Impact of Positive Culture Reports of E. coli or MSSA on De-Escalation of Antibiotic Use in a Teaching Hospital in Pakistan and the Implications

Background

Antibiotic de-escalation is a key element of antimicrobial stewardship programs that restrict the spread and emergence of resistance. This study was performed to evaluate the impact of positive culture sensitivity reports of E. coli or Methicillin sensitive Staphylococcus aureus (MSSA) on de-escalation of antibiotic therapy.

Methods

This prospective observational study was performed on 256 infected patients. The samples were obtained principally from the pus of infected sites for the identification of pathogens and culture-sensitivity testing. The data were collected from patient medical files, which included their demographic data, sample type, causative microbe and antimicrobial treatment as empiric or definitive treatment based on cultures. Data were analyzed using SPSS.

Results

Of 256 isolated microbes, 138 (53.9%) were MSSA and 118 were E. coli (46.1%). MSSA showed 100% sensitivity to cefoxitin, oxacillin, vancomycin, fosfomycin, colistin and more than 90% to linezolid (95.3%), tigecycline (93.1%), chloramphenicol (92.2%) and amikacin (90.2%). E. coli showed 100% sensitivity to only fosfomycin and more than 90% to colistin (96.7%), polymyxin-B (95.1%) and tigecycline (92.9%). The high use of cefoperazone+sulbactam (151), amikacin (149), ceftriaxone (33), metronidazole (30) and piperacillin + tazobactam (22) was seen with empiric prescribing. Following susceptibility testing, the most common antibiotics prescribed for E. coli were meropenem IV (34), amikacin (34), ciprofloxacin (29) and cefoperazone+sulbactam (25). For MSSA cases, linezolid (48), clindamycin (30), cefoperazone+ sulbactam IV (16) and amikacin (15) was used commonly. Overall, there was 23% reduction in antibiotic use in case of E. coli and 43% reduction in MSSA cases.

Conclusion

Culture sensitivity reports helped in the de-escalation of antimicrobial therapy, reducing the prescribing of especially broad-spectrum antibiotics. Consequently, it is recommended that local hospital guidelines be developed based on local antimicrobial susceptibility patterns while preventing the unnecessary use of broad-spectrum antibiotics for empiric treatment.

Adverse childhood experiences, psychological well-being, and substance use in Pakistani university students

Adverse childhood experiences are associated with risky health behaviors and adverse health outcomes worldwide, including substance use; yet, relatively fewer studies have examined linkages between adverse childhood experiences and health behaviors and outcomes in low- and middle-income countries, including countries in sub-Saharan Africa and large portions of Asia. Furthermore, fewer studies of adverse childhood experiences have examined the pathways or processes connecting adverse childhood experiences to health behaviors and outcomes. This study addressed these gaps by investigating three competing models of associations between adverse childhood experiences, psychological well-being, and substance use in 595 Pakistani University students (40.5% female; Meanage = 21.96, Standard deviation = 2.37) using path analysis. Controlling for the effects of age, sex, and socioeconomic status, adverse childhood experiences were associated with both diminished psychological well-being and higher levels of substance use. However, psychological well-being and substance use were unrelated and neither accounted for indirect effects of adverse childhood experiences on adjustment. Suggestions for furthering research on adverse childhood experiences, particularly in low- and middle-income countries, are discussed.

Teachers' Perceptions of Netiquette Practices by undergraduate Dental Students During Online Classes in Covid-19 Pandemic

Netiquettes are general rules and customs governing social and professional interactions that are considered acceptable. Objectives: To explore Teachers' perceptions of netiquette practices by undergraduate dental students during online classes in COVID-19 pandemic. Study Design: Descriptive cross-sectional Study. Methodology: Research was conducted in two leading private dental colleges of twin cities. Convenience sampling was done to obtain data. A self-constructed questionnaire comprising of open and close ended questions was disseminated to the dental faculty of both colleges through What’s App groups. Statistical analysis: SPSS software, v 21 analyzed data. Results: Responses from ninety-seven participants showed that students exhibited a casual attitude in online classes and showed lack of interest and motivation. Issues like absenteeism, distraction during classes and use of unfair means during exams were prevalent. Teachers were of the opinion that students should be guided properly on how to attend online classes and provided with constructive feedback. Faculty had a general idea about "netiquettes., however, there was a significant lack of formal knowledge regarding netiquette rules and standards. On account of this, most of the participants reported the lack of institutional guidelines for netiquette standards and practices. Therefore, a need for documented netiquettes policy in educational institutes was suggested. Conclusion: We concluded that accrediting bodies and medical institutions should formulate a policy of netiquette practices. Implementation of netiquette practices in the undergraduate curriculum is the need of time. Key Words: Netiquette Practices, Undergraduate Students, E-learning and Online Teaching.

Reflection - an effective strategy for outcome-based learning in basic medical sciences

Objective: To determine the role of guided reflection for improved learning outcomes in students of basic dental sciences. Method: The quasi-experimental comparative educational study was conducted at the Islamic International Dental College, Islamabad, Pakistan, from May to September 2019, and comprised second-year undergraduate students in the Basic Medical Sciences curriculum for Microbiology. The subjects were arbitrarily divided into Group-1, which was exposed to guided reflection, and Group-2, which was not asked to reflect on the lectures. Post-intervention, a test of 30 multiple choice questions on the selected topics was conducted to compare the level of learning between the groups. After three weeks, the same activity was repeated with the same groups, but with different topics of lectures. Data was analysed using SPSS 21. Results: Of the total 75 students, there were 28 female and 9 male students in Group-1 (Reflectors), 29 female and 9 male students in Group-2 (Non-Reflectors). Overall, there were 18 male and 57 female students. The overall mean age was 20 years The difference between the groups after the first session was not significant (p>0.05). After session 2, Group-1 score was significantly better than that of Group-2 (p<0.05). Conclusion: Reflective practices on teaching sessions at the end of lectures proved to be an effective strategy to achieve outcome-based learning.

FBG and TC/HDL ratios in type 2 diabetes mellitus

BACKGROUND

Presence of dyslipidemia, i.e. raised Total Cholesterol (TC) and decreased High Density Lipoproteins (HDL) is an established phenomenon in type 2 diabetes mellitus. Its relationship to the fasting blood sugar (FBG) level in both diabetics and non-diabetics has yet to be established. The present study aims to show such a relationship.

METHODS

150 subjects were selected and divided into two groups, one of 50 controls (non-diabetics), the other of 100 patients with type 2 diabetes mellitus. Their FBG levels were determined by enzyme oxidase method, and their TC and HDL levels were determined using a standard kit method.

RESULTS

FBG and TC:HDL ratios were increased in the patient group (p = < 0.001). Comparison of FBG and TC:HDL ratios revealed a highly significant rise (p = < 0.001) in the patient group. FBG with TC:HDL ratios between both groups showed a positive correlation (r = 0.554).

CONCLUSION

The results of the present study suggest an association between FBG and TC:HDL ratios, which may be a contributory factor to the increased prevalence of coronary artery disease in patients with type 2 diabetes mellitus.

Effect of aspirin on induction of apoptosis in HT-29 human colon adenocarcinoma cells

Aspirin (ASA) and other nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit colorectal tumorigenesis. Apoptosis is a critical determinant of tissue mass homeostasis and may play a role in carcinogenesis. We studied the effect of ASA on the survival of a human colon cancer cell line using more sensitive methods than we had applied previously. ASA induced apoptosis in HT-29 colon adenocarcinoma cells at concentrations > or =1 mM as established by: (a) morphological changes consistent with apoptosis in cells examined by fluorescence microscopy and semi-thin cell sections, and (b) DNA strand breaks: 45% of the cells were TdT-mediated dUTP nick end labeling (TUNEL) positive at 3 mM at 72 hr, and 70% were positive by the comet assay. Electron microscopy also confirmed the induction of apoptosis by ASA. ASA-induced apoptosis was not associated with: (a) a ladder pattern on genomic DNA electrophoresis, or (b) a subdiploid peak on flow cytometry. Apoptotic bodies were virtually absent on standard morphological assessments and only a few were detected on semi-thin sections. For the above reasons, this apoptosis induced by ASA is "atypical," and the unusual features of ASA-induced apoptosis, besides their taxonomic value, may offer clues to the mechanisms that control the process of apoptosis or perhaps the cancer chemopreventive properties of this compound. These findings demonstrate that ASA induces apoptosis in human colon cancer cells, bolstering the hypothesis that apoptosis may be a mechanism by which NSAIDs inhibit colon carcinogenesis. These findings should be examined in animal and/or clinical research studies in vivo.

Curcumin, a natural plant phenolic food additive, inhibits cell proliferation and induces cell cycle changes in colon adenocarcinoma cell lines by a prostaglandin-independent pathway

Curcumin, the active ingredient of the rhizome of the plant turmeric (Curcuma longa Linn), a commonly used spice, prevents cancer in animal tumor models. Its mechanism of action is unknown; curcumin may act by inhibiting arachidonic acid metabolism. To explore the mechanism of curcumin's chemopreventive effect, we studied its role in proliferation and apoptosis in the HT-29 and HCT-15 human colon cancer cell lines. Curcumin dose-dependently reduced the proliferation rate of both cell lines, causing a 96% decrease by 48 hours. No apoptosis was detected. The antiproliferative effect was preceded by accumulation of the cells in the G2/M phase of cell cycle. The effect of curcumin was similar in both cell lines, which, however, differ in their ability to produce prostaglandins. We conclude that curcumin inhibits colon cancer cell proliferation in vitro mainly by accumulating cells in the G2/M phase and that this effect is independent of its ability to inhibit prostaglandin synthesis. The role of curcumin's antiproliferative effect in human colon cancer remains to be established.

Effects of nonsteroidal anti-inflammatory drugs on proliferation and on induction of apoptosis in colon cancer cells by a prostaglandin-independent pathway

Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the incidence of and mortality from colon cancer. We observed that NSAIDs inhibit the proliferation rate, alter the cell cycle distribution, and induce apoptosis in colon cancer cell lines. We evaluated whether the inhibition by NSAIDs of prostaglandin (PG) synthesis is required for their effects on colon cancer cells by studying two human colon cancer cell lines: HCT-15 and HT-29. HCT-15, which lacks cyclooxygenase transcripts, does not produce PGs even when exogenously stimulated, whereas HT-29 produces PGE2, PGF2 alpha, and PGI2. HCT-15 and HT-29 cells, when treated for up to 72 hr with 200 microM sulindac sulfide (an active metabolite of sulindac) or 900 microM piroxicam, showed changes in proliferation, cell cycle phase distribution, and apoptosis. Treatment with PGE2, PGF2 alpha, and PGI2, following a variety of protocols, and at concentrations between 10(-6) and 10(-11) M, failed to reverse the effects of NSAIDs on these three parameters of cell growth. We concluded that NSAIDs inhibit the proliferation rate of the two colon cancer cell lines independent of their ability to inhibit PG synthesis. Thus, alternative mechanisms for their activity on tumor cell growth must be entertained. These observations may be relevant to the mechanism of colon tumor inhibition by NSAIDs.

The effect of leukotrienes B and selected HETEs on the proliferation of colon cancer cells

Eicosanoids have been implicated in colon carcinogenesis, but very little is known on the potential role of leukotrienes (LTs) and hydroxyeicosatetraenoic acids (HETEs) in this process; such compounds are produced by colonocytes and tumor infiltrating leukocytes. We studied the effect of LTB4, LTB4 methyl ester, LTB5, 12(R)-HETE, 12(S)-HETE and 15(S)-HETE (10(-10), 10(-8), 10(-6) M) on the proliferation rate, the cell cycle distribution, and the rate of apoptosis in HT-29 and HCT-15 human colon carcinoma cells. Our data show that LTB4, a lipoxygenase product, increased the proliferation rate of both cell lines in a time- and concentration-dependent manner. In HT-29 cells the concentration-response curve was bell-shaped (maximal effect at 10(-8) M). The proliferative effects of LTB4 in HT-29 cells were inhibited by SC-41930, a competitive antagonist of LTB4, suggesting the existence of an LTB4 receptor in epithelial cells. The methyl ester of LTB4 stimulated the proliferation of these cells, but LTB5, an isomer of LTB4 derived from eicosapentaenoic acid, did not. Of the HETEs, only 12(R)-HETE, a P-450 product, stimulated the proliferation of both cell lines; the other HETEs, all lipoxygenase products, failed to affect the proliferation of these cells. None of these eicosanoids had any effect on cell cycle distribution or apoptosis in either cell line. Taken together with our previous data showing that PGs stimulate colon cancer cell proliferation (Qiao et al. (1995) Biochim. Biophys. Acta 1258, 215-223), these findings indicate that arachidonic acid products synthesized via at least three different pathways (cyclooxygenase, lipoxygenase, P-450) may not be able to modulate the growth of colon cancer, and suggest a potential role in human colon carcinogenesis for LTB4 and 12(R)-HETE.

Selected eicosanoids increase the proliferation rate of human colon carcinoma cell lines and mouse colonocytes in vivo

Eicosanoids have been implicated in colon carcinogenesis, but their role remains unclear. The levels of PGE2 are elevated in colon cancer tissues and in blood draining colon tumors. The effect of eicosanoids on the proliferation of colonic cells is unknown. We studied the effect of several prostaglandins (PGs) and leukotriene (LT)B4 on the proliferation rate of the human colon adenocarcinoma cell lines SW1116 and HT-29 and of 16,16-dimethyl PGE2 (dmPGE2) on the colon of BALB/c mice. PGs E2, F2 alpha, I2, the methyl ester of PGE2, dmPGE2, and LTB4 (10(-10), 10(-8), 10(-6) M), administered for up to 72 h, stimulated cell proliferation in SW1116 cells and all but PGF2 alpha and PGI2 stimulated proliferation in HT-29 cells. The proliferative effect was time- and concentration-dependent. However, in SW1116 cells the response to PGs was 'bell-shaped', being maximal at 10(-8) M, with the 10(-10) and 10(-6) M concentrations being less effective. In HT-29 cells, the addition of methyl groups to the PGE2 molecule increased the proliferative effect. None of these eicosanoids affected the distribution of these cells in the cell cycle or their rate of programmed cell death (apoptosis). dmPGE2 stimulated 3.6-fold the proliferation of colonocytes in normal BALB/c mice. This was determined by bivariate flow cytometric analysis of the expression of proliferating cell nuclear antigen (PCNA) in virtually pure populations of mouse colonocytes. dmPGE2 did not alter the cell cycle distribution of these cells. We conclude that several PGs as well as LTB4 stimulate the proliferation of human colon carcinoma cells in vitro, while dmPGE2 has a similar effect on mouse colonocytes in vivo. These findings raise the possibility that eicosanoids may contribute to colonic carcinogenesis by stimulating the proliferation rate of tumor cells in the colon.