Detection of Plasmid Mediated AmpC-β lactamases Among Gram-Negative Uropathogens at a Tertiary Care Hospital, Dhaka City

Plasmid-mediated AmpC β-lactamase (PMABL) resistance among gram negative bacilli is an emerging problem worldwide. They likely originate from chromosomal AmpC of certain Gram-negative bacterial species and subsequently are mobilized to transmissible plasmids. There are reports of unfavorable clinical outcomes in patients infected with these organisms and treated with broad-spectrumcephalosporins. The present cross sectional study was designed to detect PMABL genes among gram negative uropathogens in a tertiary care hospital, Dhaka city, Bangladesh from January 2014 to December 2014. Total 138 gram negative uropathogens were identified by the conventional methods and were screened for AmpC production using cefoxitin discs. Confirmatory phenotypic identification was done by modified three dimensional test (MTDT). The common AmpC genotypes ACC, FOX, MOX, DHA, CIT and EBC types were determined by a multiplex PCR.PMABL genes were detected by PCR in 90% of cefoxitin resistant isolates and the molecular types of the genes detected predominantly were CIT, DHA followed by EBC and ACC types. Overall, PMABL genes were detected in 32.61% (45/138) of the studied gram negative uropathogens which is alarming. All (100%) the plasmid mediated AmpC β-lactamase producers showed resistance to amoxicillin-clavulanic acid, ceftazidime, ceftriaxone, cefotaxime and cefoxitin. These results emphasize that clinical laboratories should consider the tests for the detection of PMABL genes for infection control and formulation of effective antibiotic policy.

Addison's Disease: A Diagnostic Dilemma

Adrenal insufficiency is a rare disease, but is life threatening when overlooked. Addison's disease may be an acquired form of adrenal insufficiency due to the destruction or dysfunction of the adrenal cortex. It affects both glucocorticoid and mineralocorticoid function. Main presenting symptoms of Addison's disease such as fatigue, anorexia, vomiting and convulsion often mimics central nervous system (CNS) infections. We describe a case of Addison's disease who was initially misdiagnosed as a case of meningo-encephalitis subsequently renal tubular acidosis and finally Addison's disease. Addison's disease can remain unrecognized until acute crisis and sometimes it may be misdiagnosed.

Role of pRIFLE Criteria in Early Diagnosis of Severity Staging of Neonatal AKI and its Impact on Management

Mortality is high among sick neonates who have concomitant acute kidney injury (AKI). This observational study was done at Special Care Baby Unit (SCABU) of Dhaka Medical College Hospital (DMCH), Bangladesh from October 2013 to March 2014 to find out the role of pRIFLE criteria in prediction of severity stages of AKI in neonate and early intervention to see the immediate outcome. A total of 44 neonates with AKI were included, all were treated conservatively and with intermittent peritoneal dialysis (IPD) as needed. The neonate of ≤7 days old comprised the main bulk (n=28) and M: F = 21: 23. The diagnosis was based on eCCL criteria of pRIFLE showed that 40.9% neonates were at risk of AKI, 20.5% have had already injured. Higher proportions of neonates were classified as failure (38.6%). The distribution of biochemical parameters among three stages of AKI showed serum potassium was significantly higher in failure group (p<0.001). The serum creatinine both at baseline and at next evaluations were significantly raised in the failure group (p<0.001). However, failure group had a significantly longer hospital stay compared to risk and injury group (p<0.001). Multiorgan failure was found to be lower in the risk group compared to other two groups (p=0.026). Majority of the failure group needed dialysis as compared to the risk and injury group (p<0.001). The mortality was progressively higher from risk to failure groups (p=0.106). Overall 27% of the neonates diagnosed AKI by pRIFLE were died of the disease. The study concluded that pRIFLE staging in AKI is useful and sensitive in the diagnosis and management of AKI in neonates.

Health Related Quality of Life in Children with Nephrotic Syndrome in Bangladesh

Outcome of children with nephrotic syndrome has continued to improve over time. However minimal data exist to describe health-related quality of life in children with nephrotic syndrome. This cross sectional study was conducted over a period of six months to assess the health related quality of life in children with nephrotic syndrome in the Department of Pediatric Nephrology, Dhaka Medical College Hospital, Bangladesh. Fifty children (age ranged 2-12 years) with nephrotic syndrome who had three or more relapses diagnosed at least one year back receiving treatment and on follow up were included in this study. Quality of Life scores were collected using Bengali translated instruments- the Pediatric Quality of Life Inventory™ (PedsQL™) version 4.0 Generic Scale and the Pediatric Quality of Life Questionnaire for Nephrotic Syndrome proxy-report from parents. Medical data and Demographic data were collected from medical records, and from parents in outpatient department or hospital ward. Interviews of eligible guardians were performed individually to collect quality of life (QoL) scores. Among 50 children, mean±SD age of the children was 7±2.92 years. Most children were male (58%). Female parents respondent during interview were 62%, most parents (48%) were very poor in socioeconomic condition. Most children had frequent relapses (60%). Median time since diagnosis was 2 years. Regarding PedsQL scores, child age with physical summary score (p value <0.001), child age with social summary score (p value 0.003), frequent relapse with kidney disease summary score (p value 0.04) and time since diagnosis (p value <0.001) were statistically significant. In conclusion physical and social summary score were worst. Frequent relapse found to be an important factor in impaired QoL. Prolonged duration of the disease activity was associated with significant impairment of QoL.

Experience of Percutaneous Versus Surgically Placed Catheter for Continuous Ambulatory Peritoneal Dialysis in Children with Chronic Kidney Disease Stage-V

The lifespan and outcome of end stage renal disease (ESRD) children have dramatically improved since the development of continuous ambulatory peritoneal dialysis (CAPD), it offers several advantages over hemodialysis. Percutaneous placement of CAPD catheters in children is minimally invasive, reliable, safe and cost-effective method. Percutaneous method of CAPD catheter insertion can be used in children to avoid the complications of general anesthesia and surgery. This study was done to evaluate the efficacy of CAPD in children, to find out the complication profile of CAPD & to compare the advantages of surgical versus percutaneously placed CAPD catheters in children. This prospective longitudinal comparative study was carried out in the department of Pediatric Nephrology, Dhaka Medical College Hospital (DMCH), Bangladesh from July 2011 to June 2014. A total of 8 children with ESRD were included (Age 5-14 year, M: F=1: 1). All underwent CAPD, Group I = surgically placed CAPD catheter (N=5), Group II = percutaneously placed CAPD catheter (N=3). Average duration of CAPD in Group I and Group II were 31.6 vs. 9 (months) with a total of 158 vs. 27 patient months of CAPD respectively. The rate of complications of the 2 groups and their outcome were compared. Common complications being observed were peritonitis 1 episode per 12.1 vs. 1.8 patient months (p<0.001), catheter obstruction by omental capture 1 vs. 3 in Group I and Group II respectively. Catheter tip dislocation was commonly found in all Group II children (p<0.01) and all needed laparotomy and omentectomy. Three out of 5 in Group I is still on CAPD, 1 transferred to HD and another 1 expired due to uncontrolled hypertension with congestive heart failure. Among 3 of Group II, 2 died of repeated peritonitis and hypertensive complications and rest 1 is transferred to HD after 1year due to exit site fluid leaking. Satisfactory level of improvement of mean weight, mean serum albumin and declining of serum creatinine in both groups has been found after CAPD. Although CAPD is an effective modality of renal replacement therapy for children, but percutaneous method of catheter insertion is associated with higher rate of complications. Placement of catheter by surgical method with elective omentectomy will reduce catheter related complications. Early detection of peritonitis and prompt therapy is essential for a favourable outcome.

Risk factors of multi-drug-resistant tuberculosis in Bangladeshi population: a case control study

Despite success in tuberculosis control, multi-drug resistant tuberculosis in Bangladesh is increasing and currently multi-drug-resistant tuberculosis rate is 3.6% in new cases and 19% in re-treatment cases. This study focused on determination of multi-drug-resistant tuberculosis which is warranted for effective prevention strategy. An unmatched case control study was conducted in 2010. Purposively recruited 136 culture-proved multi-drug-resistant- tuberculosis cases and 152 cured tuberculosis patients were interviewed. Associations between exposure and outcome variables were initially tested by chi2-test, t-test. A result was considered significant at p value < 0.05. Effects of exposure variables were also assessed after adjusting for other variables by binary logistic regression models. Crude and adjusted Odds Ratio with 95% Confidence Interval was computed. Younger age (p = 0.008) and, peri-urban locality (p = 0.002) were associated with multi-drug-resistant tuberculosis. History of contact (p < 0.001) and tuberculosis in the past (p < 0.001) were four and eight times, respectively, more likely to influence multi-drug-resistant tuberculosis. Regularity [Odds Ratio 0.05; 95% Confidence Interval (0.01 to 0.39)] and always observation of treatment [Odds Ratio 0.25; 95% Confidence Interval (0.10 to 0.61)], sputum conversion [Odds Ratio 0.02; 95% Confidence Interval (0.01 to 0.08)] negatively associated with multi-drug-resistant tuberculosis. Gender and socio-economic status did not show any influence. Treatment course and sputum conversion was the best predictors. Like other developing countries adequacy of treatment is the most important exposure variable. Strengthening of control activities might contribute in preventing development of resistance in tuberculosis patients.

Low serum immunglobulin G (IgG) during nephrosis is a predictor of urinary tract infection (UTI) in children with nephrotic syndrome

Low serum level of IgG, complement C3 and C4 in nephrotic syndrome children may cause increased susceptibility to infection. Serum level of IgG and complements in nephrotic children (NS) with UTI has been analyzed in this cross sectional study. It was carried out in the department of Pediatric nephrology, National Institute of Kidney Diseases & Urology (NIKDU), Dhaka, Bangladesh. The study subjects were followed up prospectively for one year to see and compare the frequency of relapse of NS and UTI. Patients were selected in a nonrandom purposive technique. Nephrotic syndrome children with initial attack between 1-12 year of age were included over a period of one year. The patients were grouped into Group I - UTI positive and Group II - UTI negative depending on urine culture positivity and colony count >10⁵ CFU/ml. Serum IgG and complements C3, C4 levels were done in both groups during nephrosis and were compared. A total of 101 children M: F 1.7:1, mean age 5.96±3.2 years were included in this study. Group I, n=45 vs. Group II, n=56. The mean serum level of IgG was low in Group I (549.91±210.71 vs. 728.64±235.81mg/dl, p<0.001). Serum IgG level less than 700mg/dl was found in 37 vs. 23 children {x² (¹) 17.52 p<0.001, OR=6.63}. Mean serum complement C3 level was also low in Group I (123.09±40.52 vs. 143.38±37.06mg/dl, p<0.05). But complement C3 and C4 level do not carry any risk of developing UTI in nephrotic children. Higher number of children in Group II were at remission (n=24) during follow up, while frequent relapsers were high in Group I (n=22). Increased frequency of UTI attack (88 episodes) was found in Group I children compared to none in Group II during follow up. So low serum level of IgG in children with NS during nephrosis can predict UTI with an odds ratio of 6.63 as well as relapse. Serum level of C3, C4 do not associated with any risk of development of UTI in NS children.

Thyroid function in children with nephrotic syndrome

This study was done to find out the thyroid function of nephrotic children during nephrosis and to compare any significant changes of thyroid function status during nephrosis and remission. This is an observational study with prospective follow up of study subjects. It was carried out over a period of one year from July'2006 to June'2007 in the department of Paediatric Nephrology, National Institute of Kidney Diseases & Urology (NIKDU), Dhaka, Bangladesh. A total of 85 nephrotic children with initial attack and relapse cases were studied. Age ranged from 2-12 years, M: F=1.7:1. All patients were clinically euthyroid. The mean value of serum T3 (0.65±0.31 ng/ml) and T4 (5.04±4.18 μg/ml) in 85 nephrotic children during nephrosis were within normal limit. But the mean value of thyroid stimulating hormone (TSH) was higher than normal level (7.1±5.8 MIU). In 21 nephrotic children thyroid function status was compared during nephrosis and 4 weeks later after achieving remission. A significant increase in TSH level during nephrosis (9.11±6.36 vs. 4.2±3.6 MIU/L, p = 0.005) was found, which normalized during remission. No significant difference between T3 and T4 level was observed. There was a negative correlation of serum albumin with serum TSH level (r = -0.216, p = 0.047). This result suggests that children with nephrotic syndrome commonly have a state of mild or subclinical hypothyroidism during proteinuria although they are clinically euthyroid. This temporary hypothyroid state improves with remission and needs no treatment.

Qualitative and quantitative analysis of goat ovaries, follicles and oocytes in view of in vitro production of embryos

Goat ovaries were collected from the slaughterhouse and categorized as right, left, corpus luteum (CL)-present and -absent group and evaluated on the basis of weight (g), length (cm), width (cm), number of follicles, follicles aspirated and number and state of cumulus-oocyte-complexes (COCs). Comparatively higher weight [(0.66+/-0.02) vs (0.64+/-0.02) g], length [(1.17+/-0.02) vs (1.11+/-0.02) cm] and width [(0.77+/-0.02) vs (0.74+/-0.02) cm] were found in right ovaries than those of left. On the other hand significantly (P<0.05) higher weight [(0.71+/-0.03) vs (0.64+/-0.01) g] and width [(0.76+/-0.03) vs (0.75+/-0.01) cm] were found in CL-present group than those of CL-absent group of ovaries. The left ovaries contained comparatively higher number of normal COCs [(1.06+/-0.09) per ovary] than right ovaries [(1.03+/-0.10) per ovary] and the similar trend was found in total number of follicles [(4.51+/-0.25) vs (4.30+/-0.23) per ovary] and follicles aspirated [(2.55+/-0.14) vs (2.52+/-0.12) per ovary]. But the total COCs per ovary was almost similar in both ovaries [right and left: (1.85+/-0.12) and (1.85+/-0.11) per ovary, respectively]. Higher number of total COCs [(1.87+/-0.09) vs (1.76+/-0.16) per ovary], total number of follicles [(4.45+/-0.19) vs (4.16+/-0.37) per ovary], follicles aspirated [(2.55+/-0.10) vs (2.48+/-0.21) per ovary] and normal COCs [(1.12+/-0.07) vs (0.76+/-0.14) per ovary] were found in CL-absent group than those of CL-present group of ovaries.

Antidiarrhoeal activity of the ethanol extract of Paederia foetida Linn. (Rubiaceae)

Paederia foetida L. is used as a remedy for diarrhoea and dysentery in Asia, but has not been investigated for its antidiarrhoeal properties. Antidiarrhoeal activity of 90% ethanol extract of Paederia foetida was investigated in this study using castor oil and magnesium sulphate-induced diarrhoea models in mice. The extract significantly increased the latent period of diarrhoea in both the models. In the castor oil study, the purging index (PI) value lowered in 1 h of the study at (100, 250 and 500 mg/kg) doses. The effect continued up to 6-h period only at 500 mg/kg dose. The plant notably reduced the purging index value in a dose-dependent manner in magnesium sulphate-induced diarrhoea. Paederia foetida, in general, reduced the gastrointestinal motility with barium sulphate milk both in 15- and 30-min time intervals. The extract significantly decreased the cisplatin-induced gastrointestinal motility at all doses at both time intervals. The extract also enhanced the morphine-induced reduction of motility at 500 mg/kg dose level at both time intervals. The results suggest that Paederia foetida showed antidiarrhoeal activity by inhibiting intestinal motility and justify its use in traditional medicine.

Platelet Activating Factor antagonists

Platelet Activating Factor (PAF) is a D-glycerol derived phosopholipid which is a potent endogenous mediator of inflammation. PAF is synthesized and released by a variety of cell types and elicits its biological activity by interacting with specific G-protein coupled receptors found on platelets, neutrophils, and other inflammatory cells. The physiological consequences of the interaction on PAF with its receptor include an increase in vascular permeability, hypotension, bronchoconstriction, and platelet and neutrophil aggregation. These biological effects are consistent with the concept that PAF is involved in a number of inflammatory diseases such as septic shock and asthma (Arimura A., 1998). Given the potent pathophysiological effects of PAF, a great deal of effort has been focused on the discovery of agents which block the action of PAF at its receptor. Within the past 10 years, a wide range of structures have been identified as PAF antagonists. These include not only PAF analogs, but also antagonists derived form natural product as well as non-lipid synthetic compounds. Several theories have been proposed to unify these diverse structural classes, but sophisticated molecular models of the receptor have not been widely employed (Braquet P., 1987). The discovery of new PAF antagonists has relied heavily on traditional medicinal chemistry approaches. A number of PAF antagonists have advanced to clinical evaluation. While several early compounds demonstrated efficacy in animal models of asthma they have failed to provide benefit for this condition in man. The current generation of potent antagonists are being evaluated as therapies for sepsis, pancreatitis and other disorders (Braquet C., 1991).

Effects of diazepam and cinchocaine on biogenic amines

Neurochemical and behavioural research show that benzodiazepines are well know anxiolytic drugs, which are also used for the treatment of epilepsy, hypnosis and insomnia. Administration of benzodiazepine to experimental animals produces anxiolytic-like effects in various animal and decreases exploratory activity. Psychomotor stimulants such as cinchocaine also showed potent effect on brain biogenic amines and their metabolite. The present studies indicate the changes in dopamine and 5-HT and their metabolites levels after acute administration of cinchocaine and diazepam.

Role of radioiodine in management of thyroid cancer: experience with 70 cases

Results of 70 cases of differentiated thyroid carcinoma managed with I131 and surgery have been reported. These results add to the body of knowledge that already exists in the field of treatment of thyroid cancer with radioactive iodine. These results also indicate that the success of radioiodine therapy depends on adequate surgical removal of the thyroid tissue.