Candida and other yeasts of clinical importance in Aseer region,southern Saudi Arabia: Presentation of isolates from the routine laboratory setting

Objectives:

To isolate, identify, and determine the prevalence of Candida and other yeasts of clinical importance in Aseer region, Saudi Arabia.

Methods:

This is a cross-sectional study involving retrospective analysis of 6100 samples submitted to the Microbiology Laboratory, Aseer Central Hospital, Abha, Saudi Arabia between 2011 and 2012, and prospective isolation and identification of 84 isolates recovered from various clinical specimens presented to the Microbiology Laboratory between 2012 and 2013 using the classic morphological schemes and the Vitek 2 automated system.

Results:

The results of the retrospective analysis (2011-2012) indicated that of the 6100 various clinical specimens submitted to the routine microbiology analysis, 143 (2.35%) revealed the presence of Candida spp. The distribution of the 143 Candida spp. according to specimens was as follows: urine 72%, sputum 10.5%, endotracheal tube 7%, blood 4.2%, catheter tip 2.1%, throat swab 2.1%, eye swab 0.7%, wound exudates 0.7%, and cerebrospinal fluid 0.7%. The results of the prospective study (2012-2013), which involved the identification of yeast recovered from 84 specimens indicated that Candida albicans 28.6% was the predominant species, followed by Candida parapsilosis 21.4%, Candida tropicalis 14.3%, and Candida lusitaniae 9.5%.

Conclusions:

Along with the commonly encountered Candida albicans, Candida parapsilosis, Candida tropicalis, and Candida lusitaniae were detected with significant rates. Many other Candida species and some other pathogenic yeasts have been detected for the first time in the region. Urinary tract samples were the main source of Candida species.Fungal diseases notably those due to candida have become an increasing risk to human health. This is particularly true among patients with immune compromised systems.1,2 Candida and Aspergillus species are the most common agents associated with invasive fungal infections.3 Candida infections like other fungal infections are believed to be opportunistic in nature, since some aspects of the host’s defense system is impaired in some way. On the contrary, Candida infections manifest in a variety of forms ranging from superficial skin conditions, onychomycosis, oral, vaginal infections to fatal invasive illnesses that involve vital body organs such as heart, lungs, and central nervous system.1,2 Candidiasis, notably candidemia continues to be a major cause of morbidity and mortality in the health care settings. Moreover, the epidemiology of Candida infection is changing.4,5 Candida species are frequently encountered as part of the human commensal flora. Colonization mostly paves the way to candidemia and is considered an independent risk factor for the development of candidemia.1,4 The frequency of nosocomial bloodstream infections by Candida species has risen dramatically in the past 2 decades. It has been found that more than two-thirds of patients with invasive candidiasis in ICUs have candidemia. Of these isolates, the non-albicans Candida species constituted about half of the isolates and death from these invasive ICU infections was notable.1 There is a lack of sufficient literature showing in a systematic way, the incidence of fungal infections in the Kingdom of Saudi Arabia. Available data indicated that fungal infections, generally, represent approximately 10% of reported laboratory diagnosed infections; whereas gram-positive organisms (10%), gram-negative organisms (32%), and the remaining 48% were polymicrobial.6,7 The aims of this study were to isolate, identify (prospectively), and to determine the prevalence (retrospectively) of Candida infections and other yeasts of clinical importance in Aseer region, Saudi Arabia.     

Modeling and Optimization of Terbutaline Emitted from a Dry Powder Inhaler and Influence on Systemic Bioavailability Using Data Mining Technology

Purpose

Delivery of accurate doses from dry powder inhalers (DPI) involves many process variables which must be adjusted to ensure patient compliance and optimum therapy. Some of the process variables include: speed of inhalation (flow rate), assumed lung volume of patients, number and duration of inhalations.

Method

Data mining technology based on artificial neural networks and genetic algorithms were used to model the in vitro inhalation process, predict and optimize bioavailability from the inhaled doses.

Results

The delivery of terbutaline doses from Bricanyl Turbuhaler® was modeled and optimized using artificial neural network modeling and optimization software. Highly significant models (p?<?0.00001) with minimum root mean squared error and high predictability: R ²?>?81 % and 91 % for the in vitro and the in vivo models were developed, respectively. The optimized models demonstrated that an optimum emitted dose (>76 %) could be obtained if the dose was withdrawn as two inhalations with inhalation volume 4 L and flow rate 60 L/min within 4 s. The same independent variables in addition to % terbutaline emitted were modeled and optimized for % drug excreted in urine. The latter model demonstrated that optimum bioavailability (79.50 %) could be obtained from Bricanyl Turbuhaler® emitting 80–87.50 % terbutaline at a flow rate of 58–60 L/min using two inhalations irrespective of subject forced expiratory volume in 1 s (FEV₁) or the individual lung capacity.

Conclusion

Optimized in vitro/in vivo inhalation processes using data mining models can offer rapid solutions for dose variability problems and maximize the bioavailability of drugs from DPIs.     

A survey of therapeutic drug monitoring services in Malaysia

In Malaysia, therapeutic drug monitoring (TDM) service was started in the 1980s. Since then, the number of hospitals that offer the service has increased. In this paper, we report the findings of a nationwide survey describing the practice of TDM in these hospitals. Questionnaires were mailed to 128 government hospitals. Data were collected for general characteristics of the hospitals, administrative, and laboratory activities related to TDM service. One hundred and twenty-one hospitals responded to the survey. Thirty-four hospitals (28.1%) provided the service with their own TDM laboratories, 44 hospitals (36.4%) provided the service using other hospitals’ laboratories and 43 hospitals (35.5%) did not provide the service at all. TDM services were more likely to be offered in larger hospitals with various medical specialties. Since it is managed entirely by hospital pharmacists, these pharmacists assume an important role in ensuring optimum use of the TDM service.     

Preliminary Evidence for the Construct and Concurrent Validity of the DS14 in Hebrew

Background

Type D personality is a risk indicator in cardiac patients. While both the validity and reliability of the Type D scale (DS14) have been confirmed in Western Europe, less attention has been paid to the subject in other nations.

Purpose

The purpose of this study was to examine the validity of the Hebrew version of the DS14 among a sample of cardiac patients in Israel.

Method

Male patients (N?=?94) hospitalized for a first acute coronary syndrome (ACS) completed the DS14 1?month after their ACS. The Brief Symptoms Inventory (BSI) scales for depression and anxiety and the Buss?CDurkee Hostility Inventory-Dutch for measuring covert and overt aggressions were administered during the initial hospitalization (baseline). The BSI was administered again at the 6-month follow-up. At follow-up, patients were also asked about their participation in a formal cardiac rehabilitation program.

Results

The two-factor structure of the DS14 was confirmed and the DS14 subscales were internally consistent (Cronbach??s ???=?0.79/0.80). Type D cardiac patients had a significantly higher mean score on anxiety, depression, and covert aggression at baseline compared to non-Type D patients. At the 6-month follow-up, Type D was associated with more anxiety, more depression, and less attendance at a formal cardiac rehabilitation program. The prevalence of Type D in the current sample (5.3%) was found to be significantly lower than elsewhere in Europe.

Conclusion

Preliminary evidence suggests that it is possible to use the Hebrew version of the DS14 among Hebrew-speaking cardiac patients in future studies. However, the prevalence of the Type D personality in Israel should be further assessed.     

The relative lung and systemic bioavailability of terbutaline following nebulisation in non-invasively ventilated patients

Nebulising a bronchodilator during non-invasive ventilation (NIV) is effective but there is a lack of consensus on the system to use because comparator in vivo studies in these patients are difficult. Urinary pharmacokinetic methodology post inhalation could provide this information. Chronic obstructive pulmonary disease patients requiring NIV received randomised study doses of either 2 mg terbutaline nebulised from an Aeroneb Pro (AERO) or 5 mg from a Sidestream (SIDE) on days 1 and 3 of admission. Urine samples were provided at 30 min then pooled up to 24 h post inhalation and amounts of urinary terbutaline (UTER0.5 and UTER24; indices of relative lung and systemic bioavailability, respectively) were determined. Twelve consenting patients receiving NIV mean (SD) age and weight of 74.8 (8.2) years and 61.0 (10.7) kg completed the study. The mean (SD) UTER0.5 following AERO and SIDE was 9.4 (3.7) and 10.4 (4.1) μg with a mean ratio (90% confidence interval) of 89.7 (87.8, 92.3)%. UTER24 was 192.3 (52.4) and 205.3 (58.0) mcg with a mean ratio (90% CI) of 93.7 (113.5, 77.3)%. This urinary pharmacokinetic method to identity relative lung and systemic bioavailability between two nebuliser systems was easy to perform and is a useful and simple in vivo method to compare different nebulisers in patients receiving non-invasive ventilation.     

Immunotherapy as a Neoadjuvant Therapy for a Patient with Hepatocellular Carcinoma in the Pretransplant Setting: A Case Report

Systemic combination therapy of immune checkpoint inhibitors and vascular endothelial growth factors have provided the basis for improved outcomes in select patients with unresectable or metastatic hepatocellular carcinoma. However, for patients with resectable disease, surgery alone or an orthotopic liver transplant remains the standard of care. Within the realms of transplant oncology, neoadjuvant systemic therapy is currently being evaluated as a potential strategy to improve outcomes in patients with HCC. Here, we report excellent response with significant downstaging in a safe manner after neoadjuvant treatment with atezolizumab and bevacizumab in a patient diagnosed with poorly differentiated HCC. As a result of the significant response observed with safe outcomes, the patient was listed for orthotopic liver transplant (OLT) evaluation and transplanted successfully.     

The genetic landscape of autism spectrum disorders

Autism spectrum disorders (ASDs) are a group of heterogeneous neurodevelopmental disorders that show impaired communication and socialization, restricted interests, and stereotypical behavioral patterns. Recent advances in molecular medicine and high throughput screenings, such as array comparative genomic hybridization (CGH) and exome and whole genome sequencing, have revealed both novel insights and new questions about the nature of this spectrum of disorders. What has emerged is a better understanding about the genetic architecture of various genetic subtypes of ASD and correlations of genetic mutations with specific autism subtypes. Based on this new information, we outline a strategy for advancing diagnosis, prognosis, and counseling for patients and families.