Risk factors associated with morbidity and mortality outcomes of COVID-19 patients on the 28th day of the disease course: a retrospective cohort study in Bangladesh.

Diverse risk factors intercede the outcomes of coronavirus disease 2019 (COVID-19). We conducted this retrospective cohort study with a cohort of 1016 COVID-19 patients diagnosed in May 2020 to identify the risk factors associated with morbidity and mortality outcomes. Data were collected by telephone-interview and reviewing records using a questionnaire and checklist. The study identified morbidity and mortality risk factors on the 28th day of the disease course. The majority of the patients were male (64.1%) and belonged to the age group 25-39 years (39.4%). Urban patients were higher in proportion than rural (69.3% vs. 30.7%). Major comorbidities included 35.0% diabetes mellitus (DM), 28.4% hypertension (HTN), 16.6% chronic obstructive pulmonary disease (COPD), and 7.8% coronary heart disease (CHD). The morbidity rate (not-cured) was 6.0%, and the mortality rate (non-survivor) was 2.5%. Morbidity risk factors included elderly (AOR = 2.56, 95% CI = 1.31-4.99), having comorbidity (AOR = 1.43, 95% CI = 0.83-2.47), and smokeless tobacco use (AOR = 2.17, 95% CI = 0.84-5.61). The morbidity risk was higher with COPD (RR = 2.68), chronic kidney disease (CKD) (RR = 3.33) and chronic liver disease (CLD) (RR = 3.99). Mortality risk factors included elderly (AOR = 7.56, 95% CI = 3.19-17.92), having comorbidity (AOR = 5.27, 95% CI = 1.88-14.79) and SLT use (AOR = 1.93, 95% CI = 0.50-7.46). The mortality risk was higher with COPD (RR = 7.30), DM (RR = 2.63), CHD (RR = 4.65), HTN (RR = 3.38), CKD (RR = 9.03), CLD (RR = 10.52) and malignant diseases (RR = 9.73). We must espouse programme interventions considering the morbidity and mortality risk factors to condense the aggressive outcomes of COVID-19.

Antimicrobial resistance and in vitro biofilm-forming ability of Enterococci spp. isolated from urinary tract infection in a tertiary care hospital in Dhaka.

The biofilm mode of life conveys a survival advantage to the microorganism associated with it. Biofilm on an indwelling urinary catheter consists of adherent microorganisms, their extra cellular products, and host components deposited on the catheter and thus biofilm on urinary catheters results in persistent infections that are resistant to antimicrobial therapy. This study was done during the period of January 2010 to December 2010. Fifty nine enterococci isolated from 1203 urine samples were speciated by conventional microbiological methods and examined for their ability to form biofilm by microtitre plate assay and antimicrobial susceptibility testing by disc diffusion method for 10 clinically relevant antibiotics respectively. Biofilm producing Enterococci were more frequently found in catheterized than in non catheterized patient (p < 0.004). Enterococcus faecium showed increased resistantance to multiple antibiotic than Enterococcus faecalis. Significant relationship was found between biofilm production with antibiotic resistance to amoxicillin, co-trimoxazole, ciprofloxacin, gentamycin, cefotaxime, and cefuroxime. This study demonstrated a high propensity among the isolates of Enterococci to form biofilm and a significant association of biofilms with multiple drug resistance.

Effectiveness of educational interventions in improving clinical competence of residents in an internal medicine residency program in Pakistan.

INTRODUCTION: Medical education is a continuously evolving field. Training institutes and programs should have a process in place to gather continuous feedback and then make appropriate modifications in order to provide education and training effectively. Our study aimed to assess the effect of a quality improvement cycle approach in using various educational interventions within a residency. Effects were measured on the key educational outcomes of residents; medical knowledge, skills and professional attitudes using results of postgraduate examination with both written and clinical skills components. METHODOLOGY: A number of educational interventions were implemented which included changes in work hours with increased time for self-study, new educational activities including a Residents Hour, a Residents Slide Session, Grand Rounds and Journal Clubs, Clinico-pathological conferences, and a two- week postgraduate course for senior residents. Newer and improved assessment tools were also implemented, including an annual in-training mock exam based on the format of the postgraduate examination. Pass rates in postgraduate examinations (Fellow of College of Physicians and Surgeons exam and Member of Royal College of Physicians exam) were compared before and after the interventions to assess the effectiveness of the interventions. RESULTS: The first group of residents after introduction of the educational interventions completed residency training in 2001. Postgraduate exam pass rates (sometimes after two or more attempts) were 59.2% (42 of 71 graduates) before 2001 and 86.4% (38 of 44 graduates after 2001 (p = 0.002). The number of candidates passing the examinations in either their first or second attempts before 2001 was 17 of 42 (40.5%), which increased to 33 of 38 (86.8%) after 2001 (p = <0.001). CONCLUSIONS: Our study describes a number of interventions that were successful in bringing about an improvement in the performance of our residents. These can serve as a guide for postgraduate training programs, particularly those of Internal Medicine, in implementing strategies to strengthen training and enhance the performance of trainees.

A novel treatment of bromelain and acetylcysteine (BromAc) in patients with peritoneal mucinous tumours: A phase I first in man study.

BACKGROUND: Bromelain (Brom) and Acetylcysteine (Ac) have synergistic activity resulting in dissolution of tumour-produced mucin both in vitro and in vivo. The aim of this study was to determine whether treatment of mucinous peritoneal tumour with BromAc can be performed with an acceptable safety profile and to conduct a preliminary assessment of efficacy in a clinical setting. METHODS: Under radiological guidance, a drain was inserted into the tumour mass or intraperitoneally. Each patient could have more than one tumour site treated. Brom 20-60 mg and Ac 1·5-2 g was administered in 5% glucose. At 24 h, the patient was assessed for symptoms including treatment-related adverse events (AEs) and the drain was aspirated. The volume of tumour removed was measured. A repeat dose via the drain was given in most patients. All patients that received at least one dose of BromAc were included in the safety and response analysis. FINDINGS: Between March 2018 and July 2019, 20 patients with mucinous tumours were treated with BromAc. Seventeen (85%) of patients had at least one treatment-emergent AE. The most frequent treatment-related AEs were CRP rise (n = 16, 80%), WCC rise (n = 11, 55%), fever (n = 7, 35%, grade I) and pain (n = 6, 30%, grade II/III). Serious treatment-related AEs accounted for 12·5% of all AEs. There were no anaphylactic reactions. There were no deaths due to treatment-related AEs. An objective response to treatment was seen in 73·2% of treated sites. CONCLUSION: Based on these preliminary results and our preclinical data, injection of BromAc into mucinous tumours had a manageable safety profile. Considerable mucolytic activity was seen by volume of mucin extracted and radiological appearance. These results support further investigation of BromAC for patients with inoperable mucinous tumours and may provide a new and minimally invasive treatment for these patients.

Barriers in initiating insulin therapy in a South Asian Muslim community.

AIMS: Insulin therapy is often required for optimal glycaemic control. Pakistani patients display reluctance to use insulin. We aimed to determine the reasons for this and to assess impressions after initiation of insulin in our patients. METHODS: Patients with Type 2 diabetes attending Aga Khan Hospital were surveyed using a questionnaire detailing opinions on insulin use. This was a cross-sectional study of two groups, one with no experience with insulin use and the other who were insulin users. RESULTS: Three hundred and seventeen patients were interviewed, 55.8% male, mean age 53.6 years. Of 210 patients who had never used insulin, 72.9% felt insulin was a measure of last resort and 45.2% thought that tolerance developed to insulin. Only 45.7% felt insulin would reduce complications, while 24% thought that insulin use would interfere with religious obligations. Thirty-four percent thought that it was difficult or very difficult to learn insulin administration, 41% felt that they could not self-inject even if absolutely necessary and 25% stated they would not use insulin in any circumstances. There was an association of lack of education with negative image of insulin usage. Among 107 patients using insulin, 52.3% were hesitant before initiation. However, 78.5% noted an improvement in glucose control and 86% said they would recommend insulin to others. CONCLUSIONS: Reluctance to use insulin prior to initiation is high, but views improve considerably after insulin initiation. Further awareness of the benefits of insulin use needs to be highlighted and the concerns of our population addressed.

Production, characterization, in vitro and ex vivo studies of babchi oil-encapsulated nanostructured solid lipid carriers produced by a hot aqueous titration method.

An aqueous dispersion of solid fat nanoparticles of babchi oil (BOSLN) was prepared by means of the hot water titration method. Surface morphology was determined by HR-TEM which revealed a fairly spherical shape of the formulations. Further they were evaluated for in vitro drug release characteristics and ex vivo skin permeation profile, zeta potential and particle diameter, rheological measures and droplet size distribution. Highest values for steady state flux (Jss), permeability coefficient (Kp) and enhancement ratio (Er) were observed for formulation, BOSLN3 comprised of oil [10% v/v; BO (3.33%), CAT (6.67%)], Tween 80 (9.25% v/v), transcutol-P (28.75% v/v) and distilled water (53% v/v). These results suggest that the studied SLN might be promising vehicles for babchi oil in the management of psoriasis.

Evaluation of fine needle aspiration cytology of lymph nodes in Kathmandu Medical College, Teaching hospital.

BACKGROUND: Fine Needle Aspiration Cytology (FNAC) is a simple and rapid diagnostic technique. Because of early availability of results, simplicity, minimal trauma and complications, the aspiration cytology is now considered a valuable diagnostic aid and is part and parcel of a pathologist's repertoire. OBJECTIVES: The aim of the study was to evaluate the results of fine needle aspiration cytology (FNAC) of lymph nodes in our institution in comparison to result of histopathology. MATERIALS AND METHODS: The present study on 130 patients of lymphadenopathy was conducted in the Department of Pathology Kathmandu Medical College Teaching hospital, Kathmandu from June 2006 to May 2008 (2 years). RESULTS: In this series of FNAC cervical lymph nodes were 66 (50.76%), and axillary lymph nodes were 20 (15.38%). Male to female ratio of the patients was 1: 0.9. The age of patients ranged from 3 to 85 years. FNAC diagnosis was found to be as follows : reactive hyperplasia 54( 41.55%), tubercular lymphadenitis 36 (28 %), metastatic carcinoma 16 (12.3%), granulomatous lymphadenitis 12 ( 9.2 % ), lymphoma 8 (6%) and suppurative lymphadenitis 4(3%) . Out of 28 cases of FNAC 26 (92.85%) were consistent with histopathological diagnosis of tubercular lymphadenitis. In metastatic carcinoma to lymph nodes sensitivity and specificity of FNAC were 100% each. CONCLUSION: FNAC is useful and reliable in diagnosing neoplastic and non- neoplastic lesions of lymph nodes. It helps in planning surgery for malignant cases, where definitive operative intervention can be performed in one session.

Anti-inflammatory role of tempol (4-hydroxy-2,2,6,6-tetramethylpiperidin-1-oxyl) in nephroprotection.

Inflammation is one of the mechanisms involved in the acute kidney injury (AKI) caused by cisplatin (CP)-induced nephrotoxicity. Tempol (4-hydroxy-2,2,6,6-tetramethylpiperidin-1-oxyl) has powerful antioxidant activity. We investigated its potential nephroprotective effects and the underlying mechanisms that may add further benefits to its clinical usefulness in a CP-induced AKI model. Male Swiss albino mice were divided randomly into four groups: control, CP (20 mg/kg intraperitoneally), tempol (100 mg/kg/day, per os) + CP, and tempol only treatments. Blood samples were collected to analyze renal function parameters. Immunoblotting and immunohistochemical analysis were used to assess the level and localization of inflammatory markers. Tempol afforded protection to animals from CP-induced elevation of inflammatory markers as indicated by reduced expression of nuclear factor-kappa B, cyclooxygenase-2, and tumor necrosis factor-α in kidney tissue. Histological findings and analysis of kidney function markers corroborated with these findings confirming a nephroprotective role for tempol. In conclusion, this study provides important evidence for the promising anti-inflammatory effects of tempol which appears to contribute significantly to its nephroprotective action.

Role of FNAC in the diagnosis of salivary gland swellings.

OBJECTIVES: The aim of this study was to evaluate the diagnostic accuracy and efficacy of Fine needle aspiration cytology (FNAC) in various salivary gland swellings. MATERIALS AND METHODS: This retrospective study was performed at Kathmandu Medical College Teaching Hospital (KMCTH) from January 2004- December 2006.During this period a total of 978 FNAC's were done out of which 40 FNAC's were on salivary gland swellings. Correlation was done between cytological smear slides and biopsy slides. RESULTS: In this series of FNAC, 16 cases (40%) were benign neoplasms, 5 cases (12.5%) malignant neoplasms, non-neoplastic cysts 3 cases (7.5%) and inflammatory lesions 16 cases (40%).Histopathology was available in 24 cases out of which 22 cases correlated with cytology. There were no false positive reports but false negative result was seen in 4 cases. Sensitivity and specificity were 90% and 100% respectively. CONCLUSION: FNAC is useful in the diagnosis of salivary gland swellings especially in benign conditions with a sensitivity of 90% and specificity of 100%.

Hepatocyte transplantation: a review of laboratory techniques and clinical experiences.

Orthotopic liver transplantation (OLT) is standard clinical practice for patients with severe and end-stage chronic liver disease. However, the chronic shortage of donor livers and parallel growth of the transplant waiting list mean that a substantial proportion of patients die while waiting for a donor liver. Attempts to reduce the waiting list by use of split-liver and living-related live donor techniques have had some impact, but additional approaches to management are vital if the death rate is to be significantly reduced. Extensive laboratory research work and limited clinical trials have shown that hepatocyte transplantation may be useful in bridging some patients to OLT. A major limiting factor has been the shortage of mature functioning human hepatocytes, which are currently mostly obtained from livers rejected for OLT. This review examines potential hepatocyte sources, hepatocyte isolation methods and preservation protocols that have been successfully established, along with an overview of clinical results.

Rapid detection of helicobacter pylori by endoscopic brush cytology and comparison with histopathology.

OBJECTIVES: The main objective of this study was to assess antral brush cytology as an alternate approach for the diagnosis of H. pylori infection as compared to histopathology. METHODS: 75 cases with diagnosis of antral gastritis underwent endoscopic antral biopsy as well as antral brushing cytology was included irrespective of age and sex. Cytological slides were stained with Giemsa stain & biopsy slides were stained with H&E and Giemsa stain. Correlation was done between cytological smear slides and biopsy slides. RESULTS: Among 75 cases, H. pylori were positive in 55 (73.4%) cases of biopsy specimens while in brush cytology it was positive in 48 (64%) cases. In 45 (60%) of 75 cases, H. pylori was seen in both biopsy and brush cytology. CONCLUSION: Endoscopic brush cytology provides an accurate, inexpensive and easy technique in the rapid detection of H.pylori infection.

Fine needle aspiration (FNA) of soft tissue tumours (STT).

OBJECTIVES: The cytological findings of 50 ST Ts were evaluated aiming to determine the role of FNA in diagnosis of STTs METHODS: Fifty patients with soft tissue tumours underwent FNA in the preoperative investigation during a one year period. The smears were stained with Papanicolaou and May-Graunvald Giemsa stains. RESULTS: Forty-four cases were reported as benign, whereas 2 were malignant. Four cases revealed insufficient material. The malignant STTs were small round cell tumour and malignant spindle cell tumour. Cytological and histological correlation could be achieved in 40 cases. The overall sensitivity and specificity were 25% and 100% respectively with overall accuracy of 80%. CONCLUSION: A reliable diagnosis of STTs can be made with FNA when supported by other clinical and other diagnostic data.

Size-dependent superheating in confined Pb(111) films.

Molecular dynamics simulations have been carried out to explore superheating in Pb(111) films confined in an Al(111) matrix. The size dependence of the superheating has been investigated by varying the film size and keeping the host matrix unchanged. Melting is found to initiate in the interior of the film, which suggests intrinsic homogeneous nucleation. The superheating is found to be dependent on the size of the film. Superheating up to 115 K above the bulk melting temperature is achieved. A good agreement between the theoretical calculations, experimental value and the simulated results is obtained.

Lipids increase after solitary pancreas transplantation.

OBJECTIVE: The aims of this study were to determine 1) changes in lipids after solitary pancreas transplantation (SPTX) in patients with type 1 diabetes and 2) factors that influence those changes. RESEARCH DESIGN AND METHODS: Lipids were evaluated prospectively in 24 patients who underwent SPTX. Three were excluded because of early graft failure. The remaining patients (n = 21; 13 men, 8 women) were studied for changes in lipids over time (pre-SPTX, 0-2, 3-6, 7-12, and > 12 months). Glycohemoglobin, serum creatinine, BMI, and medications were also analyzed for their effects on lipid changes. RESULTS: Cholesterol, HDL, and LDL decreased in the immediate postoperative period (0-2 months), whereas triglycerides (TGs) increased (P < 0.05). At 3-6 months, cholesterol, HDL, and TG were higher than before the SPTX, whereas LDL returned to pre-SPTX levels. After 12 months, HDL and TG remained higher than their pre-SPTX levels (P < 0.05). During the study, systolic and diastolic blood pressure increased, renal function decreased, glyco-hemoglobin improved, and weight was unchanged. Changes in cholesterol/HDL ratio, HDL, and TG correlated with changes in prednisone dose (P < 0.05), and changes in TG correlated with changes in creatinine (P < 0.05). The same pattern of lipids occurred in patients prescribed or not prescribed hypolipidemic agents. CONCLUSIONS: Lipids do not improve within the 1st year after SPTX, despite improved glycemic control and blood pressure control, and renal function is worse. These results are in contrast to those reported for combined kidney-pancreas transplantation, where lipids, blood pressure, and renal function improved immediately after transplant. Further studies are needed to determine whether lipids continue to change with time after SPTX. The impact of these changes after SPTX on overall cardiovascular risk is unknown.

In vitro and in vivo inhibition of liver cancer cells by 1,25-dihydroxyvitamin D3.

Inhibitory effects of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) on the proliferation of a variety of cancer cell lines have been extensively reported. We have studied the effect of 1,25-(OH)2D3 (10(-11)-10(-6) M) on the proliferation of a number of human and rat liver cancer cell lines. Additionally, the effect of 1,25-(OH)2D3 (0.02-0.5 microg/kg per day) on the rate of growth of liver cancer cell line xenografts in nude mice was also investigated. In vitro, proliferation of Hep-3B, PLC/PRF/5, and SKHEP-1 cells was significantly inhibited by 1,25-(OH)2D3, while HTC and Novikoff cells were more resistant to the inhibitory effects of the drug. In vivo, treatment of SKHEP-1 tumor bearing nude mice with different doses of 1,25-(OH)2D3 significantly retarded tumor growth without the development of hypercalcemia.

In vitro and in vivo suppression of growth of hepatocellular carcinoma cells by albendazole.

Tubulin protein is a major target of drug molecules, and consequently, tubulin inhibitors have attracted great attention as antimitotic antitumor agents for chemotherapeutic use. It has been shown that, the benzimidazole carbamate group of antiparasitics including albendazole act by inhibiting tubulin polymerization. In this study, albendazole was tested in culture against a range of human, rat and mice hepatocellular carcinoma (HCC) cells and in vivo against human SKHEP-1 tumor growth in nude mice. Albendazole induced a dose-dependent inhibition of [(3)H]thymidine incorporation in all cell lines examined and a dramatic decline in cell numbers in SKHEP-1 cells. The inhibitory effect of albendazole was evident at the 100 nM concentration and at 1000 nM, proliferation in all cell lines examined was inhibited by more than 80%, while, proliferation of HepG2, Hep3B and SKHEP-1 were suppressed by more than 90%, compared to control. Cell cycle analysis revealed that, depending on the dose employed, albendazole can arrest SKHEP-1 cells at both G0-G1 (250 nM) and G2-M (1000 nM) phases of the cycle. Albendazole treatment (300 mg/kg per day oral for 20 days) of nude mice inoculated subcutaneously with SKHEP-1, led to profound suppression of tumor growth. Immunohistochemical analysis of these tumors revealed that compared to control, those treated with albendazole have lower growth fractions. These findings demonstrate that albendazole strongly suppresses both in vitro and in vivo proliferation of HCC cells.

Hemolytic disease of the newborn due to anti-C and anti-G masquerading as anti-D.

After several transfusions with D-negative blood, an O Rh-negative women was apparently sensitized to the C and D antigens. In her prenatal workup, it became evident that she had in fact not been sensitized to D but to G, which initially appeared as anti-D plus anti-C. This sensitization pattern is an unusual occurrence in itself. Moreover, the fetus was affected significantly and was delivered at 32 1/2 weeks with moderate hemolytic disease of the newborn. Consideration is given to points regarding current methods of screening Rh-negative women for transfusion, the use of anti-Rh immune globulin in patients sensitized to anti-C and anti-G, medicolegal implications, and continuous attention to the risk-benefit ratio in decisions to use transfusions.

Acetaminophen overdose with fetal demise.

A case of fetal demise and maternal recovery after acetaminophen overdose is presented, to our knowledge the first reported. Fetal liver and maternal serum concentrations indicate overdose to be the cause of fetal death. Maternal disseminated intravascular coagulation (DIC) may have been related to maternal acetaminophen-induced liver disease alone or to a combination of liver disease and the presence of a dead fetus.

High incidence of false positives by a latex agglutination test for the diagnosis of Clostridium difficile associated colitis in compromised patients.

Detection of Clostridium difficile cytotoxin using cell culture assays for the diagnosis of antibiotic-associated colitis has been used for over a decade. Because the methodology is time consuming and cumbersome, a recently introduced commercial latex agglutination (LA) kit has attracted much attention. We compared the sensitivity and specificity of this method with the cytotoxic assay (CTA) using diarrheal stools from 652 patients at a referral tertiary care center. Specimens from 71 (10.9%) patients were found positive with CTA and 98 (15%) by LA. Of these, 67 stools were positive by both methods. Four specimens showed cytotoxicity but were negative by LA. Of the 31 patient specimens that were positive by LA but negative by CTA, 22 were obtained from leukemic bone marrow transplant and four from renal transplant patients [corrected]. Sixteen of these patients had Giardia lamblia (four), Salmonella enteritidis (three), Blastocystis hominis (five), Rotavirus (two), and Shigella boydii (two) in their stools [corrected]. No significant organisms were found in the rest of the LA-positive and CTA-negative specimens.

Histamine content in colorectal cancer. Are there sufficient levels of histamine to affect lymphocyte function?

Histamine has been found to stimulate growth of colorectal cancer in vitro and in vivo. Histamine has also been found to inhibit lymphocyte activity in vitro at concentrations greater than 10(-7) M. The aim of our study was to determine if the histamine concentrations in human colorectal cancer were sufficient to achieve these effects. We measured the histamine content in 31 colorectal cancer specimens using a radioenzymatic assay. Results were expressed as microgram histamine per gram of fresh tissue weight. Recovery and reproducibility studies were also carried out. The median histamine concentration in colorectal cancer tissue was 8.4 micrograms/g [7.6 x 10(-5)M], ranging from 0.3 microgram/g to 20.6 micrograms/g. The high concentration of histamine in colon cancer is enough to be locally immunosuppressive.