Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria / Potencial de antiadesão e antibiofilme de Fagonia indica do deserto do Cholistão contra bactérias multirresistentes clínicas

High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-¹ against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-¹ and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-¹ against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-¹) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

A alta resistência aos antimicrobianos está associada à formação de biofilme responsável por micróbios infecciosos para suportar condições severas. Portanto, novas alternativas são necessárias como inibidores de biofilme para controlar infecções. Neste estudo, as atividades antimicrobiana e antibiofilme dos extratos de Fagonia indica foram avaliadas contra isolados clínicos MDR. O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica tem efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-¹, e valor de concentração bactericida mínima (MBC) de 500-3000 µg mL-1 contra isolados clínicos multirresistentes (MDR). O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica teve efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-¹, e concentração bactericida mínima (MBC) de 500-3000 µg mL-¹ contra isolados MDR. Os efeitos inibitórios máximos do extrato de clorofórmio Fagonia indica na formação de biofilme foi observada em Staphylococcus aureus (71,84%), seguido por Klebsiella pneumoniae (70,83%) após 48 horas, mostrando que a inibição também é dependente do tempo. Nossos resultados sobre extravasamento de proteínas de células bacterianas indicaram que isolados MDR tratados com extrato clorofórmico de Fagonia indica apresentaram vazamento máximo de proteínas de K. pneumoniae (59,14 µg mL-¹), seguido por S. aureus(56,7 µg mL-¹). Ensaios de fixação de células indicaram que o extrato de clorofórmio resultou em uma inibição de 43,5-53,5% da aderência das células a uma superfície de poliestireno. Nossos resultados revelaram que extratos de Fagonia indica inibiram [...].

Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria

Abstract High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-1) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

Resumo A alta resistência aos antimicrobianos está associada à formação de biofilme responsável por micróbios infecciosos para suportar condições severas. Portanto, novas alternativas são necessárias como inibidores de biofilme para controlar infecções. Neste estudo, as atividades antimicrobiana e antibiofilme dos extratos de Fagonia indica foram avaliadas contra isolados clínicos MDR. O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica tem efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-1, e valor de concentração bactericida mínima (MBC) de 500-3000 µg mL-1 contra isolados clínicos multirresistentes (MDR). O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica teve efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-1, e concentração bactericida mínima (MBC) de 500-3000 µg mL-1 contra isolados MDR. Os efeitos inibitórios máximos do extrato de clorofórmio Fagonia indica na formação de biofilme foi observada em Staphylococcus aureus (71,84%), seguido por Klebsiella pneumoniae (70,83%) após 48 horas, mostrando que a inibição também é dependente do tempo. Nossos resultados sobre extravasamento de proteínas de células bacterianas indicaram que isolados MDR tratados com extrato clorofórmico de Fagonia indica apresentaram vazamento máximo de proteínas de K. pneumoniae (59,14 µg mL-1), seguido por S. aureus (56,7 µg mL-1). Ensaios de fixação de células indicaram que o extrato de clorofórmio resultou em uma inibição de 43,5-53,5% da aderência das células a uma superfície de poliestireno. Nossos resultados revelaram que extratos de Fagonia indica inibiram significativamente a formação de biofilme entre isolados clínicos MDR, portanto, poderiam ser aplicados como agentes antimicrobianos e inibidores de biofilme de baixo custo contra esses isolados MDR.

Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria / Potencial de antiadesão e antibiofilme de Fagonia indica do deserto do Cholistão contra bactérias multirresistentes clínicas

High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-1) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

A alta resistência aos antimicrobianos está associada à formação de biofilme responsável por micróbios infecciosos para suportar condições severas. Portanto, novas alternativas são necessárias como inibidores de biofilme para controlar infecções. Neste estudo, as atividades antimicrobiana e antibiofilme dos extratos de Fagonia indica foram avaliadas contra isolados clínicos MDR. O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica tem efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-1, e valor de concentração bactericida mínima (MBC) de 500-3000 µg mL-1 contra isolados clínicos multirresistentes (MDR). O extrato exibiu seu efeito antibiofilme ao alterar a aderência e a desintegração da parede celular bacteriana. Fagonia indica teve efeito antibacteriano com valores de concentração inibitória mínima (CIM) variando de 125 a 500 µg mL-1, e concentração bactericida mínima (MBC) de 500-3000 µg mL-1 contra isolados MDR. Os efeitos inibitórios máximos do extrato de clorofórmio Fagonia indica na formação de biofilme foi observada em Staphylococcus aureus (71,84%), seguido por Klebsiella pneumoniae (70,83%) após 48 horas, mostrando que a inibição também é dependente do tempo. Nossos resultados sobre extravasamento de proteínas de células bacterianas indicaram que isolados MDR tratados com extrato clorofórmico de Fagonia indica apresentaram vazamento máximo de proteínas de K. pneumoniae (59,14 µg mL-1), seguido por S. aureus (56,7 µg mL-1). Ensaios de fixação de células indicaram que o extrato de clorofórmio resultou em uma inibição de 43,5-53,5% da aderência das células a uma superfície de poliestireno. Nossos resultados revelaram que extratos de Fagonia indica inibiram significativamente a formação de biofilme entre isolados clínicos MDR, portanto, poderiam ser aplicados como agentes antimicrobianos e inibidores de biofilme de baixo custo contra esses isolados MDR.

Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria.

High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-1) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

Regional five-year clinical outcomes of 289 consecutive cementless oxford uni-compartmental knee replacements at a non-inventor centre.

INTRODUCTION: Uncemented unicompartmental knee replacement offers a minimally invasive approach, faster rehabilitation and good levels of function, supported by evidence reporting low intra-operative fracture rate and mid-term stability with no implant migration at 5-years. Our aim was to examine the clinical outcomes in 289 consecutive Oxford unicompartmental knee arthroplasties (257 patients), five years post-operatively. METHODS: A retrospective study of patients treated between 2008 and 2014 in a non-inventor centre by a single surgeon was performed. Patients with anteromedial bone on bone uni-compartmental arthritis were included. Oxford Knee Scores (OKSs) at last follow-up were recorded, intra-operative complications reported with commentary on revision cases. RESULTS: Mean age of patients was 66 years (SD 9.6, 45-88 years). 122 (42%) patients were female and 135 (58%) were male. Patient in our study were ASA 1 (36%), ASA 2 (62%) and ASA 3 (01%). There were no intra-operative complications, particularly tibia fractures during impaction. The average oxford knee score was 40.1 (n = 232, Range 06 to 48, SD 8.46) at an average 6 years and 3 months from surgery, including revised patients. Six patients had their prosthesis revised within five-years of the index surgery. Five-year cumulative implant survival rate was 97.8% (95% CI 97.62 to 97.98, SE 0.09). Indications for revision were: lateral side wear (n = 1); dislocated spacer (n = 4); instability and spacer subluxation (n = 1). Thirteen patients died within five years of surgery Five-year cumulative survival rate was 94.9% (95% CI 94.87 to 94.925, SE 0.013). CONCLUSION: The proportion of patients requiring revision at five-years is lower than that generally reported for UKR. These findings add support for the use of the cementless oxford UKR outside the design centre.

A Study of the Association between Diabetes Mellitus and Chronic Hepatitis B Virus Infection / Un Estudio de la Asociación entre la Diabetes Mellitus y la Infección Crónica por el Virus de la Hepatitis B

ABSTRACT Background: Hepatitis B virus (HBV) infection and diabetes mellitus are major health problems associated with significant morbidity and mortality. The published literature suggests an association of diabetes mellitus with liver disease. However, the role of HBV infection in diabetes aetiology is still controversial. The present study was conducted to explore the veracity of this enigmatic association among Pakistani subjects. Methodology: The blood samples and clinical information were collected from chronic HBV-positive patients Group 1 (n = 120), and their age and gender were matched with those of the healthy control subjects Group 2 (n = 120). Hepatitis B virus-positive patients were also subdivided into two groups; (Group 1a and Group 1b) with and without liver cirrhosis for evaluation of the prevalence of diabetes. Results: The study revealed that there were statistically significant differences in the biochemical parameters in the HBV-positive and control groups. There was no correlation between diabetes and HBV with the prevalence of diabetes mellitus being similar in subjects with and without HBsAg (11.7% in the positive group and 10% in the controls). Since there were a relatively large number (32.5%) of HBV-positive patients with liver cirrhosis, a comparison of biochemical parameters was also carried out to evaluate the extent of the liver damage and its association with diabetes. During the comparison of HBV patients with and without cirrhosis for the prevalence of diabetes, no aetiologic association was found with diabetes. Conclusion: Study revealed that there was no correlation between HBV infection and diaabetes despite the significantly different biochemical parameters in the HBV-infected group and control subjects.

RESUMEN Antecedentes: La infección por el virus de la hepatitis B (VHB) y la diabetes mellitus son problemas de salud importantes asociados con morbilidad y mortalidad significativas. La literatura publicada sugiere una asociación de la diabetes mellitus con las enfermedades hepáticas. Sin embargo, el papel de la infección por VHB en la etiología de diabetes sigue siendo contro-versial. El presente estudio fue conducido con el propósito de explorar la veracidad de esta enigmática asociación entre sujetos paquistaníes. Metodología: Se recogieron muestras de sangre e información clínica de pacientes crónicos VHB positivos Grupo 1 (n = 120), y su edad y género fueron comparados con los de los sujetos sanos del control Grupo 2 (n = 120). Los pacientes positivos al virus de la hepatitis B también se subdividieron en dos grupos, a saber, (Grupo 1a y Grupo 1b) con y sin cirrosis hepática en relación con la prevalencia de la diabetes. Resultados: El estudio reveló que hubo diferencias significativas en estos dos grupos en los parámetros bioquímicos entre el grupo de control y el grupo VHB positivo. En estos dos grupos no hubo correlación entre la diabetes y el VHB. Puesto que hubo un número relativamente grande (32.5%) de pacientes VHB positivos con cirrosis hepática, se realizó también una comparación de los parámetros bioquímicos a fin de comprender el grado del daño hepático y su asociación con la diabetes. Durante la comparación de los pacientes con VHB con y sin cirrosis en relación con la prevalencia de diabetes, no se halló asociación etiológica con la diabetes. Conclusión: Este estudio reveló que no hubo correlación entre la infección por VHB y la diabetes, a pesar de los parámetros bioquímicos significativamente diferentes entre el grupo infectado por el VHB y los sujetos del control.

Effect of Hemodialysis on Corrected QT Interval and QTc Dispersion.

Hemodialysis patients are at higher risk of cardiovascular disease due to traditional and dialysis-related risk factors. Our aim was to study the effects of hemodialysis on the corrected QT interval (QTc) and QTc dispersion in chronic kidney disease (CKD) without clinically manifest heart disease. Two hundred cases of CKD on chronic intermittent hemodialysis of >3 months' duration were included in the study. Twelve-lead electrocardiography and samples for serum creatinine, potassium, calcium, and magnesium were taken before and after dialysis. The mean age of patients was 52.4 ± 17 years with male-to-female ratio of 3:1. QTc interval and QTc dispersion were prolonged in 47% and 59% before and 50% and 89% of patients after hemodialysis, respectively. The mean values of QTc were 433.4 ± 36.9 ms before and 451.4 ± 39.6 ms after hemodialysis (p = 0.001) and the mean values of QTc dispersion were 60.5 ± 19.3 ms before and 81.5 ± 24.4 ms after hemodialysis (p = 0.001). Similar pattern was observed in all etiological groups of CKD, except for QTc dispersion in malignancy-related CKD (p = 0.216). After hemodialysis, there was a significant fall in the mean values of serum potassium (p = 0.001), rise in serum calcium (p = 0.001), and no change in magnesium (p = 0.424). Patients with post hemodialysis QTc dispersion >74 ms had significantly low mean values of serum potassium and calcium as compared to <74 ms group. Large numbers of hemodialysis patients have a prolonged QTc interval and QTc dispersion with a significant increase in the mean values after hemodialysis. There is a significant fall in serum potassium and rise in serum calcium after dialysis.

Cytomegalovirus-Induced Polyarteritis Nodosa in a Liver Transplant Recipient.

Polyarteritis nodosa (PAN) is a necrotizing vasculitis that has been associated with viral infections, especially hepatitis B virus. We hereby report a case of tissue-invasive cytomegalovirus (CMV)-induced PAN in a liver transplant recipient presenting with acute kidney injury and active urinary sediment. Treatment directed against both PAN and CMV resulted in improvement in kidney function, normalization of urinary indices and resolution of the CMV infection. There was no recurrence of either PAN or CMV after a 3-year follow-up period.

Special care dentistry: how prepared are we?

AIM: To assess and evaluate the confidence of the undergraduate dental team in Irish dental schools regarding their training in the field of special care dentistry (SCD). METHOD: A questionnaire was distributed amongst the undergraduate dental teams within Cork University Dental School and Hospital (CUDSH) and Dublin Dental University Hospital (DDUH). The data were analysed to assess for differences between the median responses of the various groups. RESULTS: A total of 139 students participated in the study; 82 from DDUH (59 dental science students, seven dental hygiene students and 16 dental nursing students) and 57 from CUDSH (43 dental science students and 14 dental hygiene students). Twenty-two per cent (n = 30) of respondents agreed that their training had been sufficient in providing treatment or assistance for patients requiring SCD. Seventy-five per cent agreed that more emphasis should be placed on clinical training in SCD (n = 76). Thirty-one per cent of students anticipated a high level of confidence in treating patients requiring SCD upon graduation (n = 43), with dental science students feeling the least prepared amongst the dental team. CONCLUSION: Confidence levels of the undergraduate dental team were low with regard to SCD. The existing hands-on clinical training in SCD was deemed insufficient by the respondents. Students believed more emphasis should be placed on SCD training in the undergraduate curriculum.

Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study.

Glomerular diseases continue to be the leading cause of end-stage renal disease (ESRD) globally. Hence, it is important to recognize the pattern of glomerular diseases in different geographical areas in order to understand the patho-biology, incidence and progression of the disorder. Published studies from different centers in Saudi Arabia have reported contradicting results. In this retrospective study, we report our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia. A total of 348 native renal biopsies performed at our center on patients with proteinuria >1 g, hematuria and/or renal impairment during a period of 5 years (between January 2005 and December 2009) were studied by a histopathologist using light microscopy, immunofluorescence and electron microscopy, and were categorized. Results showed that primary glomerular disease accounted for 55.1% of all renal biopsies. The most common histological lesion was focal and segmental glomerulosclerosis (FSGS) (27.6%), followed by minimal change disease (MCD) (17.7%) and membrano-proliferative glomerulonephritis (MPGN) (13.0%). Secondary glomerular disease accounted for 37.9% of the glomerular diseases, with lupus nephritis (LN) being the most common lesion (54.5%), followed by hypertensive nephrosclerosis (22%), post-infectious glomerulonephritis (7.5%), diabetic nephropathy (DN) (6.8%) and vasculitides (4.5%). Four percent of all biopsies turned out to be ESRD while biopsy was inadequate in 2.8% of the cases. In conclusion, our study showed that FSGS was the most common primary GN encountered, while LN was the most common secondary GN. We encountered 14 cases of crescentic glomerulonephritis. Also, the prevalence of MPGN, MCD, IgA nephropathy and membranous GN was many folds higher in males when compared with the Western data. We believe that it is mandatory to maintain a Saudi Arabian Renal Biopsy Registry to understand better the pattern of glomerular disease in the Saudi population and to follow any change in trend.

Outcome of arthrodesis of the hindfoot as a salvage procedure for complex ankle pathology using the Ilizarov technique.

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)). Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion. These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief. Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Malignant glomus tumour of larynx: first case report and literature review.

OBJECTIVE: We describe the first reported case of a malignant glomus tumour of the larynx. METHOD: Case report and review of the world literature concerning malignant glomus tumours. RESULTS: A 37-year-old man presented with progressive hoarseness and dyspnoea. A smooth, right-sided laryngeal mass was found on flexible nasolaryngoscopy. Initial biopsy of this lesion was reported as a true 'glomus tumour', which is a benign lesion. Wide local excision was performed. The final histology of this specimen showed it to be a 'malignant glomus tumour'. Immunohistochemistry was positive for smooth muscle actin, collagen type IV, vimentin and cluster of differentiation 34 glycoprotein. Total laryngectomy was then performed as a definitive curative procedure. CONCLUSION: Glomus tumour is rarely found in visceral locations. This tumour and its malignant counterpart are rare differential diagnoses of laryngeal masses.

Profile of drug users in Karachi City, Pakistan.

Drug use has been identified as a major public issue in Pakistan. A descriptive questionnaire survey in Karachi city was made to identify the socioeconomic profile and beliefs and practices of 500 drug users The most commonly used drugs were cocaine (19.0%) and crack-cocaine (15.0%), followed by amphetamine, (11.0%), alcohol, caffeine, barbiturates and benzodiazepines (10.0% each). Key psychological factors leading tc drug use were problems with parental or marital relations or break-up of a relationship (45.0%). Drugs were seer as an escape from stressful life events (28.0%) or feelings of failure (18.2%). Many drug users blamed the origin of their drug use on bad social influences (47.0%) or socioeconomic problems (23.4%). Preventive measures are needed to decrease the rate of drug addiction in Karachi.

Profile of drug users in Karachi city, Pakistan

Drug use has been identified as a major public health issue in Pakistan. A descriptive questionnaire survey in Karachi city was made to identify the socioeconomic profile and beliefs and practices of 500 drug users. The most commonly used drugs were cocaine [19.0%] and crack-cocaine [15.0%], followed by amphetamines [11.0%], alcohol, caffeine, barbiturates and benzodiazepines [10.0% each]. Key psychological factors leading to drug use were problems with parental or marital relations or break-up of a relationship [45.0%]. Drugs were seen as an escape from stressful life events [28.0%] or feelings of failure [18.2%]. Many drug users blamed the origins of their drug use on bad social influences [47.0%] or socioeconomic problems [23.4%]. Preventive measures are needed to decrease the rate of drug addiction in Karachi

Effectiveness and tolerability of levonorgestrel intrauterine system in adolescents.

Our objective was to survey the outcome of treatment with levonorgestrel intrauterine system (Mirena LNG-IUS) at 6-18 months in a university affiliated tertiary referral hospital in adolescents. We report on a consecutive case series of 48 adolescents who had Mirena over 8 years as a day-case procedure between 2003 and 2008. The mean age was 15.3 years and all were of white British origin. The commonest indications were menorrhagia and dysmenorrhoea resistant to oral treatment. For 28/48 (58%), menstrual symptoms had a significant impact on quality-of-life; 45/48 (93.4%) reported ongoing significant improvement in their menstrual symptoms and 2/48 (4.2%) had the device removed within 4 months of insertion. We conclude that Mirena is a well tolerated and effective alternative for heavy periods +/- dysmenorrhoea in adolescents who do not respond to oral therapy.

The clandestine uterus: or how the uterus escapes detection prior to puberty.

Uterine agenesis is one of the differential diagnoses in adolescent girls with delayed menstruation. It may also be suspected earlier in childhood during investigations for other genitourinary conditions. However, accurate confirmation that the uterus is absent can be extremely difficult before puberty because of its small size. We describe ten girls referred to a specialist centre with a presumed diagnosis of an absent uterus which was later found to be incorrect. We conclude that imaging should be undertaken by clinicians with experience in management of this age group and in some girls it may be necessary to delay final diagnosis until after puberty.