Prevalence of drug resistant Enterobacteriaceae in a Nepalese tertiary care hospital

Antimicrobial resistance in Enterobacteriaceae is an emerging global public health problem. Numerous studies have reported community-acquired AmpC beta-lactamase and extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in Nepal. However, there are limited data on community-acquired Metallo-beta-lactamase (MBL) producing Enterobacteriaceae. A hospital-based descriptive cross-sectional study was conducted using 294 Enterobacteriaceae isolates from a total of 2,345 different clinical specimens collected from patients attending a tertiary care hospital in Nepal. Bacteria were isolated using standard microbiological growth media and identified using biochemical tests. For antimicrobial susceptibility testing, Kirby-Bauer disc diffusion technique was used. AmpC, ESBL, and MBL productions were detected by using combined disc method. AmpC, ESBL, and MBL productions were detected in 19.4%, 29.6%, and 8.5% of total Enterobacteriaceae isolates respectively. Higher rates of beta-lactamases production were seen among the isolates from in-patients in comparison with those from out-patients. However, 11.6%, 25%, and 3.7% of the total isolates from out-patients were AmpC, ESBL, and MBL producers respectively. The co-production of the beta-lactamases was also detected, with two Klebsiella pneumoniae isolates producing all three beta-lactamases. One MBL producing Proteus vulgaris isolate that was pan-resistant with no remaining treatment options was also isolated. Prevalence of drug resistant Enterobacteriaceae in our study was very high. Detection of AmpC, ESBL, and MBL positive isolates from out-patients, who did not have recent history of hospital visit, indicated the community dissemination of the drug resistant bacteria. This is a matter of great concern and an immediate attention to formulate strategies to prevent further development and spread of antibiotic resistance is required.

The impact of obstructive sleep apnea in children with sickle cell disease and asthma

INTRODUCTION

Asthma and obstructive sleep apnea (OSA) are chronic diseases that disproportionately affect children with sickle cell disease (SCD). The literature describes the negative impact that both conditions have on children with SCD separately; however, the effect of OSA on asthmatic children with OSA is less specific. We hypothesized that the presence of OSA in children with SCD and asthma is associated with specific hematologic markers, worse clinical outcomes, and greater healthcare utilization.

METHODS

We retrospectively evaluated children with both SCD and asthma who underwent polysomnography (PSG). We assessed their demographic information, PSG data, hematologic indices, and healthcare utilization based on the concurrent presence of OSA.

RESULTS

Fifty-nine percent of the cohort had OSA with a lower oxygen saturation (SpO2 ) nadir (87% vs. 93%, p < 0.001) and a lower median daytime SpO2 (96.5% vs. 98.5%, p < 0.05); those with OSA were more likely to have the hemoglobin SS genotype (86% vs. 46.5%, p = 0.03). Additionally, those with OSA had a higher mean corpuscular volume (87 vs. 77.2 fL, p = 0.03) and reticulocyte count (10.1% vs. 5.5%, p < 0.01). There was no difference in asthma severity or healthcare utilization between those with OSA and those without OSA.

DISCUSSION

Overall, children with SCD and asthma might be at increased risk for developing OSA, and screening for sleep-disordered breathing should be incorporated as part of their routine care.

Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study

Background and Objectives

Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV.

Methods

Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist.

Results

Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients.

Discussion

This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

Outpatient management of established bronchopulmonary dysplasia: An update

As the incidence of infants with bronchopulmonary dyspasia (BPD) has continued to rise, so has their rate of survival. Their medical management is often complex and requires the use of numerous therapies such as steroids, bronchodilators, diuretics and modalities to deliver supplemental oxygen and positive pressure. It also requires multi-disciplinary care to ensure adequate growth and to optimize neurodevelopmental outcomes. This review aims to discuss the most widely used therapies in the treatment of patients with established BPD. The focus will be on ongoing outpatient (post-neonatal intensive care) management of children with BPD. Since many of the mentioned therapies lack solid evidence to support their use, more high quality research, such as randomized controlled trials, is needed to assess their effectiveness using defined outcomes.

Cervical Papanicolaou Smear Test Screening among Patients Visiting the Outpatient Department of Gynaecology of a Tertiary Care Centre

Introduction

Carcinoma cervix is the second most common cause of death in women worldwide and the most common cause in developing countries. Cervical cancer is considered a preventable gynaecological problem as it has a long premalignant stage which can be detected by exfoliative cytology like papanicolaou smear test. The papanicolaou smear test is a simple, safe, non-invasive, and low-cost effective method for screening cervical cancer in developing countries like Nepal. The aim of the study was to find out the prevalence of cervical papanicolaou smear test screening among patients visiting the Outpatient Department of Gynaecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients visiting the Department of Gynaecology of a tertiary care centre after obtaining ethical approval from the Institutional Review Committee. Data from 14 April 2021 to 22 October 2022 were collected between 11 May 2023 to 26 May 2023 from the hospital records. Papanicolaou smear tests among the age group of 21 years up to 70 years were included in the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 11,173 patients, papanicolaou smear test was done in 572 (5.12%) (4.71-5.53, 95% Confidence Interval). Negative for intraepithelial lesion was the most common cytological pattern seen in 518 (90.55%) patients. The low-grade squamous intraepithelial lesion was the most common among abnormal epithelial cells seen in 29 (5.07%).

Conclusions

The prevalence of cervical papanicolaou smear test among patients visiting the Outpatient Department of Gynaecology was found to be similar to other studies done in similar settings.

Keywords

cervical cancer; cytology; papanicolaou smear.

Diagnostic Delay in Pediatric Vestibular Disorders

BACKGROUND

Vertigo and dizziness in children can be multi-factorial. Vestibular function tests allow an improved differential diagnosis and treatment. Delay in diagnosis of the diverse etiologies causing dizziness can adversely affect the health of children and is a matter of concern for their families. This study analyzes the delay in diagnosis and the importance of establishing a diagnosis with detailed history and neuro-otological evaluation.

METHODS

A total of 241 children presenting with vertigo to a tertiary otoneurology clinic between January 2019 and April 2022 were analyzed for the duration between the onset of symptoms and diagnosis, presenting complaints, and characteristic findings.

RESULTS

Two hundred and forty-one patients with a mean age of 12.5 ± 3.02 years (range, 5-16 years) were evaluated. About 39.4% of patients were diagnosed after over a year (with some over 5 years) of suffering from vertigo and only 18.7% of patients were diagnosed correctly within 1 month of symptom onset. The presenting features were variable with 174 (72.2%) complaining of spinning, unsteadiness, and falls seen in 36+10+37 (34.4%). Vestibular migraine was the most common diagnosis (63.39%), followed by benign paroxysmal positional vertigo (24.48%), of which the posterior canal was most affected (50.85%) followed by horizontal (40.68%) and anterior canal (8.47%). Other etiologies noted were central (14.10%) and peripheral vestibulopathy (17.42%) and variable other causes (6.19%).

CONCLUSION

Many pediatric vertigo and dizziness patients do not reach the correct diagnosis for long durations and are treated as "unspecified dizziness." A detailed examination with a multidisciplinary approach including vestibular evaluation is advocated to give definitive treatment to these children.

Large Variability of Head Angulation During the Epley Maneuver: Use of a Head-Mounted Guidance System with Visual Feedback to Improve Outcomes

BACKGROUND

The aim of this study was to show the variability in head angulation during the canalolith repositioning maneuvers to treat benign paroxysmal positional vertigo and to describe a head-mounted benign paroxysmal positional vertigo guidance system to measure the head orientation.

METHODS

A guidance system for benign paroxysmal positional vertigo was developed by NeuroEquilibrium Diagnostic Systems to measure head orientation and provide visual feedback and instructions to examiners during various maneuvers for benign paroxysmal positional vertigo. Twenty-five experienced examiners and 25 healthy volunteers (aged 21-35 years) were recruited. Each examiner applied the Epley maneuver twice in 1 volunteer: without and with the use visual feedback from a guidance system. Head orientation in both procedures was measured and compared.

RESULTS

The trained examiners demonstrated a large variability in head orientation during the Epley maneuver, which was reduced by using the benign paroxysmal positional vertigo guidance system. There was a variability of 39-65° in head orientation measured without the guidance system. The use of the guidance system reduced the variation range to a sixfold decrease in variability.

CONCLUSION

There is a large variability in head orientation when performing repositioning maneuvers, which could compromise the efficacy of benign paroxysmal positional vertigo treatment. Treatment for benign paroxysmal positional vertigo can be optimized by reducing this variability with a benign paroxysmal positional vertigo guidance system. It might also be a useful tool for teaching.

A systematic review and meta-analysis of spectral CT to differentiate focal liver lesions

AIM

To determine the feasibility of spectral computed tomography (CT) in the differentiation of focal liver lesions from hepatocellular carcinoma (HCC) using a network meta-analysis (NMA).

MATERIALS AND METHODS

The review was completed in accordance with PRISMA guidelines. Searches of three medical databases were performed. A total of nine articles were found for the qualitative synthesis. The meta-analysis was performed on five studies for the normalised iodine concentration (NIC; which is the iodine concentration in the lesion divided by the iodine concentration in the aorta) and the lesion-normal parenchyma iodine ratio (LNR; which is the iodine concentration in the lesion divided by the iodine concentration in the non-tumour hepatic parenchyma) on portal venous and arterial phase images due to sufficient data.

RESULTS

Spectral CT can be used to differentiate HCC from hepatic haemangioma (HH), focal nodular hyperplasia (FNH), regenerative nodules, neuroendocrine tumours (NETs), abscesses, and angiomyolipoma (AML). Hepatic metastases versus abscess and FNH versus HH could also be differentiated. The NMA demonstrated that HCC, NETs, and regenerative nodules could be differentiated due to lower quantitative iodine values. FNH, AML, and HH all had higher values.

CONCLUSION

Spectral CT shows promise in differentiating focal liver lesions. Studies with larger sample sizes are warranted. Future studies should be performed comparing benign lesions using quantitative markers.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Modified Interpretations of the Supine Roll Test in Horizontal Canal BPPV Based on Simulations: How the Initial Position of the Debris in the Canal and the Sequence of Testing Affects the Direction of the Nystagmus and the Diagnosis

Background and Objectives

The aim of this study was to show with three-dimensional simulations how the diagnostic supine roll test (SRT) is affected by the initial position of the debris within the horizontal canal (hc) and study the nystagmus patterns on changing the sequence of testing and its impact on the diagnosis of the side of involvement in hc-BPPV.

Methods

A 3D dynamic simulation model was developed and applied based on reconstructed MRI images and fluid dynamics. Each semicircular canal was linked to the respective extraocular muscles to visualize nystagmus generated on stimulation of the canal.

Results

The simulations of hc-canalithiasis showed that the nystagmus pattern seen with the SRT is changed by the initial position of the otolith debris within the canal and the sequence of testing. The debris changes position during SRT so that sequential steps do not start at the initial position as previously assumed. The sequence of performing the SRT steps from the right or left side influences the nystagmus pattern generated: bilateral direction-changing, bilateral direction-fixed, and unilateral nystagmus can be seen in different test conditions. The SRT itself may even reposition the debris out of the canal.

Conclusions and Clinical Implications

Simulations provide a dynamic tool to study the diagnostic SRT in hc-canalithiasis. Starting the SRT from right or left has a major impact on the test outcome (unlike the Dix-Hallpike maneuver). The findings provide a new interpretation for the results of the SRT. The simulations explain the phenomenon of direction-fixed nystagmus as a logical consequence of starting the SRT with the head turned toward the non-affected side in hc-canalithiasis with debris in the ampullary arm. They also show that unilateral nystagmus seen on SRT indicates canalithiasis of the non-ampullary arm of the side opposite to the side of nystagmus. The generation of bilateral direction-changing, bilateral direction-fixed, and unilateral nystagmus can be the cause of misdiagnoses in terms of the affected side and underlying mechanisms. Finally, a recommendation for a standardized protocol for the sequence of positional tests should be established to ensure uniform interpretation of test results.

Benefit of pulmonary subspecialty care for children with sickle cell disease and asthma

OBJECTIVE

Asthma is a recognized comorbidity in children with sickle cell disease (SCD). It increases the risk of acute chest syndrome (ACS), vaso-occlusive episodes, and early mortality. We aim to determine whether evaluation and management of children with SCD and asthma by a pulmonologist reduce rate of asthma exacerbation and ACS.

METHODS

The study included 192 patients with SCD (0-21 years) followed at Children's Hospital of Philadelphia Hematology between January 1, 2015, and December 31, 2018, with a diagnosis of asthma, wheeze, or cough. Patients were placed in two groups: those evaluated by a pulmonologist (SCD-A-P) and those not (SCD-A). Rates of emergency department (ED) visits and hospitalizations for asthma exacerbation and ACS were compared between groups and over time.

RESULTS

SCD-A-P patients (n = 70) were predominantly SCD type SS with lower hemoglobin and hematocrit compared to SCD-A patients (n = 122). SCD-A-P started with a higher average rate of hospital visits for asthma exacerbation and ACS per year (2.69 [1.02-4.37]) compared to SCD-A (0.43 [0.24-0.63]), (p < 0.001). For SCD-A-P patients with at least one hospital visit (n = 48), the average rate decreased from 3.93 (1.57-6.29) to 0.85 (0.48-1.23) following pulmonary consultation (p = 0.014) and was comparable to the SCD-A rate by study end.

CONCLUSION

SCD-A-P was mainly SCD type SS and had higher ED/hospitalization rates for asthma exacerbation and ACS compared to SCD-A, but the rates significantly decreased following pulmonology consultation. These findings support the pulmonologist's role in the multidisciplinary care of SCD patients and highlight the need for evidence-based asthma guidelines for children with SCD.

Diagnosis and management of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.

Diagnostic and Therapeutic Maneuvers for Anterior Canal BPPV Canalithiasis: Three-Dimensional Simulations

Background and Objectives: Anterior canal BPPV is a rare BPPV variant. Various diagnostic and therapeutic maneuvers have been described for its management. The aim of this study was to use three-dimensional simulation models to visualize otoconial debris movement within the anterior canal during diagnostic tests and different liberatory maneuvers. This can help to optimize existing treatment maneuvers and help in the development of better management protocols. Methods: Based on reconstructed MRI images and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Simulations of the supine head-hanging test for diagnosis of ac-BPPV were studied. Three repositioning maneuvers were simulated: 1) the Yacovino maneuver and its modifications, 2) the reverse Epley maneuver and 3) the short canal repositioning (CRP) maneuver. Results: The simulation showed that the supine head-hanging test is a good test for diagnosis of ac-BPPV affecting both labyrinths and demonstrated why there is no inversion of nystagmus on sitting up. The Yacovino maneuver was seen to be an effective treatment option for ac-BPPV without having to determine the side involved. However, simulations showed that the classical Yacovino maneuver carried a risk of canal switch to the posterior canal. To overcome this risk, a modified Yacovino maneuver is suggested. The reverse Epley maneuver was not an effective treatment. Short CRP is useful in ac-BPPV treatment; however, it requires determination of side of involvement. Conclusion: The 3D simulator of the movement of the otoconial debris presented here can be used to test the mechanism of action and the theoretical efficacy of existing diagnostic tests and maneuvers as well as to develop new treatment maneuvers to optimize BPPV treatment.

Three-dimensional simulations of six treatment maneuvers for horizontal canal benign paroxysmal positional vertigo canalithiasis

BACKGROUND AND PURPOSE

Horizontal canal benign paroxysmal positional vertigo (BPPV) is the second most common variant of BPPV after posterior canal BPPV. Various liberatory maneuvers are recommended for the treatment of horizontal canal BPPV canalithiasis (hc-BPPV-ca). The aim of this study was to show how three-dimensional (3D) dynamic simulation models visualize the movement of the clot of otoconia within the canal for a better understanding of the theoretical efficacy.

METHODS

Based on reconstructed magnetic resonance imaging and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Thereby, six treatment maneuvers for hc-BPPV-ca were simulated: two types of the roll maneuver (the original 270° and the modified 360°) as well as two Gufoni and Zuma maneuvers (for geotropic and apogeotropic nystagmus).

RESULTS

The simulations showed that the 360° roll maneuver and Zuma maneuver are effective treatment options for hc-BPPV-ca for debris in all locations within the canal. However, the original 270° roll maneuver will not be effective if the clot is in the ampullary arm of the horizontal canal. The Gufoni maneuver for geotropic hc-BPPV-ca is effective, whereas for apogeotropic hc-BPPV-ca there is a risk of treatment failure due to insufficient repositioning of the debris.

CONCLUSIONS

The 3D simulations for movement of the otoconia clots can be used to test the mechanism of action and the theoretical efficacy of existing maneuvers for the different BPPV variants. For hc-BPPV-ca, the modified 360° roll maneuver and Zuma maneuver are theoretically efficient for all subtypes, whereas Gufoni maneuver is effective for geotropic nystagmus only.

BPPV Simulation: A Powerful Tool to Understand and Optimize the Diagnostics and Treatment of all Possible Variants of BPPV

BPPV is a mechanical disorder caused by the displacement of otolith debris into the semicircular canals. The treatment involves different repositioning maneuvers to bring the debris back into the utricle. This study aims to show how dynamic simulation models based on fluid dynamics and MRI, can help to visualize and understand the movement of the debris within the canals during head movement in 3D as a function of time. The user can define the rotation angle and plane at each step of the maneuver and then the model visualizes the canal and the otoconial movement in 3D. The simulation developed also allows alteration of various parameters like the rotational head acceleration, the duration of each step of the maneuver, the initial position of the otoconial debris in the canal, the size and the number of the particles and fluid dynamics of endolymph. The clod movement is visualized in such a way that it allows a better understanding of the impact and efficacy of various liberation maneuvers and why certain maneuvers might fail when not applied properly in the clinic. The model allows simulation of multi-canal BPPV. In this paper we demonstrate the power of the model applied on the maneuvers of Semont and Yacovino when executed in different ways. The model aims to provide a visual explanation for the need of specific maneuvers for each type of BPPV. The simulator presented here can be used to test the efficacy of existing maneuvers and help in the development of new maneuvers to treat different BPPV variants.

Role of Magnetic Resonance Cholangiopancreatography in the Evaluation of Obstructive Jaundice

Background Magnetic Resonance Cholangiopancreatography is a reliable and highly sensitive imaging modality in the diagnosis of Obstructive jaundice. Objective To evaluate the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography as compared to Endoscopic Retrograde Cholangiopancreatography. Method A prospective, analytical study was conducted in the Department of Radiodiagnosis and Imaging at Dhulikhel Hospital between October 2018 and December 2020. Altogether 100 patients of all ages with obstructive jaundice undergoing Magnetic Resonance Cholangiopancreatography and Endoscopic Retrograde Cholangiopancreatography were included. The causes of obstructive jaundice as identified by Magnetic Resonance Cholangiopancreatography were compared to that of Endoscopic Retrograde Cholangiopancreatography considering Endoscopic Retrograde Cholangiopancreatography as gold standard for the diagnosis. Result Magnetic Resonance Cholangiopancreatography revealed choledocholithiasis in 60 (60%) patients, benign stricture - 14(14%), malignant stricture-11(11%), periampullary carcinoma in 8(8%) and normal study in 4(4%) patients. Endoscopic Retrograde Cholangiopancreatography showed choledocholithiasis in 59(59%) patients, strictures (benign in 13%, malignant in 10%), ascariasis in 3(3%) and normal findings in 5(5%) patients. The sensitivity, specificity, positive predictive value and negative predictive value of Magnetic Resonance Cholangiopancreatography in detecting choledocholithiasis were 96.6%, 92.3%, 95%, and 95%. The same values for benign strictures were 92.3%, 97.7%, 85.7% and 98.9%, whereas those for malignant strictures were 90.9%, 98.8%, 90.9% and 98.8%. All values were 100% for peri-ampullary carcinoma and ascariasis. Hence, Magnetic Resonance Cholangiopancreatography showed good accuracy for detecting causes of obstructive jaundice (p < 0.05) as compared to Endoscopic Retrograde Cholangiopancreatography. Conclusion Magnetic Resonance Cholangiopancreatography is an accurate, non-invasive technique in evaluation of obstructive jaundice and offers similar diagnostic value compared to Endoscopic Retrograde Cholangiopancreatography.

Central vein sign for multiple sclerosis: A systematic review and meta-analysis

AIMS

To systematically review the diagnostic value of the central vein sign (CVS) in multiple sclerosis (MS) and to meta-analyse the proportion of positive lesions for CVS needed to distinguish MS from non-MS mimics.

MATERIALS AND METHODS

A literature review was performed and a proportion meta-analysis was performed to examine the proportion of the CVS in MS lesions. Studies reporting a threshold of the CVS containing lesions with 100% diagnostic accuracy were included in the meta-analysis. This was compared to MS mimics in order to establish the discriminative value of the CVS.

RESULTS

The CVS was found to be viable at lower field strengths (3 T and 1.5 T) and automated analysis is currently less accurate than manual counting. Five studies were included for the proportional meta-analysis. From the analysis, a proportion of 45% of lesions having the CVS was suggested given that the findings that the weighted proportion was 46.4% (95% confidence interval [CI]: of 40.3%-52.6%) with low heterogeneity (I² = 0.0%; p=0.5).

CONCLUSION

Although the CVS is a clinically relevant and viable sign, further work is needed to integrate this into the existing diagnostic criteria. As manual determination is a time-consuming process, the development of automated methods will be beneficial. With improvements in computational imaging techniques, the CVS will have an important role in the diagnosis and differentiation of MS.

Extended spectrum β-lactamase producing uropathogenic Escherichia coli and the correlation of biofilm with antibiotics resistance in Nepal

BACKGROUND

Urinary tract infection (UTI) is one of the frequently diagnosed infectious diseases which is caused mainly by Escherichia coli. E. coli confers resistance against the two major classes of antibiotics due to the production of extended spectrum β-lactamase enzymes (ESBL), biofilm, etc. Biofilm produced by uropathogenic E. coli (UPEC) protects from host immune system and prevent entry of antimicrobial compounds. The main objective of this cross-sectional study was to determine the correlation of biofilm production and antibiotic resistance as well as to characterize the pgaA and pgaC genes responsible for biofilm formation among uropathogenic ESBL producing E. coli.

METHODS

A total of 1977 mid-stream urine samples were examined and cultured for bacterial strain identification. ESBL was detected by combined disc method following CLSI whereas biofilm formation was analyzed by semi-quantitative method. Furthermore, the pgaA and pgaC genes responsible for biofilm formation in UPEC were detected by multiplex PCR. All the statistical analyses were done via IBM SPSS Statistics 21 where Pearson's correlation test were used to determine correlation (-1 ≥ r ≤ 1).

RESULTS

E. coli was the predominant causative agent, which accounted 159 (59.3%) of the Gram-negative bacteria, where 81 (50.9%) E. coli strains were found to be ESBL producers. In addition, 86 (54.1%) E. coli strains were found to be biofilm producers. Both the pgaA and pgaC genes were detected in 45 (93.7%) the UPEC isolates, which were both biofilm and ESBL producers. Moreover, there was a positive correlation between biofilm and ESBL production.

CONCLUSION

The analyses presented weak positive correlation between biofilm and ESBL production in which biofilm producing UPEC harbors both pgaA and pgaC genes responsible for biofilm formation.

A Drosophila model of cigarette smoke induced COPD identifies Nrf2 signaling as an expedient target for intervention

Chronic obstructive pulmonary disease (COPD) is among the most important causes of death. Signaling systems that are relevant for tissue repair and detoxification of reactive oxygen species or xenobiotics are thought to be impaired in lungs of patients suffering from this disease. Here, we developed a simple cigarette smoke induced Drosophila model of COPD based on chronic cigarette smoke exposure that recapitulates major pathological hallmarks of the disease and thus can be used to investigate new therapeutic strategies. Chronic cigarette smoke exposure led to premature death of the animals and induced a set of phenotypes reminiscent of those seen in COPD patients, including reduced physical activity, reduced body fat, increased metabolic rate and a substantial reduction of the respiratory surface. A detailed transcriptomic analysis revealed that especially the TGF-β, Nrf2 and the JAK/STAT signaling pathways are altered by chronic cigarette smoke exposure. Based on these results, we focused on Nrf2 signaling. A pharmacological intervention study performed with oltipraz, an activator of Nrf2 signaling, increased survival of cigarette smoke exposed animals significantly. Thus, the Drosophila COPD model recapitulates many major hallmarks of COPD and it is highly useful to evaluate the potential of alternative therapeutic strategies.

Early Intratympanic Methylprednisolone in Sudden SNHL: A Frequency-wise Analysis

Sudden sensorineural hearing loss is a dire medical emergency which must be treated at the earliest to get better long term hearing results. Our study aims to determine the efficacy of intratympanic steroid (Methylprednisolone) on auditory outcomes in patients of sudden sensorineural hearing loss and study the relation between time of onset of hearing loss to start of therapy and frequency-wise recovery of hearing loss. A prospective cohort clinical study with 33 patients with sudden hearing loss of 30 dB or more were treated with the intratympanic injection of methylprednisolone and the effect of the drug was observed. In this study, 33 patients with sudden onset (unilateral or bilateral) of hearing loss were treated with intratympanic methylprednisolone. The duration at which the drug was administered and the age of the participants was taken into consideration. Main outcome measures included audiometry results at low, medium and high hearing loss frequencies. The specific frequency at which the hearing improvement took place was tabulated. It was observed that hearing improved significantly if the steroid is injected within the first 4 days of onset (p < 0.05) at all the frequencies. A gain of 15 dB or more was achieved in more than 78% patients after injecting methylprednisolone intratympanically. A statistically significant association was found between recovery rate and frequency of hearing loss with patients showing greater improvement at low hearing loss frequency in comparison to mid and high frequencies (p < 0.05). The drug efficacy does not change with the age of the patient.

Two vs four puffs of albuterol: does dose change bronchodilator response?

Background

Reversible obstruction on spirometry may be used to diagnose asthma. As per 2005 American Thoracic Society (ATS) guidelines, our pulmonary center began using 360 µg (four puffs) of albuterol rather than 180 µg (two puffs) to determine reversibility on spirometry starting in 2009.

Hypothesis

We hypothesized that fewer patients would respond to two puffs of albuterol than four puffs during spirometric testing.

Methods

We retrospectively reviewed records from new asthmatics seen in Pediatric Pulmonary Clinic from March 2002 to April 2014 who performed reproducible spirometry. Patients were divided into two groups based on whether they had received two or four puffs of albuterol for bronchodilator assessment. A positive bronchodilator response was defined as an increase of ≥12% in forced expiratory volume in one second (FEV₁) or ≥25% in forced expiratory flow (FEF_25–75%). Data were expressed as percentages and mean ± standard error of the mean values. Chi-squared test and Student’s t-test were utilized.

Results

Data were collected for 240 patients; 115 patients received two puffs of albuterol and 125 patients received four puffs. There were no significant differences in baseline characteristics between the two groups. There were no differences following two puffs or four puffs in changes in FEV₁ (10.0±1.1% vs 10.5±1.1% predicted) or FEF_25–75% (30.2±2.9% vs 33.5±2.9% predicted). Moreover, there was no difference in ATS-defined bronchodilator response between the two groups.

Conclusion

Based on the mean change in FEV₁ and overall bronchodilator responsiveness, two puffs of albuterol were not inferior to four puffs in the determination of bronchodilator responsiveness in our pediatric asthmatic patients.

An update on the post-NICU discharge management of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease which develops as a result of neonatal/perinatal lung injury. It is the commonest cause of chronic lung disease in infancy and the most frequent morbidity associated with prematurity. The incidence of BPD has continued to rise despite many advances in neonatal care and this increase has been attributed to the increased survival of younger and more premature babies. There have been many advances in the care of patients with early and evolving BPD, yet there is a paucity of data regarding outpatient management of patients with established BPD. There are limited adequately-powered high-quality studies/randomized controlled trials which assess commonly used therapies such as supplemental oxygen, bronchodilators, steroids and diuretics in patients with BPD, beyond short-term effects. Further research is needed to improve our understanding of the role of currently used treatments on the long-term outcomes of patients with established BPD, post-discharge from the neonatal intensive care unit.

Neonatal Thrombocytopenia: Its associated risk factors and outcome in NICU in a tertiary hospital in Nepal

ABSTRACTBackground: Thrombocytopenia is a frequently encountered hematological abnormality in Neonatal Intensive Care Unit (NICU). There are various maternal and neonatal risk factors associated and the incidence varies greatly depending upon the population studies. This study was performed on neonates admitted in Bharatpur Hospital NICU.Materials & Methods: In this retrospective study, 412 neonates who were admitted in NICU from November 2016 to October 2017 were included in the study. Frequency of thrombocytopenia was determined along with associated maternal and neonatal risk factors. Maternal risk factors like Pregnancy induced hypertension (PIH), Diabetes, Eclampsia, drug use and neonatal risk factors like sepsis, asphyxia, intrauterine growth retardation (IUGR), prematurity were analyzed. Requirement of platelet transfusion and the outcome were also evaluated. Results: Of the 412 neonates included, 74 had thrombocytopenia which comprised approximately 18% neonates admitted in NICU. Early onset thrombocytopenia occurring within 72 hrs comprised 91.8% while late onset thrombocytopenia occurring after 72 hrs comprised 8.2% of total thrombocytopenia. 58.1% (43) were mild , 29.7% (22) moderate and 12.2% (9) severe thrombocytopenia. The major neonatal risk factors were sepsis, asphyxia, IUGR and prematurity while gestational diabetes and PIH were maternal risk factors contributing to neonatal thrombocytopenia. Only 4.05% received platelet transfusion. 77.03% of the neonates recovered and were discharged while 12.16% neonates were referred to other centres and 5.40% neonates died.Conclusion: Neonatal thrombocytopenia accounted for 18% of neonates which were admitted in the NICU. Significant neonatal risk factors were asphyxia and sepsis and maternal risk factors were PIH and diabetes. Majority did not require platelet transfusion and outcome was also good.

A model species for agricultural pest genomics: the genome of the Colorado potato beetle, Leptinotarsa decemlineata (Coleoptera: Chrysomelidae)

The Colorado potato beetle is one of the most challenging agricultural pests to manage. It has shown a spectacular ability to adapt to a variety of solanaceaeous plants and variable climates during its global invasion, and, notably, to rapidly evolve insecticide resistance. To examine evidence of rapid evolutionary change, and to understand the genetic basis of herbivory and insecticide resistance, we tested for structural and functional genomic changes relative to other arthropod species using genome sequencing, transcriptomics, and community annotation. Two factors that might facilitate rapid evolutionary change include transposable elements, which comprise at least 17% of the genome and are rapidly evolving compared to other Coleoptera, and high levels of nucleotide diversity in rapidly growing pest populations. Adaptations to plant feeding are evident in gene expansions and differential expression of digestive enzymes in gut tissues, as well as expansions of gustatory receptors for bitter tasting. Surprisingly, the suite of genes involved in insecticide resistance is similar to other beetles. Finally, duplications in the RNAi pathway might explain why Leptinotarsa decemlineata has high sensitivity to dsRNA. The L. decemlineata genome provides opportunities to investigate a broad range of phenotypes and to develop sustainable methods to control this widely successful pest.

Can teamwork and situational awareness (SA) in ED resuscitations be improved with a technological cognitive aid? Design and a pilot study of a team situation display

Effective teamwork in ED resuscitations, including information sharing and situational awareness, could be degraded. Technological cognitive aids can facilitate effective teamwork.

OBJECTIVE

This study focused on the design of an ED situation display and pilot test its influence on teamwork and situational awareness during simulated resuscitation scenarios.

MATERIAL AND METHODS

The display design consisted of a central area showing the critical dynamic parameters of the interventions with an events time-line below it. Static information was placed at the sides of the display. We pilot tested whether the situation display could lead to higher scores on the Clinical Teamwork Scale (CTS), improved scores on a context-specific Situational Awareness Global Assessment Technique (SAGAT) tool, and team communication patterns that reflect teamwork and situational awareness.

RESULTS

Resuscitation teamwork, as measured by the CTS, was overall better with the presence of the situation display as compared with no situation display. Team members discussed interventions more with the situation display compared with not having the situation display. Situational awareness was better with the situation display only in the trauma scenario.

DISCUSSION

The situation display could be more effective for certain ED team members and in certain cases.

CONCLUSIONS

Overall, this pilot study implies that a situation display could facilitate better teamwork and team communication in the resuscitation event.

Ancestry & molecular evolutionary analyses of heat shock protein 47 kDa (HSP47/SERPINH1)

HSP47/SERPINH1 is key-regulator for collagen biosynthesis and its structural assembly. To date, there is no comprehensive study on the phylogenetic history of HSP47. Herein we illustrate the evolutionary history of HSP47/SERPINH1 along with sequence, structural and syntenic traits for HSP47/SERPINH1. We have identified ancestral HSP47/SERPINH1 locus in Japanese lamprey (Lethenteron japonicum). This gene remains on the same or similar locus for ~500 million years (MY), but chromosomal duplication was observed in ray-finned fishes, leading into three sets of three sets (I-III) of HSP47/SERPINH1. Two novel introns were inserted at the positions 36b and 102b in the first exon of only HSP47_1 gene from the selected ray-finned fishes. On the evolutionary time scale, the events of HSP47 duplications took placed between 416–360 MY ago (MYA) while intron insertion dates back to 231–190 MYA after early divergence of ray-finned fishes.

Transport of Liposome Encapsulated Drugs in Voxelized Computational Model of Human Brain Tumors

There are many obstacles in the transport of chemotherapeutic drugs to tumor cells that lead to irregular and non-uniform uptake of drugs inside tumors. The study of these transport problems will help with accurate prediction of drug transport and optimizing treatment strategy. To this end, liposome mediated drug delivery has emerged as an excellent anticancer therapy due to its ability to deliver drugs at site of action and reducing the chances of side effects to the healthy tissues. In this paper, a computational fluid dynamics (CFD) model based on realistic vasculature of human brain tumor is presented. This model utilizes dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data to account for heterogeneity in tumor vasculature. Porosity of the interstitial space inside the tumor and normal tissue is determined voxel-wise by processing the DCE-MRI images by general tracer kinetic model (GTKM). The CFD model is applied to predict transport of two different types of liposomes (stealth and conventional) in tumors. The amount of accumulated liposomes is compared with accumulated free drug (doxorubicin) in the interstitial space. Simulation results indicate that stealth liposomes accumulate more and remain for longer periods of time in tumors as compared with conventional liposomes and free drug. The present model provides us a qualitative and quantitative examination on the transport and deposition of liposomes as well as free drugs in actual human brain tumors.

Perfusion kinetics in human brain tumor with DCE-MRI derived model and CFD analysis

Cancer is one of the leading causes of death all over the world. Among the strategies that are used for cancer treatment, the effectiveness of chemotherapy is often hindered by factors such as irregular and non-uniform uptake of drugs inside tumor. Thus, accurate prediction of drug transport and deposition inside tumor is crucial for increasing the effectiveness of chemotherapeutic treatment. In this study, a computational model of human brain tumor is developed that incorporates dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data into a voxelized porous media model. The model takes into account realistic transport and perfusion kinetics parameters together with realistic heterogeneous tumor vasculature and accurate arterial input function (AIF), which makes it patient specific. The computational results for interstitial fluid pressure (IFP), interstitial fluid velocity (IFV) and tracer concentration show good agreement with the experimental results. The computational model can be extended further for predicting the deposition of chemotherapeutic drugs in tumor environment as well as selection of the best chemotherapeutic drug for a specific patient.

Data on the evolutionary history of the V(D)J recombination-activating protein 1 - RAG1 coupled with sequence and variant analyses

RAG1 protein is one of the key component of RAG complex regulating the V(D)J recombination. There are only few studies for RAG1 concerning evolutionary history, detailed sequence and mutational hotspots. Herein, we present out datasets used for the recent comprehensive study of RAG1 based on sequence, phylogenetic and genetic variant analyses (Kumar et al., 2015) [1]. Protein sequence alignment helped in characterizing the conserved domains and regions of RAG1. It also aided in unraveling ancestral RAG1 in the sea urchin. Human genetic variant analyses revealed 751 mutational hotspots, located both in the coding and the non-coding regions. For further analysis and discussion, see (Kumar et al., 2015) [1].

BPD Following Preterm Birth: A Model for Chronic Lung Disease and a Substrate for ARDS in Childhood

It has been suggested that pediatric acute respiratory distress syndrome (PARDS) may be a different entity, vis-à-vis adult acute respiratory distress syndrome (ARDS), based on its epidemiology and outcomes. A more pediatric-specific definition of PARDS to include the subgroup of patients with underlying lung (and heart) disease has been proposed. Epidemiological data suggest that up to 13% of the children with ARDS have a history of prematurity and/or underlying chronic lung disease. However, the specific contribution of bronchopulmonary dysplasia (BPD), the most common chronic lung disease in infants, to the development of PARDS is not known. BPD leads to damaged lungs with long-term consequences secondary to disordered growth and immune function. These damaged lungs could potentially act as a substrate, which given the appropriate noxious stimuli, can predispose a child to PARDS. Interestingly, similar biomarkers [KL-6, interleukin (IL)-6, IL-8, sICAM-1, angiopoietin-2, and matrix metalloproteinase-8 and -9] of pulmonary injury have been associated both with BPD and ARDS. Recognition of a unique pattern of clinical symptomatology and/or outcomes of PARDS, if present, could potentially be useful for investigating targeted therapeutic interventions.

Comparison of social circumstances, substance use and substance-related harm in soon-to-be-released prisoners with and without intellectual disability

BACKGROUND

The transition out of prison is likely to be a challenging time for prisoners with intellectual disability (ID). However, little evidence exists to inform interventions for people with ID making this transition. In this study we aimed to describe social circumstances, patterns of substance use and substance-related harm in soon-to-be-released prisoners with ID. We compare this group with those without ID, to better understand how the health-related needs of this group compare with the 'mainstream' prison population.

METHODS

Data came from face-to-face, confidential interviews with 1325 adult prisoners in seven adult prisons in Queensland, Australia. Prisoners with ID were identified using the Hayes Ability Screening Index (HASI). We used cross-sectional data to examine (i) demographics and criminographics; (ii) social circumstances; and (iii) substance use and substance use related harm. We compared characteristics of those with and without ID using univariable logistic regression.

RESULTS

Prisoners with ID (n = 115) were more likely than their peers without ID to be male, to identify as Indigenous Australian, and to report low educational attainment (<10 years) and pre-incarceration unemployment. Those with ID reported a high prevalence of poly-drug use (28.0%), unsafe tattooing (51.1%), unsafe sex (91.0%) and HCV infection (55.6%), although differences with their peers were non-significant.

CONCLUSIONS

The health and social needs of prisoners with ID transitioning into the community are a significant concern for researchers, policy makers and practitioners. Our findings highlight the need for proactive, appropriate and targeted service responses from disability, health and justice sectors.

Expression analysis of octopamine and tyramine receptors in Drosophila

The monoamines octopamine and tyramine, which are the invertebrate counterparts of epinephrine and norepinephrine, transmit their action through sets of G protein-coupled receptors. Four different octopamine receptors (Oamb, Octß1R, Octß2R, Octß3R) and 3 different tyramine receptors (TyrR, TyrRII, TyrRIII) are present in the fruit fly Drosophila melanogaster. Utilizing the presumptive promoter regions of all 7 octopamine and tyramine receptors, the Gal4/UAS system is utilized to elucidate their complete expression pattern in larvae as well as in adult flies. All these receptors show strong expression in the nervous system but their exact expression patterns vary substantially. Common to all octopamine and tyramine receptors is their expression in mushroom bodies, centers for learning and memory in insects. Outside the central nervous system, the differences in the expression patterns are more conspicuous. However, four of them are present in the tracheal system, where they show different regional preferences within this organ. On the other hand, TyrR appears to be the only receptor present in the heart muscles and TyrRII the only one expressed in oenocytes. Skeletal muscles express octß2R, Oamb and TyrRIII, with octß2R being present in almost all larval muscles. Taken together, this study provides comprehensive information about the sites of expression of all octopamine and tyramine receptors in the fruit fly, thus facilitating future research in the field.

Rehabilitation of an edentulous mouth with severe mandibular ridge resorption using neutral zone impression technique: a case report

Alveolar ridge atrophy poses a clinical challenge towards the fabrication of a successful prosthesis. Resorption of denture bearing areas results in an unstable non-retentive dentures associated with pain and discomfort. Prosthetic Rehabilitation of a patient with severely resorbed ridge is the most challenging therapy a prosthodontist can undertake. For a favourable prognosis of the denture therapy, impression technique selected should be based on the present state of the basal tissue support. This article presents rehabilitation of a patient with severely resorbed mandibular ridge with the application of neutral zone concept being incorporated into impression making in an effort to achieve successful complete denture therapy. Finally, patient had more stable, retentive and functionally efficient complete denture. In conclusion, neutral zone impression technique proved to be a quite effective method for prosthetic rehabilitation of patient with severe mandibular ridge resorption. DOI: http://dx.doi.org/10.3329/bjms.v13i4.15605 Bangladesh Journal of Medical Science Vol.13(4) 2014 p.477-480

Urochordate serpins are Classified into Six Groups Encoded by Exon-Intron Structures, Microsynteny and Bayesian Phylogenetic Analyses

Members of serpin superfamily are involved in wide array of cellular processes to control proteolytic activities of eukaryotic organisms. Vertebrate serpins are extensively studied and reported to be classified into six groups (V1-V6) based on gene structures. However, there is no study conducted for serpins in urochordates (the closest living invertebrates related to vertebrates) to date. To unravel further the phylogenetic history of serpin genes, we characterized serpin genes from two urochordates (Ciona intestinalis and Ciona savignyi). There are 11 and 5 serpins in the C. intestinalis and C. savignyi, respectively. The exon/intron structures and genomic locus comparisons together with sequence phylogenetic analysis, suggested that urochordate serpins are classified into six groups (U1-U6), different from six groups (V1-V6) of vertebrate serpins. Human α1-antitrypsin shared lower sequence identities and similarities with urochordates serpins ranged from 14-29% and 30-49%, respectively. Based on protein sequences, genes and genomic architectures, we conclude that these two urochordates do not contain a single copy of genuine ortholog of the vertebrate serpins.

Sequence and structural perspectives of bacterial β-stranded porins

Porins are integral membrane proteins found in the outer membrane of bacteria, mitochondria and chloroplasts. Herein, we have reviewed sequence and structural understanding about bacterial porins. The first porin structure from Rhodobacter capsulatus at 1.8 Å resolution in 1991 till the recent structural advancement, coupled by immunological properties, diffusion and ion permeation has been taken into account In the later part, we have presented our computational analysis of conformational mobility in selected porins. Atomic B-factors (in crystal structures) are indicative of the degree of intrinsic mobility associated with residues and secondary structural elements of a particular protein. We have explored and extended the intrinsic motilities within porins using selected six porins structures. These six porins were collected from PDB and B-factor analyses were performed using AWK scripts. Distributions of residues and mobilities were characteristic of different porins. These distribution patterns follow the level of homology at the sequence and structural level. The inner walls constituting the trimer interface were found to be more rigid than the outer walls. These mobility differences are intrinsic structural components of these porins.

Factors associated with adherence to antiretroviral therapy in HIV-infected patients in Kathmandu District, Nepal

Purpose

There are a high number of HIV-infected patients receiving antiretroviral therapy (ART) in the Kathmandu District of Nepal, but information on adherence and factors influencing it are scarce in this population. The present study aimed to estimate ART adherence among HIV-infected patients in the Kathmandu District of Nepal, and to determine the factors associated with ART adherence.

Patients and methods

This study included 316 HIV-infected patients attending three ART centers in the Kathmandu District. Information on sociodemographic characteristics, socioeconomic status, and ART use for the previous 7 days was collected via interview. Participants were considered adherent if they reported taking ≥95% of their ART as prescribed. The association between explanatory variables and ART adherence was measured using logistic regression and reported as odds ratios (OR) with 95% confidence intervals (CI).

Results

Male participants accounted for 64.6% (n=204). Overall ART adherence was 86.7%. ART adherence in men and women were 84.3% and 91.1%, respectively. Age (OR 1.04; 95% CI 1.00–1.09), travel time to ART centers (OR 1.38; 95% CI 1.12–1.71), history of illegal drug use (OR 3.98; 95% CI 1.71–9.24), and adverse effects (OR 4.88; 95% CI 1.09–21.8), were all independently and negatively associated with ART adherence. Use of reminder tools (OR 3.45; 95% CI 1.33–8.91) was independently and positively associated with ART adherence.

Conclusion

The observed ART adherence in this study is encouraging. Travel time to ART centers, self-reported adverse effects, illegal drug use, and not using reminder tools were the major determinants of ART adherence. Interventions that take these factors into account could further improve ART adherence.

Genetic variants and evolutionary analyses of heparin cofactor II

Heparin cofactor II (HCII) belongs to serpin superfamily and it acts as a thrombin inhibitor in the coagulation cascade, in a glycosaminoglycan-dependent pathway using the release of a sequestered hirudin-like N-terminal tail for interaction with thrombin. This serpin belongs to multiple member group V2 of vertebrate serpin classification. However, there is no comprehensive study illustrating the exact phylogenetic history of HCII, to date. Herein, we explored phylogenetic traits of HCII genes. Structures of HCII gene from selected ray-finned fishes and lamprey varied in exon I and II with insertions of novel introns of which one in core domain for ray-finned fishes in exon II at the position 241c. We found HCII remain nested in the largest intron of phosphatidylinositol (PI) 4-kinase (PIK4CA) gene (genetic variants of this gene cause schizophrenia) at the origin of vertebrates, dated about 500MY old. We found that sequence features such as two acidic repeats (AR1-II), GAG-binding helix-D, three serpin motifs and inhibitory reactive center loop (RCL) of HCII protein are highly conserved in 55 vertebrates analyzed. We identified 985 HCII variants by analysis of 1092 human genomes with top three variation classes belongs to SNPs (84.3%), insertion (7.1%) and deletion (5.0%). We identified 37 deleterious mutations in the human HCII protein and we have described these mutations in relation to HCII sequence-structure-function relationships. These understandings may have clinical and medical importance as well.

Need for supplemental oxygen at discharge in infants with bronchopulmonary dysplasia is not associated with worse neurodevelopmental outcomes at 3 years corrected age

OBJECTIVES

To determine if chronic oxygen dependency (discharge home on supplemental oxygen) in children with bronchopulmonary dysplasia (BPD; defined as requirement for supplemental O2 at 36 weeks postmenstrual age) predicts neurodevelopmental disability rates and growth outcomes at 36 months corrected age (CA).

STUDY DESIGN

Longitudinal cohort study.

SETTING

Southern Alberta regional center located at high altitude.

PARTICIPANTS

Preterm infants weighing ≤1250 grams with no BPD, BPD, and BPD with chronic oxygen dependency.

MAIN OUTCOME MEASURES

Neurodevelopmental and growth outcomes.

RESULTS

Of 1563 preterm infants admitted from 1995-2007, 1212 survived. Complete follow-up data were available for 1030 (85%) children. Children in BPD and BPD with chronic oxygen dependency groups had significantly lower birth weights, gestational ages, prolonged mechanical ventilation and oxygen supplementation and received more postnatal steroids, compared to those without BPD. Children with BPD and BPD with chronic oxygen dependency were more likely to be below the 5th centile in weight and height compared to those without BPD but there was little difference between the BPD and BPD with chronic oxygen dependency groups. After controlling for confounding variables, children who had BPD and BPD with chronic oxygen dependency had higher odds of neurodevelopmental disability compared to those without BPD [OR (odds ratio) 1.9 (95%CI 1.1 to 3.5) and OR 1.8 (1.1 to 2.9), respectively], with no significant difference between BPD and BPD with chronic oxygen dependency [OR 0.9 (95% CI 0.6 to 1.5)].

CONCLUSIONS

BPD and BPD with chronic oxygen dependency in children predicts abnormal neurodevelopmental outcomes at 36 months CA. However, the neurodevelopmental disability rates were not significantly higher in BPD with chronic oxygen dependency children compared to children with BPD only. Compared to those without BPD, growth is impaired in children with BPD and BPD with chronic oxygen dependency, but no difference between the latter two groups.