Evaluation of Iron Status in Patients of Chronic Kidney Disease - A study to assess the best Indicators Including Serum Transferrin Receptor Assay

Anemia is an early complication of chronic kidney disease (CKD). The iron deficiency is an important contributor, more so in the Pakistani population. As routine standalone iron tests do not accurately reflect the actual status in the complex environment of CKD, there is a need to study better indicators. Serum iron, ferritin, total iron-binding capacity (TIBC), and serum transferrin receptor (sTfR) levels were estimated in 100 primary iron deficiency anemia (IDA) patients (controls-Group 1) and 68 newly diagnosed CKD cases. The CKD patients were divided into two groups: Serum ferritin <=100 μg/L (Group 2) and >100 μg/L (Group 3). The values of percentage saturation, log of ferritin (log_ferritin), and the ratio of sTfR to log ferritin (sTfR/log_f or sTfR index) were calculated. The CKD cases were further divided depending on ferritin cut-offs of 30, 50, 70, and 100 μg/L and statistically analyzed including ROC and AUC, to choose the best diagnostic parameter for accurate assessment of iron status in CKD cases. The mean serum ferritin was 11.34 μg/L, 28.70 μg/L, and 281.81 μg/L, and the mean sTfR was 2.34 μg/ml, 1.82 μg/ml, and 1.28 μg/ml in Groups 1, 2, and 3. Among all groups, the difference was found to be significant for serum iron, log_ferritin, and sTfR/log_f. The sTfR and sTfR/log_f showed good discrimination between IDA and Anemia of chronic disease in CKD cases, but sTfR/log_f gave the best discrimination at all cut-off levels of ferritin. At a ferritin cut-off of 50 μg/L, the sTfR/log_f value of 0.83 had a sensitivity of 93.5% and specificity of 95.45%, and at a ferritin cut-off 100 μg/L, the same value of 0.83 had a sensitivity of 95.5% and specificity of 86.5%. The ratio of sTfR/log_f is the best indicator for assessing iron status in CKD. Keywords: Anemia, chronic kidney disease, ferritin, transferrin receptor DOI: 10.7176/JMPB/57-03 Publication date: July 31st 201

Correlation of Ankle Brachial Index with Peripheral Vascular Disease in Type 2 Diabetes Mellitus

Objective: The aim of this study was to correlate ankle brachial index (ABI) with peripheral vascular disease (PVD) in type 2 diabetes mellitus. Material and methods: This was a hospital based interdisciplinary prospective study. A total of 100 patients in the age group of 30 to 80 years having peripheral vascular disease with predefined inclusion criteria were included in the study. Patients with other causes of raised blood sugar or peripheral vascular disease were excluded by relevant investigations. Ankle Brachial Index (ABI) was calculated using sphygmomanometer, and Colour Doppler Ultrasound (CDU) was used to diagnose PVD. Both the ABI method and the CDU method were compared for detecting PVD. Results: In our study, mean age was 60.04 ± 5.03 years, mean body mass index was 27.10 ± 2.67 kg/m2 and mean duration of diabetes was 7.75 ± 1.50 years. Among the 68 diagnosed cases of PVD on CDU, 70.6% cases were detected to have PVD by the ABI method (true positive) whereas 20 (29.4%) cases remained undiagnosed when ABI alone was used for the diagnosis (false negative). Conversely, among 51 diagnosed cases of PVD by ABI method 5.9% cases were found to be normal on CDU (false positive). The ABI method was found to have specificity of 88.5% but the sensitivity was only 70.6%. Conclusion: ABI has a very high specificity but the sensitivity is low compared to colour Doppler ultrasound. Therefore, if ABI is abnormal, the diagnosis of PVD is almost certain but in symptomatic cases with normal ABI; colour Doppler should be performed to exclude the PVD. Keywords: Ankle Brachial Index, peripheral vascular disease, Colour Doppler Ultrasound, type 2 diabetes mellitus. DOI: 10.7176/JMPB/57-02 Publication date: July 31st 201

Impact of Dietary Counselling to Improve Nutritional Status of Hemodialysis Patients

Proper nutrition may reverse the malnutrition and can modulate renal function in hemodialysis patients. In majority of the dialysis units in Pakistan, nutritional advice is given by health professionals working in dialysis. We compared the impact of dietary counseling by a renal dietitian, on nutritional status with that by health professionals working in dialysis units in patients undergoing maintenance hemodialysis. Nutritional assessments were made using subjective global assessment (SGA) scale, which combines assessment of intake, physical findings, and functional status. Two hundred and seventy‑seven patients undergoing hemodialysis from two renal care units in Hayatabad Medical Complex Peshawar and Lahore Gernal Hospital Lahore Pakistan, were enrolled (138 patients in control group, 139 in experimental group). In the experimental group, patients were given repeated dietary counseling by a renal dietician, whereas control group patients were provided with the necessary nutritional information by another health professional. Detailed nutritional, biochemical, and SGA assessment were done on all of them at the beginning and completion of study after 6 months. Patients were categorized as well‑nourished (WN) (SGA = 1–14), mild to moderate malnourishment (MMM) (SGA = 15–35), and severe malnutrition (SM) (SGA = 36–49). In the present study, the overall malnutrition rate at baseline was 95.3%, and it dropped down to 91.7% after 6 months after nutritional counseling. In the experimental group, malnutrition status decreased from 97.2% to 89.8%, whereas in the control group, malnutrition situation remained same. Compared to baseline, in the control group, there was no improvement in the WN group. However, a shift has been observed from MMM group to SM group suggesting more number of patients are becoming malnourished. Contrarily, in the experimental group, an improvement of +7.2% in WN group and +14.3% in MMM group and a drop of −21.6% in severe malnourished group suggesting more number of patients gaining nutrition. The present study observed a significant improvement in nutritional status of patients who received counseling by the renal dietician. The reduction in SGA score was independent of reductions in serum creatinine and blood urea levels Keywords: Dietary Counselling, Nutritional Status, Hemodialysis Patients DOI: 10.7176/JMPB/55-16 Publication date:May 31st 201

Effect of Sowing Dates within a Season on Incidence and Abundance of Insect Pests of Canola Crops

Abstract.-This study describes the population difference of some insect pests on canola crops when sown at three dates i.e., mid October, early November and mid November in two years field trials during 2008-2009 and 2009-2010 at Bahawalpur. Crops sown at all three dates were invaded by similar insect pests viz., cabbage aphid, Brevicoryne brassicae Linnaeus (Hemiptera: Aphididae); turnip aphid, Lipaphis erysimi (Kaltenbach) (Hemiptera: Aphididae); peach aphid Myzus persicae Sulzer (Hemiptera: Aphididae), whitefly, Bemisia tabaci Gennadius (Hemiptera: Aleyrodidae); armyworm, Spodoptera exigua (Hübner) (Lepidoptera: Noctuidae) and pod borer, Helicoverpa armigera (Hübner) (Lepidoptera: Noctuidae). Mean seasonal population per plant of these aphids during two years in these three crops (1st, 2nd and 3rd sowing dates) was recorded for B. brassicae as 18.73, 20.81, 26.92 aphids; for L. erysimi as 14.09, 16.82 and 18.32 aphids; and for M. persicae as 0.24, 0.23 and 0.27 aphids, respectively. Other insects with low numbers per plant were observed as S. exigua with 0.10, 0.17 and 0.14 larvae; H. armigera as 0.14, 0.16 and 0.18 larvae per plant and B. tabaci as 0.32, 0.17 and 0.34 flies per plant in crops grown on 1 st , 2 nd , and 3 rd sowing dates, respectively. Result indicated that there was no difference in time of incidence of insect pests in crops in relation to different sowing dates however a clear difference was noted in per plant population (densities or abundance) of these insect pests. M. persicae, S. exigua, H. armigera and B. tabaci in all three crops were not significantly different, whereas densities of two species of aphids (B. brassicae and L. erysimi) differed significantly among three sowing dates. These two aphid species made dense colonies during mid to late season. Among the three treatments, mid November sown crop was found the most susceptible to these two aphids when compared to crops sown during mid October and early November

A prevalent disease missed under cover of an uncommon disorder- a learning experience in clinical practice

Musculoskeletal pains are secondary complication of a my apathic disorder but other causes must be ruled out through meticulous evaluation. We report a case of distal my apathy who developed back pain due to tuberculous spondylitis but was overlooked and his complaint of backache was considered outcome of mechanical deterioration of vertebral column resulting from weakness of para spinal muscles due to my apathy. After detailed evaluation, his unnoticed ailment was identified and he was started off with the right management

Using Fuzzy System To Control Cell Multiplexing In Atm Networking

The aim of this research is to design and simulate a fuzzy logiccontroller (FLC) to control the cell multiplexing in Asynchronous TransferMode(ATM) networking , which is a high performance cell oriented switchingtechnology that utilizing of small size packet to carry different types of service fortraffic and to show the effect of using the fuzzified variables (queuing messagelength and the number of inputs) on cell flow rate (control action) on the output of(FLC).The paper presents the previous works, principles of operations, cellmultiplexing, principles of fuzzy logic and internetworking with ATM network, thedesign process of system and the output of simulation. The cell flow rate on theoutput of fuzzy logic controller (FLC) which has been simulated depends on theinput variables, one of them is the queuing message (message length), and thesecond one is the number of inputs. The simulation of fuzzy controller has beenexecuted by using (MATLAB). In the light of this research, an importantconclusion can be drawn, is that increasing of the fuzzified inputs variables meansthat cell queuing will increasing so the (FLC) will achieve size of packet to belarge then the flow bit-rate of cell (control action) will decrease and when thenumber of inputs decreases that will let to achieve a high flow bit-rate as(M.Q=0.5,N=o.5,the control action (cell rate) =0.5 cells/s) and if (M.Q=0.2, N=0.5,the control action(cell rate=0.77 cells/s).Using parameters such as ( messagelength and No. of inputs)as fuzzified variables in controlling cell multiplexinggives a flexible and a high speed responding to sudden changes in selectivevariables and get bit-rate which reduces time delay for different types ofservices(text, image, video and audio) which cause to get a high throughput, that isthe maximum throughput under FLC parameters (with message length and No. ofinputs) is (562.7Mbit/s) for text message, (568Mbit/s) for image message,(563.4Mbit/s) for the video message and (563.4Mbit/s) for audio messag

Impact of neonicotinoid seed treatment of cotton on the cotton leafhopper, Amrasca devastans(Hemiptera: Cicadellidae), and its natural enemies

BACKGROUND Neonicotinoid seed treatments suppress populations of pest insects efficiently and can enhance crop growth, but they may have negative effects on beneficial arthropods. We evaluated the effects of either imidacloprid or thiamethoxam on the abundances of a sucking pest, the cotton leafhopper (Amrasca devastans), and its arthropod predators under field conditions. We also evaluated the impact of seed treatment on transgenic cotton plant growth, with pests and natural enemies present or absent. RESULTS Imidacloprid and thiamethoxam reduced pest abundance, with greater effects when dosages were higher. Treatment at recommended doses delayed the pest in reaching the economic damage threshold by around 10–15 days (thiamethoxam) and 20 days (imidacloprid). Recommended doses also enhanced plant growth under all tested conditions; growth is affected directly as well as via pest suppression. Neonicotinoid applications reduced abundance of beneficial arthropods, with lower populations after higher doses, but negative effects of imidacloprid were not apparent unless the manufacturer-recommended dose was exceeded. CONCLUSION Imidacloprid applied at the recommended dose of 5 g kg−1 seed is effective against A. devastans and appears to be safer than thiamethoxam for natural enemies, and also enhances plant growth directly. We caution, however, that possible sublethal negative effects on individual beneficial arthropods were not evaluated

The importance of alternative host plants as reservoirs of the cotton leaf hopper, Amrasca devastans, and its natural enemies

Many agricultural pests can be harboured by alternative host plants but these can also harbour the pests’ natural enemies. We evaluated the capacity of non-cotton plant species (both naturally growing and cultivated) to function as alternative hosts for the cotton leaf hopper Amrasca devastans (Homoptera: Ciccadellidae) and its natural enemies. Forty-eight species harboured A. devastans. Twenty-four species were true breeding hosts, bearing both nymphal and adult A. devastans, the rest were incidental hosts. The crop Ricinus communis and the vegetables Abelmoschus esculentus and Solanum melongena had the highest potential for harbouring A. devastans and carrying it over into the seedling cotton crop. Natural enemies found on true alternative host plants were spiders, predatory insects (Chrysoperla carnea, Coccinellids, Orius spp. and Geocoris spp.) and two species of egg parasitoids (Arescon enocki and Anagrus sp.). Predators were found on 23 species of alternative host plants, especially R. communis. Parasitoids emerged from one crop species (R. communis) and three vegetable species; with 39 % of A. devastans parasitised. We conclude that the presence of alternative host plants provides both advantages and disadvantages to the cotton agro-ecosystem because they are a source of both natural enemy and pest species. To reduce damage by A. devastans, we recommend that weeds that harbour the pest should be removed, that cotton cultivation with R. communis, A. esculentus, and S. melongena should be avoided, that pesticides should be applied sparingly to cultivate alternative host plants and that cotton crops should be sown earlier

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability