Evidence of Helicobacter pylori infection in dental plaque and gastric mucosa

OBJECTIVE

To determine the presence of Helicobacter pylori (H. pylori ) in dental plaque of individuals suffering from H. pylori associated gastric disease.

DESIGN

descriptive.

PLACE AND DURATION OF STUDY

The study was conducted at the Department of Medicine in collaboration with Departments of Dentistry and Pathology at PNS Shifa, Karachi during a period extending from July 1998 to June 1999.

PATIENTS AND METHODS

Patients presenting with symptoms/signs of chronic gastritis were included in the study. Specimens of dental plaque and gastric biopsy were collected from all the patients. The dental plaque specimen was processed for helicourease test and the gastric biopsy specimens were processed both for the helicourease test and histopathology.

RESULTS

Out of all patients studied (n=52), 32 (61.53%) were positive for helicourease test with gastric biopsy while 48 (92.30%) were positive with dental plaque. The histopathology of gastric biopsy showed H. pylori associated chronic active gastritis in 42 (80.76%) patients. Eight (15.38%) patients showed chronic active gastritis which was not associated with H. pylori while in 2 (3.84%) patients the gastric biopsy specimen was unremarkable.

CONCLUSION

Majority of the patients have possible H. pylori colonization in dental plaque while about two-thirds have H. pylori associated chronic active gastritis. Oral cavity may be the first place for colonization and then the infection involves the gastric mucosa.

Leprosy patients with lepromatous disease have an up-regulated IL-8 response that is unlinked to TNF-alpha responses

Tumor necrosis factor (TNF-alpha) in conjunction with interferon-gamma (IFN-gamma) plays an important role in lymphocyte recruitment and granuloma formation in mycobacterial diseases. Lepromatous leprosy infections are typically associated with low to absent T cell responses and the absence of INF-gamma secretion. Chemokines such as IL-8, MCP-1, and MIP-1beta, have also been shown to recruit neutrophils and lymphocytes to the site of mycobacterial infections. We have studied IL-8 expression in relation to TNF-alpha and TGF-beta in monocytes from lepromatous patients (LL) as compared with healthy endemic controls. In endemic controls, no spontaneous expression of IL-8, TNF-alpha, and TGF-beta was observed, but BCG and M. leprae induced activation of all three cytokines. Lepromatous leprosy monocytes spontaneously expressed high levels of IL-8 and TGF-beta but negligible levels of TNF-alpha. A further increase in IL-8 secretion or gene expression by BCG or M. leprae was not significant. BCG, but not M. leprae, was able to stimulate TNF-alpha activation in lepromatous leprosy subjects. TGF-beta responses in LL were parallel to those of IL-8. This suggests a vigorous and active ongoing IL-8 response in lepromatous disease that is independent of TNF-alpha activation. Therefore, in the absence of IFN-gamma and TNF-alpha activation, IL-8 may assume a pivotal role in cell recruitment in leprosy patients with disseminated mycobacterial infections.

Rapid diagnosis of pulmonary tuberculosis by mycobacteriophage assay

We evaluated FASTPlaqueTB, a recently introduced bacteriophage assay for rapid detection of Mycobacterium tuberculosis complex in sputum specimens, using 169 non-duplicate sputum specimens from patients suspected of pulmonary tuberculosis. The results of 160 specimens were analysed. FASTPlaqueTB assay detected tuberculosis in 77% (46/60) of culture-positive cases. Among the AFB smear-positive cases (n = 47) it had a sensitivity of 76% and specificity of 60% while among AFB smear-negative cases (n = 113) its sensitivity and specificity were 78% and 98%, respectively. The overall sensitivity and specificity of the technique were 77% and 96%, respectively, and the positive and negative predictive values were respectively 92% and 87%. The overall efficiency of the test was 89%. Test results were available in 48 h.

Rapid detection of rifampicin susceptibility of Mycobacterium tuberculosis in sputum specimens by mycobacteriophage assay

OBJECTIVE

To evaluate the performance of FASTPlaqueTB-RIF, a newly introduced bacteriophage assay for rapid detection of rifampicin susceptibility of Mycobacterium tuberculosis in sputum specimens.

METHODS

A comparative study of 40 sputum specimens from patients of pulmonary tuberculosis, using FASTPlaqueTB-RIF and Bactec 460 TB system carried out at the Armed Forces Institute of Pathology, Rawalpindi between September and November 2001.

RESULTS

Of the 40 clinical isolates of Mycobacterium tuberculosis tested for rifampicin (RIF) susceptibility using the Bactec 460 TB system, 28 isolates were resistant to RIF and 12 isolates were susceptible. FASTPlaqueTB-RIF identified 24 specimens as resistant to RIF. Three specimens that revealed susceptible isolates on Bactec 460, were resistant by FASTPlaqueTB-RIF while four specimens which revealed resistant isolates on Bactec 460, demonstrated susceptibility to RIF by FASTPlaqueTB-RIF. The sensitivity and specificity of FASTPlaqueTB-RIF were 86% and 73% respectively. The predictive values of positive and negative tests were 0.89 and 0.67 respectively. The overall accuracy of the technique was 82%. The phage assay took 48 hours to perform.

CONCLUSION

Early detection of rifampicin resistance by the mycobacteriophage technique direct from sputum specimens is a potentially useful new test which would allow decision regarding appropriate therapy to be made early thus having a positive impact on patient care and on prevention of spread of MDR TB.

The Lubinus patellofemoral arthroplasty: a series of 17 cases

INTRODUCTION

The Lubinus patellofemoral arthroplasty was introduced in our institution in 1994. The first 17 patients were followed-up in order to identify the short-term outcome for this prosthesis.

MATERIALS AND METHODS

The average age at surgery was 66 years (range 37-82 years). The mean follow-up was 19 months. The indications for surgery were strictly limited to radiographically proven primary osteoarthritis affecting only the patellofemoral joint (13) and secondary arthritis due to maltracking, subluxation (3) or trauma to the patella (1). At review, the range of movement and Lysholm and Tegner scores were recorded and radiographs obtained. Patients were also asked if their outcome was satisfactory or unsatisfactory.

RESULTS

At review, only 9 (53%) knees were classified as satisfactory by the patients. Further surgery had been carried out in 6 cases (35%) including revision to total knee arthroplasty in 4 (24%). Other complications included clicking and subluxation in 3 cases (18%), extension block in 3 (18%) and infection in 1 (6%). Progression of osteoarthritis to involve other compartments occurred in 2 cases (12%).

CONCLUSIONS

Many of these early problems are related to the unforgiving nature of the prosthesis on insertion. These poor early results have led us to stop using the prosthesis.

Stevens Johnson syndrome in Pakistan: a ten-year survey

OBJECTIVE

A pre-tested questionnaire-based, retrospective study to highlight the causative factors, mode of presentation, complications and outcome of patients with Stevens Johnson syndrome.

SETTING

Aga Khan University Hospital over a 10 year period.

METHODS

All case records with a diagnosis of Steven Johnson Syndrome in the period 1990 to 2000 were retrospectively reviewed. Data was retrieved on a comprehensive questionnaire. The demographic variatbles and drugs taken within the previous 21 days were noted. Date analysis was done by Epi-Info Version 6.0.

RESULTS

Of the 101 studied patient files, the most common offender was found to be the Penicillins as a group and Sulfadoxine-Pyrimethamine (Fansidar) when considering all drugs individually. Most common complications included electrolyte disturbances (13.9%) and congestive heart failure (6.9%). Mortality rate was high at 10.1%.

CONCLUSION

SJS was found to be a rare condition but having a mortality rate of 10.1%. As it can be induced by a large number of drugs, caution should be practiced while prescribing.

Are renal microgranulomas related to inflammatory tubular destruction?

Two cases of renal microgranuloma formation are reported, one in a patient with known Crohn's disease and another in a case of acute renal allograft rejection. In both cases, the microgranulomas arose as a result of inflammatory tubular destruction, in a manner analogous to that seen in patients with ulcerative colitis arising adjacent to ruptured epithelial crypts in the large intestine. Microgranulomas may occur at multiple anatomical sites in Crohn's disease, although renal microgranulomas are very rare. Non-specific inflammatory tubular destruction should be considered as a cause of renal microgranuloma formation, in addition to systemic granulomatous diseases, such as tuberculosis, sarcoid, or Crohn's disease, when granulomas are seen in the presence of inflammatory tubular destruction in renal biopsies.

Ciprofloxacin treatment failure in typhoid fever case, Pakistan

We report a case of ciprofloxacin treatment failure in a typhoid fever patient at a tertiary care hospital in Rawalpindi, Pakistan. This case shows not only the emergence of fluoroquinolone resistance in typhoid salmonellae but also the inadequacy of the current laboratory guidelines for detection of this resistance.

Bloodstream infections in febrile neutropenic patients: bacterial spectrum and antimicrobial susceptibility pattern

BACKGROUND

Bacterial infections are the major cause of morbidity and mortality among neutropenic patients. Prompt administration of empiric antimicrobial therapy for febrile neutropenic patients is considered vital. Before putting neutropenic patients on empiric antimicrobial regimens, it is essential to be aware of the spectrum of locally prevalent pathogens and their susceptibility pattern.

METHODS

We studied the bacterial spectrum and antimicrobial susceptibility pattern of organisms causing bloodstream infections in febrile neutropenic patients in Armed Forces Bone Marrow Transplant Centre, Rawalpindi and the Department of Oncology, Combined Military Hospital, Rawalpindi over a period of nine months from January to September 2002.

RESULTS

Blood specimens for culture and susceptibility testing were collected from 158 febrile patients with neutropenia. Eighty-three organisms were isolated from 60 patients. Thirty-six (43%) isolates were Gram-positive cocci and forty-seven (57%) were Gram-negative rods. Among the Gram-positive cocci, coagulase negative staphylococci (CoNS) were the predominant pathogens (26%), followed by Staphylococcus aureus (8%). Among Gram-negative rods, Escherichia coli was the predominant isolate (13%) followed by Klebsiella pneumoniae (10%). Acinetobacter johnsonii (10%) and Pseudomonas aeruginosa (7%). Nine specimens yielded polymicrobial growth. Forty percent of Staphylococcus aureus and 55% of CoNS were resistant to methicillin. All the Gram-positive isolates were susceptible to vancomycin and teicoplanin. Among the Gram-negative rods, there was 100% resistance to ampicillin, 65% to gentamicin, 47% to amikacin and 66% to third generation cephalosporins. All the gram-negative isolates were susceptible to imipenem.

CONCLUSION

The spectrum of isolates among febrile neutropenic patients in our population appears to be shifting towards Gram-positive microorganisms. Due to increasing levels of drug resistance among the isolates, a glycopeptide in combination with a carbapenem would be a prudent choice as empiric therapy in high-risk cases.

The effect of mycobacterial virulence and viability on MAP kinase signalling and TNF alpha production by human monocytes

SETTING

The success of Mycobacterium tuberculosis as a human pathogen depends on its ability to tolerate and perhaps manipulate host defense mechanisms.

OBJECTIVE

To determine the induction of tumour necrosis factor-alpha (TNF alpha), a central mediator of immunity, by human monocytes infected with virulent M. tuberculosis, M. leprae and attenuated M. bovis BCG.

DESIGN

Mycobacteria-induced cellular activation pathways of TNF alpha production was investigated using an inhibitor of protein tyrosine kinase (PTKs) and an inhibitor of mitogen-activated protein (MAP) kinases.

RESULTS

TNF alpha production was significantly lower during infection with virulent M. tuberculosis than with BCG and this differential response was independent of mycobacterial viability. TNF alpha production involved the PTK and MAP kinase pathways. Reduced TNF alpha induction by M. tuberculosis was associated with a reduction in the extent and duration of phosphorylation of extracellular-signal regulated kinases (ERK 1/2). Infection with M. leprae triggered low and transient ERK 1/2 activation as well as low TNF alpha production.

CONCLUSION

Maintenance of the differential response in both live and heat-killed preparations suggests that the reduced TNF alpha response associated with virulent mycobacteria is due to differences in the presence of components capable of triggering host pattern recognition receptors, rather than events associated with phagosome trafficking or the active release of intracellular modulators.

Factors affecting unsuccessful referral by the Lady Health Workers in Karachi, Pakistan

OBJECTIVE

To estimate the proportion of patient referral and to identify the factors associated with unsuccessful referral in Karachi, Pakistan.

METHODS

In a cross-sectional survey, a total of 347 patients referred to different health care facilities by the LHWs were interviewed. Data was collected using a structured questionnaire, on demographic characteristics of patients (age, sex, income etc) and potential factors (seriousness of medical condition, distance of health facility, attitude of health center staff etc) that can affect patient referral outcome.

RESULTS

An overall referral rate of 55% was found in this study. Out of a total of 347 patients interviewed, 265 (76.4%) were successful while 82 (23.6%) were unsuccessful referrals. Multivariate logistic regression analysis showed that objection to referral (Adjusted OR, 2.96; CI: 1.44-5.52), never referred before (Adjusted OR, 1.25; CI: 1.34-6.90), not visited the referral site before (Adjusted OR, 4.04; CI: 2.50-6.08) and no knowledge of who to meet at the referral site (Adjusted OR, 1.30; CI: 1.01-2.96) were the factors associated with unsuccessful referral. Other factors found significant were duration of the illness of the patient, anyone not known at the referral site and failure of LHW to follow up.

CONCLUSION

Our study found that a significant proportion of patients seen by the LHWs are referred to different health facilities. Improved management skills of LHWs for simple medical problems would probably reduce the number of referrals. Efforts should also be directed to enhance the communication and counseling skills of LHWs, which may reduce a significant proportion of unsuccessful referrals.

The [99mTc(N)(PNP)]2+ Metal Fragment: A Technetium-Nitrido Synthon for Use with Biologically Active Molecules. The N-(2-Methoxyphenyl)piperazyl-cysteine Analogues as Examples

The incorporation of a bioactive molecule into a nitrido-containing (99m)Tc-complex has been successfully achieved by using the [TcN(PNP)](2+) metal fragment. In this strategy, the strong electrophilic [TcN(PNP)](2+) metal fragment efficiently reacts with bifunctional chelating ligands having a pi-donor atom set, such as N-functionalized O,S-cysteine. The 2-methoxyphenylpiperazine (2-MPP) pharmacophore, which displays preferential affinity for 5HT(1A) receptors, was conjugated to the amino group of cysteine to obtain 2-MPPP-cys-OS, where 2-MPPP is 3-[4-(2-methoxyphenyl)piperazin-1-yl]propionate. The asymmetric Tc(V)-nitrido complexes, [(99g/99m)Tc(N)(PNP)(2-MPPP-cys-OS)] (PNP = PNP3, PNP4), were obtained in high yield (95%), by simultaneous addition of PNP and 2-MPPP-cys-OS ligand to a solution containing a starting (99g)/(99m)Tc-nitrido precursor. A mixture of syn and anti isomers was observed, the latter being the thermodynamically favored species. In vitro challenge experiments using the anti isomers with glutathione and cysteine indicated that no transchelation reaction occurs. Assessment of the in vitro 5HT(1A) receptor-affinity of the technetium complexes revealed that only the anti-PNP4 complex possesses some affinity for the receptor, but displayed negligible brain uptake in biodistribution studies in rats in vivo.

The efficacy of aspirin in patients undergoing infra-inguinal bypass and identification of high risk patients

AIM

Infrainguinal bypass is an effective treatment for critical lower limb ischemia but up to 1/3 of these grafts will occlude within the 1st year. The aim of this audit was to evaluate the efficacy of aspirin in maintaining graft patency and also improving patient survival.

METHODS

In a single audited year (1997) 125 bypasses were carried out. Seventy-nine were on aspirin, 34 on no treatment and 12 were on other agents and hence excluded from analysis. The indication for surgery was critical ischaemia in 101 and disabling claudication in 12. Autologous vein was used in 104 and prosthetic grafts in 9.

RESULTS

The overall 2-year primary graft patency, secondary graft patency and limb salvage were 50%, 71% and 83%, respectively. The 2-year secondary patency in patients with or without aspirin was 73% and 64%, respectively (p<0.12-log rank test). The corresponding patient survival from vascular death in the 2 groups was 73% and 70% (p<0.67-log rank test). Crural/ pedal bypass (51/75 on aspirin) and smoking (51/61 on aspirin) were independent risk factors for graft failure and vascular death respectively whilst those with a previous myocardial infarct (21/28 on aspirin) reached significance in univariate analysis only (p< 0.03).

CONCLUSION

Aspirin was not a significant factor in preventing graft failure or vascular death in patients undergoing bypass for critical limb ischemia. Dual therapy with other antiplatelet agents needs to be considered in such patients particularly those undergoing crural/pedal bypass, smokers and those with a history of previous myocardial infarction.

Frequency and antibiotic susceptibility pattern of mycobacterial isolates from extra-pulmonary tuberculosis cases

OBJECTIVE

To determine the frequency and antimicrobial susceptibility pattern of extra-pulmonary tuberculosis in Rawalpindi.

SETTING

Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi.

METHODS

Between September 2000 and August 2002, 899 pulmonary and 460 extra-pulmonary specimens from suspected cases of tuberculosis were examined. The radiometric BACTEC 460 TB system was used for culture and antimicrobial susceptibility testing.

RESULTS

Mycobacteria were isolated from 291 pulmonary specimens and 98 extra-pulmonary specimens. The frequency of extra-pulmonary tuberculosis was 25.2%. The commonest source of isolation was pus (44.9%, frequency 11.3%), followed by lymph nodes (13.3%, frequency 3.3%) and pleural fluid (13.3%, frequency 3.3%). We tested the anti-microbial susceptibility of the isolates to the four first line anti-tuberculous drugs, rifampicin, isoniazid, streptomycin and ethambutol. Of the extra-pulmonary isolates 13.3% were resistant to a single drug, 21.4% were multi-drug resistant and 9.2% were resistant to all the four drugs.

CONCLUSION

Increased awareness of the magnitude of the problem posed by extra-pulmonary tuberculosis is required so that appropriate control measures can be adopted.

Microtibial embolectomy

BACKGROUND

microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot".

METHODS

in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered.

RESULTS

twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22).

CONCLUSIONS

microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.

Neonatal sepsis: high antibiotic resistance of the bacterial pathogens in a neonatal intensive care unit in Karachi

OBJECTIVE

To study the bacterial pathogens causing neonatal sepsis and their sensitivity pattern so that guidelines can be prepared for empirical antibiotic therapy.

SETTING

The study was conducted in the neonatal intensive care unit (NICU) at PNS Shifa (Naval Hospital), Karachi during January 1997 to June 1999.

METHODS

Blood specimens for culture were drawn from 520 newborns admitted in a NICU with sepsis. The specimens were inoculated into brain heart infusion broth. Subcultures were performed on days 1, 2, 3, 5, 7 and 10. The isolates were identified by standard biochemical tests. Antibiotic resistance pattern of the isolates was studied by Modified Kirby Baur disc diffusion technique.

RESULTS

A total of 212 organisms were isolated. These included Staphylococcus aureus (n = 65), Klebsiella pneumoniae (n = 73), Acinetobacter baumannii (n = 23), Escherichia coli (n = 22), Enterobacter cloacae (n = 18), Citrobacter diversus (n = 5), Pseudomonas aeruginosa (n = 4) and group B Streptococcus (n = 2). On antibiotic sensitivity testing, 61.54% of Staphylococcus aureus isolates were found to be methicillin resistant. Susceptibility to the other common drugs was also quite low while 89.23% of these were susceptible to amikacin and 100% to vancomycin. More than 90% gram negative rods were resistant to ampicillin and co-trimoxazole. Resistance to gentamicin was as high as 90.4% for Klebsiella pneumoniae; 60.87% for Acinetobacter baumannii. Resistance to the third generation cephalosporins and the quinolone tested (ciprofloxacin) varied between 25-75%. Majority of the isolates were susceptible to meropenem and amikacin.

CONCLUSION

In view of the isolation of highly antibiotic resistant organisms, vancomycin in combination with amikacin or a carbapenem is the drug of choice for empirically treating neonatal sepsis.

Effect of zinc on hepatic lipid peroxidation and antioxidative enzymes in ethanol-fed rats

A 3-ml aliquot of 30% ethanol was fed daily to normal as well as zinc-treated (227 mg l(-1)) rats for periods of 2, 4 and 8 weeks. A highly significant increase in the levels of hepatic lipid peroxidation was observed in ethanol-fed rats after 4 and 8 weeks of treatment. On the other hand, the levels of lipid peroxidation came down significantly following ethanol feeding to zinc-treated rats. The activities of glutathione peroxidase (GPx), catalase and superoxide dismutase (SOD) in liver were elevated significantly after ethanol administration to rats for durations of 2, 4 and 8 weeks. Interestingly, zinc treatment to rats given ethanol was able to bring down the elevated levels of SOD, catalase and GPx to within normal limits, However, zinc administration alone did not cause any significant alteration in the activities of these antioxidative enzymes.

The Cardiff sib-pair study: suicidal ideation in depressed and healthy subjects and their siblings

Depression is associated with high rates of suicidal ideation, which varies in intensity from transient thoughts of wishing to be dead to the making of plans and, Finally, to attempts to kill oneself. There is limited evidence from family, twin, and adoption studies that completed suicide is familial and has a genetic etiological component. However, it is unclear whether suicidal ideation is also familial. The familiality of suicidal ideation has been examined in the subjects who participated in the Cardiff Depression Study, namely, 108 depressed probands. their nearest-aged siblings, and 105 healthy control subjects and their siblings. The study showed that 66% of depressed subjects had experienced suicidal ideation in the week prior to the interview, and that this was significantly associated with recurrent illness. Suicidal ideation was not shown to be familial. However, somewhat surprisingly, 6% of healthy, never-depressed subjects admitted to having had transient suicidal thoughts. Suicidal ideation was significantly associated with high neuroticism and psychoticism scores and severe threatening life events.