pharmamag-2013

S e r v i n g t h e P r o f e s s i o n o f P h a r m a c y

ISSN-2309-0286 www.youngpharmacists.com PharmaMag-2013

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Farrukh Mehmood (PharmD) ([email protected])

Tariq Ahmad (PharmD) ([email protected])

Editors and Publishers

YoungPharmacists

PharmaMag 2013 [email protected]

www.youngpharmacists.com

City of Publication: Lahore

Country code: PAK

Status of Publication: Current serial (c)

Start Date of Publication: 200909

Frequency: Annual (a)

Language: English (eng)

Medium: Online (cr)

ISSN : 2309-0286

Issue: 5th

Editorial

YoungPharmacists



Get Involved and Stay Informed. The days of passively pursuing your own career while ignoring the bigger picture are long gone (if they ever existed). Keep a pulse on the developments that impact the profession of pharmacy any way you can.

Being informed will better prepare you for the next wave of change. Joining organizations, going to board of pharmacy meetings, or writing letters to politicians are all ways to become more involved.

Farrukh Mehmood

Contributors

YoungPharmacists



Furqan Munir (PharmD) As-Salama Hospital, Khobar Saudi Arabia

Zia Mehmood Network Administrator Spleen Manufacturing (Pvt.) Ltd Lahore

Contents

The Issue Of Bioequivalence, Therapeutic Equivalence, And Generic Substitution Of Medicines For Treatment Of Epilep-

sy And Suggested Ways To Overcome The Problems

By Khurram Rehman; PharmD, University of Lahore; MS Pharmaceutical Analysis, Research Assistant/ Ph.D Student, University Kebangsaan Malaysia

06

Spread Of Niegleria fowleri In Pakistan With Its Brief Information, Diagnosis, And Treatment

By Maliha Bari; PharmD, Dow University of Health Sciences Karachi; Management Trainee Officer, Geofman Pharmaceuticals Pakistan

08

Management of Respiratory Distress Syndrome in Infants By Eiman Akram; PharmD, Lahore College for Women University Pakistan 11

Myths about Thalassemia By Jony Mallik; B.Pharm (Hons.), M.Pharm, Southern University Bangladesh 15

Microbial Limit Tests By Farrukh Mehmood; PharmD, R.Ph.; Microbiologist, Highnoon Laboratories Ltd., Lahore, Pakistan

21

Syringomyelia By Amna Hafeez; PharmD 24

Living With Liver Cancer... By Mehrish Memon; PharmD 26

Mismanagement of Hypertensive Emergency in a Patient Suffering from Recurrent Stroke

By Muhammad Qamar; Lecturer of Clinical Pharmacy, School of Pharmacy, Management and Science University, Malaysia

30

The "New" Health Miracles: Probiotics By Iqra Mansha; PharmD, Lahore College for Women University Pakistan 32

Indications, Contraindications, Precautions, and Counseling Parameters of Patients with Coronary Atherosclerosis and

Hepatitis

By Azzah Khadim; Mariam Ashraf; PharmD(Final Prof) University College of Pharmacy, Punjab University, Lahore Pakistan

35

Pregnancy A Crucial Stage for Women That Must Need Special Care

By Jony Mallik; B.Pharm (Hons.), M.Pharm, Southern University Bangladesh

Priyanka Das; B.Pharm (Hons.), BGC Trust Uni-versity, Bangladesh

38

The Issue Of Bioequivalence, Therapeutic Equivalence, And

Generic Substitution Of Medicines For Treatment Of Epilepsy

And Suggested Ways To Overcome The Problems

The use of generic drugs to replace brand name drugs is a fre-quent topic among all types of healthcare professionals. This is because the generics are very cheap compared to expensive inno-vators. The US food and drug administration FDA approves generic forms of brand-name drugs if they are able to show bioequiva-lence, as well as standards in drug content (active drug and ex-cipient), and manufacturing. According to FDA for a drug to be bioequivalent it should be both pharmaceutical equivalent and therapeutic equivalent. In contrast to the FDA's position several epilepsy specialists and societies, including an American Academy of Neurology, have expressed concern that generic substitution of branded drugs car-ries a greater potential risk of detrimental patient outcomes in epilepsy than in many other conditions. This increase in risk is attributed to the narrow therapeutic range of antiepileptic drugs (AEDs) Therefore many physicians and patients answer no to the ques-tion; are generic AEDs always equivalent to brand? Several cases have been reported in various studies, which had seizure frequen-cy increase after they were switched to generic antiepileptic drugs. There are several studies performed on antiepileptic drugs like Phenytoin, Valproic acid, Carbamazepine, Gabapentin and Zo-nisamide. Many of those studies concluded that changing from a brand antiepileptic drug to a generic may result in seizures. But the current FDA therapeutic equivalence testing regulations may not be adequate for AEDs and suggests that more clinical evi-dence is needed. Physicians, pharmacists, patients and policy makers should be aware that for some patients there may be risks associated with switching from brand to generic AEDS

Therefore many physicians and patients answer no to the ques-tion; are generic AEDs always equivalent to brand? Several cases have been reported in various studies, which had seizure frequen-cy increase after they were switched to generic antiepileptic drugs.

There are several studies performed on antiepileptic drugs like Phenytoin, Valproic acid, Carbamazepine, Gabapentin and Zo-nisamide. Many of those studies concluded that changing from a brand antiepileptic drug to a generic may result in seizures. But the current FDA therapeutic equivalence testing regulations may not be adequate for AEDs and suggests that more clinical evi-dence is needed. Physicians, pharmacists, patients and policy makers should be aware that for some patients there may be risks associated with switching from brand to generic AEDS. Another study interprets that most generic AED products provide total drug delivery (AUC) similar to reference products. The dif-ferences in peaks between formulations are more common. Switches between the generic AED products may cause greater changes in plasma drug concentrations than generic substitutions of reference products. Among the AEDs, phenytoin and carbamazepine have the most complex factors potentially influencing bioavailability, poor sol-ubility in water. And non linear pharmacokinetics and age related pharmacokinetics. Meaning studies in adults may not always translate to the pediatric population. None of the data published so far are sufficient to provide a firm evidence base that there is a problem with generic AEDs. The FDA believes that there are no documented examples of a gener-ic product manufactured to meet approved specifications that cannot be used interchangeably with the corresponding brand name drug. However, the majority of physicians and patients perceive that generic AEDs are not always equivalent to brand counterparts. This perception influences prescribing practices and there are many brand-necessary prescriptions for AEDs. It is un-known whether these brand-necessary prescriptions prevent breakthrough seizures or lessen adverse effects. It is unknown

By Khurram Rehman

PharmD, University of Lahore

MS Pharmaceutical Analysis

Research Assistant/ Ph.D Student

University Kebangsaan Malaysia

Page 06 www.youngpharmacists.com PharmaMag-2013

The Issue Of Bioequivalence, Therapeutic Equivalence, And

Generic Substitution Of Medicines For Treatment Of Epilepsy

And Suggested Ways To Overcome The Problems

how these specified prescriptions affect the cost of healthcare. Brand-necessary prescriptions increase the medicine costs but may decrease costs in terms of adverse events and quality of life. At the current time, a definitive scientifically valid study needs to be done to answer the question. There are two possible outcomes. Generics are truly equivalent, that is, the FDA is correct. In that case we need to educate healthcare providers and our patients. The other possibility is that one, some, or many of the generic AEDs are not equivalent. In that case, the FDA needs to recon-sider the rules it uses to determine that these products are equiva-lent.

The ultimate goal is to have truly equivalent generics that are accepted by all as being interchangeable without concern for safety and efficacy. This will result in cost savings and better quality of care. The only remaining issues would be that pills may be confused when the generic manufacturer changes be-cause the pills look different or because the excipients are differ-ent, and rarely a patient may be allergic to one of the inactive ingredients. Moreover, people with epilepsy at the extremes of age (children or older adults) often have decreases in hepatic enzyme activity and protein binding, potentially making them more susceptible to bio-in equivalence with generic formulation substitution. The first step is to assess whether problems occurring after ge-neric AED formulations switches are related to bio-in equiva-lence between the formulations. Further studies to identify pa-tient subgroups or specific factors that may increase the risk of bio in equivalence with generic formulation substitution would also be valuable then other causes of the many complaints by health-care providers and patients then could be evaluated in a randomized, controlled trial designed to test therapeutic equiva-lence with additional outcomes of adverse effects and seizure frequency. For example, such a study might determine that some people with epilepsy experience seizures or adverse effects with

the small variations in plasma concentration of the magnitude currently allowed by the FDA. Until such studies are completed, health-care providers and people with epilepsy would do well to proceed cautiously when switching to generic formulations, with health-care providers communicating to patients the potential risks and benefits of substitution. The debate over substitution of brand name drugs with generic formulations is a serious one, especially with regard to AEDs. Those with epilepsy do not have tried a generic formulation if there is any risk of a breakthrough seizure or toxicity. Although some states require substitution with generic formulation if it is available, the pharmacist can maintain some control over this situation by alerting the prescriber physician to the mandated substitution and discussing with them the associated risks. The pharmacist must also educate the patient on the risk breakthrough seizures and the implications for the patients life. If generic sub-stitution occurs the same manufacturer of the generic form should be used throughout treatment to avoid the same bioequiv-alence issues in changing between generic drugs as between ge-neric and brand name drugs. The FDA stands strongly behind its requirements for therapeutic equivalence and many generic forms are used every day, safely and effectively. However, AEDs and other drugs with narrow therapeutic index may require closer scrutiny and more stringent criteria. Currently available data on generic forms of AEDs are very limited.


Spread Of Niegleria fowleri In Pakistan With Its Brief

Information, Diagnosis, And Treatment

Introduction: Naegleria fowleri (commonly referred to as the "brain-eating ameba or brain-eating amoeba"), is a free-living microscopic ameba_*, (single-celled living organism). It can cause a very rare, but severe, infection of the brain called primary amebic me-ningoencephalitis (PAM). The ameba is commonly found in warm freshwater (e.g. lakes, rivers, and hot springs) and soil. Naegleria fowleri usually infects people when contaminated wa-ter enters the body through the nose. Once the ameba enters the nose, it travels to the brain where it causes PAM, which is usual-ly fatal. Infection typically occurs when people go swimming or diving in warm freshwater places, like lakes and rivers. In very rare instances, Naegleria infections may also occur when contam-inated water from other sources (such as inadequately chlorinated swimming pool water or heated and contaminated tapwater) en-ters the nose 1, 2, 3.

Where Naegleria fowleri is Found Naegleria fowleri is a heat-loving (thermophilic) ameba found around the world 1, 2. Naegleria fowleri grows best at higher tem-peratures up to 115F (46C) and can survive for short periods at higher temperatures 4, 5. Naegleria fowleri is naturally found in warm freshwater environments such as lakes and rivers 6-10, natu-rally hot (geothermal) water such as hot springs 11, warm water discharge from industrial or power plants 12, 13, geothermal well water 14, 15, poorly maintained or minimally chlorinated swim-ming pools 3, water heaters 16, and soil 6, where it lives by feed-ing on bacteria and other microbes in the environment. Sampling of lakes in the southern tier of the U.S. indicates that Naegleria fowleri is commonly present in many southern tier lakes in the U.S. during the summer 6-10. Naegleria is not found in salt water, like the ocean.

When Infections Occur Number of case reports of PAM by month of illness onset and probable water exposure, United States, 1962-2011. Infections linked to freshwater swimming mostly occur during the heat of summer in July and August when water temperatures peak and water levels are low. Infections can increase during heat wave years as water temperatures increase.

Diagnosis & Detection PAM and Naegleria fowleri infection can be diagnosed in the laboratory by detecting11: 1)Naegleria fowleri organisms in cerebrospinal fluid (CSF), bi-opsy, or tissue specimens, or 2)Naegleria fowleri nucleic acid in CSF, biopsy, or tissue speci-mens, or 3)Naegleria fowleri antigen in CSF, biopsy, or tissue specimens.

Naegleria fowleri Test Methods

A)Direct visualization12,13: The motile amebae can often be seen moving rapidly under a microscope when looking at a fresh sam-ple of CSF. The amebae can also be stained with a variety of stains, such as Giemsa-Wright or a modified trichrome stain, for identification. B)Immunohistochemistry (IHC)12,13: A specific antibody to Naegleria fowleri can be used in conjunction with another anti-body that deposits a chemical or glows under specific types of light (Indirect fluorescent antibody [IFA]) to directly stain the amebae in tissue. C)Polymerase Chain Reaction (PCR)14,15,16: Specific molecular tools can amplify DNA from the amebae in CSF or tissue to specifically identify if the amebae are present. Looking at strains or subtypes of Naegleria fowleri can be done, but little is known about the natural populations in the environ-ment, which makes it difficult to interpret what the findings mean. D)Ameba culture 17: The sample is added to a growth plate cov-ered in bacteria that can serve as a food source for Naegleria fowleri. Incubating at higher temperatures selects for Naegleria fowleri growth, which can be seen as tracks made by the ameba as it moves across the plate eating the bacteria. Growing Naegleria fowleri in mammalian cell culture and looking for toxic cell effects is also possible. E)Environmental Detection: Water samples can be collected, concentrated, and put into culture to grow and select for Naegleria fowleri. Samples can be tested using the serologic or molecular methods described above.

Treatment Primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri infection have been fatal 18, there have been two welldocumented survivors (one from the US in 1979 19,20and one from Mexico in 200321) who received the following treat-ment courses: In these two cases, the following combination of three drugs was

By Maliha Bari

PharmD

Dow University of Health Sciences,

Karachi

Management Trainee Officer

Geofman Pharmaceuticals

Pakistan




used successfully (in addition to Steroids to control cerebral edema): Amphotericin B (IV +/- intrathecal) (one patient received Am-photericin B [AMB] for 14 days and the other patient received it for 9 days) AND Rifampicin (oral) 10 mg/kg/day (one survivor received this dosage in three divided doses for 9 days; the other received it every 24 hours for 1 month) AND EITHER Fluconazole (IV or oral) 10 mg/kg/day (one survivor initially received this dosage IV every 24 hours but fluconazole was later switched to oral administration because the hospital ran out of IV stock) OR Miconazole (IV) 350 mg per square meter of body-surface area per day in three divided doses (one survivor received this regimen for 9 days We also recommend the use of Azithromycin. Azithromycin has both in vitro and in vivo (mouse model) efficacy against Naegleria fowleri and appears to be synergistic when administered with AMB23,26. Therefore, azithromycin may be tried as an adjunct to AMB.

Investigational Drugs Recently, an investigational drug, miltefosine27, a breast cancer and anti-leishmania drug, has shown some promise against the free-living amebae in combination with some of these other drugs. Miltefosine has shown in vitro and mouse model amebicidal activity against Balamuthia, Naegleria fowleri, and Acanthamoeba 28,28,29and has been used to successfully treat pa-tients with Balamuthia infection 30 and disseminated Acan-thamoeba infection31.

Niegleria in Pakistan Pakistani health officials in the country's biggest city, Karachi, are said to be "very concerned" about a recent spate of deaths caused by a rare brain-eating microbe. It is estimated that 98 percent of infections end up being fatal, with the patient dying 7-14 days after exposure. 31A rare brain-eating amoeba is responsible for at least 10 deaths in the Paki-stani city of Karachi in recent months, health officials believe. Musa Khan, in-charge of the World Health Organization's Dis-ease Early Warning System in Pakistan, also confirmed that the deaths were reported from Karachi. A Sindh health department official said what was of grave concern to everyone at the meet

ing was that this parasite travelled to the brain through the nose and people normally used water to clean their nose during abula-tion for prayers.33

Dr Musa Khan, head of WHOs Disease Early Warning System in Pakistan, confirmed that all the deaths had occurred in the south-ern city of Karachi. Authorities are planning to launch a local campaign to ensure the supply of clean water to its 18 million residents. People who have contracted the amoeba suffer from very mild symptoms such as fever, nausea, vomiting, stiff neck and headaches.It usually takes five to seven days to die after in-fection.34 Authorities are planning a campaign to raise awareness among health workers and the public, said Dr. Musa Khan, head of the WHO's Disease Early Warning System in Pakistan. Most health centers had already been alerted, he said. "People should avoid getting water too deep into their nostrils and make sure their water supply is properly treated," he said. Khan noted that residents should not panic, adding that there is a remote chance of the parasite expanding its breadth of exposure. "There is no need to panic over these deaths. There is a remote chance for the spread of this deadly disease," said Khan. "It is a water-borne infection and we are thoroughly inquiring about its arrival and spread here."35 The amoeba is a very effective killer with a death rate over 98 percent. Dr. Musa Khan, head of the WHO's Disease Early Warning System in Pakistan, stated : "People should avoid getting water too deep into their nostrils and make sure their wa-ter supply is properly treated36 Sindh Health Minister Sagheer Ahmed said that 10 deaths had been confirmed from the brain eating amoeba since July including three this month and most of them were young people who used public swimming pools. "The meeting has decided that the Karachi Water and Sewerage Board should increase chlorine concentrations in water at its major treatment and pumping stations," he said. "The health department has also been told to increase public awareness about the water borne parasite through various methods. ," he said.33 Khan said authorities were planning a campaign to raise aware-ness among health workers and the public, and that most health centers had already been alerted.

References 1)Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epi-demiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138(7):968-75. 2)Visvesvara GS. Free-living amebae as opportunistic agents of human disease. [PDF - 13 pages] J Neuroparasitol. 2010;1. 3)Marciano-Cabral F, Cabral G. The immune response to Naegleria fowleri amebae and pathogenesis of infection. FEMS Immunol Med Microbiol. 2007;51:243-59. 4)Griffin JL. Temperature tolerance of pathogenic and nonpathogenic free-living amoebas. Science. 1972;178(63):869-70. 5)Chang SL. Resistance of pathogenic Naegleria to some common phys-ical and chemical agents. [PDF - 8 pages] Appl Environ Microbiol. 1978;35:368-75. 6)Maclean RC, Richardson DJ, LePardo R, Marciano-Cabral F. The




identification of Naegleria fowleri from water and soil samples by nest-ed PCR. Parasitol Res 2004;93: 21117. 7)Wellings FM, Amuso PT, Chang SL, Lewis AL. Isolation and identifi-

cation of pathogenic Naegleria from Florida lakes. Appl Environ Micro-biol 1977;34:6617. 8)John DT, Howard MJ. Seasonal distribution of pathogenic free-living amebae in Oklahoma waters. Parasitol Res 1995;81:193201. 9)Duma RJ. Study of pathogenic free-living amebas in fresh-water lakes in Virginia. EPA Publication.1980;EPA-PB-126369, Summary, 1981 is EPA-600/S1-80- 037. 10)Ettinger MR, Webb SR, Harris SA, McIninch SP, C Garman G, Brown BL. Distribution of free-living amoebae in James River, Virginia, USA. Parasitol Res. 2003;89:6-15. 11)Council for State and Territorial Epidemiologists (CSTE). Case Defi-nitions for Non-notifiable Infections Caused by Free-living Amebae

(Naegleria fowleri, Balamuthia mandrillaris, and Acanthamoeba spp.) [PDF - 10 pages]. Infectious Disease Committee. 2012 12)Visvesvara GS. Amebic meningoencephalitides and keratitis: chal-lenges in diagnosis and treatment. Curr Opin Infect Dis. 2010;23(6):590-4. 13)da Rocha-Azevedo B, Tanowitz HB, Marciano-Cabral F. Diagnosis of infections caused by pathogenic freeliving amoebae. Interdiscip Per-spect Infect Dis. 2009;2009:251406. 14)Qvarnstrom Y, Visvesvara GS, Sriram R, da Silva AJ. Multiplex real

-time PCR assay for simultaneous detection of Acanthamoeba spp., Balamuthia mandrillaris, and Naegleria fowleri. J Clin Microbiol. 2006;44(10):3589-95. 15)Robinson BS, Monis PT, Dobson PJ. Rapid, sensitive, and discrimi-

nating identification of Naegleria spp. by real-time PCR and melting-curve analysis. Appl Environ Microbiol. 2006;72(9):5857-63. 16)Marciano-Cabral F, MacLean R, Mensah A, LaPat-Polasko L. Identi-

fication of Naegleria fowleri in domestic water sources by nested PCR. Appl Environ Microbiol. 2003;69:5864-9.

17)Visvesvara GS. Parasite Culture: Acanthamoeba and Naegleria spp. In: Garcia LS, editor. Clinical Microbiology Procedures Handbook. 3rd ed. Washington, DC: ASM Press; 2010. 18)Yoder JS, Eddy BA, Visvesvara GS, Capewell L, Beach MJ. The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiol Infect. 2010;138:968-75. 19)Seidel J, Harmatz P, Visvesvara GS, Cohen A, Edwards J, Turner J. Successful treatment of primary amebic meningoencephalitis. New Engl J Med 1982;306:346-8. 20)Visvesvara GS, Moura H, Schuster FL. Pathogenic and opportunistic

free-living amoebae: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea. FEMS Immunol Med Mi-crobiol. 2007;50:1-26. 21)Vargas-Zepeda J, Gomez-Alcala AV, Vasquez-Morales JA, Licea-Amaya L, De Jonckheere JF, Lores-Villa F. Successful treatment of

Naegleria PAM using IV amphotericin B, fluconazole, and rifampin. Arch Med Res. 2005;36:83-6. 22)Goswick SM, Brenner GM. Activities of therapeutic agents against

Naegleria fowleri in vitro and in a mouse model of primary amebic meningoencephalitis. J Parasitol. 2003;89:837-42. 23)Goswick SM, Brenner GM. Activities of azithromycin and amphoter-

icin B against Naegleria fowleri in vitro and in a mouse model of pri-mary amebic meningoencephalitis. [PDF - 5 pages] Antimicrob Agents Chemother. 2003;47:524-8.

24)Ferrante A. Comparative sensitivity of Naegleria fowleri to ampho-tericin B and amphotericin B methyl ester. Trans R Soc Trop Med Hyg. 1982;76:476-8.

25)Lee KK, Karr SL Jr, Wong MM, Hoeprich PD. In vitro susceptibili

ties of Naegleria fowleri strain HB- to selected antimicrobial agents, singly and in combination. Antimicrob Agents Chemother. 1979;16:217- 20. 26)Soltow SM, Brenner GM. Synergistic activities of azithromycin and

amphotericin B against Naegleria fowleri in vitro and in a mouse model of primary amebic meningoencephalitis. [PDF - 5 pages] Antimicrob Agents Chemother. 2007;51:237. 27)Kaminsky R. Miltefosine Zentaris . Curr Opin Investig Drugs. 2002;3:550-4.

28)Schuster FL, Guglielmo BJ, Visvesvara GS. In-vitro activity of miltefosine and voriconazole on clinical isolates of free-living amebas:

Balamuthia mandrillaris, Acanthamoeba spp., and Naegleria fowleri. J Eukaryot Microbiol. 2006;53:121-6. 29)Kim JH, Jung SY, Lee YJ, Song KJ, Kwon D, Kim K, Park S, Im KI,

Shin HJ. Effect of therapeutic chemical agents in vitro and on experi-mental meningoencephalitis due to Naegleria fowleri. [PDF - 7 pages] Antimicrob Agents Chemother. 2008;52:4010-16. 30)Walochnik J, Obwaller A, Gruber F, Mildner M, Tschachler E, Su-

chomel M, Duchene M, Auer H. Anti- Acanthamoeba efficacy and toxicity of miltefosine in an organotypic skin equivalent . J Antimicrob Chemother. 2009;64:539-45. 31)Martnez DY, Seas C, Bravo F, Legua P, Ramos C, Cabello AM,

Gotuzzo E. Successful treatment of Balamuthia mandrillaris amoebic infection with extensive neurological and cutaneous involvement. Clin Infect Dis. 2010;51:e7-11. 32)Brain-Eating Amoeba Behind Karachi Deaths 33)Parasite known as 'brain-eating amoeba' kills 10 people in Pak - Indi-an Express 34) Health Brain-Eating Amoeba Kills 10 in Karachi [VIDEO] UK 35) Brain-eating amoeba hits Pakistani city | The Bell Jar 36) Brain-Eating Amoeba Kills 10 Pakistanis; Water Sources Being Tested : En-starz


Management of Respiratory Distress Syndrome in

Infants

Alternative Names Hyaline membrane disease; infant respiratory distress syndrome (IRDS); Respiratory distress syndrome in infants; RDS - infants

Introduction Respiratory Distress Syndrome (RDS), also known as hyaline membrane disease, is a condition associated with severe breath-ing difficulty seen predominantly in premature infants. RDS is caused by a primary deficiency of surfactant, a substance that coats the alveoli (air sacs) in healthy lungs and prevents them from collapsing during exhalation. As a result of this deficiency, the baby cannot take up enough oxygen. RDS rarely occurs in full-term infants. In fact, nearly all infants born before 28 weeks of pregnancy develop RDS.

Respiratory distress syndrome remains a major cause of morbidi-ty and mortality in preterm infants, especially in the extremely low birth weight infants


Infants

thus promoting alveolar instability and collapse. Low levels of

SP-A and SP-B are characteristically found in tracheal secretions

and lungs of newborns with RDS.

Pathophysiology: Immature type II alveolar cells produce less surfactant, causing

an increase in alveolar surface tension and a decrease in compli-

ance. The resultant atelectasis causes pulmonary vascular con-

striction, hypoperfusion, and lung tissue ischemia. Hyaline mem-

branes form through the combination of sloughed epithelium,

protein, and edema.

Symptoms:

Very fast breathing, or periods of no breathing (apnea).

Grunting sounds, especially when exhaling (breathing out).

Retractions. The skin between and around the ribs pulls in when the baby inhales (breathes in). The middle of your baby's chest may also sink deeply in as he breathes.

Nasal flaring. The two nose openings become larger with breathing.

Pale or blue colored skin, lips, and nail beds.

Risk Factors: The condition is more common in boys, and the incidence is

higher in infants whose mothers have diabetes, because of de-

layed pulmonary maturity.

Exams and Tests

The most important investigation in an infant with respiratory distress is a chest X-ray. The chest radiograph reveals decreased lung inflation (homogenous opaque infiltrates) indicating contrast in airless lung tissue seen against air-filled bronchi, with diffuse symmet-rical reticulogranular (ground glass appearance) lung fields. De-creased lung volumes also can be detected. History while stabilizing a baby with severe respiratory distress,

it is important to get a good history. We need to know the gesta-

tion and if the baby is premature it is important to know if ante-

natal steroids have been given or not.

Most infants are less than 34 weeks gestation and the incidence

and severity increase with decreasing gestation age.

Management The management of infants is complex and requires a multidisci-plinary team approach to obtain best outcomes. The application of the basic principles of neonatal care, such as thermoregulation, cardiovascular and nutritional support, treatment of early neona-tal infection, is crucial to achieve the therapeutic goals. Clearly, surfactant replacement therapy, continuous positive airway pres-sure (CPAP), and mechanical ventilation in its different modali-ties are the mainstay for the respiratory support of these patients.


Avoiding unnecessary or poor-ly timed cesarean sections can also reduce the risk of RDS


Infants

Prevention: Reducing premature birth is the most effective preventive meth-od against RDS. Even if preterm birth cannot be prevented, the administration of a very short course (two doses 24 hours apart) of antenatal steroids to the mother has been shown to be highly effective in decreasing the severity and incidence of RDS. Antenatal steroids also decrease the incidence of other important complications of prematurity, including intraventricular hemor-rhage and bronchopulmonary dysplasia. In some cases, medicines called corticosteroids may be given to help speed up lung maturity in the developing baby. They are often given to pregnant women between 24 and 34 weeks of pregnancy who seem likely to delivery in the next week.

Avoiding unnecessary or poorly timed cesarean sections can also reduce the risk of RDS.

Treatment 1. General treatment (Nursing)

1) Insulation: placed infant in the warm box and maintain skin

temperature at 36.5 .

2) Monitoring: temperature, respiration, heart rate, blood pres-

sure and blood gas.

3) to ensure the supply of fluids and nutrition: the 1st day of 5%

or 10% glucose solution 65-75ml / (kg.d) gradually increased to

120-150ml / (kg.d) and added electrolyte condition for the better

oral feeding, so that part of parenteral nutrition supplemented.

2. Oxygen therapy and mechanical ventilation

1) Oxygen: The baby needs extra oxygen to help him breathe better. The oxygen may be warmed and mixed with mist (water vapor). Caregivers place a clear oxygen hood the baby's head. The oxygenator does the work of the lungs by oxygenating the blood and removing carbon dioxide. The continual air pressure provided by the ventilator prevents the collapse of the air sacs. As the infants lungs mature and begin to produce surfactantusually within three to five days after birththe child is weaned from the ventilator.

2) Continuous positive airway pressure and normal frequency

mechanical ventilation. The baby may need CPAP (continuous positive airway pressure) given through nasal prongs. With CPAP, the baby will have a long, plastic tube with two tiny tubes sticking up from it (nasal prongs). The nasal prongs are gently inserted into the baby's nos-trils (nose openings) and taped in place. CPAP helps the baby keep his lungs filled with air.

3) Others: high frequency oscillation or high frequency jet venti-

lator can often reduce the frequency of the negative effects venti-

lator in order to obtain better results. Antibiotics are often administered if bacterial infection is sus-

pected clinically or because of leukocytosis, neutropenia, or hy-

poxemia. Ampicillin and gentamicin are often used together

based on their effectiveness and synergy. Extracorporeal mem-

brane oxygenation, similar to an artificial external lung, is used

as a last resort in critical circumstances. Oral feedings are often

withheld if the respiratory rate exceeds 80 breaths per minute.

3. Surfactant replacement therapy Introduction of surfactant replacement for the treatment of RDS, successfully treated with a modified bovine surfactant extract (Surfactant-TA, Surfacten, Tokyo Tanabe, and Tokyo Japan) administered via endotracheal tube. All infants demonstrated remarkable improvement in oxygenation and decreased ventilato-ry requirements. Today, several types of animal based surfactants have been ap-



Infants

proved for clinical use. After endotracheal intubation, surfactant

suspension is administered through the endotracheal (ET) tube

and the infant is supported, until extubation is possible, with pos-

itive pressure ventilation and continuous positive airway pressure

(CPAP) therapy as needed. High frequency ventilation has been

shown to improve the short term management of these infants.

Conclusion Respiratory distress in a newborn is a challenging problem. It occurs in 4 to 6 percent of infants. Many of the conditions caus-ing respiratory distress are preventable. Early recognition and prompt management are required. Despite huge advances in care, RDS remains the most common

single cause of death in the first month of life. The general prin-

ciples of neonatal care and a team approach should be applied to

maximize the occurrence of good short-term and long-term out-

comes.

RDS requires the expenditure of major health financial re-

sources. The need for assisted ventilation comprises one of the

major costs of the care of premature infants.


Myths about Thalassemia

Introduction BLOOD not just a word, is a sea of chemicals. Blood consists of about 55% of plasma and 45 % of corpuscles. Among them a very vital one is RBC (Red Blood Corpuscle)/ Erythrocytes. The quantities of them may vary in male & female. As we know that RBC is the warehouse of Hemoglobin so it also be vary in two sign of human being. Hemoglobin is the iron-containing oxygen-transport metalloprotein in the red blood cells of all vertebrates as well as the tissues of some invertebrates. Each hemoglobin is consists of heme and globin where heme is the form of iron and globin is actually protein form with two different chain called (alpha) & (beta) chain. Each chain has two sub-chain respec-tively they are 1 & 2, 1 & 2.

Hemoglobin in the blood carries oxygen from the respiratory organs (lungs or gills) to the rest of the body where it releases the oxygen to burn nutrients to provide energy to power the func-tions of the organism, and collects the resultant carbon dioxide to bring it back to the respiratory organs to be dispensed from the organism.

Anemia

Among the different kinds of RBC disorder as well as Hemoglo

bin disorder, the most common is anemia.

Anemia is the critical pathological condition of blood when the total count of hemoglobin in RBCs become lower than that of normal count. There are different kinds of anemia thus it is oc-curs via various way. Anemia, one of the more common blood disorders, occurs when the level of healthy red blood cells (RBCs) in the body becomes too low. This can lead to health problems because RBCs contain hemoglobin, which carries oxy-gen to the body's tissues. Anemia can cause a variety of compli-cations, including fatigue and stress on bodily organs.

Anemia can be caused by many things, but the three main bodily mechanisms that produce it are:

1. excessive destruction of RBCs

2. blood loss

3. inadequate production of RBCs

Among many other causes, anemia can result from inherited dis-orders, nutritional problems (such as an iron or vitamin deficien-cy), infections, some kinds of cancer, or exposure to a drug or toxin.

Anemia Caused by Destruction of RBCs

Hemolytic anemia occurs when red blood cells are being de-stroyed prematurely. (The normal lifespan of RBCs is 120 days; in hemolytic anemia, it's much shorter.) And the bone marrow (the soft, spongy tissue inside bones that makes new blood cells) simply can't keep up with the body's demand for new cells. This can happen for a variety of reasons. Sometimes, infections or certain medications such as antibiotics or anti-seizure medi-cines are to blame.

By Jony Mallik

B.Pharm (Hons.)

M.Pharm

Southern University

Bangladesh



A very potent hemolytic anemia is Thalassemia and its a very crucial cause of death today. Thalassemias are inherited blood disorders. "Inherited" means that the disorder is passed from par-ents to children through genes. Thalassemias cause the body to make fewer healthy red blood cells and less hemoglobin than normal. Hemoglobin is an iron-rich protein in red blood cells. It carries oxygen to all parts of the body. Hemoglobin also carries carbon dioxide (a waste gas) from the body to the lungs, where it's exhaled. People who have thalassemias can have mild or se-vere anemia . Anemia is caused by a lower than normal number of red blood cells or not enough hemoglobin in the red blood cells.

Overview

Normal hemoglobin, also called hemoglobin A, has four protein chainstwo alpha globin and two beta globin. The two major types of thalassemia, alpha and beta, are named after defects in these protein chains. Four genes (two from each parent) are need-ed to make enough alpha globin protein chains. Alpha thalasse-mia trait occurs if one or two of the four genes are missing. If more than two genes are missing, moderate to severe anemia occurs. The most severe form of alpha thalassemia is called alpha thalassemia major or hydrops fetalis. Babies who have this disor-der usually die before or shortly after birth. Two genes (one from each parent) are needed to make enough beta globin protein chains. Beta thalassemia occurs if one or both genes are altered. The severity of beta thalassemia depends on how much one or both genes are affected. If both genes are affected, the result is moderate to severe anemia. The severe form of beta thalassemia is known as thalassemia major or Cooley's anemia. Thalassemias affect males and females. The disorders occur most often among people of Italian, Greek, Middle Eastern, Southern Asian, and African descent. Severe forms usually are diagnosed in early

childhood and are lifelong conditions. Doctors diagnose thalasse-mias using blood tests. The disorders are treated with blood transfusions, medicines, and other procedures.

A) Genetic Classification of the Thalassemia

1. Alpha Thalassemia Alpha thalassemia occurs when one or more of the four alpha chain genes fails to function. Alpha chain protein production, for practical purposes, is evenly divided among the four genes. With alpha thalassemia, the "failed" genes are almost invariably lost from the cell due to a genetic accident.

(i) The loss of one gene diminishes the production of the alpha protein only slightly. This condition is so close to normal that it can be detected only by specialized laboratory techniques that, until recently, were confined to research laboratories. A person with this condition is called a "silent carrier" because of the diffi-culty in detection.

(ii) The loss of two genes (two-gene deletion alpha thalassemia) produces a condition with small red blood cells, and at most a mild anemia. People with this condition look and feel normal. The condition can be detected by routine blood testing, however.

(iii) The loss of three alpha genes produces a serious hematologi-cal problem (three-gene deletion alpha thalassemia). Patients with this condition have a severe anemia, and often require blood transfusions to survive. The severe imbalance between the alpha chain production (now powered by one gene, instead of four) and beta chain production (which is normal) causes an accumulation of beta chains inside the red blood cells. Normally, beta chains pair only with alpha chains. With three-gene deletion alpha tha-lassemia, however, beta chains begin to associate in groups of four, producing an abnormal hemoglobin, called "hemoglobin H". The condition is called "hemoglobin H disease". Hemoglobin H has two problems. First it does not carry oxygen properly, making it functionally useless to the cell. Second, hemoglobin H protein damages the membrane that surrounds the red cell, accel-erating cell destruction. The combination of the very low produc-tion of alpha chains and destruction of red cells in hemoglobin H disease produces a severe, life-threatening anemia. Untreated, most patients die in childhood or early adolescence.

(iv) The loss of all four alpha genes produces a condition that is incompatible with life. The gamma chains produced during fetal life associate in groups of four to form an abnormal hemoglobin called "hemoglobin Barts". Most people with four-gene deletion



alpha thalassemia die in utero or shortly after birth. Rarely, four gene deletion alpha thalassemia has been detected in utero, usual-ly in a family where the disorder occured in an earlier child. In utero blood transfusions have saved some of these children. These patients require life-long transfusions and other medical support.

Example of an Inheritance Pattern for Alpha Thalassemia

2. Beta Thalassemia The fact that there are only two genes for the beta chain of hemo-globin makes beta thalassemia a bit simpler to understand than alpha thalassemia (2). Unlike alpha thalassemia, beta thalassemia rarely arises from the complete loss of a beta globin gene. The beta globin gene is present, but produces little beta globin pro-tein. The degree of suppression varies. Many causes of sup-pressed beta globin gene expression have been found. In some cases, the affected gene makes essentially no beta globin protein. In other cases, the production of beta chain protein is lower than normal, but not zero (beta-(+)-thalassemia). The severity of beta thalassemia depends in part on the type of beta thalassemic genes that a person has inherited.

(i) one-gene beta thalassemia has one beta globin gene that is normal, and a second, affected gene with a variably reduced pro-duction of beta globin. The degree of imbalance with the alpha globin depends on the residual production capacity of the defec-tive beta globin gene. Even when the affected gene produces no beta chain, the condition is mild since one beta gene functions normally. The red cells are small and a mild anemia may exist. People with the condition generally have no symptoms. The con-dition can be detected by a routine laboratory blood evaluation. (Note that in many ways, the one-gene beta thalassemia and the two-gene alpha thalassemia are very similar, from a clinical point of view. Each results in small red cells and a mild anemia).

(ii) two-gene beta thalassemia produces a severe anemia and a

potentially life-threatening condition. The severity of the disorder depends in part on the combination of genes that have been in-herited: beta-0-thal/ beta-0-thal; beta-0-thal/ beta-(+)-thal; beta-(+)-thal/ beta-(+)-thal. The beta-(+)-thalassemia genes vary greatly in their ability to produce normal hemoglobin. Conse-quently, the clinical picture is more complex than might other-wise be the case for three genetic possibilities outlined.

Example of an Inheritance Pattern for Beta Thalassemia

B) Clinical Classification of the Thalassemias

1. Alpha Thalassemia Alpha thalassemia has four manifestations, that correlate with the number of defective genes. Since the gene defect is almost invariably a loss of the gene, there are no "shades of function" to obscure the matter as occurs in beta thalassemia.

(i) Silent carrier state. This is the one-gene deletion alpha thalas-semia condition. People with this condition are hematologically normal. They are detected only by sophisticated laboratory meth-ods.

(ii) Mild alpha-thalassemia. These patients have lost two alpha globin genes.They have small red cells and a mild anemia. These people are usually asymptomatic. Often, physicians mistakenly diagnose people with mild alpha-thalassemia as having iron defi-ciency anemia. Iron therapy, of course, does not correct the ane-mia.



(iii) Hemoglobin H disease. These patients have lost three alpha globin genes. The result is a severe anemia, with small, misshap-en red cells and red cell fragments. These patients typically have enlarged spleens. Bony abnormalities particularly involving the cheeks and forehead are often striking. The bone marrow works at an extraordinary pace in an attempt to compensate for the ane-mia. As a result, the marrow cavity within the bones is stuffed with red cell precursors. These cells gradually cause the bone to "mold" and flair out. Patients with hemoglobin H disease also develop large spleens. The spleen has blood forming cells, the same as the bone marrow. These cells become hyperactive and overexpand, just as those of the bone marrow. The result is a spleen that is often ten-times larger than normal. Patients with hemoglobin H disease often are small and appear malnourished, despite good food intake. This feature results from the tremen-dous amount of energy that goes into the production of new red cells at an extremely accelerated pace. The constant burning of energy by these patients mimics intense aerobic exercise; exer-cise that goes on for every minute of every day.

(iv) Hydrops fetalis. This condition results from the loss of all four alpha globin genes. The affected individual usually suc-cumbs to the severe anemia and complications before birth.

2. Beta Thalassemia (i) Thalassemia minor, or thalassemia trait. These terms are used interchangeably for people who have small red cells and mild (or no) anemia due to thalassemia. These patients are clinically well, and are usually only detected through routine blood testing. Phy-sicians often mistakenly diagnose iron deficiency in people with thalassemia trait. Iron replacement does not correct the condition. The primary caution for people with beta-thalassemia trait in-volves the possible problems that their children could inherit if their partner also has beta-thalassemia trait. These more severe forms of beta-thalassemia trait are outlined below.

(ii) Thalassemia intermedia. Thalassemia intermedia is a confus-ing concept. The most important fact to remember is that thalas-semia intermedia is a description, and not a pathological or ge-netic diagnosis. Patients with thalassemia intermedia have signif-icant anemia, but are able to survive without blood transfusions. The factors that go into the diagnosis are:

The degree to which the patient tolerates the anemia.

The threshold of the physician to transfuse patients with tha-lassemia.

(iii) Thalassemia major. This is the condition of severe thalasse-mia in which chronic blood transfusions are needed (3). In some patients the anemia is so severe, that death occurs without trans-fusions. Other patients could survive without transfusions, for a while, but would have terrible deformities. While transfusions are life-saving in patients with thalassemia major, transfusions ultimately produce iron overload. Chelation therapy, usually with the iron-binding agent, desferrioxamine (Desferal), is needed to prevent death from iron-mediated organ injury.

Relationship of the Genetic and Clinical Classifications of Tha-lassemia

The advent of modern molecular biology permits the genetic classification of thalassemias, outlined earlier in this document. A rough correlation exists between the clinical and genetic classi-fications. The relationship between genetics and clinical state is not absolute, however:

thalassemia trait (minor)- normal beta gene/ thalassemia gene ( beta zero or +)

thalassemia intermedia- often two beta-(+)-genes

thalassemia major- two beta-(+)-genes (where the plus is not substantial); beta-(+)-gene/ beta-0-gene; beta-0-gene/ beta-0-gene

Signs and Symptoms of Thalassemias

A lack of oxygen in the bloodstream causes the signs and symp-toms of thalassemias. The lack of oxygen occurs because the body doesn't make enough healthy red blood cells and hemoglo-bin. The severity of symptoms depends on the severity of the disorder.



No Symptoms Alpha thalassemia silent carriers generally have no signs or symptoms of the disorder. The lack of alpha globin protein is so minor that the body's hemoglobin works normally.

Mild Anemia People who have alpha or beta thalassemia trait can have mild anemia. However, many people who have these types of thalasse-mia have no signs or symptoms. Mild anemia can make you feel tired. Mild anemia caused by alpha thalassemia trait might be mistaken for iron-deficiency anemia.

Mild to Moderate Anemia and Other Signs and Symptoms People who have beta thalassemia intermedia have mild to mod-erate anemia. They also may have other health problems, such as:

Slowed growth and delayed puberty. Anemia can slow down a child's growth and development.

Bone problems. Thalassemia may cause bone marrow to expand. Bone marrow is the spongy substance inside bones that makes blood cells. When bone marrow expands, the bones be-come wider than normal. They may become brittle and break easily. An enlarged spleen. The spleen is an organ that helps your body fight infection and remove unwanted material. When a person has thalassemia, the spleen has to work very hard. As a result, the spleen becomes larger than normal. This makes anemia worse. If the spleen becomes too large, it must be removed.

Severe Anemia and Other Signs and Symptoms People who have hemoglobin H disease or beta thalassemia ma-jor (also called Cooley's anemia) have severe thalassemia. Signs and symptoms usually occur within the first 2 years of life. They may include severe anemia and other health problems, such as:

A pale and listless appearance

Poor appetite

Dark urine (a sign that red blood cells are breaking down)

Slowed growth and delayed puberty

Jaundice (a yellowish color of the skin or whites of the eyes)

An enlarged spleen, liver, or heart Bone problems (especially with bones in the face)

Complications of Thalassemia Better treatments now allow people who have moderate and se-vere thalassemias to live much longer. As a result, these people must cope with complications of these disorders that occur over time.

Heart and Liver Diseases Regular blood transfusions are a standard treatment for thalasse-mias. Transfusions can cause iron to build up in the blood (iron

overload). This can damage organs and tissues, especially the heart and liver. Heart disease caused by iron overload is the main cause of death in people who have thalassemias. Heart disease includes heart failure, arrhythmias (irregular heartbeats), and heart attack.

Infection Among people who have thalassemias, infections are a key cause of illness and the second most common cause of death. People who have had their spleens removed are at even higher risk be-cause they no longer have this infection-fighting organ.

Thalassemias Treatment Treatments for thalassemias depend on the type and severity of the disorder. People who are carriers or who have alpha or beta thalassemia trait have mild or no symptoms. Theyll likely need little or no treatment.

A) Standard Treatments i) Blood Transfusions Transfusions of red blood cells are the main treatment for people who have moderate or severe thalassemias. This treatment gives you healthy red blood cells with normal hemoglobin. During a blood transfusion, a needle is used to insert an intravenous (IV) line into one of your blood vessels. Through this line, you receive healthy blood. The procedure usually takes 1 to 4 hours. Red blood cells live only for about 120 days. So, you may need re-peated transfusions to maintain a healthy supply of red blood cells. If you have hemoglobin H disease or beta thalassemia in-termedia, you may need blood transfusions on occasion. For ex-ample, you may have transfusions when you have an infection or other illness, or when your anemia is severe enough to cause tiredness. If you have beta thalassemia major (Cooley's anemia), youll likely need regular blood transfusions (often every 2 to 4 weeks). These transfusions will help you maintain normal hemo-globin and red blood cell levels. Blood transfusions allow you to feel better, enjoy normal activities, and live into adulthood. This treatment is lifesaving, but it's expensive and carries a risk of transmitting infections and viruses (for example, hepatitis). How-ever, the risk is very low in the United States because of careful blood screening.

ii) Iron Chelation Therapy The hemoglobin in red blood cells is an iron-rich protein. Thus, regular blood transfusions can lead to a buildup of iron in the blood. This condition is called iron overload. It damages the liv-er, heart, and other parts of the body. To prevent this damage, doctors use iron chelation therapy to remove excess iron from the body. Two medicines are used for iron chelation therapy.

Deferoxamine is a liquid medicine that's given slowly under



the skin, usually with a small portable pump used overnight. This therapy takes time and can be mildly painful. Side effects include problems with vision and hearing. Deferasirox is a pill taken once daily. Side effects include head-ache, nausea (feeling sick to the stomach), vomiting, diarrhea, joint pain, and tiredness.

iii) Folic Acid Supplements Folic acid is a B vitamin that helps build healthy red blood cells. Your doctor may recommend folic acid supplements in addition to treatment with blood transfusions and/or iron chelation thera-py.

iv) Blood and Marrow Stem Cell Transplant A blood and marrow stem cell transplant replaces faulty stem cells with healthy ones from another person (a donor). Stem cells are the cells inside bone marrow that make red blood cells and other types of blood cells. A stem cell transplant is the only treatment that can cure thalasse-mia. But only a small number of people who have severe thalas-semias are able to find a good donor match and have the risky procedure.

B) Possible Future Treatments Researchers are working to find new treatments for thalassemias. For example, it might be possible someday to insert a normal hemoglobin gene into stem cells in bone marrow. This will allow people who have thalassemias to make their own healthy red blood cells and hemoglobin. Researchers also are studying ways to trigger a person's ability to make fetal hemoglobin after birth. This type of hemoglobin is found in fetuses and newborns. After birth, the body switches to making adult hemoglobin. Making more fetal hemoglobin might make up for the lack of healthy adult hemoglobin.

Thalassemias Prevention? You cant prevent thalassemias because theyre inherited (passed from parents to children through genes). However, prenatal tests can detect these blood disorders before birth. Family genetic studies may help find out whether people have missing or altered hemoglobin genes that cause thalassemias. If you know of family members who have thalassemias and you're thinking of having children, consider talking with your doctor and a genetic counselor. They can help determine your risk for passing the disorder to your children.


Microbial Limit Tests

The Microbial Limit Tests are designed to perform the qualitative

and quantitative estimations of specific viable microorganisms

present in samples. It includes tests for total viable count

(bacteria and fungi) and Escherichia coli. The most care must be

taken in performing the tests, so that microbial contamination

from the outside can be avoided. When test samples have antimi-

crobial activity or when they include antimicrobial substances,

these antimicrobial properties must be eliminated by dilution,

filtration, neutralization, inactivation, or other appropriate means.

The tests should be conducted for samples prepared by mixing

multiple portions randomly chosen from individual ingredients or

products. When samples are diluted with fluid medium, the tests

must be conducted quickly. Due attention must be paid to the

effective quality control and the prevention of biohazard.

Total Viable Aerobic Count This test is to determine mesophilic bacteria and fungi which grow under aerobic conditions. Psychrophilic, thermophilic, ba-sophilic, and anaerobic bacteria and microorganisms which re-quire specific ingredients for growth may give a negative result, even if they exist in a significant number. There are four methods for this test: 1) Membrane filtration method 2) Pour plate method 3) Spread plate method 4) Serial dilution method (most probable number method). An appropriate method should be taken from among these four, depending on purposes. If automated methods are comparable or superior in sensitivity and accuracy to the methods given here, they may be used. Different media and incubation temperature are required for the growth of bacteria and fungi (molds and yeasts). The serial dilution method is applicable only to bacteria. (Image 01)

Preparation of Test Fluids To dissolve or dilute the sample, use phosphate buffer (pH 7.2),

sodium chloridepeptone buffer solution, or fluid medium used for

the test. Unless otherwise specified, use 10 g or 10 ml of the sam-

ple. However, a different weight or volume of the sample should

be used, depending on the nature of the sample. Adjust the test

fluid to pH 6 to 8. Use the test fluid within one hour after prepa-

ration.

Fluid Samples or Soluble Solid Samples: Take 10 g or 10 ml of

the sample and mix with the buffer or fluid medium given above

to make 100 ml. Use this mixture as the test fluid. For a fluid

sample including insoluble substances, shake well just before

mixing make a homogeneous suspension. Insoluble solid samples

Take 10 g of the sample, grind to a fine powder, and suspend it in

the buffer or fluid medium given above to make 100 ml. Use this

suspension as the sample fluid. A larger volume of the buffer or

fluid medium than specified here may be used to make a suspen-

sion, depending on the nature of the sample. If necessary, a

blender may be used to disperse the insoluble particles well in the

suspension. Also, an appropriate surfactant (e.g., 0.1% w/v poly-

sorbate 80) may be added to help dissolve the sample.

Fatty Samples: For semisolid samples and liquids consisting

mainly of lipid, take 10 g or 10 ml of the sample; emulsify the

sample in the buffer or fluid medium given above using a surfac-

tant such as polysorbate 20 or polysorbate 80, and make to 100

ml. Use this emulsified sample as the sample fluid. If necessary,

warm at a temperature not exceeding 45C to emulsify the sam-

ple. Avoid warming for not longer than 30 minutes.

Procedure (1) Membrane Filtration Method This method is applied to the sample which contains antimicrobi-al substances. Use membrane filters of an appropriate material with a pore size of 0.45 m or less. Filters about 50 mm across are recommended, but other sizes may be used. Sterilize the fil-ters, filtration apparatus, media, and other apparatus used. Usual-ly, measure two test fluids of 10 ml each; pass each sample through a separate filter. Dilute the pretreated test fluid if the bacteria concentration is high, so that 10 to 100 colonies can de-velop per filter. After filtration, wash each filter three times or more with an appropriate liquid such as phosphate buffer, sodium chloride-peptone buffer, or fluid medium. The volume of the washings should be about 100 ml each. If the filter used is not about 50 mm in diameter, use an appropriate volume of washing, depending on the size of the filter. If the sample includes lipid, polysorbate 80 or an appropriate emulsifier may be added to the washings. After filtration, for bacteria detection, place the two filters on a plate of soybean-casein digest agar medium, and for fungi detection, add an antibiotic to the medium and place them on a plate of one of Sabouraud glucose agar, potato-dextrose agar, or GP agar media. Incubate the plates at least for 5 days at 30-35C for bacteria detection and at 20-25C for fungi detec-tion, and count the number of colonies. If counts obtained are

By Farrukh Mehmood

PharmD, R.Ph.

Microbiologist

Highnoon Laboratories Ltd.

Lahore, Pakistan



considered to be reliable in shorter incubation time than 5 days, these counts may be adopted for calculation of the viable count.

(2) Pour Plate Method Use petri dishes 9-10 cm in diameter. Use at least 2 agar media

for each dilution. Take 1 ml of the test fluid or its dilution into

each petri dish aseptically, add to each dish 15 to 20 ml of steri-

lized agar medium, previously melted and kept below 45C, and

mix. For bacteria detection, use soybean-casein digest agar medi-

um and for fungi detection, use one of Sabouraud glucose agar,

potato-dextrose agar, and GP agar media, to which antibiotic has

previously been added. After the agar solidifies, incubate at least

for 5 days at 30 to 35C for bacteria detection and at 20 to 25C for fungi detection. If a large number of colonies develop, calcu-

late viable counts based on counts obtained from plates with not

more than 300 colonies per plate for bacteria detection and from

plates with not more than 100 colonies per plate for fungi detec-

tion. If counts are considered to be reliable in a shorter incuba-

tion time than 5 days, these counts may be adopted.

(Image 02) (3) Spread Plate Method Place 0.05-0.2 ml of the test fluid on the solidified and dried sur-face of the agar medium and spread it uniformly using a spread-er. Proceed under the same conditions as for the Pour Plate Meth-od, especially about petri dishes, agar media, incubation tempera-ture and time, and calculation method. (4) Serial Dilution Method (Most Probable Number Method) Use 12 test tubes: 9 containing 9 ml of soybean-casein digest

medium each and 3 containing 10 ml of the same medium each

for control. Prepare dilutions using the 9 tubes. First, add 1 ml of

the test fluid to each of three test tubes and mix to make 10-times

dilutions. Second, add 1 ml of each of the 10-times dilutions to

each of another three test tubes and mix to make 100-times dilu-

tions. Third, add 1 ml of each of the 100-times dilutions to each

of the remaining three test tubes and mix to make 1,000-times

dilutions. Incubate all 12 test tubes for at least 5 days at 30 - 35

C. No microbial growth should be observed for the control test

tubes. If the determination of the result is difficult or if the result

is not reliable, take a 0.1ml fluid from each of the 9 test tubes and

place it to an agar medium or fluid medium, incubate all media

for 24 to72 hours at 30 to 35C, and check them for the absence

or presence of microbial growth. Calculate the most probable

number of microorganisms per ml or gram of the sample, using

the table given below.

Note: When the number of test tubes showing microbial growth

is not more than two for test tubes containing 0.1 g or 0.1 ml of a

sample, the most probable number of microorganisms is possibly

100 or less per gram or ml of the sample.


The number of test tubes in which mi-crobial growth is observed, when the amount of the sample given below (per test tube) is added

The most prob-able number of mi-croorganisms per gram or ml 0.1 g or

0.1 ml 0.01 g or 0.01 ml

1 mg or 1 l

3 3 3 3

3 3 3 3

3 2 1 0

1100 1100 500 200

3 3 3 3

2 2 2 2

3 2 1 0

290 210 150 90

3 3 3 3

1 1 1 1

3 2 1 0

160 120 70 40

3 3 3 3

0 0 0 0

3 2 1 0

95 60 40 23


(Image 01)

(Image 02)


Syringomyelia

Syringomyelia is the formation of fluid filled cavity or cyst (syrinx) within the spinal cord that may enlarge with time caus-ing damage to the spinal cord along with pain, stiffness and weakness in shoulder, neck, back and legs.

Signs And Symptoms Other symptoms include loss of the ability feeling to extremes hot and cold especially in hand, headache, facial pain and numb-ness, spinal curvature and bowel and bladder function problem. Signs and symptoms may develop with time with, although sud-den onset may occur with coughing and straining followed by weakness, progressive loss in sensation and weakness in arms and legs.

Complications Complications include scoliosis, motor movements, chronic pain and Horner syndrome. If condition not treated in time it may re-sult in injury to spinal cord.

Causes

Chiari formation (congenital abnormality of the brain, in which part of brain tissue may protrude into the Spinal cord).

Spinal cord tumor

Spinal cord injuries

Inflammation surrounding spinal cord

Meningitis

Arachnoiditis

Tethered spinal cord syndrome

Spinal scar tissue

Diagnosis Syringomyelia is diagnosed by number of ways.

Magnetic resonance imaging of spine and spinal cord ( help in beginning stage diagnosis).

Electromyography that measures the muscle weakness

Cerebrospinal fluid pressure level and analysis of cerebro-spinal fluid by performing lumbar puncture

Computed axial tomography that scan patient head to detect any tumor and hydrocephalus

Myelogarm

Treatment Surgery is the only treatment for syrigomyelia.The main pur-pose of surgery is to provide more space for the cerebellum at the base of skull and cervical spine to treat Chiari formation. Some-times additional operations are necessary for successful eradica-tion of syringomyelia. Congenital syringomyelia may require piece of cervical vertebrae at the site of cavity formation to be removed. If syringomyelia is due to tumor, that result in obstruction then

removal of tumor is necessary. Drainage of cavity (drainage just stop progression, have no con-cern with the elimination of symptoms associated with syringo-myelia) using drainage tubes, catheter and valve .This system is also called shunt. Physical therapy management depends upon severity and impact of the disease. Neurological examination clears that at which level the syrinx occur. Physical therapy techniques include fol-lowing:

RoM (range of motion) stretching and mobilization of neck and upper limb.

Muscle strength

Neck stability

Balance

Copying

Occupational therapy

Medication

To alleviate the pain during syringomyelia single or combi-nation of medicines are used; but is not concerned with the removal of syringomyelia.

Analgesics are the best ever option to treat syringomyelia. In one pain management plan, an around-the-clock opiate such as fentanyl patches or Oxycontin are used in conjunction with a fast-acting opiate.

For classical back pain weak or strong opioids are used such as Tramdol along with medications that relives neuropathic pain symptoms shooting and stabbing pain (neurontin).

Cortisteroids, such as prednisolone, or non-steroidal anti-inflammatory drugs may relieve the symptoms but not the deterioration. Long term use of these drugs is not advised.

Anticonvulsants, such as gabapentin have been successful in some more severe cases, but they may be very expen-sive. Pregabalin, amitriptyline and oral opioids (pethidine or methadone) are alternatives. Methylsulfonylmethane (MSM) is recommended by some veterinary neurologists as

By Amna Hafeez

PharmD


Syringomyelia

a dietary supplement.

Drugs which reduce the production of cerebrospinal fluid, including proton pump inhibitors such as omeprazole, and the diuretic, furosemide (Lasix), and spironolactone, may be useful,but clinical data on their use and effectiveness is lack-ing. Carbonic anhydrase inhibitors, such as acetazolamide also serve to decrease the flow of cerebrospinal fluid, but their adverse side effects of abdominal pain, lethargy, and weakness limit long term use.

Life Style Changes Avoid such activities that may worse the symptoms of syringo-myelia such as

Playing high impact sports such as football.

Straining during bowel movement

Excessive coughing

Sky diving

Chinese Art Of Healing Qigong is a traditional form of Chinese energy excise and heal-ing art for the body and mind. Qigong is ideal for re-establishing balance between body and mind and for helping to heal people who are struggling with chronic degenerative con-ditions such as paralysis, diabetes, and syringomyelia.


Living With Liver Cancer...

About The Liver The liver is the largest organ in the digestive system and second

largest organ in the human body. It is a blood-rich, wedge-shaped

gland located in the right side of the abdomen, below the dia-

phragm and near the colon, right kidney, duodenum, gallbladder

and stomach.

Location And Anatomy Of The Liver

Important Functions of the Liver The primary function of liver is to filter what an individual eats, drinks, breathes and gets on their skins. The liver also carries out a variety of other important functions including:

What Is Liver Cancer Overview Liver cancer is characterized by the growth or spread of abnor-mal or malignant cells in the liver tissue. Liver cancer (hepatocellular carcinoma) is a cancer from the liv-er. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells and is called hepatocellular cancer or carcinoma.

Risk Factor

A major risk factor for the development of HCC is cirrhosis/cirrhosis is an ongoing liver disease that involves the repeated breakdown and repair of the liver tissue, eventually leading to a loss of liver functions. Several different factors can lead to a cir-rhosis, most common are:

By Mehrish Memon

PharmD


PRODUCTION: the liver in involve in building pro-

teins that are important for cell growth.

STORAGE: The liver acts as storage site for car-

bohydrates, iron and vitamins until the body

needs them. The liver stores and releases blood

sugar or glucose into the bloodstream to provide

energy for the body to function.

BILE SECRETION: the liver produces bile, a sub-

stance that helps the digestion and absorption of

food assists in digestion. Ile is a yellowish-

brown or green liquid stored in the gall bladder.

ELIMINATION: finally, the liver breaks down sub-

stances like alcohol, drug and waste products


Sign & Symptoms:

Symptoms May Include Weight loss, lack of appetite, itching of the skin, unususal tired-ness, feeling very full after a small meal, a hard lump on the right side just below the rib cage, jaundice, ascites, nausea.

What Is Staging System, And What Does It Have To Do With Disease There are a no of different staging system for liver cancer.


(HBV)hepatitis B virus

(05 %ore thanm)

(HCV)hepatitis C virus

excessive alcohol

consumption

seisead liver yfatt

icoholalcnon

aflatoxicosis

diabetes

Staging is important, because it helps doctors determine which type of treatment to use in individual patients.


Doctors often use the categories below to describe a person's liver cancer. Localized resectable - The cancer is found only in the liver and the entire tumor can be removed by surgery. Localized and locally advanced unresectable - The cancer is found only in the liver and it has not spread. However, it cannot be removed (resected) by surgery. This might be because you have cirrhosis and you would not have enough healthy liver tis-sue left after surgery. Your cancer might also be localized unre-sectable if it has spread throughout the liver or it is too close to where the liver meets the main arteries, and bile duct.

Advanced - The cancer has spread throughout most of the liv-er or it is has spread to the lymph nodes or other organs. The tumor cannot be removed by surgery.

Recurrent recurrent disease is cancer that has come back-either to the liver or to another part of the body-after initial treat-ment or surgery. At what stage are most people with liver cancer Diagnosed? It's not unusual for liver cancer to be diagnosed at more advance stages, because many people don't have unususal symptoms in the early stages of the disease. The majority of the patients are diagnosed at more advanced stages.

Screening And Diagnosis The goals of Screenig are to diagnose HCC earlier and to im-prove prognosis. With the incidence of HCC on the rise ,screening is important for individuals at risk. Hepatocellular Carcinoma (HCC) Liver cancer may be discovered in a routine checkup if the doctor feeks hard lumps in the abdomen or by imaging examinations. To confirm a diagnosis of liver cancer, doctor may use the follow-ing :

Choice Of Therapy For Liver Cancer Care is frequently co ordinated through a multidisciplinary group of physician specializing in hepatoma. This team of spe-cialists usually includes surgeons, oncologists, radiologists, gas-troenterologist, radiation therapists and pathologlists. The best treatment for primary liver cancer is to remove surgical-

ly, removing the part of liver containing the tumor may result in a

cure and long term survival.

1: Surgical Resection (Removal) Liver Transplant


BLOOD TEST , including:

complete blood count,

alpha-fetoproteins tu-

mor marker test.

ULTRASOUND, COMPUT-

ED TOMOGRAPHY, MRI,

BIOPSY.



2. A similar technique, using microscopic radioactive particles instead of chemotherapy injected into the blood vessels, is called radioembolization or selective in-ternal radiation therapy (SIRT). This uses radioactive yttrium at-tached to glass microspheres and may be as effective as chemoem-bolization for small and multiple tumors.

3. Radiation therapy uses high-dose energy like X-rays aimed at a small part of the body and can frequently destroy cancer cells. The liver, though, may be more sensitive to the radiation than the tumor is, so standard radiation is seldom used. However, there are new specially focused techniques called conformal or stereotactic radiation that may be useful in certain cases.

4. Chemotherapy refers to drugs that are usually given by pill or by vein. They are designed to work throughout the entire body, not just the liver, so tumors out-side the liver will be treated as well. Recently, agents that direct-ly attack the microscopic blood vessels in the tumor, called anti-angiogenic drugs, have proven to be very helpful. Sorafenib, the first drug to be approved specifi-cally for hepatoma, was intro-duced in 2007. Sorafenib is a pill that slows the growth of the can-cer and helps keep many patients alive longer.

Mismanagement of Hypertensive Emergency in a

Patient Suffering from Recurrent Stroke

Abstract A 66-year-old man was presented to emergency department of Hospital Pulau Pinang with complaints of general weakness, pain in lower limb, history of known cerebrovascular accident and medication history of Metroprolol, Diltiazem, Hydrochlorothia-zide, Ranitidine and Gemfibrozil. Patient blood pressure and heart rate on admission to the hospital were 180/120 mm Hg and 40 beats per minute respectively. Metoprolol was withheld and therapy was started with IV Atropine stat. Patient was referred to medical ward. On the same day blood pressure reached to 200/130 mm Hg. To treat hypertensive emergency immediate release (IR) sublingual Nifedipine and intravenous Isosorbide dinitrae were added to the patients past medication of Diltiazem, Hydrochlorothiazide, Ranitidine and Gemfibrozil, which reduced BP to 150/90 mm Hg. The main issue in the present case was inappropriate use of IR Nifedipine and rapid and too much reduc-tion of BP in hypertensive emergency in patient suffering from recurrent stroke. The discrepancy between evidence-based rec-ommendations and real-time practice in the clinical settings is not uncommon. The use of IR Nifedipine and too much and too rapid reduction of BP should be discouraged to avoid uncontrolled BP reduction and precipitation of ischemic events.

Key Words Guidelines, Hypertensive emergency, Nifedipine, Stroke. Introduction Hypertensive emergency is a form of severe hypertension charac-terized by a severe elevation in blood pressure (> 180/120 mm Hg) complicated by evidence of impending or progressive target organ dysfunction. Examples of target organ dysfunction include coronary ischemia, disordered cerebral function, cerebrovascular events, pulmonary edema, and renal failure. Prompt recognition and early treatment of hypertensive emergency is crucial in pre-venting or halting progressive target organ damage [1]. Accord-ing to Malaysian Clinical Practice Guidelines on management of hypertension (CPG 2008) BP of the emergency hypertensive patient should be reduced rapidly by 25% over a period of 3 to 12 hours but not lower than 160/90 mm Hg, because too rapid re-duction of BP (within minutes to hours) may precipitate ischemic events [1]. Oral or sublingual drugs with rapid onset of action like immediate release (IR) Nifedipine can result in an uncon-trolled BP reduction and may precipitate ischemic events; there-fore its use is discouraged in the treatment of hypertensive emer-gency [1-6]. Case Description A 66-year-old man who fell in bathroom was presented to emer-gency department of Hospital Pulau Pinang, Malaysia with gen-eral weakness, pain in lower limb, mild shortness of breath (SOB), history of known cerebrovascular accident (CVA) and medication history of Metroprolol, Diltiazem, Hydrochlorothia-zide, Ranitidine and Gemfibrozil. On examination patient had BP reading of 180/120 mm Hg, with heart rate of 40 beats per mi-nute. The attending doctor at emergency department made the impression of sinus bradycardia, electrolyte imbalance and un

controlled hypertension. Metoprolol was withheld and therapy began with intra venous (IV) Atropine, along with patients past medications of Diltiazem, Hydrochlorothiazide, Ranitidine, Gemfibrozil. The patient was referred to medical ward. On the same day after ECG report, the attending medical doctor at medi-cal ward concluded that the patient is suspected of bradycardia secondary to B-blockers and recurrent stroke. At the same time very high blood pressure (200/130 mm Hg) was noted. To treat hypertensive emergency immediate release (IR) sublingual Nife-dipine and intravenous Isosorbide dinitrae were added to the pa-tients past medication, which resulted in too rapid and too much decrease in patients BP to a level of 150/90 mm Hg. Discussion Despite the availability and wide dissemination of guidelines which document the best available practices for management of hypertension, deviation from guidelines in clinical practice is not uncommon [7]. According to CPG (2008) BP control in hyper-tensive emergency is best achieved with parenteral drugs [1]. Malaysian guidelines treatment options for hypertensive emer-gency are given in Table 1. In past IR Nifedipine due to its fast acting and ease of administration was the drug of choice for treat-ing hypertensive crises [2]. But later on its use was found to be associated with life-threatening adverse effects such as severe hypotension, cerebral ischemia, acute myocardial infarction, re-flex tachycardia, conduction abnormalities, and even death [3-5, 8, 9]. Nifedipine causes BP lowering through peripheral vasodi-lation. The use of IR Nifedipine in hypertensive emergency can be life threatening particularly in patients suffering from cerebral ischemia and due to this reason its use is discouraged by hyper-tension management guidelines [1, 6]. In the present case the patient was suffering from recurrent stroke; a condition in which cerebral perfusion is directly proportional to the systematic BP. Too rapid and too much BP reduction in such patients as ob-served in the present case can lower cerebral perfusion to the ischemic area and thus worsen the target organ damage [8].

By Muhammad Qamar

Lecturer of Clinical Pharmacy

School of Pharmacy,

Management and Science University

Malaysia


Mismanagement of Hypertensive Emergency in a

Patient Suffering from Recurrent Stroke

Conclusion To avoid life threatening adverse effects such as severe hypoten-sion, cerebral ischemia, acute myocardial infarction, cardiac ar-rhythmias, and death, the use of IR Nifedipine which causes too rapid and too much reduction in BP should be discouraged in hypertensive emergency. The present case report shows doctors non adherence to guidelines recommendations while managing hypertensive emergency which can pose a serious threats to pa-tients lives. Remedial measures like continuing medical educa-tion and availability of clinical pharmacist to participate in col-laborative practices can line up the doctors practices in compli-ance with guidelines.

Conflict Of Interest The author declare no conflict of interest, in part or whole. No funding was received for this study. Acknowledgement We thank all the doctors and record keeping staff of Hospital Pulau Pinang, Malaysia for helping us in collecting the data. References 1. Malaysian Hypertension Guideline Working Group. Clinical Practice Guidelines on Management of Hypertension, 3rd ed. 2008. MOH/P/PAK/156.08 (GU). 2. Mansoor, A.F. and L. von Hagel Keefer. The dangers of immediate-release nifedipine for hypertensive crises. P & T 2002; 27(7): 362-365.

3. Wachter, R.M. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med 1987; 147(3): 556-558. 4. OMailia, J.J., G.E. Sander, and T.D. Giles. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive ur-gencies. Ann Internal Medicine 1987; 107(2): 185-186. 5. Peters, F.P.J., C. Zwaan, and L. Kho. Prolonged QT interval and ven-tricular fi brillation after treatment with sublingual nifedipine for malig-nant hypertension. Arch Intern Med 1997; 157(22): 2665-2666 6. Chobanian, A.V., et al. Seventh report of the Joint National Commit-tee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003; 42(6): 1206-1252. 7. Borzecki, A.M., S.A. Oliveria, and D.R. Berlowitz. Barriers to hyper-tension control. Am Heart J 2005; 149(5):785-794. 8. Jung, S.Y., et al. Short-acting nifedipine and risk of stroke in elderly hypertensive patients. Neurology 2011; 77(13):1229-1234. 9. Schwartz, M., et al. Oral nifedipine in the treatment of hypertensive urgency: cerebrovascular accident following


The "New" Health Miracles: Probiotics

What are Probiotics? The Food and Agriculture Organization of the United Nations (FAO) defines probiotics as "live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host."

Probiotics are bacteria that help maintain the natural balance of organisms (micro-flora) in the intestines. The largest group of probiotic bacteria in the intestine is lactic acid bacteria, of which Lactobacillus acidophilus, found in yogurt with live cultures, is the best known. Yeast is also a probiotic substance. Probiotics are also available as dietary supplements. They are actually alive bacteria. Most people think of antibiotics and anti-bacterial products when you mention bacteria. Both of those kill bacteria so why would you want to consume anything that has

live bacteria in it?

It's all about balance. Our digestive system normally has what we would call "good" bacteria and "bad" bacteria. Maintaining the correct balance be-tween the "good" bacteria and the "bad" bacteria is necessary for optimal health, which is goal of Probiotics.

Gastro-Intestinal Tract Within your gastrointestinal tract, there is intestinal micro-flora or micro-biota. The complex ecosystem of GIT contains over 400 bacterial species. Small amounts can be found in your stom-ach and small int

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