A brief frailty screening tool in Tanzania: external validation and refinement of the B-FIT screen.

BACKGROUND: Identifying older people who are most vulnerable to adverse outcomes is important. This is particularly so in low-resource settings, such as those in sub-Saharan Africa (SSA), where access to social and healthcare services is often limited. AIM: To validate and further refine a frailty screening tool for SSA. METHODS: Phase I screening of people aged 60 years and over was conducted using the Brief Frailty Instrument for Tanzania (B-FIT). In phase II, a stratified, frailty-weighed sample was assessed across a range of variables covering cognition, physical function (including continence, mobility, weakness and exhaustion) nutrition, mood, co-morbidity, sensory impairment, polypharmacy, social support and self-rated health. The frailty-weighted sample was also assessed for frailty according to the comprehensive geriatric assessment (CGA), which we used as our 'gold standard' diagnosis. RESULTS: Of 235 people in the frailty-weighted sample, 91 (38.7%) were frail according to CGA, the median age was 73 years and 136 (57.9%) were female. In multivariable modelling, physical disability (Barthel index), cognitive impairment (IDEA cognitive screen), calf circumference, poor distance vision and problems engaging in social activities were found to be associated with frailty. After developing a scoring system, based on regression coefficients, a modified B-FIT screen (B-FIT 2) had an area under the receiver operating characteristic curve of 0.925, a sensitivity of 86.2% and a specificity of 88.8%. DISCUSSION: The inclusion of items assessing nutrition, social support and sensory impairment improved the performance of the B-FIT. CONCLUSIONS: The B-FIT 2 should be externally validated.

Legal Highs, Lethal Lows.

Novel Psychoactive Substances (NPS), sometimes referred to as Legal Highs, are newly available drugs with psychoactive properties that are not currently prohibited by United Nations Drug Conventions. Despite many of these compounds still being 'legal' and readily available via online mail-order companies and high-street 'headshops', their rapid emergence in the UK has been associated with increasing hospital admissions, enquiries on TOXBASE® and fatalities. It is therefore vital that Acute Physicians have a good understanding of the issues in recognizing, investigating and managing patients presenting to the AMU with toxicity due to legal highs. This article outlines the classification and effects of various novel psychoactive substances and presents a strategy for management according to the prevailing toxidrome.

The clinician, the lab and the patient: Understanding lab diagnostics to eradicate tuberculosis.

BACKGROUND: Diagnostic modalities for diagnosing Tuberculosis caused by Mycobacterium group of organisms include mainly AFB smear by Ziehl Neelsen carbol fuchsin smear microscopy, GeneXpert (CB NAAT) molecular method, Line probe assay (Molecular method) and AFB culture (Liquid automated systems and solid media) methods. METHODS: This study was initiated to understand and prioritize TB lab diagnosis, with reference to selection of lab diagnostic tests and its order of preference for MTC and NTM/MOTT closely associating it with the TB irradication program initiated by the Government of India. RESULT AND CONCLUSION: The results and discussion bring to light the importance of each test and the purpose of their requisition. When diagnosis is handled half heartedly eradication of TB becomes a challenge. All the efforts including planning, resources in the form of manpower, infrastructure, finances, education, time etc., would be hampered. This challenge is not only for India but the globe. For countries harboring TB, Correct diagnostic request and timely diagnosis and treatment is the key to eradication of tuberculosis.

Anaesthetic management of robot-assisted laparoscopic surgery.

Recent trend shows that minimally invasive surgery is in great demand. Robot-assisted procedures have become more popular, as they overcome several drawbacks of traditional laparoscopic techniques. Robotic surgery, however, might necessitate changes in how patients are positioned and how staff and equipment are organised generally, which might go against the traditional approach to anaesthesia care. The novel effects of this technology have the potential to produce paradigm-shifting therapeutic improvements. To provide better anaesthetic treatment and advance patient safety, anaesthesiologists should be aware of these developments by understanding the fundamental components of robotic surgical systems.

Nanocapsular dispersion of thymol for enhanced dispersibility and increased antimicrobial effectiveness against Escherichia coli O157:H7 and Listeria monocytogenes in model food systems.

Essential oils are marginally soluble in water, making it challenging to evenly disperse them in foods and resulting in an increased tendency to bind with food lipids and proteins, resulting in lowered antimicrobial efficacy. In the current study, free and nano-dispersed (ND) thymol were compared in terms of their antimicrobial efficacies against Escherichia coli O157:H7 ATCC 43889 and 43894 and Listeria monocytogenes strains Scott A and 101 in apple cider and 2% reduced-fat milk. Apple cider was adjusted to pHs 5.5 and 3.5, and antimicrobial tests were performed at 0.3-, 0.5-, 0.75-, and 1.0-g/liter thymol concentrations at 35, 32, 25, and 4°C. Overall, 0.5 and 1.0 g/liter thymol in nano-dispersion and along with free thymol were inhibitory and bactericidal, respectively, against bacterial strains under all treatment conditions. At pH 5.5, 0.5 g/liter ND thymol was bacteriostatic against L. monocytogenes and E. coli for up to 48 h. At pH 3.5, L. monocytogenes controls did not survive beyond 12 h but E. coli survived and was inhibited by 0.5 g/liter ND thymol after 12 and 48 h in apple cider. E. coli strains were significantly sensitive to 4°C and pH 3.5 (P < 0.05). When bacteria were tested in 2% reduced-fat milk at 35 or 32°C, ND and free thymol demonstrated inhibition at 4.5 g/liter. Thus, the current technology seems to be promising and novel, enabling thymol-containing nano-dispersions that are not only transparent but also effective against pathogens in food applications, especially in clear beverages.

Erector spinae plane block for postoperative analgesia following percutaneous nephrolithotomy under spinal anaesthesia- A randomised controlled study.

Background and Aims: Postoperative pain is a multitude of various irksome sensory, emotional and mental experiences aggravated by surgical trauma and associated with autonomic, endocrine, metabolic, physiological and behavioural responses. The aim of this study was to evaluate the effect of erector spinae plane block (ESPB) in postoperative analgesia following percutaneous nephrolithotomy (PCNL) under spinal anaesthesia. Methods: This prospective randomised study was conducted on sixty American Society of Anesthesiologists physical status I and II patients scheduled for PCNL under spinal anaesthesia. They were randomised into two equal groups of thirty patients. ESPB was given in group A with 20 ml of injection bupivacaine 0.25% and dexamethasone 8 mg and group B received injection tramadol 1.5 mg/kg intravenously immediately after PCNL. The primary outcome was comparison of visual analogue scale (VAS) score in the first 24 h postoperatively, whereas secondary objectives included hemodynamic variables and requirement of rescue analgesia. Results: VAS score in group A (ESPB) with mean of 3.15 ± 0.68 was comparatively low when compared to group B with mean of 6.61 ± 0.50 at 6 hours. After 4 h postoperatively, VAS scores continued to be higher and significant number of patients required rescue analgesia in group B. Conclusion: ESPB reduced VAS score, provided adequate postoperative analgesia, with similar haemodynamic changes and adverse effects in comparison to the conventional analgesia with tramadol in PCNL.

Antimicrobial Resistance Surveillance in Typhoidal Salmonella in Ahmedabad in an Era of Global Antimicrobial Resistance Surveillance Systems.

INTRODUCTION: India possibly carries the highest burden of antimicrobial resistant typhoidal salmonellae in the world. We report on the health-care ecosystem that produces data on antimicrobial resistance (AMR) testing and the resistance patterns of typhoidal Salmonella isolates in the city of Ahmedabad. MATERIALS AND METHODS: Through municipality records and internet searches, we identified 1696 private and 83 public laboratories in the city; 4 medical colleges, 4 health-care institution attached laboratories, and 4 corporate laboratories (CLs) were performing culture and antibiotic sensitivity testing (AST), but only 2 medical colleges and 1 CL shared their data with us. There was considerable variation in culturing and sensitivity testing methodology across laboratories. RESULTS: Out of 51,260 blood cultures, Salmonella isolates were detected in only 146 (0.28%). AST was conducted on 124 isolates, of which 67 (54%) were found resistant. Multidrug resistance was absent. Concurrent resistance to more than one antibiotic was very high, 88%, among the 67 resistant isolates. Ciprofloxacin resistance varied widely between the private and public sector laboratories. Notably, isolates from the private sector laboratory showed complete resistance to azithromycin. CONCLUSIONS: High resistance to ciprofloxacin and azithromycin observed in Ahmedabad may be due to the increased use of these two antibiotics in the public and private sectors, respectively. The need of the hour is to identify a representative sample of laboratories from both the public and the private sectors and encourage them to participate in the national AMR surveillance network.

Anti-leukemic and anti-angiogenic effects of d-Limonene on K562-implanted C57BL/6 mice and the chick chorioallantoic membrane model.

BACKGROUND: d-Limonene, a monoterpene from citrus fruit has been found to have chemopreventive and chemotherapeutic activities in various types of cancers. In this study, we evaluated the in vivo effect of d-Limonene on a K562-induced model of chronic myeloid leukemia (CML) in C57BL/6 mice. METHOD: The tail vein injection model of K562 cells in immunocompromised C57BL/6 mice was developed and evaluated for characteristics of the disease. The mice were treated with d-Limonene and evaluated for haematological parameters. We also evaluated the effect of d-Limonene on angiogenesis using the chick chorioallantoic membrane (CAM) assay. RESULTS: In a complete blood count, a significant dose-dependent reduction in white blood cell, neutrophil and lymphocyte counts, but an elevation in red blood cell count and haemoglobin content was observed with d-Limonene treatment compared to the disease control or untreated group. In the CAM assay, d-Limonene produced a significant dose-dependent reduction in number of blood vessels in treatment groups compared to the vehicle-treated group. CONCLUSION: These studies suggest promising anti-leukemic and anti-angiogenic effects of d-Limonene in the treatment of CML.

Prevalence of Frailty in Older Community-Dwelling Tanzanians According to Comprehensive Geriatric Assessment.

OBJECTIVES: To investigate the prevalence of frailty using a Comprehensive Geriatric Assessment (CGA) in older community-dwelling adults living in rural northern Tanzania. DESIGN: Cross-sectional survey. SETTING: Five randomly selected villages in Hai District, Kilimanjaro region, Tanzania. PARTICIPANTS: All adults aged 60 and older living in the selected villages were eligible to participate, including older adults with cognitive impairment provided a close relative was able to assent on their behalf. All participants were community dwelling because institutionalization is very rare. MEASUREMENTS: Participants were screened using a short frailty screening tool, the Brief Frailty Instrument for Tanzania (B-FIT), comprising an abbreviated test of cognitive function and the Barthel Index, which assesses functional independence. Based on B-FIT score, a frailty-weighted, stratified sample was selected for in-depth assessment using CGA and characterized as frail or not frail. RESULTS: Two hundred thirty-six CGAs were performed in 1,207 people screened, 91 of whom were deemed frail. After adjusting for stratification, the prevalence of frailty was 19.1% (95% confidence interval=15.2-23.1). CONCLUSION: This is the first study in sub-Saharan Africa to report the prevalence of frailty in community-dwelling older adults according to a CGA. The strengths of reporting frailty according to a CGA include the ability to consider likely medical diagnoses based on clinical assessment and to assess individuals' social circumstances and environment.

Mutation analysis of BRCA1/2 mutations with special reference to polymorphic SNPs in Indian breast cancer patients.

BACKGROUND: Germline mutations BRCA1 and BRCA2 contribute almost equally in the causation of breast cancer (BC). The type of mutations in the Indian population that cause this condition is largely unknown. PURPOSE: In this cohort, 79 randomized BC patients were screened for various types of BRCA1 and BRCA2 mutations including frameshift, nonsense, missense, in-frame and splice site types. MATERIALS AND METHODS: The purified extracted DNA of each referral patient was subjected to Sanger gene sequencing using Codon Code Analyzer and Mutation Surveyor and next-generation sequencing (NGS) methods with Ion torrent software, after appropriate care. RESULTS: The data revealed that 35 cases were positive for BRCA1 or BRCA2 (35/79: 44.3%). BRCA2 mutations were higher (52.4%) than BRCA1 mutations (47.6%). Five novel mutations detected in this study were p.pro163 frameshift, p.asn997 frameshift, p.ser148 frameshift and two splice site single-nucleotide polymorphisms (SNPs). Additionally, four nonsense and one in-frame deletion were identified, which all seemed to be pathogenic. Polymorphic SNPs contributed the highest percentage of mutations (72/82: 87.8%) and contributed to pathogenic, likely pathogenic, likely benign, benign and variant of unknown significance (VUS). Young age groups (20-60 years) had a high frequency of germline mutations (62/82;75.6%) in the Indian population. CONCLUSION: This study suggested that polymorphic SNPs contributed a high percentage of mutations along with five novel types. Younger age groups are prone to having BC with a higher mutational rate. Furthermore, the SNPs detected in exons 10, 11 and 16 of BRCA1 and BRCA2 were higher than those in other exons 2, 3 and 9 polymorphic sites in two germline genes. These may be contributory for BC although missense types are known to be susceptible for cancer depending on the type of amino acid replaced in the protein and associated with pathologic events. Accordingly, appropriate counseling and treatment may be suggested.

Resolution of ipilimumab induced severe hepatotoxicity with triple immunosuppressants therapy.

We describe a case of a patient from Far North Queensland, Australia, with life-threatening hepatotoxicity caused by ipilimumab induced immune-related adverse events (irAEs). Our patient presented with non-specific symptoms including malaise, lethargy and fevers. Her work up revealed acute hepatitis, which was presumed to be related to ipilimumab treatment for her metastatic melanoma. Causality for ipilimumab was assessed with the CIOMS scale (Council for International Organizations of Medical Sciences) and provided a causality level of 'highly probable' (score +9). She was started on methylprednisolone as per guidelines for ipilimumab induced irAEs. On the second day of treatment her transaminases enzymes unexpectedly rose several hundred times. Investigations for other causes of acute hepatitis including abdominal imaging were negative. She was started up front on equine antithymocyte globulin, mycophenolate moefetil and continued on methylprednisolone. She recovered clinically and biochemically in 2 weeks and continues to remain well.

Evaluation of bupivacaine-clonidine combination for unilateral spinal anesthesia in lower limb below-knee orthopedic surgery.

BACKGROUND AND OBJECTIVES: The purposes of this study were to evaluate the onset, quality and duration of sensory and motor blockade between hyperbaric bupivacaine and clonidine combination with bupivacaine alone when administered intrathecally for unilateral spinal anesthesia in below-knee orthopedic surgery, efficacy of clonidine for post-operative analgesia and side-effects of clonidine, if any. METHODS: Sixty ASA I and ASA II patients scheduled for elective surgery with time duration up to 90 min were studied. Patients were randomised in two equal groups by the lottery method. Group A (control group) was given Inj. bupivacaine (hyperbaric) 0.5% - 12.5 mg (2.5 ml) + 0.5 ml of normal saline intrathecally. Group B (clonidine group) was given Inj. bupivacaine (hyperbaric) 0.5% - 12.5 mg (2.5 ml) + 50 mcg clonidine in 0.5 ml volume intrathecally. RESULTS: The mean peak sensory block was earlier in Group B (4.7±1.23 min) as compared with Group A (6.27±1.51 min). The mean peak motor block was earlier in Group B (6.17±1.20 min) as compared with Group A (8.63±1.71 min). The two-segment regression of sensory block was longer in Group B (106.23±9.17 min) as compared with Group A (104.43±17.75 min), which is clinically significant. Requirement of rescue analgesia was considerably prolonged in Group B (450.33±95.10 min) as compared with Group A (220±36.36 min), which was also clinically highly significant. CONCLUSION: Intrathecal clonidine potentiates bupivacaine induced spinal sensory block and, motor block and reduces the analgesic requirement in the early post-operative period in unilateral spinal anesthesia for lower limb below knee surgery.

Caco-2 accumulation of lutein is greater from human milk than from infant formula despite similar bioaccessibility.

SCOPE: Clinical evidence suggests that the bioavailability of lutein is lower from infant formula than from human milk. The purpose of this study was to assess characteristics of human milk and lutein-fortified infant formula that may impact carotenoid delivery. METHODS AND RESULTS: Carotenoid bioaccessibility and intestinal absorption were modeled by in vitro digestion coupled with Caco-2 human intestinal cell culture. Twelve human milk samples were assessed from 1-6 months postpartum, and 10 lutein-fortified infant formula samples from three lutein sources in both ready-to-use and reconstituted powder forms. The relative bioaccessibility of lutein was not different (p > 0.05) between human milk (29 ± 2%) and infant formula (36 ± 4%). However, lutein delivery was 4.5 times greater from human milk than infant formula when including Caco-2 accumulation efficiency. Caco-2 accumulation of lutein was increasingly efficient with decreasing concentration of lutein from milk. Carotenoid bioaccessibility and Caco-2 accumulation were not affected by lactation stage, total lipid content, lutein source, or form of infant formula (powder vs. liquid). CONCLUSION: These data suggest that the bioavailability of carotenoids is greater from human milk than infant formula primarily due to intestinal absorptive processes, and that absorption of lutein is potentiated by factors from human milk especially at low lutein concentration.

Antimicrobial activity of nanodispersed thymol in tryptic soy broth.

Food safety is a continuing challenge for the food industry due to sporadic illness outbreaks caused by foodborne pathogens. Plant essential oils have been studied extensively as natural antimicrobials to control foodborne pathogens. However, their hydrophobic nature makes application in foods difficult because of their low water solubility, adverse impact on sensory quality, and binding with food components, which can interfere with antimicrobial efficacy. The objective of this study was to characterize antimicrobial activities of transparent nanodispersions of thymol encapsulated in whey protein isolate-maltodextrin conjugates, with comparison to free thymol. Tests were conducted for Escherichia coli O157:H7 strains ATCC 43889 and 43894, Salmonella Typhimurium strain 2576, Listeria monocytogenes strains Scott A and 101, and Staphylococcus aureus strains 27708 and SA113 in tryptic soy broth at various pHs and temperatures. Results indicate that the MIC for nanodispersed and free thymol against all strains of both gram-negative and gram-positive pathogens tested was 500 ppm at pH 6.8 and at the optimal growth temperature, with the exception of E. coli O157:H7 and L. monocytogenes strain Scott A, which were inhibited by 300 ppm of free thymol. Nanodispersed thymol was further tested at 500 ppm for inhibition of E. coli O157:H7 and L. monocytogenes at 35, 32, 25, and 4°C in tryptic soy broth adjusted to pH 5.5 and 3.5. At pH 5.5, L. monocytogenes was completely inhibited after 3 h, and E. coli O157:H7 showed a reduction of 1.0 to 3.0 log CFU/ml after 48 h. At pH 3.5, L. monocytogenes controls did not grow, but E. coli O157:H7 survived. At both pH 5.5 and 3.5, no significant effect of temperature on antimicrobial activity was observed at 500 mg/ml nanodispersed thymol. The present study demonstrated that transparent nanodispersions of thymol have promising antimicrobial activity against a broad spectrum of foodborne pathogens.

Nanodispersed eugenol has improved antimicrobial activity against Escherichia coli O157:H7 and Listeria monocytogenes in bovine milk.

There has been great interest in intervention strategies based on plant essential oils to control pathogens such as Escherichia coli O157:H7 and Listeria monocytogenes (Lm). However, the poor solubility of essential oils in water makes it difficult to disperse evenly in food matrices, impacting food quality and antimicrobial efficacy. In the present study, eugenol was dispersed in nanocapsules prepared with conjugates of whey protein isolate (WPI) and maltodextrin (MD, of various chain lengths). When eugenol was encapsulated in the conjugate made with MD40 at a WPI:MD mass ratio of 1:2, the nanodispersion was transparent and was characterized for antimicrobial efficacy against E. coli O157:H7 strains ATCC 43889 and 43894, and Lm strains Scott A and 101 in tryptic soy broth (TSB) and milk with different fat levels (whole, 2% reduced fat, and skim) at 35 or 32 °C, with comparison to the same levels of free eugenol. In TSB, antimicrobial efficacy of nanodispersed eugenol against E. coli O157:H7 and Lm was not improved, with minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) values being 0.25 g/L higher than those of free eugenol. Free eugenol performed better in TSB because there was no interfering compound and the MIC and MBC were below the solubility of eugenol. In milk, nanodispersed eugenol was consistently observed to be more effective than free eugenol, with MIC and MBC values above the solubility limit of eugenol. The nanodispersed eugenol was speculated to be evenly distributed in food matrices at concentrations above the solubility limit and supplied the antimicrobial locally when the binding caused eugenol level below the inhibition requirement. Nanodispersed eugenol thus provides a novel approach for incorporation in foods to improve antimicrobial efficacy without changing turbidity.