Reducing post-operative length of stay, is it worth the effort?

BACKGROUND: Studies show that reducing the length of hospital stay (LOS) for surgical patients leads to cost savings. We hypothesize that LOS has a nonlinear relationship to cost of care and reduction may not have a meaningful impact on it. We have attempted to define the relationship of LOS to cost of care. We utilized the itemized bill, generated in real time, for hospital services. MATERIALS: Adult patients admitted under General, Neuro, and Orthopedic surgery over a 3-month period, with an LOS between 4 and 14 days, were the study population. Itemized bill details were analyzed. Charges in Pakistani rupees were converted to US dollar. Ethical exemption for study was obtained. RESULTS: Of the 853 patients, 38% were admitted to General Surgery, 27% to Neurosurgery, and 35% to Orthopedics. A total of 64% of the patients had an LOS between 4 and 6 days; 36% had an LOS between 7 and 14 days. Operated and conservatively managed constituted 82% and 18%, respectively. Mean total charge for operated patients was higher $3387 versus $1347 for non-operated ones. LOS was seen to have a nonlinear relationship to in-hospital cost of care. The bulk of cost was centered on the day of surgery. This was consistent across all services. The last day of stay contributed 2.4%-3.2% of total charge. CONCLUSIONS: For surgical patients, the cost implications rapidly taper in the postoperative period. The contribution of the last day of stay cost to total cost is small. For meaningful cost containment, focus needs to be on the immediate perioperative period.

Citric Acid Confers Broad Antibiotic Tolerance through Alteration of Bacterial Metabolism and Oxidative Stress.

Antibiotic tolerance has become an increasingly serious crisis that has seriously threatened global public health. However, little is known about the exogenous factors that can trigger the development of antibiotic tolerance, both in vivo and in vitro. Herein, we found that the addition of citric acid, which is used in many fields, obviously weakened the bactericidal activity of antibiotics against various bacterial pathogens. This mechanistic study shows that citric acid activated the glyoxylate cycle by inhibiting ATP production in bacteria, reduced cell respiration levels, and inhibited the bacterial tricarboxylic acid cycle (TCA cycle). In addition, citric acid reduced the oxidative stress ability of bacteria, which led to an imbalance in the bacterial oxidation-antioxidant system. These effects together induced the bacteria to produce antibiotic tolerance. Surprisingly, the addition of succinic acid and xanthine could reverse the antibiotic tolerance induced by citric acid in vitro and in animal infection models. In conclusion, these findings provide new insights into the potential risks of citric acid usage and the relationship between antibiotic tolerance and bacterial metabolism.

Isolation and partial characterization of a novel bacteriocin from Pseudomonas azotoformans with antimicrobial activity against Pasterella multocida.

In this study, a bacteriocin PA996 isolated from Pseudomonas azotoformans (P. azotoformans) was purified to homogeneity by ammonium sulphate precipitation and SP-Sepharose column chromatography. P. azotoformans began to grow at 6 h, reached exponential phase at 12-18 h. Bacteriocin PA996 was produced at 18 h and reached a maximum level of 2400 AU/mL. The molecular mass of purified bacteriocin PA996 was estimated by SDS-PAGE and its molecular mass was approximately 50 kDa. By screening in vitro, the bacteriocin PA996 showed an antimicrobial activity against Pasteurella multocida (P. multocida). The bacteriocin PA996 showed antibacterial activity in the range of pH2-10 and it was heat labile. The inhibitory activities were diminished after treatment with proteinase K, trypsin and papain, respectively, while catalase treatment was ineffective. The minimal inhibitory concentration (MIC) and bactericidal kinetics curves showed that the bacteriocin PA996 had a good inhibitory ability against P. multocida. Our data indicate that bacteriocin PA996 could inhibit the growth of P. maltocida and it may have the potential to apply as an alternative therapeutic drug.

Chemical profiling, HPLC characterization and in-vitro antioxidant potential of Pakistani propolis collected from peripheral region of Faisalabad.

Propolis is a highly adhesive and resinous product of honey bee (Apis mellifera L.) which is produced from the exudations of plants. Bee propolis being a source of bioactive compounds like polyphenols and flavonoids imparts numerous biological properties including, antioxidant, anti-inflammatory, antimicrobial and anticancer activities. Present study was designed to elucidate the composition and antioxidant status of locally available propolis using in-vitro conditions. Propolis collected from locally found apiaries and its hydroalcoholic extract of propolis was prepared using different concentrations of ethanol and methanol. The results regarding proximate composition of propolis showed a higher proportion of ether extract (85.59±0.87%) and lowest contents of crude fiber (0.31±0.08%). Among the mineral's sodium, potassium and calcium was found in a concentration of 11.33±0.91, 52.10±2.9 and 10.53±0.83.59±0.23mg/Kg respectively whilst zinc was noticed as 3.59±0.23mg/Kg. HPLC characterization indicates a highest concentration of Chlorogenic acid 31.80±2.56mg/Kg whereas gallic acid (0.21±0.01mg/Kg) was found in lowest concentration among the polyphenols. Ethanol extract represents more phenolic contents, DPPH activity and antioxidant status as 327.30±14.89mg/gGAE, 73.18±4.43% and 60.59±4.38% accordingly in comparison to methanol and water extract. Bee propolis found an effective source of natural antioxidants which retards the production of free radicals and reactive oxygen species thus help to cope oxidative stress.

Preventive role of propolis against hyperglycemia and hyperlipidemia in Sprague dawley rats (Rattus norvegicus) animal modelling system.

Human diets with functional ingredients showed promising role in management of diseases of modern age like hyperglycemia and hyperlipidemia and even cancer. The study designed to elucidate role of honeybee propolis for management of hyperglycemia and hyperlipidemia states through animal modeling system. Hydroalcoholic extract of propolis was used for development of functional drink with standard recipe and addition of specified dose of extracts (400mg/500mL). Animals were grouped into three studies including study-I fed on regular diet, study-II fed on sucrose enrich diet and study-III fed on diet enriched with cholesterol and monitored to evaluate the results. Various parameters like feed consumption, liquid intake of animals measured regularly whereas body weight recorded at the end of each week of study. At the end of the study animals were analyzed for different blood indicators like blood lipid indices (cholesterol, LDL, HDL concentration and triglyceride contents)), glucose concentration and insulin contents as well. The maximum feed and drink intake were examined in animals, fed with control diet whereas a non substantial mode of intake was recorded in rest of two groups of animals. The consumption of honeybee propolis based drink reduced cholesterol (6.63% to 10.25%) and LDL (9.96% to 11.23%), whilst a sharp increase in HDL level was ranged as 4.12 to 4.49% among animal groups fed with high cholesterol and high sucrose diet. Blood glucose level was decreased by 10.25% and 6.98% however 6.99% and 4.51% increase were observed in plasma insulin level in both studies, study-II and study-III correspondingly. The overall findings of the study showed that drinks prepared using propolis of propolis found effective for management of hyperglycemia and hypercholesterolemia in present animal modelling system.

Non-enzymatic electrochemical dopamine sensing probe based on hexagonal shape zinc-doped cobalt oxide (Zn-Co2O4) nanostructure.

A non-enzymatic dopamine electrochemical sensing probe was developed. A hexagonal shape zinc-doped cobalt oxide (Zn-Co2O4) nanostructure was prepared by a facile hydrothermal approach. The combination of Zn, which has an abundance of electrons, and Co3O4 exhibited a synergistically electron-rich nanocomposite. The crystallinity of the nanostructure was investigated using X-ray diffraction. A scanning electron microscope (SEM) was used to examine the surface morphology, revealing hexagonal nanoparticles with an average particle size of 400 nm. High-resolution transmission electron microscopy (HR-TEM) was used to confirm the nanostructure of the doped material. The nanostructure's bonding and functional groups were verified using Fourier transform infrared spectroscopy (FTIR). The electrochemical characterization was conducted by using electrochemical impedance spectroscopy (EIS), cyclic voltammetry (CV), and amperometry. The resistivity of the electrode was confirmed through EIS and showed that the bare glassy carbon electrode (GCE) exhibited higher charge transfer resistance as compared to modified Zn-Co2O4/GCE. The sensing probe was developed by modifying the surface of GCE with Zn-Co2O4 nanostructure and tested as an electrochemical sensor for dopamine oxidation; it operated best at a working potential of 0.17 V (vs Ag/AgCl). The developed sensor exhibited a low limit of detection (0.002 µM), a high sensitivity (126 µA. µM-1 cm-2), and a wide linear range (0.2 to 185 µM). The sensor showed a short response time of < 1 s. The sensor's selectivity was investigated in the presence of coexisting species (uric acid, ascorbic acid, adrenaline, epinephrine, norepinephrine, histamine, serotonin, tyramine, phenethylamine, and glucose) with no effects on dopamine determination results. The developed sensor was also successfully used for determining dopamine concentrations in a real sample.

Ascorbic acid antagonizes the sedative effect of diazepam possibly through inhibition of GABA(Aρ1) and GABA(B1) receptors.

Gamma-aminobutyric acid (GABA) receptors belong to a ligand-gated ion channels family and are markedly expressed at the axon terminals of retinal bipolar cells. Ascorbic acid (AA), a known and vital antioxidant in the brain can modulate GABA receptors. We postulate that AA would antagonize benzodiazepines' effect via GABA receptor(s) interacting pathway. Here, we evaluated the modulatory sedative effect of AA on diazepam (DZP)'s anxiolytic effects in Swiss albino mice. The anxiolytic study was accomplished by using open-field, hole-board, and by swing and light-dark tests taking DZP as a standard anxiolytic drug. To understand the possible modulatory effects of AA, animals were co-administered with AA and DZP and/or its antagonist flumazenil (FLU). Additionally, an in-silico study was undertaken against GABA(A1), GABA(B1), and GABA(Aρ1) receptors. Data suggest that AA at 25 mg/kg (i.p.) increased (p<0.05) the number of field cross, rearing, number of hole cross, and swing and residence, while decreased grooming and dark residence parameters as compared to the control and DZP groups. In addition, AA and/or FLU combined with DZP (2 mg/kg, i.p.) reversed DZP-mediated sedative effects in mice. Results from in silico study suggest that AA has good interactions with GABA(Aρ1) and GABA(B1) receptors. In conclusion, DZP is a GABA receptor agonist and AA may reverse DZP-mediated sedative effects in a non-competitive binding fashion in mice through inhibition of GABA(Aρ1) and GABA(B1) receptors.

Untargeted profiling of field cultivated bush tea (Athrixia phylicoides DC.) based on metabolite analysis.

Bush tea (Athrixia phylicoides DC.) is an aromatic South African indigenous plant used for many decades as a health beverage and medicine. Several studies have extensively investigated wild bush tea's secondary metabolites, but the entire profiling of cultivated bush tea's metabolites is limited in the literature. Thus, the objective of this study was to profile cultivated bush tea metabolites using liquid chromatography-quadrupole time of flight-tandem mass spectrometry (LC-QTOF-MS). The 31 metabolites profiled included; benjaminamide, chlorogenate, chrysosplenetin, coumarin, 6Z-docosenamide, naringenin 7-O-ß-d-glucoside, 5-p-coumaroylquinic acid, integrastatin A, luteolin 7-O-(6-O-malonyl-ß-d-glucoside), 1,3-dicaffeoylquinic acid, magnoshinin, okanin, (2S)-5-hydroxy-7-methoxy-6,8-dimethylflavanone, (9Z,12Z,15Z)-octadecatrienoic acid, 2″-deamino-2″-hydroxy-6″-dehydroparomamine, O-butanoylcarnitine, myricitrin, gorlic acid, tetracenomycin X, sakuranin, d-tryptophan, linoleamide, laricitrin 7-monoglucoside, l-ß-phenylalanine, l-proline, pheophytin A, pheophorbide A, PI(18:0/20:4(8Z,11Z,14Z,17Z), stearidonic acid, and gibberellin A14 aldehyde. These annotated metabolites included phenolics, flavonoids, and quinic acids, indicating that bush tea is rich in metabolites, which have a potential wide range of health benefits.

Palmatine antioxidant and anti-acetylcholinesterase activities: A pre-clinical assessment.

There is evidence that palmatine (PA), an alkaloid isolated from the Guatteria friesiana plant, has some important biological activities, including anti-inflammatory and antidepressant effects. In this study, the antioxidant and anti-acetylcholinesterase (AChE) effects of PA were assessed. The antioxidant capacity was evaluated in vitro and in vivo through 7 distinct assays, and the anti-AChE activity was determined in vitro. The standards, trolox and ascorbic acid were used for the in vitro antioxidant test, while hydrogen peroxide was selected as a stressor for the Saccharomyces cerevisiae test. Additionally, PA was also combined with trolox and ascorbic acid to determine the likelihood of synergistic effects occurrence to what concerns to antioxidant potential. PA exhibited a potent and concentration-dependent antioxidant potential, although a stronger antioxidant activity was stated using the PA + trolox combination. PA was also found to inhibit AChE activity when compared to the negative control. Thus, PA may be viewed as a promissory phytotherapeutic agent to manage oxidative stress-mediated neurological diseases, especially the Alzheimer's and Parkinson's diseases.

Modulatory-antibiotic activity of the essential oil from Eucalyptus citriodora against MDR bacterial strains.

The growing number of bacterial strains resistant to therapeutic agents has been surpassing the various antibiotics developed by the chemical and pharmaceutical industries. This problem has driven the development of research using agents with antimicrobial potential, with an emphasis on plant-derived natural products. This study evaluated the chemical compounds present in Eucalyptus citriodora essential oil (EOEc) cultivated in northeastern Brazil and its properties as an antibacterial agent and resistance modifier against methicillin-resistant Staphylococcus aureus (MRSA) and ß-lactamase-producing strains. The EOEc was obtained using the hydrodistillation method, later analyzed by GC/MS, presenting a total of twelve compounds, with citronellal (65.45%); citronellol (14.87%); isopulegol (11.80%) and citronellyl acetate (2.51%) as its main constituents. The microdilution test was used to determine the minimum inhibitory concentration (MIC) and the bacterial resistance modulation of the essential oil. The EOEc did not present significant activity against the tested strains (MIC > 1000 µg mL-1). However, when evaluating the capacity of the EOEc to modify the resistance of S. aureus and E. coli strains to different antimicrobials, synergistic effects were obtained with reduced MIC values for all tested antibiotics being obtained. The EOEc showed antimicrobial and ß-lactam optimizing potential against resistant strains, presenting itself as a possible alternative for the use of these drugs at concentrations lower than those indicated against resistant strains.

Phytochemical characterization of the Ziziphus joazeiro Mart. metabolites by UPLC-QTOF and antifungal activity evaluation.

The aim of this study was to evaluate the antifungal and modulatory potential of the Ziziphus joazeiro bark and leaf extracts, both in isolation and in association with fluconazole, against resistant species from the Candida genus. Antifungal assays were used to determine the half maximal inhibitory concentration (IC50) of the extract in isolation and in combination with fluconazole using the broth microdilution method and spectrophotometric readings, followed by verification of the minimum fungicidal concentration by solid medium subculture. According to the cell viability curve, both extracts inhibited fungal growth in a concentration dependent manner, in addition to showing inhibitory concentrations similar to fluconazole. However, the extracts behaved in a fungistatic manner with minimum inhibitory concentration > 8.19 mg/mL and IC50 values ranging from 0.450 mg/mL to 9 mg/mL. The minimum inhibitory concentration for both extracts decreased when in combination with fluconazole, with the AEL standing out against Candida albicans URM 4387, displaying an IC50 equal to that of fluconazole (0.002 mg/mL). Nevertheless, fluconazole antagonism was observed against the tested strains. Overall, the evaluation of both extracts against Candida spp. presented inhibitory concentration values greater than fluconazole. Moreover, despite these being chemically complex crude extracts, they did demonstrate antifungal effects and properties that concur with their ethno-biological aspect.

Antitumor effects of citrinin in an animal model of Sarcoma 180 via cytogenetic mechanisms.

Citrinin (CIT) is a cytotoxic, hepatotoxic, nephrotoxic and cardiotoxic metabolite obtained from Penicillium citrinum, that has been increasingly searched as an anticancer drug candidate. In this study, we assessed the antitumor effects of citrinin, using cytogenetic biomarkers for genotoxicity in Sarcoma 180 (S-180) ascitic fluid cells of mice. Citrinin, extracted from P. citrinum acetonitrile extract, was characterized by LC-MS. Cytotoxic assessment was done through using comet (alkaline version) and micronucleus assays. In S-180 cells, CI50 of CIT was 3.77 µg/mL, while at 12.5 and 100 µg/mL, CIT was as cytotoxic as doxorubicin (2 µg/mL). At 0.5, 1.0 and 2.0 µg/mL, it induced genotoxicity and mutagenicity in S-180 cells, especially at 2 µg/mL, triggering oxidative damage similar to hydrogen peroxide (10 mM). The antitumor effects were evidenced by a marked increase in S-180 cells apoptosis and necrosis due to clastogenic and/or aneugenic cytogenetic effects (micronucleus formation), as well as by induction of nucleoplasm bridges and nuclear buds, culminating in S-180 apoptosis and necrosis. CIT has potential as drug candidate for antitumor purposesbyinvolving cytogenetic mechanisms.

High Cell Selectivity and Bactericidal Mechanism of Symmetric Peptides Centered on d-Pro-Gly Pairs.

Antimicrobial peptides (AMPs) have a unique action mechanism that can help to solve global problems in antibiotic resistance. However, their low therapeutic index and poor stability seriously hamper their development as therapeutic agents. In order to overcome these problems, we designed peptides based on the sequence template XXRXXRRzzRRXXRXX-NH2, where X represents a hydrophobic amino acid like Phe (F), Ile (I), and Leu (L), while zz represents Gly-Gly (GG) or d-Pro-Gly (pG). Showing effective antimicrobial activity against Gram-negative bacteria and low toxicity, designed peptides had a tendency to form an α-helical structure in membrane-mimetic environments. Among them, peptide LRpG (X: L, zz: pG) showed the highest geometric mean average treatment index (GMTI = 73.1), better salt, temperature and pH stability, and an additive effect with conventional antibiotics. Peptide LRpG played the role of anti-Gram-negative bacteria through destroying the cell membrane. In addition, peptide LRpG also exhibited an anti-inflammatory activity by effectively neutralizing endotoxin. Briefly, peptide LRpG has the potential to serve as a therapeutic agent to reduce antibiotic resistance owing to its high therapeutic index and great stability.

A computational structural analysis of functional attributes of hypodermin A and B proteins: A way forward for vaccine development.

Hypodermosis is a parasitic disease of cattle. The pathogenicity of the disease is attributed to Hypodermin proteins (Hypodermin A, Hypodermin B and Hypodermin C). Studies suggest that Hypodermin proteins may be defined as Serine proteases and collagenases. The structure of both proteases Hypodermin A and Hypodermin B were modeled using the Swiss-model server followed by its validation using Procheck, Errat and Verify-3D. Afterwards, both Hypodermin A and Hypodermin B were docked against collagen in order to study its interaction with respective Hypodermin proteins. The structure of both Hypodermin A and Hypodermin B showed more bent towards hydrophobic nature as more beta sheets were present in them. Both structures were also superimposed to check out similarities and differences present between them. Serine, Aspartic acid, Histidine, Glutamic acid and Lysine are found as interacting residues that are involved in hydrogen bonding with collagen. The interactions are found in the active domain region of Hypodermin proteins. The interacting residues were present in the active region of the hypodermin proteins thus validating the docking studies. This study may help in the drug development against hypodermosis with least side effects.

Biosynthesis and role of 3-methylbutanal in cheese by lactic acid bacteria: Major metabolic pathways, enzymes involved, and strategies for control.

Branched chain aldehyde, 3-methylbutanal is associated as a key flavor compound with many hard and semi-hard cheese varieties. The presence and impact of this flavor compound in bread, meat, and certain beverages has been recently documented, however its presence and consequences regarding cheese flavor were not clearly reported. This paper gives an overview of the role of 3-methylbutanal in cheese, along with the major metabolic pathways and key enzymes leading to its formation. Moreover, different strategies are highlighted for the control of this particular flavor compound in specific cheese types.

Valentino appendix: a report of 3 cases.

We present three cases of young male patients with perforated duodenal ulcer that were diagnosed and treated as appendicitis with appendectomy. They presented with peritonitis and were treated accordingly. Because of the misdiagnosis, their hospital course was significantly prolonged. This morbidity could have been avoided by careful history-taking, examination and per-operative findings.

Characterization of Carnobacterium maltaromaticum LMA 28 for its positive technological role in soft cheese making.

Carnobacterium maltaromaticum is a lactic acid bacterium isolated from soft cheese. The objective of this work was to study its potential positive impact when used in cheese technology. Phenotypic and genotypic characterization of six strains of C. maltaromaticum showed that they belong to different phylogenetic groups. Although these strains lacked the ability to coagulate milk quickly, they were acidotolerant. They did not affect the coagulation capacity of starter lactic acid bacteria, Lactococcus lactis and Streptococcus thermophilus, used in dairy industry. The impact of C. maltaromaticum LMA 28 on bacterial flora of cheese revealed a significant decrease of Psychrobacter sp. concentration, which might be responsible for cheese aging phenomena. An experimental plan was carried out to unravel the mechanism of inhibition of Psychrobacter sp. and Listeria monocytogenes and possible interaction between various factors (cell concentration, NaCl, pH and incubation time). Cellular concentration of C. maltaromaticum LMA 28 was found to be the main factor involved in the inhibition of Psychrobacter sp. and L. monocytogenes.

Morbidity meetings: what makes it to; what stays out of the forum.

OBJECTIVES: To review the utility of morbidity and mortality forum in General Surgery at a tertiary care hospital in Karachi, Pakistan. METHODS: The retrospective study was conducted at the Aga Khan University Hospital and reviewed morbidity data from March to May 2009. Case notes of all patients admitted to the General Surgical service during the study period were reviewed to identify in-hospital morbidities. RESULTS: There were a total of 340 inpatients during this period. Case notes identified 61 (17.94%) patients with morbidities; 35 (57.37%) males and 26 (42.62%) females. The morbidity record for the same period identified 32 (52.5%) patients, while 29 (47.5%) morbidities were missed. Of the total morbidities, 32 (52.5%) patients were admitted to the general ward, and 29 (47.5%) to high dependency areas. Nine (28%) morbidities identified in the general ward, and 23 (79%) in high dependency areas were formally presented. Morbidities related to the abdominal cavity were the commonest (n = 22; 36%). Wound-related (n = 17; 28%) and cardio-pulmonary (n = 8; 13%) complication were the next most frequent. CONCLUSIONS: Abdominal cavity morbidities were the most common in this review followed by wound related and cardiopulmonary complications. The morbidity and mortality forum is an educational activity that has stood the test of time and continues to be the cornerstone of post-graduate education. It should be considered a mandatory activity in all postgraduate training programmes.

Transcriptomic Changes and satP Gene Function Analysis in Pasteurella multocida with Different Levels of Resistance to Enrofloxacin.

Pasteurella multocida (Pm) is one of the major pathogens of bovine respiratory disease (BRD), which can develop drug resistance to many of the commonly used antibiotics. Our earlier research group found that with clinical use of enrofloxacin, Pm was more likely to develop drug resistance to enrofloxacin. In order to better understand the resistance mechanism of Pm to enrofloxacin, we isolated PmS and PmR strains with the same PFGE typing in vitro, and artificially induced PmR to obtain the highly resistant phenotype, PmHR. Then transcriptome sequencing of clinically isolated sensitive strains, resistant and highly drug-resistant strains, treated with enrofloxacin at sub-inhibitory concentrations, were performed. The satP gene, of which the expression changed significantly with the increase in drug resistance, was screened. In order to further confirm the function of this gene, we constructed a satP deletion (ΔPm) strain using suicide vector plasmid pRE112, and constructed the C-Pm strain using pBBR1-MCS, and further analyzed the function of the satP gene. Through a continuously induced resistance test, it was found that the resistance rate of ΔPm was obviously lower than that of Pm in vitro. MDK99, agar diffusion and mutation frequency experiments showed significantly lower tolerance of ΔPm than the wild-type strains. The pathogenicity of ΔPm and Pm was measured by an acute pathogenicity test in mice, and it was found that the pathogenicity of ΔPm was reduced by about 400 times. Therefore, this study found that the satP gene was related to the tolerance and pathogenicity of Pm, and may be used as a target of enrofloxacin synergistic effect.