Results from Expanded Access Programs: A Review of Academic Literature

BACKGROUND

Although expanded access is an increasingly used pathway for patients to access investigational medicine, little is known on the magnitude and content of published scientific research collected via expanded access.

METHODS

We performed a review of all peer-reviewed expanded access publications between January 1, 2000 and January 1, 2022. We analyzed the publications for drugs, diseases, disease area, patient numbers, time, geographical location, subject, and research methodology (single center/multicenter, international/national, prospective/retrospective). We additionally analyzed endpoints reported in all COVID-19-related expanded access publications.

RESULTS

We screened 3810 articles and included 1231, describing 523 drugs for 354 diseases for 507,481 patients. The number of publications significantly increased over time ([Formula: see text]). Large geographical disparities existed as Europe and the Americas accounted for 87.4% of all publications, whereas Africa only accounted for 0.6%. Oncology and hematology accounted for 53% of all publications. Twenty-nine percent of all expanded access patients (N = 197,187) reported on in 2020 and 2021 were treated in the context of COVID-19.

CONCLUSIONS

By summarizing characteristics of patients, diseases, and research methods described in all scientific literature published on expanded access, we provide a unique dataset for future research. We show that published scientific research on expanded access has surged over the past decades, partly due to COVID-19. However, international collaboration and equity in geographic access remain an issue of concern. Lastly, we stress the need for harmonization of research legislation and guidance on the value of expanded access data within real-world data frameworks to improve equity in patient access and streamline future expanded access research.

Green Synthesis, Characterizations of Zinc Oxide Nanoparticles from Aqueous Leaf Extract of Tridax procumbens Linn. and Assessment of their Anti-Hyperglycemic Activity in Streptozoticin-Induced Diabetic Rats

Herein, zinc oxide nanoparticles (ZnO NPs) were greenly synthesized from Tridax procumbens aqueous leaf extract (TPE) and characterized physically (e.g., Fourier-transform infrared (FTIR) spectroscopy and scanning electron microscopy (SEM)) and biologically (test of their anti-diabetic activity). Anti-diabetic activities of TPE and TPE-derived ZnO NPs have been carried out in a streptozotocin (STZ)—induced diabetic rat model. Diabetes mellitus (DM) was induced with a single intraperitoneal dosage of the glucose analogue STZ (55 mg/Kg) known to be particularly toxic to pancreatic insulin-producing beta-cells. TPE and TPE-derived ZnO NPs were administered orally, once every day for 21 days in diabetic rats, at 100 and 200 mg/Kg, respectively. The standard antidiabetic medication, glibenclamide, was used as a control at a dose of 10 mg/Kg. Various parameters were investigated, including bodyweight (bw) variations, glycemia, lipidaemia, glycated hemoglobin (HbA1c), and histopathological alterations in the rat’s liver and pancreas. The TPE-mediated NPs were small, spherical, stable, and uniform. Compared to TPE and, to a lesser extent, glibenclamide, TPE-derived ZnO NPs lowered blood glucose levels considerably (p < 0.05) and in a dose-dependent manner while preventing body weight loss. Further, positive benefits for both the lipid profile and glycated hemoglobin were also noticed with TPE-derived ZnO NPs. The histopathological assessment revealed that synthesized TPE-derived ZnO NPs are safe, non-toxic, and biocompatible. At 200 mg/Kg/day, TPE-derived ZnO NPs had a more substantial hypoglycemic response than at 100 mg/Kg/day. Thus, in this first reported experimental setting, ZnO NPs biosynthesized from the leaf extract of Tridax procumbens exert more potent anti-diabetic activity than TPE and glibenclamide. We conclude that such a greenly prepared nanomaterial may be a promising alternative or complementary (adjuvant) therapy, at least to the current Indian’s traditional medicine system. Translational findings are prompted in human populations to determine the efficacy of these NPs.

Factors influencing the use of postoperative bilevel positive airway pressure (BiPAP) in patients undergoing adult cardiac surgery: A retrospective cohort study

BAckground and Aims

Respiratory complications are one of the biggest challenges following cardiac surgery, which can lead to hypoxia and acute respiratory failure (ARF). The aim of this study to identify the factors led to BiPAP application for postoperative respiratory complications and its effectiveness as the main outcome measures after cardiac surgery.

Methods

It was a retrospective cohort study with consecutive sampling technique. A total of 335 postcardiac surgery patients medical record was reviewed who were underwent for surgery from November 1, 2018 to November 30, 2019. 265 patients were finalized for the recruitment, five patients were excluded before the final analysis. Data of 260 patients were analyzed for compiling of results.

Results

The mean age was 59 years. 196 (75.4%) patients were males and females were 64 (24.6%). Mean weight was 72 kg and mean body mass index (BMI) 26.67 kg/m²_. BiPAP application was in 38 (14.6%) patients and significantly high in with high BMI, (p < 0.05). There are significant associations of BiPAP application patients with COPD (p < 0.05). Patients with positive fluid balance, cardiac dysfunction, and required inotropic support were significantly associated with BiPAP need (p < 0.05), respectively.

Conclusion

BiPAP is effective to treat ARF and other respiratory complications after adult cardiac surgeries. High BMI, atelectasis, and pneumonia are also the independent factors causing ARF. BiPAP can be a successful tool for preventing the adverse effects of postoperative pulmonary complications after cardiac surgery.

Does Multimodal Therapy Influence Functional Outcome After Total Knee Arthroplasty?

Psychosocial health may influence the outcomes after total knee arthroplasty (TKA). We investigated the hypothesis that multimodal therapy influences the quality of life and function in patients diagnosed with osteoarthritis of the knee joint. Secondly, in patients who then proceed to have TKA post-multimodal therapy, does the response to the multimodal therapy influence the overall functional outcome of surgery? Patients diagnosed with osteoarthritis of the knee were enrolled in the study and prospectively followed-up. A total of 526 patients were enrolled and available for the study. All participants were enrolled for 12 classes of 60-minute duration over 6-weeks. Apart from an exercise program, the class also included physiotherapist-led education and a 'weight management' lecture by a dietitian. In summary, the multimodal therapy program improved the SF-12, OKS, pain scores (visual analogue scale) and WOMAC scores significantly. The multimodal therapy protocol can optimize patients' psychological scores prior to TKA and may enhance ultimate functional outcome.

Robotic technology: current concepts, operative techniques and emerging uses in unicompartmental knee arthroplasty

Unicompartmental knee arthroplasty (UKA) is associated with improved functional outcomes but reduced implant survivorship compared to total knee arthroplasty (TKA).

Surgeon-controlled errors in component positioning are the most common reason for implant failure in UKA, and low UKA case-volume is associated with poor implant survivorship and earlier time to revision surgery.

Robotic UKA is associated with improved accuracy of achieving the planned femoral and tibial component positioning compared to conventional manual UKA.

Robotic UKA has a learning curve of six operative cases for achieving operative times and surgical team comfort levels comparable to conventional manual UKA, but there is no learning curve effect for accuracy of implant positioning or limb alignment.

Robotic UKA is associated with reduced postoperative pain, decreased opiate analgesia requirements, faster inpatient rehabilitation, and earlier time to hospital discharge compared to conventional manual UKA.

Limitations of robotic UKA include high installation costs, additional radiation exposure with image-based systems, and paucity of studies showing any long-term differences in functional outcomes or implant survivorship compared to conventional manual UKA.

Further clinical studies are required to establish how statistical differences in accuracy of implant positioning between conventional manual UKA and robotic UKA translate to long-term differences in functional outcomes, implant survivorship, complications, and cost-effectiveness.

Cite this article: EFORT Open Rev 2020;5:312-318. DOI: 10.1302/2058-5241.5.190089

The effect of anterior cruciate ligament resection on knee biomechanics

AIMS

The objectives of this study were to assess the effect of anterior cruciate ligament (ACL) resection on flexion-extension gaps, mediolateral soft tissue laxity, maximum knee extension, and limb alignment during primary total knee arthroplasty (TKA).

METHODS

This prospective study included 140 patients with symptomatic knee osteoarthritis undergoing primary robotic-arm assisted TKA. All operative procedures were performed by a single surgeon using a standard medial parapatellar approach. Optical motion capture technology with fixed femoral and tibial registration pins was used to assess study outcomes pre- and post-ACL resection with knee extension and 90° knee flexion. This study included 76 males (54.3%) and 64 females (45.7%) with a mean age of 64.1 years (SD 6.8) at time of surgery. Mean preoperative hip-knee-ankle deformity was 6.1° varus (SD 4.6° varus).

RESULTS

ACL resection increased the mean extension gap significantly more than the flexion gap in the medial (mean 1.2 mm (SD 1.0) versus mean 0.2 mm (SD 0.7) respectively; p < 0.001) and lateral (mean 1.1 mm (SD 0.9) versus mean 0.2 mm (SD 0.6) respectively; p < 0.001) compartments. The mean gap differences following ACL resection did not create any significant mediolateral soft tissue laxity in extension (gap difference: mean 0.1 mm (SD 2.4); p = 0.89) or flexion (gap difference: mean 0.2 mm (SD 3.1); p = 0.40). ACL resection did not significantly affect maximum knee extension (change in maximum knee extension = mean 0.2° (SD 0.7°); p = 0.23) or fixed flexion deformity (mean 4.2° (SD 3.2°) pre-ACL release versus mean 3.9° (SD 3.7°) post-ACL release; p = 0.61). ACL resection did not significantly affect overall limb alignment (change in alignment = mean 0.2° valgus (SD 1.0° valgus; p = 0.11).

CONCLUSION

ACL resection creates flexion-extension mismatch by increasing the extension gap more than the flexion gap. However, gap differences following ACL resection do not create any mediolateral soft tissue laxity in extension or flexion. ACL resection does not affect maximum knee extension or overall limb alignment. Cite this article: Bone Joint J 2020;102-B(4):442-448.

The Changing Face of Infection, Diagnosis, and Management in the United Kingdom

Prosthetic joint infection is still a rare but devastating complication following total hip and knee arthroplasty. The incidence of prosthetic joint infection ranges from 2% to 4% in primary procedures as opposed to nearly 20% in revisions. The challenges that arise here include mainly diagnostic uncertainty, management in immunocompromised patients, recurrent infection, infection around a well-fixed implant, and substantial bone loss, and require careful preoperative assessment and well-defined management plans. This article summarizes recent developments in the diagnosis and management of this increasingly prevalent issue specifically focusing on outcomes following debridement, antibiotics, and implants retention and one-stage revision procedures.

Risk factors, diagnosis and management of prosthetic joint infection after total hip arthroplasty

Introduction: Although a relatively rare complication, the incidence and prevalence of prosthetic joint infection (PJI) is certainly rising. This is mainly due to the number of arthroplasties performed each year and our ability to capture more cases. There is currently no consensus in the optimal diagnosis and management of the infected total hip arthroplasty. Various management techniques have been described in literature.Areas covered: We discuss and summarize the literature in diagnosing prosthetic joint infection (PJI) including next-generation sequencing. An in-depth critical analysis of the biomarkers and the novel tests available in the market is reviewed including the evolving nature of the diagnostic criteria for PJI. The key issues in managing infected THA are identified.Expert commentary: The senior authors' expert opinion on diagnostic criteria is discussed. We also stress the importance of tissue/fluid analysis of microbiology and histology being key to diagnosis of PJI. The indications of one-stage versus two-stage revision arthroplasty is examined, including techniques for successful one-stage revision.

Use of preoperative opioids increases duration of hospital stay following elective lower limb arthroplasty. - A snapshot of UK practice

This study is one of the first in the UK where to assess the link between pre-operative opioid use and length of stay or complications. The primary objective was to test our hypothesis; that low dose pre-operative opioids will not lead to an increase in complications and LOS in lower limb arthroplasty patients. 640 records were found and 625 patients were included whom received elective primary or revision surgery. It was found that Pre-operative opioids >12 MED does increase LOS.

Novel Bat Alphacoronaviruses in Southern China Support Chinese Horseshoe Bats as an Important Reservoir for Potential Novel Coronaviruses

While bats are increasingly recognized as a source of coronavirus epidemics, the diversity and emergence potential of bat coronaviruses remains to be fully understood. Among 1779 bat samples collected in China, diverse coronaviruses were detected in 32 samples from five different bat species by RT-PCR. Two novel alphacoronaviruses, Rhinolophus sinicus bat coronavirus HKU32 (Rs-BatCoV HKU32) and Tylonycteris robustula bat coronavirus HKU33 (Tr-BatCoV HKU33), were discovered from Chinese horseshoe bats in Hong Kong and greater bamboo bats in Guizhou Province, respectively. Genome analyses showed that Rs-BatCoV HKU32 is closely related to BatCoV HKU10 and related viruses from diverse bat families, whereas Tr-BatCoV HKU33 is closely related to BtNv-AlphaCoV and similar viruses exclusively from bats of Vespertilionidae family. The close relatedness of Rs-BatCoV HKU32 to BatCoV HKU10 which was also detected in Pomona roundleaf bats from the same country park suggests that these viruses may have the tendency of infecting genetically distant bat populations of close geographical proximity with subsequent genetic divergence. Moreover, the presence of SARSr-CoV ORF7a-like protein in Rs-BatCoV HKU32 suggests a common evolutionary origin of this accessory protein with SARS-CoV, also from Chinese horseshoe bats, an apparent reservoir for coronavirus epidemics. The emergence potential of Rs-BatCoV HKU32 should be explored.

Evaluation of a human in vitro skin test for predicting drug hypersensitivity reactions

The occurrence of drug hypersensitivity reactions (DHRs) following administration of low molecular weight (LMW) drugs is an important health concern. However, in vivo animal models which could be used as tools for the prediction of DHRs are lacking. As a result, research has focused on development of in vitro tools for predicting DHRs. In this study a novel human in vitro pre-clinical skin explant test was used to predict T cell-mediated hypersensitivity responses induced by LMW drugs. Responses in the skin explant test for 12 LMW drugs associated with T cell-mediated hypersensitivity in the clinic (abacavir, amoxicillin, carbamazepine, diclofenac, lamotrigine, lapatinib, lumiracoxib, nevirapine, ofloxacin, phenytoin, propranolol, sulfamethoxazole) were compared with responses for 5 drugs with few/no reports of T cell-mediated hypersensitivity reactions (acetaminophen, cimetidine, flecainide, metformin, verapamil). Changes in skin histology following in vitro exposure to the drugs as well as T cell proliferation and interferon gamma (IFNγ) production were studied. The results of the skin explant assays showed a good positive correlation (r = 0.77, p < .001) between the test outcome (prediction of positive or negative) and the clinical classification of the tested drugs. The T cell proliferation assay showed a correlation of r = 0.60 (p < .01) and the IFNγ assay r = 0.51 (p < .04). The data suggest that the skin explant model could be a useful tool to predict the potential of LMW drugs to induce DHRs.

Redox imbalance correlates with high Nugent score in bacterial vaginosis

AIM

The main goal of this work was to highlight the significance of redox imbalance in the pathophysiology of bacterial vaginosis (BV). We studied the pro-oxidant (malondialdehyde) and antioxidants (glutathione, total antioxidant capacity) in the vaginal fluids of women and compared them on the basis of their Nugent score (NS).

METHODS

Women were clinically screened using Amsel criteria (≥2 were regarded as positive) and were further screened for NS on the basis of microscopic examination. Subjects were classified into one of three groups - healthy controls, intermediate, and BV - on the basis of NS (0-3, 4-6, and 7-10, respectively). High vaginal swabs were collected from the study participants in order to estimate the levels of pro and antioxidants in the vaginal fluids.

RESULTS

Our results indicated that levels of both pro- and antioxidants were elevated in high vaginal swabs of women in the intermediate (NS: 4-6) and BV (NS: 7-10) groups as compared to those of healthy control women. The difference in mean values for total antioxidant capacity and glutathione was found to be statistically significant. Furthermore, in the BV group (NS: ≥7) both antioxidants (glutathione and total antioxidant capacity) and the pro-oxidant, malondialdehyde, were found to be negatively correlated to NS. Interestingly, the correlation between NS and malondialdehyde was statistically significant.

CONCLUSION

Our results suggest a significant correlation between redox imbalance and NS, which signifies changes in vaginal ecology from normal flora (Lactobacillus spp.) towards a more mixed bacterial population representing BV.

Role of 1.5 mm microplates in treatment of symphyseal fracture of mandible: A stress analysis based comparative study

AIMS AND OBJECTIVES

To perform comparative finite element analysis (FEA)for 2.0 mm standard miniplate and 1.5 mm microplate in isolated symphyseal mandibular fractures.

MATERIAL AND METHOD

Two FE models of mandible were developed and symphyseal fracture was created in both of them. Each fractured model was reduced and fixed using two mini plates and two microplates, respectively according Champ's principle. Stresses thus developed in the plates after application of masticatory load were observed in the models.

RESULTS

Results of the study indicated there was no significant difference in the stresses developed in either of the bone plating system.

CONCLUSION

1.5 mm Microplates can be used in place of 2.0 mm miniplates in isolated symphyseal fractures of the mandible.

Visible and Sub-visible Particle Formation for a Model Bioconjugate

The time-course and extent of visible particle (VP) and sub-visible particle (SVP) formation was monitored as a function of interfacial area (IA) for a model bioconjugate. To facilitate particle formation, the bioconjugate was agitated in a glass vial and exposed to IAs up to 478 mm². Since vials had equal fill and headspace volumes, the area of the air-water interface was varied by placing vials on angled blocks at 0°, 30°, 60°, or 90° from the horizontal. A significant increase in visible and sub-visible particle formation was observed with increasing air-water IA. Exposure to IAs below ∼305 mm² resulted in the formation of very few particles, while IAs > ∼305 mm² resulted in substantial particle formation. Visible and sub-visible particle morphology varied with interfacial area and time. The sub-visible particles initially increased with time but did not reach steady state; instead the initial increase was followed by complete depletion. These phenomena indicate that visible particle formation likely increased at the expense of the sub-visible particle population and demonstrate a potential link between the two particle populations for this model bioconjugate. Initiation of particle formation did not result in corresponding decreases in protein concentration or increases in soluble aggregates. However, extended agitation time resulted in a significant decrease in protein concentration.

High Diversity of Genogroup I Picobirnaviruses in Mammals

In a molecular epidemiology study using 791 fecal samples collected from different terrestrial and marine mammals in Hong Kong, genogroup I picobirnaviruses (PBVs) were positive by RT-PCR targeting the partial RdRp gene in specimens from five cattle, six monkeys, 17 horses, nine pigs, one rabbit, one dog, and 12 California sea lions, with 11, 9, 23, 17, 1, 1, and 15 sequence types in the positive specimens from the corresponding animals, respectively. Phylogenetic analysis showed that the PBV sequences from each kind of animal were widely distributed in the whole tree with high diversity, sharing 47.4–89.0% nucleotide identities with other genogroup I PBV strains based on the partial RdRp gene. Nine complete segment 1 (viral loads 1.7 × 10⁴ to 5.9 × 10⁶/ml) and 15 segment 2 (viral loads 4.1 × 10³ to 1.3 × 10⁶/ml) of otarine PBVs from fecal samples serially collected from California sea lions were sequenced. In the two phylogenetic trees constructed using ORF2 and ORF3 of segment 1, the nine segment 1 sequences were clustered into four distinct clades (C1–C4). In the tree constructed using RdRp gene of segment 2, the 15 segment 2 sequences were clustered into nine distinct clades (R1–R9). In four sea lions, PBVs were detected in two different years, with the same segment 1 clade (C3) present in two consecutive years from one sea lion and different clades present in different years from three sea lions. A high diversity of PBVs was observed in a variety of terrestrial and marine mammals. Multiple sequence types with significant differences, representing multiple strains of PBV, were present in the majority of PBV-positive samples from different kinds of animals.

Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage

The reconstruction of a full-thickness defect of the distal third of the nose requires the restoration of all three anatomical layers. A practical method for three-layer reconstruction of the lower third of the nose and the long-term results of this technique are presented herein. A combined reconstruction technique was utilized, including a reverse subcutaneous pedicled nasolabial flap to restore the nasal mucosa, an auricular cartilage graft for structural support, and a forehead flap for cutaneous coverage of the defect. This technique was applied in 21 patients following the full-thickness excision of basal cell carcinoma of the lower part of the nose. All patients (12 male and nine female; mean age 59.8 years) were treated successfully and were satisfied with the aesthetic and functional outcomes. The wound had to be further revised in three cases for the correction of contour or residual deformities; however, no further complications were experienced. One patient had a wound infection and the cartilage had to be removed. The grafting procedure was repeated successfully after resolution of the infection. Donor site morbidity was unremarkable. Combined flaps from the forehead and nasolabial regions with an incorporated auricular cartilage graft can be used to reconstruct full-thickness defects of the lower third of the nose.

Ease of insertion of the laryngeal mask airway in pediatric surgical patients: Predictors of failure and outcome

BACKGROUND

Laryngeal mask airway (LMA) is an useful alternative to endotracheal tube for airway management. The risk of life-threatening adverse respiratory events during its use is rare, but we need to know about the risk-adjusted prediction of its insertion failure requiring rescue tracheal intubation and its impact on patient outcome.

MATERIALS AND METHODS

Five hundred patients; 6 months to 12-year-old, American Society of Anesthesiologists I and II scheduled to undergo elective surgical procedures that require general anesthesia were included in this study. LMA was inserted after induction of anesthesia. The insertion conditions, intra, and postoperative events were recorded. Our primary outcome variable was trial success from the first time.

RESULTS

We recorded 426 cases (85.2%) of first trial success with clear airway compared to 46 case (9.2%) of second trial success (P ≤ 0.001). Predictors of failure of first attempt of LMA insertion include abnormal airway anatomy (91%), body weight <16 kg and age below 5 years (44%), the use of LMA size of 1 and 1.5 (3.8%), the intraoperative lateral position (3.8%).

CONCLUSION

The data obtained from this study support the use of the LMA as a reliable pediatric supraglottic airway device, demonstrating relatively low failure rates. Predictors of LMA failure in the pediatric surgical population should be independently considered.

TRIAL REGISTRATION

The study is registered in the Australian and New Zealand clinical trial registry with the allocated trial number: ACTRN12614000994684. Web address of trial: http://www.ANZCTR.org.au/A CTRN12614000994684.aspx.

Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (bla OXA-23-like, bla OXA-24-like, bla OXA-51-like, and bla OXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The bla OXA-51-like gene was present in all 112 isolates, 75 (67 %) carried bla OXA-23-like, 7 (6.2 %) carried bla OXA-58-like genes, and 5 (4.5 %) carried bla OXA-24-like genes. With a 90 % similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakır. The bla OXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

An in vitro human skin test for assessing sensitization potential

Sensitization to chemicals resulting in an allergy is an important health issue. The current gold-standard method for identification and characterization of skin-sensitizing chemicals was the mouse local lymph node assay (LLNA). However, for a number of reasons there has been an increasing imperative to develop alternative approaches to hazard identification that do not require the use of animals. Here we describe a human in-vitro skin explant test for identification of sensitization hazards and the assessment of relative skin sensitizing potency. This method measures histological damage in human skin as a readout of the immune response induced by the test material. Using this approach we have measured responses to 44 chemicals including skin sensitizers, pre/pro-haptens, respiratory sensitizers, non-sensitizing chemicals (including skin-irritants) and previously misclassified compounds. Based on comparisons with the LLNA, the skin explant test gave 95% specificity, 95% sensitivity, 95% concordance with a correlation coefficient of 0.9. The same specificity and sensitivity were achieved for comparison of results with published human sensitization data with a correlation coefficient of 0.91. The test also successfully identified nickel sulphate as a human skin sensitizer, which was misclassified as negative in the LLNA. In addition, sensitizers and non-sensitizers identified as positive or negative by the skin explant test have induced high/low T cell proliferation and IFNγ production, respectively. Collectively, the data suggests the human in-vitro skin explant test could provide the basis for a novel approach for characterization of the sensitizing activity as a first step in the risk assessment process.

Forehead flap in maxillofacial surgery: Our experiences

The forehead flap is a commonly used technique to reconstruct the deep and large nasal defects. It can be conveniently performed under local or general anesthesia and provides a very good color and texture matching to the nasal skin, which makes it a suitable graft harvesting site for nasal reconstruction. It has only single disadvantage disadvantagethat it is a two-stage procedure and “finishing” surgeries are needed occasionally for best surgical and cosmetic outcome. In this paper, we describe three different applications of forehead flaps.

Comparative study of detection of bacteremia after different oral surgical procedures

Introduction:

The purpose of this study is to compare the efficiency of culture methods in detecting microorganisms appearing in the bloodstream after various oral surgical procedures and effect of preoperative antibiotics and antiseptic rinses on bacteremia.

Materials and Methods:

The prevalence of bacteremia at various intervals of time (pre- and post-surgical) was studied in three different groups presenting with indications to surgical intervention. Two of the groups were given presurgical prophylaxis (systemic antibiotic and antiseptic rinse) while, in one group, no prophylactic measure was adopted. Blood samples were withdrawn from the subjects at specific pre- and post-surgical time intervals, and microbiological analysis was done. The findings were compared with a control group involving healthy individuals and a group involved in maxillofacial trauma where the breach of oral mucosal integrity was not surgically planned.

Results:

The presence of bacteremia was not observed in all five groups at baseline while postsurgery (30 min, 60 min, and 90 min) in only three groups (preoperative antibiotic, without prophylaxis, and 1% Povidone iodine rinse). At all postsurgery periods (30 min, 60 min and 90 min), the presence of bacteremia was evident highest in without prophylaxis group followed by 1% Povidone iodine rinse and preoperative antibiotic the least.

Response of first-line antibiotic therapy in patients with febrile neutropenia during treatment of hematological disorders

Patients with hematological disorders develop febrile neutropenia (FN); most of these events remain undetermined in origin. We performed a prospective study to determine the microbiological characteristics of infections and their response to the first-line antibiotic therapy in FN. The study was conducted at National Institute of Blood Disease and Bone Marrow Transplant. Two-hundred episodes of FN were assessed for the bacterial growth, antimicrobial susceptibility pattern and response to the first-line treatment of FN. All patients were given Ceftazidime and Amikacin Bosch Pharmaceutical (Pvt. Ltd), as first-line antibiotic in FN. Out of 200 episodes we had 108 clinically and microbiologically documented infections. The isolated frequencies for gram negative and gram positive organisms were n = 52 and 49 (48 and 45 %) respectively. Among gram negative micro-organisms, Escherichia coli (E. coli) was isolated in 15 (28.8 %), Klebsiella pneumonae in 4 (7.6 %) and Pseudomonas aeruginosa in 10 (19.2 %) were in highest frequencies. Methicillin sensitive staphylococci emerged as the frequently isolated gram-positive bacteria. Eight-one episodes (45.3 %) responded to the first-line treatment and death reported in 20 cases (10 %). Our study showed almost equal trend of gram positive and gram negative bacteria isolated from patients suffering from neutropenic fever. Empirical use of Ceftazidime and Amikacin as first-line antibiotics was able to cover the infection only in 45.3 % of episodes suffering from FN.

Metastatic adenocarcinoma of the mandible-a rare entity

Metastasis of the liver and lung malignancies to the jaw bones is very rare and the mandible is the commonest site of involvement. The frequent primary sites for metastasis to jaw bones are breast in females and lungs in males. This is a case report of the metastatic adenocarcinoma of the mandible which originated from liver or lung. Diagnosis of such metastatic lesions is difficult and challenging to identify the primary site.

Study on serum glucose level among smear positive pulmonary tuberculosis patients in Bangladesh

This case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh in cooperation with the Outpatient Department and Medicine Units of Mymensingh Medical College Hospital, Fulbaria Upazilla Health Complex, Mymensingh and some DOTS centers of BRAC, a non-government organization during the period of July 2006 to June 2007. The aim of the study was to explore the status of serum glucose level in smear positive Bangladeshi pulmonary tuberculosis patients. A total of 120 people of different age groups were included in this study. Subjects were divided into two groups - Group I (Control; n=60) - apparently healthy people selected matching by age, sex and socioeconomic status with the cases and Group II (Case; n=60) - people with smear positive pulmonary tuberculosis. Serum glucose (fasting) was estimated by colorimetric principle. Statistical analysis was done by using SPSS windows package. Among the groups, mean±SD of serum glucose (fasting) in Group II (5.91±1.02mmol/L) was significantly higher (p<0.001) than in Group I (4.87±0.57mmol/L). It is evident from the study that serum glucose level significantly increases in smear positive pulmonary tuberculosis patients.

Maintaining and restoring cytoplasmic male sterility systems in pepper (Capsicum annuum L.)

We studied the efficiency of maintaining and restoring cytoplasmic male sterility (CMS) systems in pepper (Capsicum annuum L.). An Rf-linked molecular marker was employed to analyze the interaction between 6 CMS lines (A), 5 maintainers (B), and 6 restorers (C). Sterility was maintained in the matings of lines 201A x 200B, 203A x 200B, 206A x 200B, 200A x 201B, 206A x 201B, 200A x 202B, 200A x 203B, 200A x 206B, and 201A x 206B. All 6 restorers restored the fertility of lines 200A, 202A, 203A, and 204A, except that 213C could not restore the fertility of lines 200A and 204A. However, the 6 restorers had diverse restoring abilities in individual CMS lines. The Rf-linked molecular marker was amplified by PCR in lines 207C, 208C, and 213C. This DNA marker was only found in the F1 hybrids M39, M14, M19, M25, M13, M20, and M22. We conclude that the restorers 208C and 207C can transmit the Rf gene or the Rf-linked marker to F1 hybrids.

Serum calcium level among smear positive pulmonary tuberculosis patients in Bangladesh

This case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh in cooperation with the Outpatient Department and Medicine Units of Mymensingh Medical College Hospital, Fulbaria Upazilla Health Complex, Mymensingh and some DOTS centers of BRAC, a non-government organization during the period of July 2006 to June 2007. The aim of the study was to explore the status of serum calcium level in smear positive Bangladeshi pulmonary tuberculosis patients. A total of 120 people of different age groups were included in this study. Subjects were divided into two groups - Group I (Control; n=60) apparently healthy people selected matching by age, sex and socioeconomic status with the cases and Group II (Case; n=60) people with smear positive pulmonary tuberculosis. Serum calcium was estimated by colorimetric principle. Serum calcium was adjusted by serum albumin concentration. Statistical analysis was done by using SPSS windows package. Among the groups, mean±SD of adjusted serum calcium in Group II (2.41±0.15mmol/L) was significantly higher (p<0.001) than that in Group I (1.85±0.11mmol/L). It is evident from the study that serum calcium level significantly increases in smear positive Bangladeshi pulmonary tuberculosis patients.

The pollen wall and tapetum are altered in the cytoplasmic male sterile line RC₇ of Chinese cabbage (Brassica campestris ssp pekinensis)

Cytoplasmic male sterile line RC(7) of Chinese cabbage produces mature anthers without pollen. To understand the mechanisms involved, we examined the ultrastructural changes during development of the microspores. Development of microspores was not affected at the early tetrad stage. During the ring-vacuolated period, some large vacuoles appeared in the tapetum cells, making them larger, extending to the anther sac center during the monocyte period. At the same time, the tapetum degenerated as the microspores aborted, resulting in pollen-deficient anthers. As a result, the locules collapsed and the anthers shriveled. The callose was degraded in the pollen walls; abnormal deposits of electrodense material gave rise to irregular spike-shaped structures, rather than the characteristic rod-like shape of the B7 bacula. The internal intine wall of RC(7) was thinner than that of the B7 type. At the mitosis I microspore stage, the tapetum cells contained multiple plastids, with numerous small spherical plastoglobuli, and lipid bodies. Based on these observations, we suggest that RC(7) abortion may be due to mutated genes that normally regulate development of the pollen wall and cell walls in the RC(7) line.

Exogenous abscisic acid increases antioxidant enzymes and related gene expression in pepper (Capsicum annuum) leaves subjected to chilling stress

To elucidate how physiological and biochemical mechanisms of chilling stress are regulated by abscisic acid (ABA) pretreatment, pepper variety (cv. 'P70') seedlings were pretreated with 0.57 mM ABA for 72 h and then subjected to chilling stress at 10°/6°C (day/night). Chilling stress caused severe necrotic lesions on the leaves and increased malondialdehyde and H(2)O(2) levels. Activities of monodehydroascorbate reductase (DHAR), dehydroascorbate reductase, glutathione reductase, guaiacol peroxidase, ascorbate peroxidase, ascorbate, and glutathione increased due to chilling stress during the 72 h, while superoxide dismutase and catalase activities decreased during 24 h, suggesting that chilling stress activates the AsA-GSH cycle under catalase deactivation in pepper leaves. ABA pretreatment induced significant increases in the above-mentioned enzyme activities and progressive decreases in ascorbate and glutathione levels. On the other hand, ABA-pretreated seedlings under chilling stress increased superoxide dismutase and guaiacol peroxidase activities and lowered concentrations of other antioxidants compared with untreated chilling-stressed plants. These seedlings showed concomitant decreases in foliage damage symptoms, and levels of malondialdehyde and H(2)O(2). Induction of Mn-SOD and POD was observed in chilling-stressed plants treated with ABA. The expression of DHAR1 and DHAR2 was altered by chilling stress, but it was higher in the presence than in the absence of ABA at 24 h. Overall, the results indicate that exogenous application of ABA increases tolerance of plants to chilling-induced oxidative damage, mainly by enhancing superoxide dismutase and guaiacol peroxidase activities and related gene expression.

Pseudomyxoma peritonei - a case report

Pseudomyxoma peritonei (PMP) is rare in our clinical practice. The patient was a lady of 45 years admitted at the department of Obstetrics & Gynaecology in Sir Salimullah Medical College & Mitford Hospital (SSMC & MH) Dhaka with the complaints of swelling of the abdomen for 3 months associated with pain in the same region and weight loss. On examination a large swelling was palpated occupying the umbilical, hypogastric, both iliac, and part of both lumber regions. It was cystic, mildly tender, and immobile with ill defined margins. Computer tomography (CT) showed a cystic mass in the pelvic cavity extending upto the mid abdomen. Huge ascites was also noted. CT guided FNAC showed benign mucinous cystadenoma. Laparotomy was done which showed that the peritoneal cavity was filled up with mucinous material and there was a tumor in the right ovary which was free from adhesion. Left ovary and uterus were atrophic. Hysterectomy with bilateral salpingoophorectomy was done. Abdomen was cleared from the mucinous material as far as possible. Her postoperative recovery was uneventful. Histopathology report showed borderline mucinous cystadenoma of the ovary. She was referred to the oncology department. No chemotherapy was given but kept under follow-up.

Repeatedly pairing vagus nerve stimulation with a movement reorganizes primary motor cortex

Although sensory and motor systems support different functions, both systems exhibit experience-dependent cortical plasticity under similar conditions. If mechanisms regulating cortical plasticity are common to sensory and motor cortices, then methods generating plasticity in sensory cortex should be effective in motor cortex. Repeatedly pairing a tone with a brief period of vagus nerve stimulation (VNS) increases the proportion of primary auditory cortex responding to the paired tone (Engineer ND, Riley JR, Seale JD, Vrana WA, Shetake J, Sudanagunta SP, Borland MS, Kilgard MP. 2011. Reversing pathological neural activity using targeted plasticity. Nature. 470:101-104). In this study, we predicted that repeatedly pairing VNS with a specific movement would result in an increased representation of that movement in primary motor cortex. To test this hypothesis, we paired VNS with movements of the distal or proximal forelimb in 2 groups of rats. After 5 days of VNS movement pairing, intracranial microstimulation was used to quantify the organization of primary motor cortex. Larger cortical areas were associated with movements paired with VNS. Rats receiving identical motor training without VNS pairing did not exhibit motor cortex map plasticity. These results suggest that pairing VNS with specific events may act as a general method for increasing cortical representations of those events. VNS movement pairing could provide a new approach for treating disorders associated with abnormal movement representations.

Bilateral Transverse Facial Cleft as an Isolated and Asyndromic Deformity

Congenital macrostomia or transverse facial cleft is a rare congenital craniofacial anomaly, which affects the esthetics and functions of oral cavity. It is usually associated with deformities of other structures developed from the first and second branchial arches. Bilateral transverse cleft, occurring alone is uncommon. Since the deformity is rare, its treatment has not been commonly described in the literature. We report a case of congenital bilateral macrostomia as an isolated, asyndromic deformity to add one more case in the literature and surgical technique has been discussed here.

Prevention and management of antineoplastic therapy induced oral mucositis

With the scientific advancements in the management of malignant diseases, the treatment is expensive and bears high morbidity in term of oral mucositis. It is a debilitating condition and has been researched extensively for its pathogenesis and treatment. Various treatment options include barrier forming, mucosal protectants, mouth rinses, growth factors, lasers and midline-sparing procedures. Some agents are used locally while others are administered systemically. Despite the availability of a wide range of treatment options for mucositis, a cost-effective treatment is yet to be evolved.

Congenital giant melanocytic nevi

Nevi are common skin tumors caused by abnormal overgrowth of cells from the epidermal and dermal layers of the skin. Most nevi are benign, but some pre-cancerous nevi must be monitored or removed. The giant congenital nevus is greater than 10 cm in size, pigmented and often hairy. Between 4% and 6% of these lesions will develop into a malignant melanoma. Since approximately 50% of the melanoma develop by the age of two, and 80% by the age of seven, early removal is recommended. The objective of this paper is to present a unique case of giant nevi and their surgical management.

Fixed drug eruptions due to cotrimoxazole

This prospective study on Fixed Drug Eruption (FDE) was carried out between January 2003 to December 2006 in Dermatology department of Mymensingh Medical College Hospital & private chambers. This study was carried out with an objective to see the specific site of involvement and other clinical parameters in FDE due to cotrimoxazole. In each case, a detailed history was taken and a thorough physical examination was done by at least one dermatologist. Patients with suspected FDE, who had consented, were included in the study. Oral re-challenge test was done in each case after written or verbal consent of the patient or legal guardian. For oral re-challenge, usually half of the usual therapeutic dose of the suspected drug (s) was given first and reactions were observed and if no reaction, then full therapeutic dose was given and then again reactions were observed. In case of no reaction to one drug, the next drug was tested after 2 to 7 days. Age & sex distribution, number of attacks of FDE, number of lesions, distribution of sites of involvement were determined in each case of FDE. All informations were recorded in pre-tested data sheet. Among 93 patients of suspected FDE, 61 patients were confirmed as FDE with identified causes, of which 36 cases were due to cotrimoxazole (59.02%). Age range of patients was from 5 years to 65 years with mean of 24.92 years. Male was predominantly affected (M:F=6.2:1). In 50% cases presenting attack was the 2nd attack. Rest 50% had 3 to more than 10 attacks. Number of lesions was: 2-5 lesions in 50%, solitary lesion in 16.67%, 6-10 lesions in 13.89% and more than 10 lesions in 19.44% cases. Sites of involvement in cases of FDE due to cotrimoxazole (n=36) were as follows: lips 58.33%, genitalia 33.33%, oral 13.89%, trunk 38.89%, limbs 55.56%, hands 16.67%, feet 19.44%, face 19.44% and conjunctiva 2.78%.

Delayed replantation of avulsed teeth

Dental injuries are very common and their extent has been classified by Ellis. Avulsion of tooth is a grievous injury and ranges from 1-16% among the traumatic injuries, of which maxillary anterior are commonest. Reimplantation of avulsed teeth is a standard procedure. However, it has certain limitations. Most often their management is very challenging. In this case report we are presenting the management of maxillary incisors by replantation after 36 hrs in a 12 year old girl.

Unusual manifestation of a concurrent demodectic and sarcoptic mange in a Zebu-Friesian cross-bred heifer

We describe a rare case of a concurrent demodectic and sarcoptic mange in a 2-year-old heifer in Khartoum, Sudan. The lesions were massive lumps of granulomatous tumour-like dermatitis with thick, nodular folds mainly covering the head, neck and shoulders. Histopathological examination of the lesions revealed the presence of both Demodex bovis and Sarcoptes scabiei. The animal died regardless of the anti-parasitic treatment it received.

Behavioral effects of acute and chronic triazolam treatments in albino rats

Previous behavioral studies on triazolam (TZ), which are small in number, could only speculate about tolerance to the anxiolytic effect of TZ, as the experiments did not cover sufficient time (of 4 to 7 days) for tolerance to develop. Therefore longer time for chronic TZ administration is used. We investigated the effects of TZ on motor activity and exploratory behavior using plus maze and open field. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of TZ (0.25 mg/kg-4.0 mg/kg). In the second set of experiments, rats were treated chronically with a single daily dose of TZ (started with 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks (representing clinical use). In the third, rats were treated chronically with three daily doses of TZ (started with 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days (mimicking drug abuse). Acute TZ administration produced dose dependent anxiolytic effects and a decrease in motor activity with higher doses. Chronically treated rats, either once daily or three times daily doses, showed tolerance to both anxiolytic and sedative effects of TZ. It may be concluded that tolerance to the anxiolytic and sedative effects of TZ would develop after chronic administration either with clinical use or its abuse.

Effect of nifedipine on alprazolam - induced anxiolysis and brain GABA level changes in albino rats

OBJECTIVE

The present study investigates the effects of alprazolam (ALP) and nifedipine alone or in combination on behavior and on g-aminobutyric acid (GABA) levels, in discrete brain regions of albino rats.

METHODS

The anxiolytic effect was studied using a plus maze model and brain levels of GABA were measured using high performance liquid chromatography. Four acute treatment groups of rats were used. In the first they were treated with 1% Tween 80 (1ml/kg), in the second with nifedipine (10mg/kg), in the third with ALP (2mg/kg) and in the fourth with ALP in addition to nifedipine in the respective doses. The work was carried out at the Faculty of Pharmacy of Al-Fateh University, Tripoli, Libya in the first half of 2002.

RESULTS

The results indicate that the anxiolytic effect of ALP was not modified by nifedipine. Nifedipine by itself significantly decreased the motor activity (decrease in total lines crossed), this effect was apparently antagonized by ALP. Alprazolam administration produced an increase of GABA levels in cerebellum and striatum and a decrease in the brain stem. Nifedipine per-se had no effect on GABA levels in the brain stem but it partially antagonized ALP-induced inhibitory effect on GABA in this region. Alprazolam significantly increased GABA levels in the striatum, while nifedipine alone had no effect on neurotransmitter levels and did not modify the ALP effect in this brain region. Alprazolam or nifedipine had no significant effect on GABA levels in midbrain, cerebral cortex and whole brain. There were no significant changes in GABA levels in midbrain and whole brain with drug combination. However, the combination decreased GABA levels significantly in the cerebral cortex.

CONCLUSION

It may be concluded that, the anxiolytic effect of ALP possibly occurs through changes in brain GABA levels (an increase in cerebellum and striatum with a decrease in brain stem). The effect was not modified by nifedipine which per se had no affect on GABA levels in any brain area. The significant decrease in GABA levels in cerebral cortex by ALP-nifedipine combination may be due to the mutual closure of calcium channel (mentioned in literature) resulting in inhibition of the EAA-ergic input to GABA-ergic neuron.

Brain glycine levels in triazolam-treated albino rats

The present study investigates the effects of acute and chronic administration of triazolam in albino rats on glycine levels in different brain areas. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of triazolam (0.25 mg/kg-4.0 mg/kg i.p.). In the second experiment, rats were treated chronically by a single daily dose of triazolam (started by 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks, simulating clinical use. In the third, rats were treated chronically three daily doses of triazolam (started by 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days, simulating a form of drug abuse. Brain levels of glycine and plasma levels of triazolam were measured using HPLC technique. The acute triazolam administration produced an increase in glycine levels in almost all brain areas studied. The chronic administration of single daily dose of triazolam produced normal glycine levels in most of the brain areas; this indicates the development of tolerance to glycine content increasing action of triazolam. The chronic administration of three daily doses of triazolam produced a decrease in glycine levels in almost all brain regions studied, which might be a prerequisite for oncoming withdrawal syndrome.

Evolution of hepatitis B virus polymerase gene sequence during famciclovir therapy for chronic hepatitis B

Prolonged administration of nucleoside analogues for chronic hepatitis B may result in the emergence of hepatitis B viral polymerase mutants. To gain insight into the mechanism involved in the virus's resistance to famciclovir, the amino acid sequences of the terminal protein and reverse-transcriptase (RT) domains of the viral polymerase were determined during therapy among 28 patients. The antiviral response was independent of viral genotypes, and nonresponse to famciclovir was associated with a complex variability of the RT domain. No mutation in the YMDD motif was observed, whereas an L528M mutation was clearly selected by famciclovir treatment in 2 patients, as well as 14 novel mutations in 7 patients. Clone sequence analysis of the RT domains of patients undergoing retreatment with famciclovir and/or lamivudine showed the selection of a preexisting drug-resistant mutant in one case and indicated that sequential antiviral therapy may allow the rapid selection of resistant strains.