Medico-Legal Implications of Video Recordings of Clinic Visits in Malpractice Claims Against Medical Providers

OBJECTIVE

Although audio-video recordings of clinic visits improve patient satisfaction and recall, the associated presumed risk of increased malpractice claims limits their use. In this study, we identified whether video recording clinic visits was associated with increases in professional liability claims.

METHODS

From 2015 to 2017, the institution's loss run was analyzed, and the rates of medical malpractice claims per physician-year were compared between physicians who used video recordings of clinic visits (V-RoCs) and those who did not. The term "users" was applied to all physicians whose mean percentage of patient visits with video recording was greater than the mean percentage for the practice overall.

RESULTS

Over three years, 15,254 patients used V-RoCs. The use of video recordings for clinic visits increased at a rate of 23% per year. No association was found between video recordings and increased malpractice claims. The rate of all claims between users and nonusers did not differ significantly (P=0.66). Of seven paid claims or lawsuits from 2000 to 2017, none were against physicians who used video recordings.

CONCLUSION

Video recording of patient-physician encounters was not associated with an increase in malpractice lawsuits. According to federal law, a patient can legally record a clinic encounter without physician consent, which has many ethical implications. Formalizing the recording process is beneficial for both parties and allows the resource to be used to its maximum potential.

Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery

OBJECTIVE

The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression.

METHODS

A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS).

RESULTS

Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months.

CONCLUSIONS

With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Redundant nerve roots indicate higher degree of stenosis in lumbar spine stenotic patients

OBJECTIVES

Redundant Nerve Root (RNR) is a tortuous and elongated radiological appearance of cauda equina on Magnetic Resonance Imaging (MRI) in Lumbar Spinal Canal Stenosis (LSCS) patients. This study evaluated preoperative spinal morphometry associated with the development of RNR.

METHODS

The retrospective cohort was conducted at The Aga Khan University Hospital, and included patients undergoing decompressive spinal surgery secondary to degenerative LSCS in 2015. The patients were divided into two groups with respect to the presence of preoperative RNR. Spinal morphometry was defined by several radiological parameters, including areas of dural sac (DSA), spinal canal, spinal foramen, facets, and spinal joints, and bilateral angles based on vertebral anatomy.

RESULTS

A total of 55 patients were enrolled with a mean age of 57.1 years, in which 22 (40%) expressed RNR in their MRI. The RNR group had significantly lower mean DSA (59.64 vs 84.01 mm2; p = 0.028), bilateral posterior facet angle (Right: 33.84 vs 46.21, p = 0.004; Left: 36.43 vs 43.80, p = 0.039) and higher bilateral anterior facet angles (Right: 54.85 vs 44.57, p = 0.026; Left: 55.27 vs 46.36, p = 0.050) compared to the non-RNR group. The other bidimensional and angular parameters did not observe any statistical difference between the two groups.

CONCLUSION

RNR was associated with a higher degree of stenosis in patients with LSCS. Bilateral anterior and posterior facets angles contribute to its development, indicating particular spinal morphology to be vulnerable to the stenotic disease.

Opportunities and constraints for cleaner production policy in the developing world: a case study of Sindh Region, Pakistan

The current industrial and economic activities in Sindh Province, Pakistan, polluted the region's water, air, soil, and marine resources. However, there is a rising demand for eco-friendly production, and it is important to develop new policies and tools to combat environmental degradation and enhance economic development. Cleaner Production (CP) provides opportunities to address many of these issues. Employed method for this study was based on three approaches: a literature review and stakeholder mapping; a collection of data and information from key stakeholders through focal group discussions, consultative workshops, and one-on-one meetings; and analysis and synthesis of data that were gathered from different sources. The analysis of collected information provides an overview of CP strategies moving forward. Participant workshops gave in-depth information on policy implementation, technological impediments to methods that have been employed elsewhere, and needed capacity building as well as financial consequences of policy implementation. Through increasing financial resources and institutional resources, the expansion of CP will help to replace the conventional methods of waste treatment with an eco-efficiency approach to preventing pollution at the source, thus reducing the need for expensive pollution control and management costs for environmental compliance. Experiences, achievements, and implementation pitfalls from this study can provide a lesson to other developing countries to improve their economic and environmental sustainability.

Profile: Maternal and Child Health Surveillance System in peri-urban areas of Karachi, Pakistan

A Maternal and Child Health Surveillance System (MCHSS) was set up by the department of pediatrics and child health, Aga Khan University, Pakistan in peri-urban areas of Karachi to provide a platform for various research projects. It was established in five low-socioeconomic communities in a stepwise manner between  2003 and 2014. The total area currently under surveillance is 18.6 km2 covering a population of 302,944. We maintain a record of all births, deaths, pregnancies, and migration events by two monthly household visits. Verbal autopsies for stillbirths, deaths of children under the age of five years and adult female deaths are also conducted. For over a decade, the MCHSS has been a platform for a variety of studies describing the burden of various infectious diseases like typhoid, pneumonia and diarrhea, evaluation of effectiveness of various treatment regimens for neonatal sepsis, assessment of the acceptance of hospitalized care, determination of the etiology of moderate to severe diarrhea, assessment of burden and etiology of neonatal sepsis and a multi-center cohort study measuring the burden of stillbirths, neonatal and maternal deaths. More recently we have also established a bio-repository of the well-characterized maternal and newborn cohort. Through a well-established MCHSS, we aim to provide concrete evidence base to guide policy makers to make informed decisions at local, national, and international levels.

Effect of Rumex dentatus on Gastrointestinal Protection and Toxicology in Rodents via Investigating H+/K+-ATPase, Calcium Channels, and PDE Mediated Signaling

This present study aims to delineate Rumex dentatus crude extract (Rd.Cr), n-Hexane, ethyl acetate, aqueous fractions (Rd.n-Hex, Rd.ETAC, and Rd.Aq), and emodin for antidiarrheal, antisecretory effects, anti-spasmodic, gastrointestinal transient time, anti-H. pylori, antiulcer effects, and toxicology. Plant extracts attributed dose-dependent protection against castor oil-induced diarrhea and dose-dependently inhibited intestinal fluid secretions in mice. They decreased the distance transverse by charcoal in the gastrointestinal transit model in rats. In rabbit jejunum preparations, it causes a concentration-dependent relaxation of both spontaneous and K⁺ (80 mM)-induced contraction, Rd.n-Hex and verapamil were relatively potent against K⁺-induced contractions and shifted the Ca²⁺ concentration-response curves (CRCs) to the right, Rd.Cr and Rd.ETAC shifted the isoprenaline-induced inhibitory CRCs to the left, showing potentiating effect similar to papaverine. Rd.n-Hex showed anti-H. pylori effect. Extracts and emodin also show an inhibitory effect against H⁺/K⁺-ATPase. Rumex dentatus showed a gastroprotective and antioxidant effect. Histopathological evaluation showed improvement in cellular architecture and decrease in the expression of inflammatory markers such as cyclooxygenase (COX2), tumor necrosis factor (TNF-α), and phosphorylated nuclear factor kappa B (p-NFƙB), validated through immunohistochemistry, ELISA, and western blot techniques. In RT-PCR, it decreases H⁺/K⁺-ATPase mRNA levels. Rumex dentatus was analyzed for certain safety aspects and exhibited a relative safety profile as no impairment was observed in kidneys, heart, liver, and brain further assisted by biochemical and hematological analysis. Docking studies revealed that emodin against H⁺/K⁺-ATPase pump and voltage gated L-type calcium channel showed E-value of −7.9 and −7.4 kcal/mol, respectively. MD simulations and molecular mechanics Poisson Boltzmann surface area and molecular mechanics Generalized Born surface area MMPBSA/GBSA findings are consistent with the in-vitro, in-vivo, and docking results. In conclusion, Rumex dentatus extracts and its phytoconstituent could be considered a potent antioxidant and anti-inflammatory drug candidates that possess anti-diarrheal, anti-secretary, antispasmodic, anti-H. pylori, and anti-ulcer potential. Toxicity studies were done according to OECD standards 425. It belongs to group 5 (LD50 > 2000 mg/kg), which suggests that it is in the lower toxicity class.

Phytochemical and GCMS approaches to identify active constituents in Erythrina suberosa bark extract and evaluation of its therapeutic potency

Humans rely on plants as a necessitous source of their food, energy, cosmetics and medicines, as medicinal plants are rich source of new therapeutically active compounds from decades. Current study was designed to separate and identify active constituents of Erythrina suberosa bark extract using phytochemical screening and gas chromatography and mass spectroscopy, respectively and evaluated their therapeutic activities. E. suberosa bark extract contained saponins, glycosides, alkaloids, tannins, terpenoids, phenols and 44 active compounds identified by phytochemical and gas chromatography and mass spectroscopic analysis. Therapeutic potentials of E. suberosa bark extract was evaluated by such as cytotoxicity, anti-inflammatory and antioxidant assay. Surprisingly, bark extract shows the concentration dependent cytotoxicity against human fibroblast malignant melanoma-144 cell lines and remarkably inhibited (15.18(plusmn;1.13%, at 400mg/ml) growth of cancer cells after 24 hours treatment. In addition, the E. suberosa bark extract also exhibited anti-inflammatory effect at higher doses (400mg/kg) and moderate antioxidant activity is also noticed through (2, 2-diphenyl-1-picrylhydrazyl radical) assay. These findings indicate that E. suberosa bark extract exhibited prominent anticancer and anti-inflammatory activities and might be serve as a potent therapeutic agent in future.

Single-position prone lateral transpsoas approach: early experience and outcomes

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach.

METHODS

A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence.

RESULTS

Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3-4 (n = 15), L2-3 (n = 12), and L4-5 (n = 11). L1-2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale-back and leg pain) identified significant improvement.

CONCLUSIONS

This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.

Bergapten Attenuates Nitroglycerin-Induced Migraine Headaches through Inhibition of Oxidative Stress and Inflammatory Mediators

The present study intended to examine the effect of bergapten and possible mechanisms involved in the treatment of migraine-associated symptoms in the rat model. Five doses of nitroglycerin (10 mg/kg) were injected intraperitoneal to induce migraine headaches in rats with a one-day break between each dose. Treatment groups received nitroglycerin followed after 1 day by bergapten (50 or 100 mg/kg), saline (10 mL/kg), or sumatriptan (50 mg/kg) once daily for 10 days. Behavioral observations were analyzed 2 h after nitroglycerin injections and 1 h 40 min after treatment. The animals were sacrificed 24 h after the last treatment dose. Samples of trigeminal nucleus caudalis (TNC) and cerebral cortex were collected and analyzed for antioxidant activity and expression of inflammatory markers by immunohistochemistry and enzyme-linked immunosorbent assay. Our findings revealed that bergapten notably decreases headache by altering mechanical allodynia, thermal allodynia, light phobicity, and the number of head-scratching incidence in rats. In the cortex and TNC regions, antioxidant factors were restored, and lipid peroxidation was significantly reduced. Furthermore, bergapten decreased the expression of inflammatory markers, such as nuclear factor kappa B (NF-Kb) and tumor necrosis factor-alpha (TNF-α), as evidenced by immunohistochemistry and ELISA. These results suggest that bergapten exhibits headache-relieving activity, possibly mediated through antioxidant and anti-inflammatory pathways.

Comparative analysis of the combined petrosal and the pretemporal transcavernous anterior petrosal approach to the petroclival region

OBJECTIVE

The combined petrosal (CP) approach has been traditionally used to resect petroclival meningioma (PCM). The pretemporal transcavernous anterior petrosal (PTAP) approach has emerged as an alternative. A quantitative comparison of both approaches has not been made. This anatomical study compared the surgical corridors afforded by both approaches and identified key elements of the approach selection process.

METHODS

Twelve cadaveric specimens were dissected, and 10 were used for morphometric analysis. Groups A and B (n = 5 in each) underwent the CP and PTAP approaches, respectively. The area of drilled clivus, lengths of cranial nerves (CNs) II-X, length of posterior circulation vessels, surgical area of exposure of the brainstem, and angles of attack anterior and posterior to a common target were measured and compared.

RESULTS

The area of drilled clivus was significantly greater in group A than group B (mean ± SD 88.7 ± 17.1 mm2 vs 48.4 ± 17.9 mm2, p < 0.01). Longer segments of ipsilateral CN IV (52.4 ± 2.33 mm vs 46.5 ± 3.71 mm, p < 0.02), CN IX, and CN X (9.91 ± 3.21 mm vs 0.00 ± 0.00 mm, p < 0.01) were exposed in group A than group B. Shorter portions of CN II (9.31 ± 1.28 mm vs 17.6 ± 6.89 mm, p < 0.02) and V1 (26.9 ± 4.62 mm vs 32.4 ± 1.93 mm, p < 0.03) were exposed in group A than group B. Longer segments of ipsilateral superior cerebellar artery (SCA) were exposed in group A than group B (36.0 ± 4.91 mm vs 25.8 ± 3.55 mm, p < 0.02), but there was less exposure of contralateral SCA (0.00 ± 0.00 mm vs 7.95 ± 3.33 mm, p < 0.01). There was no statistically significant difference between groups with regard to the combined area of the exposed cerebral peduncles and pons (p = 0.75). Although exposure of the medulla was limited, group A had significantly greater exposure of the medulla than group B (p < 0.01). Finally, group A had a smaller anterior angle of attack than group B (24.1° ± 5.62° vs 34.8° ± 7.51°, p < 0.03).

CONCLUSIONS

This is the first study to quantitatively identify the advantages and limitations of the CP and PTAP approaches from an anatomical perspective. Understanding these data will aid in designing maximally effective yet minimally invasive approaches to PCM.

Prone Single-Position Lateral Lumbar Interbody Fusion With Posterior Decompression and Pedicle Screw Fixation for the Treatment of Grade II Spondylolisthesis: 2-Dimensional Operative Video

Lateral lumbar interbody fusion (LLIF) provides indirect decompression without disruption of the posterior elements. It involves a larger implant footprint than that of posterior approaches. LLIF is typically performed with the patient in the lateral decubitus position. When a posterior fixation is indicated, a second-stage procedure is performed with the patient in the prone position. Single-position surgery provides the potential advantage of decreased operative time because both procedures can be performed without patient repositioning. Single-position LLIF and posterior fixation in the prone position have not been well validated to date. Herein, techniques for LLIF, percutaneous pedicle screw fixation, and facetectomy in the prone position are shown. A 76-yr-old woman with osteoporosis presented with severe back and bilateral leg pain refractory to conservative management and imaging findings of grade 2 dynamic anterolisthesis at L4-L5 with severe stenosis. She underwent LLIF with percutaneous pedicle screw fixation and facetectomy. She was placed on a Jackson table in the prone position for the entire procedure, which was performed in a single stage. Percutaneous pedicle screws were placed, followed by a left-sided minimally invasive facetectomy. A left-sided retroperitoneal transpsoas approach was used to perform the LLIF in standard fashion. Finally, the rods were locked into place. Postoperatively, the patient was neurologically stable, and imaging confirmed good hardware placement. At the 6-wk follow-up, the patient was doing well. This case demonstrates the feasibility of performing LLIF and posterior fixation in a single stage in the prone position. The patient provided informed consent. Used with permission from Barrow Neurological Institute.

The Glossopharyngo-Cochlear Triangle-Part I: Quantitative Anatomic Analysis of High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

BACKGROUND

An extended retrosigmoid approach can offer sufficient space for clip reconstruction of some high-riding posterior inferior cerebellar artery (PICA) aneurysms.

OBJECTIVE

To quantitatively investigate the glossopharyngo-cochlear triangle (GCT) and anatomic structures within it.

METHODS

Extended retrosigmoid craniotomies were performed on 10 sides of cadaveric heads, and the GCT was identified in each specimen. The length of the base and the area of the GCT were measured. The depth of the vertebrobasilar system and the abducens nerve to the GCT were measured. The proximal and distal exposable and controllable points on the vertebrobasilar system were identified. Two imaging-based patient selection algorithms are provided using the lengths from those points to the vertebral artery dural entry point and the superoinferior distances from those points to the inferior edge of the foramen magnum. Other factors related to accessibility via the GCT were investigated.

RESULTS

The mean (standard deviation [SD]) area of the GCT was 45.7 (12.55) mm2. The mean (SD) depth of the abducens nerve was 14.3 (1.42) mm. The mean (SD) superoinferior distances from the foramen magnum to those points were 23.1 (7.39), 24.7 (8.25), 30.0 (9.56), and 32.6 (7.79) mm, respectively. The lower segment of the vertebrobasilar system was more superficial in the setting of a high-lying vertebrobasilar junction (VBJ) than a low-lying VBJ.

CONCLUSION

We describe the GCT in an extended retrosigmoid approach for high-riding PICA aneurysms and evaluate the spatial relationship of the neurovascular structures within it. Two potential algorithms are offered for preoperative patient selection.

Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism

Introduction Venous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries. Methods Data were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018. Results We identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery. Conclusions Based on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.

AB0168 BODY MASS INDEX IS ASSOCIATED WITH SIGNIFICANT ECHOCARDIOGRAPHIC ABNORMALITIES IN RHEUMATOID ARTHRITIS

Background:

Overweight/obesity is associated with a high incidence of chronic autoimmune diseases such as rheumatoid arthritis (RA). In RA, obesity represents an increasingly prevalent comorbidity even at its first presentation, with more than 60% of patients with RA classified as overweight or obese by the body mass index (BMI ≥25 kg/m2). On the other hand, RA is related with excess cardiovascular disease (CVD) mortality, which accounts for over 50% of premature deaths in RA. Obesity contributes to the development of inflammation via changes in metabolism and function of adipose tissue and it appears to coexist with other CVD risk factors such as hypertension, insulin resistance and dyslipidemia.

Objectives:

For the first time, this study looks at the effect of the BMI on echocardiography parameters in established RA cases.

Methods:

A cross section study was carried out to recruit patients meeting the 2010 ACR/EULAR criteria during 2019. Standard trans-thoracic echocardiography examination was performed by a specialist cardio-sonographer who was blinded to the status of the participants. The echocardiography parameters studied included left ventricular dimensions, wall geometry, systolic and diastolic parameters, ejection fraction, right ventricular size and function, valve structure and function, aortic root dimensions, pulmonary pressures and pericardium. Anthropometric measurements of BMI were carried out as weight in kilograms divided by the square of height in meters (kg/m2). Data was analysed using the BMI as the explanatory variable and repeating the simple linear regression analysis using the echocardiography parameters as outcome variables. P value of <0.05 was considered significant.

Results:

During the one-year period, 44 RA patients were recruited, of which 91% (40) were female and 4 (9 %) male. The mean (SD) of age was 50±13 years (Min 28, Max 72). The mean (SD) of BMI was 30.887 ± 6.348 Kg/m2 (Min 21, Max 44.38). As per BMI classification of obesity, only 11% patients were found to have normal BMI. Echocardiography revealed that 14% patients had aortic regurgitation, 2% had aortic stenosis, 2% had mitral stenosis, and 7% had tricuspid regurgitation.

Using BMI as an explanatory variable, with echocardiography parameters as outcome variables, it was found that BMI contributed positively in a linear manner to the Interventricular Septal thickness in diastole (mm) (p=0.004, CI: 0.048-0.227), LV End Diastolic Diameter (mm) (p=0.033, CI: 0.033-0.722), LV mass (g) (0.04, CI: 0.022-6.339), Early Diastolic Velocity, E, by PW mitral inflow measurement (cm/s) (p=0.02, CI: 0.150-1.933), E/E’ ratio by Tissue Doppler study (p=0.01, CI: 0.025-0.225), and to Right Ventricle function measured by Tricuspid Annular Plane Systolic Excursion (TAPSE) (mm) (p=0.02, CI: 0.035-0.346).

Conclusion:

Obesity and Inflammation overlap syndrome may interplay to produce various cardiovascular abnormalities. Body Mass Index is shown to be associated with significant echocardiographic abnormalities including left ventricular dimension, diastolic parameters and right ventricular function. In view of the complex interrelation between obesity, rheumatoid arthritis and cardiovascular disease, measuring Body Mass Index might help predict adverse cardiovascular events in rheumatoid arthritis patients.

References:

[1]Body mass index and the risk of rheumatoid arthritis: a systematic review and dose-response meta-analysis. Qin B, Yang M, Fu H, Ma N, Wei T, Tang Q, Hu Z, Liang Y, Yang Z, Zhong R. Arthritis Res Ther. 2015; 17(1): 86. doi: 10.1186/s13075-015-0601-x.

[2]Cardiac eccentric remodeling in patients with rheumatoid arthritis. Pascale V, Finelli R, Giannotti R, Coscioni E, Izzo R, Rozza F, Caputo D, Moscato P, Iaccarino G, Ciccarelli M. Sci Rep. 2018; 8: 5867. doi: 10.1038/s41598-018-24323-0.

Disclosure of Interests:

None declared

Enhanced Accumulation of Cisplatin in Ovarian Cancer Cells from Combination with Wedelolactone and Resulting Inhibition of Multiple Epigenetic Drivers

PURPOSE

Cisplatin resistance is a major concern in ovarian cancer treatment. The aim of this study was to investigate if wedelolactone could perform better in resistant ovarian cancer cells when used in combination with cisplatin.

METHODS

Growth inhibitory potential of wedelolactone and cisplatin was investigated through MTT reduction assay in ovarian cancer cell lines including A2780 (sensitive), A2780cisR (cisplatin resistant) and A2780ZD0473R. Resistance factor (RF) of drugs was determined in these three cell lines. Combination index (CI) was calculated as a measure of combined drug action. Effect of this combination on changes in the cellular accumulation of platinum levels and platinum-DNA binding was also determined in vitro using AutoDock Vina while the effect of wedelolactone on inhibition of possible key culprits of resistance including Chk1, CD73, AT tip60, Nrf2, Brd1, PCAF, IGF1, mTOR1 and HIF2α was investigated in silico.

RESULTS

Cisplatin and wedelolactone showed a dose-dependent growth inhibitory effect. RF value of wedelolactone was 1.1 in the case of A2780cisR showing its potential to bring more cell death in cisplatin-resistant cells. CI values were found to vary showing antagonistic to additive outcomes. Additive effect was observed for all sequences of administration (0/0, 0/4 and 4/0 h) in A2780cisR. Enhanced cellular accumulation of cisplatin was observed in parent and resistant cells on combination. Docking results revealed that among the selected oncotargets, Chk1, CD73, Nrf2, PCAF and AT tip60 were more vulnerable to wedelolactone than their respective standard inhibitors.

CONCLUSION

These findings have shown that additive outcome of drug combination in A2780cisR and raised levels of platinum accumulation followed a clear pattern. This observation indicates that the presence of wedelolactone might have contributed to sensitize A2780cisR. However, in silico results point to the possible effects of this compound on epigenetic factors involving tumor microenvironment, epithelial mesenchymal transition, and immune-checkpoint kinases.

Role of redundant nerve roots in clinical manifestations of lumbar spine stenosis

Background

Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR.

Methods

This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores.

Results

The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups.

Conclusion

RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR.

Enhanced neuroprotective and antidepressant activity of curcumin-loaded nanostructured lipid carriers in lipopolysaccharide-induced depression and anxiety rat model

The present study aims to develop curcumin-loaded nanostructured lipid carriers (CUR-NLCs) and investigate their neuroprotective effects in lipopolysaccharide (LPS)-induced depression and anxiety model. Nanotemplate engineering technique was used to prepare CUR-NLCs with Compritol 888 ATO and oleic acid as solid and liquid lipid, respectively. Poloxamer 188, Tween 80 and Span 80 were used as stabilizing agents for solid-liquid lipid core. The physicochemical parameters of CUR-NLCs were determined followed by in vitro drug release and in vivo neuroprotective activity in rats. The optimized CUR-NLCs demonstrated nanometric particle size of 147.8 nm, surface charge of -32.8 mV and incorporation efficiency of 91.0%. CUR-NLCs showed initial rapid followed by a sustained drug release reaching up to 73% after 24 h. CUR-NLCs significantly elevated struggling time and decreased immobility time in forced swim and tail suspension tests. A substantial increase in time spent and number of entries into the light and open compartments was observed in light-dark box and elevated plus maze models. CUR-NLCs improved the tissue architecture and suppressed the expression of p-NF-κB, TNF-α and COX-2 in brain tissues from histological and immunohistochemical analysis. CUR-NLCs improved the neuroprotective effect of curcumin and can be used as a potential therapeutics for depression and anxiety.

Contribution of Attenuation of TNF-α and NF-κB in the Anti-Epileptic, Anti-Apoptotic and Neuroprotective Potential of Rosa webbiana Fruit and Its Chitosan Encapsulation

Rosa webbiana L. (Rosaceae) is one of the least reported and most understudied members of this family. It is native to the Himalayan regions of Pakistan and Nepal. The anti-convulsant effect of n-hexane extract of fruit of Rosa webbiana was investigated in a pentylenetetrazole (PTZ)-induced animal model of epilepsy. Male Sprague-Dawley rats were divided into six groups (n = 7) including control, PTZ (40 mg/kg), diazepam (4 mg/kg) and n-hexane extract (at 50, 150 and 300 mg/kg). Convulsive behavior was observed and resultant seizures were scored, animals sacrificed and their brains preserved. Chitosan nanoparticles were prepared using the ionic gelation method and characterized by UV-analysis, zeta potential and Fourier transform infrared spectroscopy (FTIR). The effects of all the treatments on the expression of phosphorylated cytokine tumor necrosis factor α (p-TNF-α) and phosphorylated transcription factor nuclear factor kappa B (p-NF-κB) expression in the cortex and hippocampus of the brains of treated rats were studied through enzyme linked immunosorbent assay (ELISA) and morphological differences and surviving neuronal number were recorded through hematoxylene and eosin (H&E) staining. Significant changes in seizures score and survival rate of rats were observed. Downregulation of neuro-inflammation, p-TNF-α and p-NF-κB was evident. Gas Chromatography-Mass Spectrometry (GC-MS) analysis of this fraction showed multiple constituents of interest, including esters, alkanes and amines.

Natural Dietary Supplement, Carvacrol, Alleviates LPS-Induced Oxidative Stress, Neurodegeneration, and Depressive-Like Behaviors via the Nrf2/HO-1 Pathway

PURPOSE

Major depressive disorder (MDD) is a debilitating human health condition characterized by mood swings and is associated with a high probability of suicide attempts. Several studies have reported a role of neuroinflammation in MMD, yet the efficacy of natural drug substances on neuroinflammation-associated depression has not been well-investigated. The present study examined the neuroprotective effects of carvacrol on lipopolysaccharide (LPS)-induced neuroinflammation, depression, and anxiety-like behavior.

METHODS

Male Sprague Dawley rats were divided into two experimental cohorts to determine the effects and the effective dose of carvacrol (whether 20 mg/kg or 50 mg/kg), and further demonstrate the mechanism of action of nuclear factor E2-related factor (Nrf2) in depression.

RESULTS

We found marked neuronal alterations in the cortex and hippocampus of LPS-intoxicated animals that were associated with higher inflammatory cytokine expression such as cyclooxygenase (COX2), tumor necrosis factor-alpha (TNF-α), and c-Jun N-terminal kinase (p-JNK). These detrimental effects exacerbated oxidative stress, as documented by a compromised antioxidant system due to high lipid peroxidase (LPO). Carvacrol (20 mg/kg) significantly reverted these changes by positively modulating the antioxidant gene Nrf2, a master regulator of the downstream antioxidant pathway. To further investigate the role of Nrf2, an inhibitor of Nrf2 called all-trans retinoic acid (ATRA) was used, which further exacerbated LPS toxicity with a higher oxidative and inflammatory cytokine level. To further support our notion, we performed virtual docking of carvacrol with the Nrf2-Keap1 target and the resultant drug-protein interactions validated the in vivo findings.

CONCLUSION

Collectively, our findings suggest that carvacrol (20 mg/kg) could activate the endogenous master antioxidant Nrf2, which further regulates the expression of downstream antioxidants, eventually ameliorating LPS-induced neuroinflammation and neurodegeneration.

Modifications in lumbar facet joint are associated with spondylolisthesis in the degenerative spine diseases: a comparative analysis

BACKGROUND

Magnetic resonance imaging (MRI) is important in the assessment of degenerative spine disease. However, its role is limited in the identification of spinal instability; therefore, weight-bearing and dynamic studies like X-rays are required. The supine position eliminates the gravitational pull, corrects the vertebral slippage, and opens the facet joints leading to the collection of the synovial fluid into the joint space, which is detected on the MRI and can serve as a marker for instability. We aim to compare the facet fluid, facet hypertrophy, facet angle, and disc degenerative changes among the patients presenting with degenerative spondylolisthesis (DS) and those without.

METHODS

We performed a retrospective review for all the patients treated at our institution from January 2015 to December 2016. Facet Fluid Index (FFI) (ratio of facet fluid width and facet joint width) was calculated to assess the joint fluid. The percentage of spondylolisthesis was measured on X-rays. Each radiological parameter was compared between the two groups, i.e., patients with DS and patients without DS. A p value < 0.05 was considered significant.

RESULTS

In total, 61 patients, 28 with DS and 33 without DS, were enrolled. Baseline characteristics were similar in the two groups (p > 0.05). The average values of FFI, facet fluid width, and the difference between the superior and inferior facet were significantly higher in the group with instability (p < 0.05). Multivariate analysis demonstrated a 4.44 (95% confidence interval [CI] 2.03-5.365) times increase in the odds of instability with a unit increase in FFI, p < 0.0001.

CONCLUSIONS

We report a positive linear correlation between the facet joint effusion and facet hypertrophy on MRI and the percentage of vertebral translation on X-ray. Prospective studies will determine if these markers can play a role in predicting spinal instability.

Benzimidazole Derivative Ameliorates Opioid-Mediated Tolerance during Anticancer- Induced Neuropathic Pain in Mice

BACKGROUND

Cancer is known to be the second significant cause of death worldwide. Chemotherapeutic agents such as platinum-based compounds are frequently used single-handedly or accompanied by additional chemotherapies to treat cancer patients. Chemotherapy-induced peripheral painful neuropathy is seen in around 40% of patients who are treated with platinum-based compounds, including cisplatin. This not only decreases the quality of life of patients but also patients' compliance with cisplatin.

OBJECTIVES

Nalbuphine, an opioid, is frequently used to treat acute and chronic pain, coupled with cisplatin in cancer patients. However, long term use of nalbuphine induces tolerance to its analgesic effects. We employed the same strategy to induce tolerance in mice.

METHODS

Here, we investigated analgesic effects of 2-[(pyrrolidin-1-yl) methyl]-1H-benzimidazole (BNZ), a benzimidazole derivative, on nalbuphine-induced tolerance during cisplatin-induced neuropathic pain using hot plate test, tail-flick tests and von Frey filament in mouse models. Furthermore, we investigated the effects of BNZ on the expression of Tumor Necrosis Factor-alpha (TNF-α) in the spinal cord.

RESULTS

The results showed that BNZ reduced tolerance to analgesic effects of nalbuphine and TNF-α expression in mice.

CONCLUSION

BNZ could be a potential drug candidate for the management of nalbuphine-induced tolerance in cisplatin-induced neuropathic pain.

Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers

BACKGROUND

The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA.

METHODS

After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique.

RESULTS

In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively.

CONCLUSIONS

This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.

An association between exposure to Middle East Respiratory Syndrome (MERS) and mortality rate of Coronavirus Disease 2019 (COVID-19)

OBJECTIVE

Our objective was to find an association between exposure of a population to Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and mortality rate due to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) across different countries worldwide.

MATERIALS AND METHODS

To find the relationship between exposure to MERS-CoV and mortality rate due to SARS-CoV-2, we collected and analyzed data of three possible factors that may have resulted in an exposure of a population to MERS-CoV: (1) the number of Middle East Respiratory Syndrome (MERS) cases reported among 16 countries since 2012; (2) data of MERS-CoV seroprevalence in camels across 23 countries, as working with camels increase risk of exposure to MERS-CoV; (3) data of travel history of people from 51 countries to Saudi Arabia was collected on the assumption that travel to a country where MERS is endemic, such as, Saudi Arabia, could also lead to exposure to MERS-CoV.

RESULTS

We found a significantly lower number of Coronavirus disease 2019 (COVID-19) deaths per million (deaths/M) of a population in countries that are likely to be exposed to MERS-CoV than otherwise (t-stat=3.686, p<0.01). In addition, the number of COVID-19 deaths/M of a population was significantly lower in countries that reported a higher seroprevalence of MERS-CoV in camels than otherwise (t-stat=4.5077, p<0.01). Regression analysis showed that increased travelling history to Saudi Arabia is likely to be associated with a lower mortality rate due to COVID-19.

CONCLUSIONS

This study provides empirical evidence that a population that was at an increased risk of exposure to MERS-CoV had a significantly lower mortality rate due to SARS-CoV-2, which might be due to cross-protective immunity against SARS-CoV-2 in that population because of an earlier exposure to MERS-CoV.

Contralateral interoptic approach to paraclinoid aneurysms: a patient-selection algorithm based on anatomical investigation and clinical validation

OBJECTIVE

Aneurysms that arise on the medial surface of the paraclinoid segment of the internal carotid artery (ICA) are surgically challenging. The contralateral interoptic trajectory, which uses the space between the optic nerves, can partially expose the medial surface of the paraclinoid ICA. In this study, the authors quantitatively measure the area of the medial ICA accessible through the interoptic triangle and propose a potential patient-selection algorithm that is based on preoperative measurements on angiographic imaging.

METHODS

The contralateral interoptic trajectory was studied on 10 sides of 5 cadaveric heads, through which the medial paraclinoid ICA was identified. The falciform ligament medial to the contralateral optic canal was incised, the contralateral optic nerve was gently elevated, and the medial surface of the paraclinoid ICA was inspected via different viewing angles to obtain maximal exposure. The accessible area on the carotid artery was outlined. The distance from the distal dural ring (DDR) to the proximal and distal borders of this accessible area was measured. The superior and inferior borders were measured using the clockface method relative to a vertical line on the coronal plane. To validate these parameters, preoperative measurements and intraoperative findings were reviewed in 8 clinical cases.

RESULTS

In the sagittal plane, the mean (SD) distances from the DDR to the proximal and distal ends of the accessible area on the paraclinoid ICA were 2.5 (1.52) mm and 8.4 (2.32) mm, respectively. In the coronal plane, the mean (SD) angles of the superior and inferior ends of the accessible area relative to a vertical line were 21.7° (14.84°) and 130.9° (12.75°), respectively. Six (75%) of 8 clinical cases were consistent with the proposed patient-selection algorithm.

CONCLUSIONS

The contralateral interoptic approach is a feasible route to access aneurysms that arise from the medial paraclinoid ICA. An aneurysm can be safely clipped via the contralateral interoptic trajectory if 1) both proximal and distal borders of the aneurysm neck are 2.5-8.4 mm distal to the DDR, and 2) at least one border of the aneurysm neck on the coronal clockface is 21.7°-130.9° medial to the vertical line.

Comparison of Surgical Outcomes and Recurrence Rates of Cystic and Solid Vestibular Schwannomas

Objective  Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design  This is a retrospective review of prospectively collected data. Setting  This study is set at single high-volume neurosurgical institute. Participants  We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures  Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results  Of a total of 112 tumors, 24% ( n  = 27) were CVSs and 76% ( n  = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence ( p  ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis ( p  = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis ( p  ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs ( p  ≥ 0.47). Conclusion  Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience

PURPOSE

Repair of giant paraoesophageal herniae (GPEH) is technically challenging and requires significant experience in advanced foregut surgery. Controversy continues on suture versus mesh cruroplasty with the most recent systematic review and meta-analysis putting the onus on the operating surgeon. Study aim was to review whether the biological prosthesis (non-cross-linked bovine pericardium and porcine dermis) and the technique adopted for patients with GPEH had an influence on clinical and radiological recurrences.

METHOD

A retrospective analysis of a prospectively collected data of 60 consecutive patients with confirmed 5 cm hiatus hernia and ≥ 30% stomach displacement in the thorax that were operated in the upper gastrointestinal unit of a large district general hospital between September 2010 and August 2017. Pre and post-surgery Gastro-Oesophageal Reflux Disease Questionnaire [(GORD-HRQOL)] and a follow up contrast study were completed.

RESULTS

60 included 2 (3%) and 58 (97%) emergency and elective procedures respectively with a male: female ratio of 1:3, age 71* (Median) (42-89) years, BMI 29* (19-42) and 26 (43%) with ASA III/IV. Investigations confirmed 46* (37-88) mm and 42* (34-77) mm transverse and antero-posterior hiatal defect respectively with 60* (30-100)% displacement of stomach into chest. Operative time and length of stay was 180* (120-510) minutes and 2* (1-30) days respectively. One (2%) converted for bleeding and 2 (3%) peri-operative deaths. Five (8%), 5 (8%) and 4 (7%) have dysphagia, symptomatic and radiological recurrences respectively. GORD-HRQOL recorded preoperatively was 27* (10-39) dropping significantly postoperatively to 0* (0-21) (P < 0.005) with 95% patient satisfaction at a follow up of 60* (36-84) months.

CONCLUSIONS

Our technique of laparoscopic GPEH repair with biological prosthesis is safe with a reduced symptomatic and radiological recurrence and an acceptable morbidity and mortality.

Role of stereotactic radiosurgery in the treatment of acromegaly

Acromegaly is a rare, indolent disease due to overproduction of growth hormone. Surgery is identified as primary treatment, but has its limitation, thus frequently requiring alternate treatment options as adjunct to surgery. Stereotactic radiosurgery (SRS) has been used as adjuvant and alternate therapy in patients with inoperable or residual disease; or those not fit for surgery. It has shown reasonable results for treating macroadenoma and tumours invading cavernous sinuses with significant reduction in tumour size and durable endocrinological remission. Factors favouring better outcomes include time from last resection to SRS, older age, peri-procedural withdrawal of medication, higher margin and maximum dose.Hypopituitarism is the most common side effects and requires yearly screening. With the new advances in the field Fractionated-stereotactic radiosurgery and cyber-knife robotic radiosurgery have been introduced with promising preliminary results..

Profile: Health and Demographic Surveillance System in peri-urban areas of Karachi, Pakistan

The Aga Khan University’s Health and Demographic Surveillance System (HDSS) in peri urban areas of Karachi was set up in the year 2003 in four low socioeconomic communities and covers an area of 17.6 square kilometres. Its main purpose has been to provide a platform for research projects with the focus on maternal and child health improvement, as well as educational opportunities for trainees. The total population currently under surveillance is 249,128, for which a record of births, deaths, pregnancies and migration events is maintained by two monthly household visits. Verbal autopsies for stillbirths, deaths of children under the age of five years and adult female deaths are conducted. For over a decade, the HDSS has been a platform for a variety of studies  including, calculation of the incidence of various infectious diseases like typhoid bacteremia, pneumonia and diarrhea, evaluation of effectiveness of various treatment regimens for neonatal sepsis, assessment of the acceptance of hospitalized care, determination of the etiology of moderate to severe diarrhea, assessment of burden and etiology of neonatal sepsis and a multi-centre cohort study measuring the burden of stillbirths, neonatal and maternal deaths. We have also established a bio-repository of a well-defined maternal and newborn cohort. Through a well-established HDSS rooted in maternal and child health we aim to provide concrete evidence base to guide policy makers to make informed decisions at local, national and international levels.

Genetic diversity and comparison of diagnostic tests for characterization of foot-and-mouth disease virus strains from Pakistan 2008-2012

We report the laboratory analysis of 125 clinical samples from suspected cases of foot-and-mouth disease (FMD) in cattle and Asian buffalo collected in Pakistan between 2008 and 2012. Of these samples, 89 were found to contain viral RNA by rRT-PCR, of which 88 were also found to contain infectious FMD virus (FMDV) by virus isolation (VI), with strong correlation between these tests (κ = 0.96). Samples that were VI-positive were serotyped by antigen detection ELISA (Ag-ELISA) and VP1 sequence acquisition and analysis. Sequence data identified FMDV serotypes A (n = 13), O (n = 36) and Asia-1 (n = 41), including three samples from which both serotypes Asia-1 and O were detected. Serotype A viruses were classified within three different Iran-05 sublineages: HER-10, FAR-11 and ESF-10. All serotype Asia-1 were within Group VII (Sindh-08 lineage), in a genetic clade that differs from viruses isolated prior to 2010. All serotypes O were classified as PanAsia-2 within two different sublineages: ANT-10 and BAL-09. Using VP1 sequencing as the gold standard for serotype determination, the overall sensitivity of Ag-ELISA to correctly determine serotype was 74%, and serotype-specific sensitivity was 8% for serotype A, 88% for Asia-1 and 89% for O. Serotype-specific specificity was 100% for serotype A, 93% for Asia-1 and 94% for O. Interestingly, 12 of 13 serotype A viruses were not detected by Ag-ELISA. This study confirms earlier accounts of regional genetic diversity of FMDV in Pakistan and highlights the importance of continued validation of diagnostic tests for rapidly evolving pathogens such as FMDV.

Loop-mediated isothermal amplification (RT-LAMP): a new approach for the detection of foot-and-mouth disease virus and its sero-types in Pakistan

Successful disease management requires a rapid and sensitive diagnosis method that can recognize early infection even before the manifestation of its clinical signs. The only available field diagnostic tests for foot-and-mouth disease (FMD) are lateral flow devices, commonly known as chromatographic strips. Low sensitivity and inability to detect FMD virus (FMDV) at the serotype level are limitations of lateral flow devices. Therefore, a reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) was standardized using universal and sero-type specific genes in a single tube. This test does not require sophisticated equipment and can detect FMDV at serotype level in about 60 min. In addition, the sensitivity and specificity of this test is comparable to conventional reverse transcriptase PCR and real time PCR (rRT-PCR).

Isolation, identification, and phylogenetic analysis of reassortant low-pathogenic avian influenza virus H3N1 from Pakistan

During routine avian influenza surveillance in Pakistan, a low-pathogenic avian influenza virus (LPAI) subtype H3N1 was isolated for the first time from domestic chickens. The higher seroprevalence of H3N1 was recorded in both commercial and domestic poultry in ecological zones of Pakistan where the geographical proximity with neighboring countries and attractive birding sites provide better opportunities for frequent movements of wild and migratory birds, and their intermingling with the local domestic and commercial poultry. Subsequent whole genome sequencing of this virus revealed a new introduction of a reassortant Eurasian avian strain, which was distinguishable from corresponding human and swine strains isolated elsewhere. Phylogenetically, the HA gene was mostly clustered with Nordic (Scandinavian) strains of influenza viruses, whereas the NA and PB1 genes showed a maximum nucleotide sequence homology with the Indian H11N1, and the PB2 gene was found to be closely related to the Altai H5N2. The Matrix and NP genes of H3N1 mostly clustered with the European avian influenza viruses (AIV), whereas its NS and PA genes showed maximum nucleotide homologies with the African (Egypt) AIV strains. A sequence and amino acid analysis revealed an LP motif, avian-like receptor specificity, potential glycosylation sites, and sensitivities to oseltamivir, zanamivir, and amantadine. Some point mutations possessed by this Pakistani AIV H3N1 were also found in human, equine, and swine H3 influenza viruses. This H3N1 isolate showed less nucleotide sequence homology with the previously known Pakistani AIV as compared with other Eurasian AIV strains.

Detection and seroprevalence of infectious bronchitis virus strains in commercial poultry in Pakistan

This study was conducted to investigate the incidence of infectious bronchitis virus (IBV) in commercial broiler and layer flocks in Pakistan. Serum samples from 16 layers and 9 broiler flocks were screened against M-41, D-274, D-1466, and 4-91 strain antigens using hemagglutination inhibition assay. Overall, 88% of the flocks were seropositive for M-41 antibodies, whereas 40, 52, and 8% of the flocks were positive for D-274, D-1466, and 4-91 IBV strains, respectively. The M-41 antigen was also detected in lungs and tracheal tissues of the clinically positive infectious bronchitis cases. Phospholipase C treatment of the lung and tracheal tissue homogenates from IBV-positive chickens increased the detection limit for M-41 strain from 1.3% positive samples in simple hemagglutination assay to 30.6% positivity when the same samples were treated with phospholipase C. Similarly, reverse transcription-PCR was a much better M-41 detection tool as compared with the classical agar gel precipitation assay utilized to screen tissue homogenates from IBV-positive chickens. In conclusion, this survey clearly demonstrates that several strains of IBV are prevalent in poultry flocks in Pakistan. By utilizing such diagnostic techniques it is possible to conduct a detailed epidemiological study to determine the full economic impact of this disease.

Avian influenza in Pakistan: outbreaks of low- and high-pathogenicity avian influenza in Pakistan during 2003-2006

From November 2003 to June 2004 an epidemic of high pathogenicity avian influenza (HPAI) virus of subtype H7N3 affected the major layer and broiler-breeder raising areas of the country. This was accompanied by an outbreak of low pathogenicity avian influenza (LPAI) virus of type H9N2 in broilers and layers, which continued during 2005. Subsequently, in February 2006 avian influenza virus (AIV) subtype H5N1 was for the first time found in two isolated commercial flocks in this country. The HPAI outbreak of 2003-2004 was eventually overcome by enforcing biosecurity measures, controlling poultry movements, using inactivated vaccines, and introducing a comprehensive AI surveillance network throughout the country. However, similar measures undertaken to control H9N2 outbreaks have not been successful in the affected areas, with continuing increased mortality and heavy production losses in broilers and layers, respectively. A similar strategy has been devised to combat the spread of newly introduced H5N1 HPAIV. The description of these outbreaks and the results of the control strategy are reported here.