Validation of acute physiologic and chronic health evaluation II scoring system software developed at The Aga Khan University, Pakistan.

OBJECTIVE: To assess the predictive performance of Acute Physiologic and Chronic Health Evaluation II (APACHE II) software available on the hospital intranet and analyze interrater reliability of calculating the APACHE II score by the gold standard manual method or automatically using the software. MATERIALS AND METHODS: An expert scorer not involved in the data collection had calculated APACHE II score of 213 patients admitted to surgical Intensive Care Unit using the gold standard manual method for a previous study performed in the department. The same data were entered into the computer software available on the hospital intranet (http://intranet/apacheii) to recalculate the APACHE II score automatically along with the predicted mortality. Receiver operating characteristic curve (ROC), Hosmer-Lemeshow goodness-of-fit statistical test and Pearson's correlation coefficient was computed. RESULTS: The 213 patients had an average APACHE II score of 17.20 ± 8.24, the overall mortality rate was 32.8% and standardized mortality ratio was 1.00. The area under the ROC curve of 0.827 was significantly >0.5 (P < 0.01) and had confidence interval of 0.77-0.88. The goodness-of-fit test showed a good calibration (H = 5.46, P = 0.71). Interrater reliability using Pearson's product moment correlations demonstrated a strong positive relationship between the computer and the manual expert scorer (r = 0.98, P = 0.0005). CONCLUSION: APACHE II software available on the hospital's intranet has satisfactory calibration and discrimination and interrater reliability is good when compared with the gold standard manual method.

Abscopal effect of low-LET γ-radiation mediated through Rel protein signal transduction in a mouse model of nontargeted radiation response.

Ascertaining the ionizing radiation (IR)-induced bystander response and its preceding molecular regulation would increase our understanding of the mechanism of acute and delayed radiobiological effects. Recent evidence clearly prompted that radiation-induced nuclear factor kappa B (NF-κB) would play a key role in bystander responses in nontargeted cells. Accordingly, we investigated the orchestration of NF-κB signaling after IR in a nontargeted distant organ. Heart tissues from C57/BL6 mice either mock irradiated or exposed (limited to lower abdomen 1 cm diameter) to single-dose IR (SDR: 2 or 10 Gy) or fractionated IR (FIR, 2 Gy per day for 5 days) were examined for onset of abscopal NF-κB signal transduction, translated activity, downstream functional signaling and associated DNA damage. Radiation significantly induced NF-κB DNA binding activity in nontargeted heart. Transcriptional profiling showed that 51, 46 and 26 of 88 genes were significantly upregulated after 2 Gy, 10 Gy and FIR. Of these genes, 22 showed dose- and fractionation-independent upregulation. Immunohistochemistry revealed a robust increase in p65 and cMyc expression in distant heart after SDR and FIR. Immunoblotting revealed increased phosphorylation of p38 after 2 Gy and extracellular signal-regulated kinases 1/2 after 10 Gy in nontargeted heart. In addition, IR exposure significantly enhanced DNA fragmentation in nontargeted heart. Together, these data clearly indicated an induced abscopal response in distant organ after clinically relevant IR doses. More importantly, the results imply that orchestration of NF-κB signal transduction in nontargeted tissues may serve as an effector and could play a key role in induced abscopal responses.

Breastfeeding and cognitive development of children: assessment at one year of age.

Breastfeeding is the fundamental component of child survival strategy. It significantly influences neurological development of children. The study was conducted to assess whether exclusive and prolonged breastfeeding improves children's cognitive development, including low birth weight (LBW) babies, in a developing country setting like Bangladesh. This observational study was done on a cohort of newborn infants who were discharged from the special care baby unit of Dhaka Shishu Hospital during January 2006 to December 2008 with proper counseling about exclusive and prolonged breastfeeding. Their neuro-developmental follow-up was started at 4 weeks postnatal age and continued at 3-monthly intervals up to 1 year of age. At each visit, cognitive development was assessed using the Bayley Scales of Infant Development (BSID II). Cognitive development was compared between the babies of exclusive vs. non exclusive breastfeeding, normal weight vs. low birth weight and male vs. female babies. A total of 105 cases were successfully followed-up during this period. Out of these 47(44.8%) babies were exclusively breastfed up to 6 month of age and 58(55.2%) were in nonexclusive group. Overall Psychomotor Development Index (PDI) was slightly more (108.40 ± 23.06 vs. 103.23 ± 19.87) in the exclusive breast fed babies in comparison to nonexclusive breast fed babies, but was significantly more in babies having birth weight >2.5 kg in comparison to those having birth weight of <2.5 kg. Other parameters of cognitive development were more or less same in both normal and LBW groups. Mental and motor development was same in both boys and girls. In behavior ratings, cooperation was significantly high (5.89 ± 2.54 vs. 4.71 ± 3.13, p=0.05) and vocalization (5.89 ± 1.07 vs. 4.58 ± 1.16) was also high, though not significant, in girls than boys.

Vasopressin for the management of catecholamine-resistant anaphylactic shock.

Severe anaesthetic anaphylaxis is relatively uncommon. Oxygen, fluids and epinephrine are considered to be the mainstay for treatment of cardiovascular collapse and current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of a cardiovascular collapse. Recently, evidence has emerged in the support of the use of vasopressin in cardiopulmonary resuscitation; it is also recommended for the treatment of ventricular fibrillation, septic shock and post-cardiopulmonary bypass distribution shock. Currently, there is no algorithm or guideline for the management of anaphylaxis that include the use of vasopressin. We report a 24-year-old woman who developed severe anaphylactic shock at induction of anaesthesia while undergoing laparoscopic cholecystectomy. Circulation shock was refractory to epinephrine and high doses of pure alpha-agonist phenylephrine and norepinephrine. Single intravenous dose of two units of vasopressin re-established normal circulation and blood pressure.

Purification and some properties of galectin-1 derived from water buffalo (Bubalus bubalis) brain.

An increasing number of galectins have been found in various animal species, the most abundant of which is galectin-1. The purpose of the present study was to purify and characterize galectin-1 from buffalo brain. We purified the galectin using a combination of ammonium sulphate fractionation and affinity chromatography and the homogeneity was determined by both native polyacrylamide gel electrophoresis (PAGE) and denaturing SDS-PAGE. The molecular weight of the galectin as determined by SDS-PAGE under reducing conditions and by gel filtration column under native conditions was 13.8 and 24.5 kDa, respectively, suggesting a dimeric form of galectin. The most potent inhibitor of the galectin activity was lactose, giving complete inhibition of hemagglutination at 0.8 mM. Galectin showed higher specificity towards human blood group A. Free thiol groups were estimated at a molar ratio of 2.9. The effects of alkylating reagents (iodoacetate and iodoacetamide) on saccharide binding of the galectin were studied. Both alkylating reagents significantly inactivated the activity of the galectin within 20 min. The temperature and pH stability of the galectin were determined. Our findings based on physico-chemical properties, carbohydrate and blood group specificities of the galectin may have future implications in biological and clinical applications.

Comparison of ketorolac with morphine for intra-operative analgesia in patients undergoing total abdominal hysterectomy.

OBJECTIVE: To compare ketorolac 0.35 mg x kg(-1) with morphine 0.1 mg x kg(-1) for hemodynamic stability, efficacy of analgesia and incidence of side effects in patients undergoing elective total abdominal hysterectomy. METHODS: Fifty ASA I and II patients, were enrolled in a prospective, randomized and double blind study. They were divided in two equal groups. Group K received Inj. Ketorolac 0.35 mg x kg(-1) while group M received Inj. Morphine 0.1 mg x kg(-1) 5 minutes before induction of anaesthesia. Hemodynamic responses to laryngoscopy, endotracheal intubation, and surgical incision were noted. RESULTS: Data was entered and analysis was done using SPSS version 10.0. Student-t test and comparison of proportions were done where required. ANOVA was done and a p-value of <0.05 was considered statistically significant. There was a significant rise in heart rate, systolic, diastolic and mean arterial pressure in ketorolac group (K) as compared to baseline values at points of endotracheal intubation and surgical incision. Patients in Morphine group (M) showed a significant increase in heart rate only. There was no statistically significant difference between the two groups for supplemental analgesia requirement intraoperatively and postoperatively. Complications seen with group K were increased surgical wound bleeding in 2 patients (8%), nausea and vomiting in 4 patients (16%) while in group M there was nausea and vomiting in 5 patients (20%), and respiratory depression in 1 patient (4%). CONCLUSION: Although hemodynamic stability at points of painful stimulation was lower in patients given ketorolac as compared to morphine, Ketorolac has a place in the intraoperative pain relief in Pakistan and other developing countries where availability of powerful narcotics is erratic.

Use of stents in the palliative treatment of malignant gastric outlet and duodenal obstruction.

AIM: To evaluate the efficacy of stenting in the palliation of malignant duodenal and gastric outlet obstruction. MATERIALS AND METHODS: We retrospectively reviewed our series of patients who underwent stenting for malignant upper gastrointestinal obstruction between March 1998 and December 1999. From January 2000 data have been acquired prospectively. Our series comprises 21 stents successfully deployed in 15 patients. RESULTS: The technical and clinical success was 93% (14/15 patients). One patient required endoscopic negotiation of recurrent gastric carcinoma at the gastrojejunostomy site after failure to cross the lesion fluroscopically. Two patients required re-intervention 2 and 5 weeks after initial stent placement, for migration and ingrowth respectively. Eighteen stents were placed transorally, two stents transhepatically and one via a transgastric approach. Early complications (pain < 3 days) occurred in two patients (13%) and late complications (ingrowth, overgrowth and migration) occurred in three patients (20%). The median survival was 2.4 months (range 2-4 months). CONCLUSION: Stenting provides a less invasive palliative option than surgery with the advantage of lower morbidity and complication rates. It has the advantage of high technical and clinical success rates facilitated by alternative routes of access into the upper gastrointestinal tract via transgastric and transhepatic routes in addition to the traditional peroral route.

Anatomical variations of internal jugular vein as seen by "Site Rite II" ultrasound machine--an initial experience in Pakistani population.

OBJECTIVE: To determine the anatomical variations of the internal jugular vein (IJV) in Pakistani adult population with the help of Site Rite II ultrasound machine. MATERIAL AND METHOD: The right IJV relation to the carotid artery was visualized at four different landmarks (angle of the mandible, thyroid cartilage, cricoid cartilage, and the supraclavicular area). Size of IJV in comparison to carotid artery was also seen. RESULTS: In 49 cases the IJV was found in aberrant relation to carotid artery at the angle of the mandible (p value < 0.05), 22 at the thyroid cartilage, 20 at the cricoid cartilage, and 46 at the supraclavicular area (p value < 0.05). In 93% of cases the IJV was found to be larger than the carotid artery. CONCLUSION: Care should be taken while cannulating IJV at the angle of the mandible and supra clavicular area by external landmark guided technique. Ultrasound guided technique should be used in every anticipated difficult case.

Uric acid mediates photodynamic inactivation of caprine alpha-2-macroglobulin.

Uric acid (2,6,8 trioxopurine), the end product of purine metabolism in mammalian systems, has shown a wide range of antioxidant properties including scavenging of hydroxyl radical and singlet oxygen. In this study we show that in the presence of visible light, uric acid disrupted caprine alpha-2-macroglobulin (alpha(2) M) structure and antiproteolytic function in vitro. Proteinase cleaves the bait region of caprine inhibitor inducing major conformational changes and entrapping the enzyme within its molecular cage. In contrast to native alpha(2) M, modified antiproteinase lost half of its antiproteolytic potential within 4 hours of uric acid exposure. The changes in uv-absorption spectra of the treated protein suggested possible spatial rearrangement of subunits or conformational change. Analysis of the mechanism by which alpha(2) M was inactivated revealed that the process was dependent on generation of superoxide anion and hydrogen peroxide. Our findings suggest that antiproteolytic activity of caprine alpha(2) M could be compromised via oxidative modification mediated by uric acid. Moreover, low concentrations of alpha(2) M were found to stimulate superoxide production by some unknown mechanism.

Dopamine induced protein damage in mitochondrial-synaptosomal fraction of rat brain.

Dopamine during in vitro oxidation induced covalent cross-linking of membrane proteins in rat brain crude mitochondrial-synaptosomal fraction. The process is not inhibited by hydroxyl radical scavengers, lipid soluble anti-oxidants, metal-chelator or catalase, but reduced glutathione produced a dramatic inhibition of cross-linking. The protein cross-linking mediated by dopamine is not associated with any detectable membrane lipid peroxidation but significant formation of protein bound quinone takes place during incubation. Our results indicate that reactive quinones rather than oxygen free radicals are involved in dopamine induced protein cross-linking in rat brain membrane fraction.

Success and limitations of a naked plasmid transfection protocol for keratinocyte growth factor-1 to enhance cutaneous wound healing.

Our group and others have previously reported enhancement of cutaneous wound healing following the transfection of tissue with plasmid vectors expressing the DNA for growth factors. In these experiments, growth factor treated animals were usually compared to animals treated with control plasmid vector. To achieve consistent transfection, high DNA plasmid load and repeated penetrations of the wound by needle or gene gun were required. In the current experiments, we assessed the effect of the plasmid load and repeated tissue penetrations on wound healing of excisional wounds in diabetic C57 mice. Animals received 5 mm excisional wounds, and were assigned to the following groups, no treatment, phosphate buffered saline solution injections, and plasmid vector injection with and without the keratinocyte growth factor-1 gene. Intradermal injections of 100 microg plasmid were given adjacent to the wounds at days 1-5, 7 and 11. At day 9, wound closure was more advanced in keratinocyte growth factor-1 treated animals compared to those treated with control plasmid. But a detrimental effect of the DNA plasmid injection was evident from a comparison of the DNA control group versus the non-injected group. Therefore, the challenge for developing an effective system for the enhancement of wound healing lies in improving transfection efficiency.

Recommendations for water supply in arsenic mitigation: a case study from Bangladesh.

Arsenic problems have been observed in several countries around the world. The challenges of arsenic mitigation are more difficult for developing and poor countries due to resource and other limitations. Bangladesh is experiencing the worst arsenic problem in the world, as about 30 million people are possibly drinking arsenic contaminated water. Lack of knowledge has hampered the mitigation initiatives. This paper presents experience gained during an action research on water supply in arsenic mitigation in rural Singair, Bangladesh. The mitigation has been implemented there through integrated research and development of appropriate water supply options and its use through community participation. Political leaders and women played key roles in the success of the mitigation. More than one option for safe water has been developed and/or identified. The main recommendations include: integration of screening of tubewells and supply of safe water, research on technological and social aspects, community, women and local government participation, education and training of all stakeholders, immediate and appropriate use of the available knowledge, links between intermediate/immediate and long term investment, effective coordination and immediate attention by health, nutrition, agriculture, education, and other programs to this arsenic issue.

Complications of endotracheal intubation in mechanically ventilated patients in a general intensive care unit.

During a period of one year, 126 patients were prospectively audited to analyse complications of endotracheal intubation in a general intensive care unit setting. A total of 62 complications were observed in 48 patients. The most frequent complications during intubation were hypotension and bradycardia. The blockage of endotracheal tubes significantly increased with the duration of intubation. Sore throat was the commonest (22%) complication following extubation. Other complications like stridor and ulceration of mouth and lips which followed extubation were not related to the duration of intubation.

A crosslinked tetrameric alpha 2M that binds but incompletely entraps trypsin.

A crosslinked preparation of alpha-2-macroglobulin was obtained by treatment of the purified human plasma inhibitor with glutaraldehyde at low temperature. The preparation migrated as a 780 KDa polypeptide in SDS-PAGE and with mobility comparable with that of trypsinized native alpha-2-macroglobulin under nondenaturing conditions. Trypsinization of the glutaraldehyde treated alpha-2-macroglobulin further increased its electrophoretic mobility in non-denaturing gels and resulted in the association of the proteinase with the crosslinked inhibitor. Trypsin associated with crosslinked alpha-2-macroglobulin, unlike that associated with native inhibitor was incompletely protected from soybean trypsin inhibition.

Total intravenous anaesthesia with propofol and buprenorphine.

A combination of propofol infusion and two bolus doses of buprenorphine, 2.5 or 5.0 micrograms/kg were evaluated in a total intravenous anaesthesia technique in 36 patients of ASA grade 1 or 2 undergoing cholecystectomy. Additional boluses of propofol were given intravenously if needed. Systolic blood pressure after tracheal intubation increased significantly only in those who received the smaller dose of buprenorphine. Patients in both groups remained haemodynamically stable throughout surgery with minimal side effects. Recovery was fast even with prolonged infusions and without major side effects. No patient reported awareness on postoperative questioning.

Effects of nitrofurans on adrenal cortical tissue in chickens.

In chicken adrenal glands, aspartate transaminase (AST) activity is concentrated in the adrenal cortical cells. Administration of a bolus dose of furazolidone (200 mg/kg) to the birds produced a decrease in AST activity in the adrenal glands and a general disorganization in the ultrastructure of the adrenal cortical cells. Many adrenal cortical mitochondria appeared to be moribund, being swollen, without cristae or apparently empty. These effects preceded atrophy of the adrenal cortical tissue, which was most marked in the central part of the adrenal glands. The atrophy was still present after 12 weeks, and it is therefore suggested that nitrofurans may be useful in the treatment of Cushing's disease in other animal species. When furazolidone or furaltadone was given in the diet at therapeutic levels, blebs of an electron-dense substance developed in adrenal cortical mitochondria and AST activity in the adrenal glands was reduced. These effects were found to be reversible, and the treatments did not produce atrophy of the adrenal cortical tissue.

Bioavailability, disposition kinetics and renal clearance of ampicillin following three routes of administration in sheep.

Bioavailability, disposition kinetics and renal clearance of ampicillin were investigated in 8 sheep following intravenous (i.v.), or intramuscular (i.m.) injection of 10 mg/kg or oral administration of 20 mg/kg dose. Peak of absorption was achieved in 26 +/- 9 min (mean +/- SD) after i.m. and 85 +/- 24 min after oral administration. The relative bioavailability of i.m. injected drug was 95 +/- 20 per cent compared to only 37 +/- 7 per cent following oral administration of double the dose. The disposition kinetics parameters of ampicillin were comparable in sheep with all three routes of drug administration. The renal clearance of ampicillin varied between 0.20 and 0.62 ml/min.kg while total body clearance was 50 to 64 ml/min.kg. The fractional urinary excretion of ampicillin in the first 8 hours after dosing was less than 1 per cent of the dose by all three routes.

Pharmacokinetics of sulfamethazine in buffaloes.

Pharmacokinetic parameters which describe distribution and elimination of sulfamethazine were determined in buffaloes. Following intravenous administration of a single dose (100 mg/kg), disposition of the drug was described in terms of biexponential expression: Cp = Ae alpha t + Be-beta t. Based on total (free and bound) sulfonamide levels in the plasma, pseudo-distribution equilibrium was rapidly attained and the half-life value of 5.54 +/- 0.41 h (mean +/- S.D., n = 8) was recorded. Body clearance was 56 +/- 7 ml x kg-1 x h-1. Based on this study we suggest an intravenous dosage regimen consisting of 38.4 mg sulfamethazine/kg body-weight repeated at 12 h inrervals. With this dosage level the predicted plasma concentrations will oscillate between 125 and 25 micrograms/ml during the steady-state. The influence of febrile states and bacterial diseases on predicted levels remains to be verified experimentally.