Cryptococcosis and Cryptococcal Meningitis: A Narrative Review and the Up-to-Date Management Approach

Cryptococcosis is a fungal infectious disease that enormously impacts human health worldwide. Cryptococcal meningitis is the most severe disease caused by the fungus Cryptococcus, and can lead to death, if left untreated. Many patients develop resistance and progress to death even after treatment. It requires a prolonged treatment course in people with AIDS. This narrative review provides an evidence-based summary of the current treatment modalities and future trial options, including newer ones, namely, 18B7, T-2307, VT-1598, AR12, manogepix, and miltefosine. This review also evaluated the management and empiric treatment of cryptococcus meningitis. The disease can easily evade diagnosis with subacute presentation. Despite the severity of the disease, treatment options for cryptococcosis remain limited, and more research is needed.

Novel Therapies for Celiac Disease: A Clinical Review Article

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

Evidence of high-frequency genomic reassortment of group A rotavirus strains in Bangladesh: emergence of type G9 in 1995

We characterized 1,534 rotavirus (RV) strains collected in Bangladesh from 1992 to 1997 to assess temporal changes in G type and to study the most common G and P types using reverse transcription-PCR, oligonucleotide probe hybridization, and monoclonal antibody-based enzyme immunoassay. Results from this study combined with our previous findings from 1987 to 1991 (F. Bingnan et al., J. Clin. Microbiol. 29:862-868, 1991, and L. E. Unicomb et al., Arch. Virol. 132:201-208, 1993) (n = 2,515 fecal specimens) demonstrated that the distribution of the four major G types varied from year to year, types G1 to G4 constituted 51% of all strains tested (n = 1,364), and type G4 was the most prevalent type (22%), followed by type G2 (17%). Of 351 strains tested for both G and P types, three globally common types, type P[8], G1, type P[4], G2, and type P[8], G4, comprised 45% (n = 159) of the strains, although eight other strains were circulating during the study period. Mixed G and/or P types were found in 23% (n = 79) of the samples tested. Type G9 RVs that were genotype P[6] and P[8] with both long and short electrophoretic patterns emerged in 1995. The finding of five different genotypes among G9 strains, of which three were frequently detected, suggests that they may have an unusual propensity for reassortment that exceeds that found among the common G types. We also detected antigenic changes in serotypes G2 and G4 over time, as indicated by the loss of reactivity with standard typing monoclonal antibodies. Our data suggest that a vaccine must provide protection against type G9 RVs as well as against the four major G types because G9 strains constituted 16% (n = 56) of the typeable RV strains and have predominated since 1996.

Prevalence and correlates of mental retardation among children in Karachi, Pakistan

This paper reports estimates of the prevalence of mental retardation and associated factors based on a population survey of 2- to 9-year-old children in Greater Karachi, Pakistan. A two-phase survey was implemented during the years 1988-1989. In the first phase, a cluster sample of 6,365 children (5,748 from urban areas and 617 from rural areas) was screened for disabilities using a parental report known as the Ten Questions instrument. In the second phase, all children with positive screening results and a 10% sample of those with negative results were referred for structured medical and psychological assessments. Estimates of the prevalence of mental retardation were 19.0/1,000 children (95% confidence interval (CI) 13.5-24.4) for serious retardation and 65.3/1,000 children (95% CI 48.9-81.8) for mild retardation. Both estimates were considerably higher than respective prevalence estimates obtained in industrialized countries and in selected less developed countries. In this population, lack of maternal education was strongly associated with the prevalence of both serious (odds ratio = 3.26, 95% CI 1.26-8.43) and mild (odds ratio = 3.08, 95% CI 1.85-5.14) retardation. Other factors that were independently associated with mental retardation in Karachi included histories of perinatal difficulties, neonatal infections, postnatal brain infections, and traumatic brain injury, as well as current malnourishment. Further research is needed to assess the contribution of consanguineous marriage, improvements in child survival, and other factors to the unusually high prevalence of mental retardation in this population.

Epilepsy in Pakistan: stigma and psychosocial problems. A population-based epidemiologic study

PURPOSE

To assess the stigmatization and psychosocial problems of persons with epilepsy in Pakistan.

METHODS

A population-based, cross-sectional epidemiologic study of 241 persons with epilepsy identified from an at-risk population of 24,130 individuals (64.7% from urban and 35.3% from rural areas). Of these patients, 77% suffered from recurrent non-febrile generalized convulsions. We evaluated degree of stigmatizations (i.e., avoidance by friends, neighbors, and others), and the effect of epilepsy on other psychosocial aspects (e.g., marriage), and also the relationships between gender and level of education of the patients, and stigmatization.

RESULTS

Patients with epilepsy in Pakistan do not appear to be highly stigmatized, but their education and grades are affected by the disorder. They have difficulty performing activities of daily living and find it hard to make decisions about whether to marry or to have children. Women believed that they were more dangerous to others, received less help from their families, and, more frequently than men, encouraged others to avoid them. Women were also more likely than men to express the belief that people with epilepsy should not marry, but in fact, women more frequently married as compared men-a fact influenced by social and cultural pressures, including pressure from family, because it is nearly always the responsibility of the parents to arrange the marriage of a daughter. Influence of education indicates that people with epilepsy who have higher education, as compared with those with less education, had fewer children, were less often avoided by their classmates and neighbors, had fewer problems with plans for education, less frequently encouraged others to avoid them, were more frequently married, and believed that they were more dangerous to others. Most people believed that their conditions had a physical basis; only 3.1% attributed their epilepsy to supernatural causes.

CONCLUSIONS

Stigmatization regarding epilepsy has not been proven to be an important feature in the culture of Pakistan because none of the observations are statistically significant as per P-value.

Comparative epidemiology of epilepsy in Pakistan and Turkey: population-based studies using identical protocols

PURPOSE

To determine comparative prevalence rates, demographics, phenomenology, seizure classification, presumptive etiology, treatment status, and selected socioanthropological aspects of epilepsy in Pakistan and Turkey.

METHODS

A population-based, cross-cultural comparative study of epilepsy was designed with identical protocols to be performed simultaneously in Pakistan and Turkey. The essential feature of the design was an unselected population, with reference to their previous medical contact, and use of standardized International Community-Based Epilepsy Research Group (ICBERG) protocols to assess cross-cultural differences.

RESULTS

In all, 24,130 persons in Pakistan and 11,497 persons in Turkey (both urban and rural, of all ages and both sexes) were studied. The crude prevalence rate of epilepsy was 9.98 in 1,000 in Pakistan and 7.0 in 1,000 in Turkey (14.8 in 1,000 in rural and 7.4 in 1,000 in urban areas of Pakistan; 8.8 in 1,000 in rural and 4.5 in 1,000 in urban areas of Turkey). In both countries, epilepsy was twice as prevalent in rural areas than in urban areas. Mean age of onset of epilepsy was 13.3 years in Pakistan and 12.9 years in Turkey. Overall frequency of seizure types was similar in both countries, with no urban/rural differences. The frequency distribution in Pakistan and Turkey, respectively, was as follows; generalized tonic-clonic, 80.5 and 65.4%; simple partial, 5 and 7.4%; complex partial, 5 and 12.3%; generalized absence, 0.8 and 4.9%; tonic and atonic, 5.8 and 3.7% each; and myoclonic, 5.8 and 1.2%. A putative cause for the epilepsy could be attributed in 38.4% of cases in Pakistan and 35.7% of cases in Turkey. Only 3% of patients in Pakistan, but 71% of patients in Turkey, believed that their illness was due to supernatural causes. The treatment status was very poor. In Pakistan, 27.5% of people with epilepsy in urban areas and 1.9% of people with epilepsy in rural areas were receiving antiepileptic drugs (AEDs) at the time of the survey. In, Turkey 30% of patients were receiving AEDs (marginally higher in rural areas).

CONCLUSIONS

The prevalence of epilepsy is slightly higher in Pakistan than in Turkey; some marginal differences in age and sex distribution, are not statistically significant. The results are comparable to those in Ecuador, where the same epidemiologic protocol was used.

The ten questions screen for childhood disabilities: its uses and limitations in Pakistan

OBJECTIVE

To assess the accuracy of the ten questions screen as a measure of childhood disability for epidemiologic studies in populations lacking resources for professional assessment of children's development and functioning.

DESIGN

Household survey and screening of children in phase one followed by clinical assessments in phase two.

SETTING

Karachi, Pakistan.

PARTICIPANTS

A cluster sample of 6365 children, aged 2 to 9 years, screened using the ten questions and a subsample referred for clinical assessments.

MAIN RESULTS

Although the sensitivity of the ten questions as a global screen for serious cognitive, motor, and seizure disabilities is high (84-100%), its sensitivity for identifying and distinguishing specific types of disability and for detecting vision, hearing, and mild disabilities, overall, is limited (generally < 80% and as low as 4% for mild vision disability). The predictive value of a positive screening result is also limited-using the ten questions in surveys without clinical confirmation results in overestimation of the prevalence of serious disability by more than 300%.

CONCLUSIONS

The ten questions screen is not an assessment tool. Its utility lies in its ability to screen or select a fraction of the population at high risk for serious disability. As a screening tool, it allows scarce diagnostic and other professional resources to be efficiently directed toward those at high risk.

Epilepsy in Pakistan: a population-based epidemiologic study

A house-to-house, cross-sectional, population study of epilepsy on 24,130 individuals of all ages from southern Pakistan indicates an age-specific prevalence rate of 9.99 in 1,000 (14.8 in 1,000 in rural and 7.4 in 1,000 in urban areas) for recurrent, nonfebrile "active" epilepsy in Pakistan. Mean onset of epilepsy was 13.3 years, and 74.3% epileptic persons were aged < 19 years at onset of the disorder. The most common seizure type was tonicclonic in 77% [primary generalized tonic-clonic (GTC) in 59% and secondarily generalized in 18%], simple partial (SPS) in 5%, complex partial (CPS) in 6%, generalized absence in 1%, tonic in 3%, and myoclonic in 3% cases. Multiple seizures types in the same person were evident in 9.6% of only the generalized group. A putative cause could be suggested in 38.4% of cases: 32% had a positive family history of epilepsy, most common among siblings. Common perceived precipitants included fever in 29.2% and emotional disturbances in 16.6%. Only 3% of epileptic persons believed that their illness was due to super-natural causes. Treatment status was very poor, with only 2% rural and 27% urban epileptic persons receiving antiepileptic drugs (AEDs) at the time of the survey. We discuss the logistic and management problems of population-based epidemiologic studies in developing countries.

Women's involvement in a rural Bangladesh water and sanitation project

Rural women were involved in a water and sanitation project (WSS) in which health impacts were compared between children in two areas: intervention and comparison areas. In intervention area people were provided with handpumps, latrines and hygiene education, whereas, in the comparison area, people did not receive these project inputs. In the intervention area women were directly involved in the site selection of handpumps and latrines, their installation, construction, and maintenance. Observations on women's involvement and their performances in the intervention area are presented. About 89% of the pumps maintained by women (n = 30), and 86% of those maintained by project workers (n = 49) were found to be in good working condition. Women supervised the construction of all 754 latrines, fenced 58% of the projects-supported latrines (n = 268) and emptied the pits of 65% of the 276 filled-up latrines. Socio-cultural factors were not barriers to women's involvement and performance. The findings have policy implications for effective involvement of rural women towards the development of sustainable WSS programs.

Prevalence of epilepsy in children (a population survey report)

A population based epidemiologic study carried out in a lower socioeconomic suburb of Karachi, identified 23 children with epilepsy among 994 children (3-9 year old) surveyed for childhood disabilities. Nineteen had major epilepsy, 2 petitmal and one each had focal motor and myoclonic attacks. The high frequency of epilepsy may be due to consanguinity, central nervous system, infections and birth and accidental trauma.

Epidemiology of shigellosis in Teknaf, a coastal area of Bangladesh: a 10-year survey

The epidemiological data on shigellosis in Teknaf, a coastal area of Bangladesh, were reviewed for a 10-year period (1975-84). Certain similarities and differences were observed in the epidemiology of the disease in Teknaf when compared with urban Dhaka and rural Matlab. Similarities included: round-the-year infection with two peaks, one in the monsoon period and the other in the winter period; high male to female attendance ratio at the treatment centre; the predominance of infection in the under-15-year age group; high mortality rate in the under-5-year age group of both sexes and in females of all age groups; the multiple drug resistance of organisms. Differences included the higher isolation rate of organisms in Teknaf (42.1% as against 11-12% in Dhaka and Matlab) and the preponderance of Shigella dysenteriae 1 infection in females in Teknaf. The unusually high isolation rate of shigella makes Teknaf the area with the highest incidence of shigellosis in Bangladesh.

Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.

Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh

The nutritional impact of a water and sanitation intervention in a rural community of Bangladesh, comprising the provision of handpumps, construction of latrines and hygiene education was assessed. During 3 years, the quarterly anthropometric measures of about 200 children aged 12-35 months from the intervention community were compared with those of a similar number of children from a control area. The interventions reduced the incidence of diarrhoea by 25 per cent among the children less than 5 years of age. There was no significant difference in nutritional status, however, between the two groups of children. Moreover, within the intervention area, indicators of water and latrine use were not significantly related to the children's nutritional status. This suggests that either the obtained reduction of diarrhoea was not large enough to have an impact on nutritional status or that diarrhoea is not an important cause of malnutrition in this community.

Persistent diarrhoea in a rural area of Bangladesh: a community-based longitudinal study

As part of a health impact evaluation of a water supply and sanitation project in a rural area of Bangladesh, diarrhoeal morbidity was recorded in children 0-4 years of age using weekly recall in household interviews, during the period March 1984 to December 1987. During the baseline year, 1984, the incidence rate of all diarrhoea episodes (3.8 episodes per child per year), and those defined as persistent, duration greater than 14 days (0.6 episodes per child per year), showed a similar age distribution, peaking in the 12-23 month age group. Sixteen per cent of all episodes were classified as persistent, and this proportion was greatest in the 0-5 month age group (25%). Children suffering at least one episode of persistent diarrhoea in 1984 also experienced a higher incidence of acute diarrhoea (less than = 14 days duration) than those suffering acute diarrhoea only (4.2 versus 3.7 episodes per child per year). Persistent diarrhoea showed a similar seasonal pattern to that of all episodes. Rates of abdominal pain, isolation of Shigella spp and a diagnosis of dysentery were significantly higher in persistent episodes than in acute episodes. Closer follow-up of children during 1986 and 1987, through the recording of all periods of absence of the child from the home, showed that overall diarrhoea incidence rates were little affected when absence was taken into account, but that the incidence of persistent diarrhoea and the proportion of episodes classified as persistent were significantly reduced. The implications of this methodological problem are discussed.

Measuring change in nutritional status: a comparison of different anthropometric indices and the sample sizes required

The usefulness of different anthropometric indices to detect nutritional changes at the community level, ie, in a number of children considered as a group, was compared by using data from a longitudinal study from rural Bangladesh which followed up quarterly an average of 413 children aged 6-35 months from December 1984 to December 1987. Weight change, mid-upper arm circumference and weight-for-height responded most quickly to seasonal variations of the food situation. Height-for-age was more responsive to long-term variations. Although similar conclusions were reached when proportions of children below a cut-off point or mean indices were compared, the comparison of mean indices required a smaller sample size to detect changes. The difference in sample size needed ranged from 48 to 61 per cent. All indices varied significantly with age, which suggests that precise knowledge of age is essential for proper interpretation of nutritional surveillance data.

Trace element studies on Karachi population. Part IV: Blood copper, zinc, magnesium and lead levels in psychiatric patients with depression, mental retardation and seizure disorders

Blood copper, zinc, magnesium and lead levels were determined by atomic absorption spectroscopy for 15 males and 16 females suffering from depression, 6 males and 1 female with mental retardation and 3 males and 4 females with seizure disorders. They were all under no medication and belonged to low income groups. No difference in copper levels was found between the sexes in any of the groups. The levels in all the groups were significantly higher than in the normals. In depressives, males had significantly higher zinc levels than females and only female depressives had significantly different (lower) levels from normals. In both depressives and normals, males had higher magnesium levels than females but no group of patients had significantly different levels from normals. Lead levels were significantly higher in female depressives and for those with seizure disorders than for controls. At least one metal abnormality was found in 21 (67.7%) depressive, 5 (71.4%) of those with mental retardation and 6 (85.7%) with seizure disorders.

Are diarrhoea control programmes likely to reduce childhood malnutrition? Observations from rural Bangladesh

Growth of rural Bangladeshi children aged 6-35 months was examined in relation to the history of diarrhoea in 1772 3-month intervals. Weight gain and linear growth were lower in intervals with a history of diarrhoea than in intervals without diarrhoea. However, comparison of weight and height gains in intervals during which diarrhoea occurred at the beginning or at the end showed that after non-bloody diarrhoeas children catch up and that deficits in weight gain and linear growth were no longer apparent a few weeks later. These findings suggest that the effect of diarrhoea on growth is transient and that efforts to control diarrhoea are unlikely to improve children's nutritional status in the long term.

Vivalan, a new anti-depressant-report on an out-patient trial

The study on 20 patients referred from the psychiatric out-patients of the Jinnah Postgraduate Medical Centre, who were given Vivalan showed marked improvement in 14 patients (70%). Three showed mild improvement while three did not respond. The drug appears to be an advance in the range of anti-depressants presently available. It is of interest to note that Vivalan is not tricyclic compound, nor does it inhibit monoamine oxidase in vitro.

Thiothixene and trifluoperazine in acutely disturbed schizophrenic patients

In acutely disturbed newly admitted patients at Neuropsychiatric Unit, Karachi, the efficacy of thiothixene is not significantly different as compared to trifluoperazine. In trifluoperazine group also all the target symptoms improved while 'depressive mood' and 'suspiciousness' did not change significantly. In thiothixene group significant improvement was noticed on all the target symptoms except 'tension' and 'depressive mood'. The ethnic or genetic make up of the patient population was concluded to be the reason for non-effectiveness of thisthixene on effective psychopathology in acute schizophrenia. The extra-pyramidal side effects were clinically more pronounced in thiothixene group.