Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Secular trends of Streptococcus pyogenes sepsis in Pakistan and analysis of clinical features in a hospitalized cohort

Streptococcus pyogenes or Group A Streptococcus (GAS) is a re-emerging pathogen of significant public health importance. We present trends in GAS blood cultures over a 10 year period in Pakistan and characteristics of hospitalized patients with GAS sepsis over three years at a tertiary care hospital in Karachi, Pakistan. Blood cultures positive for GAS from 2004 -2014 were recorded at the clinical microbiology laboratory of the Aga Khan University and studied for trends in positivity rates. Medical records of patients hospitalized at the Aga Khan University hospital from 2012-2014 were also examined for clinical features and outcomes. GAS trends show a steady rate of blood culture positivity over 11 years, with higher rates in those >50 years, and seasonality favouring winter months. Case fatality rate in the hospitalized cohort was 34.1% (n= 14; of 41 patients). Malignancy predominated as the underlying predisposing factor among the 15-49 age group. Presence of sepsis was an independent predictor of mortality in GAS bacteremia. Studies of GAS trends in developing regions are important to inform changing epidemiology. GAS septic shock continues to have high case fatality despite antibiotic treatment. Early recognition, aggressive, goal-directed therapy for sepsis and prevention are possible control measures to prevent high mortality.

Association of ABO and Rh blood groups with breast cancer

Objectives

The aim of this study was to determine the association of “ABO” and “Rhesus” blood groups with incidence of breast cancer.

Methods

In this study, we identified 70 research documents from data based search engines including “PubMed”, “ISI-Web of Knowledge”, “Embase” and “Google Scholar”. The research papers were selected by using the primary key-terms including “ABO blood type”, “Rhesus” blood type and “breast cancer”. The research documents in which “ABO” and “Rhesus” blood types and breast cancer was debated were included. After screening, we reviewed 32 papers and finally we selected 25 research papers which met the inclusion criteria and remaining documents were excluded.

Results

Blood group “A” has high incidence of breast cancer (45.88%), blood group “O” has (31.69%); “B” (16.16%) and blood group “AB” has (6.27%) incidence of breast cancer. Blood group “A” has highest and blood group “AB” has least association with breast cancer. Furthermore, “Rhesus +ve” blood group has high incidence of breast cancer (88.31%) and “Rhesus –ve” blood group has least association with breast cancer (11.68%).

Conclusion

Blood group “A” and “Rhesus +ve” have high risk of breast cancer, while blood type “AB” and “Rhesus –ve” are at low peril of breast cancer. Physicians should carefully monitor the females with blood group “A” and “Rh +ve” as these females are more prone to develop breast cancer. To reduce breast cancer incidence and its burden, preventive and screening programs for breast cancer especially in young women are highly recommended.

Relationship between circulating levels of IFN-gamma, IL-10, CXCL9 and CCL2 in pulmonary and extrapulmonary tuberculosis is dependent on disease severity

Protection against Mycobacterium tuberculosis infection is dependent on T cell and macrophage activation regulated by cytokines. Cytokines and chemokines produced at disease sites may be released into circulation. Data available on circulating cytokines in tuberculosis (TB) is mostly on pulmonary TB (PTB) with limited information on extrapulmonary disease (EPul-TB). We measured interferon-gamma (IFN-gamma), interkeukin-10 (IL-10), CXCL9 and CCL2 in sera of patients (n = 80) including; PTB (n = 42), EPul-TB (n = 38) and BCG vaccinated healthy endemic controls (EC, n = 42). EPul-TB patients comprised those with less severe (LNTB) or severe (SevTB) disease. Serum IFN-gamma, IL-10 and CXCL9 levels were significantly greater while CCL2 was reduced in TB patients as compared with EC. IFN-gamma was significantly greater in PTB as compared with LNTB (P = 0.002) and SevTB (P = 0.029). CXCL9 was greater in PTB as compared with LNTB (P = 0.009). In contrast, CCL2 levels were reduced in PTB as compared with LNTB (P = 0.021) and SevTB (P = 0.024). A Spearman's rank correlation analysis determined a positive association between IFN-gamma and IL-10 (rho = 0.473, P = 0.002) and IFN-gamma and CXCL9 (rho = 0.403, P = 0.008) in the PTB group. However, in SevTB, only IFN-gamma and CXCL9 were positively associated (rho = 0.529, P = 0.016). Systemic levels of cytokines are reflective of local responses at disease sites. Therefore, our data suggests that in PTB increased IFN-gamma and CXCL9 balanced by IL-10 may result in a more effective cell mediated response in the host. However, elevated inflammatory chemokines CXCL9 and CCL2 in severe EPul-TB without concomitant down modulatory cytokines may exacerbate disease related pathology and hamper restriction of M. tuberculosis infection.

Dengue outbreak in Karachi, Pakistan, 2006: experience at a tertiary care center

This is the first report of the largest epidemic of dengue hemorrhagic fever (DHF) virus infection (2006) with IgM-confirmed cases from Karachi, Pakistan. Medical records of 172 IgM-positive patients were reviewed retrospectively for demographic, clinical and laboratory data. Patients were categorized into dengue fever (DF) and DHF according to the WHO severity grading scale. The mean+/-SD age of the patients was 25.9+/-12.8 years, 55.8% were males and the hemoconcentration was recorded in a small number of patients [10 (7.0%)]. Male gender [odds ratio (OR)=14.7, P=0.003), positive history of vomiting (OR=4.3, P=0.047), thrombocytopenia at presentation (OR=225.2, P<0.001) and monocytosis (OR=5.8, P=0.030) were independently associated with DHF, but not with DF. Five cases (2.9%) had a fatal outcome, with a male-to-female ratio of 1:4. Three were from a pediatric group (<15 years). Pulmonary hemorrhages, disseminated intravascular coagulation and cerebral edema preceded death in these patients. The results have highlighted significant findings, such as adult susceptibility to DHF, pronounced abdominal symptoms and lack of hemoconcentration at time of presentation in the study population. These findings may play an important role in the case definitions of future studies from this part of the world.

Elevated serum CCL2 concomitant with a reduced mycobacterium-induced response leads to disease dissemination in leprosy

Mycobacterium leprae and Mycobacterium tuberculosis are successful intracellular pathogens which down regulate host immune responses. T-cell interferon-gamma (IFNgamma) and macrophage tumour necrosis factor-alpha (TNFalpha) activate chemokines such as, C-C chemokine ligand-2 (CCL2) and CCL5, which play a role in granuloma formation. Lepromatous leprosy is characterized by defective granulomas with lowered T-cell- and macrophage-mediated responses. Tuberculosis (TB) can be localized to the lung, whereby discreet granulomas are formed. The role of chemokines in leprosy infections is as yet unclear. We compared chemokine responses in lepromatous leprosy and pulmonary tuberculosis patients. Circulating serum CCL2 was raised while CCL5 was lowered in leprosy, as compared with TB patients and healthy controls. However, both Mycobacterium bovis BCG- (P=0.08) and M. leprae-induced (P=0.05) CCL2 secretion was reduced in leprosy. In leprosy, BCG induced greater CCL2 (P=0.01), TNFalpha (P=0.02) and somewhat greater CCL5 (P=0.08) than M. leprae, while CXCL8 induction was comparable. Overall levels of Mycobacterium-induced CCL2, TNFalpha and CXCL8 were two to threefold lower, and CCL5 was 10-fold lower in leprosy as compared with TB. Reduced inducible CCL2 combined with a lowered TNFalpha response in lepromatous leprosy may contribute to the unrestricted growth and dissemination of mycobacteria found in the disease.

Crimean-Congo haemorrhagic fever virus: sequence analysis of the small RNA segments from a collection of viruses world wide

Crimean-Congo haemorrhagic fever virus (CCHFv) is a member of the genus Nairovirus in the family Bunyaviridae. It possesses a tripartite, single stranded RNA genome of negative polarity consisting of large (L), medium (M) and small (S) segments. CCHF virus is enzootic in life stock and wild animals in many parts of the Middle East, Asia and Africa and is also recognised in Southeast Europe. Severe disease, manifest as haemorrhagic fever and high mortality rates (up to 50%), is only recognised in humans. We have determined the complete sequence of the small genomic RNA segment from several strains of CCHF virus from outbreaks in Pakistan 2000, Baghdad 1976 and Uzbekistan 1967. Phylogenetic analysis of three datasets of sequences from the small genomic RNA segment available from a range of strains indicates that they can be divided into seven subtypes. Superimposed on this pattern are links between distant geographic locations, pointing to the existence of a global reservoir of CCHFv. In some cases these links may originate from trade in livestock, and long-distance carriage of virus or infected ticks during bird migration.

Diffuse neonatal hemangiomatosis associated with Simpson-Golabi-Behmel syndrome: a case report

Diffuse neonatal hemangiomatosis (DNH) is a rare disorder characterized by multiple cutaneous and visceral hemangiomas that usually presents in newborns and has a high mortality rate. While previously reported cases of DNH describe multiple cutaneous hemangiomas, we present a patient with a single hemangioma of the ear, who also had DNH of the central nervous system and visceral organs. Furthermore, in this report we present a new constellation of findings, namely, a Simpson-Golabi-Behmel syndrome (SGBS). The practical implication on the basis of the experience with our patient is the need to ensure adequate diagnostics for patients with large hemangiomas as well as for patients with multiple cutaneous hemangiomas, because DNH also can occur in single hemangiomas in rare cases.

Development and testing of an assessment tool for integrated learning

OBJECTIVE

Development of integrated questions for undergraduate medical students and assessing students' capability to retain and apply basic concepts in an integrated way.

METHOD

Multiple choice questions, attempting to probe understanding and application of different concepts, affiliated with different subjects and topics, were developed. As a pilot these were administered to the students of third year and final year at the end of their certifying examinations as a mock test. The following year these questions were introduced in the continuous assessments and subsequently the certifying examinations (in third year) as 33% of the whole examination. Difficult indices, item analysis and internal consistency (alpha) were calculated for all the questions.

RESULTS

The difficulty indices of integrated questions indicated that students found the integrated questions difficult.

CONCLUSION

There was a significant change of distribution in terms of scoring for the integrated questions. Students' power to integrate showed reliable improvement when tested in the certifying examinations.

Pericardial effusion as a cause of morbidity in patients on maintenance hemodialysis: is it preventable?

OBJECTIVE

Cardiovascular diseases are the cause for 45% mortality and 20% morbidity in hemodialysis (HD) patients. Pericardial effusion (PE) accounts for 03-04% of all deaths in HD patients as a result of tamponade, arrhythmias or heart failure. This study aims to find out the prevailance and precipitating factors for PE in hemodialysis patients.

PATIENTS AND METHODS

Fifty-five patients were identified for echo-cardiographic assessment on the basis of signs and symptoms suggestive of PE i.e., hypotension during dialysis, dyspnea, globular heart in chest x-ray, raised JVP, soft heart sounds and low voltage ECG. A matched controlled group of 55 patients for age, sex, dialysis schedule, cause of ESRD and dialysis bath, was also studied echocardiographically.

RESULTS

Pericardial Effusion was detected in 12 patients (10.9%), 10 (83.3%) were on 2/week and only two on 3/week dialysis. Of these 75% were non-compliant in fluid intake and 58.3% were irregular in treatment. The morbidity of PE in study group (18.2%) is significantly higher as compared to controls (3.6%) (P = < 0.05). No correlation was found between development of PE and high iPTH and low albumin levels. Ten patients with mild PE responded to vigorous dialysis. Two patients developed cardiac tamponade needing pericardiocentesis.

CONCLUSION

We have identified 2/week dialysis (inadequate dialysis dose), acetate bath and fluid and dialysis non-compliance as factors contributing to development of PE in HD patients.

Influence of anti-rejection therapy on the timing of cytomegalovirus disease and other infections in renal transplant recipients

Infections are an important cause of mortality and morbidity in renal transplant recipients. To study the impact of anti-rejection therapy on the timing of infections, the records of 599 consecutive renal transplants, performed prior to 31 December 1996 at the Royal Melbourne Hospital, were reviewed. Patients were grouped according to acute rejection (AR) episode and treatment during the first 6 months after transplantation. Group 1 [n = 168 (35%)] patients did not experience any episode of AR. Group 2 [n = 169 (35%)] patients had one or more episodes of AR and received high doses of steroids. Group 3 [n = 141 (30%)] patients had more than one episode of AR and received anti-lymphocyte antibodies in addition to high doses of steroids. Infections were more common in Groups 2 and 3 but only cytomegalovirus (CMV) disease occurred earlier in patients treated with lympholytics. Given the high incidence and early onset of CMV disease in patients receiving lympholytics and considering that an effective prophylactic protocol remains undetermined, pre-emptive treatment with ganciclovir in this high risk group appears justified.

Impact of acute rejection therapy on infections and malignancies in renal transplant recipients

BACKGROUND

Infections and malignancies are important causes of mortality and morbidity in renal allograft recipients. Their risk increases with increasing immunosuppression.

METHODS

In an attempt to quantitate the increase in the risk of these complications in association with antirejection therapy, we reviewed the records of all renal allograft recipients of our center transplanted during the cyclosporin era. We sub-divided the patients into three groups based on acute rejection episodes during the first 6 months posttransplant, and the treatment for acute rejection: those who did not develop AR--group 1 (n=168); those who had one or more episodes of acute rejection and were treated with high dose corticosteroids --group 2 (n=169); those who in addition to corticosteroids required cytolytics (OKT3) and/or other drugs--group 3 (n=141).

RESULTS

52% patients in group 1, 71% patients in group 2 and 86% patients in group 3 had one or more episodes of infection during the first 6 months posttransplantation. Relative risk for group 2 and 3 were 1.56 (P=0.0002) and 2.98 (P<0.00001), respectively. Infection/patient rates at 6 months were 0.67, 1.23, and 2.79 in groups 1, 2, and 3 respectively. Groups 1 and 2 had a similar number of cases with squamous and basal cell carcinoma, however, there were few cases with these malignancies in group 3. No case of lymphoma was seen in group 1; there were four cases in group 2 and nine in group 3. There was no significant difference in patient survival in group 1 and 2, however, patients in group 3 had a reduced patient survival (1 vs. 3 P<0.001, 2 vs. 3 P=0.067). Graft survival was best in group 1 and worst in group 3 (1 vs. 2 P<0.05; 1 vs. 3 P<0.00001; 2 vs. 3 P<0.01).

CONCLUSIONS

In renal transplant recipients the risk of infections and lymphoma increases with increasing immunosuppression and hence mortality and morbidity associated with it. When adding a potent immunosuppressive agent to rescue a kidney one needs to consider the serious and at times fatal side effects given the modest beneficial effect on long-term outcome.

Immune response profile in patients with active tuberculosis in a BCG vaccinated area

Tuberculosis patients with pulmonary (N = 95) or lymph node disease (N = 23) were assessed for Th1 responses (PPD skin test and lymphocyte blastogenic and interferon gamma) and Th2 responses (polyclonal and antigen specific IgE). Skin test responses to PPD and lymphocyte proliferative responses to crude mycobacterial antigens (PPD, culture filtrate and sonicate) and recall antigens (tetanus toxoid and streptolysin O) were significantly suppressed (p < 0.001) in patients with pulmonary disease compared to endemic controls. However, mitogen (phytohemagglutinin)-stimulated responses were comparable in patients and controls. Polyclonal and antigen specific (M. tuberculosis culture filtrate) IgE responses which are considered to be surrogate markers for Th2 responses were significantly higher in patients with pulmonary disease compared to healthy endemic controls (Mann Whitney analysis p < 0.01). Patients with lymph node disease showed strong Th1 responses but did not show significant responses for either polyclonal or antigen specific IgE. Thus overall suppression of T cell memory response was observed only in patients with pulmonary disease but not in patients with lymph node disease suggesting that sequestration of antigen in different compartments leads to differential activation of Th1 and Th2 responses. PPD skin test responses were highly positive in endemic controls (47% positive) and household contacts (86% positive). Furthermore, PPD positivity decreased with disease severity. Therefore PPD positivity in a BCG vaccinated TB endemic area cannot be used as a diagnostic marker for active tuberculosis particularly in advanced disease.

Over-the-counter availability of antimicrobial agents, self-medication and patterns of resistance in Karachi, Pakistan

To determine whether the free availability of antimicrobial agents leads to misuse through self-medication, a house-to-house semi-structured interview was held in three different socio-economic areas of Karachi, Pakistan. Of the 2348 households visited, 1342 (57%) participated; this included 9209 individuals. Three hundred and twenty-two (3.5%) had used one or more antimicrobial in the previous 4 weeks, equivalent to 43 agents per 1000 persons per month. The most frequently used agents were amoxycillin (16.7%), co-trimoxazole (15.7%), erythromycin (10.9%), ampicillin/cloxacillin (Ampiclox, 9.1%) and metronidazole (4.5%). Of these, 91.4% were prescribed by a physician, 2.3% were advised by a chemist and 6.3% were used as self-medication. Self-medication increased with socio-economic status. High levels of resistance were found to ampicillin, co-trimoxazole, chloramphenicol and erythromycin. If these high resistance levels are related to the high frequency of antimicrobial use, over-the-counter availability cannot be held responsible. Education of the medical profession seems to be the single most important tool to control misuse of antimicrobial agents. Innovative approaches for continuous medical education are urgently needed.

Microbial colonizers in leprosy skin ulcers and intensity of inflammation

The microflora of 55 patients with leprosy skin ulcers was studied and related to a weighted inflammatory score (IS). The control group consisted of 18 ulcers with different underlying pathology. Leprosy ulcers were characterized by the exclusive presence of two types of branching gram-positive rods; a particular interesting proposal is that Mycobacterium leprae share common antigens with these unusual "leprosy ulcer associated" organisms and group G beta-hemolytic streptococci. In the leprosy group, corynebacteria and branching rods accounted for 97% of gram-positive bacilli and Bacillus species constituted only 3%. In the control group, B. species formed 50% of gram-positive rods; the rest were corynebacteria (p = 0.03). In the leprosy group, one third of the gram-positive bacteria were branching rods; none of them was acid fast. Ten of them were identified as Arcanobacterium haemolyticum, and the remaining 7 could not be identified. The IS of leprosy patients was lower than in the control group. The presence of more than two species of facultative or aerobic gram-negative rods or single species of pyogenic gram-positive cocci correlated with a high IS. The presence of two or more different pyogenic cocci resulted in a lower IS. Further studies into the nature of leprosyunique organisms as well as the inflammation inhibition factors in mixed infections are warranted. It is recommended that management of ulcers should consist of the application of local disinfection and early treatment of episodes of inflammation with a combination of fluoroquinolone and penicillin.

Predictors of mortality in hemodialysis

One hundred and five patients enrolled in the maintenance haemodialysis programme at The Kidney Centre were studied retrospectively to identify patient characteristics associated with increased mortality. Hypertension (relative risk 10.03, P < 0.001), serum albumin < 3 G/dl (relative risk 2.60, p < 0.05), diabetes mellitus as a cause of End Stage renal disease (relative risk 2.54, p < 0.001), age > 55 years (relative risk 1.8, p) were associated with higher risk of mortality, while sex had no statistically significant effect.