Antibiotics resistance as a major public health concern: A pharmaco-epidemiological study to evaluate prevalence and antibiotics susceptibility-resistance pattern of bacterial isolates from multiple teaching hospitals

BACKGROUND

Multi Drugs Resistance (MDR) is among the most worrisome healthcare issues resulting from inappropriate and indiscriminate utilization of antimicrobial agents which has compromised the efficacy and reliability of antimicrobial agents (AMAs). This has not only put a huge burden on the health care system but also is a major cause of morbidity and mortality. This project was designed to evaluate the prevalence of various microbial strains among patients admitted to various teaching hospitals and to assess their susceptibility and resistance towards clinically approved antibiotics.

METHODS

The study was conducted during August 2021-February 2022 to determine the prevalence of common resistant strains of bacteria and to analyze their susceptibility pattern to the commonly prescribed antibiotics using standard procedures. One hundred and thirty biological samples including urine, blood, cerebrospinal fluid (CSF), wound swabs, pus and sputum were collected from the site of infection from the patients admitted at different wards of North West General Hospital (NWGH), Peshawar, Pakistan, Khyber Teaching Hospital (KTH), Peshawar Pakistan, and Hayat Abad Medical Complex (HMC) Peshawar Pakistan. Samples were collected and cultured following standard hospital procedures. The cultured samples were subjected to identification procedures including Gram staining, morphological characterization of bacterial colonies and biochemical assessments. The identified bacteria were tested for their susceptibility using Kirby-Bauer disc diffusion method. The diameter of Inhibitory Zones (DIZ) was analyzed following Clinical and Laboratory Standards Institute (CLSI) criteria. Minimum Inhibitory Concentrations (MICs) were evaluated using agar dilution method. Antimicrobials sensitivity were presented as antibiogram following CLSI M39 standard.

RESULTS

A total of one hundred and thirty biological samples were collected, out of which one hundred and nine samples were positive for bacterial growth and were further processed for detailed analysis. The frequency and type of bacteria isolated from various cultures indicated that Gram negative bacteria (n = 92/109) were more dominant than Gram-positive (n = 17/109) pathogens. The most prevalent bacteria isolated was Escherichia coli (29.35 %), followed by Staphylococcus aureus (15.59 %), and Klebsiella spp, (12.84 %). In addition, other pathogens including, Enterobacter spp, Citrobacter spp, and Acinetobacter spp. showed a prevalence of 9.175 %, 8.25 %, and 5.50 % respectively. As indicated in the antbiogram, several organisms exhibited considerble decline in the sensitivies towards various antibiotics. A high percentage of resistance was observed against some antibiotics including trimethoprim, co-trimoxazole, amoxicillin/clavulanate, ciprofloxacin, piperacillin/tazobactam, cefotaxime and ceftazidime.

CONCLUSION

The prevalence of resistant strains of pathogens is increasing day by day, while the antibiotics commonly prescribed against them are losing their efficacy, which is pushing the world to the era of pre-antibiotics. Unfortunately, the discovery of novel antibiotics is limited and researchers speculate that the is pushing towards pre-antibiotics era. Subsequently, efforts must be directed towards ensuring rational antibiotics use to prevent emergence of MDR pathogens. Our findings indicated that Gram negative bacteria including Escherichia coli was most prevalent. Other bacterial strains including S. aureus, Klebsiella spp, Enterobacter spp, Citrobacter spp, and Acinetobacter spp. were found among the causative agents. Unfortunately, considerable decline in the sensitivities of various bacterial isolated were observed towards the tested antibiotics. Previous studies reported the high prevalence of E. coli and S. aureus in clinical samples of Pakistani hospitals including hospitals in Peshawar and thus our findings are in agreement with the previous reports. Pharmacists being experts can play their role by promoting the optimal use of antimicrobial agents and educating healthcare professionals, patients and the public.

Association of serum leptin and resistin levels among obese Saudi patients with acute myocardial infarction in Asir region

In the current scenario, the importance of cardiac biomarkers in diagnosing, assessing, and managing people with cardiovascular discomfort is required. This cross-sectional study examined the relationship between serum leptin and resistin levels among obese people with acute myocardial infarction (AMI) with varying body mass index (BMI). The cardio and diabetic biomarkers among the 77 Saudi patients with hypoxia who lived in the Asir region were analyzed in the study. The patients were categorized into three groups, namely, group 1 (control), group 2 (AMI with normal BMI), and group 3 (AMI with varying BMI). Our results showed a positive correlation between serum glucose, HbA1C, triglycerides, Troponin-I (cTnI), creatine kinase MB (CK-MB), leptin, and resistin in patients with AMI. We also observed significantly lower HbA1C, cholesterol, and insulin values in groups 2 and 3. A statistical difference between the groups with and without AMI and between the genders was noticed. BMI with leptin showed a positive connection in group 3 but no association was observed for groups 1 and 2. A stronger relationship between BMI and leptin levels in men in Group 3 than in women was observed. In all three groups, resistin levels did not correlate with BMI. Thus, circulating leptin concentrations do not significant impact AMI compared to participants with and without AMI. However, resistin levels were considerably higher in obese individuals with AMI. Therefore, we suggest that resistin can be used as a pro-inflammatory marker to detect AMI disorder with varying BMI and as a prognostic marker associated with AMI.

Antibacterial and Antibiofilm Activities of β-Lapachone by Modulating the Catalase Enzyme

Background: Bacterial infections constantly have a large impact on public health, because of increased rates of resistance and reduced frequency of development of novel antibiotics. The utility of conventional antibiotics for treating bacterial infections has become increasingly challenging. The aim of the study was to assess the antibacterial effect of β-Lapachone (β-Lap), a novel synthetic compound. Methods: The antibacterial activity of the β-Lap compound was examined against laboratory strains by agar well diffusion method and broth dilution assay. Growth kinetics in presence of β-Lap on Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa (ATCC 27853) were assessed by microplate alamarBlue assay. Crystal violet blue assay was used for biofilm inhibition and biofilm eradication. P. aeruginosa catalase (KatA) complexed with β-Lap was modeled using molecular docking approach. Results: β-Lap exhibited potent antimicrobial activity against laboratory strains of bacteria with MIC of 0.2 mM for S. saprophyticus and Staphylococcus aureus, and 0.04 mM for Staphylococcus epidermidis and Pseudomonas aeruginosa ATCC 27853. The inhibition of catalase enzyme was found to be the cause for its antibacterial activity. Bioinformatics analysis suggests that β-Lap can inhibit KatA activity by interacting with catalase proximal active site and heme binding site. The activity of some commercial antibiotics was enhanced in association with β-Lap. In addition, β-Lap inhibited the biofilm formation and eradicated the already formed and ultra-mature biofilms of aforesaid bacterial strains. Conclusion: These observations indicated that β-Lap could be a promising antibacterial agent for the treatment and prevention of infectious diseases.

Comparison of Creatine Kinase-MB, Troponin-I, Troponin-T, Triiodothyronine, Thyroxine, Apoprotein-B and Homocysteine between Non-smokers, Smokers at High Altitudes, and Smokers at Sea Level

Earlier diagnosis of heart disease can occur via awareness of biochemical changes. Keeping this in view, we wanted to determine if there was any difference between biochemical heart parameters between non-smokers (the control group), smokers who live at a high altitude, or smokers who live at sea level. There were 180 participants categorised into three groups, A, B, and C, depending upon their smoking/non-smoking classification, or distance from sea level. Blood samples were taken as per requirements to check levels of creatine kinase-MB, troponin-I, troponin-T, Triiodothyronine (T3), Thyroxine (T4), Apolipoprotein B (apo-B), and homocysteine, and subjected to enzyme-linked immunoassay (ELISA) investigations. Creatine kinase-MB, troponin-I, troponin-T, T3, thyroxine, apoprotein-B, and homocysteine all exhibited a noteworthy difference (p≤0.01) when compared between non-smokers and smokers (either at a high altitude or sea level), but only troponin I and T3 showed a noteworthy difference when compared between smokers at a high altitude versus at sea level (p≤0.01) as follows: Creatine kinase-MB, p=0.434; troponin-I, troponin-T, p=0.208; T3, p≤0.01; thyroxine, p=0.190; apoprotein-B, p=0.008; and homocysteine, p=0.039. It has been found that significant differences exist between smokers and non-smokers regarding cardiovascular (CV) pathology, whether the person resides at a high altitude or sea level. However, additional studies should be performed to find the correlation between smokers at a high altitude versus and smokers at sea level, which can change the treatment methods at high altitudes and pave the way for finding new medicines.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Modulating the production of xylanase by Bacillus pumilus BS131 through optimization using waste fiber sludge

In recent days, cheapest alternative carbon source for fermentation purpose is desirable to minimize production cost. Xylanases have become attractive enzymes as their potential in bio-bleaching of pulp and paper industry. The objective of the present study was to identify the potential ability on the xylanase production by locally isolated Bacillus pumilus BS131 by using waste fiber sludge and wheat bran media under submerged fermentation. Culture growth conditions were optimized to obtain significant amount of xylanase. Maximum xylanase production was recorded after 72 hours of incubation at 30 °C and 7 pH with 4.0% substrate concentration. In the nutshell, the production of xylanase using inexpensive waste fiber sludge and wheat-bran as an alternative in place of expensive xylan substrate was more cost effective and environment friendly.

Phytochemical Screening and In-Vitro Antibacterial and Anticancer Activity of Crude Extract of Matricaria aurea

BACKGROUND

Infectious diseases constantly represent the source of sickness as well as mortality in human beings. Herbal applications in human life through using plants for antibacterial and anticancer activity have shown the potential medicinal outcome.

OBJECTIVES

To evaluate the antibacterial and anticancer activities of the crude extract of Matricaria aurea.

MATERIALS AND METHODS

The antibacterial activity of the crude flowers of M. aurea extract was examined against reference and clinical bacterial strains by agar well diffusion method. Minimum inhibitory concentrations and minimum bactericidal concentrations were determined by micro broth dilution assays using MH broth. Herbal extract was employed over human breast adenocarcinoma cell line (MCF-7), hepatocellular carcinoma cell line (HepG-2) and colorectal adenocarcinoma cell line (HCT-116) to optimize cancer cells proliferation by SRB assay.

RESULTS

The data has shown that the extract from M. aurea had significant antimicrobial activity against the tested microorganisms. The plant extract showed higher antibacterial activity against the reference strain of Streptococcus pyogenes. The MIC and MBC varied between 0.38-12.5 mg/ml and 3.1-200 mg/ml respectively. Synergy study elucidated the significant bacteriostatic effect of M. aurea extract on S. aureus and S. saprophyticus. The data of SRB assay deliver the potential anticancer activity through cell death.

CONCLUSION

This study delivers innovative information that M. aurea possessed excellent bio-activities against pathogenic microbes and cancer cells, which drive attention for further research to explore the active components responsible for biological efficacies.

61 Outcomes of An Advanced Nurse Practitioner-Led Pops Service in A District General Hospital

Introduction

There is an increased need for geriatrician input to older adults outside of the medical wards. There is a lack of geriatricians to contribute to these services. An example includes the Proactive care of older people undergoing surgery (POPS) service where geriatricians perform comprehensive geriatric assessment (CGA) to identify comorbidities and geriatric syndromes which may lead to poor post-operative outcomes. Advanced nurse practitioners (ANP) are highly skilled staff members and are increasingly used to provide the POPS service. We wanted to review the outcomes of our Nurse Led POPS service.

Methods

Patients aged over 70 admitted as an emergency to upper gastrointestinal and colorectal surgery were assessed by the POPS ANP using CGA. Assessments were completed on a proforma. Data was collected prospectively on a data collection form documenting new issues detected and interventions made. The results were analysed using an Excel spreadsheet.

Results

147 patients were reviewed by the ANP between November 2018 and March 2019. All patients were screened for frailty, cognitive impairment and delirium. 37.41% were clinically frail, 17.72% had cognitive impairment and 11.56% had delirium. New issues were identified in 90.47% of these patients; polypharmacy (80.27%), new catheter (53.74%), weight loss (46.94%), incontinence (36.05%), falls (29.25%) and pain (25.17%). Medical issues were also identified including electrolyte abnormalities (47% patients), acute kidney injury (22% patients), cardiac issues (8% patients) and respiratory problems (7% patients). Additional interventions included stopping medication (27.89%), starting new medication (20.41%), requesting further investigations (97.28%), referring to allied health professionals (95.24%) and advanced care planning (15.65%).

Conclusions

A POPS ANP can effectively conduct CGA identifying new medical issues and geriatric syndromes missed by the surgical teams in an acute setting.

Identification of native endophytic Trichoderma spp. for investigation of in vitro antagonism towards Armillaria mellea using synthetic- and plant-based substrates

AIMS

To isolate endophytic Trichoderma species and investigate the potential for biological control of the root rot pathogen Armillaria mellea.

METHODS AND RESULTS

In all, 40 Trichoderma isolates were obtained from a range of host plants and identities were confirmed by ITS, rpb2 and tef1 sequence. When tested in dual culture assays for antagonism against A. mellea, Trichoderma isolates overgrew the A. mellea colonies within four days and by eight days 38 Trichoderma isolates significantly reduced A. mellea colony size. Armillaria mellea was unable to be recovered from five of eight co-cultivations tested, suggesting Trichoderma had killed the A. mellea in these cases. Pre-colonized hazel disks were used to determine what happens in a more heterogeneous situation with A. mellea and a refined set of eight Trichoderma isolates. Similar to plate-based assays, Trichoderma quickly covered A. mellea stopping any further growth and two Trichoderma isolates were able to eradicate A. mellea.

CONCLUSIONS

Of the Trichoderma spp. tested, endophytic isolates of Trichoderma virens and T. hamatum offered the greatest antagonism towards A. mellea. Using pre-colonized hazel disks was of great importance for this work to demonstrate the fungal interactions in plant material.

SIGNIFICANCE AND IMPACT OF THE STUDY

Controlling Armillaria root rot is difficult with chemical treatments, thus an environmentally benign and cost-effective alternative is required. This study highlights the prospect of biological control as an effective, environmentally friendly alternative to chemicals.

Integron mediated antimicrobial resistance in diarrheagenic Escherichia coli in children: in vitro and in silico analysis

The exchange of genes between bacterial chromosome and plasmid(s) and their integration into integrons are mainly responsible for acquisition and dissemination of antibiotic resistance. We investigated the role of integrons and their underlying molecular mechanisms leading to development of adaptability in E. coli and eventual resistance to antimicrobials. Escherichia coli isolates (n = 120); including 40 diarrheagenic isolates, an even number of isolates from cases other than diarrhea, and equal number of isolates from healthy children recovered from fresh stool samples were used for identification of integron genes and gene cassettes. The association of integrons with antibiotic resistance was assayed before phylogenetic analysis. DNA sequence analysis revealed class 1 and 2 integrons in 55.83% and 21.66% isolates, respectively. The integron presence was found significantly associated with the probability of antibiotic resistance in E. coli; the association being highest with class 1 integron. Modelling and molecular docking along with molecular dynamics simulation analyses found ceftriaxone and amoxicillin as potential inhibitors of dihydrofolate reductase (DHFR). The class 1 integrons of these pathogenic isolates can serve as prospective therapeutic targets using specific silencing strategies and combinational antimicrobial therapy. The findings may be useful for the development of a potent and versatile drug for DHFR inhibition.

GC-MS analysis of Myrtus communis extract and its antibacterial activity against Gram-positive bacteria

BACKGROUND

Myrtus communis is a typical plant of Mediterranean area. The different parts of this plant such as berries, branches, and leaves have been used worldwide as a traditional/folk medicine for the treatment of various ailments and diseases.

METHODS

Ethanolic leaf extract of the plant was prepared by Soxhlet extraction method. Zone of inhibition, minimum inhibitory concentration and minimal bactericidal concentration were determined by well diffusion method and microplate alamar blue assay. GC-MS analysis was carried out to identify the compounds present in the extract. Microscopy and ImageJ software were used respectively for morphology and cell-length measurements. GraphPad Prism was used for statistical analysis.

RESULTS

The ethanolic extract showed strong inhibitory effect against Gram-positive and acid-fast bacteria with significant inhibition-zone size (9-25 mm), MIC (4.87-78 μg/ml), as well as MBC (0.3-20 mg/ml). However, no effect was observed on the growth of Gram-negative bacteria. The growth inhibition was found to be associated with the damage of cell wall as the extract-treated cells were sensitive to cell wall-targeting antibiotics and displayed the cell wall damage-depicting morphological defects. GC-MS analysis confirmed the presence of novel compounds in addition to the most representative compounds of the essential oils/extracts of M. communis of other country origins.

CONCLUSION

These results demonstrate that M. communis leaf extract could be the source of compounds to be used for the treatment of Gram-positive bacterial infections. This is the first report, which provides insights into the mechanism of action of the extract in inhibiting the growth of Gram-positive bacteria.

Cancer drug resistance: A fleet to conquer

Cancer is a disease that claims millions of lives each year across the world. Despite advancement in technologies and therapeutics for treating the disease, these modes are often found to turn ineffective during the course of treatment. The resistance against drugs in cancer patients stems from multiple factors, which constitute genetic heterogeneity like gene mutations, tumor microenvironment, exosomes, miRNAs, high rate of drug efflux from cells, and so on. This review attempts to collate all such known and reported factors that influence cancer drug resistance and may help researchers with information that might be useful in developing better therapeutics in near future to enable better management of several cancers across the world.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial

Background

Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs.

The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision.

Methods/design

This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.

Discussion

A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions.

Trial registration

Trial Registration Number: ISRCTN 25616490. Registered on 1 January 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.

Clinicopathological Spectrum Of Gall Bladder Cancer In Kashmir - An Institutional Study

Gallbladder cancer is a highly aggressive malignancy that usually presents at an advanced incurable stage. It is the fifth most common gastro-intestinal tumor and leads to approximately 2800 deaths in United States annually. This was a retrospective study carried out in the Department of Pathology, Sher-i-Kashmir Institute of Medical Sciences, a 650-bed super speciality hospital in Kashmir valley. We reviewed the histopathological records of all the patients who were diagnosed as carcinoma gallbladder from Dec 2009-Dec 2013. Gross findings and histopathological findings were noted from the departmental archival material and clinical records of the patients including the clinical presentation, laboratory investigations, radiological investigations, pre-operative diagnosis and intra-operative findings, were retrieved from the hospital records. We analyzed 57 cases of carcinoma gallbladder for their clinicopathological features It included 19 males and 37 females. In our study, adenocarcinomas accounted for 87.5% of total carcinomas. Incidentally, all but one patient where gall stones were found, adenocarcinomas were seen. We have 4 patients of squamous cell carcinoma. In our series we have a single case of small cell carcinoma which was positive for neuroendocrine markers. In our study, gall stones were seen only in 8 cases (14%) of the total cases.

Patient-reported outcomes during and after definitive chemoradiotherapy for oesophageal cancer

BACKGROUND

Limited data describe patient-reported outcomes (PROs) of localised oesophageal cancer treated with definitive chemoradiotherapy(CRT). The phase 2/3 SCOPE-1 trial assessed the effectiveness of CRT±cetuximab. The trial for the first time provided an opportunity to describe PROs from a multi-centre group of patients treated with CRT that are presented here.

METHODS

Patients undergoing CRT±cetuximab within the SCOPE-1 trial (258 patients from 36 UK centres) completed generic-, disease- and treatment-specific health-related quality of life (HRQL) questionnaires (EORTC QLQ-C30, QLQ-OES18, Dermatology Life-Quality Index (DLQI)) at baseline and at 7, 13, 24, 52 and 104 weeks. Mean EORTC functional scale scores (>15 point change significant), DLQI scores (>4 point change significant) and proportions of patients (>15% significant) with 'minimal' or 'severe' symptoms are presented.

RESULTS

Questionnaire response rates were good. At baseline, EORTC functional scores were high (>75%) and few symptoms were reported except for severe problems with fatigue, insomnia and eating-related symptoms (e.g., appetite loss, dysphagia, dry mouth) in both groups(>15%). Functional aspects of health deteriorated and symptoms increased with treatment and by week 13 global quality of life, physical, role and social function significantly deteriorated and more problems with fatigue, dyspnoea, appetite loss and trouble with taste were reported. Recovery occurred by 6 months (except severe fatigue and insomnia in >15% of patients) and maintained at follow-up with no differences between groups.

CONCLUSIONS

CRT for localised oesophageal cancer has a significant detrimental impact on many aspects of HRQL; however, recovery is achieved by 6 months and maintained with the exception of persisting problems with severe fatigue and insomnia. The data suggest that the HRQL recovery after definitive CRT is quicker, and there is little lasting deficit compared with treatment including surgery. These data need to be compared with HRQL data from studies evaluating treatments including surgery for oesophageal cancer.

Open anterior hip dislocation in a young adult with exposed femoral head and no neurovascular damage

ABSTRACT

Anterior hip dislocation is common in younger adults and is the result of severe, high energy trauma such as high-velocity motor vehicle accidents or falls from great heights. A similar mechanism of injury would cause a femur neck fracture in older patients. Of these, open anterior hip dislocations are extremely rare and are usually associated with other soft tissue and bony injuries. We report a case of an open anterior hip dislocation with normal neurovascular status in a third world setting.

KEY WORDS

trauma, open anterior, dislocation, hip, femoral head, osteonecrosis.

Mycobacterium tuberculosis conserved hypothetical protein rRv2626c modulates macrophage effector functions

Secretory proteins of Mycobacterium tuberculosis are the major immunomodulators of the host immune response. Open reading frame (ORF) Rv2626c, encoding a conserved hypothetical protein eliciting a strong humoral immune response in patients with tuberculosis (TB), was shown to be up-regulated upon infection in mice under hypoxic conditions. We now show that recombinant Rv2626c protein (rRv2626c) can bind to the surface of murine macrophages and elicit the type-1 immune response, as manifested by nitric oxide (NO) secretion and expression of inducible nitric oxide synthase (iNOS). Significant induction of pro-inflammatory cytokines [interleukin (IL)-12 and tumour necrosis factor (TNF)-alpha] was evident upon stimulation of murine macrophages, as well as peripheral blood mononuclear cells (PBMCs) isolated from patients with active TB disease, with rRv2626c. Stimulation with rRv2626c also enhanced the expression of costimulatory molecules such as B7-1, B7-2 and CD40 on murine macrophages. We further show that the production of NO and pro-inflammatory cytokines in response to rRv2626c is mediated by the transcription factor nuclear factor (NF)-kappaB, and this was further confirmed using pyrrolidine dithiocarbamate (PDTC), a specific pharmacological inhibitor of NF-kappaB. Rv2626c therefore appears to modulate macrophage effector functions by eliciting both innate and adaptive immune responses, suggesting its possible use as a vaccine candidate.

Systematic review of the nutritional supplements dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of osteoarthritis

OBJECTIVE

Conventional treatment of osteoarthritis (OA) with non-steroidal anti-inflammatory drugs is associated with serious gastrointestinal side effects and in view of the recent withdrawal of some cyclo-oxygenase-2 inhibitors, identifying safer alternative treatment options is needed. The objective of this systematic review is to evaluate the existing evidence from randomised controlled trials of two chemically related nutritional supplements, dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of OA to determine their efficacy and safety profile.

METHODS

The electronic databases [Cochrane Library, Medline, Embase, Amed, Cinahl and NeLH (1950 to November 2007)] were searched. The search strategy combined terms: osteoarthritis, degenerative joint disorder, dimethyl sulfoxide, DMSO, methylsulfonylmethane, MSM, clinical trial; double-blind, single blind, RCT, placebo, randomized, comparative study, evaluation study, control. Inclusion and exclusion criteria were applied. Data were extracted and quality was assessed using the JADAD scale.

RESULTS

Six studies were included [evaluating a total of 681 patients with OA of the knee for DMSO (N=297 on active treatment); 168 patients for MSM (N=52 on active treatment)]. Two of the four DMSO trials, and both MSM trials reported significant improvement in pain outcomes in the treatment group compared to comparator treatments, however, methodological issues and concerns over optimal dosage and treatment period, were highlighted.

CONCLUSION

No definitive conclusion can currently be drawn for either supplement. The findings from all the DMSO studies need to be viewed with caution because of poor methodology including; possible unblinding, and questionable treatment duration and dose. The data from the more rigorous MSM trials provide positive but not definitive evidence that MSM is superior to placebo in the treatment of mild to moderate OA of the knee. Further studies are now required to identify both the optimum dosage and longer-term safety of MSM and DMSO, and definitive efficacy trials.

Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis

Complementary treatments for osteoarthritis (OA) are sought by patients for symptomatic relief and to avoid the iatrogenic effects of non-steroidal anti-inflammatories. This systematic review evaluates the efficacy of the nutritional supplement Perna Canaliculus (green-lipped mussel, GLM) in the treatment of OA and substantially adds to previous work by focussing solely on GLM use in OA as well providing a re-analysis of the original trial data. Randomized or quasi-randomized controlled trials (comparative, placebo-controlled or crossover) were considered for inclusion from Cochrane Library, Medline, Embase, Amed, Cinahl, Scopus and NeLH databases where adults with OA of any joint were randomized to receive either GLM vs. placebo, no additional intervention (usual care), or an active intervention. The methodological quality of the trials was assessed using the JADAD scale. Four RCTs were included, three placebo controlled, the fourth a comparative trial of GLM lipid extract vs. stabilized powder extract. No RCTs comparing GLM to conventional treatment were identified. All four studies assessed GLM as an adjunctive treatment to conventional medication for a clinically relevant time in mild to moderate OA. All trials reported clinical benefits in the GLM treatment group but the findings from two studies cannot be included in this review because of possible un-blinding and inappropriate statistical analysis. The data from the two more rigorous trials, in conjunction with our re-analysis of original data suggests that GLM may be superior to placebo for the treatment of mild to moderate OA. As a credible biological mechanism exists for this treatment, further rigorous investigations are required to assess efficacy and optimal dosage.

Clinical evaluation of the efficacy of anesthesia and patient preference using the needle-less jet syringe in pediatric dental practice

Most dentists are aware that local anesthetic injections produce the highest incidence of disruptive behavior in children. Both psychological and physiological monitoring of the response of children to dental injection, support empirical observations of clinicians. The needle-free injector delivers local anesthesia without the use of a needle. This is accomplished by delivering the anesthetic solution under high compressive forces. One hundred children between the ages of 3 to 13 years underwent operative procedures using Madajet XL. There was a statistically significant difference in favor of the instrument. The instrument was completely successful in providing anesthesia.

Stress from exercise in the below sea level environment causes an increase in serum testosterone levels in trained athletes

A comparative study (n = 20) of serum levels of leutinizing hormone (LH) and testosterone (T) between male trained athletes (high-school students, 16-18 years old) living in North and South Shouna in the Jordan Valley (JV), 320-360 meters below sea level, and those living in Ramtha and Irbid, 550-650 meters above sea level, was conducted in November, 1999. Serum levels of LH and T were also measured in these athletes following a 20 Km noncompetitive run. The air temperatures on the day of the experiment was comparable (25 degrees C in North and South Shouna versus 23 degrees C in Ramtha and Irbid). Before exercise, serum levels of LH and T in athletes of the below sea level environment (North and South Shouna) were similar to those levels in athletes of the above sea level environment (Ramtha and Irbid). Exercise caused a significant increase in serum levels of both LH and T only in athletes of North and South Shouna. It seems likely that the higher secretion of LH contributes, at least in part, for the higher serum levels of T following exercise. Taken together, these data suggest that exercise has an effect on LH and T secretion that is similar to that of fasting. And finally, the below sea level environmental factors, such as the high barometric pressure, as well as the genetic background of the athletes affect the pituitary and adrenal cortex as well as testicular tissue, resulting in the secretion of more LH and T.

Lactate dehydrogenase activity and insulin and lactate levels at an altitude below sea level (-350 m) compared to those at an altitude above sea level (620 m) after exercise

This study was designed to investigate the effect of exercise at 350 m below sea level altitude (-350 m) on the serum levels of lactate dehydrogenase (LDH), insulin, and lactate. The study was carried out on ten trained adult males with mean age of 23.3 +/- 3.4 years following a 21-km noncompetitive run. Venous blood was withdrawn from the subjects before exercise and 5 min post exercise. For comparison purposes, a similar study was performed with the same subjects but at 620 m above sea level (+620 m). The results show a significant increase in LDH and lactate levels after exercise only at low altitude (-350 m). Serum insulin levels decreased significantly after exercise at both altitudes. These changes in serum levels of LDH, insulin, and lactate at different altitudes suggest that a type of metabolic adjustment is present that meets energy requirements during exercise.

Seasonal pattern of leutinizing, follicle-stimulating hormone, testosterone and progesterone in adult population of both sexes in the Jordan Valley

Differences were observed in hormonal levels between in both sexes of people living in Irbid City (620 meters above sea level) and in the Jordan Valley (360 meters below sea level). In addition, exercise was shown to differentially affect hormonal levels of both sexes at the above and below sea level locations. Serum levels of leutinizing hormone (LH) and testosterone (T) in adult male and serum levels of follicle-stimulating hormone (FSH) and progesterone (P) in adult female people were investigated in Irbid City and in the Jordan Valley during the years 1997 and 1998. The levels of these hormones were followed each month during this period. In males living in Irbid City, LH and T peaked from March through June, and in females at the same site, FSH and P also peaked from March through June. These data confirm the seasonal variation in sex hormones reported elsewhere in (wo)man and in other species. In males and females of the Jordan Valley, serum levels of LH, FSH, T and P were all higher than those of Irbid City throughout the year. Additionally, peaks of LH and T in male and FSH and P in female subjects in the Jordan Valley were observed from March through September. The high levels of these hormones and the extension of their peaks are suggested to be due to effects of the environmental factors of the Jordan Valley (high temperature, high barometric pressure) compared to those in Irbid City and other areas located at above sea level altitude.

Haplotypes of the beta-globin gene as prognostic factors in sickle-cell disease

Wecollaborated with researchers from Egypt, Syrian Arab Republic and Jordan in a study of patients with sickle-cell disease from those countries, and from various parts of Saudi Arabia, in order to investigate the influence of genetics on the clinical presentation of the disease, and to attempt to determine the origin of the sickle-cell gene in Arabs. Our results suggest that beta-globin gene haplotypes influence the clinical presentation of sickle-cell disease, and that there are at least two major foci for the origin of the sickle-cell gene, one in the eastern part of Saudi Arabia, and the other in the populations of North Africa and the north-western part of the Arabian peninsula

Prevalence of thalassaemia in schoolchildren in north-eastern Badia, Jordan

The prevalence of the different types of thalassaemia and that of iron deficiency anaemia was investigated in 1020 schoolchildren [age range: 6-15 years]from the north-eastern Badia region of Jordan. beta-thalassaemia minor was the most prevalent [3.04%], followed by alpha 2-thalassaemia [2.06%]. Only three cases of alpha 1-thalassaemia and one case of beta-thalassaemia major were found. Iron deficiency anaemia was diagnosed in 54 children [5.3%][33 males, 21 females]. The mean values of the blood characteristics of the normal, haemoglobinopathic and iron-deficient children were examined and compared

Haplotypes of the beta-globin gene as prognostic factors in sickle-cell disease

We collaborated with researchers from Egypt, Syrian Arab Republic and Jordan in a study of patients with sickle-cell disease from those countries, and from various parts of Saudi Arabia, in order to investigate the influence of genetics on the clinical presentation of the disease, and to attempt to determine the origin of the sickle-cell gene in Arabs. Our results suggest that beta-globin gene haplotypes influence the clinical presentation of sickle-cell disease, and that there are at least two major foci for the origin of the sickle-cell gene, one in the eastern part of Saudi Arabia, and the other in the populations of North Africa and the north-western part of the Arabian peninsula.

Prevalence of thalassaemia in schoolchildren in north-eastern Badia, Jordan

The prevalence of the different types of thalassaemia and that of iron deficiency anaemia was investigated in 1020 schoolchildren (age range: 6-15 years) from the north-eastern Badia region of Jordan. beta-thalassaemia minor was the most prevalent (3.04%), followed by alpha 2-thalassaemia (2.06%). Only three cases of alpha 1-thalassaemia and one case of beta-thalassaemia major were found. Iron deficiency anaemia was diagnosed in 54 children (5.3%) (33 males, 21 females). The mean values of the blood characteristics of the normal, haemoglobinopathic and iron-deficient children were examined and compared.

Exercise at low altitude (Jordan Valley) causes changes in serum levels of ACTH, insulin, cortisol and lactate

This study was designed to examine the effects of exercise on adrenocorticotropic hormone (ACTH) and cortisol at low altitude (350 meters below sea level) and to compare these effects with those at a moderate level altitude (620 meters above sea level). Ten male trained athletes participated in a 21-K(m) non-competitive race. Serum levels of ACTH, luteinizing hormone (LH), growth hormone and cortisol were measured before and after the race at each of the altitudes. A significant increase in serum levels of ACTH was observed in response to this exercise only at low altitude. Serum levels of growth hormone were increased at both altitudes. Those of LH were not affected. Serum cortisol levels were increased following exercise at both altitudes. It is proposed here that ACTH may play a role in acclimatization to exercise at low altitudes. The role of growth hormone and LH in this conditioning process seems to be insignificant. Additionally, serum levels of insulin and lactate were also measured in these experiments. Exercise caused a decrease in serum insulin levels at both altitudes. Serum levels of lactate were decreased only at low altitude. These changes of serum levels of insulin and lactate suggest a type of metabolic adjustment to meet energy requirements. Changes in energy metabolism can be correlated by changes in the ratio of insulin to serum cortisol levels and those of other counter-regulatory hormones in response to exercise at both altitudes.

Acute effects of exercise at low altitude (350 meters below sea level) on hormones of the anterior pituitary & cortisol in athletes

The purpose of this study was to examine the effects of exercise on anterior pituitary hormones (adrenocorticotropic hormone (ACTH), leutinizing hormone (LH) and growth hormone) as well as on cortisol at low altitude (350 meters below the sea level) and to compare these effects with those at a moderate level altitude (620 meters above the sea level). Ten male athletes with running experience participated in a 21-Km competitive race. Serum levels of ACTH, LH, growth hormone and cortisol were measured before and after the race at each of the altitudes. A significant increase in the serum levels of ACTH and growth hormone were observed in response to this exercise at low altitude. Similar exercise at 620 meters above the sea level resulted in a significant increase only in the serum levels of growth hormone. Serum levels of LH were not affected by this kind of exercise at both altitudes. Serum cortisol levels were increased following exercise at both altitudes. Altogether, these observations show a differential response of the anterior pituitary to exercise at low and normal altitudes. These data suggest that ACTH may have a role in the acclimatization to exercise at low altitudes. The role of growth hormone and LH in this conditioning process seems to be insignificant. The changes in serum cortisol levels in response to exercise at both altitudes correlate well with the effect of exercise on energy metabolism.

Glucose-6-phosphate dehydrogenase isozymes in Jordan Valley

The mean levels of glucose-6-phosphate dehydrogenase (G-6-PD), its deficiency prevalence, and its isozyme type distribution were estimated and compared in five-to-ten-year-old normal school children in two populations of Jordan: the North Jordan Valley (90% black) and Irbid (not black). The prevalences of G-6-PD deficiency in North Jordan and Irbid were 5.5% and 4.62% respectively, and were statistically not different (P>0.05). However, the mean levels of G-6-PD in North Jordan Valley and Irbid were 119.4 IU/10(9) RBC and 128.4 IU/10(9) RBC respectively, and were statistically different (P<0.05). The distribution of G-6-PD isozyme type A (the African types) and type B in North Jordan Valley were 21.5% and 78.5% respectively, and the corresponding rates in Irbid were 5.4% for type A and 94.6% for type B. There was an association between the isozyme type and the region (P<0.05). The high prevalence of the African type of G-6-PD isozyme in Jordan is discussed.

Thyroid function in children with beta-thalassemia major in north Jordan

Basal thyroid function was assessed by serum thyroxine, tri-iodothyronine and thyroid-stimulating hormone levels in 90 patients 2-10 years old with beta-thalassaemia major. Based on measured serum ferritin levels, patients were classified into two groups: group (I) which included 63 patients with ferritin concentrations ranging from 300 to 7000 ng/ml (mild iron overload) and group (II) which included 27 patients with ferritin concentrations higher than 7000 ng/ml (severe iron overload). The results of thyroid function in both groups were compared with those of 50 control subjects. In group (I), the mean concentrations of all measured hormones were not significantly different from those of the controls. In group (II), the mean concentrations of thyroxine and tri-iodothyronine decreased by 29 and 35 per cent (P < 0.05), respectively, and the mean concentration of thyroid-stimulating hormone showed a 2.6-fold increase (P < 0.01) in comparison with those of the controls. The data clearly demonstrate the occurrence of impaired thyroid function and its possible association with iron overload in a considerable proportion of transfusion-dependent beta-thalassaemic patients.

Cortisol levels in children with haemoglobinopathies in north Jordan

Serum cortisol levels of 100 children 3-10 years old with various haemoglobinopathies were measured. The mean cortisol levels of sickle cell trait, sickle cell disease, beta-thalassemia minor and alpha 2-thalassemia were significantly (P < 0.05) lower than those of normal subjects. The decrease in cortisol levels varied from 25 (in the sickle cell trait group) to 57 per cent (in the alpha 2-thalassemia group) of the mean cortisol levels of the control group. These results suggest the presence of hypoadrenalism and its possible association with the indicated haemoglobinopathies.

Phospholipids regulate growth and function of MDCK cells in hormonally defined serum free medium

The effects of the simple phospholipids phosphatidic acid (PA) and lysophosphatidic acid (LPA) on the growth and function of Madin Darby Canine Kidney (MDCK) cells has been studied. We observed that PA and LPA not only stimulated the growth of MDCK cells (at 20 microM), but also stimulated the growth of normal rabbit kidney cells in serum free medium (albeit at a lower dosage of 5 microM). Evidence was obtained that PA interacts synergistically with insulin so as to elicit a growth stimulatory effect. Recently, extracellular PA and LPA were proposed to stimulate mitogenesis in several types of animal cells by binding to particular sites on the plasma membrane which are coupled to signaling mechanisms such as adenylate cyclase via a pertussis toxin sensitive, inhibitory guanosine triphosphate binding protein (Gi protein) (15). However, even when the pertussis toxin dosage was increased to 50 ng/ml, LPA still had a dramatic growth stimulatory effect on MDCK cells. In the absence of LPA pertussis toxin was slightly growth stimulatory to MDCK cells. Phospholipids such as PA and LPA have been observed to prevent prostaglandin-induced increases in adenylate cyclase activity in other cell types via their effects on such a pertussis toxin sensitive Gi protein. If PA and LPA act on MDCK cells in this manner, then these phospholipids may possibly prevent the effect of PGE1 on the growth of normal MDCK cells. However PGE1 was still growth stimulatory to normal MDCK cells. The effects of PA on PGE1 independent variants of MDCK cells, which have elevated intracellular cyclic AMP levels (22), were also examined. In the presence of PA, PGE1 remained growth inhibitory, rather than growth stimulatory to the PGE1 independent cells. However, the PA dosage required to elicit an optimal growth response (5 microM) was dramatically reduced, as compared with normal MDCK cells (20 microM). This altered dosage requirement could be explained by the elevated intracellular cyclic AMP levels in the PGE1 independent variants. Like PGE1 and 8-bromocyclic AMP, PA and LPA also significantly increased the initial rate of Rb+ uptake by confluent monolayers of MDCK cells. The increase in the initial rate of Rb+ uptake could be explained by an increase in the ouabain-sensitive component of Rb+ uptake. An increase in the initial rate of ouabain-insensitive Rb+ uptake was also observed in LPA treated MDCK cell cultures.

Sickle cell/beta-thalassemia in North Jordan

Clinical and haematological features of 50 patients with sickle cell/beta-thalassemia (SB0 or SB+) are investigated. Total haemoglobin value was not significantly different (P greater than 0.05) in both types. Haemoglobin F and S were significantly higher (P less than 0.05) in SB0 than SB+ while haemoglobin A2 level was lower in SB0 than SB+. One SB0 case with exceptionally high HbF (32 per cent) with severe clinical course was found. In this case, the high HbF did not ameliorate the clinical severity. Heterogeneity in each type of sickle cell/beta-thalassemia is discussed. The differentiation of SB0 and sickle cell disease is best made on the basis of family study.

Prevalence of hemoglobinopathies in north Jordan

Blood samples from 1,000 subjects, 2-80 years old, were tested to explore the prevalence of alpha-thalassemia trait, high persistent HbF (HPFH), sickle cell trait and beta-thalassemia minor in northern Jordan. Hematological parameters and hemoglobin electrophoresis were carried out on all samples. Results showed 10 (1%) subjects were sickle cell trait, 35 (3.5%) were heterozygous beta thalassemia, 31 (3.1%) alpha thalassemia trait and 10 (1%) high persistent HbF. The prevalence rates were different from those reported in neighbouring countries and their significance is discussed. No other abnormal hemoglobin types were observed.

Prevalence of haemoglobinopathies in school children in Jordan Valley

Blood samples were drawn from 456 healthy children, 6-10 years old, to explore the prevalences of haemoglobinopathies in Northern Jordan Valley. The children were selected by the multi-stage random sampling technique. Complete blood count, haemoglobin electrophoresis and haemoglobin A2 (HbA2) estimations were carried out on all the samples. The prevalences of beta-thalassaemia minor, alpha-thalassaemia trait, sickle cell trait, and hereditary elliptocytosis were 15(3.3%), 16(3.5%), 2(0.44%) and 4(0.89%), respectively.

Sickle cell-thalassemia in a Jordanian family

A family case report of sickle cell-thalassemia syndrome shows three problems concerning this disease. Firstly, the problem of differentiating sickle cell-thalassemia from the sickle cell disease; secondly, the wide range varieties in clinical picture; thirdly and finally contradiction in the criteria of prognosis. In this report sickle cell-thalassemia case was confirmed by constructing a hemoglobin electrophoresis pedigree for the patient. Clinical varieties and prognosis of sickle cell-thalassemia in this family are discussed.