Prevalence of primary multidrug resistance to anti-tuberculosis drugs in Pakistan

SETTING

Pakistan ranks sixth in the world in terms of tuberculosis (TB) burden, with a World Health Organization estimated incidence of 181 per 100000, or 286000 new cases annually. Hospital-based data indicate a significant problem of multidrug-resistant TB (MDR-TB) in the country and highlight the need to assess its extent at community level. In this cross-sectional study, sputum samples from 742 untreated newly diagnosed pulmonary TB patients from all over the country were used.

OBJECTIVE

To assess the prevalence of primary drug resistance in Pakistan.

RESULTS

Of 672 culture-positive patients, 76 (11.3%) showed resistance to one or more drugs. Resistance to streptomycin (10 microg/ml) was found in 36 (5.4%) patients, isoniazid (INH) (1 microg/ml) in 51 (7.6%), rifampicin (RMP) (5 microg/ml) in 15 (2.2%), ethambutol (10 microg/ml) in 12 (1.8%) and pyrazinamide in 22 (3.3%) samples. Forty-six (6.8%) of the isolates tested were resistant to a single drug, 10 (1.5%) to two drugs, 12 (1.8%) to three drugs, and 6 (0.9%) to four drugs, while 2 (0.3%) isolates were resistant to all five first-line agents. Primary MDR-TB was 1.8% (n=12) (INH 1 microg/ml, RMP 5 microg/ml).

CONCLUSION

The results of this study show a prevalence of primary MDR-TB in Pakistan of <2%, which needs to be addressed through an effective DOTS strategy.

Cefaclor AF vs Clarithromycin in acute exacerbation of chronic bronchitis (B3M-PK-AJBG)

OBJECTIVE

To compare the efficacy and safety of Cefaclor AF vs Clarithromycin in the treatment of acute exacerbation of chronic bronchitis in adult subjects.

PATIENTS AND METHODS

This study was conducted on 300 patients suffering from acute exacerbation of chronic bronchitis, who attended the out patient clinics of ten different hospitals throughout Pakistan. Pneumonia, bronchiectasis and tuberculosis were excluded with the help of chest radiography and sputum smear examination. Pretherapy sputum culture and sensitivity (c/s) were tested and patients were randomized and supplied with either tablet Cefaclor 375 mg or tablet Clarithromycin 250 mg to be taken twice daily. Patients were evaluated at day 0 and then at day 3-5 and day 10-11. Post therapy sputum c/s was done on day 10-11. A fourth and final visit was planned on day 20-24 which was optional. At each visit, the severity of disease and the signs and symptoms were recorded on the clinical report forms according to the preset standards.

RESULTS

Of 136 patients in the Cefaclor group and 142 patients in the Clarithromycin group, cure was achieved in 44 vs 35 subjects, improvement in 78 vs 91 subjects and failure in 16 vs 18 subjects among Cefaclor vs Clarithromycin groups respectively. The overall clinical efficacy (cure and improvement combined ) was 88.4% in the Cefaclor group and 87.5% in the Clarithromycin group. Nine patients in the Cefaclor group and patients in the Clarithromycin group had one adverse event whereas twelve patients in each group had two or more adverse events.

CONCLUSIONS

The above results show that both Cefaclor AF and Clarithromycin are equally effective and safe in the treatment of acute exacerbation of chronic bronchitis in adult patients.

Intrathoracic migration of a humeral orthopedic pin

Intrathoracic migration of orthopedic fixation pins occurs infrequently but can have dire consequences if not recognized. Described herein is the case of an orthopedic pin that migrated from the proximal humerus into lung parenchyma. After preoperative computed tomography and fluoroscopy, the pin was removed via thoracotomy.

Influence of organic acids on the mobility of heavy metals in soil amended with some insecticides

The mobility (Rf value) of some heavy metals, such as: Co, Zn, Ag, Cu, and Pb was measured through soil amended with some insecticides, such as: endosulfan, chlorpyrifos, dimethoate and methyl demeton using distilled water, formic, acetic and oxalic acids as mobile phase. The enhancement in the mobility of metal ions in all the amended soils formic, acetic and oxalic acids as mobile phase. The enhancement in the mobility of metal ions in all the amended soils followed the order: Co > Zn > Ag > Cu > Pb. On the otherhand the mobility followed the order: endosulfan > chlorpyrifos > dimethoate > methyl dementon for the amended insecticides and the order: formic > acetic > oxalic acids for the mobile phase in natural as well as amended soils. Mobility of ions increased upto a concentration of 0.25 mg 100 g-1 of soils thereafter it was decreased in all the systems. The results have been explained on the basis of the nature of heavy metals, insecticides, organic acids and the solubilities of the salts formed in the soil-insecticide-amended systems.

Separation and purification of Echis coloratus venom and some biological and biochemical effects of the proteins

Crude venom of Echis coloratus was separated into seven protein fractions using 7% preparative native polyacrylamide gel electrophoresis. The effect of crude venom and seven venom protein fractions (F1-F7) from Echis coloratus on key metabolic activities of fibroblast cultures was investigated. Confluent cultures were incubated with the venom proteins for 3 h at 37 degrees C. The specific activity of phosphofructokinase, was significantly lowered upon incubation with the crude venom and with fractions 2, 3, 4 and 6. Citrate synthase activity was significantly lowered by the crude venom and by fractions 2 and 3. Glycogen phosphorylase activity was significantly increased by the crude venom and by fractions 2, 3, 4 and 6 leading to a significant concurrent drop in glycogen content. Creatine kinase activity was significantly increased by the crude venom and by fractions 3, 4, 5 and 6. Cellular ATP levels rose significantly upon incubation with the crude venom and with fractions 3, 4, 5 and 6. Incubation of cell sonicates with all the venom proteins did not significantly alter the activity or content of any of the studied parameters.

Evaluation and selection of bio-relevant dissolution media for a poorly water-soluble new chemical entity

The purpose of this work is to develop a bio-relevant dissolution method for formulation screening in order to select an enhanced bioavailable formulation for a poorly water-soluble drug. The methods used included a modified rotating disk apparatus for measuring intrinsic dissolution rate of the new chemical entity (NCE) and the USP dissolution method II for evaluating dissolution profiles of the drug in three different dosage forms. The in vitro dissolution results were compared with the in vivo bioavailability for selecting a bio-relevant medium. The results showed that the solubility of the NCE was proportional to the concentration of sodium lauryl sulfate (SLS) in the media. The apparent intrinsic dissolution rate of the NCE was linear to the rotational speed of the disk, which indicated that the dissolution of the drug is a diffusion-controlled mechanism. The apparent intrinsic dissolution rate was also linear to the surfactant concentration in the media, which was interpreted using the Noyes and Whitney Empirical Theory. Three formulations were studied in three different SLS media using the bulk drug as a reference. The dissolution results were compared with the corresponding bioavailability results in dogs. In the 1% SLS--sink conditions--the drug release from all the formulations was complete and the dissolution results were discriminative for the difference in particle size of the drug in the formulations. However, the data showed poor IVIV correlation. In the 0.5% SLS medium--non-sink conditions--the dissolution results showed the same rank order among the tested formulations as the bioavailability. The best IVIV correlation was obtained from the dissolution in 0.25% SLS medium, an over-saturated condition. The conclusions are: a surfactant medium increases the apparent intrinsic dissolution rate of the NCE linearly due to an increase in solubility. A low concentration of surfactant in the medium (0.25%) is more bio-relevant than higher concentrations of surfactant in the media for the poorly water-soluble drug. Creating sink conditions (based on bulk drug solubilities) by using a high concentration of a surfactant in the dissolution medium may not be a proper approach in developing a bio-relevant dissolution method for a poorly water-soluble drug.

Objective measures of the efficacy of noninvasive positive-pressure ventilation in amyotrophic lateral sclerosis

The impact of noninvasive positive-pressure ventilation (NIPPV) on pulmonary function studies, quality of life, and survival was assessed in patients with amyotrophic lateral sclerosis. NIPPV did not change the rate of decline of the forced vital capacity (FVC) and forced expiratory volume in the first second (FEV(1)) (2.31 and 2.09 percent-predicted points per month, respectively). NIPPV resulted in a drop of FEV(1) by 5.94 percent-predicted points (P = 0.07), and of maximal inspiratory pressure by 6.33 percent-predicted points (P = 0.11). The change in FEV(1) and FVC pre- and postintervention correlated with the corresponding change in maximal inspiratory pressure. Fatigue and mastery scores were improved by NIPPV. Median survivals in patients intolerant and tolerant of NIPPV were 5 and 20 months, respectively (P = 0.002). Although NIPPV has no impact on the rate of decline of lung function and may have deleterious effects on spirometric measures, it may improve quality of life and survival.

Simultaneous determination of carbaryl, malathion, fenitrothion, and diazinon residues in sesame seeds (Sesamum indicum L.)

A method is described for the simultaneous determination of carbaryl (1-naphthyl methylcarbamate), malathion [diethyl (dimethoxythiophosphorylthio) succinate], fenitrothion (O,O-dimethyl O-4-nitro-m-tolyl phosphorothioate), and diazinon (O,O-diethyl O-2-isopropyl-6-methylpyrimidin-4-yl phosphorothioate) in sesame (Sesamum indicum L.) seeds. Sesame seeds were Soxhlet extracted with n-hexane, and the extract was subjected to a liquid-liquid partitioning and column cleanup to remove the oily coextractives prior to analysis by high performance liquid chromatography (HPLC). The mean percent recoveries (+/- standard deviations) from sesame seeds fortified with carbaryl (0.004 to 0.035 microgram/g), malathion (0.53 to 4.25 microgram/g), fenitrothion (0.22 to 1.78 microgram/g), and diazinon (0.54 to 4.35 microgram/g) were 83.3 +/- 5.7, 85.5 +/- 6.6, 85. 6 +/- 7.2, and 88.4 +/- 4.8, respectively. The method was used for the simultaneous analysis of carbaryl, malathion, fenitrothion, and diazinon residues in sesame seeds obtained from an Ethiopian field crop that had been treated with the pesticides during its growing period.

Role of Tc-99m MIBI in the evaluation of single pulmonary nodules: a preliminary report

BACKGROUND

Survival in bronchial carcinoma is closely related to the stage of the disease at the time of diagnosis and a single pulmonary nodule represents a potentially curable stage. This study was conducted to assess the feasibility of using Tc-99m labelled 2-methoxy isobutyl isonitrile (MIBI) to differentiate benign from malignant single pulmonary nodules.

METHODS

A prospective study was conducted in the outpatient pulmonary clinic at the Cleveland Clinic Foundation. Twenty five patients with single pulmonary nodules considered indeterminate by their physicians and undergoing a procedure for tissue diagnosis were evaluated by Tc-99m MIBI SPECT scanning prior to definitive testing. Assessment of MIBI uptake was done qualitatively (subjectively) and quantitatively and correlated with the histopathology and nodule size.

RESULTS

Of the 21 patients with malignant lesions, 18 had increased uptake of MIBI corresponding to the location of the nodule and were considered positive. The predominant tumour types were large cell (n = 5) and adenocarcinoma (n = 10). All four patients with benign lesions had negative MIBI scans. For malignancy the overall specificity was 100%, sensitivity was 85.7%, positive predictive value was 100%, and negative predictive value was 57%. Quantitative uptake of MIBI correlated with the diameter of the nodule with a correlation coefficient of 0.61 by Spearman's rank sum test. This relationship was statistically significant (p = 0.02).

CONCLUSION

This preliminary study suggests that Tc-99m MIBI has a very high specificity and positive predictive value for malignant single pulmonary nodules and might be a useful non-invasive diagnostic modality in their management.

Does the donor-recipient ABO blood group compatibility status predict subsequent lung transplantation outcomes?

BACKGROUND

The study was conducted to compare lung transplantation outcomes between ABO-identical (AI) and ABO-compatible (AC) recipients.

METHODS

Charts of lung allograft recipients transplanted between February, 1990 and October, 1995 were reviewed. Standard triple-drug immunosuppression and general antimicrobial prophylaxis were provided. Surveillance spirometry was administered every three months. Flexible bronchoscopy (FB) with transbronchial biopsies (TBBs) were undertaken for clinical indications. Time to event analysis on acute (AR) and chronic (CR) rejection and actuarial survival were determined by Kaplan-Meier analysis. Cumulative curves were compared with a log rank test. Comparisons of age, maximum forced expiratory volume in one second (FEV1) in the single (SLT) and double (DLT) lung recipients, duration of intensive care unit and hospital stay were carried out using the Wilcoxon Rank Sum test. Gender, race, underlying diagnoses, cytomegalovirus (CMV) status and pulmonary reimplantation response (PRR) were compared by Chi-square or Fisher's exact test where appropriate.

RESULTS

Of the 100 lung recipients (age = 42.5 +/- 13.4 years; M:F = 50:50), 64 were AI and 36 AC. Median follow-up was 22 (range = 0-78) months. Outcome did not differ significantly between the 2 groups in terms of intensive care unit and hospital stay, PRR incidence and grade, incidence and frequencies of AR, median time and grade of first AR, maximum FEV1 for SLT and DLT recipients, incidence of CR and survival at 12 months.

CONCLUSIONS

As the donor supply remains limited, this could considerably simplify the logistics of future transplantation.

Acute pulmonary edema after lung transplantation: the pulmonary reimplantation response

BACKGROUND

Although the development of noncardiogenic pulmonary edema or pulmonary reimplantation response (PRR) after lung transplantation has been well described, the incidence has not been established and the relationship of PRR to clinical risk factors has not been analyzed.

STUDY OBJECTIVES

(1) To describe the incidence of PRR in lung transplant recipients, (2) to identify the predictors of PRR, (3) to examine the correlation of suspected predictors with the severity of PRR, and (4) to evaluate the impact of PRR on morbidity and mortality of lung transplant recipients.

DESIGN

Retrospective review of clinical records and radiographic studies.

SETTING

Tertiary care referral center.

PATIENTS

Ninety-nine consecutive patients with end-stage lung disease undergoing lung transplantation between February 1990 and October 1995.

METHODS

Review of clinical records and postoperative chest radiographs of all lung transplant recipients to identify patients who experienced PRR. Chest radiographs of patients with PRR were graded for severity on a scale of 0 (none) to 5 (very severe). Demographic, pre- and perioperative factors were also evaluated along with short- and long-term survival of patients with PRR.

RESULTS

Fifty-six of 99 lung transplant recipients (57%) experienced PRR. The median ischemia time of patients with and without PRR was 168 and 180 min, respectively (p = 0.62). The incidence of PRR was 51% in patients without preoperative pulmonary hypertension, 78% in mild to moderate pulmonary hypertension, and 58% in patients with severe pulmonary hypertension (p = 0.10). Incidence and severity of PRR was similar in patients receiving right, left, or double-lung transplantation. Similarly, age and sex of the recipients and underlying lung disease did not affect the incidence or severity of PRR. The incidence and severity of PRR was higher in patients undergoing cardiopulmonary bypass during lung transplantation. Patients with PRR had prolonged duration of mechanical ventilation and ICU stay. Overall, PRR did not affect the survival of the patients. However, survival of female lung transplant recipients was significantly better than male recipients (median survival, 60 vs 21 months; p = 0.02).

CONCLUSIONS

Acute pulmonary edema or PRR occurs frequently (57%) after lung transplantation. In this series, PRR was not associated with a prolonged ischemia time, preoperative pulmonary hypertension, the type of lung transplant, underlying lung disease, or age or sex of recipients. However, use of cardiopulmonary bypass during surgery was associated with increased incidence and severity of PRR. Also, the development of PRR resulted in prolonged mechanical ventilation and a longer ICU stay, but did not affect survival. Female lung transplant recipients survived significantly longer than male recipients. The reason for this difference in survival is unclear.

Effect of acute coronary occlusion on the size of the dynamically perfused coronary capillary bed in the dog

The aim of the present study was to investigate the influence of reduced left anterior descending (LAD) coronary arterial blood flow on the size of the perfused coronary capillary surface area (CCSA) in dogs. The transcoronary hydrolysis (v) of the specific ACE substrate, [3H]benzoyl-Phe-Ala-Pro, was estimated and the parameter Amax/Km (proportional to the size of the perfused CCSA) was calculated. By means of a ligature placed around the LAD, LAD blood flow was transiently reduced to 36.0 +/- 4.1 (E1) and 17.4 +/- 4.3% (E2) of control; in a separate maneuver the first diagonal branch of the LAD was ligated to achieve 40.0 +/- 6.7% (E3) of control flow. The v values remained unchanged at around 0.7 for E1, E2, and E3 determinations, suggesting unaltered substrate transit time through the coronary capillary bed. Amax/Km values decreased to 36 +/- 5, 17 +/- 4, and 47 +/- 10% of control for E1, E2, and E3 determinations, respectively, reflecting a flow-proportional decrease in CCSA. Values of the transpulmonary measures of v and Amax/Km performed at the beginning and end of the protocol were unchanged. These results support the hypothesis that reduction in coronary blood flow will produce proportional decreases in the size of the CCSA. This new procedure can thus serve as a useful tool for investigating alterations in the size of the CCSA in different species and under various pathophysiologic challenges.

Paired pulse suppression and facilitation in human epileptogenic hippocampal formation

Paired pulse stimulation has commonly been employed to investigate changes in excitability in epileptic hippocampal tissue employing the in vitro slice preparation. We used paired pulse stimulation in the intact temporal lobe of patients with temporal lobe seizures to compare the excitability of pathways in the epileptogenic hippocampus (located in the temporal lobe in which seizures arise) with those in the non-epileptogenic hippocampus of the contralateral temporal lobe (in the hemisphere to which seizures spread). A total of 20 patients with temporal lobe seizure onsets were studied during chronic depth electrode monitoring for seizure localization. Intracranial in vivo stimulation and recording sites included the hippocampus, entorhinal cortex, subicular cortex and parahippocampal gyrus. A comparison of all hippocampal pathways located in the temporal lobe where seizures typically started (n = 37) with those in temporal lobes contralateral to seizure onset (n = 53) showed significantly greater paired pulse suppression of population post-synaptic potentials on the epileptogenic side (F(1,87) = 6.1, P < 0.01). Similarly, mean paired pulse suppression was significantly greater for epileptogenic perforant path responses than for contralateral perforant path responses (F(1,13) = 7.5, P < 0.01). In contrast, local stimulation activating intrinsic associational pathways of the epileptogenic hippocampus showed decreased paired pulse suppression in comparison to the epileptogenic perforant path. These results may be a functional consequence of the formation of abnormal recurrent inhibitory and recurrent excitatory pathways in the sclerotic hippocampus. Enhanced inhibition may be adaptive in suppressing seizures during interictal periods, while abnormal recurrent excitatory circuits in the presence of enhanced inhibition may drive the hypersynchronization of principal neurons necessary for seizure genesis.

Bioavailability in rats of bound pesticide residues from tolerant or susceptible varieties of soybean and canola treated with metribuzin or atrazine

Susceptible or tolerant varieties of soybean treated with metribuzin, or canola treated with atrazine were grown in a controlled environment. Shoots and fruits were harvested at maturity and extracted exhaustively with methanol. The extracted materials containing bound 14C residues were subsequently fed to rats for two days. The elimination of 14C in urine and feces was monitored for 4 days and the distribution of radioactivity in liver, kidney and heart was studied. Higher 14C residues in urine were present in animals fed fruits compared to shoots of soybean or canola of both susceptible and tolerant varieties. The bound atrazine residues from the pods of Atr Tower (tolerant variety of canola) were more bioavailable than Tower (susceptible variety of canola). Bioavailability of bound atrazine from the shoots of canola in both varieties was very low. In soybean fed animals, bound metribuzin derived 14C from the susceptible variety (Maple Amber) was more bioavailable than from the resistant variety (Maple Arrow). However, feeding the animals with susceptible or tolerant varieties of soybean or canola containing bound residues of 14C metribuzin or 14C atrazine for two days did not result in the accumulation of radioactivity in the body organs studied. Thus our data show that the bioavailability of these bound pesticides was dependent on the type of plant parts ingested and the variety of plant species.

Effect of noninvasive positive-pressure ventilation on survival in amyotrophic lateral sclerosis

BACKGROUND

Noninvasive positive-pressure ventilation may benefit patients with amyotrophic lateral sclerosis and respiratory insufficiency.

OBJECTIVE

To determine 1) whether patients tolerant of noninvasive positive-pressure ventilation have better survival than intolerant patients and 2) whether bulbar symptoms account for intolerance of noninvasive positive-pressure ventilation.

DESIGN

Observational cohort study.

SETTING

Tertiary care referral center.

PATIENTS

39 patients with amyotrophic lateral sclerosis who were treated with noninvasive positive-pressure ventilation.

INTERVENTION

Noninvasive positive-pressure ventilation was started for patients with new orthopnea, new hypercapnia, or both. Patients were divided into two groups: those tolerant of and those intolerant of noninvasive positive-pressure ventilation.

RESULTS

The risk for death from onset of respiratory insufficiency was higher for intolerant patients than for tolerant patients (relative risk, 3.1 [95% CI, 1.8 to 9.6]). Moderate or severe bulbar symptoms were more prevalent among intolerant patients than among tolerant patients (67% compared with 33%; P = 0.04).

CONCLUSIONS

Among patients with amyotrophic lateral sclerosis, those who are tolerant of noninvasive positive-pressure ventilation have better survival than do those who are intolerant. Bulbar symptoms partially account for intolerance of noninvasive positive-pressure ventilation.

Bioavailability of bound pesticide residues and potential toxicologic consequences - an update

The growing demand for enhanced food productivity to meet the needs of the global population has led farmers to use sophisticated agricultural technology in which pesticides play a crucial role. Pesticide use has a positive and dramatic impact on agricultural production through protection of crops against insects, pests, and disease, but every effort must be made to ensure that application is safe and, more importantly, to assure safety for human and environmental health. Since our initial review (1), global usage of pesticides has increased and knowledge regarding the biological significance of bound pesticide residues has expanded. The fact that more reports are appearing in the literature signifies an increased awareness of the presence of bound pesticide residues and indicates that a greater number of scientists are attempting to establish the potential toxicologic consequences of this pesticides residue fraction. Rico (2), in a review in 1990, concluded that covalently bound residues in edible animal tissues were not carcinogenic, were not readily bioavailable, and hence produced little, if any, adverse effects. Whether this conclusion is applicable to the presence and consequences of bound pesticide residues in plants and food commodities remains unanswered. Thus, the aim of this updated review is not simply to list studies on bioavailability of bound pesticide residues in grains subsequent to the review in 1992 (1) but also to establish the toxicological impact of this chemical fraction on health.

Right ventricular mass measurement by electron beam computed tomography. Validation with autopsy data

RATIONALE AND OBJECTIVES

Validation of right ventricular mass quantitation by electron beam computed tomography in humans has not been performed. The ability of electron beam computed tomography to accurately determine the septal component of the right ventricle also has not been determined. This article addresses both issues.

METHODS

Twenty human adult hearts obtained at autopsy were scanned by electron beam computed tomography in a short-axis projection. Planimetry of the right ventricular free wall and septal components of each slice was performed and summed to determine right ventricular mass. These measurements were compared against comparable measurements obtained by autopsy weights of the hearts.

RESULTS

Right ventricular free wall weights by electron beam computed tomography (53.9 +/- 18.4 g) correlated well (slope = .92, r = .92, standard error of the estimate = 7.4 g, P < .001) with autopsy weights (55.8 +/- 18.4 g). Right ventricular septal weights by electron beam computed tomography (6.1 +/- 2.3 g) correlated poorly (slope = .04, r = .11, standard error of the estimate = 2.4 g, P = .65) with autopsy weights (13.9 +/- 6.3 g).

CONCLUSIONS

Electron beam computed tomography quantitation of right ventricular mass is accurate in humans if only the free wall and not the septal component is utilized.