Strategies for the use of Ginkgo biloba extract,EGb 761®, in the treatment and management of mild cognitive impairment in Asia: Expert consensus

BackgroundMild cognitive impairment (MCI) is a neurocognitive state between normal cognitive aging and dementia, with evidence of neuropsychological changes but insufficient functional decline to warrant a diagnosis of dementia. Individuals with MCI are at increased risk for progression to dementia; and an appreciable proportion display neuropsychiatric symptoms (NPS), also a known risk factor for dementia. Cerebrovascular disease (CVD) is thought to be an underdiagnosed contributor to MCI/dementia. The Ginkgo biloba extract, EGb 761^®, is increasingly being used for the symptomatic treatment of cognitive disorders with/without CVD, due to its known neuroprotective effects and cerebrovascular benefits.AimsTo present consensus opinion from the ASian Clinical Expert group on Neurocognitive Disorders (ASCEND) regarding the role of EGb 761^® in MCI.Materials & MethodsThe ASCEND Group reconvened in September 2019 to present and critically assess the current evidence on the general management of MCI, including the efficacy and safety of EGb 761^® as a treatment option.ResultsEGb 761^® has demonstrated symptomatic improvement in at least four randomized trials, in terms of cognitive performance, memory, recall and recognition, attention and concentration, anxiety, and NPS. There is also evidence that EGb 761^® may help delay progression from MCI to dementia in some individuals.DiscussionEGb 761^® is currently recommended in multiple guidelines for the symptomatic treatment of MCI. Due to its beneficial effects on cerebrovascular blood flow, it is reasonable to expect that EGb 761^® may benefit MCI patients with underlying CVD.ConclusionAs an expert group, we suggest it is clinically appropriate to incorporate EGb 761^® as part of the multidomain intervention for MCI.     

Chronic Active Antibody-Mediated Rejection Following COVID-19 Infection in a Kidney Transplant Recipient: A Case Report

Kidney transplant recipients who develop coronavirus disease 2019 (COVID-19) are at increased risk of life-threatening illness, which often requires reducing immunosuppression despite the potential risk of causing an allograft rejection. Herein, we describe the clinical presentation and course of a kidney transplant recipient who acquired COVID-19 and was hospitalized with severe symptoms and hypoxemia. Upon admission, the patient was found to have elevated de novo donor-specific antibodies (DSA) yielding a positive cytotoxicity crossmatch and concurrent elevated plasma donor-derived cell-free DNA (dd-cfDNA) level, indicating a possible ongoing rejection despite improvement in his serum creatinine. Because of persistent positive COVID-19 tests and stable serum creatinine, a kidney allograft biopsy was initially deferred and his dd-cfDNA and DSA were monitored closely postdischarge. Three months later, because of persistent elevated dd-cfDNA and positive DSA, a kidney allograft biopsy was performed, which showed chronic active antibody-mediated rejection. Accordingly, the patient was treated with intravenous immunoglobulin and his maintenance immunosuppressive regimen was increased.     

Acceptability of human papillomavirus vaccination among medical students in Mangalore,India

Background

The highly prevalent cervical cancer can be prevented through a vaccine. However, the uptake of the Human Papillomavirus vaccine in the general population continues to be low. Medical students, as healthcare providers in the future, would be influential in affecting the community's views and thereby the uptake of the Human Papillomavirus vaccine. Hence, there is a need to promote the right attitude for prompt implementation of this vaccine among medical students. None of the studies in India have so far documented the proportion of vaccinated population among medical students or an intervention strategy to eliminate the barriers to Human Papillomavirus vaccine.

Evaluation of the National Tuberculosis Surveillance System in Sana’a,Yemen, 2018: Observational Study

BackgroundTuberculosis remains a public problem that is considered one of the top causes of morbidity and mortality worldwide. The National Tuberculosis Control Program in Yemen was established in 1970 and included in the national health policy under the leadership of the Ministry of Public Health and Population to monitor tuberculosis control. The surveillance system must be evaluated periodically to produce recommendations for improving performance and usefulness.ObjectiveThis study aims to assess the usefulness and the performance of the tuberculosis surveillance system attributes and to identify the strengths and weaknesses of the system.MethodsA quantitative and qualitative evaluation of the national tuberculosis surveillance system was conducted using the Centers for Disease Control and Prevention’s updated guidelines. The study was carried out in 10 districts in Sana’a City. A total of 28 public health facilities providing tuberculosis services for the whole population in their assigned catchment areas were purposively selected. All participants were interviewed based on their involvement with key aspects of tuberculosis surveillance activities.ResultsThe tuberculosis surveillance system was found to have an average performance in usefulness (57/80, 71%), flexibility (30/40, 75%), acceptability (174/264, 66%), data quality (4/6, 67%), and positive predictive value (78/107, 73%), and poor performance in simplicity (863/1452, 59%) and stability (15%, 3/20). In addition, the system also had a good performance in sensitivity (78/81, 96%).ConclusionsThe tuberculosis surveillance system was found to be useful. The flexibility, positive predictive value, and data quality were average. Stability and simplicity were poor. The sensitivity was good. The main weaknesses in the tuberculosis surveillance system include a lack of governmental financial support, a paper-based system, and a lack of regular staff training. Developing an electronic system, securing governmental finances, and training the staff on tuberculosis surveillance are strongly recommended to improve the system performance.     

Is metformin poised for a second career as an antimicrobial?

Metformin, a widely used antihyperglycaemic, has a good safety profile, reasonably manageable side‐effects, is inexpensive, and causes a desirable amount of weight loss. In 4 studies of patients with tuberculosis (1 prospective and 3 retrospective), metformin administration resulted in better outcomes. In mice with several models of endotoxemia, metformin diminished levels of proinflammatory cytokines and improved survival. Laboratory studies showed effectiveness of the drug on multiple pathogens, including Trichinella spiralis, Staphylococcus aureus, Pseudomonas aeruginosa, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Metformin administration in humans and mice produced major changes in the composition of the gut microbiota. These recently discovered microbe‐modulating properties of the drug have led investigators to predict wide therapeutic utility for metformin. The recent easing in United States Food and Drug Administration (FDA) guidelines regarding administration of metformin to patients with kidney disease, and reduced anxiety about patient safety in terms of lactic acidosis, increase the probability of broadening of metformin's usage as a treatment of infectious agents. In this text we review articles pertinent to metformin's effects on microorganisms, both pathogens and commensals. We highlight the possible role of metformin in a wide range of infectious diseases and a possible expansion of its therapeutic profile in this field. A systematic review was done of PubMed indexed articles that examined the effects of metformin on a wide range of pathogens. Metformin was found to have efficacy as an antimicrobial agent in patients with tuberculosis. Mice infected with Trypanosomiasis cruzi had higher survival when also treated with metformin. The drug in vitro was active against T. spiralis, S. aureus, P. aeruginosa, and hepatitis B virus. In addition there is emerging literature on its role in sepsis. We conclude that metformin may have a potential role in the therapy for multiple infectious diseases. Metformin, in addition to its traditional effects on glucose metabolism, provides anti‐microbial benefits in patients with tuberculosis and in a very wide range of other infections encounters in vitro and in vivo.     

Oxidative stress,antioxidant defenses,and schizophrenia

Schizophrenia is a complex neuropsychiatric disorder with a prevalence of nearly 1% of the world population. Accumulating evidence suggests that increase in production of reactive oxygen species (ROS) along with decrease in antioxidants and antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase) may be closely associated with the pathogenesis of schizophrenia. Genes associated with glutamate transmission, dopamine transmission, synaptic plasticity, mitochondrial function, oxidative stress, lipid metabolism, and neuroinflammation have been closely linked to schizophrenia. Proteins encoded by many of the above genes affect the level of ROS, and lipid mediators that regulate signaling in the brain through cross‐talk among glutamate, dopamine, and eicosanoid receptors. Under physiological conditions, this refines the communication between neurons, glial cells and vascular cells, but in schizophrenia, the cross‐talk might initiate and promote oxidative stress‐mediated abnormal neuronal signaling responsible for symptoms of the disease.