional activation of LRPM; and enhanced their microbicidal activity through release of reactive oxygen species and nitric oxide. Culture supernatant from activated cells also revealed lysozyme activity. Cells of LRPM were positive for alpha-naphthyl acetate esterase enzyme indicating macrophage lineage. Our results indicate that this cell line can be a useful in vitro tool to study the role of macrophages in teleost immune system and to evaluate the effects of new aquaculture drugs. The LRPM cell line represents the first reported leukocyte cell line of peritoneal origin from any freshwater species of fish.

Injection safety at primary health care level in south-western Saudi Arabia

In a study of injection safety in Abha health district, Saudi Arabia, data were collected from 47 physicians and 85 nurses at 24 primary health care centres, using an observation checklist and an interview questionnaire. All centres used individually packed disposable syringes and puncture-proof containers to collect used needles. Needlestick injury in the previous year was reported by 14.9% of physicians and 16.5% of nurses (0.21 and 0.38 injuries/person/year respectively). Logistic regression analysis identified recapping the needle after use (physicians and nurses) and bending the needle before disposal (physicians) as significant risk factors for injury.

Altitude and bronchial asthma in south-western Saudi Arabia

Through a house-to-house survey, 1325 people aged 11+ years registered at 2 primary health care centres (1 at high altitude and 1 at sea level) in Asir region, Saudi Arabia, were interviewed and examined for weight, height and peak expiratory flow rate. The prevalence of bronchial asthma at sea level (19.5%) was significantly higher than at high altitude (6.9%). Illiteracy, low income, use of coal and wood for heating, having a mud or tent house, lack of electricity inside dwellings and presence of sheep were also significant risk factors for bronchial asthma. In multivariate logistic regression, only altitude was found to be significantly associated with bronchial asthma (adjusted odds ratio = 3.94).

Primary health care emergency services in Abha district of southwestern Saudi Arabia

To study emergency services delivery in all 30 primary health care centres in Abha district of Asir region, Saudi Arabia, data were collected about equipment and facilities, physicians' practices and attitudes, and patients' utilization of and satisfaction with emergency services. Two centres had no devoted place for emergency services. Lack of some essential equipment and drugs was evident. The greatest continuing medical education need for doctors was the management of cardiovascular emergencies (72.3%). Many doctors (40.4%) did not consider the majority of cases as true emergencies. Many patients (43.7%) used the centres for emergency services, the most common being trauma, burns and orthopaedics (47.8%). Most patients were satisfied overall with emergency services (82.2%).

Neuroprotective effect of Acorus calamus against middle cerebral artery occlusion-induced ischaemia in rat

The neuroprotective potential of ethanol:water (1:1) extract of rhizomes of Acorus calamus (AC-002) has been investigated in middle cerebral artery occlusion (MCAO)-induced ischaemia in rats. A significant behavioural impairment in Rota-Rod performance and grid walking was observed in rats, 72 hours after MCAO as compared to sham-operated animals. These rats also exhibited an increase in lipid peroxidation (cortex -157%, corpus striatum - 58%) and a decrease in glutathione levels (cortex - 59%, corpus striatum - 34%) and superoxide dismutase (SOD) activity (cortex - 64%, corpus striatum - 32%) as compared to sham-operated animals. Ischaemic rats treated with AC-002 (25 mg/kg, p.o.) exhibited a significant improvement in neurobehavioural performance viz. Rota-Rod performance and grid walking as compared to the MCAO group. Interestingly, treatment with AC-002 in MCAO rats significantly decreased malonaldialdehyde levels in cortex as compared to ischaemic rats. A significant increase in reduced glutathione levels and SOD activity was also observed both in cortex and corpus striatum in MCAO rats treated with AC-002 in comparison to MCAO rats. Treatment with AC-002 in MCAO rats also reduced the contralateral cortical infarct area (19%) as compared to MCAO rats (33%). Neurological function score was improved in the AC-002-treated rats as compared to the MCAO group. The results of the present study indicate the neuroprotective efficacy of A. calamus in the rat model of ischaemia.

Knowledge and attitudes towards AIDS among Saudi and non-Saudi bus drivers

We explored the AIDS knowledge and attitudes of long-distance (non-Saudi) and in-city (Saudi) bus drivers in Saudi Arabia. The 69 non-Saudi drivers tended to score higher on knowledge than the 40 Saudi drivers although there were several gaps in their knowledge. As regards attitude, more Saudis knew that chastity could protect against AIDS and both groups tended to think that they were not the kind of people to get AIDS. Intensive health education and follow up is highly recommended for this sector of workers.

Tuberculous spondylitis: analysis of 69 cases from Saudi Arabia

DESIGN

Retrospective chart and radiographic review of all cases admitted to the authors' hospital and diagnosed to have tuberculous spondylitis.

OBJECTIVE

To identify the frequency, presenting features, utility of diagnostic tests, and treatment outcome of spinal tuberculosis in a tertiary care center.

METHODS

All cases of spinal tuberculosis treated in the authors' hospital over 14 years were reviewed. Only those with histologic or microbiologic confirmation or those who responded to antituberculous spondylitis therapy were included. Outcome was assessed according to predefined criteria.

RESULTS

Between 1985 and 1998, 69 cases of tuberculous spondylitis were found, i.e., 5% of all tuberculous spondylitis cases diagnosed. The mean age was 52.8 years (range, 15-80 years), and 37 (53.6%) were male. Only five patients had a history of tuberculosis. The most frequent symptoms were backache (84%) and fever (32%), and the most frequent sign was spinal tenderness (45%). Nineteen (28%) patients had paraparesis and 12 (17%) had kyphosis. Except for elevated sedimentation rate (94.5%), the laboratory workup was not helpful. Both computed tomography and magnetic resonance imaging were found to be helpful in diagnosis, often with complementary information. Thirty-eight patients (55%) had thoracic spine involvement and 55 patients (80%) had paraspinal abscesses. Tissue aspirates had a yield of 70%, 35%, and 57% for granulomas, acid-fast bacilli smear, and culture, respectively. Medical therapy alone was given in 37 cases (54%), whereas 32 patients (46%) required additional surgical intervention, mainly those with spinal cord compression, spinal deformity, or risk of spinal instability. There was definite improvement in 63 cases (91%). The best outcome was in those patients presenting early before the occurrence of spinal deformity or neurologic symptoms.

CONCLUSION

Tuberculous spondylitis is prevalent in the authors' hospital. Both computed tomography and magnetic resonance imaging are extremely helpful for diagnosis, and tissue aspirate is a good confirmatory method. A good outcome is expected if the diagnosis is made in early stages before the appearance of spinal deformity and neurologic symptoms. Surgical intervention can be avoided in these cases regardless of the presence or absence of paraspinal abscesses.

Age dependent aneuploidy and telomere length of the human vascular endothelium

RATIONALE

Aneuploidy and telomere length are two major parameters that have been associated with cellular senescence in vitro. In order to explore the role of aneuploidy and telomere length in aging of the human vasculature, we studied these two parameters in direct preparations of endothelial cells of the human abdominal aorta.

METHODS

Using fluorescent in situ hybridization on 'touch prep' slides, we evaluated aneuploidy of two autosomes (chromosomes 6 and 16) and sex chromosomes in non cultured endothelial cells of the abdominal aorta as a function of the donor's age.

RESULTS

We found that the frequency of aneuploidy of vascular endothelial cells significantly increased with age. This was expressed by age-dependent tetrasomy (r(s)=0.56, P=0.006 for chromosome 6; and r(s)=0.54, P=0.008 for chromosome 16), and age dependent loss of the Y chromosome (r(s)=0.85, P=0.0003). In addition, we found that telomere length was inversely correlated with age (r=-0.38, P=0.008). DATA INTERPRETATION: These findings suggest that indicators of cellular senescence, earlier observed in vitro, are also expressed in the human vascular endothelium in vivo. Aneuploidy and telomere attrition might thus play a role in the aging of the human vasculature.

Central obesity in elderly individuals in south-western Saudi Arabia: prevalence and associated morbidity

Central obesity in all individuals aged 65 years and over (n = 810) in the catchment areas of three primary health care centres in Abha was determined from the waist circumference (WC) and waist-to-hip ratio (WHR). The age-adjusted prevalence of central obesity was 32.4% and 43.5% based on the WC and WHR indicators respectively. WC was significantly associated with the risk of diabetes and hypertension, while WHR was significantly associated with the risk of diabetes only. These findings suggest that reducing the prevalence of central obesity in old age would decrease the risk of diabetes and hypertension. WC is a powerful independent predictor mainly of hypertension risk, while WHC is a good predictor of the risk of diabetes.

Increasing resistance of M. tuberculosis to anti-TB drugs in Saudi Arabia

The incidence of drug resistance in Mycobacterium tuberculosis (MTB) isolated from our hospital between April 1996 and March 1998 was compared with an earlier study (1993-1995). Thirty (29.7%) of 101 MTB isolates were resistant to one or more anti-TB drugs and 21 (20%) of 101 were multi-drug resistant M. tuberculosis (MDR-TB). Resistance was most common to isoniazid (28.7%), followed by streptomycin (22.8%) and rifampicin (20.8%). Resistance to pyrazinamide and ethambutol was 7.9 and 6.9%, respectively. There was a three-fold increase in resistance compared with the earlier study.

Psychosocial assessment of geriatric subjects in Abha City, Saudi Arabia

Psychosocial assessment of geriatric subjects was carried out through a home-based survey of people aged 65 years and over (n = 810) in the catchment areas of 3 primary health care centres. All the participants had a structured interview and were given a short version of the geriatric depression scale. Depression was found in 17.5% of the subjects, more commonly in women (27.7% versus 12.7%). The combined effect of impaired perceived health status (52.4%) and functional capacity (26.6%), loneliness (4.5%), single status (24.3%), and lack of education (80.5%) explained 23.7% of the variance in depression score by multiple regression analysis. Depression is a problem among the geriatric population in the region, especially women. Periodic home psychosocial screening of geriatrics is recommended.

Brucellosis in pregnant women

Brucella species occasionally cause spontaneous human abortion, but theories regarding whether they do so more frequently than do other infectious pathogens remain controversial. We reviewed 92 pregnant women who presented with acute brucellosis at a Saudi Arabian hospital. From 1983 through 1995, the cumulative incidence of pregnancy and brucellosis was 1.3 cases per 1000 delivered obstetrical discharges. The incidence of spontaneous abortion in the first and second trimesters was 43%, and the incidence of intrauterine fetal death in the third trimester was 2%. Antepartum antimicrobial therapy with cotrimoxazole or cotrimoxazole/rifampin was protective against spontaneous abortion (relative risk, 0.14; 95% confidence interval, 0.06--0.37; P<.0001). The beneficial effect of treatment occurred in women with febrile illness; vaginal bleeding at presentation usually led to spontaneous abortion. This study demonstrated that the incidence of spontaneous abortion among pregnant women with brucellosis is high and that these women should receive prompt therapy with antimicrobial agents when they present for medical care.

Diagnostic value of Brucella ELISA IgG and IgM in bacteremic and non-bacteremic patients with brucellosis

The diagnostic value of Brucella ELISA IgG and IgM has been evaluated in patients with brucellosis. Serum samples and blood cultures were collected from 83 patients with brucellosis. The sera were tested by Brucella ELISA for Brucella IgM and IgG antibodies. All 44 controls were negative for IgG and IgM. Brucella melitensis was isolated from blood cultures of 30/83 (36.1%) patients. Among the 30 bacteremic patients, 24 (80%) had an increased IgM titer of > or = 200. Of the 53 non-bacteremic patients, 41 had IgM titer > or = 200, while 22 had IgG titer of > or = 1,600. The ELISA IgM and IgG tests achieved a specificity and sensitivity of 100% and 96% respectively, while the positive and negative predictive values were 100% and 94% respectively. The Brucella ELISA is a reliable and sensitive test in the diagnosis of brucellosis. The test is rapid, easy to perform and can be automated.

Telomere attrition of the human abdominal aorta: relationships with age and atherosclerosis

Little is known about the turnover rate (i.e. the rate of replication and death) of cells in the intima and media of human arteries as a function of age and atherosclerosis. One indicator of the replicative history of cells is telomere length. In this work we explored the rate of telomere attrition as a function of age and atherosclerosis in cells of the human abdominal aorta. Telomere length, measured by the terminal restriction fragment using Southern analysis, was determined in the intima and media of the distal (infrarenal) versus proximal (suprarenal) segments of the abdominal aorta. Telomere length was then correlated with age and atherosclerotic grade. The rate of age-dependent telomere attrition was higher in both the intima and media of the distal versus proximal abdominal aorta. In addition, telomere length was negatively correlated with atherosclerotic grade. However, after adjustment for age, this relationship was not statistically significant. The high rate of age-dependent telomere attrition in the distal abdominal aorta probably reflects enhanced cellular turnover rate due to local factors such as an increase in shear wall stress in this vascular segment.

Audit of a diabetic health education program at a large Primary Health Care Center in Asir region

OBJECTIVE

To evaluate the health education program in a large Primary Health Care Center, to find out the problems faced by the staff and to suggest the practical and relevant solutions.

METHODS

This study was carried out at Wasat Abha Primary Health Care Center, Asir region during 1997. The files of diabetics who attended the center were evaluated for health education topics by using a checklist. The essential structure of diabetic health education program was assessed by using another check list designed by the investigators. Data entry and analysis was carried out through SPSS package. Chi-square test was applied wherever necessary.

RESULTS

The total number of diabetics who attended Wasat Abha Primary Health Care Center was 198. The duration of diabetes mellitus was 7.7+5.8 years. Ninety percent of these were married, 50.5% were educated and 79% were employed. Compliance to appointment was good in 60% and poor in 30% of diabetics. About 73% of the diabetics received at least one health education topic while 27% did not receive any health education at all. Only 33% of diabetic patients had adequate health education. Ninety one percent were provided with diabetic identification cards, 80% were explained about diabetes and 77% were educated about the role of diet. Essential structure for diabetes education program was found to be unsatisfactory.

CONCLUSION

Effective diabetic health education program needs the availability of all essential structures, community participation and integration of the government and private sectors. The deficiencies in the structures and the process of health education programs in our practice are almost universal to other Primary Health Care Centers in the Asir region. Providing the Primary Health Care Centers with all essential structures and annual auditing are complimentary to a successful diabetic health education program.

Clinico-diagnostic experience with tuberculous lymphadenitis in Saudi Arabia

OBJECTIVES

To describe the diagnosis and outcomes of tuberculous lymphadenitis in a low HIV-seroprevalence population at a hospital in Riyadh, Saudi Arabia.

METHODS

Retrospective case series of tuberculous lymphadenitis from 1983 to 1998 were examined.

RESULTS

There were 99 cases with a median age of 38 years and a female preponderance (female/male ratio of 1.3 : 1). Eighty per cent had cervical involvement and 36% had systemic symptoms. Eighty-nine per cent had their lymphadenopathy for more than 1 month. The diagnostic yield of tuberculin skin testing was 83%, of chest X-ray was 27%, of fine-needle aspiration was 46%, and of excisional lymph node biopsy was 97%. Only one-third of patients received a tuberculin test. There was no significant difference in outcome between 6 and 9 months of chemotherapy, and paradoxical enlargement of nodes occurred in only 6%.

CONCLUSIONS

Tuberculous lymphadenitis in our study population was predominantly cervical in location. The diagnostic yield of FNA was lower than that reported in the literature, and might be improved by more frequent tuberculin skin testing, multiple aspirations of lymph nodes, or use of excisional biopsy as the initial diagnostic procedure. Most patients responded well to chemotherapy, with few complications.

Measles antibody titre in children up to 5 years of age in rural areas of Aligarh District, India

OBJECTIVE

To determine the pattern of decline of maternal antibodies in 0-9 month old infants and to study the prevalence of measle antibodies and their levels in 9 month to 5 year old children, regardless of their immunization status.

METHODS

A cross-sectional study covering 456 children in the 0-5 year age group residing in 9 registered villages in a rural area of Aligarh District was conducted. The study included the interview of parents, clinical examination of children, and Hemagglutination Inhibition Test for Measles Antibody Titre.

RESULTS

There was rapid decline in seropositivity from 100% in the 0-3 month age group to 18% in the 6-9 month age group. There was a positive correlation (r = 0.77) between decline of seropositivity and age. Measle immunization coverage rate was 64.5%. In 202 children where immunization was confirmed by availability of card, sero-conversion was 96.5%. Of the 118 unvaccinated children, 9% were sero-positive. Of the 71 children who had a history of measles infection, 75% were seropositive indicating correct identification of measle infection by the parents.

The changing spectrum of Group B streptococcal (GBS) infection in infants of Saudi Arabia

This study describes the incidence, clinical presentation and outcome of neonatal Group B streptococcal (GBS) infection in a Saudi Arabian Hospital. Charts of all neonates with GBS infection admitted to our hospital during a 5-year period (1990-1994) were reviewed retrospectively. Of the 29,601 live births, 23 neonates had GBS infection, giving an overall incidence rate of 0.8 per 1000 live births. The incidence rate appeared to increase from 0.2 per 1000 live births in 1990 to 1.2 per 1000 live births in 1994 (not statistically significant (P=0.07)). Of the 23 neonates with GBS infection, 16 (70%) were full term infants (gestation > or = 37 weeks). In contrast, 7 (30%) were preterm infants (gestation < 37 weeks). Ten (44%) mothers had premature rupture of membrane. Intrapartum fever and/or urinary tract infection was observed in 9% of the mothers. Nineteen (82%) of the neonates had early onset GBS infection, whereas only 4 infants (18%) had late-onset infection. Blood and CSF cultures were positive in 21 (91%) and 5 (21%), respectively. Complications of GBS infection were as follows: sepsis without focus of infection 15 (65%); meningitis 5 (22%); pneumonia 3 (13%); urinary tract infection 2 (9%). None of these complications had any significant association with the onset of infection (P>0.1). The overall case-fatality rate was 9%. The incidence of GBS infection appears to be increasing in Saudi neonates and measures to prevent perinatal transmission need to emphasized and implemented.

Brucella bacteraemia: clinical and laboratory observations in 160 patients

OBJECTIVES

To describe the clinical, serological, and prognostic features of bacteraemic brucellosis in an endemic region.

METHODS

Retrospective case series of 160 patients admitted from 1983 to 1995 to a hospital providing secondary and tertiary level medical care in Saudi Arabia. All patients had positive blood cultures for Brucella species, predominantly Brucella melitensis.

RESULTS

Bacteraemia was documented in 38% of 545 cases of brucellosis admitted to our institution during the study period. The main clinical syndromes were febrile illness alone (44%) or fever with arthritis (42%). Of 68 isolates that were speciated, 93% were Brucella melitensis. Initial agglutinating antibody titre was > or =1:320 in 96% of the patients. Antimicrobial resistance of B.melitensis isolates was: co-trimoxazole, 29%; rifampicin, 3.5%; streptomycin, 0.6%; and tetracycline, 0.6%. No increase in resistance was noted over the 13-year study period. Commonly used antimicrobial regimens consisted of streptomycin plus tetracycline or rifampicin plus doxycycline given for 6 weeks. Seven patients (5%) had relapse of their symptoms after antimicrobial therapy. Three of these had infective endocarditis with repeated bacteraemia. These patients required aortic valve replacement and recovered after surgery. The remaining four patients responded to a second course of therapy.

CONCLUSIONS

Brucella bacteraemia is an acute febrile disease often associated with rheumatologic complaints. Most patients have an agglutinating antibody titre > or =1:320 and respond well to standard chemotherapy regimens with low mortality.

The need for traditional birth attendants (dayas) in Saudi Arabia

Preferences of women living in remote areas regarding delivery place and attendant were surveyed, opinions of primary health care (PHC) doctors about traditional birth attendants' (TBA) maternal care were assessed and training needs for TBAs were identified using questionnaires and a focus group discussion. Home deliveries and TBAs were preferred by approximately 24% and 38% of the women respectively. The fact that they were women and psychological comfort were the main reasons for preferring TBAs. TBAs disclosed many harmful practices. No PHC centre help was sought by 75% of TBAs. Lack of cooperation between PHC centres and TBAs was a concern of most of the doctors. Training and links to PHC services for TBAs are needed.

Effect of extracapsular cataract extraction and phacoemulsification performed after trabeculectomy on intraocular pressure

PURPOSE

To determine whether there is a difference in intraocular pressure (IOP) control between extracapsular cataract extraction (ECCE) and phacoemulsification performed after successful trabeculectomy.

SETTING

Eye Unit, St. Woolos Hospital, Newport, United Kingdom.

METHODS

This retrospective study comprised 55 patients with glaucoma who had had trabeculectomy and subsequently had cataract surgery. Extracapsular cataract extraction was performed in 34 eyes and phacoemulsification in 21. The IOP before cataract surgery was used as a baseline for comparison with the IOP at 6 and 12 months and at the last follow-up visit (mean 44.26 months in the ECCE group and 15.09 months in the phacoemulsification group). At the 3 postoperative examinations, the IOP was recorded before and after institution of medical treatment.

RESULTS

In the ECCE group, the IOP exceeded the target pressure in 7 eyes and required medical treatment; it remained uncontrolled in 1 eye at the final visit. In the phacoemulsification group, the IOP was less than 18 mm Hg without any medication and within the target pressure in all 21 eyes. The IOP increase after ECCE was statistically significant (mean IOP was 13.61 mm Hg before and 15.53 mm Hg after ECCE; P = .0297). After treatment was instituted, there was no statistically significant difference in the IOP compared with the preoperative value (P = .0796 at 6 months, .677 at 1 year, and .4419 at the final visit in the ECCE group and .0703, .2220, and .1035, respectively, in the phacoemulsification group).

CONCLUSION

The findings indicated that IOP was better controlled by phacoemulsification than by ECCE in patients who had had filtration surgery.

Compliance and control of diabetes in a family practice setting, Saudi Arabia

This study aimed to identify some determinants of compliance with diet, anti-diabetic drugs and the appointment system amongst diabetic patients (n = 294) attending a family practice setting. The results showed that good compliance with diet was significantly higher among males (P = 0.01) and those with good diabetic control (P = 0.01), while good compliance with appointment systems was significantly associated with type II diabetes (P < 0.01) and good care (P < 0.01). Compliance with drugs showed no significant association with any of the studied determinants (P > 0.05). When multiple regression analysis was applied, the degree of control of diabetes, its duration and the total score of care were the only predictors of the three aspects of compliance (P < 0.05).

Efficiency of utilisation of energy from maize- and broken rice-based diets in old White Leghorn and Rhode Island Red laying hens

1. The efficiency of utilisation of metabolisable energy (ME) for maintenance (k(m)) from diets containing maize and broken rice (BR) at 500 g/kg was studied in old White Leghorn (WL) and Rhode Island Red (RIR) laying hens using the respiration calorimetry technique. The maize-based diet contained 180.8 g crude protein (CP)/kg and 16.4 MJ gross energy (GE)/kg while the BR-based diet contained 173.2 g CP/kg and 16.3 MJ GE/kg. Diets were fed for 10 d, while an energy and nitrogen metabolism study was conducted during 3 d on an ad libitum-fed diet followed by another 3 d on two-thirds of the ad libitum-fed quantity. 2. ME values for the maize- and BR-based diets for WL hens were 73.3% and 77.6% of the GE, whereas for the RIR hens these were 77.7% and 80.0%, respectively. 3. Fasting heat productions, determined at the end of 24 h fast for WL and RIR hens were 473.2 and 366.1 kJ/kg W0.75/d, respectively. During fasting WL and RIR hens utilised body energy reserves with efficiencies of 84.9% and 73.7%, respectively. 4. The k(m) of maize- and BR-based diets for the WL hens were 81.6% and 79.6%, whereas for the RIR hens these were 74.2% and 76.0%, respectively. 5. ME for maintenance of WL and RIR hens were 589 and 499.6 kJ/kg W0.75/d, respectively. 6. It is concluded that although WL and RIR hens differ significantly in energy metabolism, their efficiency of utilisation of energy from maize- and BR-based diets are similar.

Kaposi's sarcoma in a liver transplant series

At our center one hundred eighteen patients have received liver transplants between July 1, 1991 and December 10, 1997. We describe the only one of them to our knowledge who developed Kaposi's sarcoma. It was disseminated, involving the gastrointestinal tract, lungs, multiple lymph nodes and peripancreatic soft tissues. She had no cutaneous Kaposi's sarcoma. Her massive gut involvement was not apparent clinically, even by colonoscopic examination with multiple biopsy specimens. She was diagnosed at postmortem examination.

Evolution of brain tuberculomas under standard antituberculous treatment

The treatment of brain tuberculomas is primarily medical. Surgery, excision or biopsy, is generally performed when the diagnosis is in doubt or there is no response to medical therapy. The aim of this study was to determine the radiological evolution of intracranial tuberculomas under standard anti-tuberculous drug therapy and to establish guidelines for better management of these patients. Eighteen patients were studied retrospectively. None of them had surgical intervention and all were treated by standard antituberculous drugs and had serial computed tomography (CT) scans until disappearance or stabilization of brain lesions. The regression of lesions' size and number was slow in the first month (mean -7.3%) then became rapid after this (-15% to -20% per month). A paradoxical increase in size was noted in three patients in the first month. All three had associated meningitis. All tuberculomas disappeared on CT scan after 12 months of therapy. Most of the edema images disappeared by 6 months. This study would suggest that a long treatment regimen of 15-18 months may not be necessary in most intracranial tuberculomas occurring in non-immunocompromised patients. It also demonstrates that medical trial in well tolerated suspected cases should last for at least 2 months before considering other etiologies or surgical exploration.

On the tissue/species dependence of cathepsin B isozymes

Characterization of cathepsin B from buffalo kidney and goat spleen showed the presence of isozymes in case of the goat spleen (GSCB-I and GSCB-II) whereas cathepsin B from buffalo kidney exhibited only one form (BKCB). The molecular weights determined by SDS-PAGE for GSCB-I, GSCB-II, and BKCB were 25.7, 26.6 and 25.5 kDa respectively. The kinetic parameters (Km and Vmax) of GSCB-I showed close similarities with BKCB against alpha-N-benzoyl-DL-arginine-2-napthylamide whereas GSCB-II was closer to the buffalo enzyme with regards to its activity against Z-Arg-Arg-MCA and Z-Phe-Arg-MCA. All the three enzymes had similar sensitivities towards urea, antipain and leupeptin. However, clear differences were observed in the inhibition patterns of the enzyme with iodoacetic acid and iodoacetamide. Differences in the kinetic, immunogenic and some catalytic properties of GSCB-I and II, which had similarities with regard to most of their physico-chemical properties, were considered to be due to the existence of two isozyme forms in goat spleen cathepsin B preparations. Absence of such a multiplicity in forms of the enzyme from buffalo kidney was accordingly attributed to the absence of cathepsin B isozymes in this species. These observations taken together therefore, indicate a probable species/tissue dependence of cathepsin B.

Sublingual lorazepam as premedication in peribulbar anesthesia

PURPOSE

To assess the efficacy of sublingual lorazepam in inducing amnesia when used as a premedication for peribulbar anesthesia.

SETTING

Department of Ophthalmology in a large district general hospital.

METHODS

Following local ethical committee approval, a prospective, randomized, placebo-controlled, double-blind study of patients having routine cataract or glaucoma surgery under local anesthetic was undertaken. Patients older than 90 years of age or who were frail, confused, or unfit for surgery were excluded, as were those who weighed less than 50 kg, swallowed the tablet, or had missing data. Sixty volunteer patients were randomly given 1 mg of lorazepam or a placebo tablet by sublingual route 1 hour preoperatively. All patients were assessed for sedation, akinesia, intraoperative analgesia, and patient response including amnesia.

RESULTS

There was no significant difference between groups in sedation, analgesia, or akinesia. Overall patient response was better in the lorazepam group (P = .05). Patient-reported incidence of amnesia was significantly higher in the lorazepam than in the placebo group (P < .05).

CONCLUSIONS

Sublingual lorazepam improved patient comfort by inducing amnesia, and in the low dose used in this study, did not adversely affect surgery by undue heavy sedation.