A new anti-inflammatory lupane in Ziziphus jujuba (L.) Gaertn. var. hysudrica Edgew

Objectives

To investigate extracts of the stem bark of Ziziphus jujuba (L.) Gaertn. var. hysudrica Edgew. (Rhamnaceae) for anti-inflammatory activity and isolate the active principle(s).

Methods

The dry powder was macerated separately in three types of solvents to prepare methanol extract (ME), ethyl acetate extract (EE), and chloroform extract (CE). Following in vitro anti-inflammatory screening, the most active extract was selected to isolate the active compound. Both, the active extract and isolated compound were further tested on rats using the carrageenan-induced inflammation model. The blood and paw tissue were subjected to qPCR, and histopathology, respectively.

Key findings

CE showed comparatively higher anti-inflammatory activity (85.0-95.0 %) in all in vitro assays, except the heat-induced membrane stabilization model (p < 0.05), and upon column chromatography, it yielded a pure crystalline compound. The compound was a pentacyclic triterpenoid (Lupane), named as hydroxymethyl (3β)-3-methyl-lup-20(29)-en-28-oate (Hussainate). CE (500 mg/kg) and Hussainate (1.0 mg/kg) reduced edema in 5 h after carrageenan administration. The activity of Hussainate was found to be comparable to that of dexamethasone (standard). The possible activity mechanism was the downregulation of tumor necrosis factor-alpha (TNF-α), cyclooxygenase-2 (COX-II), NF-κB, and IL-1β.

Conclusions

This study reveals that chloroform extract of the stem's bark of Z. jujuba may be used to prepare standardized anti-inflammatory herbal products using Hussainate as an active analytical marker. Hussainate may be used as a lead to develop anti-inflammatory drugs.

Evaluation of in vitro anticancer potential of pharmacological ethanolic plant extracts Acacia modesta and Opuntia monocantha against liver cancer cells

Abstract Acacia modesta (AM) and Opuntia monocantha (OM) are distributed in Pakistan, Afghanistan and India. Both of these plants have different pharmacological properties. This study was designed to evaluate anticancer potential of Acacia modesta (AM) and Opuntia monocantha (OM). Liver cancer cell line HepG2 was used for assessment of anticancer activity. For the evaluation of anti-proliferative effects, cell viability and cell death in all groups of cells were evaluated via MTT, crystal violet and trypan blue assays. For the evaluation of apoptosis ELISA of p53 performed. Furthermore, LDH assay to find out the ability of malignant cells to metabolize pyruvate to lactate and antioxidant enzymes activity (GSH, CAT and SOD) at the end HPLC was performed to find active compound of AM and OM. Cytotoxicity (MTT), Viability assays (trypan blue, crystal viability, MUSE analysis) showed more dead, less live cells in plant treated groups with increase of concentration. Scratch assay for the anti-migratory effect of these plants showed treated groups have not ability to heal scratch/wound. ELISA of p53 for cellular apoptosis showed more release of p53 in treated groups. Antioxidant assay via glutathione (GSH), superoxide dismutase (SOD), catalase (CAT) showed less anti-oxidative potential in treated cancer groups. LDH assay showed more lactate dehydrogenase release in treated groups compared with untreated. HPLC analysis showed the presence of phytochemicals such as steroids, alkaloids, phenols, flavonoids, saponins, tannins, anthraquinone and amino acids in AM and OM plant extracts. Based on all these findings, it can be concluded that ethanolic extracts of Acacia modesta and Opuntia monocantha have promising anti-cancer potential.

Sustained intra-cartilage delivery of interleukin-1 receptor antagonist using cationic peptide and protein-based carriers

OBJECTIVE

Blocking the interleukin-1 (IL-1) catabolic cascade following joint trauma can be achieved using its receptor antagonist, IL-1Ra. However, its clinical translation for osteoarthritis therapy has been unsuccessful due to its rapid joint clearance and lack of targeting and penetration into deep cartilage layers at therapeutic concentrations. Here, we target the high negative charge of cartilage aggrecan-glycosaminoglycans (GAGs) by attaching cationic carriers to IL-1Ra. IL-1Ra was conjugated to the cartilage targeting glycoprotein, Avidin, and a short length optimally charged cationic peptide carrier (CPC+14). It is hypothesized that electro-diffusive transport and binding properties of IL-1Ra-Avidin and IL-1Ra-CPC+14 will create intra-cartilage depots of IL-1Ra, resulting in long-term suppression of IL-1 catabolism with only a single administration.

DESIGN

IL-1Ra was conjugated to Avidin or CPC+14 using site specific maleimide linkers, and confirmed using gel electrophoresis, high-performance liquid chromatography (HPLC), and mass spectrometry. Intra-cartilage transport and retention of conjugates was compared with native IL-1Ra. Attenuation of IL-1 catabolic signaling with one-time dose of IL-1Ra-CPC+14 and IL-1Ra-Avidin was assessed over 16 days using IL-1α challenged bovine cartilage and compared with unmodified IL-1Ra.

RESULTS

Positively charged IL-1Ra penetrated through the full-thickness of cartilage, creating a drug depot. A single dose of unmodified IL-1Ra was not sufficient to attenuate IL-1-induced cartilage deterioration over 16 days. However, when delivered using Avidin, and to a greater extent CPC+14, IL-1Ra significantly suppressed cytokine induced GAG loss and nitrite release while improving cell metabolism and viability.

CONCLUSION

Charge-based cartilage targeting drug delivery systems hold promise as they can enable long-term therapeutic benefit with only a single dose.

Association of propofol induction dose and severe pre-incision hypotension among surgical patients over age 65

STUDY OBJECTIVE

We aimed to study the association between propofol induction dose (mg/kg) and pre-incision severe hypotension (Mean Arterial Pressure (MAP) ≤ 55 mmHg) among patients ≥65 years of age.

DESIGN

Retrospective Observational.

SETTING

40 centers participating in the Multicenter Perioperative Outcomes Group consortium.

PATIENTS

Patients ≥65 years of age undergoing non-cardiac, non-vascular surgery who received propofol for general anesthetic induction prior to endotracheal intubation between January 2014 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS

The primary exposure was total propofol induction dose in mg/kg, and the primary outcome was occurrence of severe hypotension (MAP≤55 mmHg) prior to surgical incision, stratified by non-invasive vs. invasive blood pressure monitoring type.

MAIN RESULTS

Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe hypotension (MAP≤55 mmHg). When stratified by blood pressure monitoring type, 20.7% with non-invasive blood pressure measurements, and 35.0% with invasive blood pressure measurements had the outcome. After controlling for a variety of patient and procedural factors, there was a significant independent association between propofol induction dose and pre-incision hypotension (Non-invasive blood pressure cohort odds ratio (OR) 1.10; 95% confidence interval (CI) 1.07 to 1.13; p < 0.001; and Invasive blood pressure cohort OR 1.15; 95%CI 1.10 to 1.21; adjusted p < 0.001). The association was robust to alternative definitions of the outcome, including less severe hypotension (MAP≤65 mmHg) and blood pressure drop from baseline as a continuous measure. Although no threshold safe induction dose was identified at which hypotension was avoided, an analysis of propofol dose greater or less than 1.5 mg/kg (i.e. the maximum FDA-defined typical induction dose) demonstrated that doses in excess of the FDAs threshold were positively associated with odds of severe hypotension (Non-invasive cohort: OR 1.05; 95% CI 1.02 to 1.08; p < 0.001; Invasive cohort: OR 1.11; 95%CI 1.05 to 1.17; adjusted p < 0.001).

CONCLUSIONS

In a multicenter cohort of geriatric surgical patients receiving propofol for general anesthetic induction and endotracheal intubation, severe pre-incision hypotension (MAP ≤55 mmHg) that has previously been associated with postoperative morbidity was common. The dose of propofol used was significantly associated with increased odds of this outcome after controlling for a number of clinically relevant factors. Future studies that are designed to test different approaches to anesthesia induction for reducing severe post induction pre-incision hypotension are warranted.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Relationship Between Glucose Time in Range in Diabetic and Non-Diabetic Patients and Mortality in Critically Ill Patients

Background: Shorter time spent in specific blood glucose ranges is associated with mortality benefit in critically ill patients. However, various time in range values are reported, each based on a specific blood glucose range. Objective: To evaluate relationship between percentage of time spent at various blood glucose ranges (TIR) and mortality in critically ill patients. Methods: Single-center, retrospective, cohort study that included adult patients admitted to ICU for at least one day. We evaluated the relationship between TIR at prespecified blood glucose ranges and hospital mortality in diabetic and non-diabetic patients Results: Of the 5287 patients included, 3705 (70.0%) were non-diabetic and 1582 were diabetic (29.9%). Diabetic patients had higher in-hospital mortality rate (15.8%) compared to non-diabetic patients (11.3%), p < 0.0001, and with higher incidence of hyperglycemia (77.8% vs. 39.4%) and hypoglycemia (14.3% vs. 10%) compared to non-diabetic patients, p < 0.0001. The highest median TIR for both diabetic [76% (49.1 − 97.8%)] and non-diabetic patients [100% (92.3--100%)] was at blood glucose range of 70-180 mg/dL. In non-diabetic cohort, the only optimal TIR of 40% at blood glucose range of 70-120 mg/dL was identified. Non-diabetic patients stratified into TIR 70-120 mg/dL > 40% reported significantly lower mortality (7.0%) rate compared to patients with TIR 70-120 mg/dL < 40% (15.7%), OR 0.52, 95% CI 0.27-0.97, adjusted-p = 0.03. In diabetic patients, no relationship was detected between TIR at all predefined glucose ranges and hospital mortality. Conclusion: Critically ill non-diabetic patients who spent at least 40% of time in blood glucose range of 70-120 mg/dL had improved survival. This association was not observed in diabetic patients.

Preoperative evaluation of geriatric patients undergoing liver transplantation

PURPOSE OF REVIEW

As the population of the world is aging the number of geriatric patients undergoing liver transplantation (LT) is also increasing. They pose a unique challenge for the caregivers, as they have age-related physiological changes, multiple comorbidities and cirrhosis-related pathologies.

RECENT FINDINGS

Twenty-two percent of patients who undergo LT are older than 65 years. Many patients suffer from nonalcoholic steatohepatitis (NASH), hepatocellular carcinoma and hepatitis-C virus. Incidence of NASH tends to increase with age, obesity, diabetes and metabolic syndrome. Elderly patients require comprehensive cognitive, cardiac and pulmonary evaluation prior to LT. Cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension and frailty are of specific concern.

SUMMARY

Proportion of elderly patients who are undergoing LT continues to increase. These patients require comprehensive cardiopulmonary and frailty evaluation. Consensus-based practice advisories need to be developed to standardize preoperative evaluation of geriatric patients awaiting LT.

Assessment of automated craving across substances and across cultures: stability-analysis of the Craving Automated Scale (CAS)

BACKGROUND

The transition from hedonic to compulsive use in Substance Use Disorders (SUD) is a critical point in SUD progression and hence relevant for assessment and treatment. To measure the habitual patterns of substance consumption, the Craving Automated Scales (CAS) for alcohol (CAS-A), substances (CAS-S) and cigarette smoking (CAS-CS) were developed and introduced to different countries. In this study, we aimed to investigate the structural stability of CAS across substances and cultures.

METHODS

This study analyzed the CAS-scores of a sample of 370 participants in Germany, China and the UK, including 262 opioid-users, 65 smokers and 43 alcohol-users. We performed stability analyses to check the stability (i. e. factorial invariance) of factor solutions. Based on confirmed stability of the general factor (gfactor) solution and the calculations rule obtained in the previous validation of CAS-alcohol (CAS-A), the factor structures of CAS-A, CAS-S and CAS-CS were compared.

RESULTS

The gfactor solutions based on calculations rule shows good stability, with the mean stability coefficients of 0.990 and 0.977 for CAS-S and CAS-CS respectively. The gfactor patterns were similar for CAS-A, CAS-S and CAS-CS, as well as across samples (Germany, China and the UK), with most factor-loadings larger than 0.7. Based on these findings, CAS-S and CAS-CS were also associated with established clinical measures of SUD.

CONCLUSIONS

Our findings suggest the two-gfactor solution based on a proposed calculation rule has a high stability across substances and cultures. This could be in line with common neurobiological mechanisms underlying habitual substance use. Moreover, comparing CAS with established clinical tools suggests that CAS might assess the automated behavior in substance consumption in a more sophisticated way.

Pressure-Regulated Ventilator Splitting for Disaster Relief: Design, Testing, and Clinical Experience

The coronavirus disease 2019 (COVID-19) pandemic has revealed that even the best-resourced hospitals may lack sufficient ventilators to support patients under surge conditions. During a pandemic or mass trauma, an affordable, low-maintenance, off-the-shelf device that would allow health care teams to rapidly expand their ventilator capacity could prove lifesaving, but only if it can be safely integrated into a complex and rapidly changing clinical environment. Here, we define an approach to safe ventilator sharing that prioritizes predictable and independent care of patients sharing a ventilator. Subsequently, we detail the design and testing of a ventilator-splitting circuit that follows this approach and describe our clinical experience with this circuit during the COVID-19 pandemic. This circuit was able to provide individualized and titratable ventilatory support with individualized positive end-expiratory pressure (PEEP) to 2 critically ill patients at the same time, while insulating each patient from changes in the other's condition. We share insights from our experience using this technology in the intensive care unit and outline recommendations for future clinical applications.

Variation in propofol induction doses administered to surgical patients over age 65

BACKGROUND/OBJECTIVES

Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.

DESIGN

Retrospective observational study using the Multicenter Perioperative Outcomes Group data set.

SETTING

Thirty-six institutions across the United States.

PARTICIPANTS

A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.

INTERVENTION

None.

MEASUREMENTS

Total induction bolus dose of propofol administered.

RESULTS

The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older.

CONCLUSION

The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.

Prevalence of rhabdochoniasis in snow trout of river Swat and river Panjkora, Khyber Pakhtunkhwa province, Pakistan

This research was aimed to explore the helminth parasitic diseases in Schizothorax plagiostomus (the snow trout) from river Swat and river Panjkora, Pakistan. Collection of 360 fish specimens have done from the lower, middle and upper reaches of both the rivers through gill nets, cast nets, dragon nets and hooks. All the samples were examined in the University of Malakand, Zoology Department for helminth parasites during the months from January 2015 to December 2016. Of the total examined fish samples 21.9% (n=79) were infected with Rhabdochona spp including 17.7% (n=32/180) in river Swat and 26.6% (n=47/180) in river Panjkora. Highest month-wise prevalence (p=0.09878,p<0.05) was reported in May (30%), then by February and October each (26.6%) while the lowest during August (13.3%). Highest prevalence (p=0.9723, p<0.05) was reported in summer season (26.6%), while lowest in the winter season (20%). Adults were highly infected (p=< 0.0001) in prevalence (63.7%) followed by sub-adults (13.2%) while no infection was found in juvenile specimens. Females fish samples had higher (p=0.0277, p>0.05) prevalence (28.8%) than males (16.6%). Fishes of the lower reaches had highest (p=0.0029, P>0.05) prevalence (31.7%) followed by middle reaches (16.5%) while the lowest prevalence was observed in samples of fish collected from upper reaches (9.87%). Present study address that Rhabdochona spp in the intestine of snow trout has a long term relationship and call as a natural infection in cyprinids and zoonotic risk to human.

Feeding habit of Brown trout (Salmo trutta fario) in upper parts of river Swat, Pakistan

Salmo trutta fario is the most important fish species of family Salmonidae inhibited in cool waters all over the world including the nortern parts of Pakistan. This study was aimed to find out the prey selection and feeding habits of the species. One hundred and eighty five Salmo trutta fario were captured from March 2016 to April 2017. Feeding intensity as represented by a fullness index (FI), changing with various length groups and season. Out of 185 Brown trout 24 fish stomaches were found empty. The most important and common food items of brown trout were Brachycentridae, Blepharocera, Hydropsychidae, ephemerella spp. Kruskal Wallis H-test were applied on feeding intensity groups consisting of three month group. The test statistic for K.W-H-test were (H=8.13 with df =3) had a p-value of 0.043 < (alpha=0.05 indicates favor of the alternative hypothesis of at least one difference among the feeding intensity groups. The linear relationship of N with index of relative importance and %IRI denoted by least square regression line (N = 35.2 + 22.1%IRI), shows that for 22 prey there is 1% change in IRI. The relationship between total length (mm) and fish body weight (gm) is expressed by Pearson correlation coefficient (r = 0.976), showed that total length (mm) and fish body weight (gm.) is highly correlated. Descriptive statistics are used for the stomach fullness, which shows that feeding intensity was recorded higher from March to May. A total of 2289 preys was recorded including the most common were; Trichoptera, Hydropsychidae, Brachycentridae, diptera, blepharocera, ephemerala, chironomida, honey bees, grass hopper, locust, trout egg, trochanter, plant tissue, stones were retrieved from the gut contents of brown trout. According to index of relative importance IRI% four preys represents major components of the diet. The highest IRI% was recorded in Brachycentridae (39.38%), followed by blepharocera (13.23%), Hydropsychidae (10.76%) and ephemerella spp (8.28%). The relationship between IRI and FO is (r =0.556) is moderately correlated with coefficient of determination (r2=0.31). This study will help in the development of an artificial diet for the species for better growth performance in captivity.

Inhibition of L-NAME-induced hypertension by combined treatment with apocynin and catalase: the role of Nox 4 expression

Reactive oxygen species (ROS) such as superoxide (O2-) generated by NAD(P)H oxidases have emerged as important molecules in blood pressure regulation. This study investigated the effect of apocynin and catalase on blood pressure and renal haemodynamic and excretory function in an L-NAME induced hypertension model. Forty Male Wistar-Kyoto (WKY) rats (n=8 per group) were treated with either: vehicle (WKY-C); L-NAME (WKY-L, 15 mg/kg/day in drinking fluid); WKY-L given apocynin to block NAD(P)H oxidase (WKY-LApo, 73 mg/kg/day in drinking water.); WKY-L given catalase to enhance ROS scavenging (WKY-LCat, 10000 U/kg/day i.p.); and WKY-L receiving apocynin plus catalase (WKY-LApoCat) daily for 14 days. L-NAME elevated systolic blood pressure (SBP), 116+/-1 to 181±4 mmHg, reduced creatinine clearance, 1.69+/-0.26 to 0.97+/-0.05 ml/min/kg and fractional sodium excretion, 0.84+/-0.09 to 0.55+/-0.09 % at day 14. Concomitantly, plasma malondialdehyde (MDA) increased six fold, while plasma total superoxide dismutase (T-SOD), plasma nitric oxide (NO) and plasma total antioxidant capacity (T-AOC) were decreased by 60-70 % and Nox 4 mRNA expression was increased 2-fold. Treatment with apocynin and catalase attenuated the increase in SBP and improved renal function, enhanced antioxidative stress capacity and reduced the magnitude of Nox4 mRNAs expression in the L-NAME treated rats. This study demonstrated that apocynin and catalase offset the development of L-NAME induced hypertension, renal dysfunction and reduced oxidative stress status, possibly contributed by a reduction in Nox4 expression during NOS inhibition. These findings would suggest that antioxidant compounds such as apocynin and catalase have potential in treating cardiovascular diseases.

E. coli expression and immunological assessment of expressed recombinant Newcastle disease virus hemagglutinin-neuraminidase protein in chickens

Every year, the poultry industry experiences significant economic losses due to epidemics of Newcastle disease virus (NDV). Developing new vaccines by identifying and using the immunogenic hemagglutinin-neuraminidase (HN) protein can protect the poultry industry. In the present study, the full-length HN protein was expressed in Escherichia coli (E. coli) BL21 (DE3) cells, purified via affinity chromatography and detected via western blot analysis using His-specific antibodies. The purified HN protein was further evaluated in chickens to study the immune response against NDV. The successful production of HN-specific IgY proved the activity of the purified HN protein. IgY was present in the serum of immunized chickens. However, the immune response was higher in chickens immunized with purified HN protein along with complete and incomplete adjuvants than in chickens immunized with only the HN protein. Keywords: protein; Newcastle disease virus; poultry; infectious diseases; vaccines.

Regional Anesthesia is Underutilized for Carotid Endarterectomy Despite Improved Perioperative Outcomes Compared with General Anesthesia

BACKGROUND

The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database.

METHODS

The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching.

RESULTS

There were 26,206 CEAs, and 14% (n = 3,664) were performed under RA, with no change in relative utilization during the study period (P = 0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P < 0.001) and White (90.8% vs. 83.5%; P < 0.001) but less likely to have diabetes (28.2% vs. 31.2%; P = 0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P < 0.001), and heart failure (1.0% vs. 1.5%; P = 0.02) and be symptomatic (37.4% vs. 42.7%; P < 0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay.

CONCLUSIONS

CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

The restorative effect of apocynin and catalase in l-arginine induced hypotension on normotensive subjects - the role of oxidative stress

L-arginine is a substrate for nitric oxide synthase (NOS) responsible for the production of NO. This investigation studied the effect of apocynin, an NADPH oxidase inhibitor and catalase, an H2O2 scavenger on L-arginine induced oxidative stress and hypotension. Forty Wistar-Kyoto rats were treated for 14 days with vehicle, L-arginine (12.5mg/ml p.o.), L-arginine+apocynin (2.5mmol/L p.o.), L-arginine+catalase (10000U/kg/day i.p.) and L-arginine plus apocynin+catalase respectively. Weekly renal functional and hemodynamic parameters were measured and kidneys harvested at the end of the study for histopathological and renal NADPH oxidase 4 (Nox4) assessments. L-arginine administration in normotensive rats decreased systolic blood pressure (120±2 vs 91±2mmHg) and heart rate (298±21 vs 254±15b/min), enhanced urinary output (21.5±4.2 vs 32±1.9ml/24h , increased creatinine clearance (1.72±0.56 vs 2.62±0.40ml/min/kg), and fractional sodium excretion (0.88±0.16 vs 1.18±0.16 %), caused proteinuria (28.10±1.93 vs 35.26±1.69mg/kg/day) and a significant decrease in renal cortical blood perfusion (292±3 vs 258±5bpu) and pulse wave velocity (3.72±0.20 vs 2.84±0.13m/s) (all P<0.05). L-arginine increased plasma malondialdehyde (by ~206 % P<0.05) and NO (by~51 %, P<0.05) but decreased superoxide dismutase (by~31 %, P<0.05) and total antioxidant capacity (by~35 %, P<0.05) compared to control. Renal Nox4 mRNA activity was approximately 2.1 fold higher (P<0.05) in the L-arginine treated rats but was normalized by apocynin and apocynin plus catalase treatment. Administration of apocynin and catalase, but not catalase alone to rats fed L-arginine, restored the deranged renal function and structure, prevented hypotension and enhanced the antioxidant capacity and suppressed Nox4 expression. These findings suggest that apocynin and catalase might be used prophylactically in states of oxidative stress.

The restorative effect of apocynin and catalase in l-arginine induced hypotension on normotensive subjects – the role of oxidative stress

L-arginine is a substrate for nitric oxide synthase (NOS) responsible for the production of NO. This investigation studied the effect of apocynin, an NADPH oxidase inhibitor and catalase, an H2O2 scavenger on L-arginine induced oxidative stress and hypotension. Forty Wistar-Kyoto rats were treated for 14 days with vehicle, L-arginine (12.5mg/ml p.o.), L-arginine+apocynin (2.5mmol/L p.o.), L-arginine+catalase (10000U/kg/day i.p.) and L-arginine plus apocynin+catalase respectively. Weekly renal functional and hemodynamic parameters were measured and kidneys harvested at the end of the study for histopathological and renal NADPH oxidase 4 (Nox4) assessments. L-arginine administration in normotensive rats decreased systolic blood pressure (120±2 vs 91±2mmHg) and heart rate (298±21 vs 254±15b/min), enhanced urinary output (21.5±4.2 vs 32±1.9ml/24h , increased creatinine clearance (1.72±0.56 vs 2.62±0.40ml/min/kg), and fractional sodium excretion (0.88±0.16 vs 1.18±0.16 %), caused proteinuria (28.10±1.93 vs 35.26±1.69mg/kg/day) and a significant decrease in renal cortical blood perfusion (292±3 vs 258±5bpu) and pulse wave velocity (3.72±0.20 vs 2.84±0.13m/s) (all P<0.05). L-arginine increased plasma malondialdehyde (by ~206 % P<0.05) and NO (by ~51 %, P<0.05) but decreased superoxide dismutase (by ~31 %, P<0.05) and total antioxidant capacity (by ~35 %, P<0.05) compared to control. Renal Nox4 mRNA activity was approximately 2.1 fold higher (P<0.05) in the L-arginine treated rats but was normalized by apocynin and apocynin plus catalase treatment. Administration of apocynin and catalase, but not catalase alone to rats fed L-arginine, restored the deranged renal function and structure, prevented hypotension and enhanced the antioxidant capacity and suppressed Nox4 expression. These findings suggest that apocynin and catalase might be used prophylactically in states of oxidative stress.

An Analysis of Anesthesia Induction Dosing in Female Older Adults

BACKGROUND/OBJECTIVES

In the context of an aging surgical population, appropriate anesthetic induction dose adjustments for the older adult remain poorly defined. In the present study, we describe the prevalence of excess induction agent dose in reference to US Food and Drug Administration (FDA) guidance and seek to investigate the possible association of such excess dose with postinduction hypotension and postoperative acute kidney injury (AKI).

STUDY DESIGN

A retrospective observational study was conducted in a large tertiary teaching hospital in accordance with our a priori analytic protocol as registered on ClinicalTrials.gov (NCT03699696). For inclusion, patients had to be 65 years or older and to have received general anesthesia with propofol induction for gynecologic oncology surgery between December 1, 2014 and July 8, 2018. Descriptive variables of the patients, machine-captured perioperative vital signs, induction anesthetic, and vasopressor/inotrope administrations were recorded.

MAIN OUTCOME MEASURES

A total of 541 female patients met inclusion criteria. The mean (standard deviation) age of the cohort was 72.20 (5.93) years. Regarding the primary outcome, 65.43% (354 patients, 95% confidence interval 61.2-69.4) of the cohort received more than the FDA recommended 1-1.5 mg/kg induction dose for patients of advanced age undergoing general anesthesia.

RESULTS

The percentage of patients receiving doses in excess of the FDA guidance remained substantial across all age groups, but decreased progressively with increasing 5-year age intervals (from 74% among those aged 65-69 years to 44% among those aged > 80 years). Excess propofol dose in the present cohort was not associated with our a priori definition of postinduction hypotension. Regarding AKI, among the 30 patients suffering this outcome, it occurred less often in patients who received higher propofol doses (4.1% [9/217] vs. 15.3% [21/138], p < 0.001), a result that may have been confounded by differential rates of missingness.

CONCLUSIONS

Older adults commonly receive propofol induction doses in excess of the FDA guidance. The immediate hemodynamic effects of these doses on postinduction hypotension were not seen in the present cohort, suggesting that propofol dose adjustments may serve as a marker of physicians' judgments as to the frailty of patients. The relevance of the AKI association is difficult to interpret due to the non-differential missingness of AKI data between the two groups.

Ni0.4Cu0.2Zn0.4TbxFe2-xO4 nanospinel ferrites: Ultrasonic synthesis and physical properties

The Fe³⁺ ions were replace with Tb³⁺ ions as highly paramagnetic rare earth element within the structure of Ni_0.4Cu_0.2Zn_0.4Fe₂O₄ nano-spinel ferrites (NSFs). The structural, magnetic, spectroscopic and optic properties have been studied in details. All products have been synthesized via ultrasonic approach via Qsonica ultrasonic homogenizer, frequency: 20 kHz and power: 70 W for 60 min. No annealing or calcination process was applied for any product. The microstructural analysis of products has been done via X-ray powder diffractometry (XRD) which presented the cubic spinel structure with nanosized distribution of all. The cubic morphology of all products were confirmed by both HR-TEM and FE-SEM. Optical band gap (E_g) values were assessed by applying %DR (percent diffuse reflectance) analysis and Kubelka-Munk theory. The Tauc schemes showed that E_g values are in a narrow range (1.87-1.98 eV). The quadrupole splitting, line width, hyperfine magnetic field, isomer shift values and cation distribution have been determined from ⁵⁷Fe Mossbauer analysis. The magnetic properties of various nanoparticles have been obtained from VSM (vibration sample magnetometer) measurements at 10 and 300 K (RT). The magnetic results revealed superparamagnetic and soft ferromagnetic traits at 10 and 300 K, respectively. M_s (saturation magnetization) and M_r (remanence) initially increase with increasing Tb³⁺ substituting level up to x = 0.06 then diminish for further x values. H_c (coercivity) shows an opposite variation tendency of M_s and M_r. The observed magnetic traits are deeply discussed in relation with the structure, morphology, magnetic moments and cation distributions.

Structural, magnetic, optical properties and cation distribution of nanosized Co0.7Zn0.3TmxFe2-xO4 (0.0 ≤ x ≤ 0.04) spinel ferrites synthesized by ultrasonic irradiation

This study expressed the influence of Tm substitution on the structural, optical and magnetic properties of Co-Zn spinel ferrites (Co_0.7Zn_0.3Tm_xFe_2-xO₄ (0.0 ≤ x ≤ 0.04)). The different compositions were synthesized by sonochemical method using Qsonica ultrasonic homogenizer, frequency: 20 kHz and power: 70 W for 60 min. XRD patterns proved the presence of single-phase spinel ferrites with crystallites size in the 8-10 nm range. Cation distribution approved the occupancy of octahedral (B) site by Tm. The morphology and the elements stoichiometry are obtainable through FE-SEM, EDX and elemental mapping. Optical band gap (E_g) values were estimated via DR % (percent diffuse reflectance) investigations and Kubelka-Munk theory. Tauc plots revealed that direct E_g values are ranging between 1.49 and 1.68 eV. The analyses of magnetization versus magnetic field, M(H), were performed. The following magnetic parameters like saturation magnetization M_s, squareness ratio (SQR = M_r/M_s), magnetic moment n_B, coercivity H_c and remanence M_r have been evaluated. M(H) curves revealed the superparamagnetic (SP) at RT and ferromagnetic property at 10 K. It was showed that the Tm³⁺ substitutions significantly affect the magnetic properties of host spinel ferrites. An increasing trend in the M_s, M_r, H_c, and n_B values was noticed for lower Tm³⁺ substitution content.

Structural, magnetic, optical properties and cation distribution of nanosized Ni0.3Cu0.3Zn0.4TmxFe2-xO4 (0.0 ≤ x ≤ 0.10) spinel ferrites synthesized by ultrasound irradiation

In this study, Tm³⁺ ion substituted NiCuZn nanospinel ferrites, Ni_0.3Cu_0.3Zn_0.4Tm_xFe_2-xO₄ (0.0 ≤ x ≤ 0.10), have been synthesized sonochemically. The structural, spectroscopic, morphological, optic and magnetic investigation of the samples were done by X-ray powder diffractometry (XRD), Fourier transform infrared spectrophotometry (FT-IR), UV-Vis diffused reflectance (%DR) spectrophotometry, transmission and scanning electron microscopies (TEM and SEM) along with EDX, Vibrating sample magnetometry (VSM), respectively. The purity of prepared products were confirmed via XRD, FT-IR, EDX and elemental mapping analyses. The analyses of magnetization versus M(H) (applied magnetic field) were performed at 300 and 10 K. The following magnetic parameters like M_s (saturation magnetization), SQR = M_r/M_s (squareness ratio), n_B(magnetic moment), H_c (coercivity) and M_r (remanence) have been discussed. M(H) loops revealed superparamagnetic property at RT and soft ferromagnetic nature at 10 K. It is showed that the Tm³⁺ substitutions significantly affect the magnetizations data. A decreasing trend in the M_s, H_c, M_r, and n_B values was detected with Tm³⁺ substitution.

Effect of single-dose intravenous tranexamic acid on postoperative nasal bleed in septoplasty

OBJECTIVE

Postoperative nasal bleeding is a common complication of septoplasty and may lead to painful procedure of nasal packing to stop bleeding. Since Tranexamic acid (TXA) has been reported to reduce bleeding, the purpose of this study is to investigate the effect of single dose of intravenous TXA on postoperative nasal bleed associated with septoplasty.

MATERIALS AND METHODS

This prospective randomized, double-blinded clinical trial consisted of 176 patients aged 18-55 years who underwent septoplasty for symptomatic deviated nasal septum. These participants were randomly divided into 2 groups; 88 patients were given normal saline (Control group) and 88 patients were administered a single shot of intravenous TXA 10mg/kg (TXA group). Operative technique applied was same in all cases. At the end of surgery nasal packs, nasal splints or trans-septal suturing were not done. Nasal bleeding was monitored after surgery and up to 2 weeks postoperatively.

RESULTS

Patients receiving TXA showed significantly less postoperative nasal bleeding compared with controls. Extensive bleeding in terms of number of gauze pads used and duration was also higher in placebo with a statistically significant difference (all P=<0.05). Seven patients required nasal packing in control group to stop bleeding as compared to one patient in TXA group. Adverse reactions to TXA were minimal, and these were easily managed conservatively.

CONCLUSION

Single intravenous dose of TXA is shown to be effective and safe agent in preventing postoperative nasal bleeding after septoplasty therefore avoiding additional techniques of nasal packing, intranasal splint or trans-septal suturing during surgery.

Impact of La3+ and Y3+ ion substitutions on structural, magnetic and microwave properties of Ni0.3Cu0.3Zn0.4Fe2O4 nanospinel ferrites synthesized via sonochemical route

In the current study, Ni_0.4Cu_0.2Zn_0.4La_xY_xFe_2−xO₄ (x = 0.00 − 0.10) nanospinel ferrites (NSFs) were fabricated via an ultrasonic irradiation route. The creation of single phase of spinel nanoferrites (NSFs) was investigated by X-ray powder diffractometry (XRD) and selected area diffraction pattern (SAED). The cubic morphology of all samples was confirmed by scanning and transmission electron microscopies (SEM and TEM) respectively. The UV-Vis investigations provided the direct optical energy band gap values in a narrow photon energy interval of 1.87–1.92 eV. The ⁵⁷Fe Mössbauer spectroscopy analysis explained that the hyperfine magnetic fields of Octahedral (Oh) and Tetrahedral (Td) sites decreased with substitution. The paramagnetic properties of NPs decrease with increase of content of doped ions. Investigations of magnetic properties reveal a superparamagnetic nature at 300 K and soft ferromagnetic trait at 10 K. The M_s (saturation magnetization) and M_r (remanence) decrease and the H_c (coercivity) increases slightly with La³⁺ and Y³⁺ substitution. The observed magnetic traits are deeply discussed in relation with the morphology, structure, magnetic moments and cation distributions. The microwave characterization of the prepared NSFs showed that, dissipation (i.e., absorption) of incoming microwave energy occurs at a single frequency, for each sample, lying between 7 and 10.5 GHz. The reflection losses (RL) at these frequencies range from −30 to −40 dB and the mechanism of which is explained in the framework of dipolar relaxation and spin rotation. The best microwave properties were obtained with a LaY concentration of x = 0.08 having an RL of −40 dB @ 10.5 GHz and an absorption bandwidth of 8.4 GHz @ −10 dB. With these high values of RL and absorbing bandwidth, LaY doped NiCuZn NSF products would be promising candidates for radar absorbing materials in the X-band.

The best microwave properties for the NSFs were obtained with an LaY concentration of x = 0.08, RL of −40 dB @ 10.5 GHz and absorption bandwidth of 8.4 GHz @ −10 dB. The NSF products show promise as radar absorbing materials in the X-band.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice. Trial registration ISRCTN 01591254.

Ultrastructure and 3D transmission electron tomography of collagen fibrils and proteoglycans of swollen human corneal stroma

BACKGROUND

The transparency of the cornea is regulated by the unique organization of collagen fibrils (CFs) which is maintained by proteoglycans (PGs). The interlacing of CF lamellae in the anterior stroma provides the biomechanical properties of the cornea.

OBJECTIVE

To investigate the alterations of CFs and PGs in the swollen cornea, with special reference to the anterior stroma by using electron microscopy and 3D ultrastructural tomography.

METHOD

Nine healthy normal scleral corneal rings (age from 40 to 65 years) were hydrated individually in deionised water to induce swelling in the cornea. Three of them were hydrated for 2hr whereas the other three were hydrated for 48hr. The remaining three scleral normal corneal rings were used as a control.The corneas were processed for electron microscopy (EM) to study the CFs and PGs. Ultrathin sections were observed using transmission electron microscopy (JOEL 1400) and digital images of CFs, PGs and lamellae were captured using a bottom mounted Quemesa camera and iTEM Soft Imaging System. The software program 'Composer-x64, version 3.4.2.0' was used to construct individual 3D images from 120 digital images taken from -60 to + 60 degree angles.

RESULTS

The 3D tomography showed the degeneration of microfibrils within the CFs of the swollen cornea. The CF diameter was significantly reduced and the interfibrillar spacing significantly increased in both the 2hr and 48hr hydrated corneas compared to the normal cornea. Within the hydrated corneas, the CF diameter was smaller and the interfibrillar spacing was increased in the middle and posterior stroma compared to the anterior stroma. The PG area in both the 2hr and the 48hr hydrated cornea was reduced in the anterior stroma, whereas it was increased in middle and posterior stroma compared to the normal cornea. The density of the PGs in both the 2hr and the 48hr samples, was reduced compared to the density of PGs in the normal cornea.

CONCLUSION

The CFs, PGs and lamellae had degenerated, caused by swelling. 3D imaging demonstrated that the impairment of the microfibrils and PGs within the CF, is caused by the excessive hydration or swelling in the anterior as well as in the middle and posterior stroma. The lamellae of the anterior stroma which provides the biomechanical strength in the normal cornea, had degenerated in the swollen corneas due to the presence of the damaged CFs and PGs.

Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors

Background

Although factor Xa inhibitors have become a popular choice for chronic oral anticoagulation, effective drug reversal remains difficult due to a lack of specific antidote. Currently, 4-factor prothrombin complex concentrate (4F-PCC) is considered the treatment of choice for factor Xa inhibitor-related major bleeding. However, safety of 4F-PCC and its risk of thrombosis when used for this off-label purpose remain unclear. The purpose of this retrospective study is to determine the rate of thromboembolism when 4F-PCC is used for the emergent reversal of factor Xa inhibitors.

Methods

We conducted a single-center retrospective review of medical records between 2013 and 2017. Patients were included if they received 4F-PCC to reverse rivaroxaban, apixaban, or edoxaban for emergent invasive procedures or during episodes of major bleeding defined as bleeding with hemodynamic instability, fall in hemoglobin of 2 g/dL, or bleeding requiring blood transfusion. Thrombotic events including myocardial infarction, pulmonary embolism, deep vein thrombosis, cerebral vascular accident, and arterial thrombosis of the limb or mesentery were recorded if they occurred within 14 days of 4F-PCC administration. Data was analyzed using point and interval estimation to approximate the rate and confidence interval of thromboembolic events.

Results

Forty-three patients were identified in our review. Doses of 4F-PCC were determined by the treating physician and mainly ranged from 25 to 50 IU/kg. Twenty-two patients (51.2%) received both sequential compression devices (SCDs) and subcutaneous heparin for DVT prophylaxis. Twenty-one patients (48.8%) were placed on SCDs only. Three patients received concomitant FFP. Thrombotic events within 14 days of 4F-PCC administration occurred in 1 out of 43 patients (2.1%, 95% CI [0.1–12.3]). This thrombotic event was an upper extremity DVT which occurred 1 day after the patient received 1325 IU (25 IU/kg) of 4F-PCC to reverse rivaroxaban for traumatic intracranial hemorrhage. The patient was taken for emergent decompressive craniotomy after rivaroxaban reversal. In patients who did not undergo surgery or who underwent minor invasive procedures, no thrombotic events were noted.

Conclusion

Based on our preliminary data, the thromboembolic rate of 4F-PCC when given at a dose of 25–50 IU/kg to emergently reverse rivaroxaban and apixaban appears acceptable. Since many patients who require 4F-PCC to emergently reverse factor Xa inhibitors will be at high risk of developing thrombotic events, practitioners should be highly vigilant of these complications. Large, multicenter prospective trials are needed to further determine this risk.

A Pilot Analysis of the Association Between Types of Monitored Anesthesia Care Drugs and Outcomes in Transfemoral Aortic Valve Replacement Performed Without General Anesthesia

OBJECTIVE

The types of agents used for monitored anesthesia care (MAC) and their possible differential effects on outcomes have received less study despite increased use over general anesthesia (GA) in transfemoral aortic valve replacements (TAVRs). In this pilot analysis of patients undergoing TAVR using MAC, the authors described the anesthetic agents used and sought to investigate the possible association of anesthetic agent choice with outcomes and the extent to which total weight and time-adjusted doses of anesthetics declined with increasing 10-year age increments.

DESIGN

Retrospective observational study.

SETTING

Tertiary teaching hospital.

PARTICIPANTS

Ninety-three participants scheduled to undergo TAVR, with a primary plan of conscious sedation between November 2014 and June 2016, were included.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Types of MAC were divided into 4 primary groups, but 2 groups were focused: propofol (n = 39) and dexmedetomidine plus propofol (n = 34). Conversion to GA occurred in 6 participants (6.45%) and was not associated with the type of sedation received. The authors also compared patients who received dexmedetomidine with those who did not in accordance with their a priori analytic plan. There were no associations between the use of dexmedetomidine and postoperative delirium or intensive care unit/hospital length of stay. No significant trends in medication dose adjustments were seen across increasing 10-year age increments.

CONCLUSIONS

A wide breadth of MAC medications is in use among TAVR patients and does not support differences in outcomes. Despite recommendations to reduce anesthetic drug dosing in the elderly, no significant trends in dose reduction with increasing age were noted.

Pattern of first- and second-line drug resistance among pulmonary tuberculosis retreatment cases in Pakistan

BACKGROUND

Drug resistance in general, and multidrug-resistant tuberculosis (MDR-TB) in particular, threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Pakistan.

OBJECTIVE

To obtain population-based data on Mycobacterium tuberculosis drug resistance in Pakistan.

METHODS

To obtain drug resistance data, we conducted a population-based study of TB cases in all provinces of Pakistan. We performed culture and drug susceptibility testing on M. tuberculosis isolates from patients with a prior history of anti-tuberculosis treatment (retreatment cases) from all over the country.

RESULTS

Of 544 isolates from previously treated cases, 289 (53.1%) were susceptible to all first-line drugs, 255 (46.9%) were resistant to at least one anti-tuberculosis drug and 132 (24.3%) were MDR-TB. Among MDR-TB isolates, 47.0% were ofloxacin (OFX) resistant. Extensively drug-resistant TB was found in two (0.4%) isolates.

CONCLUSION

Prevalence of drug resistance in retreatment isolates was high. The alarmingly high prevalence of OFX resistance among MDR-TB isolates may threaten the success of efforts to control and treat MDR-TB.