High risk and low prevalence diseases: Metformin toxicities.

INTRODUCTION: Metformin toxicity is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of metformin toxicity, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence. DISCUSSION: Metformin is a common medication used for treatment of diabetes mellitus. Metformin toxicity is a spectrum of conditions that may be differentiated into three subgroups: metformin-associated lactic acidosis (MALA), metformin-induced lactic acidosis (MILA), and metformin-unrelated lactic acidosis (MULA). MILA is a condition found predominantly in patients chronically taking metformin or those with large acute overdoses. Conversely, MULA occurs in patients on metformin but with a critical illness stemming from a separate cause. MALA is rare but the most severe form, with mortality rates that reach 50%. Differentiating these entities is difficult in the ED setting without obtaining metformin levels. Patients with metformin toxicity present with nonspecific gastrointestinal symptoms and vital sign abnormalities. Laboratory analysis will reveal a high lactate with anion gap metabolic acidosis. Patients presenting with elevated lactate levels in the setting of metformin use should be considered at risk for the most severe form, MALA. Patients with MALA require aggressive treatment with intravenous fluids, treatment of any concomitant condition, and early consideration of hemodialysis, along with specialist consultation such as nephrology and toxicology. CONCLUSIONS: An understanding of metformin toxicity can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Molecular detection of virulence markers to identify diarrhoeagenic Escherichia coli isolated from Mula-Mutha river, Pune District, India.

In this study presence of virulence genes in multidrug resistant Escherichia coli isolated from Mula-Mutha river, Pune, India was undertaken. The objective was to understand whether the isolates were of diarrhoeagenic or of environmental origin. This was essential since the river flows through urban and rural parts of Pune and its water is used not only for industrial and agricultural purposes but also for domestic usage. One hundred and two multidrug E. coli isolates were selected from our previous study which detected genes coding for antibiotic resistance as well as identified integrons associated with multidrug resistance. Isolates were subjected to multiplex PCR to detect presence of virulence genes, set1A, set1B, sen astA, aggA, aafA, pet, stx1 and stx. Sequencing was performed to confirm the amplified PCR product. Seven of the 102 E. coli isolates showed gene set1A alone identifying them as Enteroaggregative E. coli. Thus, the findings revealed that majority of drug resistant E. coli were environmental in origin. The presence of antibiotic resistant genes, integrons in the environment as well as diarrhoeagenic E. coli isolates is a warning and calls for efficient public health measures to ensure that untreated sewage and industrial waste does not enter the Mula-Mutha river.

Seasonal prevalence of antibiotic-resistant bacteria in the river Mula-Mutha, India.

The river Mula-Mutha in Pune District, India, is linked to a number of major drinking water sources in villages situated along its banks. This study assessed the seasonal variations in bacteriological water quality along the Mula-Mutha river using Thermotolerant Faecal Coliforms (TFC) as indicator bacteria for faecal contamination as per the WHO standard guidelines for drinking water. Eight points were chosen based on a survey carried out focusing on different sources of contamination which may influence water quality. Based on the survey of antibiotics used to treat routine diseases and ailments in villages, ceftazidime and ciprofloxacin were selected to screen and enumerate antibiotic-resistant (AR) TFC. The water samples were collected and analyzed along the Mula-Mutha riverbank in three seasons. The highest TFC load was recorded during the monsoon at all eight sampling points. The percentages of ciprofloxacin-resistant TFC among the TFC isolated in post-monsoon, pre-monsoon and monsoon were 21%, 2.3%, and 64%, to those resistant to ceftazidime 9%, 0.5%, and 36% and to the combination 38%, 0.7%, and 43%, respectively. Downstream from Manjari, at Khamgaontek, antibiotic-resistant TFC were detected in all three seasons though the number isolated was less. Still further downstream at Walki, the numbers decreased considerably. The findings highlighted the heavy load of AR TFC detected in the river Mula-Mutha at points adjoining Pune City. This was probably due to the release of domestic and hospital wastes from the city into the river.

A New Fossil Species of Nothotsuga from the Mula Basin, Litang County, Sichuan Province and Its Paleoclimate and Paleoecology Significance.

In this paper, we describe a new fossil species, Nothotsuga mulaensis Z. Li & J.L. Dong sp. nov. The discovery of the fossil species was based on well-preserved fossil seed cones that were found in the Mula Basin in Xiamula village, Litang County, Sichuan Province, southwestern China. The shapes of these fossils were characterized by ovate seed cones, rhombic or suborbicular scales with auriculate bases, and the bracts were ligulate-spathulate in shape. This finding suggests that Nothotsuga once had a wide distribution range in China and that it also inhabited the eastern Tibetan Plateau (TP). Nothotsuga mulaensis was distributed in an intermountain lake basin, at altitudes from 2000 to 2300 m, in a warm and humid environment. This finding also suggests that the eastern TP may have provided good habitat for Nothotsuga during the Miocene. In addition, we propose that the uplift, accompanied by the severe cooling and aridification that occurred after the Miocene, caused the disappearance of this species of Nothotsuga in the eastern TP.

Effect of Mula Bandha Yoga in Mild Grade Pelvic Organ Prolapse: A Randomized Controlled Trial.

BACKGROUND: Pelvic organ prolapse is the growing health issue related to women of the reproductive and postmenopausal age group in India and across the globe. Treatment option for pelvic organ prolapse includes both surgical and non-surgical intervention. The development of pelvic organ prolapse is an indication for major surgery among 20% of all women. Nevertheless, the recurrence of pelvic organ prolapse is detected among 58% of the patient after surgery. This highlights the need for preventive measures for reducing the impact of pelvic organ prolapse. AIMS AND OBJECTIVE: To study the effect of 3 months yoga therapy in female patients suffering from mild pelvic organ prolapse. MATERIAL AND METHODS: 50 Participants were allocated into two groups (25 in each group) by generating Random allocation sequence. Women aged 20-60 with symptomatic mild pelvic organ prolapse in the yoga group were offered Mulabandha yoga therapy along with other conventional treatment modalities, while the control group was only on conventional treatment. All participants gave written informed consent. An assessment was done by improvement in chief complaints and Pelvic Floor Distress Inventory-20 (PFDI-20) & Pelvic floor impact Questionnaire-7 (PFIQ-7) at baseline and at the end of 4, 8 & 12 weeks. Results At the end of 12 weeks, Post-study comparison between the two groups showed a significant improvement in chief complaints like perennial pain, P/V discharge, Perineal muscle laxity and Feeling of something coming out P/V (P < 0.001). Participants in the yoga group improved by (on average) 5.7 (95% confidence interval 3.1 to 14.7) points more on the PFDI-20 than did participants in the control group (P = 0.1) and a mean score of PFIQ-7 was also improved significantly. CONCLUSIONS: Although Mulabandha (Root Lock) yoga therapy led to a significantly greater improvement in PFDI-20 & PFIQ-7 scores the difference between the groups was below the presumed level of clinical relevance (15 points). More studies are needed to identify factors related to the success of Mulabandha (Root Lock) yoga therapy and to investigate long-term effects.

Antibiotic Resistance Characterization of Environmental E. coli Isolated from River Mula-Mutha, Pune District, India.

In the current study, ceftazidime- and ciprofloxacin-resistant—or dual drug-resistant (DDR)—E. coli were isolated from river Mula-Mutha, which flows through rural Pune district and Pune city. The DDR E. coli were further examined for antibiotic resistance to six additional antibiotics. The study also included detection of genes responsible for ceftazidime and ciprofloxacin resistance and vectors for horizontal gene transfer. Twenty-eight percent of the identified DDR E. coli were resistant to more than six antibiotics, with 12% being resistant to all eight antibiotics tested. Quinolone resistance was determined through the detection of qnrA, qnrB, qnrS and oqxA genes, whereas cephalosporin resistance was confirmed through detection of TEM, CTX-M-15, CTX-M-27 and SHV genes. Out of 219 DDR E. coli, 8.2% were qnrS positive and 0.4% were qnrB positive. Percentage of isolates positive for the TEM, CTX-M-15 and CTX-M-27 genes were 32%, 46% and 0.9%, respectively. None of the DDR E. coli tested carried the qnrA, SHV and oqxA genes. Percentage of DDR E. coli carrying Class 1 and 2 integrons (mobile genetic elements) were 47% and 8%, respectively. The results showed that antibiotic resistance genes (ARGs) and integrons were present in the E. coli isolated from the river at points adjoining and downstream of Pune city.

Taxa de recuperação e características morfológicas de embriões muares (Equus caballus x Equus asinus) / Recovery rate and morphologic features of cross bred embryos (Equus caballus x Equus asinus)

A Transferência de Embrião (TE) contribuiu efetivamente para a produção de equinos e outras espécies. O mercado de muares tem apresentado um contínuo crescimento, entretanto, a aplicação das biotecnologias para a produção desses animais ainda é escassa. O presente estudo avaliou a taxa de recuperação embrionária e as características dos embriões provenientes do cruzamento de éguas com jumentos. Os embriões foram recuperados entre os dias 6 e 9 após a ovulação, dessa forma foi realizada a avaliação da taxa de recuperação embrionária e avaliação das características relacionadas com a idade, morfologia e diâmetro embrionário. A taxa de recuperação embrionária total foi de 55,9% (71/127), e não apresentou diferença para as colheitas realizadas em diferentes dias (D6-D9). Foram recuperados embriões nos estágios de mórula, blastocisto inicial, blastocisto e blastocisto expandido. O tamanho dos embriões variou entre 147-1688μm e a média do diâmetro de todos os embriões recuperados foi de 438,04μm. A recuperação de embriões muares pode ser realizada entre os dias 6 e 9 após a ovulação, e propicia a recuperação de embriões nos primeiros estágios de desenvolvimento.(AU)

Production biotechnologies, particularly embryo transfer (ET) has constantly been contributed to reproduce horses and other species. The mules market has shown continuous growth, however, the biotechnology for mule assisted reproduction is still scarce. The aim of this study was to evaluate the embryo recovery rate and the features of the embryos from mares bred with donkeys. The embryos recovery attempts were performed on days 6 to 9 after ovulation, in order to evaluate the embryo recovery rate and the features related to age, morphology and embryonic diameter in each day. The overall embryo recovery rate was 55,9% (71/127), and there was no significant difference (p>0,05) on different days (D6-D9). Embryos were recovered in stages of mórula, early blastocyst, blastocyst and expanded blastocyst. The diameter of the embryos ranged from 147-1688μm and the mean diameter of all the embryos collected was 438,04μm. The collection of hybrid embryos might be performed between days 6 and 9 after ovulation, and provides recovery of embryos in the early stages of development.(AU)

Diagnóstico por imagem de Body Packers: relato de caso / Image diagnosis of Body Packers: case report

Introdução: o Brasil é atualmente a principal rota de tráfico de drogas da América Latina. Em aeroportos internacionais, passageiros com perfil considerado como suspeito pela Polícia Federal são conduzidos até serviços de pronto-atendimento para serem avaliados, ainda que assintomáticos e sem alterações visíveis. Objetivos: discutir, a partir de um relato de caso, os métodos de imagem diagnósticos para body packers mais utilizados na prática. Métodos: relato de caso de paciente atendido pelo Centro de Informações e Atendimento Toxicológico (CIAT) do Hospital Pronto-Socorro João XXIII em Belo Horizonte (MG). Resultados: um paciente trazido pela Polícia Federal, que negava ter ingerido pacotes de cocaína e estava assintomático com exame físico normal, foi submetido à propedêutica por imagem. Foi realizado uma tomografia computadorizada (TC) de abdome que evidenciou inúmeros corpos estranhos pelo trato gastrointestinal do paciente. Foi realizado também uma radiografia simples de abdome não foi útil em mostrar com precisão a localização e quantificação dos papelotes. Conclusões: tendo em vista o fato de que a ruptura de um único invólucro pode provocar intoxicação grave e muitas vezes fatal, a ausência de mensuração quantitativa e os falso-negativos da radiografia simples de abdome tornam esse método limitado. Sugerimos que a TC seja o método de imagem inicial, o que garante maior rapidez e precisão no manejo do caso, economia no tempo de estadia do paciente e maior segurança para o mesmo.(AU)

Introduction: Brazil is currently the main drug traffic route of Latin America. At international airports, passengers considered as suspect by the Federal Police are driven to emergency care services to be evaluated, even if asymptomatic and no visible abnormalities. Objectives: discuss, from a case report, the most used in practice diagnostic imaging methods. Methods: case report of patient assisted by the Center for Information and Toxicological Assistance (CIAT), Hospital Pronto-Socorro João XXIII in Belo Horizonte (MG). Results: a patient brought by the Federal Police, denied having ingested packets of cocaine and was asymptomatic with a normal physical examination, underwent imaging workup. A computed tomography (CT) was performed and revealed that many foreign bodies into the gastrointestinal tract of the patient. A plain abdominal x-ray was also made and wasn't helpful in showing the exact location and quantification of packets. Conclusions: considering the fact that the rupture of a single packet can cause severe intoxication, often fatal, the absence of quantitative measurement and the false-negative of plain abdominal x-ray make this method limited. We suggest that CT should be the initial imaging method, which provides greater speed and accuracy in handling the case, reducing the patient's length of stay and providing greater security.(AU)