Ceftriaxone-induced Kounis syndrome: A case report and review of the literature

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

Economic valuation of selected ecosystem services in Islamabad Capital Territory (ICT), Pakistan

Abstract Payment for ecosystem services (PES) is a mechanism where a consumer is able and ready to pay for the protection of the precise ecosystem service and there must be a provider such as local societies receiving an economic resource, who in return, must have the ability to maintain that ecosystem service. Economic valuation provides basis for payment for ecosystem services. Therefore, objective of this study was to evaluate tourism and carbon stock services of the Islamabad Capital Territory (ICT), Pakistan. Two forest zones (Chirpine and Scrub) of Islamabad capital territory (ICT) were selected for estimation of carbon stock and their carbon credits and carbon worth, a questionnaire-based survey was conducted for tourism as a payment for ecosystem services. The method for carbon stock assessment was systematic sampling for Chirpine forest whereas random sampling was done for scrub forest. The size of sampling plot was 17.84 m radius, and a total of 93 plots (49 Scrub zone and 44 Chirpine zone) was taken in the study area. The carbon stock of both zones (Chirpine and Scrub zone) is 22556.75 ton/ha (Chirpine 20105.79, Scrub 2450.96) and total carbon dioxide sequestered by both zone is 82557.72 ton/ha (Chirpine 73587.2, Scrub 8970.52), total carbon credits of both zone is 302160.87 (Chirpine 269328.97, Scrub 32831.9) and the carbon worth of both Chirpine and scrub zone is 4532418.92 $ (Chirpine 4039937.09$, Scrub 492481.83$). Similarly, from tourism point of view, in Shakar Parian, 94% tourists were agreed for PES whereas 6% were disagreed for the PES (the 6% tourist were disagreed to contribute for PES, 40% were agreed for Rs.5 contribution and 54% for Rs.10.). moreover, in Lake view Park, 97% tourists were agreed and 3% are disagreed (In Lake View Park 5% tourists were disagreed for the PES contribution whereas 32% were agreed for Rs.5 and 63% were for Rs.10). In Damen e Koh, around 87% tourist were agreed and 13% were disagreed, (24% were agreed for the contribution of Rs.5 and 63% tourists were agreed for the contribution of Rs.10). In Marghazar Zoo, 93% tourists were agreed (22% were agreed for contribution of Rs.5 and 71% tourist were agreed for contribution of Rs.10) and 7% are disagreed for PES whereas 7% tourists were not agreed for contribution. PES may implement to compensate forest and parks manager to ensure better management of the forests and parks. Due to prime location and scenic beauty of the ICT, it has huge potential for implementation of PES mechanism for sustainable forest management and conservation. Therefore, it is recommended that Capital Development Authority (CDA) Islamabad should devise a plan for implementation of PES in forests and parks of ICT for its sustainable management of recreational and forest resources.

Yield, carbon stock, and price dynamics of agroforestry tree species in district Mardan, Khyber Pakhtunkhwa, Pakistan

Abstract A socio-economic study was conducted in district Mardan of the Khyber Pakhtunkhwa (KP) province of Pakistan to get a comprehensive knowledge of the agroforestry tree species grown on the farmlands, their yield, and carbon stock. For yield and carbon stock estimation, data were collected from 59 sample plots by measuring the diameter, height, volume, and biomass of selected agroforestry tree species through D-tape and Haga altimeter. A total of 59 sample plots were inventoried using 2.5 percent sampling intensity. Each sample plot has an area of 0.5 ha, where each tree with a Diameter at Breast Height (DBH) ≥ 5 cm was inventoried. The calculated amount of volume of each tree species was then converted to biomass by multiplying it by the density of wood and the Biomass Expansion Factor (BEF). Total yield and C stock for the selected agroforestry tree species were 11535.2 metric tons and 2102.2 metric tons, respectively. Populus euroamericana is classified as the main tree with 28% growing stock prior to Morus alba by 21%, while Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Acacia nilotica, Salix tetrasperma, and Bombax ceiba consist of 15%, 12%, 8%, 6%,7% and 3% growing stock respectively. Among the species found in different sampling plots the yield of Populus euroamericana was found to be 4747.5 metric tons and it was followed by the species Morus alba found at 2027.3 metric tons. Similarly, the volume for Melia azedarach, Eucalyptus camaldulensis, Dalbergia sissoo, Salix spp, Boombox ceiba, and Acacia nilotica was 1532.2 tons,1503 ton,745.7,203.5ton, 555.4ton and 220.5ton, respectively. The carbon stock for Populus euroamericana was calculated as 777.8 ton/ha, while for Eucalyptus camaldulensis, Melia azedarach, Morus alba, Dalbergia sissoo, Acacia nilotica, Salix species, and Bombax ceiba it was calculated as 312.3ton/ha, 272.1ton/ha, 363ton/ha, 245.1ton/ha, 51.4ton/ha, 27.3ton/ha and 53.2ton/ha, respectively. The questionnaire survey conducted for price dynamics showed that the majority of respondents purchase timber from the market for construction. But they use farm trees with low-quality city construction. They dislike using local timber in the conventional building as timber from farm trees is liable to insect attack. Rs. 50,000-100000, (33.33%) of daily sales was concluded from 50% of the trader while (16.7%) of the traders have their sales between Rs.150,000-200,000. Therefore, it is concluded by the authors that both provincial and federal government should promote agroforestry in Pakistan through different incentives because it has the potential to cope with dilemma of deforestation of natural forests and improve the livelihood of local peoples. It is strongly recommended that special projects just like the Ten Billion Tree Afforestation Project (T-BTTP) should be launched for agroforestry plantation and promotion in the country to sustain the ecological harmony and uplift the socio-economic condition of the peoples of Pakistan.

A first principles study of a van der Waals heterostructure based on MS2 (M = Mo, W) and Janus CrSSe monolayers

The strategy of stacking two-dimensional materials for designing van der Waals heterostructures has gained tremendous attention in realizing innovative device applications in optoelectronics and renewable energy sources. Here, we performed the first principles calculations of the geometry, optoelectronic and photocatalytic performance of MS₂-CrSSe (M = Mo, W) vdW heterostructures. The mirror asymmetry in the Janus CrSSe system allows the designing of two models of the MS₂-CrSSe system by replacing S/Se atoms at opposite surfaces in CrSSe. The feasible configurations of both models of the MS₂-CrSSe system are found energetically, dynamically and thermally stable. The studied heterobilayers possess an indirect type-I band alignment, indicating that the recombination of photogenerated electrons and holes in the CrSSe monolayer is hence crucial for photodetectors and laser applications. Remarkably, a red-shift in the optical absorption spectra of MS₂-CrSSe makes them potential candidates for light harvesting applications. More interestingly, all heterobilayers (except W(Mo)S₂-CrSSe of model-I(II)) reveal appropriate band edge positions of the oxidation and reduction potentials of the photocatalysis of water dissociation into H⁺/H₂ and O₂/H₂O at pH = 0. These results shed light on the practical design of the MS₂-CrSSe system for efficient optoelectronic and photocatalytic water splitting applications.

Environmental sustainability assessment of wooden furniture produced in Pakistan

Life cycle assessment was carried out for a conventional wooden furniture set produced in Mardan division of the Khyber Pakhtunkhwa province of Pakistan during 2018-19. Primary data regarding inputs and outputs were collected through questionnaire surveys from 100 conventional wooden furniture set manufacturers, 50 in district Mardan and 50 in district Swabi. In the present study, cradle-to-gate life cycle assessment approach was applied for a functional unit of one conventional wooden furniture set. Production weighted average data were modelled in the environmental impacts modelling software i.e., SimaPro v.8.5. The results showed that textile used in sofa set, wood preservative for polishing and preventing insects attack and petrol used in generator had the highest contribution to all the environmental impact categories evaluated. Total cumulative energy demand for wooden furniture set manufactured was 30,005 MJ with most of the energy acquired from non-renewable fossil fuel resources.

Ambient pressure x-ray photoelectron spectroscopy setup for synchrotron-based in situ and operando atomic layer deposition research

An ambient pressure cell is described for conducting synchrotron-based x-ray photoelectron spectroscopy (XPS) measurements during atomic layer deposition (ALD) processes. The instrument is capable of true in situ and operando experiments in which it is possible to directly obtain elemental and chemical information from the sample surface using XPS as the deposition process is ongoing. The setup is based on the ambient pressure XPS technique, in which sample environments with high pressure (several mbar) can be created without compromising the ultrahigh vacuum requirements needed for the operation of the spectrometer and the synchrotron beamline. The setup is intended for chemical characterization of the surface intermediates during the initial stages of the deposition processes. The SPECIES beamline and the ALD cell provide a unique experimental platform for obtaining new information on the surface chemistry during ALD half-cycles at high temporal resolution. Such information is valuable for understanding the ALD reaction mechanisms and crucial in further developing and improving ALD processes. We demonstrate the capabilities of the setup by studying the deposition of TiO₂ on a SiO₂ surface by using titanium(IV) tetraisopropoxide and water as precursors. Multiple core levels and the valence band of the substrate surface were followed during the film deposition using ambient pressure XPS.

Forest yield prediction under different climate change scenarios using data intelligent models in Pakistan

This study aimed to develop and evaluate data driven models for prediction of forest yield under different climate change scenarios in the Gallies forest division of district Abbottabad, Pakistan. The Random Forest (RF) and Kernel Ridge Regression (KRR) models were developed and evaluated using yield data of two species (Blue pine and Silver fir) as an objective variable and climate data (temperature, humidity, rainfall and wind speed) as predictive variables. Prediction accuracy of both the models were assessed by means of root mean squared error (RMSE), mean absolute error (MAE), correlation coefficient (r), relative root mean squared error (RRMSE), Legates-McCabe's (LM), Willmott's index (WI) and Nash-Sutcliffe (NSE) metrics. Overall, the RF model outperformed the KRR model due to its higher accuracy in forecasting of forest yield. The study strongly recommends that RF model should be applied in other regions of the country for prediction of forest growth and yield, which may help in the management and future planning of forest productivity in Pakistan.

Seroprevalence and risk factors of Toxoplasma gondii infection in women with recurrent fetal loss from the province of Khyber Pakhtunkhwa, Pakistan

BACKGROUND

In women with a bad obstetric history (BOH), infection is an established cause of recurrent fetal loss. A common infecting agent is the protozoan parasite Toxoplasma gondii (T. gondii). The aim of this study was to measure the prevalence of toxoplasmosis in women with recurrent fetal loss from the Khyber Pakhtunkhwa province of Pakistan.

METHODS

The study included 360 females aged 16-40 years, of which 180 had a bad obstetric history (study group) and the other 180 had no such history (control group). Blood serum samples were tested for toxoplasma IgM antibodies by Enzyme Linked Immunosorbent Assay and for toxoplasma IgG antibodies using an Immunochromatographic technique.

RESULTS

The overall seroprevalence of toxoplasma infection in study group females was 40.6% and in control group females it was 7.2%. Specifically, IgM prevalence was 12.8% in the study group and 1.1% in the control group. IgG prevalence was 23.9% in the study group and 6.1% in the control group. IgM and IgG combined prevalence was 3.9% in the study group cases. There is a statistically significant association between BOH and seropositivity for T. gondii (p < 0.0001, Chi square test). Various risk factors associated with T. gondii seroprevalence in study and control groups were analyzed.

CONCLUSION

The seroprevalence of toxoplasmosis was significantly higher in women with a bad obstetric history compared to those with no such history. Associated risk factors had no significant effects on the results.

Anakinra in hospitalized patients with severe COVID-19 pneumonia requiring oxygen therapy: Results of a prospective, open-label, interventional study

Objective

The aim of this study was to evaluate the efficacy of anakinra in patients who were admitted to hospital for severe COVID-19 pneumonia requiring oxygen therapy.

Methods

A prospective, open-label, interventional study in adults hospitalized with severe COVID-19 pneumonia was conducted. Patients in the interventional arm received subcutaneous anakinra (100 mg twice daily for 3 days, followed by 100 mg daily for 7 days) in addition to standard treatment. Main outcomes were the need for mechanical ventilation and in-hospital death. Secondary outcomes included successful weaning from supplemental oxygen and change in inflammatory biomarkers. Outcomes were compared with those of historical controls who had received standard treatment and supportive care.

Results

A total of 69 patients were included: 45 treated with anakinra and 24 historical controls. A need for mechanical ventilation occurred in 14 (31%) of the anakinra-treated group and 18 (75%) of the historical cohort (p < 0.001). In-hospital death occurred in 13 (29%) of the anakinra-treated group and 11 (46%) of the historical cohort (p = 0.082). Successful weaning from supplemental oxygen to ambient air was attained in 25 (63%) of the anakinra-treated group compared with 6 (27%) of the historical cohort (p = 0.008). Patients who received anakinra showed a significant reduction in inflammatory biomarkers.

Conclusion

In patients with severe COVID-19 pneumonia and high oxygen requirement, anakinra could represent an effective treatment option and may confer clinical benefit.

Trial registration number

ISRCTN74727214.

Abstract P4-01-02: Early detection of residual breast cancer through a robust, scalable and personalized analysis of circulating tumour DNA (ctDNA) antedates overt metastatic recurrence

Background:

Many breast cancer patients relapse after primary treatment but there are no reliable tests to detect distant metastases before they become overt. Here we show earlier identification of recurring patients through a scalable personalised ctDNA analysis. The method is applicable to all patients, and not limited to hot-spot mutations typically detected by gene panels.

Methods:

Forty-nine non-metastatic breast cancer patients were recruited following surgery and adjuvant therapy. Plasma samples (n=208) were serially collected semi-annually. Using the analytically validated SignateraTM workflow, we determined mutational signatures from primary tumour whole exome data and designed personalised assays targeting 16 variants with high sensitivity by ultra-deep sequencing (average &gt;100,000X). The patient-specific assay was used to detect the presence of the mutational signature in the plasma.

Results:

In 16 of 18 (89%) clinically-relapsing patients, ctDNA was detected ahead of metastatic relapse being diagnosed by clinical examination, radiological and biochemical (CA15-3) measurements, and remained ctDNA-positive through follow-up. Of the 2 patients not detected by ctDNA, one had a small local recurrence only (now resected) and the other had three primary tumours. None of the 31 non-relapsing patients were ctDNA-positive at any time point (n=142). Metastatic relapse was predicted by Signatera with high accuracy and a lead time of up to 2 years (median=9.5 months).

Conclusions:

The use of a scalable patient-specific ctDNA-based validated workflow detects breast cancer recurrence ahead of clinical detection. Accurate and earlier prediction by ctDNA analysis could provide a means of monitoring breast cancer patients in need of second-line salvage adjuvant therapy in order to prevent overt life-threatening metastatic progression.

Citation Format: Coombes RC, Armstrong A, Ahmed S, Page K, Hastings RK, Salari R, Sethi H, Boydell A-R, Shchegrova SV, Fernandez-Garcia D, Gleason KL, Goddard K, Guttery DS, Assaf ZJ, Balcioglu M, Moore DA, Primrose L, Navarro SL, Aleshin A, Rehman F, Toghill BJ, Louie MC, Zimmermann BG, Lin C-HJ, Shaw JA. Early detection of residual breast cancer through a robust, scalable and personalized analysis of circulating tumour DNA (ctDNA) antedates overt metastatic recurrence [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-02.

Simulating Transplant Small-for-size Grafts Using Human Liver Monosegments: The Impact of Portal Perfusion Pressure

Small-for-size-liver grafts (SFSG) in adult transplant recipients have elevated risk of graft failure, limiting its application in clinical liver transplantation. Relevant preclinical model of SFSG is lacking. Relevant to deceased-donor split liver transplant and living-donor liver transplant in adult recipients, in this study, we present our initial characterization of SFSG model using monosegments of a discarded human donor liver.

The role of testicular nuclear receptor 4 in chemo-resistance of docetaxel in castration-resistant prostate cancer

Docetaxel-based therapy is one of the first-line options for castration-resistant prostate cancer (CRPC). However, a large proportion of CRPC patients show different extents of docetaxel resistance. The current study aims to investigate the role of testicular nuclear receptor 4 (TR4) in docetaxel resistance in CRPC. TR4 expression level in prostate biopsy samples from CRPC patients treated with docetaxel was measured by immunohistochemistry (IHC). Alternation of TR4 expression in prostate cancer (PCa) cell line PC3 was applied to find out the influence of TR4 on half-maximal inhibitory concentration (IC50), cell viability and cell apoptosis. Patients who failed to achieve prostate-specific antigen (PSA) response (<50% PSA reduction from baseline) after docetaxel-based chemotherapy had a comparatively higher TR4 expression than those who achieved PSA response (⩾50% PSA reduction from baseline). Knocking down TR4 in PC3 cells led to a lower IC50 dose, poorer cell viability and more cell apoptosis when treated with docetaxel, whereas overexpression of TR4 in PC3 led to a higher IC50 dose, better cell viability and less cell apoptosis. TR4 enhances the chemo-resistance of docetaxel in CRPC. It may serve as a biomarker to determine the prognosis of docetaxel-based therapy and as a potential therapy target to combine with docetaxel to better suppress CRPC.

The role of mast cells on angiogenesis in oral squamous cell carcinoma

Objective: Angiogenesis or neovascularization has long been known to aid in progression and metastasis of malignant tumors. Tumor angiogenesis is a complex event mediated by angiogenic factors released from cancer cells and or by host immune cells. Mast cells may induce tumor progression and potentiate metastasis by stimulating angiogenesis. The purpose of the present study was to validate topographic distribution of micro vessel density (MVD) and mast cell density (MCD) and help to elucidate the possible role of mast cells in tumor angiogenesis and correlating this with advanced disease parameters. Study Design: MVD and MCD were investigated in tumor specimens from 30 patients diagnosed with different histologic grades of oral squamous cell carcinoma (OSCC). Intratumor vessels were stained with collagen Type IV antibody and mast cells with Toluidine blue before being measured by light microscopy. Results: There was a significant correlation between MVD and disease progression and number of blood vessels increased from well to poorly differentiated OSCC where as MCD decreased. Conclusions: These findings suggest that angiogenesis indeed occur in OSCC and might be used as an index to inflect the aggression of the disease however mast cells make up only a part of complex process of angiogenesis along with other factors secreted by tumor.

Key words:Angiogenesis, mast cells, oral squamous cell carcinoma, progression, metastasis.

First- and second-line drug resistance patterns among previously treated tuberculosis patients in India

Culture and drug susceptibility testing results of 2816 tuberculosis (TB) patients from across India who had failed repeated treatments from 2001 to 2004 were retrospectively analysed at the Tuberculosis Research Centre, Chennai. Of 1498 (53%) identified as having multidrug-resistant TB (MDR-TB), 671 (44.8%) were resistant to > or =1 second-line drugs (SLDs): 490 (32.7%) to ethionamide, 245 (16.4%) to ofloxacin and 169 (11.3%) to kanamycin; 69 (4.6%) were extensively drug-resistant TB (XDR-TB). Although from a highly select and non-representative patient group, such high SLD resistance levels, including XDR-TB, among MDR-TB patients is of concern. The prevention of MDR/XDR-TB through quality DOTS services, however, remains the priority. In addition, rapid scale-up of quality programmatic management under the RNTCP is needed, with more control and rational use of SLDs outside the programme.

Transplant professionals vary in the long-term medical risks they communicate to potential living kidney donors: an international survey

BACKGROUND

Discussing long-term medical risks with potential living donors is a vital aspect of informed consent. We considered whether there are global practice variations in the information communicated to potential living kidney donors.

METHODS

Transplant professionals participated in a survey to determine which long-term risks are communicated to potential living kidney donors. Self-administered questionnaires were distributed in person and by electronic mail.

RESULTS

We surveyed 203 practitioners from 119 cities in 35 different countries. Sixty-three percent of participants were nephrologists, and 27% were surgeons. Risks of hypertension, proteinuria or kidney failure requiring dialysis were frequently discussed (usually over 80% of practitioners discussed each medical condition). However, many practitioners do not believe these risks are increased after donation, with surgeons being less convinced of long-term sequelae compared with nephrologists (P < 0.01). About 30% of practitioners discuss long-term risks of premature cardiovascular disease or death with potential donors.

CONCLUSIONS

Transplant professionals vary in the long-term risks they communicate to potential donors. Improving consensus will enhance decision-making, and emphasize best practices which maintain good, long-term donor health.

How stigmatizing is Stigma in the life of people living with HIV: A study on HIV positive individuals from Chennai, South India

The nature and intensity of AIDS stigma are shaped by the social construction of the epidemic in different locales. Stigma therefore needs to be discussed in its cultural context. This clinic-based study aims at understanding stigma among 203 HIV positive individuals from Chennai, South India. The study throws light on the impact of stigma on the quality of life among these individuals. It also discusses the gender implications of stigma. This study brings out the findings that actual stigma experienced among those infected with HIV is much less (26%) as compared to the fear of being stigmatized or perceived stigma (97%). Internalizing of stigma was found to have a highly significant negative correlation with quality of life in the psychological domain and a significant negative correlation in the environmental domain. However individuals who did experience actual stigma seemed more determined to live and experience an above moderate quality of life. The implication of this study encourages HIV infected individuals to rise above stigma, avoid internalizing their stigmatized feelings and work toward a better quality of life. Health providers need to address these issues in their care for HIV infected individuals.

Lost in publication: Half of all renal practice evidence is published in non-renal journals

Physicians often scan a select number of journals to keep up to date with practice evidence for patients with kidney conditions. This raises the question of where relevant studies are published. We performed a bibliometric analysis using 195 renal systematic reviews. Each review used a comprehensive method to identify all primary studies for a focused clinical question relevant to patient care. We compiled all the primary studies included in these reviews, and considered where each study was published. Of the 2779 studies, 1351 (49%) were published in the top 20 journals. Predictably, this list included Transplantation Proceedings (5.9% of studies), Kidney International (5.3%), American Journal of Kidney Diseases (4.7%), Nephrology Dialysis Transplantation (4.3%), Transplantation (4.2%), and Journal of the American Society of Nephrology (2.4%). Ten non-renal journals were also on this list, including New England Journal of Medicine (2.4%), Lancet (2.3%), and Diabetes Care (2.2%). The remaining 1428 (51%) studies were published across other 446 journals. When the disciplines of all journals were considered, 59 were classified as renal or transplant journals (42% of articles). Other specialties included general and internal medicine (16%), endocrinology (diabetes) and metabolism (6.5%), surgery (6.2%), cardiovascular diseases (6.1%), pediatrics (4.3%), and radiology (3.3%). About half of all renal practice evidence is published in non-renal journals. Browsing the top journals is important. However, relevant studies are also scattered across a large range of journals that may not be routinely scanned by busy physicians, and keeping up with this literature requires other continuing education strategies.

Fenretinide stimulates redox-sensitive ceramide production in breast cancer cells: potential role in drug-induced cytotoxicity

The synthetic retinoid N-(4-hydroxphenyl) retinamide (4HPR) has manifold actions, which may contribute to its chemopreventive effects on breast cancer cell growth and progression. A role for ceramide as a stress-response signal is investigated here during the cytotoxic action of 4HPR in MCF-7 cells. N-(4-hydroxphenyl) retinamide induced a dose-dependent decline in cell growth and survival associated with a maximal 10-fold increase in ceramide production at 10 μM. N-(4-hydroxphenyl) retinamide exhibited a greater potency than all-trans retinoic acid (ATRA) on growth inhibition and ceramide production. The synthetic peroxisome proliferator-activated receptors agonist troglitazone (TGZ), but not the native ligand 15-deoxy-delta 12,14-prostaglandin J₂, abrogated both these actions of 4HPR but not that of ATRA. The antioxidant N-acetylcysteine mimicked the abrogative effect of TGZ on 4HPR action, while the exogenous oxidant H₂O₂ also stimulated ceramide production. The inhibitors of de novo ceramide synthesis, fumonisin B₁ and myriocin, blocked the ceramide response to 4HPR and partially reversed the apoptotic response, but did not prevent the overall decline in cell survival. The pancaspase inhibitor Z-VAD fmk reduced the decrease in cell survival caused by 4HPR, but did not affect the ceramide response. These findings describe a novel redox-sensitive elevation of ceramide levels associated with the cytotoxic response of breast cancer cells to 4HPR. However, a major mediatory role for this sphingolipid in this context remains equivocal.

Evaluation of a two-reagent cold staining method for detection of acid-fast bacilli

SETTING

Tuberculosis Research Centre, Chennai, India.

OBJECTIVE

To evaluate a two-reagent cold staining method for detection of acid-fast bacilli in sputum smears. SPUTUM SAMPLES: Two hundred and forty-four samples from pulmonary tuberculosis patients attending Tuberculosis Research Centre were used.

METHODS AND DESIGN

Two smears were prepared from each of the samples, of which one was allotted to the two-reagent cold staining method and the other to the Ziehl-Neelsen (Z-N) method. The smears were read blind by a single technician. To ensure correct grading, a senior technician checked all positives and 20% of the negative smears. All the samples were processed by modified Petroff's method for culture of Mycobacterium tuberculosis.

RESULTS

The concordance (smear grade one above and one below) between the methods was 90% (kappa value, 0.7). The performance of the cold method and the Z-N method was similar when their smear results were compared with culture results (cold method vs. culture, kappa = 0.61; ZN method vs. culture, kappa = 0.67)

CONCLUSION

The two-reagent cold staining method was found to be as sensitive and specific as the Z-N method. However, large-scale multicentric studies in different climatic conditions need to be conducted to assess its efficacy in the diagnosis of pulmonary tuberculosis.

Washing of new microscopic glass slides in dichromate solution does not influence sputum AFB smear results

SETTING

Microscopy centres in Tiruvallur District, Tamil Nadu, India, implementing DOTS.

OBJECTIVE

To know whether washing new glass slides in dichromate solution is essential for effective sputum acid-fast bacilli microscopy.

METHODS

Two direct smears were prepared from each of 1750 sputum samples. One was made on dichromate solution-cleaned new glass slides and the other was made on unwashed new glass slides. The smears were blinded and examined.

RESULTS

Of the 1750 specimens, 13.5% and 13.08% were positive for AFB using washed and unwashed slides, respectively (P = 0.12). The concordance between these two (including one grade above and one below) was 98.7%.

CONCLUSION

Washing of new glass slides in dichromate solution is not essential for AFB microscopy.

Interleukin 1 components in cicatricial pemphigoid. Role in intravenous immunoglobulin therapy

Interleukin (IL-)1 is an important mediator of inflammatory responses and plays an important role in the pathogenesis of various autoimmune diseases. Cicatricial pemphigoid (CP) is a multisystem autoimmune inflammatory disease. We have studied the role of IL-1 in its pathogenesis. We have investigated the serum levels of IL-1 components (IL-1alpha, IL-1beta, and IL-1Ra), and determined the role of intravenous immunoglobulin (IVIg) therapy in patients with CP. Serum levels of IL-1alpha and beta were significantly higher in untreated patients with active disease compared to levels in patients in prolonged clinical remission and normal human controls (P<0.0001). The serum levels of IL-1Ra were higher in patients in prolonged clinical remission compared to patients with active disease (P=0.002). Hence elevated levels of IL-1alpha and beta and low levels of IL-1Ra correlate with disease activity. The levels of IL-1alpha and beta were statistically significantly higher in sera of CP patients with active disease pre-IVIg therapy compared to post-IVIg therapy (P<0.0001). Statistically significantly higher levels of IL-1Ra were present in post-IVIg treatment serum samples when compared to levels in pre-IVIg treatment (P<0.0001). In the in vitro experiments, the levels of IL-1alpha and beta produced by the peripheral blood mononuclear cells (PBMC) isolated from patients before IVIg therapy were significantly higher when compared to the PBMC isolated from post-IVIg patients (P<0.0001). Significantly higher levels of IL-1Ra were observed in the supernatants of PBMC collected from pre-IVIg patients and cultured with exogenously added IVIg, when compared to the levels of PBMC to which IVIg was not added (P<0.0001). IL-1 may be an important cytokine involved in the pathogenesis of CP. The regulation of IL-1 could be one of the mechanisms, amongst others, by which IVIg may exert its beneficial effect in the treatment of CP.

Visceral leishmaniasis in District Dir, NWFP

Visceral leishmaniasis is endemic in District Dir, NWFP. We evaluated 10 patients with visceral leishmaniasis at DHQ Hospital Timergara District Dir, N.W.F.P. All patients were in the age range 2 to 10 years. The predominant clinical features in these were chronic fever (10), splenomegaly (10), hepatomegaly (10), weight loss (10) and abdominal distention (5). Lymphadenopathy was absent. Common laboratory abnormalities included anaemia (10), leucopenia (7), thrombocytopenia (10) and hypergammaglobulinaemia (10). Formal Gel test was positive in all patients (100%) and all had positive bone marrow smears for Leishmania Donovani (L.D.) bodies (10). The response to stibogluconate (Glucantime Sodium) therapy was good with a 100 percent cure rate.

Elevated blood copper/zinc ratios in assaultive young males

In research conducted over the past 20 years, we have observed abnormal trace-metal concentrations, including elevated serum copper and depressed plasma zinc, in blood samples collected from violence-prone individuals. The purpose of the study reported here was to test the validity of our observation that assaultive young males have elevated blood copper/zinc (Cu/Zn) ratios when compared to a control group of young males with no history of assaultive behavior. All male patients between the ages of 3 years and 20 years who made a first visit to the outpatient Pfeiffer Treatment Center in Naperville, Ill., during a two-month period were evaluated. Based on interviews with patients and their families and application of a standardized behavior scale, 135 assaultive young males and 18 controls with no history of assaultive behavior were identified. Blood samples were collected from test subjects and controls and analyzed for serum copper and plasma zinc concentrations by an independent laboratory using atomic absorption methods. The median Cu/Zn ratio for the assaultive subjects was 1.40 compared to 1.02 for controls, a statistically significant difference (t = 5.94; p < 0.01).

"Inappropriate" physician habits in prescribing oral nifedipine capsules in hospitalized patients

Despite the absence of an approved Food and Drug Administration (FDA) indication, the use of oral or "sublingual" nifedipine for hypertension in the hospitalized patient has become an increasingly common practice. The purpose of the study was to assess the clinical circumstances for which the drug was being prescribed and the practices of attending and resident physicians. Dosing of oral nifedipine capsules in medical and surgical inpatients was studied prospectively in three central Connecticut hospitals (University, community-teaching, and private nonteaching) during a 60-day period from January to March, 1994. Through evaluation of computerized pharmacy and medical records, data were collected on diagnostic reasons for ordering nifedipine, pre- and posttreatment blood pressures, dosing frequency, clinical documentation associated with drug prescription, and adverse events. Physicians and nurses at the respective hospitals were unaware of the conduct of the study. The incidence of nifedipine capsule administration at all three hospitals was 3.4% (152 dosings in 83 patients/4489 hospitalized patients/ 60 days). Practice habits and blood pressure changes differed minimally among hospitals and physicians. Sixty-three percent of nifedipine orders were given over the telephone for arbitrary and asymptomatic blood pressure elevations and 98% of the orders lacked bedside patient evaluation. Follow-up of the blood pressure was performed within 1 h in 51% of patients and within 2 h in 24%, while in 25% there was no documentation of follow-up until 2 to 6 h after nifedipine dosing. Mean pretreatment blood pressure was 186/94 +/- 20/16 mm Hg (range: 150 to 260 mm Hg systolic and 50 to 125 mm Hg diastolic). Blood pressure fell 32/16 +/- 22/16 mm Hg (range: -92 to +8 mm Hg systolic and -90 to +28 mm Hg diastolic) and was related to the level of pretreatment blood pressure (r = 0.53 for systolic blood pressure, and r = 0.49 for diastolic blood pressure, P < .001 for both). Large, asymptomatic blood pressure reductions were common. One hypertensive patient experienced severe hypotension accompanied by an anterior wall myocardial infarction. These data demonstrate inappropriate physician prescribing of oral nifedipine in hospitalized patients characterized by a lack of proper assessment prior to drug dosing, highly arbitrary treatment parameters that were written without regard for symptoms or underlying illnesses, and slow follow-up for evaluation of the clinical response to therapy.

A direct rifampicin sensitivity test for tubercle bacilli

A direct sensitivity test for rifampicin has been standardised for early detection of resistance for the mycobacterium tuberculosis smear positive sputum samples. Indirect sensitivity tests set up from primary cultures of the same samples served as controls. The direct test showed 95 per cent agreement with the standard indirect test and as such 74 per cent and 90 per cent of the resistant strains were detected by the fourth week and fifth week, respectively, with an overall gain of 4-5 wks time. Resistance could be detected earlier for multibacillary specimens. This direct sensitivity test on Lowenstein Jensen (LJ) medium offers a feasible alternative for laboratories which lack facilities to perform drug susceptibility tests by the rapid but sophisticated and costly BACTEC method. The method is simple to perform, economic, reliable and amenable to confirmation by the indirect test, if needed.

Susceptibility of south Indian strains of Mycobacterium tuberculosis to tuberactinomycin

A total of 114 strains of Mycobacterium tuberculosis isolated from sputum samples of 114 patients of pulmonary tuberculosis in south India, were coded and tested for their in vitro susceptibility to tuberactinomycin (Tum) incorporated in Lowenstein-Jensen (LJ) medium. Of these strains, 95 (83.3%) and 15 (13.2%) were susceptible to Tum at 25 and 50 mg/l respectively. Only 4 (3.5%) strains were inhibited at 100 mg/l or more. Of the 37 drug sensitive strains, 2 (5.4%) were not susceptible to Tum at 25 mg/l compared to 17 (22.1%) of 77 strains-resistant to one or more of antituberculosis drugs (P less than 0.02). The drug susceptibility pattern of the strains revealed that there was no significant association of resistance between Tum and streptomycin or rifampicin or ethambutol or ethionamide or isoniazid. However, 15 (53.6%) of 28 kanamycin (K) resistant strains were not susceptible to Tum at 25 mg/l. This cross resistance between Tum and K was further studied in 24 and 15 K sensitive and resistant strains respectively, by correlating their proportion resistance at 16 mg/l and it was found to have a significant positive correlation (r = 0.55; P less than 0.01).

Leptomeningeal metastases: comparison of clinical features and laboratory data of solid tumors, lymphomas and leukemias

We reviewed 63 cases of cytologically confirmed leptomeningeal metastases (LM). 31 (49%) had solid tumors 17 (27%) had leukemia and 15 (24%) had lymphoma. The most common presenting symptom was pain (76%) with radicular discomfort (58%), headache (32%), neck or back pain (17%). The predominant neurological signs were mental status abnormalities (49%), weakness (47%), seizures (14%). The mode of presentation varied with tumor type. Patients with leukemia (18%) and lymphoma (13%) tended to present frequently with LM without systemic involvement, or during periods of apparent remission (leukemia 35%, lymphoma 27%), while patients with solid tumors had established systemic metastases (90%) at time of presentation. Laboratory studies did not vary among the groups. 71% had positive cytology on the first lumbar puncture (LP) and only 8% required more than 2 LPs. The cell count was a poor predictor of positive cytology as 29% of LP's with positive cytology and 36% of all LP's had less than 4 cells/mm. We conclude that 1) LM presents with pain and seizures more frequently than has been previously recognized; 2) LM is frequently the mode of presentation in patients with leukemia and lymphoma and; 3) cytology is positive frequently in CSF specimens with normal cell counts and chemistries.