Evaluation of Adverse Drug Events in Patients on Anti-Retroviral Therapy Regimen at Omdurman Voluntary Counselling and Testing and Anti-Retroviral Therapy Center in Sudan - A Cross-Sectional Study

Background

Anti-retroviral therapy-related adverse drug events are accounted as a main cause of anti-retroviral therapy non-adherence. In Sudan, pharmacovigilance studies are relatively rare and obstructed by the problem of under-reporting. It is a well-defined issue worldwide and is highly reported in developing countries. This study aimed to evaluate the prevalence of adverse events associated with anti-retroviral therapy among adult patients with immunodeficiency virus at Omdurman Voluntary Counselling and Testing and Anti-retroviral Therapy Center.

Methods

The study was a descriptive cross-sectional study conducted through direct interviews with 429 patients at the selected center using the Adverse Drug Events (ADEs) reporting form. The collected data were analyzed by The Statistical Package for Social Sciences.

Results

More than half (55.5%) of the participants experienced adverse events, with 48.7% having experienced them at the beginning of treatment. Central nervous system manifestations were the most common adverse events. By using the Naranjo scale, most adverse events showed a "probable" relationship to anti-retroviral medicines. Based on the chi-square test, medication regimen was significantly associated with the presence of ADEs (namely abdominal pain and jaundice) (p values = 0.03 and 0.001), respectively.

Conclusion

This study clearly stated that ART-related ADEs are common among Sudanese PLHIV and with central nervous system being the main adverse events. More pharmacovigilance studies and efforts by healthcare providers should be applied targeting ART-related ADEs under-reporting in Sudanese healthcare facilities.

Health-Related Quality of Life in Sudanese Children with Nephrotic Syndrome: A Comparative Cross-Sectional Study

Background

Nephrotic syndrome (NS) is an essential chronic disease in children that has a major impact on a child's health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL of Sudanese children with NS and clinical parameters that can influence their HRQoL.

Methods

This study was a descriptive cross-sectional of children with NS conducted in Khartoum state hospitals. A standardized PedsQLTM 4.0 Scale Score evaluated the HRQoL of the participants. Patients' socio-demographics, clinical data, and disease complications were collected using a data collection sheet. This study assessed the HRQoL of children with NS and compared it with apparent age and sex-matched to three groups (healthy children, children with chronic diseases, and kidney-transplanted children).

Results

80 children with NS were recruited from April to August 2021. Children over eight years old represented (63.8%) of the study subjects. The total mean HRQoL scores of nephrotic children were significantly lower than those of healthy children (78.46 ± 24.01) (p = 0.001) and those with other chronic diseases (78.45 ± 24.01) (p= 0.006); however, it was not significantly different from those with kidney transplantation. Socio-demographics did not significantly affect the total mean HRQoL scores of children with NS. Clinical parameters such as the duration of illness, "less than one year" (p= 0.006), and the minimum change nephropathy histopathology (p= 0.035) significantly lowered the total mean HRQoL scores of NS children. Regression analysis further confirmed that edema, proteinuria, and hospital admission had a high impact on the total mean HRQoL.

Conclusion

The total mean HRQoL scores of children with NS were low and significantly lower than healthy children. Parameters such as the patient's socio-demographics and phenotype of NS had no significant effect on the total mean HRQoL scores of children with NS. However, other clinical parameters significantly lowered their total mean HRQoL scores.

The Extent of Antibiotic Dispensing in Self-Medication Encounters in Sudan: A Simulated Patient Study Focusing on Cefixime Sale

Background

Antibiotics play an important role in decreasing morbidity and mortality worldwide. However, inappropriate use of them by patients or healthcare professionals contributes to their resistance rendering them less efficacious. Community pharmacists (CPs) have a significant part in reducing antibiotic resistance. Therefore, this study aimed to investigate the dispensing of antibiotics without prescription in community pharmacies with an emphasis on cefixime dispensing.

Methods

A cross-sectional, simulated patient (SP) study was conducted in the Khartoum locality. A total of 238 community pharmacies were randomly chosen using simple random sampling. One scenario of uncomplicated urinary tract infection was designed, and six female pharmacy students who were trained to act as SPs presented the scenario. Descriptive statistics were applied to report the study outcomes.

Results

In the 238 pharmacy visits, at least one antibiotic was dispensed without a prescription in 69.3% of the simulated visits. Among the dispensed antibiotics, ciprofloxacin was the most dispensed antibiotic followed by cefixime representing 51.5% and 41.8%, respectively, of total dispensed antibiotics. Cefixime was dispensed as a first choice by CPs in 29% of the visits, and in the rest of the visits, only 37.3% of CPs refused to dispense cefixime after SP demand.

Conclusion

The findings revealed a high rate of antibiotics dispensing without prescription by CPs in Khartoum state, and cefixime was obtained with ease before and after the patient's demand. Urgent corrective actions such as imposing strict regulations, monitoring pharmacists' practice, and endorsing educational programs for pharmacists are needed to prevent inappropriate antibiotic dispensing practices.

The Prevalence and Severity of Potential Drug-Drug Interactions in Internal Medicine Ward at Soba Teaching Hospital

Background

Multiple drug therapies are commonly used to achieve a desired therapeutic goal, especially in hospitalized patients. However, drug-drug interactions might occur and threaten the patients' safety.

Objective

This study aims to assess the prevalence and severity of potential drug-drug interactions (PDDIs) in the internal medicine ward at Soba Teaching Hospital.

Methods

A retrospective cross-sectional hospital-based study was carried out in the internal medicine ward at Soba Teaching Hospital from June 2021 to December 2021. The data was collected from patients' medical records. PDDIs were identified using Lexicomp® drug interaction software.

Results

A total of 377 patients were included in this study, and overall prevalence of PDDIs was 62.9%. We have identified 989 potential DDIs and 345 pairs of interacting drugs, the mean of the PDDIs per patient was 4.17 ± 4.079. Among 345 PDDIs most were of moderate interactions 70.1% (n=242) followed by Minor interactions 19.1% (n=66). The most common type of interaction was of category C representing 63.5% (n=219). A significant association was observed between the occurrence of PDDIs with patients' age, presence of chronic diseases, length of hospital stay, and number of medications received by the patients.

Conclusion

Drug-drug interactions were highly prevalent in the internal medicine ward. Therefore, certain attempts are required to increase the awareness of the physicians about these interactions and minimize their occurrence.

Heart surgery in a pediatric patient with congenital heart disease and hemophilia B: A case report from Sudan

Key Clinical Message

A multidisciplinary team approach, careful hemostasis, and factor replacement therapy are important in the perioperative management of hemophiliac patients undergoing pediatric cardiac surgery.

Abstract

The combination of congenital heart diseases (CHD) and hemophilia is rare; furthermore, heart surgery and perioperative management of such cases is challenging. This report illustrates the challenges of pediatric cardiac surgery in an infant with both hemophilia B and CHD. Multidisciplinary team approach, careful hemostasis, and factor replacement therapy were key to success without hemorrhagic complications before, during and after surgery.

Perceptions of Community Pharmacists Towards Patient Counseling and Continuing Pharmacy Education Programs in Sudan

Background

Community pharmacists are uniquely positioned at the heart of communities, and their patient counseling role is the cornerstone for achieving the required therapeutic goals. Therefore, the main objective of this study is to explore the perceptions of community pharmacists regarding patient counseling, and their perception towards continuing pharmacy education programs.

Methods

A descriptive, cross-sectional design was performed among randomly selected 238 community pharmacies in Khartoum locality (Sudan) from September 2022 to December 2022. The data were collected using a self-administered questionnaire adopted from a previous study with few minor modifications, which was adding three sociodemographic questions. Descriptive statistics were carried out according to the study objective to analyze the pharmacists' responses.

Results

The majority of the community pharmacists gave counseling and understood its importance to the patients, most of them (70.6%) took 1-5 minutes during the dispensing process. The dose was the most provided information by community pharmacists (26.7%) followed by administration (23.7%) and duration (22.4%). Few (28.2%) of the patients ask the pharmacists about the cost of the medication. Lack of patients' interest (55%) was the major barrier to effective counseling followed by lack of time (47.9%). Almost all (96.2%) pharmacists in this study were interested in continuing pharmacy education programs, and they preferred programs focusing on common diseases (36.6%), and common drugs (30.3%).

Conclusion

This study showed that the majority of community pharmacists in the Khartoum locality had positive perceptions toward patient counseling and they were interested in continuing pharmacy education programs.

Prevalence and Predictors of Antibiotic Self-Medication in Sudan: A Descriptive Cross-Sectional Study

BACKGROUND

Self-medication with antibiotics (SMA) is one of the common factors which precipitate antimicrobial resistance, yet if effective implementations are amended it can be effortlessly controlled. The present study aimed to estimate the prevalence and predictors of SMA in Sudan.

METHODS

The study adopted a cross-sectional study design conducted in all Sudan states between June and December 2021. Multi-stage stratified cluster sampling was used. A semi-structured questionnaire was used for data collection. Descriptive statistics were used to present the data. Binary logistic regression was computed to investigate the possible factors which associated with SMA.

RESULTS

Out of 1492 participants surveyed, 71.3% utilize antibiotics as self-medication. The derived reasons for SMA were convenience (63.3%) and cost-saving (34.8%). Tonsillitis was the most common ailment behind SMA (55.5%). Log-binominal regression revealed that non-insured and low level of education participants were more likely to predict SMA. Regarding the practice, 40% changed the dose and/or antibiotics mainly owing to improvement (53.7%) or worsening of the condition (37.9%). The most commonly used antibiotic was amoxicillin/clavulanic acid (32.5%).

CONCLUSIONS

Two out of three individuals in Sudan practice SMA mainly to manage upper respiratory tract ailments. Thus, the necessity of implementing an antimicrobial stewardship program throughout the country, as well as implementing effective legislation to prohibit dispensing antibiotics without prescription is urgently required.

Expression profiles of lncRNAs and their possible regulatory role in monocrotaline-induced HSOS in rats

Aims: Long non-coding RNAs (lncRNAs) contribute to the regulation of vital physiological processes and play a role in the pathogenesis of many diseases. Monocrotaline (MCT) can cause large-scale outbreaks of toxic liver disease in humans and animals in the form of hepatic sinusoidal obstruction syndrome (HSOS). Although many experiments have been carried out to explain the pathogenesis of Monocrotaline-induced hepatic sinusoidal obstruction syndrome and to develop treatments for it, no studies have examined the role of Long non-coding RNAs in this condition. This study aimed to investigate the Long non-coding RNAs-mRNA regulation network in Monocrotaline-induced hepatic sinusoidal obstruction syndrome in rats. Main methods: We established a model for MCT-induced hepatic sinusoidal obstruction syndrome, and then carried out microarray for liver tissues of SD rats in a model of early hepatic sinusoidal obstruction syndrome (12 h Monocrotaline treatment vs. control group) to investigate the differentially expressed Long non-coding RNAs and mRNAs in early hepatotoxicity. This was followed by RT-PCR analysis of selected Long non-coding RNAs, which were markedly altered. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genome analyses were also conducted. Key findings: 176 Long non-coding RNAs (63 downregulated and 113 upregulated) and 4,221 mRNAs (2,385 downregulated and 1836 upregulated) were differentially expressed in the Monocrotaline-treated group compared to the control group. The biological processes identified in GO enrichment analysis as playing a role in hepatotoxicity were positive regulation of guanosine triphosphate phosphohydrolase, liver development, and the oxidation-reduction process. Pathway analysis revealed that the metabolism pathways, gap junction, and ribosome biogenesis in eukaryotes were closely related to Monocrotaline-induced hepatotoxicity. According to these analyses, LOC102552718 might play an essential role in hepatotoxicity mechanisms by regulating the expression of inositol 1,4,5-trisphosphate receptor-1 (Itpr-1). Significance: This study provides a basis for further research on the molecular mechanisms underlying Monocrotaline-induced hepatotoxicity and its treatment, especially in the early stage, when successful treatment is critical before irreversible liver damage occurs.

Self-care Behaviors among Sudanese Patients with Heart Failure: A Cross-sectional Assessment

Background: Selfcare is a vital component of heart failure management that is known to improve the outcomes. However, little is known about the status of self-care behaviors among patients with heart failure in Sudan. Objectives: This study aimed to assess the self-care behaviors among Sudanese patients with heart failure at a tertiary hospital in Sudan. Methods: A cross-sectional single-institutional study was conducted across three-month period in 2021. A total of 200 heart failure patients were enrolled, and data was collected through patients’ interview. Descriptive and binary logistic regression analyses were processed to check the effect of different factors on the patients’ adherence levels. Results: Out of 200 heart failure patients, 53.5% were females, and the mean age of patients was 60 (± 13.7 SD) years. Among them, only 4.5% of heart failure patients reported adequate adherence to their self-care recommendations and the mean total score was 42.6 (± SD15.5). Adherence to self-care recommendations wasn’t significantly associated with age, gender, marital status, education level, and comorbidity. Conclusion: In this study, the overall adherence to self-care behavior was found to be extremely low among Sudanese heart failure patients, and selectively adherence to prescribed medications was good. These outcomes put light on a major opportunity for further prospective follow–up studies, which have an intervention approach for each self–care recommendation to improve the heart failure situation in Sudan.

Perception of Pharmacy Teachers About Their Roles and Current Practice at Governmental Universities in Sudan

BACKGROUND

Pharmacy educator has a number of roles and responsibilities, an information provider, clinical trainer, role model on-the-job, formal teaching settings, course planner and resource material creator, student assessor, and curriculum evaluator.

OBJECTIVE

This study aimed to assess the perception and commitment of pharmacy teachers in Sudanese governmental universities about their roles and educational responsibilities.

MATERIALS AND METHODS

Descriptive cross-sectional study was conducted at governmental pharmacy colleges in Sudan from November 2020 to July 2021. Data were collected using an online self-administered questionnaire adapted from the Association for Medical Education in Europe (AMEE) Guide No. 20. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 26 and Microsoft Excel version 16.

RESULTS

Out of 125 participants, 61.6% were female and 65.6% were lecturers. Approximately half of them had less than five years' experience. The most important role perceived and the highest committed one was a lecturer in the classroom setting. Only half of the participants had good perceptions and commitment regarding teachers' roles. Age, designation, and continuous professional development were significantly associated with participants' commitment. Also, a significant association was found between the perception and practice of the participants.

CONCLUSION

Only half of pharmacy educators were found to have a good perception and good commitment regarding their role as teachers.

Assessment of Potentially Inappropriate Prescribed Medications in Older Patients Using STOPP/START Criteria at Soba University Hospital: A Descriptive Retrospective Study

Background: Potentially inappropriate prescriptions (PIPs) have significant clinical, humanistic, and economic impacts. Identifying PIPs may reduce their burden of adverse drug events. “Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) and Screening Tool of Alert doctors to the Right Treatment (START) criteria” are promising tools that formulated to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in geriatrics. To determine the PIMs and PPOs using STOPP/START criteria and to determine the most frequent PIPs. Methods: The study was a descriptive cross-sectional hospital-based retrospective study. Medical files of elderly (≥65 years) patients admitted to the internal medicine unit at Soba university hospital from January to July 2020 were used. Data were collected using a checklist of STOPP/START criteria (version 2) to determine PIPs. Statistical package for social sciences was used for data analysis. Results: A total of 100 patients were included, around 59% were aged between 65-70 years, and 58% were males. The mean number of medications was 5.3 ± 1.9 drugs/patient. The results showed that the prevalence of PIPs was 68%. The STOPP criteria detected 209 PIMs in 42 patients, whereas the START criteria detected 155 PPOs in 45 patients. Furthermore, the drugs that used beyond the indication period was the most common PIMs, whereas the most detected PPOs were observed in the cardiovascular system medications. Conclusion: The study revealed a high prevalence of PIPs among elderly patients. This necessitates a further evaluation of its impact on clinical outcomes and implements interventions to improve prescribing practice.

Optimal Medical Therapy for Secondary Prevention of Acute Coronary Syndrome: A Retrospective Study from a Tertiary Hospital in Sudan

Background

Five-medication regimen is recommended for patients after acute coronary syndrome (ACS) as a secondary prevention strategy at discharge to reduce recurrence and improve mortality.

Objective

This study aimed to assess prescribing of optimal medical therapy (OMT) as five-medication regimens for secondary prevention at discharge after ACS in Sudan.

Methods

A retrospective cohort study was performed at a tertiary hospital located in Wad Medani, Sudan, in the period between January and December 2019. Data were collected from patients’ files. OMT was defined as a combination of five medications; aspirin and P2Y12 inhibitors, statins, beta-blockers (BBs), and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) or if a valid contraindication was documented.

Results

Of the 619 patients throughout the study period, 591 were selected based on inclusion and exclusion criteria. The median age of patients was 60 years, and 58.9% of patients were male. Diabetes (44.5%) and hypertension (42%) were the most common risk factors. Most patients (58.4%) were diagnosed with ST-segment elevation myocardial infarction. About 99.7% of patients were on aspirin, 99.5% on statins, 97% on clopidogrel, 96.8% on dual antiplatelet therapy, 70.4% on BBs, and 57.9% on ACEIs/ARBs. OMT for secondary prevention was prescribed to 267 (45.2%) patients with ACS at discharge.

Conclusion

Although prescriptions for all five guideline-recommended medications after ACS were suboptimal, the study showed a positive trend in prescribing most individual medications.

Antiviral Activity of Approved Antibacterial, Antifungal, Antiprotozoal and Anthelmintic Drugs: Chances for Drug Repurposing for Antiviral Drug Discovery

Drug repurposing process aims to identify new uses for the existing drugs to overcome traditional de novo drug discovery and development challenges. At the same time, as viral infections became a serious threat to humans and the viral organism itself has a high ability to mutate genetically, and due to serious adverse effects that result from antiviral drugs, there are crucial needs for the discovery of new antiviral drugs, and to identify new antiviral effects for the exciting approved drugs towards different types of viral infections depending on the observed antiviral activity in preclinical studies or clinical findings is one of the approaches to counter the viral infections problems. This narrative review article summarized mainly the published preclinical studies that evaluated the antiviral activity of drugs that are approved and used mainly as antibacterial, antifungal, antiprotozoal, and anthelmintic drugs, and the preclinical studies included the in silico, in vitro, and in vivo findings, additionally some clinical observations were also included while trying to relate them to the preclinical findings. Finally, the structure used for writing about the antiviral activity of the drugs was according to the families of the viruses used in the studies to form a better image for the target of antiviral activity of different drugs in the different kinds of viruses and to relate between the antiviral activity of the drugs against different strains of viruses within the same viral family.

The Practice of the Community Pharmacists in Managing Potential Drug-Drug Interactions: A Simulated Patient Visits

Background

Drug-drug interactions (DDIs) can cause treatment failure and serious adverse drug reactions, leading to morbidity and mortality. Due to their significant effects on the patient’s health, community pharmacists (CPs) competence in detecting and preventing these interactions is essential to provide optimal health services. Thus, this study aimed to explore the performance of the CPs in situations involving the presence of potential DDIs.

Methods

A cross-sectional, simulated patient study was conducted in 235 community pharmacies in the Khartoum locality. Two scenarios were used to evaluate the performance of the CPs. Ten final year B. Pharm. students were selected to act as simulated patients (SPs); they were trained for two weeks to familiarize their roles. All encounters were documented immediately after leaving the pharmacy by the SPs in the data collection form.

Results

All planned SPs visits were completed, resulting in 470 visits. None of the CPs asked about the patients’ medication history in both scenarios. After the SPs provided information about the drug used currently by the patient, 13.6% and 23.4% of the CPs had identified the potential DDIs in scenario 1 and scenario 2, respectively. In scenario 1, 59.4% distinguished the interaction of simvastatin with both drugs, while, in scenario 2, 74.5% recognized the interaction of warfarin with both drugs. In identifying DDIs, around half of the CPs were dependent on their knowledge or using drug interaction checker programs. The most common intervention made by the CPs was referring the patient to the prescriber (56.3% CPs in scenario 1 and 60% CPs in scenario 2).

Conclusion

CPs practice in identifying and managing potential DDIs was poor. The current CPs practices need substantial improvement. Therefore, professional education and the use of software programs in community pharmacies should be encouraged.

Perceived Academic Stress, Causes, and Coping Strategies Among Undergraduate Pharmacy Students During the COVID-19 Pandemic

BACKGROUND

Academic stress is a common problem among medical students, and the COVID-19 health crisis lockdown further worsened it. High academic stress has a negative impact on students learning and overall performance.

OBJECTIVE

To assess perceived academic stress, causes, and coping strategies among undergraduate pharmacy students during the COVID-19 pandemic.

METHODS

A descriptive cross-sectional study was conducted among undergraduate pharmacy students at the University of Khartoum. Data were collected from randomly selected participants using three validated self-administered questionnaires; perceived stress scale, study habits inventory, and mental health inventory. Data were analyzed using SPSS software, and descriptive statistics and chi-square were employed.

RESULTS

The response rate in our study was 99.6% (251/252). About 87% of the participants were females. The majority of participants (92%) experience academic stress, with a mean score (24.99 ± 5.159), the level of academic stress ranging from low (4.3%), moderate (73.2%), to high (22.5%). Approximately 80% of the percipients reported academic stress during all exam times with a mean score (25.33 ± 4.976). The level of academic stress was significantly associated with participants' gender (P-value: 0.042), and living conditions (P-value: 0.001). The most common factors that were significantly associated with academic stress were difficulty in remembering all that is studied (66.7%, P=0.006) and worrying about the exams (54.1%, P=0.011). Moreover, the most frequent strategies used to cope with academic stress were praying (84.4%) and maintaining some control over the situation (61.9%).

CONCLUSION

The study revealed a high prevalence of academic stress among percipients. Academic counseling, monitoring of mental status, and implementation of stress reduction programs are highly recommended.

Incidence and Risk Factors of Contrast-Induced Acute Kidney Injury in Sudanese Patients Undergoing Coronary Angiography: A Descriptive Prospective Study

Background: Contrast-induced acute kidney injury (CI-AKI) has been reported to be the third most common cause of hospital-acquired acute kidney injury (AKI) and is associated with significant morbidity and mortality.

Objectives: This study aimed to assess the incidence and risk factors of CI-AKI in Sudanese patients undergoing coronary angiography.

Methods: The study was a descriptive, prospective, hospital-based study conducted at Alshaab Hospital between January and April 2019. A total of 163 patients undergoing coronary angiography were enrolled, and a checklist was used to collect data. Chi-square and regression analyses were performed to identify the risk factors of CI‑AKI. CI‑AKI was defined as a rise in serum creatinine ≥25% above baseline within three days after percutaneous coronary angiography (PCA).

Results: CI‑AKI incidence in patients undergoing coronary angiography was 31.9% (52/163). Among independent variables, diabetes mellitus, the type of coronary angiography, and the volume of contrast medium were statistically significantly (p-value ˂ 0.05) associated with CI-AKI development. Logistic analysis showed that diabetes (odds ratio (OR): 15.2; 95% CI: 6.771-33.974; p = 0.001), percutaneous coronary intervention (PCI) (OR: 2.4; 95% CI: 1.168-4.901; p = 0.017), and the volume of contrast medium (OR 2.1; 95% CI: 1.440-3.054; p = 0.001) were independent predictors correlated to CI‑AKI development.

Conclusion: The incidence of CI-AKI is 31.9%, and diabetes mellitus, PCI, and high volume of contrast medium are associated with a higher risk of CI-AKI in patients undergoing coronary angiography.

Pharmaceutical Care Network Europe (PCNE) Drug-Related Problems Classification Version 9.1: First Implementation in Sudan

Background: Clinical pharmacy services are an emerging specialty in Sudan. Many tools exist to document drug-related problems (DRP), such as the Pharmaceutical Care Network Europe (PCNE) classification. However, none has been attempted and published in Sudan. Objectives: The study aimed to identify the DRP and its characteristics in real hospital setting using non-modified version of PCNE. Method: Prospective study of clinical pharmacists' interventions during the routine care work of reviewing patients over a period from December 2020 to February 2021 at the wards of National Cancer Institute, University of Gezira, Sudan. Main outcome measure Using non-modified PCNE version 9.1 to identify the number, types, causes of the DRP, clinical pharmacists' interventions, acceptance, and outcomes. Results: Five minutes (range, 3-15 minutes) was the median time spent for evaluation and intervention by the clinical pharmacists, a total of 51 DRP were discovered among 40 patients with an average of 1.3 DRP per patient, an adverse drug event (possibly) occurring (29.4%) was the main problem, no or incomplete drug treatment (27.5%) was the main causes, above one-third of the clinical pharmacists' interventions were proposed to the prescriber, these interventions were accepted in 96% and fully implemented among 72.5% of the cases. At the end of the process, the majority of DRP (72.5%) were totally solved. Conclusion: Non-modified PCNE version 9.1 provides a suitable tool for the DRP process for Sudanese clinical pharmacists during routine work in the oncology setting. It hence can be considered as an optimal tool for further quality and policymaking.

Assessment of Community Pharmacist's Practice and Patient Counselling Toward Acute Diarrhea Treatment in Khartoum Locality: A Simulated Patient Study

Background

Acute diarrhea is one of the most common health problems globally as a minor ailment, it is widely managed by community pharmacists (CPs). Professional patient counseling provided in community pharmacies is essential to decide about acute diarrhea and avoid treatment failure properly.

Objective

To assess CPs’ history-taking practice, medication dispensing, and patient counseling in response to acute diarrhea in adults.

Methods

A cross-sectional, covert simulated patient (SP) study was conducted in 235 community pharmacies in the Khartoum locality. Two scenarios were used, one scenario assesses afterwards compliance to treatment guidelines and patient counseling, and second scenario determines afterwards if pharmacists referred patients to medical consultation. Six final-year pharmacy students were involved as SPs. All encounters were audio-recorded by SP. Then the investigator filled the checklist that was intended to evaluate the overall practice of pharmacists.

Results

As planned, 235 pharmacies were visited twice, resulting in a total of 470 visits (visit completion rate: 100%). In history taking, the most asked questions were the patient’s age (89.8% for scenario 1 and 88.5% for scenario 2). Followed by the presence of blood in the stool (25.5% for scenario 1 and 28.1% for scenario 2). In scenario 1, loperamide was the most dispensed medication (81.3%), while oral rehydration solution (ORS) was dispensed in 0.9% of the visits. In counseling, verbal and written instructions were provided in 47.7% of the visits. Duration of medications was mentioned in 3.8%, advice about fluid intake was offered in 7.2% of the visits. In scenario 2, 17% of the pharmacists managed patient history well to refer patients to medical consultation, while 42.6% recommended referral after sufficient information was provided by the SP.

Conclusion

CPs’ practice in counseling toward acute diarrhea was poor; referral to medical consultation was below expectation. The current CPs dispensing practices need improvement; thus, professional education should be encouraged.

Clinical Pharmacist's Intervention to Improve Medication Titration for Heart Failure: First Experience from Sudan

Background

Medications known to improve outcomes in heart failure (HF) are either not prescribed or prescribed at sub-therapeutic doses. The addition of clinical pharmacists to the HF team positively impacts optimizing prognostic medications for a patient with HF with reduced ejection fraction (HFrEF).

Objective

To assess the intervention of the clinical pharmacist as part of the multidisciplinary (MD) team in up-titration to achieve target doses of key therapeutic agents for HFrEF.

Methods

This was a prospective one group pretest-posttest interventional study; a comparison of the target dose achievement of key therapeutic agents for HFrEF was performed before and after clinical pharmacist interventions.

Results

Out of 110 HFrEF patients, 57.3% were males, and the mean age of patients was 55.8 years (SD 12.6). Cardiomyopathy was the leading cause of HF. At baseline, 86% were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEIs/ARBs/ARNi) and 93.6% on beta blockers (BBs). At the end of study, the proportion of patients achieved the target dose was significantly increased (0 vs 77.4%, 6.8 vs 85.4%, and 0 vs 55.6%) for ACEIs, ARBs and ARNi, respectively, and (8.6% vs 66.1%; P = 0.001) for BBs. Moreover, the up-titration process was associated with significant improvement in most clinical as ejection fraction and New York Heart Association (NYHA) scale and laboratory characteristics.

Conclusion

As a part of the MD team in the outpatient HF clinic, the clinical pharmacists increased the percentage of HFrEF patients achieving the target or maximal doses of key therapeutic agents and improving clinical and laboratory parameters.

Assessment of Anticonvulsant Activities of Petroleum Ether Extract of Anacyclus pyrethrum Roots on Experimental Rats

Background: Epilepsy is one of the most common neurological conditions and a significant cause of morbidity and mortality. Objectives: The present study aimed to evaluate the anticonvulsant activity of the petroleum ether extract of the root of Anacyclus pyrethrum on Pentylenetetrazole (PTZ)-induced seizure model in Wistar rats. Methods: The composition of the petroleum ether extract of A. pyrethrum was first analyzed using Gas Chromatography-Mass Spectrometry (GC-MS). Subsequently, the anticonvulsant activities of these extracts (70 and 140 mg/kg, intraperitoneal injection) were evaluated on PTZ-induced seizures in rats. The protection rate against induced seizures, latency, and duration of seizures, as well as neurological symptoms, were assessed and compared to those protected by phenobarbital. Results: GC/MS analysis of the petroleum ether extract showed that the main components were octadecadienoic acid, hexadecanoic acid, diheptylcyclopropene, naphthalene, and methyl stearate. The extract (70 and 140 mg/kg) was found to provide significant protection against PTZ-induced seizures. Moreover, compared to the negative control, the extracts increased the latency of induced-convulsion and reduced the duration of epilepsy. Interestingly, the extracts showed a reduction in neurological symptoms and the severity of seizures compared to the negative control. All of these outcomes manifested in a dose-dependent manner. Conclusion: The petroleum ether extract of A. pyrethrum may produce anticonvulsant effects by reducing the duration of seizures and delaying the latency of seizures induced by PTZ.

Bacteriological profile and antibiotic susceptibility of diabetic Foot infections at Ribat University hospital; a retrospective study from Sudan

Purpose

Diabetic foot infection (DFI) is one of the most feared complications of diabetes. In Sudan, the number of cases and the problems associated with diabetic foot infections increased in recent years. This study aimed to assess the bacteriological profile of patients with DFIs and their antibiotic susceptibility pattern.

Methods

A descriptive retrospective cross-sectional study was carried out at Surgery Department of Ribat University Hospital. All medical records of patients with DFIs during the period from September 2017 to February 2019 were reviewed using data collection sheet. The collected data were analyzed using Statistical Package for Social Sciences.

Results

Out of 250 DFI patients, 73.2% of them were males, and 86.4% of them had type 2 diabetes mellitus, and most of them suffered from diabetes for more than 10 years. Regarding culture results, 64.7% and 35.3% of the samples revealed presence of single microorganism and mixed infections, respectively. A total of 335 bacterial isolates were identified, gram-negative were more prevalent than gram-positive organisms. The most frequently isolated organisms were Proteus spp. Staphylococcus aureus, and Escherichia coli. Furthermore, antibiotic susceptibility pattern showed that imipenem, amikacin and vancomycin have the highest activity against isolated bacteria, and all isolates were found to be completely resistant to different cephalosporin drugs.

Conclusion

Among the studied samples, gram-negative bacteria were found to be more common in DFI patients, Proteus spp. and S. aureus were the most common microorganisms. Moreover, different isolated microorganisms showed to have different degrees of resistance and sensitivity to various antibacterial drugs.

The Incidence of Oxaliplatin-Induced Peripheral Neurotoxicity at Khartoum Oncology Hospital: A Cross-Sectional Survey

Objective:

Using oxaliplatin-based chemotherapy in the treatment of cancer patients can cause a unique form of acute and chronic peripheral neurotoxicities. This study mainly aims to assess the incidence of oxaliplatin-induced peripheral neuropathy (OXAIPN).

Methods:

A cross-sectional study among 121 patients treated with oxaliplatin-based chemotherapy was conducted during the period of January to April 2019 at Khartoum Oncology Hospital. The incidence of acute neurotoxicity was assessed using a descriptive questionnaire for most common hyperexcitability and transient symptoms, while the incidence of chronic neurotoxicity was measured by the 20-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for patients with chemotherapy-induced peripheral neuropathy and graded by the National Cancer Institute's Common Terminology Criteria for Adverse Events, Version 4.03.

Results:

Acute and chronic OXAIPN were found in 49.6% and 41.3% of patients, respectively. Most of the patients who developed acute OXAIPN symptoms manifested cold-induced pharyngolaryngeal dysesthesias (73.3%) or perioral paresthesias (71.7%). No significant association exists between the severity of chronic neurotoxicity and basic demographics. Most (79.1%) of the patients did not inform the doctors about their complaints, and 43.5% of those who informed doctors did not take any medication to manage OXAIPN.

Conclusions:

This study exhibits that oxaliplatin-based chemotherapy can cause symptoms of peripheral neurotoxicity in most of the patients with colorectal or gastric cancer in the form of acute neurotoxicity or chronic neurotoxicity.

Impact of guidelines implementation for the rational use of prophylactic antibiotics in elective cesarean sections at Elqutainah Teaching Hospital

BACKGROUND

The clinical pharmacists have a sensible role in the implementation of guidelines by ensuring proper patient selection and medication use. This study aimed to implement a hospital guideline for the rational use of prophylactic antibiotics in elective cesarean sections (ECS) by establishing compliance with international guidelines regarding prophylactic antibiotic use in ECS at Elqutainah Teaching Hospital in White Nile State, Sudan, and define the area of medication cost-saving.

METHODS

A quasi-experimental design without control group was used from April to June 2018. 195 participants were included, 94 participants before and 101 participants after the intervention and data were collected using a designed checklist by the researchers. The intervention is based on withdrawal metronidazole dosage forms from prophylactic antibiotics for ECS according to international guidelines in antibiotics prophylaxis toward ECS. Finally, the data were compared between pre- and post-intervention.

FINDINGS

Before intervention; all participants had received intravenous cefuroxime and metronidazole infusions prior ECS and oral cefuroxime or amoxicillin-clavulanic acid, and metronidazole for 7 days upon discharge. While after the intervention, all participants didn't receive any metronidazole dosage forms before and after ECS also didn't receive amoxicillin-clavulanic acid. However, the dosage regimen of cefuroxime didn't change. This intervention was meaningful in minimizing overuse of antibiotics prophylaxis in the ECS, and reducing staff workload along with medication cost.

CONCLUSIONS

Clinical pharmacist intervention was concisely changing the physicians' practice toward using updated guidelines of the rational use of prophylactic antibiotics for ECS.

Prescription patterns of antipsychotics in the management of first episode psychosis at three psychiatric hospitals in Khartoum, 2018: A descriptive cross-sectional study

BACKGROUND

First-Episode Psychosis (FEP) is defined as the first treatment contact with psychiatric service, regardless of the duration of symptoms. This study aims to determine the antipsychotics prescription patterns in FEP patients at three psychiatric hospitals in Khartoum.

METHOD

A descriptive cross-sectional retrospective hospital-based study was conducted at Eltigani Elmahi, Taha Baasher, and Abd Elaal Aledrissi Psychiatric hospitals in Khartoum State, Sudan, during the period March to July 2018. Medical records of patients with FEP were identified and reviewed to look for demographic data, the onset of symptoms, investigations requested, and medications prescribed. Data were recorded and subjected to statistical analysis using the Statistical Package for Social Sciences.

RESULT

Reviewing the medical records of the 98 FEP patients (66 males and 32 females) included in the study showed that the majority of patients (94.8%) were medicated with combinations of psychotropic medications. The most commonly used combination was Haloperidol, Olanzapine, Promethazine, and Benzodiazepines. And only 5.1% of the whole population was treated with an atypical antipsychotic (Olanzapine) as a monotherapy.

CONCLUSION

Based on prescription patterns and requested investigations, there was a wide gap between the actual practice regarding antipsychotics prescriptions for FEP at the three psychiatric hospitals and the evidence-based guidelines in this respect.

Drug Utilization Evaluation of Vancomycin among Patients in Jafar Ibn Auf Pediatric Hospital, 2018

Background: Vancomycin is an antibiotic of growing importance in the treatment of hospital-acquired infections; with a particular emphasis on its value in the fight against Methicillin-resistant Staphylococcus aureus. Increasing reports of Vancomycin resistance have raised concerns about the effectiveness of this drug. Drug utilization evaluation has an important role in controlling rational use of antibiotics to prevent the emergence of resistance. Methods: We conducted a retrospective 6-months study at Jafar Ibn Auf pediatric hospital. Data including patient's demographics, diagnosis, Dosage regimen, and treatment duration were reviewed. The concordance of practice with the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines and principles of antibiotic therapy was assessed. Results: 127 medical records were reviewed in this study. Sepsis (29%) and Pneumonia (19.6%) were the most common indications. Culture test was requested in 20.5% of patients. Monitoring of serum creatinine was carried in 81.1% of patients. Based on HICPAC guidelines vancomycin was administered appropriately in 67.7% percent of cases. Considering the infusion rate, most of patients with specific order were received vancomycin in 1 hour. Conclusions: The results showed that vancomycin was used empirically without subsequent adjustment of the antimicrobial agent according to culture and sensitivity data and lack of paying enough attention to the infusion rate and serum creatinine monitoring.

Drug Utilization Evaluation of Vancomycin among Patients in Jafar Ibn Auf Pediatric Hospital, 2018

Background: Vancomycin is an antibiotic of growing importance in the treatment of hospital-acquired infections; with a particular emphasis on its value in the fight against Methicillin-resistant Staphylococcus aureus. Increasing reports of Vancomycin resistance have raised concerns about the effectiveness of this drug. Drug utilization evaluation has an important role in controlling rational use of antibiotics to prevent the emergence of resistance. Methods: We conducted a retrospective 6-months study at Jafar Ibn Auf pediatric hospital. Data including patient's demographics, diagnosis, Dosage regimen, and treatment duration were reviewed. The concordance of practice with the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines and principles of antibiotic therapy was assessed. Results: 127 medical records were reviewed in this study. Sepsis (29%) and Pneumonia (19.6%) were the most common indications. Culture test was requested in 20.5% of patients. Monitoring of serum creatinine was carried in 81.1% of patients. Based on HICPAC guidelines vancomycin was administered appropriately in 67.7% percent of cases. Considering the infusion rate, most of patients with specific order were received vancomycin in 1 hour. Conclusions: The results showed that vancomycin was used empirically without subsequent adjustment of the antimicrobial agent according to culture and sensitivity data and lack of paying enough attention to the infusion rate and serum creatinine monitoring.

Biochemical and computational evaluation of Triptolide-induced cytotoxicity against NSCLC

Triptolide is the major bioactive component isolated from the Chinese Medicinal plant Tripterygium wilfordii. Despite the growing interest and the plethora of reports discussing the pharmacological activity of this diterpenoid, no clear consensus regarding its cellular targets and full mechanism of action has been reached. In the present work, a combined in vitro and in silico approach was used to evaluate the biological activity of Triptolide on Non-small cell lung cancer (NSCLC). In vitro, Triptolide treatment induced apoptosis in NSCLC cell lines and down-regulated the phosphorylation of AKT, mTOR, and p70S6K. Triptolide also impacted cellular glycolysis as well as the antioxidant response through the impairment of glucose utilization, HKII, glutathione, and NRF2 levels. Molecular docking results examined the possible interactions between Triptolide and AKT and predicted an allosteric binding to AKT-1 structure. Molecular dynamics simulations were further used to evaluate the stability of the complex formed by Triptolide's best conformer and AKT. These findings provide an insightful approach to the anticancer effect of Triptolide against NSCLC and highlight a possible new role for AKT/mTOR HKII inhibition.

Investigating the CYP2E1 Potential Role in the Mechanisms Behind INH/LPS-Induced Hepatotoxicity

Tuberculosis (TB) is one of the oldest infectious diseases that affected humankind and remains one of the world's deadliest communicable diseases that could be considered as global emergency, but the discovery and development of isoniazid (INH) in the 1950s paved the way to an effective single and/or combined first-line anti-TB therapy. However, administration of INH induces severe hepatic toxicity in some patients. Previously, we establish a rat model of INH hepatotoxicity utilizing the inflammatory stress theory, in which bacterial lipopolysaccharide (LPS) potentially enhanced INH toxicity. These enhancing activities ranged between augmenting the inflammatory stress, oxidative stress, alteration of bile acid homeostasis, and CYP2E1 over-expression. Although pre-treatment with dexamethasone (DEX) helped overcome both inflammatory and oxidative stress which ended-up in alleviation of LPS augmenting effects, but still minor toxicities were being detected, alongside with CYP2E1 over expression. This finding positively indicated the corner-stone role played by CYP2E1 in the pathogenesis of INH/LPS-induced liver damage. Therefore, we examined whether INH/LPS co-treatment with CYP2E1 inhibitor diallyl sulfide (DAS) and DEX can protect against the INH/LPS-induced hepatotoxicity. Our results showed that pre-administration of both DAS and DEX caused significant reduction in serum TBA, TBil, and gamma-glutamyl transferase levels. Furthermore, the histopathological analysis showed that DAS and DEX could effectively reverse the liver lesions seen following INH/LPS treatment and protect against hepatic steatosis as indicated by absence of lipid accumulation. Pre-treatment with DAS alone could not completely block the CYP2E1 protein expression following INH/LPS treatment, as appeared in the immunoblotting and immunohistochemistry results. This is probably due to the fact that the combined enhancement activities of both INH and LPS on CYP2E1 protein expression levels might resist the blocking probabilities of DAS. In the meantime, addition of DEX to the DAS/INH/LPS combination caused a significant reduction in CYP2E1 protein expression as revealed by the immunoblotting and fading coloration in immunohistochemistry results. Thus, addition of DEX and DAS together caused strong protection against INH/LPS-induced hepatic damage. These findings reveal the potential therapeutic value of combining DAS and DEX with INH in TB management for reducing the potential risk and incidences of hepatotoxicity.

Pristimerin exhibits in vitro and in vivo anticancer activities through inhibition of nuclear factor-кB signaling pathway in colorectal cancer cells

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignancies associated with high mortality rate worldwide. We previously reported that pristimerin inhibits cell growth and induces apoptosis in CRC cells.

HYPOTHESIS/PURPOSE

To further understand the molecular mechanism by which pristimerin elicits its anticancer activities on colon cancer cells, we investigated its effect on nuclear factor-κB (NF-κB) signaling pathway.

STUDY DESIGN

This study consisted of both in vitro and in vivo experiments involving HCT-116 cell line and xenograft mouse model. Molecular techniques such as qRT-PCR, western blotting and immunofluorescence were used to demonstrate pristimerin in vitro effect on NF-κB signaling pathway; whereas it's in vivo activity was analyzed by western blot and immunohistochemistry on tumor tissues.

RESULTS

Our in vitro results on HCT-116 cells showed that pristimerin inhibited IKK phosphorylation, IкB-α degradations and IкB-α phosphorylation in both dose- and time- dependent manners, which caused suppression of NF-кB p65 phosphorylation, nuclear translocation and accumulation of NF-кB. Moreover, pristimerin was found to inhibit both constitutive activated-NF-кB and tumor necrosis factor-α (TNF-α)- and lipopolysaccharide (LPS)-induced activation of NF-кB signaling pathway. Furthermore, our in vivo results on xenograft animal model revealed that pristimerin inhibited tumor growth mainly through suppressing NF-кB activity in tumor tissues.

CONCLUSION

Pristimerin antitumor activities were mainly mediated through inhibition of NF-кB signaling pathway in colon tumor cells. These findings further explain that pristimerin has the therapeutic potential for targeting colon cancer.

Potential Deoxycytidine Kinase Inhibitory Activity of Amaryllidaceae Alkaloids: An In Silico Approach

Background:

Plants of the Amaryllidaceae family have been under intense scrutiny for the presence of a couple of alkaloidal secondary metabolites with endued cytotoxic activity, such as pancratistatin (1), 7-deoxypancratistatin (2), narciclasine (3), 7-deoxynarciclasine (4), trans-dihydronarciclasine (5), and 7-deoxy-trans-dihydronarciclasine (6). Nevertheless, preclinical evaluation of these alkaloids has been put on hold because of the limited quantity of materials available from isolation.

Aim:

To explore the underlying cytotoxic molecular mechanisms of the Amaryllidaceae alkaloids (1–6) and to assess their absorption, distribution, metabolism, excretion, and toxicity (ADMET) profiles using chemoinformatic tools.

Materials And Methods:

AutoDock 4.0 software along with different in silico chemoinformatic tools, namely PharmMapper, Molinspiration, MetaPrint2D, and admetSAR servers, were used to assess the drugability of the Amaryllidaceae alkaloids (1–6).

Results:

Deoxycytidine kinase (dCK) (PDB: 1P60) was predicted as a potential target with fitting score of 5.574. In silico molecular docking of (1–6) into dCK revealed good interactions, where interesting hydrogen bonds were observed with the amino acid residues—Gly-28 and Ser-35—located in the highly conserved P-loop motif. This motif plays a special role in dCK function. Contrary to (1), in silico pharmacokinetic results have shown good absorption and permeation and thus good oral bioavailability for (2–6).

Conclusion:

The in silico docking data have proposed that the reported cytotoxic activity of the Amaryllidaceae alkaloids (1–6) could be mediated through dCK inhibition. In addition, the ADMET profile of these alkaloids is promising and thus (1–6) could be candidates for future drug development.

Anticancer Potential and Molecular Targets of Pristimerin: A Mini- Review

Pristimerin, a natural triterpenoid isolated form Celastrus and Maytenus spp, has been shown to possess a variety of biological and pharmacological effects. Recently, pristimerin has attracted more attention, especially for its potential anticancer activities. The anticancer activities of pristimerin have been illustrated in various cancer cell lines and animal models. It has been found to inhibit in vitro and in vivo proliferation, survival, angiogenesis and metastasis of tumor cells. These activities have been attributed to its modulation of various molecular targets such as cyclins, apoptosis- related proteins, proteasome activity, reactive oxygen species, as well as NF-kB, AKT/mTOR and MAPK/ERK pathways. This mini-review discussed the cellular impact and animal studies of pristimerin treatment, with more attention on the various molecular targets of pristimerin.

Dexamethasone Pretreatment Alleviates Isoniazid/Lipopolysaccharide Hepatotoxicity: Inhibition of Inflammatory and Oxidative Stress

Isoniazid (INH) remains a cornerstone key constitute of the current tuberculosis management strategy, but its hepatotoxic potentiality remains a significant clinical problem. Our previous findings succeed to establish a rat model of INH hepatotoxicity employing the inflammatory stress theory in which non-injurious doses of inflammatory-mediating agent bacterial lipopolysaccharides (LPS) augmented the toxicity of INH that assist to uncover the mechanisms behind INH hepatotoxicity. Following LPS exposure, several inflammatory cells are activated and it is likely that the consequences of this activation rather than direct hepatocellular effects of LPS underlie the ability of LPS to augment toxic responses. In this study, we investigated the potential protective role of the anti-inflammatory agent dexamethasone (DEX), a potent synthetic glucocorticoid, in INH/LPS hepatotoxic rat model. DEX pre-treatment successfully eliminates the components of the inflammatory stress as shown through analysis of blood biochemistry and liver histopathology. DEX potentiated hepatic anti-oxidant mechanisms while serum and hepatic lipid profiles were reduced. However, DEX administration was not able to revoke the principal effects of cytochrome P450 2E1 (CYP2E1) in INH/LPS-induced liver damage. In conclusion, this study illustrated the DEX-preventive capabilities on INH/LPS-induced hepatotoxicity model through DEX-induced potent anti-inflammatory activity whereas the partial toxicity seen in the model could be attributed to the expression of hepatic CYP2E1. These findings potentiate the clinical applications of DEX co-administration with INH therapy in order to reduce the potential incidences of hepatotoxicity.

Pristimerin demonstrates anticancer potential in colorectal cancer cells by inducing G1 phase arrest and apoptosis and suppressing various pro-survival signaling proteins

Pristimerin is a naturally occurring triterpenoid that has a cytotoxic effect on several cancer cell lines. However, the cytotoxic effects of pristimerin as well as its molecular mechanisms of action against colorectal cancer have never been explored. In the present study, we investigated the anticancer potential of pristimerin, and examined the different signaling pathways affected by its action in three colon cancer cell lines namely HCT-116, COLO-205 and SW-620. Pristimerin was found to possess potent cytotoxic and proliferation inhibitory effects against these cell lines. Cell cycle analysis revealed G1 phase arrest, which was strongly associated with decreased expression of cyclin D1 and cyclin-dependent kinases (cdk4 and cdk6) with concomitant induction of p21. Pristimerin also induced apoptosis in a dose-dependent manner. Cell plasma membrane alterations studied by Annexin V/PI double staining, loss of mitochondrial membrane potential (ΔΨm), measurements of caspase activities and the inhibitory effect of Z-VAD-FMK (a caspase inhibitor) confirmed the apoptotic effect of pristimerin. Moreover, western blot data showed that apoptotic induction was associated with activated caspase-3 and -8, PARP-1 cleavage and modulation of the expression levels of Bcl-2 family proteins. Additionally, pristimerin treatment downregulated the phosphorylated forms of EGFR and HER2 proteins, and subsequently caused a decrease in the phosphorylated forms of Erk1/2, Akt, mTOR and NF-κB proteins. Taken together, these results suggest that pristimerin may have potential as a new targeting therapeutic strategy for the treatment of colon cancer.

Rare bone infections "excluding the spine"

Bone infections are usually due to haematogenous spread from distant infected organs. Spread of local sepsis or contamination of open wounds are less frequent routes of infection. The commonest cause of osteomyelitis is Staphylococcus aureus. The term rare bone infections refers to diseases where only a few percent affect bone or diseases which are essentially rare; these include bacteria, fungi, parasites and non-specific conditions. Common examples are tuberculosis, salmonellosis, brucellosis, hydatidosis, madura, actinomycosis, aspergillosis and American fungal infections. Certain bone infections have become exceedingly rare, particularly atypical mycobacteria, viral embryopathies and spirochaetes. Rare bone infections are encountered in many parts of the world commonly in the tropics and in the U. S. Immunocompromise and ease of travel can lead to increased incidence. A high index of clinical suspicion is necessary for diagnosis. Specific laboratory diagnosis is not always possible. Radiographs, computed tomography, isotope studies and magnetic resonance are useful but may not make the diagnosis. Aspiration or biopsy is necessary. Rare bone infections may simulate non-infective bone lesions.

Case report: radiological and endoscopic management of bile leak following laparoscopic cholecystectomy

Due to the ever increasing popularity of laparoscopic cholecystectomy (LC), many radiologists and gastroenterologists have noticed an epidemic of bile duct injuries due to subsequent complications. We report on five cases of post-LC minor bile duct injuries and document our preliminary experience in their management. Although the majority of minor bile leaks resolve spontaneously, particularly if a surgical drain has been left in situ, percutaneous drainage (PD) can be used alone or in addition to endoscopic management to treat symptomatic bile leaks and biloma formation. Bile leaks without associated abdominal collections should be first identified by endoscopic cholangiography followed by sphincterotomy and/or stenting. Surgery should only be reserved for cases of major bile duct injury if PD and endoscopic management have failed initially.