Interferon lambda-3 rs12979860 variants and response to pegylated interferon in chronic hepatitis-c genotype-3

Objective: To assess the role of single nucleotide polymorphisms [SNPs] near the interferon lambda-3 [IFNX3] [formal IL-28B] gene rs12979860 in predicting sustained virologic response [SVR] in hepatitis-C virus genotype-3 [HCV-3]

Study Design: Descriptive, analytical study

Place and Duration of Study: Department of Medicine, The Aga Khan University Hospital, Karachi, from July 2012 to June 2014

Methodology: Patients with HCV-3 were classified as sustained virologic response [SVR], relapsers and non-responders. SNP rs12979860 was determined by PCR-RFLP protocol. Differences between categorical variables were assessed by chi-square or Fisher's exact test, while those between continuous variables were evaluated using the Mann-Whitney U-test. Binary logistic regression analysis by forward conditional method was performed by using significant variables with p-values less than 0.05 as the criteria for model inclusion

Results: Out of 115 patients, rs12979860 genotype-CC, CT, TT was found in 37 [32.2%], 70 [60.9%], and 8 [7%] patients. 72 patients were male with median age of 45 years. Cirrhosis was present in 32 patients. Patients with response failures [no response and relapse, n=36 and 29, respectively] had higher baseline gamma glutamyl transferase [GOT] level [p < 0.001], higher alanine aminotransferase [p=0.027] and cirrhosis [p=0.001] than patients with SVR. Genotype-CC was present in 16/65 in response failures compared to 21/50 who achieved SVR [p=0.048]. Rapid virologic response [RVR] [p < 0.001], low GGT [p=0.001] and absence of cirrhosis [p=0.039] were the independent predictive factors for SVR. In patients who could not achieve RVR and in patients with cirrhosis, SVR was seen more in with genotype-CC [p=0.007 and 0.038]

Conclusion: In patients infected with HCV-3, IFNA3 rs12979860, SNP has less impact on SVR

Effect of season on Length-tension relation of gastrocnemius muscle of Uromastix Hardwickii

Seasonal variations in the biological activities of animals are commonly reported in literature. However, these variations are not studied yet in correlation with the structure and function of skeletal muscles in general and their mechanics in particular. This study was conducted on skeletal muscles of a reptile, Uromastix, to determine the effect of season on the shape of length-tension curves, active tension, passive tension and tension equilibrium length [TEL]. Result demonstrates that active tension obtained from gastrocnemius muscle was found to increase significantly from the winter [December] to peak summer month [June], which showed a significant fall till the second winter [December]. The passive tension was also found to increase significantly [P<0.0005] from winter [December] to peak summer [June] which also decreased significantly till the second winter [December]. Change in both the active and passive tensions has resulted in a rise in the average values of tension equilibrium length from the winter [December] to peak summer [June] and fall till second winter [December] .It is concluded that length-tension parameters exhibit variations between different seasons and reflect a dominancy of contractile elements towards summer and elastic elements towards winter in the gastrocnemius muscles of Uromastix

Mechanical characteristics of rib cage elevator muscle of reptile uromastix hardwickii

Skeletal muscles are diverse in their contractile properties, with significant differences existing among and within various animal species, Uromastix is one of the desert adapted reptile that possesses unique mechanical characteristics for its skeletal muscles. Additionally, in the absence of diaphragm, this reptile involves one of its chest muscle named recently as Rib Cage Elevator [RCE] muscle that lilt the rib cage during active respiration. The purpose of this study was to test that increased frequency of stimulation alters the mechanical activity in RCE muscles as well or not and is there and difference in various strips of the RCE muscle of this animal in terms of endurance to high frequency of stimulation, fatigue and which of this strip is mainly responsible for lifting of rib cage during active respiration in this reptile in the absence of diaphragm. For this purpose isolated strips of rib cage elevator muscle of Uromastix, [superior, middle and inferior] were used for isometric recordings to compare their mechanical activity. The isometric twitch [Strength 50V. duration 0.5ms and frequency 1Hz] and tetanus [Strength 50V. duration 0.5ms and frequencies. 16, 24, 40, 80, 160 and 240Hz] were recorded with 2 min rest in between each record. The twitch contraction [CT] and twitch and tetanus half relaxation time [1/2RT], were also calculated together with the maximum rate of rise in twitch and tetanic tensions at above frequencies. The average values of twitch and tetanic tensions as well as twitch CT, tetanus 1/2RT, rate of rise in twitch and tetanus at values frequency along with endurance, were greater in inferior and middle strips than that of the superior one. The mechanical activity of RCE muscle of Uromastix also depends on the stimulation frequency and mostly significant difference exists in the superior, middle and inferior ones. Therefore, on the basis of greater endurance observed after high frequency of stimulation in the inferior strip of this muscle, it is concluded that it is mainly playing active role in RCE muscle to lift the rib cage during active respiration in Uromastix in the absence of diaphragm

Recovery muscular paralysis in cerebral stroke patient: a case study using surface electromyography and dynamometery

To evaluate the recovery from muscular paralysis in Cerebral Stroke Patients using Surfaced Electromyography [SEMG] and hand dynamometry. Design: SEMG and muscle force recorded from a patient of Cerebral Stroke suffering from hemiparesis. Setting: The records were obtained from various affected and normal muscles of the patient on three consecutive visits at Neuromuscular Lab, Department of Physiology, University of Karachi. Subjects: As case studies a patient who met cerebrovascular accident and was treated at a local hospital was examined for SEMG and hand dynamometry. Main outcome measures: SEMG and hand dynamometry are useful tools to assess recovery in affected muscles in cerebral stroke patients. The muscle force was recorded only from Flexor Digitorum Profundus [FDP] that demonstrated significantly lesser values in the affected FDP than its contra-lateral normal one. While, SEMG parameters have demonstrated significantly higher values in the affected Trapezius [TPZ] and Biceps Brachii [BB] while lesser values in FDP, DI and Gastrocnemius [GAS] on first visit. All of these parameters showed significantly lesser values on third visit, in all the affected muscles. Conclusions: Changes in SEMG and muscle force parameters during recovery from hemiparesis, follows the reorganization in cerebral cortex for the revival of muscular performance

Euro-scoring for risk stratification in CABG surgery [10 Years experience]

Aim of the study was to evaluate patients pre operatively with Euroscoring System to judge the end point, hospital mortality in CABG done in last ten years by a single surgeon. Form June 1989 to June 1999 the data of 262 cases of CABG done was collected on the data sheet each case was scored pre operatively with Euroscoring System. The different groups were made from this system, Group 1 Score 0-1, Group 2 Score 3-4, Group 3 Score 5-6, Group 4 Score 7-8, Group 5 >9. Another Grouping was Group 1 score 0-5, and Group 2 score 6-10 and Group 3 score 11-15. Pre op data was collected and analyzed by SPSS Version 7.5. The End point was hospital mortality. In this group of 262 patients, the age range was 25-77 with the mean 52.41 years, 248 [94.7 percent] were males and 14 [5.3 percent] were females. In this whole cohort of patients 227 [86.6 percent] were having stable angina pectoris and 35 [13.4 percent] were having unstable angina Pre op angina status was Class 1 in 5 [1.9 percent], Class II 88 [33.6 percent], Class III 132 [50, 4 percent] and Class IV were 37 [14.1 percent]. There were 116 [44.3 percent] hypertensive, 56 [21.4 percent] were diabetics and 9 [3.4 percent] were obese. Recent myocardial Infarction was there in 9 [3.4 percent] of cases, the old non Q- wave infarction was present in 18 [6.9 percent] of cases and Q - wave infarction was present in 42 [16 percent] of cases. Pre op Ejection fraction was good in [EF >50 percent] in 204 [77.9 percent] cases, Fair [EF 30-49 percent] in 50 [19.1 percent] cases, poor [EF<30 percent] in 8 [3.1 percent] cases. Pre op support of intra-aortic balloon counterpulsation [IABP] was used in 3 [1.1 percent], pre operative ventilation was done in 1 [0.4 percent], Inotropic support was present in 4 [1.5 percent], and vasodilators were given in 14 [5.3 percent] cases, Elective surgery was done in 92 percent, urgent in 4 percent, emergency in 3 percent and salvage surgery was done in 1 percent of cases. Mortality in Euroscore Group I [Score 0-1] was 3.1 percent, in Group II [Score 2-3] 9.4 percent, in Group III [Score 4-5] 19 percent, in Group IV [Score 6-7] 25 percent and in Group VI [Score >9] the mortality was 60 percent. The Euro score from 0-5 was having 6.1 percent mortality, the score from 6-10 was having 20 percent and the score from 11-15 was having 80 percent mortality. On Logistic regression overall predictive accuracy of Euroscoring is very good [90 percent]. Predictive accuracy, 37 percent of deaths could be explained on the existing variables, positive predictive value is 19.05 percent and negative predictive value is 99.17 percent. The predictive accuracy of Euroscoring changes with various risk groups, in low risk Groups [Score 0-5] and [Score 6-10] Euroscore predicts survival more accurately. In high risk Group [11-15] Euroscoring better predicts mortality rather than survival. The factors included in permutations of Euroscore explain only 37 percent of the observed mortality. It is noted that the observed mortality is consistently higher than that predicted by logistic regression. Euroscoring is a good tool of risk stratification to predict the out come but not ideally suited to our clinical circumstances. Though we have documented an overall predictive accuracy of 92 percent, it is limited in its usefulness because it does not take into consideration certain risk factors found to be important in our patient population. In addition, the relative weight assigned to various risk factors in scoring needs to be readjusted for our patient population in the light of observations made on our patient population. There is a need to develop a scoring system of our own which could be used for better prediction of outcomes in our clinical circumstances

Ropivacaine combined with sufentanil for intrathecal labor analgesia; a comparion with bupivacaine

To compare the onset, duration and quality of analgesia as wall a' the side effects between ropivacaine and bupivacaine, combined with sufentanil, when injected intrathecally as a part of combined spinal epidural technique for labor analgesia. This controlled double-blinded study included 60 primiparous women ASA physical status I/II, in early labor [cervical dilatation 2-5 cm] where they received labor analgesia using, combined spinal epidural technique. They were randomly assigned into 3 equal groups [20 women in each] to receive one of the three intrathecal study solutions; BS Group: bupivacaine 2.5 mg and sufentanil 10 micro g. RS2.5 Group: [n =20] ropivacaine 2.5 mg and sufentanil 10 micro g, RS4 Group: ropivacaine 4 mg and sufentanil 10 micro g. Every 5 mm for the first 30 mm then every 15 mm until first analgesic request, blood pressure, pulse rate and respiratory rate were recorded and pain was assessed using a 4-point verbal rating score. Motor block was assessed before and 20 mm after injection using 4-point modified Bromage score. Fetal heart rate and uterine activity were monitored. The use of prostaglandins [PGE[2]] or oxytocin was recorded The mode of delivery, 1-mm and 5-mm Apgar scores and umbilical artery pH were also recorded. The duration of analgesia was not significant different between groups. The duration of analgesia in BS Group was [105 +/- 26 mm] compared to [97 +/- 19 mm] in RS2.5 Group and [110 +/- 23 mm] in RS4 Group. Motor impairment was significantly more in BS group [40%] compared to both ropivacaine groups [0% and 15%]. Analgesia was adequate in all groups but the quality of analgesia was considered superior in 85 Group as more pain assessments were grade 0 compared to both ropivacaine groups and the difference was significant when compared to the group given the equivalent ropivacaine dose [2.5 mg]. [1 Intrathecal ropivacaine [2.5 mg] has the same onset and duration or analgesia as bupivacaine [2.5 mg] when either of them is added to sufentanil. 10 micro g for labor analgesia. However, ropivacaine has the advantage of less motor block. [2] Increasing the dose of IT ropivacaine to 4 mg with sufenil has no advantage over 2.5 mg dose. [3] The IT technique and drugs used were well tolerated and safe for both mothers and babies

Small doses of rocuronium versus mivacurium for short procedures

Rocuronium bromide is a non-depolarizing muscle relaxant [NDMR]. It has a fast rate of onset of action, intermediate duration and rapid recovery. Mivacurium is a short acting [NDMR] that undergo rapid breakdown by plasma cholinesterase leads to rapid spontaneous recovery. In this study rocuronium, in two small doses 0.3 and 0.45mg/ kg were compared with mivacurium 0.2mg/kg as regard, intubations, onset, clinical duration and reversal either spontaneous or induced, using neostagmine and glycopyrrolate. This study divided into two parts. In part I, quality of neuromuscular block for intubation was studied, 90 patients were allocated randomly to one of three groups [n=30] to receive rocuronium 0.3mg/kg [group 1], rocuronium 0.45mg/kg [group 2] and mivacurium 0.2mg/kg [group 3]. Each group divided into two equal subgroups [a and b]. The trachea was intubated after 60 sec in subgroups la and 2a, after 90 sec in subgroup Ib, 2b and 3a and after 120sec in subgroup 3b. Intubating conditions were graded as excellent, good or poor. In part II, assessment of onset, clinical duration and time for reversal were studied. 90 patients were randomly assigned to one of three groups [n=30], group I received rocuronium 0.3mg/kg, group II received rocuronium 0.45mg/kg and group III received mivacurium 0.2mg/kg. The onset, maximum degree of block and clinical duration were measured. When T[25] was reached, the three groups divided into equal subgroups a and b. Subgroups la, Ila and IlIa undergo spontaneous recovery and subgroups Ib lIb and Illb were received neostagmine 50 micro g/kg and glycopyrrolate 10microg/kg. Results: The frequency of distribution of excellent and good in-tubating conditions were high in subgroups 2b and 3b, but the patients with excellent conditions were more in subgroup 3b, no patient with poor intubating conditions in both subgroups. There were no significant difference between the subgroups Ib, 2a and 3a regarding intubation conditions. The onset was significantly rapid in group II and slow in group III, clinical duration was significantly longer in group II compared with groups I and II. While there were no significant difference, in clinical duration of action, between groups I and II. When spontaneous recovery time TOP [0.7] compared, we found that group III had significantly short spontaneous recovery time. On the other side, group II had significantly long spontaneous recovery time. In groups I and II, the induced recovery time were much rapid than spontaneous. While in group III there was no significant difference between spontaneous or induced recovery. Rocuronium has minimal side effects, provides conditions more suitable for rapid tracheal intubation. With small doses 0.3 and 0.45mg/kg of rocuronium, clinical duration of action became short and recovery, especially induced, became rapid. Rocuronium can be used for short procedures, but a dose of 0.45mg/kg was more accepted as intubating dose especially when intubations were attempted after 90sec. A dose of 0.3mg/kg can be used as intubating dose only under adequate anesthetic depth. Mivacurium as short acting muscle relaxant may be beneficial for short procedures. Also, spontaneous recovery of mivacurium was significantly short while there was no significant difference in induced recovery when compared to rocuronium either 0.3 or 0.45mg/kg, but its delayed onset made it unsuitable for rapid intubations. The principal side effects of mivacurium are facial flushing and transient fall in blood pressure due to moderate histamine release. The duration of action of mivacurium is prolonged in patients with atypical plasma cholinesterase as well as those with end stage liver or renal disease. Mivacurium is indicated for short procedures when anticholinesterase agents must be avoided

Acinetobacter septicemia

Acinetobacter spp. Glucose non-fermenter, Gram negative rods and normal commensal of human sin, are increasingly frequent pathogens for nosocomial infections. The organism is noteworthy because of it's widespread resistance to most available antibiotics and serious outcome. Most reported incidences were hospital acquired infections like infected wounds, ventilator associated pneumonias or chatheter-related infections in critically-ill immuno-compromised patients. Community acquired acinetobacter infections are extremely rare; most reported instances being pneumonias in patients with underlying disease. We report a case of community acquired multi-resistant Acinetobacter septicemia in an apparently immuno-competent patient presenting as ARDS and ending fatally