A comparative study on the antifungal effect of potassium sorbate, chitosan, and nano-chitosan against Rhodotorula mucilaginosa and Candida albicans in skim milk acid-coagulated (Karish) cheese.

Background and Aim: Yeasts are common contaminants in the cheese industry, which frequently arise from raw milk, the surrounding environment, and equipment, resulting in economic losses in addition to health hazards. This study aimed to compare the antifungal effect of chitosan and nano-chitosan as natural preservatives with a commonly used chemical preservative (potassium sorbate) against Rhodotorula mucilaginosa and Candida albicans. Materials and Methods: Laboratory Karish cheese was manufactured with the addition of potassium sorbate, chitosan, nano-chitosan, and their combinations at different concentrations. The survival of R. mucilaginosa and C. albicans was monitored in different treatments (CR, PR1, PR2, CR1, CR2, NR1, NR2, MR, CC, PC1, PC2, CC1, CC2, NC1, NC2, MC) during storage in a refrigerator with continuous measurement of pH. The impact of using these antifungal agents on the organoleptic parameters of Karish cheese during storage was also evaluated. Results: There was a significant decrease in the count of yeasts in all treatments from the 3rd day of storage, while the mixture of 0.1% potassium sorbate (MR) and 2% chitosan (MC) improved the antifungal effect of chitosan with a lower potassium sorbate concentration and showed the best antifungal effects against both R. mucilaginosa and C. albicans. This combination reduced the yeast count from 8.92 and 9.57 log10 colony-forming unit (CFU)/g in MR and MC treatments, respectively, until it became undetectable on the 9th day of storage, which was earlier than for all other treatments. It was noted that the addition of chitosan nanoparticles (ChNPs) at either 0.25% (NR1 and NC1) or 0.5% (NR2 and NC2) during the manufacturing of Karish cheese significantly lowered the counts of R. mucilaginosa and C. albicans compared with chitosan with a higher molecular weight, but significantly lower than potassium sorbate until 6th day of storage as all treatments of chitosan nanoparticles became significantly higher than potassium sorbate treatments. After 9 days of storage, NR2 and NC2 treatments showed the most significant decreases in count (3.78 and 4.93 log10 CFU/g, respectively), indicating better stability of ChNPs. At the end of the storage period, PR2, PC2, CR2, and CC2 showed significantly high pH values among the groups of 4.8, 5.0, 4.8, and 5.1, respectively. The overall acceptability was significantly higher in treated Karish cheese samples than in the control group, especially at the end of the storage period. Conclusion: Potassium sorbate, chitosan, and ChNPs are effective antifungal preservatives against R. mucilaginosa and C. albicans. In addition, the combination of chitosan with potassium sorbate showed synergistic antifungal activity. These additives also preserve the sensorial criteria longer than for cheese without preservatives.

Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel.

AIM: The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs). BACKGROUND: The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed. REVIEW RESULTS: The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required. CONCLUSION: Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel.

Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.

The effect of human interferon alpha on replication of different bovine viral diarrhea virus strains.

Bovine viral diarrhea virus (BVDV) exists in two main biotypes: cytopathic (cp) and noncytopathic (ncp). Although some studies were done on the effect of interferon alpha (IFN-α) on BVDV, the effect of exogenous IFN against BVDV biotypes remains unclear. In the present study, we evaluated the comparative effect of exogenous human IFN-α (HuIFN-α) on different BVDV biotypes and genotypes. The results showed that exogenous HuIFN-α greatly inhibited the growth of different BVDV biotypes and genotypes. However, HuINF-α has a significant inhibitory effect on cp biotype compared to ncp one without significant variation between different genotypes. The effect of HuIFN-α on BVDV reached the maximum level at early stages of infection (0-20 h post infection) and increased in a dose-dependent manner (10-500 U/ml). Quantitative real-time RT-PCR was used to evaluate the effect of exogenous HuIFN-α on RNA synthesis of both BVDV biotypes. HuIFN-α reduced RNA production of cp by 4 logs compared to only 2 logs for ncp strains. Additionally, the antiviral effect of IFN-α against both BVDV biotypes seems to be independent of the RNA-dependent protein kinase (PKR) activation as assayed by direct analysis of in vivo phosphorylation of eIF2-α and by 2-aminopurine (2-AP) treatment. Collectively, these results indicated that the exogenous HuIFN-α treatment has an inhibitory effect not only on cp BVDV biotype but also on the ncp BVDV. The antiviral effect of exogenous HuIFN-α was biotype, time, dose but not genotype dependent. PKR has no role in the inhibitory effect suggesting that other IFN-antiviral pathways were involved. Keywords: BVDV biotypes; HuIFN-α; RNA synthesis; PKR-independent.

Gold Nanoparticles as a Direct and Rapid Sensor for Sensitive Analytical Detection of Biogenic Amines.

A new optical sensor was developed for rapid screening with high sensitivity for the existence of biogenic amines (BAs) in poultry meat samples. Gold nanoparticles (GNPs) with particle size 11-19 nm function as a fast and sensitive biosensor for detection of histamine resulting from bacterial decarboxylation of histidine as a spoilage marker for stored poultry meat. Upon reaction with histamine, the red color of the GNPs converted into deep blue. The appearance of blue color favorably coincides with the concentration of BAs that can induce symptoms of poisoning. This biosensor enables a semi-quantitative detection of analyte in real samples by eye-vision. Quality evaluation is carried out by measuring histamine and histidine using different analytical techniques such as UV-vis, FTIR, and fluorescence spectroscopy as well as TEM. A rapid quantitative readout of samples by UV-vis and fluorescence methods with standard instrumentation were proposed in a short time unlike chromatographic and electrophoretic methods. Sensitivity and limit of detection (LOD) of 6.59 × 10-4 and 0.6 µM, respectively, are determined for histamine as a spoilage marker with a correlation coefficient (R 2) of 0.993.

Clinical effectiveness and safety of vildagliptin in >19 000 patients with type 2 diabetes: the GUARD study.

The present GUARD study was a prospective, non-interventional study evaluating the clinical effectiveness, safety and tolerability of vildagliptin with or without metformin in adult patients with type 2 diabetes mellitus (T2DM) studied in routine clinical practice. Patients were enrolled from countries across four geographical regions. The primary endpoint was change in glycated haemoglobin (HbA1c) concentration from baseline after 24 weeks of treatment with vildagliptin with or without metformin. Of 19 331 patients analysed, 3511 received vildagliptin and 15 820 received vildagliptin plus metformin. At week 24, the mean HbA1c was reduced significantly from baseline by -1.27% (vildagliptin: -1.17%; vildagliptin plus metformin: -1.29%; p < 0.0001). Significant reductions in HbA1c from baseline were consistently reported regardless of patient age, body mass index (BMI) or baseline HbA1c. Weight and BMI were also significantly reduced from baseline. Vildagliptin treatment with or without metformin was generally well tolerated. It provided clinically relevant glycaemic and weight control, and was well tolerated in a large multi-ethnic population of patients with T2DM studied in routine clinical practice.

Direct skin involvement of cervical lymph node metastasis from mucosal squamous cell carcinoma of the head and neck.

INTRODUCTION: Direct skin involvement of nodal metastasis from mucosal head and neck squamous cell carcinoma has traditionally been considered a poor prognostic indicator. METHODS: This retrospective review identified eight patients (five with mucosal upper aerodigestive and three with occult primary squamous cell carcinoma) who presented between 2000 and 2007 with direct skin involvement of nodal metastasis. RESULTS: Five patients were treated with extended radical and three with extended modified radical neck dissection. Closure was achieved directly (four cases), with local (two) or pedicled (two) flaps. Surgery was always followed by radiotherapy (pan-mucosal or to the primary site). The five-year recurrence-free and disease-specific survival rates were 100 per cent. CONCLUSION: It is exceptionally rare to encounter direct skin involvement of metastatic lymph nodes from mucosal head and neck squamous cell carcinoma without evidence of involvement of other anatomical structures. Surgical intervention is possible and combined modality treatment with curative intent is essential, as most patients can have a favourable outcome.

Minimally invasive, video-assisted thyroidectomy: first experience from the United Kingdom.

INTRODUCTION: Minimally-invasive, video-assisted thyroidectomy (MIVAT) was developed to reduce scarring/trauma associated with cervical incisions used in open thyroidectomy. Results from various centres have been published internationally but none from the UK. This study reports the first results from the UK and compares them with other centres. We also aim to compare the results of a single-surgeon experience in a small/moderately-sized hospital to those of larger tertiary centres. PATIENTS AND METHODS: Retrospective analysis of a single surgeon experience in a district general hospital RESULTS: The cohort was 55 patients (52 female, 3 male), mean age 48 years (range, 21-77 years) who had 64 MIVAT procedures. There were 49 hemithyroidectomies (HTs), 2 isthmusectomy, 4 total thyroidectomies (TTs) and 9 completion thyroidectomies (CTs) with median operating time of 86 min (IQR 66-110 min). Individual operating times were HT 85 min (IQR 60-110 min); TT 130 min (IQR 100-140 min) and CT 77 min (IQR 70-98 min). Median operating time was shorter in the second half of this series (76 min vs 92 min; P < 0.001). Length of stay was < 1 day in 92%. Conversions occurred in 6.3% with no haematoma or re-operation. Transient voice change was present in 7 (11%), permanent unilateral recurrent laryngeal nerve palsy in 2 (3%), and transient hypocalcaemia in 2 (3%). CONCLUSIONS: The first results from the UK are similar to those of other international centres. A single-surgeon practice can obtain results comparable to larger tertiary centres provided there is sufficient case-load. MIVAT is safe and effective, but has a steep learning curve with rapid improvement observed within first 30 cases. Future studies should focus on objective assessment of scar/cosmesis and cost-effectiveness. MIVAT is an acceptable alternative to open surgery in highly selected patients.

Is a head bandage useful after otoplasty? A quasi-randomized controlled study of complications and patient satisfaction.

We conducted a prospective, quasi-randomized, controlled study to evaluate the incidence of postoperative complications and the degree of long-term patient satisfaction associated with the use or nonuse of a head bandage following otoplasty (pinnaplasty). Our study population was made up of 84 consecutively presenting patients who had undergone bilateral otoplasty (either an antihelical or conchaplasty procedure) for the correction of prominent ears under general anesthesia from January 2000 through March 2005. Patients ranged in age from 5 to 56 years (median: 13); 69 patients (82%) were aged 19 years and younger. Of the 84 patients, 61 (73%) received a postoperative head bandage and 23 (27%) did not. Data on complications were collected prospectively from case notes. Data on long-term satisfaction were obtained prospectively on the basis of answers to a questionnaire survey (90% response rate) in which patients rated their satisfaction on a visual analog scale from 0 (not at all satisfied) to 10 (completely satisfied). We found no significant difference between the head-bandage group and the no-head-bandage group with respect to complication rates (36 and 26%, respectively; p = 0.3) or long-term patient satisfaction scores (6.56 and 8.46; p = 0.09). According to multiple regression analysis, the performance of conchaplasty (as opposed to antihelical procedures) appeared to be the only independent variable that influenced both of the outcomes measures (i.e., fewer complications and greater long-term patient satisfaction). Two independent variables were found to influence long-term patient satisfaction only: the presence/absence of any complication and the individual surgeon who performed the procedure. There was no correlation between individual surgeons and complications. We conclude that the use of a head bandage is not necessary or advantageous following otoplasty for the correction of prominent ears, particularly in patients who have undergone cartilage plication.

Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review.

BACKGROUND: Recurrent laryngeal nerve palsy (RLNP) is a recognised possible complication after thyroid surgery. It may present with a variety of symptoms, such as voice change and respiratory symptoms. However, it may remain undetected and the true incidence may be under-reported. The aim of this study was to determine the reported incidence of temporary and permanent palsy after thyroid surgery using different vocal assessment methods. METHODS: A Medline search was performed. A systematic review was undertaken which included 27 articles and 25,000 patients. RESULTS: The average incidence of temporary RLNP after thyroid operations is 9.8% and the incidence of permanent RLNP is 2.3%. The RLNP rate varied according to the method of examining the larynx and ranged from 26% to 2.3%. Most of the reviewed studies recommend a follow-up period up to 1 year to assess and evaluate RLNP. CONCLUSION: Our study has identified that different methods are used to diagnose RNLP and that a wide variety of reported RLNP rates exist. We propose establishment of a 'gold standard' for assessing the voice after thyroidectomy to reduce reporting bias.

Developing a Web 2.0 telemedical education system: the AJAX-Cocoon portal.

Web 2.0 technologies such as wikis, podcasts/vodcasting, blogs and semantic portals could be quite effective tools in e-learning for health professionals. If effectively deployed, such tools can offer a way to enhance students', clinicians' and patients' learning experiences, and deepens levels of learners' engagement and collaboration within medical learning environments. However, Web 2.0 requires simplicity of use as well as integration with modern web technologies. This article presents a Web 2.0 telemedical portal, which provides a social community-learning paradigm from the desk of the physician, the student, the hospital administrator, or the insurer. The presented portal utilises RESTful web services and techniques like content syndication, mushups and Asynchronous JavaScript API and XML (AJAX). The designed portal is based on the Apache Cocoon RESTful framework for sharing Digital Imaging and Communications in Medicine (DICOM) medical case studies. Central to this article is the integration between Cocoon and AJAX. The proposed AJAX-Cocoon portal utilises a JSP portlet architecture, which manages the interaction dynamics and overcomes the shortcomings of the JSR 168 and WSRP 1.0 standards.

Natural radioactivity levels and radiation hazard indices in granite from Aswan to Wadi El-Allaqi southeastern desert, Egypt.

Studies on radiation level and radionuclide distribution in granite from Aswan to Wadi El-Allaqi area that is located in southeastern desert of Egypt were undertaken. The samples collected from five locations: Gabal El Mesala, Umm Hibal, Abu Herigle, Abu Marw and Deneibit El Quleib. The purpose of this study is to provide a baseline map of radioactivity background levels in the investigated area environment, and this study will be used as reference information to assess any changes in the radioactive background level due to geological processes. The highest average values of 226Ra and 232Th concentrations (24.00 and 31.28 Bq kg(-1), respectively) were observed at Abu Herigle region, whereas the highest average value of 40K concentration, 589.95 Bq kg(-1), was detected in Umm Hibal. The absorbed dose rate in air was found to be in the range between 5.40 and 45.11 nGy h(-1), and radium equivalent activity concentration was found in the range between 29.57 and 71.85 Bq kg(-1). Also the representative external hazard index values for the corresponding samples were also estimated and given.

Isolated malleus neck fracture.

Isolated fracture of the malleus seems to be an extremely rare ossicular injury. All previously reported cases involved the handle of the malleus. This is the first reported case of fracture of the neck of the malleus. The diagnosis can easily be missed because the tympanic membrane remains intact. Furthermore, the history may not be suggestive. Surgical repair is particularly difficult.

Cochlear implant outcomes and quality of life in the elderly: Manchester experience over 13 years.

OBJECTIVES: To objectively evaluate the clinical and functional outcomes of cochlear implantation in an elderly population. DESIGN: Retrospective comparative study. SETTING: Neurotology unit at Manchester Royal Infirmary, a supraregional tertiary referral centre in collaboration with Adult Cochlear Implant Programme at The University of Manchester. PARTICIPANTS: All cochlear implant procedures (38) undertaken on post-lingually deafened elderly patients (age range at the time of implantation 65-80 years, n = 34) in the period from 1989 to 2002. MAIN OUTCOME MEASURES: Medical and surgical outcomes. Audiological performance outcomes for isolated words, words in sentences in quiet and noise. Functional outcome measures used are self-reported measures of the social, psychological and emotional aspects of quality of life, and the differences between expectations for functional outcomes and the realization of functional outcomes. They included expectation profiles, Glasgow Benefit inventory (GBI) and Glasgow Health Status Inventory Questionnaire (GHSI). RESULTS: There was statistically significant improvement post-implantation of both open and closed set test scores (P < 0.01). Eighty-two percentage of patients were completely satisfied with their cochlear implants. Patients judged that implantation restored half the loss of quality of life that they had experienced as a result of severe-profound deafness with a highly significant (P < 0.001) improvement in overall quality of life after implantation. The commonest post-operative observation was transient mild pyrexia. CONCLUSIONS: The age of a cochlear implant candidate should not be a factor in the candidacy decision-making process. The quality of life of our elderly recipients was significantly improved after cochlear implant.

The influence of the Internet on decision making in acoustic neuroma.

OBJECTIVE: To determine the access to and the use of the Internet by acoustic neuroma patients as a medical information source, and the influence of the Internet on decision-making, as well as the patients' views on the quality of particular sites. MATERIALS AND METHODS: A retrospective 27-item questionnaire was sent to 138 consecutive acoustic neuroma patients diagnosed between 1997 and 2002. The study included patients treated by conservative, radiotherapeutic and surgical modalities. MAIN OUTCOME MEASURES: Patient demographics, the extent of Internet use as well as quality and quantity of available information. RESULTS: There were 86.95 per cent questionnaires available for analysis. Twenty-four per cent accessed the Internet to obtain information about acoustic neuromas. Ninety-seven per cent of patients said that the information provided in the clinic matched with the information obtained from the websites, 49 per cent said that the information obtained from the Internet did not influence decision making regarding acceptance of treatment of their tumour. Some patients said the Internet information was depressing, devastating, and they would never look up the Internet again for medical information. CONCLUSION: A significant proportion of our patients accessed the Internet for information. Caution should be exercised when advising patients regarding websites as the information on the Internet is often not controlled or checked for accuracy. Acoustic neuroma specialists and ENT surgeons in general should familiarize themselves with related websites so that patients can then be directed to high-quality sites.

Stylomandibular tenotomy in the transcervical removal of large benign parapharyngeal tumours.

We used a simple modification of the transcervical approach in a selected group of nine patients with large benign parapharyngeal space tumours, all of whom met the following inclusion criteria: The tumour was benign on fine needle aspiration, the encapsulated tumour was not attached to skull base or great vessels in the parapharyngeal space on imaging. Adequate exposure was achieved by just dividing the stylomandibular ligament and retracting the mandible anteriorly. It was possible to remove the tumours successfully and safely in all nine patients without the need for mandibulotomy or superficial parotidectomy. In seven cases, the tumour crossed the midline. There were no major perioperative neurological or vascular complications. On subsequent follow up, there were no clinical or radiological signs of residual or recurrent tumour.

Effectiveness of clinical guidelines for the presumptive treatment of streptococcal pharyngitis in Egyptian children.

BACKGROUND: Primary prevention of acute rheumatic fever requires antibiotic treatment of acute streptococcal pharyngitis. In developing countries, clinicians must rely on clinical guidelines for presumptive treatment of streptococcal pharyngitis since bacterial culture and rapid diagnostic tests are not feasible. We evaluated the WHO Acute Respiratory Infection guideline in a large urban paediatric clinic in Egypt. METHODS: Children between 2 and 13 years of age who had a sore throat and pharyngeal erythema were enrolled in the study. Clinical, historical, and demographic information was recorded and a throat culture for group A beta-haemolytic streptococci was done. Sensitivity (% of true-positive throat cultures) and specificity (% of true-negative throat cultures) were calculated for each clinical feature. The effect of various guidelines on correct presumptive treatment for throat-culture status was calculated. FINDINGS: Of 451 children with pharyngitis, 107 (24%) had group A beta-haemolytic streptococci on throat culture. A purulent exudate was seen in 22% (99/450) of these children and this sign was 31% sensitive and 81% specific for a positive culture. The WHO Acute Respiratory Infections (ARI) guidelines, which suggest treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific; 13/107 children with a positive throat culture would correctly receive antibiotics and 323/344 with a negative throat culture would, correctly, not receive antibiotics. Based on our data we propose a modified guideline whereby exudate or large cervical nodes would indicate antibiotic treatment, and this guideline would be 84% sensitive and 40% specific; 90/107 children with a positive throat culture would correctly receive antibiotics and 138/344 with a negative throat culture would, correctly, not receive antibiotics. INTERPRETATION: The WHO ARI clinical guideline has a high specificity but low sensitivity that limits the unnecessary use of antibiotics, but does not treat 88% of children with a positive streptococcal throat culture who are at risk of acute rheumatic fever. A modified guideline may be more useful in this population. Prospective studies of treatment guidelines from many regions are needed to assess their use since the frequency of pharyngitis varies.

PIP: In developing country settings without access to bacterial culture and rapid diagnostic tests, the prevention of acute rheumatic fever depends on clinicians' presumptive treatment of streptococcal pharyngitis. This study evaluated the effectiveness of World Health Organization (WHO) acute respiratory infection guidelines in a large pediatric clinic (Abu Reesh Children's Hospital) in Cairo, Egypt. 451 children 2-13 years of age with sore throat and pharyngeal erythema were enrolled, 107 (24%) of whom had group A beta-hemolytic streptococci on throat culture. Purulent exudate, present in 99 (22%) of these children, was 31% sensitive and 81% specific for a positive culture. The WHO guidelines, which recommend treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific. Based on these guidelines, 13 of 107 children with a positive throat culture would correctly receive antibiotics and 323 of 344 with a negative culture would not receive antibiotics. A modified guideline in which exudate or large cervical nodes would indicate antibiotic treatment would be 84% sensitive and 40% specific. With this modification, 90 of 107 children with a positive throat culture would correctly receive antibiotics and 138 out of 344 with a negative culture would not receive treatment. However, additional prospective studies from other regions of Egypt are necessary before modified guidelines are implemented.