Investigations of Limeum indicum Plant for Diabetes Mellitus and Alzheimer's disease Dual Therapy: Phytochemical, GC-MS Chemical Profiling, Enzyme Inhibition, Molecular Docking and In-vivo Studies

Limeum indicum has been widely utilized in traditional medicine but no experimental work has been done on this herb. The primary objective of this study was to conduct a phytochemical analysis and assess the multifunctional capabilities of aforementioned plant in dual therapy for Alzheimer's disease (AD) and Type 2 diabetes (T2D). The phytochemical screening of ethanol, methanol extract, and their derived fractions of Limeum indicum was conducted using GC-MS, HPLC, UV-analysis and FTIR. The antioxidant capacity was evaluated by DPPH method. The inhibitory potential of the extracts/fractions against α-, β-glucosidase acetylcholinesterase (AChE), butyrylcholinesterase (BChE) and monoaminine oxidases (MAO-A & B) was evaluated. Results revealed that acetonitrile fraction has highest inhibitory potential against α-glucosidase (IC50=68.47±0.05µg/mL), methanol extract against β-glucosidase (IC50=91.12±0.07µg/mL), ethyl acetate fraction against AChE (IC50=59.0±0.02 µg/mL), ethanol extract against BChE  (28.41±0.01µg/mL), n-hexane fraction against MAO-A (IC50=150.5±0.31µg/mL) and methanol extract for MAO-B (IC50=75.95±0.13µg/mL). The docking analysis of extracts\fractions suggested the best binding scores within the active pocket of the respective enzymes. During the in-vivo investigation, ethanol extract produced hypoglycemic effect (134.52±2.79 and 119.38±1.40 mg/dl) after 21 days treatment at dose level of 250 and 500 mg/Kg. Histopathological findings further supported the in-vivo studies.

Phytochemical Analysis, HPLC Profiling and Anti-oxidant Potential of Euphorbia nivulia Buch.-Ham

Euphorbia nivulia (EN) one of the members of Euphorbiaceae family, is a medicinal plant of Cholistan Desert (Punjab, Pakistan) that is traditionally used for a number of diseases. The plant is enriched with many phyto-constituents including flavonoids, triterpenes and polyphenols. In present study, crude extract as well as various fractions were assessed for phytochemical analysis, HPLC profiling, radical scavenging property and total phenolic and flavonoid contents. Hydro-alcoholic (70%) crude extract of EN was subjected to fractionation using different solvents including n-hexane, chloroform, butanol and aqueous. After performing the phytochemical screening and HPLC profiling, antioxidant activity was estimated by using DPPH and FRAP assays. Total flavonoid and phenolic contents were also estimated. HPLC analysis confirmed the presence of flavonoids and polyphenols like quercitin, gallic acid, caffeic acid, vanillic acid, benzoic acid, chlorogenic acid, syringic acid and ferulic acid in crude extract as well as butanol and aqueous fractions. Results revealed that butanol fraction showed maximum phenolic (143.26±2.65 mg/g GA/g) and crude extract showed maximum flavonoid (69.80±1.212 mg/g Q) contents. Maximum antioxidant potential was displaced by butanol fraction which was IC50=0.04±0.02 by DPPH and 1193.77±12.4 μmol TE/ml by FRAP respectively. Current study is the first information about the HPLC profiling of phenolic compounds in EN and its antioxidant potential that could be a step forward towards ethno-pharmacological based phyto-medicine.

Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial

AIMS

To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care.

METHODS

Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA_1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA_1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol.

RESULTS

Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA_1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively].

CONCLUSIONS

The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

Variation in growth and evaluation of cross-protection in Listeria monocytogenes under salt and bile stress

AIMS

Exposure of Listeria monocytogenes to osmotic stress can induce increased resistance to subsequent lethal exposure to cell envelope stressors, such as nisin and bile salts. We wanted to determine if similar cross-protection phenotypes could occur when L. monocytogenes strains were treated with osmotic stress and exposed to sublethal levels of the cell envelope stressor, bile.

METHOD AND RESULTS

Growth phenotypes were measured for six L. monocytogenes strains exposed to 6% NaCl, 0·3 and 1% bile in BHI. To evaluate cross-protection, cells were pre-exposed to 6% NaCl, followed by exposure to BHI+1% bile for 26 h and vice versa. Significant increases in λ (lag phase) and doubling time were observed under salt and bile stresses compared with BHI alone. Average λ and N_max (maximum cell density) in 0·3 and 1% bile for all strains were significantly lower than that in 6% NaCl. Pre-exposure to 6% NaCl followed by exposure to 1% bile significantly increased λ (P < 0·05), whereas pre-exposure to 1% bile followed by exposure to 6% NaCl led to formation of filamentous cells, with no changes in cell density over 26 h.

CONCLUSIONS

Variation in growth characteristics was observed among strains exposed to bile. Exposure to osmotic stress did not lead to increased resistance to bile. Exposure to bile significantly impacted the ability of L. monocytogenes to adapt to grow under osmotic stress, where cells did not multiply but formed filamentous cells.

SIGNIFICANCE AND IMPACT OF THE STUDY

Pre-exposure to a cell envelope stress and subsequent exposure to an osmotic stress appears to pose a significant stress to L. monocytogenes cells.

Serological and Molecular Investigation of Coxiella burnetii in Small Ruminants and Ticks in Punjab, Pakistan

Coxiellosis is a zoonotic disease caused by the obligate intracellular bacterium Coxiella burnetii affecting the productive and reproductive capabilities of animals. This study was conducted to gain insight into the seroprevalence of coxiellosis in small ruminants in seven farms of the Punjab, Pakistan. Potential risk factors were assessed. In total, 1000 serum samples (500 from sheep and 500 from goats) and 163 ticks were collected from the ruminants. All these 163 ticks were merged into 55 pools (29 pools for ticks from sheep and 26 pools for ticks from goat). Serum samples were investigated using an indirect ELISA and PCR. Coxiella burnetii DNA was detected in 29 pooled seropositive samples and 11 pooled ticks by real-time qPCR. Serological analysis revealed a prevalence of 15.6% and 15.0% in sheep and goats, respectively. A significant association was found between seropositivity and different variables like district, lactational status, reproductive status, body condition and reproductive disorders. Univariate analysis showed that detection of C. burnetii DNA in tick pools was significantly associated with the presence of ticks on sheep and goats. However, a non-significant association was found for the prevalence of C. burnetii DNA in serum pools. Hence, C. burnetii infection is prevalent in small ruminants and ticks maintained at livestock farms in Punjab, Pakistan.

De Novo Collapsing Glomerulopathy in Renal Allograft in Association with BK Virus Nephropathy in a Child and Stabilization of Renal Function by Elimination of Viremia

Well-recognized association between HIV 1 infection and collapsing glomerulopathy (CG) raises the possibility that intrarenal infection by other viruses may also contribute to the development of this lesion in native or post-transplant kidneys. There is evidence in literature about association of these lesions with cytomegalovirus, Epstein–Barr virus, hepatitis C virus, and parvovirus B19 infections. Here, we present a case report of post-transplant BK virus nephropathy in a male child who was found to have CG in subsequent biopsy 2 months later. His renal function and proteinuria were stabilized on elimination of viremia.

The impact of sexual harassment on job satisfaction, turnover intentions, and absenteeism: findings from Pakistan compared to the United States

The purpose of this study was to compare and contrast how differences in perceptions of sexual harassment impact productive work environments for employees in Pakistan as compared to the US; in particular, how it affects job satisfaction, turnover, and/or absenteeism. This study analyzed employee responses in Pakistan (n = 146) and the United States (n = 102, 76) using questionnaire data. Significant results indicated that employees who were sexually harassed reported (a) a decrease in job satisfaction (b) greater turnover intentions and (c) a higher rate of absenteeism. Cross-cultural comparisons indicated that (a) Pakistani employees who were sexually harassed had greater job dissatisfaction and higher overall absenteeism than did their US counterparts and (b) Pakistani women were more likely to use indirect strategies to manage sexual harassment than were US targets.

Pathologies en-route of oral basaloid malignancies to basaloid squamous cell carcinoma

Accurate histopathological diagnosis of any tumour is imperative because of variable prognostic and clinical implications. Basaloid squamous cell carcinoma (BSCC) is a rare distinctive histological variant of oral squamous cell carcinoma (OSCC) exhibiting an aggressive clinical course and poor prognosis. The advanced stage of presentation is speculatively responsible for this biological behaviour which is manifested by development of metastasis and subsequently poor survival. However, the non-specific clinical appearance and histopathological resemblance of BSCC with OSCC and other oral basaloid malignancies (OBM) especially in limited sample size poses diagnostic difficulties. The article emphasizes on the diagnostic criteria and pitfalls encountered in making the differential diagnosis of BSCC from OBMs along with report of a case presented at a dental college in January 2012.

A randomised controlled trial on beneficial effects of early feeding post-Caesarean delivery under regional anaesthesia

INTRODUCTION

We prospectively investigated the incidence of ileus, nausea/vomiting, and hospital course of non-labouring women fed immediately after Caesarean delivery under regional anaesthesia.

METHODS

196 patients were randomised into either the early-fed group (250 ml clear fruit juice 30 minutes postoperatively, and unlimited solid food thereafter) or the control group (clear feeds allowed after two hours, advanced to solids as tolerated).

RESULTS

Both groups had similar baseline demographics and operative characteristics. Bowel sounds were present immediately postoperatively in 90.8 percent (early group) versus 95.9 percent (control). The early-fed group had reduced time to first drink (0.86 +/- 0.6 hours versus 14.4 +/- 18.2 hours) and solid food intake (4.2 +/- 2.7 hours versus 20.0 +/- 6.8 hours), earlier passage of flatus (14.4 +/- 9.4 hours versus 21.0 +/- 10.4 hours) and first stool (44.4 +/- 18.7 hours versus 65.6 +/- 25.4 hours), shorter duration of intravenous hydration (12.8 +/- 7.5 hours versus 22.4 +/- 5.8 hours), and earlier removal of intravenous cannulae (20.5 +/- 6.7 hours versus 24.7 +/- 7.8 hours), with all p-values less than 0.001. Early-fed mothers also mobilised (23.1 +/- 6.8 hours versus 27.4 +/- 7.6 hours), commenced breastfeeding (26.5 +/- 14.1 hours versus 38.8 +/- 21.8 hours), and were ready for discharge earlier (44.3 +/- 10.4 hours versus 62.0 +/- 12.7 hours), compared to the control group, with all p-values less than 0.001. There was no difference in mild ileus symptoms (3.1 percent). Earlier solid intake resulted in more nausea (10.2 percent versus 2 percent, p-value is 0.033), which was self-limiting. Maternal satisfaction rated higher in the early-fed group (90 versus 60, on visual analogue scale score 0-100, p-value is less than 0.001).

CONCLUSION

This prospective randomised trial showed no increase in ileus with early feeding post-Caesarean delivery under spinal anaesthesia, with added benefits of earlier intravenous cannulae removal, ambulation, breastfeeding initiation and potential for shorter hospitalisation. Despite increased nausea in those taking solids earlier (but not feeds), maternal satisfaction rated higher in the early-fed group.

Inclusion of an S-nitrosylating agent in the insufflating gas does not alter gastric activity in rats following pneumoperitoneum

BACKGROUND

We have previously shown that mixing the S-nitrosylating agent ethyl nitrite with carbon dioxide can attenuate pneumoperitoneum-induced decreases in splanchnic blood flow, but it was unclear if this agent would alter gastric function. This question was answered using rats by assessing gastric emptying and gastrointestinal transit times following gavage with radioactive chromium.

METHODS

There were five experimental groups: absolute control, anesthesia control, and carbon dioxide alone or with 100 or 300 parts per million ethyl nitrite. The period of insufflation was 1 h, and all animals were euthanized 6.5 h after chromium administration.

RESULTS

The mean amount of radioactivity remaining in the stomach ranged between 16% and 27% of the total administered; these differences were not statistically significant (p > 0.05). Modest differences in chromium distribution were identified in the gastrointestinal tract, but for all treatments, the peak amount of radioactivity was located in the distal portion. Location of the peak, expressed as a percentage of total tract length, varied between 70% and 85% (p = 0.366).

CONCLUSIONS

This study found no adverse effect of ethyl nitrite on postoperative gastric emptying or gastrointestinal transit time following pneumoperitoneum. The findings support continued assessment of the clinical utility of ethyl nitrite in the setting of laparoscopic surgery.

Rehabilitation outcomes of cardiac and non-cardiac anoxic brain injury: a single institution experience

OBJECTIVE

To compare the functional outcomes of patients with anoxic brain injury (ABI) due to cardiac and non-cardiac aetiologies.

DESIGN

Retrospective chart review over 4 years.

SETTING

Freestanding rehabilitation hospital.

PARTICIPANTS

Thirteen patients with cardiac ABI and 13 patients with non-cardiac ABI.

INTERVENTION

Comprehensive, multi-disciplinary inpatient rehabilitation services.

MAIN OUTCOME MEASURES

Rehabilitation hospital length of stay (LOS) and cost; Functional Independence Measure (FIM) scores and its various sub-sets on admission and discharge; FIM efficiency and change; and discharge disposition.

RESULTS

Patients with cardiac ABI were similar in gender and ethnicity when compared to patients with non-cardiac ABI but were older (average age 52 vs 42) with a higher percentage of cardiac patients married (77% vs 39%). No statistically significant differences were found between the two groups on all sub-sets of the FIM on admission and discharge as well as the different FIM efficiencies. However, there was a trend for the cardiac ABI patients to have a greater efficiency in improving mobility during rehabilitation when compared to non-cardiac ABI patients. The rehabilitation hospital LOS was approximately 28 days less for patients with cardiac ABI (41.49 vs 69.84 days), but this difference was not statistically significant (p=0.26). The mean rehabilitation cost for patients with cardiac ABI was approximately $14,000 less than that for those with non-cardiac ABI ($44,181 vs $58,187). This difference was not statistically significant (p=0.15). Cardiac ABI patients were more likely to be discharged directly to home from rehabilitation when compared to non-cardiac ABI patients (p=0.06).

CONCLUSION

This pilot study demonstrates some differences in the recovery patterns of patients with ABI who had a cardiac aetiology and those who had non-cardiac aetiologies. While both groups experienced similar progress during rehabilitation, those with cardiac ABI made gains with a shorter LOS and less rehabilitation costs when compared to non-cardiac ABI patients. These data suggest a trend towards greater cost and length of stay for patients with ABI who had non-cardiac aetiologies.

Evaluation of surgical and anaesthesia response times for crash caesarean sections--an audit of a Singapore hospital

INTRODUCTION

The Royal College of Obstetricians and Gynaecologists published the "Organisational Standards for Maternity Services" in 1995, in which they proposed that there be a maximum decision-to-delivery time of 30 minutes for urgent caesarean sections (CS). In 1997, our institution established a protocol for extremely urgent ("crash") CS to expedite delivery time and to conform to this standard.

MATERIALS AND METHODS

The objective of this prospective audit was to determine the surgical and anaesthesia response times in our institution after the protocol had been implemented. The audit was conducted in KK Women's and Children's Hospital from February 2003 to January 2004, over a 12-month period. Upon activation of a "crash" CS, the attending anaesthetist was required to record the decision-to-anaesthesia time, decision-to-delivery time and the perinatal outcome.

RESULTS

Ninety-eight cases of "crash" CS were identified from a total of 3629 elective and non-elective CS, with 80 cases having complete data. The mean decision-to-delivery interval was 7.7 min+/-3.0 (SD) with 100% of deliveries made within 17 minutes. The mean decision-to-anaesthesia time was 3.5 min+/-2.0 (SD) with all the patients anaesthetised within 10 minutes. The majority (88.8%) of the patients had general anaesthesia for "crash" CS while the rest had successful epidural block extension. There was no significant difference in the decision-to-delivery interval or mean cord blood pH with respect to the type of anaesthesia given.

CONCLUSIONS

We achieved 100% deliveries within the proposed 30-minute decision-to-delivery time interval by implementing a protocol for "crash" CS. Both general anaesthesia and extension of existing epidural block are acceptable modes of anaesthesia and do not delay delivery of the fetus.

Long-term behavioral assessment of guinea pigs following neonatal pneumoperitoneum

BACKGROUND

Using guinea pigs, we previously demonstrated that pneumoperitoneum during pregnancy produces behavioral deficits in the offspring. In the current study, the purpose was to determine if CO(2) pneumoperitoneum during the early postnatal period also produced behavioral anomalies.

METHODS

Following delivery, guinea pig pups were randomly assigned to one of three treatment groups: CO(2) pneumoperitoneum (P), laparotomy (L), or isolation control (I). Surgeries were performed on postnatal day (PND) 5 under isoflurane anesthesia; control pups were isolated from the dams for an equivalent period of time. On PNDs 10, 20, 40, and 60, behavior was assessed by monitoring locomotor and exploratory activity.

RESULTS

A total of 29 animals were studied. We observed no immediate morbidity or mortality and the manipulations did not appear to affect postnatal growth. On PND 10, pups in group P exhibited lower levels of locomotor activity compared to L and I neonates, but this difference resolved as the animals got older. Histologic assessment of the adult offspring brains revealed no evidence of neurologic injury.

CONCLUSION

These data suggest that unlike insufflation during pregnancy, neonatal pneumoperitoneum does not produce behavioral deficits.

Simultaneous bilateral quadriceps tendon rupture in renal patients

AIMS

Simultaneous bilateral quadriceps tendon rupture occurs in patients with renal disease. It has been hypothesized that the length of renal disease and the length of dialysis may correlate with the development of tendon ruptures. This study aims to characterize the factors involved in patients with renal disease and simultaneous bilateral quadriceps tendon rupture.

METHODS

All reported cases of simultaneous bilateral quadriceps tendon rupture were identified using MEDLINE. Each case was reviewed for information regarding this injury.

RESULTS

Of the 65 cases reviewed, 24 cases involved patients with renal disease. Males were more often affected than females, almost a 2 : 1 ratio. The mean age of injury was 36 years. Most patients (63%) had signs of secondary hyperparathyroidism. The average length of renal disease was 13 years while the average length on dialysis was 6.5 years. Age, gender, mechanism of injury, time before diagnosis, location of rupture, method of repair, presence of hyperparathyroidism, length of renal disease or length on dialysis were not related to functional outcome. However, length on dialysis was related to mechanism of injury.

CONCLUSIONS

Most patients with renal disease and simultaneous bilateral quadriceps tendon rupture have good functional recovery. Duration of dialysis is related to spontaneous tendon rupture and should be considered a complication of chronic renal failure.

Empirical formulation of a generic query set for clinical information retrieval systems

Information needs in clinical practice take the form of specific questions about a given clinical situation, and are best satisfied by concise and specific information retrieval. We sought to develop a comprehensive set of generic queries for information retrieval from electronic medical information resources. We collected one hundred and ten real-world questions asked at the point of care in a variety of settings, and from these developed a set of generic queries of which each of the real-world queries could be shown to be a special case. To provide allowed values for each of the concept terms in the queries, we defined generic nouns as unions of UMLS semantic types, and specified which of these were appropriate to each query. We have begun to use the set to index reference texts from general and subspecialty medicine, and found it capable of full text indexing in the clinical domain. We hypothesize that the query set can serve as a basis for more specialized query sets, and that it will remain generalizable to other electronic medical resources, indexing tasks, and non-UMLS controlled vocabularies.

Differential responses to ATPgammaS in the mesenteric and hindlimb vascular bed of the cat

The mechanism by which the purinergic agonist adenosine 5'-O-(3 thiotriphosphate) (ATPgammaS) decreases vascular resistance was investigated in the mesenteric and hindlimb vascular beds of the cat. Injections of ATPgammaS into the hindlimb perfusion circuit elicited dose-dependent decreases in perfusion pressure while injections into the mesenteric circuit produced a biphasic response with an initial vasopressor response followed by a vasodepressor response. In the mesenteric vascular bed the pressor response to ATPgammaS was blocked by a P2X1 receptor antagonist. Also an inhibitor of nitric oxide synthase enhanced the vasoconstrictive responses to ATPgammaS. However, the vasodepressor response in the mesenteric bed was not altered by the adminstration of an alpha adrenergic receptor antagonist, a cyclooxygenase inhibitor, a P2Y1 receptor antagonist, or a K+ATP channel blocking agent. These data suggest that the vasopressor response to ATPgammaS in the mesenteric vascular bed of the cat is mediated via P2X1 receptor activation. The differential responses to ATPgammaS in the hindlimb and mesentery suggest differences in purinergic receptor distribution in the vascular system of the cat. In addition, the results suggest that prostaglandin synthesis, P2Y1 receptor activation, alpha receptor inhibition, and K+ATP channels activation play little to no role in mediating the vascular response to ATPgammaS in the mesentery of the cat.

An in vitro resistance study of levofloxacin, ciprofloxacin, and ofloxacin using keratitis isolates of Staphylococcus aureus and Pseudomonas aeruginosa

PURPOSE

We compared levofloxacin with ciprofloxacin and ofloxacin using the in vitro susceptibilities of Staphylococcus aureus (SA) and Pseudomonas aeruginosa (PA) keratitis isolates.

DESIGN

Retrospective, clinical laboratory study of antibiotic susceptibility among keratitis isolates.

PARTICIPANTS

Keratitis isolates from 200 patients with either SA or PA keratitis.

METHODS

Minimum inhibitory concentrations (MICs) were determined for levofloxacin, ofloxacin, and ciprofloxacin for 93 SA keratitis isolates (68 fluoroquinolone-resistant and 25 susceptible, as determined by disk diffusion) and 107 PA keratitis isolates (13 fluoroquinolone-resistant and 94 susceptible). National Committee for Clinical Laboratory Standards susceptibilities were determined and analyzed statistically. Time kill studies were determined for fluoroquinolone-susceptible and -resistant isolates to all antibiotics at 8 microg/ml. The killing rates were determined by regression, and the colony count decreases were analyzed.

MAIN OUTCOME MEASURES

The susceptibilities and potencies of levofloxacin, ciprofloxacin, and ofloxacin to SA and PA were determined from the MICs. Time kill studies determined the killing rates and decreases in colony counts.

RESULTS

The fluoroquinolone-resistant SA susceptibilities to levofloxacin, ofloxacin, and ciprofloxacin were only 22%, 10%, and 3%, respectively. The fluoroquinolone-susceptible SA were 100% susceptible to all antibiotics, with levofloxacin demonstrating the best potency. The fluoroquinolone-resistant PA were resistant to all antibiotics. The fluoroquinolone-susceptible PA isolates were highly susceptible to levofloxacin, ofloxacin, and ciprofloxacin, with ciprofloxacin demonstrating the highest potency. For fluoroquinolone-susceptible SA and PA, the time kill studies determined that the killing rates and decreases in colony counts were equivalent for all three antibiotics tested. The time kill studies demonstrated no colony count decreases for the fluoroquinolone-resistant SA and PA.

CONCLUSIONS

Taken together, our susceptibility and time kill data failed to demonstrate convincing differences in the susceptibility of SA and PA keratitis isolates to levofloxacin, ciprofloxacin, and ofloxacin. In general, bacterial isolates that were resistant to ciprofloxacin and ofloxacin were also resistant to levofloxacin.

Mycobacterium haemophilum in immunocompromised patients

Mycobacterium haemophilum, a recently described pathogen, can cause an array of symptoms in immunocompromised patients. To date, 90 patients with this infection have been described worldwide. We report our institution's experience with 23 patients who were treated from 1990 through 2000. Fourteen patients had undergone bone marrow transplantation, 5 were infected with human immunodeficiency virus, 3 had hematologic malignancies, and 1 had no known underlying immunosuppression. Clinical syndromes on presentation included skin lesions alone in 13 patients, arthritis or osteomyelitis in 4 patients, and lung disease in 6 patients. Although patients with skin or joint involvement had favorable outcomes, 5 of 7 patients with lung infection died. Prolonged courses of multidrug therapy are required for treatment. A diagnosis of M. haemophilum infection must be considered for any immunocompromised patient for whom acid-fast bacilli are identified in a cutaneous, synovial fluid or respiratory sample or for whom granulomas are identified in any pathological specimen.

Vasodilator responses to ATP and UTP are cAMP dependent in the mesenteric vascular bed of the cat

BACKGROUND

This study was designed to examine the responses to and the mechanism by which purinergic agonists decrease vascular resistance in the mesenteric vascular bed of the cat.

METHODS AND RESULTS

Injections of ATP, UTP, and 2-MethylThioATP (2-MetSATP) into the mesenteric perfusion circuit elicited dose-dependent decreases in perfusion pressure while injections of beta,gamma-MethylATP (beta,gamma-MetATP) produced a biphasic response with an initial vasopressor response followed by a vasodilator response. The order of potency of the vasodilator response was 2-MetSATP > ATP > UTP > beta,gamma-MetATP. The vasodilator responses to ATP, UTP, 2-MetSATP, and beta,gamma-MetATP were increased in duration by the cAMP phosphodiesterase inhibitor, rolipram. However, vasodilator responses were not altered by the adminstration of a nitric oxide synthase inhibitor, a cGMP phosphodiesterase inhibitor, or a cyclooxygenase inhibitor. Treatment with PPADS, a P2X(1), P2Y(1), and P2Y(4) receptor antagonist, did not alter vasodilator responses to the purinergic agonists; however, the vasopressor component of the response to beta,gamma-MetATP was decreased.

CONCLUSIONS

These data suggest that ATP, UTP, 2-MetSATP, and beta,gamma-MetATP dilate the mesentary vascular bed in the cat by a cAMP dependent mechanism, and that nitric oxide or prostaglandin release, cGMP accumulation, or activation of P2X(1), P2Y(1), or P2Y(4) receptors play little or no role in mediating vasodilator responses to the purinergic agonists in this regional vascular bed. In addition, these results suggest that the pressor component of the response to beta,gamma-MetATP is mediated by the activation of P2X(1) receptors.

Comparison of sevoflurane-nitrous oxide anaesthesia with the conventional intravenous-inhalational technique using bispectral index monitoring

Ninety-one patients were randomly allocated to one of two groups. Group A was induced with a single vital capacity breath of 6% (end-tidal) sevoflurane in nitrous oxide-oxygen (2 : 1 l.min-1), whereas group B was induced with intravenous fentanyl 1 microg.kg-1 + propofol 2 mg.kg-1 followed by nitrous oxide-oxygen (2 : 1 l.min-1) and sevoflurane. Induction was considered to have been achieved when the bispectral index value decreased to below 70. Mean induction time in group A (95.2 s, 95% CI 88.5-101.9 s) was longer than group B (70.3 s, 95% CI 66.3-74.3 s; p < 0.0001). Mild coughing was more common in group A, but relative hypotension was more common in group B. There was no difference in the emergence times. Thirty minutes after emergence, there was no difference in the incidence of adverse effects, with the exception of essentially mild abdominal pain which was more frequent in group A.

The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour

Sixty patients in early labour were randomly allocated to one of three groups. The control group received intrathecal fentanyl 25 microg, the ropivacaine group received intrathecal fentanyl 25 microg and ropivacaine 2.5 mg while the bupivacaine group received intrathecal fentanyl 25 microg and bupivacaine 2.5 mg. The incidence of pruritus was 100% in controls, compared with 85% in the ropivacaine group (not significant) and 75% in the bupivacaine group (p = 0.003). The severity of pruritus was significantly less in the ropivacaine (p = 0.006) and bupivacaine (p = 0.001) groups. Most patients developed pruritus by 30 min. Pruritus above the abdomen was not reduced in patients receiving local anaesthetics. There were no significant differences in the mean pain visual analogue score, systolic blood pressure, maternal heart rate and upper level of reduced pin-prick sensation in the first 30 min. Intrathecal ropivacaine and, more so, intrathecal bupivacaine reduce the incidence and severity of pruritus from intrathecal fentanyl for labour analgesia.

New therapies for treating hypertension: what every physician should know

Hypertension is a prevalent health problem and a major cause of morbidity and mortality in the United States. It is one of the most important modifiable risk factors for multiple medical problems including coronary artery disease, congestive heart failure, and end-stage renal disease. There are many efficacious antihypertension medications, each with its own indications and side effect profile. Furthermore, new drugs are being developed rapidly. This article features how to diagnose hypertension as well as describes pharmacological and nonpharmacological treatment options. The properties, proper use, and side effect profile of each of the nine classes of antihypertension drugs commonly used and three classes of medications on the horizon will be described. The purpose of this manuscript is to familiarize physicians with the antihypertension regimens commonly employed and to introduce drugs which may become available in the near future.

A devastating ocular pathogen: beta-streptococcus Group G

PURPOSE

To report the clinical findings, treatment, and outcomes of four cases of beta-streptococcus Group G (BHS-G) ocular infection.

METHODS

The medical and microbiologic records of four cases of BHS-G ocular infection were retrospectively reviewed.

RESULTS

Two cases of BHS-G endophthalmitis and two cases of BHS-G keratitis were recorded. Three patients developed fulminant infection within 12 hours of the onset of symptoms. One patient's history was incomplete. One patient developed endophthalmitis from a contaminated donor button; another following cataract surgery. One developed keratitis in a keratoplasty suture tract; and another patient developed a corneal abscess after being struck with a tree branch. The patient with the contaminated donor button developed overwhelming endophthalmitis resulting in no light perception vision, severe pain, and evisceration. The postoperative cataract patient developed a purulent endophthalmitis and is still hypotonus with light perception vision. The second keratitis patient developed a significant suture abscess with marked stromal loss but eventually healed. The traumatic keratitis patient developed a large ulcer with hypopyon and descemetocele but was lost to follow-up.

CONCLUSIONS

This is the first report of a series of BHS-G ocular infections. The ocular infections were characterized by rapid onset, extreme inflammation, and--despite in vitro antibiotic sensitivity--a poor or sluggish response to antibiotic therapy.

Comparison of internal medicine, pediatric, and medicine/pediatrics applicants and factors influencing career choices

BACKGROUND

A reemergence of medical students choosing primary care is occurring, with medicine/pediatrics as an increasingly popular option. We compared applicants to pediatrics, medicine, and medicine/pediatrics and the factors that influence career choice.

METHODS

We designed a survey to gather objective data and information shown to influence career choices. Applicants interviewing in our three primary care programs completed the survey.

RESULTS

Pediatric applicants were more likely to be women and to choose their career in the 2nd year of medical school. Medicine/Pediatrics applicants had the highest interest in practicing primary care and in pursuing an academic career. However, they had the smallest number of role models. The average education debt was the same.

CONCLUSION

Differences in applicants applying to primary care programs may be used to target particular applicants and to counsel medical students on career choice.

Human pulmonary dirofilariasis: review of the literature

BACKGROUND

The dog heartworm Dirofilaria immitis is known to cause solitary pulmonary nodules in humans. Human pulmonary dirofilariasis (HPD) is more prevalent along the coastal regions of the United States, especially along the Mississippi River Valley. Diagnosis is generally made by surgical resection, since HPD is often preoperatively presumed to be lung cancer.

METHODS

I searched for relevant clinical articles and case reports on HPD, using MEDLINE and the Index Medicus. I carefully reviewed each article for information regarding HPD.

RESULTS

Of the 37 cases reviewed, 29 (78.4%) were in the southern and southeastern states. The youngest patient was a 33-year-old woman, and the oldest was a 79-year-old man (mean age, 57.3 years). This literature review found that 43.2% were symptomatic, 51.4% were asymptomatic, and 5.4% were not recorded. Solitary lesions were found in 89.7%, with a mean diameter of 1.9 cm.

CONCLUSION

Based on the available literature and epidemiologic data, HPD should be considered in the differential diagnosis of pulmonary nodules in the appropriate clinical and geographic setting.

Treatment of symptomatic chronic adenotonsillar hypertrophy with amoxicillin/clavulanate potassium: short- and long-term results

OBJECTIVE

To evaluate the short- and long-term effects of treatment of symptomatic chronic adenotonsillar hypertrophy (CATH) with a 30-day course of amoxicillin/clavulanate potassium (AMOX/CLAV).

PATIENTS

Children 2 to 16 years of age with obstructive symptoms attributable to CATH, who did not have a history of recurrent adenotonsillitis.

DESIGN

A prospective, randomized, double-blinded, placebo-controlled trial.

SETTING

Ambulatory clinic of a tertiary care hospital.

INTERVENTION

Patients were randomly treated with 30-day courses of either placebo (PLAC) or AMOX/CLAV (40 mg/kg in 3 divided doses daily).

OUTCOME MEASURES

Patients' signs and symptoms were assessed by physical examination and by both physician and parental forced-choice questionnaires 1, 3, and 24 months after treatment. The decision to proceed to surgery or to continue expectant management was made for all patients by the same physician, based on reported symptoms and physical findings.

RESULTS

Treatment with a 30-day course of AMOX/CLAV significantly reduced the need for surgery in the short term compared with PLAC (37.5% vs 62.7%) at 1-month follow-up). The reduced need for surgery in the AMOX/CLAV-treated group persisted at 3 months (AMOX/CLAV 54.5% vs PLAC 85.7%) and 24 months (AMOX/CLAV 83.3% vs PLAC 98.0%).

CONCLUSIONS

A 30-day course of AMOX/CLAV significantly reduces the need for surgery in children with obstructive adenotonsillar hypertrophy at 1-month follow-up. This relative reduction persists at 3 and 24 months posttreatment, although the absolute percentages of patients requiring surgery increased in both groups as time after treatment increased. The reduction in symptoms in AMOX/CLAV-treated patients is modest but significant even in long-term follow-up. The precise role of this treatment for CATH is yet to be determined; however, our results suggest that a 30-day course of AMOX/CLAV can be used in situations when a temporary relief in symptoms is desirable or surgery would incur unacceptable risk.

A unique case of Cryptococcus laurentii keratitis spread by a rigid gas permeable contact lens in a patient with onychomycosis

PURPOSE

We report the first case of fungal keratitis caused by Cryptococcus laurentii, a nonneoformans species.

METHODS

A case of C. laurentii keratitis in a diabetic, gas permeable contact lens wearer was diagnosed after microbiologic evaluation of the corneal button after emergent keratoplasty. The excised cornea was also culture positive for Staphylococcus aureus and Fusarium solani. The medical history was significant for onychomycosis of the right great toe 2 months previously. Cultures of the toenail and of the contact lens case were also positive for C. laurentii and F. solani.

RESULTS

An initial penetrating keratoplasty with histopathologically clear margins was unsuccessful in preventing intraocular spread of the fungal infection. Despite a repeat limbus-to-limbus therapeutic keratoplasty, pars plana vitrectomy, multiple anterior chamber washouts, intravitreal antifungal injections, and systemic antifungal treatment, the eye was ultimately lost due to ongoing inflammation, ocular hypotony, and a total retinal detachment. Histopathologic examination of the enucleated eye demonstrated filamentous fungi but no yeast forms.

CONCLUSIONS

C. laurentii, a nonneoformans species, should be included in the differential diagnosis of fungal keratitis. This unique case also demonstrates the importance of a thorough clinical history and proper contact lens hygiene, particularly in a diabetic patient.

Acute pain service, Kandang Kerbau Hospital, 1995--a first year's experience

AIM

To determine the efficacy and safety of the different modes of post-operative analgesia in the first 24 hours for both caesarean section and major gynaecological procedures.

METHODS

Being a purely descriptive study, the patients were not randomised to the post-operative analgesic mode. The choice was made both by the patient and the anaesthetist. The modes employed were continuous intravenous morphine, continuous intravenous pethidine, epidural morphine/bupivacaine, epidural bupivacaine/fentanyl and spinal morphine. During the first 24 hours, the patients' maximum pain scores, ability to sleep well, presence of nausea and/or vomiting, pruritus, respiratory depression and drowsiness and/or giddiness were elicited. Backache and inflammation at the site of insertion of the epidural catheter were also elicited in patients on regional analgesia. They were also asked if they were satisfied with the Pain Service.

RESULTS

Out of 2,024 patients, 60% had undergone caesarean section and 40% had undergone major gynaecological procedures. Continuous intravenous morphine, the most common mode, was used in 83% of obstetric patients and 47.9% of gynaecological patients. Only one obstetric patients and one gynaecological patient complained of severe pain at rest while 12 obstetric patients and 3 gynaecological patients had severe pain on movement or coughing. Side-effects, most commonly nausea and/or vomiting and drowsiness and/or giddiness, were present in 8.8% of obstetric patients and 32.5% of gynaecological patients. 99.3% of obstetric patients and 99.6% of gynaecological patients were overall satisfied with their analgesia.

CONCLUSION

Our post-operative analgesic modes were found to be effective and safe.

Comparison of responses to rat and human adrenomedullin in the hindlimb vascular bed of the cat

Responses to rat (r) adrenomedullin (ADM) and human (h) ADM were compared in the hindlimb vascular bed of the cat under conditions of controlled blood flow. Intra-arterial injections of rADM and hADM in doses of 0.03-1 nmol caused dose-related decreases in hindlimb perfusion pressure. In terms of relative vasodilator activity, rADM was similar to hADM. The time course of the vasodilator response and the recovery half times (T1/2) for the vasodilator response to rADM and hADM were not significantly different. Decreases in hindlimb perfusion pressure in response to rADM and hADM were not altered by the calcitonin gene-related peptide receptor antagonist, rCGRP(8-37), at the same time, vasodilator responses to calcitonin gene-related peptide (CGRP) were significantly reduced. The T1/2 of the vasodilator response to rADM and hADM were significantly greater after administration of the cAMP-selective, type IV phosphodiesterase inhibitor, rolipram. These data demonstrate that decreases in hindlimb perfusion pressure in response to rADM and hADM are similar and that vasodilator responses to rADM are not dependent on the activation of CGRP receptors in the hindlimb vascular bed of the cat. These data further suggest that decreases in hindlimb perfusion pressure in response to rADM are mediated by smooth muscle increases in cAMP levels.

A case of tracheal obstruction during oesophageal removal of a foreign body

A patient was admitted with an impacted foreign body in the oesophagus. Repeated attempts to remove it during oesophagoscopy proved difficult and caused obstruction of the trachea during manipulation of the foreign body. A smaller endotracheal tube was subsequently placed in the trachea relieving the obstruction.

Lipoid proteinosis

A 20-year old male presented with hoarseness of voice since birth, beaded papular lesions on both eyelids, multiple hypopigmented atrophic scars on trunk and extremities and yellowish infiltrated plaques on tongue, palate and buccal mucosae. Patient was diagnosed clinically as a case of lipoid proteinosis. It was confirmed by mucosal biopsy.

Immunological studies in oral submucous fibrosis

Oral submucous fibrosis (OSMF) is a high risk precancerous condition. The possible role of immunological factors in the pathogenesis of this condition was evaluated in 113 cases and 25 controls. The male/female ratio was 1.5/1. The mean age of males was significantly lower than that of females. The mean ESR levels were within normal limits, but for a higher than 20 mm fall per hr. in 40% of the cases. The serum IgA, IgG, and IgM levels were elevated significantly as compared to the controls. Circulating auto-antibodies and tissue-deposited antibodies were also found in 33% and 40% of the cases, respectively. From the analysis of the results, it is difficult to ascribe an auto-immune basis for the causation of OSMF. The female bias and elder age group, the factors generally considered in favour of an immune disorder, was not found in our study. However, raised ESR in 40% and serum globulin levels in 47% of the patients, distinctly higher levels of serum immunoglobulins, and positivity for circulating and tissue deposited antibodies in 33% and 34% of the cases respectively, do indicate an immunological basis. Therefore, further studies are required to ascertain the role of cellular immune mechanism and genetic parameters to explain the etiopathogenesis of this complex clinical entity.

Community-acquired methicillin-resistant Staphylococcus aureus infections in otolaryngology

Soon after the introduction of methicillin, strains of Staphylococcus aureus resistant to methicillin were reported. Methicillin-resistant Staphylococcus aureus (MRSA) has become a common hospital pathogen, often resistant to multiple antibiotics, while causing significant morbidity and mortality. Community-acquired MRSA infections have been infrequently documented. Most reports have been associated with intravenous drug abuse. This report reviews 15 patients with community-acquired MRSA infections of the head and neck. None admitted to intravenous drug use. Additionally, no patient was known to be a healthcare worker. The MRSA strains showed antibiotic susceptibility and resistance profiles different from typical hospital-acquired MRSA isolates. All but one infection resolved with adequate surgical or appropriate antibiotic therapy. Clinicians should become aware of the possibility of community-acquired MRSA in the patient who has had continued infection despite antibiotic therapy.

Creatine kinase and its isoenzyme MB in patients after open heart surgery

Total serum creatine kinase (CK) and its isoenzyme MB (CKMB) were measured before and 4, 24, 48 and 72 hours after termination of cardiopulmonary bypass in patients undergoing (I) atriotomy, (II) ventriculotomy and (III) coronary artery bypass surgery. All patients were free of postoperative complications and myocardial infarction as defined by clinical course, 12 lead ECG and 2D echocardiography. Peak elevation of CK occurred at 24th hour and CKMB at 4th hour and then gradually declined. There was no relation between the peak level of rise of CK or CKMB with cross clamp time or bypass time. The 96th percentile values of absolute CKMB level at 4, 24, 48 and 72 hours may suggest perioperative myocardial infarction with specificity of 95%. In addition, the rising value of CKMB beyond 24 hours after the termination of bypass may also suggest occurrence of myocardial infarction.