Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1

Within the field of biomedicine, the scope of alginate application is broad and includes: wound healing, cell transplantation, delivery of bioactive agents such as chemical drugs and proteins, heat burns, acid reflux, and weight control applications. Recently the alginate based biomaterials for the treatment of myocardial infarction are entering into the advanced clinical trials stage. The non-thrombogenic nature of this polymer has made it an attractive candidate for cardiac applications, including scaffold fabrication for heart valve tissue engineering. The next pivotal property of alginates is their ability to form films, fibers, beads and virtually any shape in a variety of sizes. Moreover, alginates could form the gels in mild conditions, for example by adding calcium salt to an aqueous solution of alginate. The calcium ions displace the sodium from the alginate, and grasp the long alginate molecules together, resulting in a gel. This property is a base for obtaining the alginate scaffold with complex geometry of the aortic heart valve, in a few easy steps. These steps could be freely adjusted to yield the structure consenting precisely allocated viable cells. Alginate scaffold preparation was carried out by immersing the agarose mold saturated in CaCl2 solution (2% w/w). The calcium ions diffused form the mold and cross-linked alginate, subsequently the mold was removed. Obtained structure closely matched the mold geometry. The mold was made by casting the agarose into the 3d printed form. Moreover by extending the time of mold immersion into the sodium alginate solution, the thickness of scaffold and its composition can be controlled. The details of the process are discussed in this report. The drawback of alginate is that it yields relatively soft mechanically unstable structures. As reported elsewhere, that could improve if the scaffold will be saturated with viable proliferating cells. Alternatively the hydrogel can be reinforced by polymeric yarns.

Plaques that build up in the lining of the coronary arteries are made up of lipids, inflammatory cells, smooth muscle cells and connective tissue. Thormbosis of a not necessarily occlusive but unstable plaque most often causes episodes of unstable angina and myocardial infarction (MI). Preventing this sudden and adverse event seems to be the only effective startegy to reduce mortality and morbidity of coronary artery disease (CAD). Countries in the Middle East bear a heavy burden from cardiovascular disease. The population of Qatar is particularly prone to CAD with patients presenting with MI at a young age. The prevalence of CAD is in turn promoted by risk factors such as smoking, hypertension, dyslipidemia, diabetes and sedentary lifestyles. Metabolomics approaches to the identification of disease biomarkers rely principally on the comparitive analysis of metabolite expression in normal and disease patients, animal models or cell cultures to identify aberrantly expressed proteins or concentration changes in metabolites that may represent new biomarkers or elucidate a disease mechanism. Lipidomics is the global identification and quantification of a diverse range of lipids in biological systems and is a subset field in metabolomics. The eukaryotic lipidome might compise of 10,000 to 100,000 individual species of lipids originating from a few hundred lipid classes. These lipids are distributed as part of biological membranes, energy storage substances and sometimes function as signal transducers. Altered lipid metabolism and dyslipidemia in the context of inflammation and oxidative stress are driving forces in the transition from stable to unstable plaques. Therefore, a characteristic lipid signature within unstable human plaques and also in the circulating blood plasma could be a predictor of an oncoming cardiac event. This ongoing study was conducted on samples volunteered by acute coronary syndrome (ACS) patients at the Heart Hospital, Doha, Qatar. ACS is a term that describes any condition brought on by the sudden reduced blood flow to the heart due to thrombosis in the coronary arteries and encompasses unstable angina (UA) and both ST-segment elevation (STEMI) and non ST-segment elevation myocardial infarction (NSTEMI). A complete occlusive thrombi leads to extensive myocardial cell death and typically produces an elevated ST-segment in the electrocardiogram. In UA, ischemia occurs unpredictably and suddenly and is caused by the temporary formation of blood clots within the coronary arteries. Unstable angina often occurs before a MI. Distinguished from ACS are patients with stable angina (SA) who develop symptoms due to exertional ischemia. The aim of this study was to profile the global individual lipid levels of subjects in Qatar with unstable CAD, comparing global lipid levels between patients with unstable angina and ST-elevated myocardial infarction. We chose to discover the lipid biomarkers using a workflow utilizing tandem mass spectrometry with on-line ultra-high pressure liquid chromatography (UPLC-MS/MS). Mass spectrometry is a powerful technique that can be used to identify unknown compounds, to quantify known materials and to elucidate the structure and chemical properties of molecules. Recent advances in the accuracy and speed to the technology allow data acquisition for the global analysis of proteins, lipids and metabolites from complex samples such as blood plasma or serum. As we were trying to discover a new lipid biomarker, a technique that would maximise the number of compounds detected, identified and quantified them was favourable. Once the samples were analysed by tandem mass spectrometry, the ion intensity data from each sample was aligned with each other by retention time and lipid mass, normalised and deconvoluted. The signals were then attributed to a particular lipid species by utilising a lipid database and comparing the mass of the detected lipid and piecing together information gained from the fragment data of that lipid from the orbitrap. Statistical analyses of the signals for each individual lipid were then conducted by comparing within group percent coefficient of variation (?CV), fold change and analysis of variance (ANOVA) tests between sample groups and q-value and power calculations. Principal component analysis (PCA) was conducted in order to differentiate the samples under supervised conditions into STEMI and UA groups. A total of 1,663 and 874 lipid compounds were identified in positive and negative modes of mass spectrometry respectively. Of these, 7 compounds showed a significant change (ANOVA p-value <  or equal to 0.001) between the STEMI and UA groups. The identities of these compounds are yet to be elucidated. Of the compounds with a significant change between sample groups of ANOVA p-value <  or equal to 0.005, five compounds were able to be identified by mass and spectral matching with a lipid database. The PCA scores plot, which distributes samples in multi-dimensional space according to the variance seen in each principal component, showed very low evidence of discrimination between the sample groups with sample scores clustered in a single mixed pattern. This analysis suggests that the lipid abundance changes between the sample groups were difficult to find. This was most likely due to a combination of two reasons: (1) large within-group biological variance that needs to be overcome to detect the between-group variances and (2) the low differences in lipid concentrations between the sample groups. With a greater number of samples, this results is expected to change as the power of the study would increase. Successful results obtained from this study will aid healthcare professional in intervening with appropriate treatment in persons showing no symptoms but are under threat of developing angina or acute MI. The discovery of a lipid biomarker could assist healthcare professionals in prevention of an acute cardiac event thereby saving lives.

Recently multiple examples of applications of knitted fabrics in HVTE were reported. One of the most frequently citrated strategy was developed in Mela's group. In that case, the fibrin constituting the leaflets of valves is enforced using a warp-knitted tubular mesh, made out of polyethylene terephthalate (PET). In all reports, the authors evaluated biocompatibility of the construct by encapsulating the cells in the fibrin gel constituting the leaflets and quantifying the secreted ECM proteins. Other authors reported that in vivo implantation with fibrin-based tissue-engineered heart valves revealed an absence of calcification, thrombus formation, aneurysm development or stenosis. After 90 days of implantation, it was also observed that a monolayer of endothelial cells was formed, which exhibits the promise of fibrin scaffolds for HVTE. This approach is potentially adaptable for the intelligent scaffold development, which will require replacing non-degradable yarns with bioresorbable yarns. This would be necessary since in the smart solutions; the synthetic yarns need to be finally absorbed and replaced by extra cellular matrix proteins, deposited by in situ recruited cells. PET is not a bioresorbable material, thus alternative strategies need to be proposed to enable growth of valve tissue within the patient. The solutions proposed by Mela and colleagues are promising and encourageable. Inspired by these reports, we fabricated valve leaflets using spatial PET knitted fabric. The construct obtained very closely matched the histological structure of leaflets with 3 layer architecture. This is already important accomplishment towards scaffold closely matching architecture of native valves. The future steps will involve replacing PET with polycaprolactone yarns to enhance construct biocompatibility.

Background

According to the World Health Organization Report on Tuberculosis in 2013, it is estimated that 9 million people developed tuberculosis and 1.5 died of the disease. In Qatar, the incidence of tuberculosis is the highest in the Gulf countries but this mainly depends on migrant laborers from countries with high incidence, especially Nepal, India, and the Philippines. It is important to consider that only India contributes with the 25% of the global burden of tuberculosis. Among the strategies for the prevention and control of tuberculosis are included measures to promote the early diagnosis and the compliance with treatment. The delay in the diagnosis has a critical role in the control of tuberculosis and it constitutes a threat for the community and it worsens the prognosis for the patient's improvement in the clinical status. In a literature review of 52 studies, Sreeramareddy CT et al reported that (median or mean) total delay, patient delay, healthcare system delay for diagnosis of tuberculosis were ranging from 25 to 185 days, 4.9 to 16.2 days and 2 to 8.9 days respectively. The overall average patient delay was similar to health system delay (31.03 versus 27.2 days). According to a multinational study about diagnostic delay carried out in the Eastern Mediterranean Region (EMR) in 2003–2004 the mean duration of delay between the onsets of symptoms until treatment with anti-tuberculosis drugs ranged from one month and a half to 4 months in the different countries. The mean delay was 46 days in Iraq, 57 in Egypt, 59.2 in Yemen, 79.5 in Somalia, 80.4 in the Syrian Arab Republic, 100 in Pakistan, and 127 in the Islamic Republic of Iran. This report comments that the infection control programs are able to detect an average of one third of smear-positive tuberculosis cases, while the rest continue to transmit infection in the community until treated, whether adequate or inadequate by other health sectors. Recently published papers report total diagnosis delay of 60 days (Porto Alegre and Yemen, 2013), and 36 days (Guimaraes, 2015), patient delay of 15 days (Brazil, 2013 - Porto Alegre, 2013) and system delay of 15 days (Croatia, 2013) and 18 days (Porto Alegre, 2013). No previous reports have been published about the topic in Qatar. Based on the previous information and on the national goal for prevention and control of communicable diseases we considered necessary to conduct an epidemiological research to describe the diagnostic delay in tuberculosis, as an initial step for a population-based study.

Objective

– To identify the diagnostic delay in patients with tuberculosis and to describe the patient and healthcare system components.

– To test the method of collection of information for the design of a population-based study.

Methods

An exploratory study was carried out in 49 newly diagnosed tuberculosis patients admitted to a hospital facility during the period of May-October, 2015 Criteria for inclusion:

– Patient who accepts to answer the questions during a regular clinical interview.

– Patient with a clinical status who allows the interview, regardless of the type of tuberculosis (pulmonary or extra pulmonary) Criteria for exclusion

– Unstable clinical status that interferes with a proper communication

– Language barrier that could not be overcome due to unavailability of interpreter for any specific language.

Procedure During the admission period, and during the regular clinical evaluation, the patients answered the study questions. The interview was conducted by a nurse, using an interpreter if considered necessary. It was collected information about the first time the patient arrived in Qatar and the date of onset of symptoms related with tuberculosis. If the patient visited an outpatient or emergency department of another healthcare facility during the symptomatic period and before the admission, it was defined the date and the type of facility (primary level facility, hospital facility) and if the treatment recommended included antibiotics. The date of diagnosis was considered to be the date of the collection of the confirmatory laboratory test (acid fast bacilli or GeneXpert PCR positive for mycobacterium tuberculosis complex in clinical samples).

Definitions

– Patient delay was considered as the time between symptoms onset and first contact with the healthcare system, regardless the category or level of care provided by the facility (primary healthcare facility, hospital).

– System delay was considered as the time between the first contact with the healthcare system and the diagnosis.

Analysis

Data were entered in JMP 10.0 (SAS Institute, http://www.jmp.com). Descriptive statistical methods were used. Median and percentile distribution was calculated for patient and healthcare system delay, and boxplot graph was obtained. The interquartile range [IQR] was calculated (Q3 – Q1).

Results

The patients have lived in Qatar a mean time of 5.5 years, with a maximum of 32 years. All patients were confirmed with pulmonary or pleural tuberculosis by means of a smear positive for acid fast bacilli, PCR positive for mycobacterium tuberculosis complex in clinical samples (sputum, pleural fluid, biopsy samples). The median total delay was 30 days (IQR 23.5 days, maximum 365 days), the patient delay was 21 days (IQR 22 days, maximum 362 days), and the system delay was 3 days (IQR 8 days, maximum 60 days). 26 patients out of 42 who visited another facility before admission (61.9%) were attended in a primary healthcare facility and 16 patients (38.1%) in a hospital facility. The 92% of these patients received antibiotic treatment for the management of the respiratory symptoms and were discharged from these ambulatory contacts. After that, due to no improvement of their clinical status they were admitted to hospital and the diagnosis of tuberculosis was confirmed. The above-mentioned results highlight the contribution of the patient component in the diagnosis delay in tuberculosis, which constitutes a significant risk for community transmission. Consequently, this finding should guide the actions for the prevention and control of tuberculosis. It is important to stand out the strengths of the tuberculosis program in Qatar, including the availability of the latest technology for its diagnosis (Gene Xpert PCR, Quantiferon TB Gold, PCR for rifampicin resistance), which is performed in a central laboratory at a national level, and a devoted Tuberculosis clinic for diagnosis and follow up with devoted staff with expertise on this field. In addition, the national law supports the free of charge healthcare services for tuberculosis patients, including the admission in hospital, anti tuberculosis treatment and follow-up.

Conclusion

Our findings provide insights about the delay of tuberculosis diagnosis and the need to identify strategies for its reduction, especially the patient component.

Recommendations

To conduct a population-based or cohort study to identify the risk factors and determinants for delay in the diagnosis of tuberculosis, including detailed information about the health-seeking behavior of patients with suspected tuberculosis.

Background

Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care (Field and Lohr 1992). Higher quality of care and improved cost effectiveness are important goals in guideline development, optimally resulting in improved health (Woolf et al., 1999). Moreover, the process of guideline development addresses the need to decrease variability in professional practice, and practitioners' desire to legitimize their profession in the eyes of external stakeholders (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). The concept of evidence-based practice, supported by clinical guidelines, is a common aspect of health care today. Currently there is no formal training or education sessions to unify the Physical therapy practice in the department, which in turn resulting in greater practice variations and results. Grater variability in professional practice directly influences the outcome of patient care. To counteract this, Physical therapy unit, Rumailah hospital, Qatar has developed Physical therapy specific clinical practice guideline called ‘PAAS Guideline’ (Physical Therapy After Acute Stroke) to enhance the effectiveness and efficiency of post acute stroke Physical therapy care. Evidence argues that guideline-adherent care results in better health outcomes, quality of care, shorter treatment period and reduced cost of care. The phase I of the PAAS G adherence trail focuses on the knowledge dissemination phase of the clinical practice guideline through a structured competency workshop and its effectiveness. ‘Physical Therapy After Acute Stroke’ (PAAS) guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care ‘exclusively’ developed by the Physical therapists of Rumailah hospital. The goal of the PAAS guideline is to improve the quality, transparency, and uniformity of the physical therapy provided to patients whose main diagnosis is a stroke (cerebrovascular accident), throughout the chain of integrated care, by explicitly describing the Physical therapist's management of these patients on the basis of scientific research, adjusted where necessary on the basis of consensus among Physical therapy experts in primary, secondary and tertiary care, as well as associated professions in the field.

Objective

To find out the effectiveness of a cost effective competency workshop in disseminating knowledge of ‘Physical Therapy After Acute Stroke (PAAS) guideline’ among physical therapist of Rumailah Hospital, Qatar Method Participants and procedure: Through the intranet system of the Hamad Medical Corporation the competency workshop was announced well in advance of the date. The workshop and the competency training were made mandatory for all the Physical therapists practicing the neurological Physical therapy of Rumailah hospital. The supervisors of other Physical therapy department were informed to select physical therapists practicing stroke physical therapy in their unit in order to coalesce the practice across the corporation.

Workshop Structure

The program offered Physical therapists free one day eight hour PAAS guideline training. Upon successful completion of the workshop (60% marks in the post competency examination), participants will receive a ‘PAAS guideline competency certificate’ of one year validity. One full day was prepared as a competency training day by cancelling all the clinical related works of that day. The essential clinical duties of the day were rescheduled to one public holiday with 2 physical therapists on overtime coverage. The cost of the program was strictly controlled with an intention to create a cost effective workshop model which can be employed even in other units. We used our gym hall as the lecture room with all the furniture and audio-visual medias of the department. A two time simple snack was provided by using unit and hospital petty cash facility. All the printing and the publication works were done using the unit internal resources. Medical corporation media was informed to cover the event. The pre and post workshop competency exam were conducted at the beginning and very end of the program with 30 minutes given to answer 20 guideline related questions. A feedback recording was taken concerning the workshop and the arrangement in a structured course feedback form.

The training

Program agenda of the workshop was announced well in advance of the date (Table 1). All the topics were the direct reflections of the PAAS guideline converted to power point presentations. The 1-day, 8 hour training was organized in a ‘constructivist didactics’ way followed by clinically relevant examples as a way to maximize active participation by the attendees. A course and session objectives and lesson plan were given before every presentation. For every five slides of the powerpoint presentation, one review question was given inorder to refresh and refocus the attendees back to the session. The conclusion was made interactive by highlighting all the key points discussed on the session and by randomly asking the attendees to expand the key words into ideas that has learned. A five minute break was given for every presentation which was used as a question and answer session. The specialists of the department of the physical therapy, conducted the training. All the training presentations were unified in there structure and content and verified for errors well in advance of the course. The PAAS guideline was made available to all the participants before the workshop. Participating Physical therapists received author-developed handouts adapted from the workshop. The guideline was presented as seven sessions covering the seven topics of the PAAS guideline. The trainers did not target training with special conclusion nor were attendees told what would be learned and evaluated at the end of the training. However, participants were encouraged to increase the number and diversity of reflections used, diminish the frequency of questions and increase the use of open questions. PAAS guideline knowledge building was the clear goal of the training, but the emphasis was on the participants understanding and amalgamation of the given evidences with the current practices and experiences they have.

Competency examination

The participants of the PAAS guideline training were required to complete a guideline competency exam at the beginning and at the end of the training. The objectives of the competency exam was to evaluate and document the percentage of knowledge acquisition by the attendees. We believed that a respectable launch of the PASS guideline implementation should begin from an effective and equally distributed knowledge dissemination process. Twenty questions were created from the eight sessions of the guideline based on the Bloom's taxonomy. PAAS competency examination was designed with 10% questions to test the knowledge domain, 20% with comprehension, 25% with application, 20% analysis, 15% with synthesis and 10% to test the evaluation skills (Fig. 1). A total 30 minutes were provided to complete the examination. Test validation As a part of test validation 3 Physical therapy specialists with stroke rehabilitation experience from different hospital background were given the designed questionnaire and were asked to mark any questions that were unclear to them when they were taking the test. After the test, a discussion session was organized to ensure their understanding of the test questions was the same as what was intended. Two questions were adjusted based on this ‘internal pre-testing’ measure.

Results

The candidates were given the pre and post examination with the same question set. No information or clues were given to the participants regarding the posttest examination during the pretest or workshop. The same question set was used inorder to quantify the transfer of knowledge from the workshop. The maximum possible mark in the question set was 20. The average mark scored by the candidates in the pretest was six (6) out of 20 with standard deviation of (SD) 1.9. The average mark scored by the candidates in the post test was 14.5 out of 20 with standard deviation of (SD) 3.0 indicating difference of 8.5 marks with standard deviation of (SD) 1.6 between the two examinations. This has proven that the cost effective competency workshop succeeded in improving PAAS guideline knowledge to 141.7% compared to the pre workshop. Figure 2 represents the PAAS G examination mark analysis. A paired t test was executed to analyze the pre and post workshop test results. The t statistics was observed as, t = 21.496, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference. The null hypothesis was rejected, since p <  0.05 (Table 2).

Conclusion

There is strong evidence (p <  0.05) that the cost effective competency workshop improved PAAS G knowledge. In this data set, it improved marks, on average, by approximately 8.5 points or 141.7% with a 95% Confidence Interval (7.7–9.3). The feedback evaluation revealed an overall very good to excellent rating for the competency workshop (Fig. 3).

Implication

PAAS guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care, developed by the guideline task force of Physical therapy unit, Rumailah Hospital. PAAS Guideline offers recommendations for appropriate care. An evaluation of the guideline adherence and practice variations helps to fine tune the Physical therapy care to a highest possible standard of practice. A proper assessment of the relationship between the process of Physical therapy care and outcomes with a comprehensive set of process indicators will be implemented during the year 2016. We strongly believe that by means of systematic approach and implementation we can change the culture of practice so that it can suit and align with the international quality care in evidence based manner there by uplifting the corporation and its vision of becoming an internationally recognized center of excellence in health care. We believe that this ‘small changes will make a big difference in our health care system in the coming years’.

Physical Therapy, Practice behavior, Clinical practice guideline, Adherence

References

Field, Marilyn J., and Kathleen N. Lohr. “A provisional instrument for assessing clinical practice guidelines.” (1992). Grimshaw, Jeremy, et al. “Developing and implementing clinical practice guidelines.” Quality in Health care 4.1 (1995): 55.

Grimshaw, Jeremy, Martin Eccles, and Ian Russell. “Developing clinically valid practice guidelines.” Journal of evaluation in clinical practice 1.1 (1995): 37–48.

Grol, Richard. “Successes and failures in the implementation of evidence-based guidelines for clinical practice.” Medical care 39.8 (2001): II–46.

Grol, Richard, and Jeremy Grimshaw. “From best evidence to best practice: effective implementation of change in patients' care.” The lancet 362.9391 (2003): 1225–1230.

Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.

Introduction

Most of neurological disorders are network-based diseases. The networks associated with these diseases usually involve spatially disturbed brain regions. Thus efforts were recently evolving from identifying pathological “zones” toward identifying “networks”. In a very recent review, Fornito and colleagues revealed that the identification of alterations in brain networks is one of the most promising paradigms in brain disorders research (Fornito and Bullmore, 2014; Fornito et al., 2015). So far, approaches based on graph theory have characterized the brain networks as sets of nodes connected by edges (Bullmore and Sporns, 2009). Once the nodes (brain regions) and edges (functional/structural connections between regions) are defined from neuroimaging technique, methods based on graph theory may be used to describe the topological properties of the identified networks. This network-based analysis has been largely used to investigate normal (Bressler and Menon, 2010) and pathological (Fornito et al., 2015) brain activities from numerous modalities. It has been used in many clinical applications such as Alzheimer's disease (He et al., 2008; Lo et al., 2010; Mallio et al., 2015; Stam et al., 2007), schizophrenia (Fornito et al., 2011; Liu et al., 2008; van den Heuvel et al., 2013) and autism (Guye et al., 2010; Li et al., 2014). However, a precise tracking of the spatiotemporal dynamics of large-scale pathological networks is still an unsolved issue (Hutchison et al., 2013). The only noninvasive technique that provides the sufficient temporal resolution to track dynamics of brain activity at millisecond scale is the Electro/Magneto encephalogram (EEG/MEG).

Methods

Therefore, the focus of our work is to develop advanced methods to, noninvasively, identify dynamics of functional brain networks using dense EEG signals (256 electrodes). The key advantage of our method, called ‘EEG source connectivity’ (Fig. 1), is the possibility of identifying functional brain networks with excellent temporal (∼ 1 ms) and spatial resolutions (Hassan et al., 2015a; Hassan et al., 2014; Hassan et al., 2015b). The EEG source connectivity involves two main steps: i) the reconstruction of regional time series by solving the EEG inverse problem and ii) the estimation of the functional connectivity using phase synchronization among oscillations present in the time-courses of reconstructed regional time series. The method was originally developed to track dynamics of functional brain networks during short time cognitive activity such as picture naming task ( < 1 second) (Hassan et al., 2015a). In this abstract, we show the first results of applying EEG source connectivity method to two neurological disorders: Epilepsy and Parkinson's disease. Figure 1: Illustrative structure of the proposed method. Dense EEG were used to record data from patients (and healthy control). Structural MRI images will be also recorded, segmented and then anatomically parcellated into a desired number of brain regions (regions of interest). The functional connectivity was then computed giving rise to high-resolution functional brain networks. These networks (graphs) will be finally characterized (quantified) using approach from graph theory to characterize the brain networks (regions and sub regions) involved in the analyzed pathology.

Results

First, in the context of epilepsy, data were recorded from epileptic patients who underwent a full pre-surgical evaluation for drug-resistant partial epilepsy. The patients had a comprehensive evaluation including detailed history and neurological examination, neuropsychological testing, structural MRI, standard 32-channels (Micromed) as well as High-Resolution 256-channels (EGI, Electrical Geodesic Inc.) scalp EEG with video recordings and intracerebral EEG recordings (SEEG). We applied our method to identify epileptogenic networks from the scalp dense-EEG. We also estimated the functional network from depth-EEG. The results revealed a very good matching between networks identified from noninvasive EEG and those obtained using the intra-cerebral electrodes (ground truth). We were able, for the first time from scalp recordings, to identify the network of brain regions (nodes) involved in the generation of the seizure as selected by the epileptologist. Second, we recently applied the EEG source connectivity method to detect alterations in functional networks involved in cognitive impairments. Dense-EEG (128 electrodes) were recorded during task-free paradigm (resting state, eye closed) to produce whole-brain functional connectivity networks in patients with different cognitive phenotypes (Dujardin et al., 2013): 1) cognitively intact patients, 2) patients with mild cognitive impairment and 3) patients with very severe cognitive impairment. Functional connectivity was assessed between each pair of 68 brain regions in 124 patients at different EEG frequency bands. Network measures were realized at global level topology, region-wise connectivity and edge-wise connectivity. Using Network Based Statistics (NBS) (Zalesky et al., 2010), results showed significant differences at alpha band (7–13 Hz) between all groups. The quantification of the networks showed that most of significant alterations (decreased connections) were frontotemporal (functional connections between frontal and temporal lobes) which perfectly match with previous findings of cognitive impairments in patient with neurodegenerative disorders (Pievani et al., 2011).

Discussion

We consider that the identification of pathological brain networks from noninvasive EEG recordings is a topic of great interest. The results of the EEG source connectivity methods on cognitive task (Hassan et al., 2015a) as well on neurological disorders such as epilepsy and Parkinson's disease as presented here, may open new perspectives in the clinical use of such approach. These network dysfunctions may be specific to the clinical syndromes and, in Parkinson's disease and frontotemporal dementia for instance, network disruption may track the pattern of pathological alterations. We speculate that our findings might have practical repercussions for diagnostic purpose, allowing earlier detection of neurodegenerative diseases and tracking of disease development.

Acknowledgment

This work has received a French government support granted to the CominLabs excellence laboratory and managed by the National Research Agency in the “Investing for the Future” program under reference ANR-10-LABX-07-01.

References

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Bullmore, E., Sporns, O., 2009. Complex brain networks: graph theoretical analysis of structural and functional systems. Nature Reviews Neuroscience 10, 186–198.

Dujardin, K., Leentjens, A.F., Langlois, C., Moonen, A.J., Duits, A.A., Carette, A.S., Duhamel, A., 2013. The spectrum of cognitive disorders in Parkinson's disease: A data-driven approach. Movement Disorders 28, 183–189.

Fornito, A., Bullmore, E.T., 2014. Connectomics: a new paradigm for understanding brain disease. European Neuropsychopharmacology.

Fornito, A., Yoon, J., Zalesky, A., Bullmore, E.T., Carter, C.S., 2011. General and specific functional connectivity disturbances in first-episode schizophrenia during cognitive control performance. Biological psychiatry 70, 64–72.

Fornito, A., Zalesky, A., Breakspear, M., 2015. The connectomics of brain disorders. Nature Reviews Neuroscience 16, 159–172.

Guye, M., Bettus, G., Bartolomei, F., Cozzone, P.J., 2010. Graph theoretical analysis of structural and functional connectivity MRI in normal and pathological brain networks. Magnetic Resonance Materials in Physics, Biology and Medicine 23, 409–421.

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Zalesky, A., Fornito, A., Bullmore, E.T., 2010. Network-based statistic: identifying differences in brain networks. NeuroImage 53, 1197–1207.

Background

There has been some anecdotal evidence linking certain infectious pathogens (such as Chlamydia pneumoniae) with stroke. C. pneumoniae infection may be one of several contributing factors for the development of inflammation of blood vessels and atherosclerosis. Furthermore, a number of inflammatory markers (such as plasma CRP, fibrinogen, IL-6, IL-1ra, ESR, WCC) have recently been linked with acute ischemic stroke. However, their value in predicting short and long-term prognosis has been questioned and deemed to be not useful in defining outcomes due to the lack of evidence and cost implications.

Aims

The aims of this study are to (i) investigate the presence of C. pneumoniae in both echogenic and echolucent carotid plaques; and (ii) explore their role in the destabilization of the plaque, leading to embolization and cerebrovascular events.

Methods

(i) Study design: A prospective study involving carotid plaque specimens collected from routine endarterectomy surgical operations. Carotid plaques were removed en bloc during surgery to preserve the entire plaque structure. (ii) Carotid plaque samples: Twenty specimens of carotid atherosclerotic plaques (ten predominantly echolucent, Types I & II and ten predominantly echogenic Types III & IV) were used. The non-invasive ultrasonic appearance (i.e. echogenicity or echolucency) and the quantitative grading of these plaques were determined pre-operatively using duplex scanning aided by computerized measurements according to the criteria adopted by Gray-Weale et al. (1988). (iii) Immunohistochemistry: Levels of C. pneumoniae, Matrix Metalloproteinase-3 (MMP3), Nitric Oxide Synthase (NOS), Superoxide Dismutase (SOD) enzymes in echogenic (fibrous) and echolucent (lipid-laden) atherosclerotic carotid plaques were determined using immuno-histochemical and Western blotting techniques. (iv) Histological methods: Haematoxylin-Eosin stain was performed to stain the slides that will be used for morphological studies by light microscopy. For Laser Scanning Confocal Microscopy (LSCM), slides were stained with saturated aqueous fluorescein for a few minutes and then dehydrated, cleared and mounted in DPX. Carotid plaque specimens were first examined by light microscopy (at magnification 10, 40 times) to characterize the following histological features: necrosis, calcification, fibrous cap, erosion or ulceration, hemorrhage, fibrous tissue and lipid content. Sections from the same specimens were then analyzed using LSCM; slides were viewed with 488 excitation and 515 LP emission. The presence or absence as well as the pattern of distribution of these markers (proteins) were correlated with the histological and preoperative ultrasonic appearances of the plaques.

Results

Ultrasound imaging of carotid plaques revealed 10 with echolucent (lipid-laden/unstable) properties and 10 with echogenic (fibrous/stable) features. Intense immune-reactivity for C pneumoniae was observed in two thirds of echolucent plaques, clustering near endothelial cells of the intimal region, and in the neo-endothelial regions of the specimens. By contrast, low level and scattered C pneumoniae immune-reactivity was observed in echogenic plaques. MMP-3 (stromelysin) level was higher in echolucent than in echogenic plaques. High levels of this enzyme were observed near regions of ulceration, necrosis and in areas where the fibrous cap was thin or torn. Isoforms of NOS enzymes were seen in all carotid plaques irrespective of intra-plaque features however, levels of inducible NOS (NOS-II) were higher in echolucent than in echogenic plaques. Higher levels of immune-reactive SOD were also observed in plaques with higher degree of stenosis (more than 75%–80% measured by ultrasound scan). No direct relationship was evident between the neurological features experienced by the study group and the immuno-histochemical findings. There was however a relationship between the morphology of the plaque and the immuno-histochemical results. Both bright-field microscopy and Laser Scanning Confocal Microscopy (LSCM) were used to generate 3D images of surgically removed carotid plaques. 3D imaging of carotid plaques, using LSCM showed that most specimens were predominately composed of lipid material, comprising necrotic core of amorphous debris and cholesterol clefts, with varying degrees of fibrous tissue present in all plaques. Regions of actual fibrous cap disruption and some ulceration were also seen. Fraying of the fibrous cap was notable with fibrous cap erosion and exposure of underlying necrotic core to lumen. The extent of breaks in the fibrous cap varied with each plaque. Evidence of carotid plaque vulnerability (to rupture) was demonstrated by reduced fibrous cap thickness, a large lipid-necrotic core, and increased inflammatory cells infiltrate with evidence of cracking.

Discussion

Although the findings of this study are suggestive that C. pneumoniae may be involved in the worsening and destabilization of the carotid atherosclerotic plaque, more evidence is needed to ascertain whether C. pneumoniae infection may be an independent, modifiable risk factor for ischemic stroke. Results of this study also showed that MMP3 or its pro-enzyme may play an important role in digesting fibrous tissue of the plaque, leading to thinning or tearing of the fibrous cap. This might result in subsequent destabilization of the plaque, leading to embolization and cerebrovascular events. Furthermore, increased level of SOD expression in carotid plaques might be linked to the degree of stenosis of the affected carotid artery. Enzymes identified in this study may have been influenced by (i) inflammatory conditions prevailing in these plaques (e.g., C. pneumoniae might be responsible for triggering cascades of inflammatory events leading to activation of these enzymes), or (ii) shear stress which might be responsible for stimulation of these enzymes. The 3D geometry of carotid plaque also showed evidence of shearing stresses, resulting from fluid flow which might contribute to the degree of instability of the plaque. This is a complex process which might also include the mechanical activation of enzymes such as matrix metalloproteinases, nitric oxide synthases and Superoxide Dismutase. The behavior of these enzymes in response to fluctuations in the velocity field in both echogenic and echolucent plaques is yet to be investigated. Possible activation of these enzymes by fluid dynamical instabilities and the implications of such activation on the destabilization and progression of atherosclerotic plaques require further investigation. Once the role of 3D geometry and microrheology on plaque stability has been investigated and quantified, more opportunities will be available for translating the results into clinical applications.

Conclusion

There is a need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable. It has been suggested that mechanically induced or flow-sensitive enzymes contain positive and negative shear stress response elements in their encoding genes and can be stimulated or suppressed according to the nature of blood flow. However, it is still not possible to show any definite link between specific enzyme(s) and cerebrovascular events. Such an association is probably multifactorial and mediated by a combination of the degree of stenosis, plaque morphology, dynamic and biological factors. We are currently investigating the link between certain inflammatory markers and cerebral blood flow and cerebral auto-regulation in patients presenting with Transient Ischemic Attack (TIA or mini stroke) for the first time to explore further the role of inflammation in stroke. This study has just started; it involves 200 patients recruited from Qatar and UK. One of its outcomes will be to correlate impaired cerebral auto-regulation with a range of pro-inflammatory and anti-inflammatory markers in first time TIA patients. In doing so, we will study the profile, rather than just the level, of these inflammatory markers in each patient, taking into account the time lapse between onset of symptoms and the collection of blood specimen (for cytokines analysis) from each patient. “Part of this study was made possible by grant NPRP 6 – 565 – 3 – 141 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the author[s].”

Background

Worldwide, cerebrovascular disease (CVD) is the leading disease-related cause of chronic disability; the second most common cause of death and dementia; and a significant burden to patients, caregivers, and healthcare systems. Major risk factors for stroke include diabetes, hypertension, smoking and dyslipidemia which are highly prevalent in the gulf region. Indeed in Qatar, the incidence of cerebrovascular disease is increasing and most patients have major vascular risk factors. In data from the HMC Stroke Registry ∼71% of patients presenting with stroke had diabetes and indeed diabetes was undiagnosed at the time of presentation in 35% of patients. Current imaging techniques to detect early sub-clinical cerebral damage and hence those at risk of stroke includes computerized tomography (CT) and magnetic resonance imaging (MRI). MRI in particular can detect features of small vessel disease such as accumulating silent infarcts, cerebral microbleeds [CMB], periventricular white matter hyperintensity and perivascular spaces which all predict a higher risk of stroke. However, these abnormalities provide a measure of vascular and not neuronal integrity and it is not feasible or practical to undertake MRI simply to identify those at risk of stroke. There is therefore an unmet need for a rapid, non-invasive, sensitive, cost-effective, reproducible and easily imaging biomarker for neuronal damage in subjects at risk of stroke. We have pioneered the technique of corneal confocal microscopy (CCM). Our studies (NIH (5RO1-NS46259-03, R01DK077903-01A1 NINDS), JDRF (17-2008-1031, 8-2008-362)) have shown that corneal confocal microscopy (CCM) can quantify early axonal damage in diabetic neuropathy (1), reliably (2), with high sensitivity and specificity (3). Furthermore, we have shown that subjects with impaired glucose tolerance (IGT) and other vascular risk factors also show corneal nerve loss using CCM (4). Furthermore, these abnormalities improve with an improvement in blood pressure, lipids and HbA1c, all risk factors for stroke (5) and with change in glucose tolerance (6). We have recently published a large normative reference database (7) and developed an automated image analysis algorithm to enable rapid and objective quantification of corneal nerve morphology (8). We therefore hypothesized that CCM may identify corneal nerve loss driven by the common vascular risk factors which may lead to stroke and thereby provide a surrogate for cerebral neuronal loss. Hence, CCM may allow us to identify subjects who may be at high risk of developing stroke and enable risk stratification and targeted risk factor intervention in these individuals.

Aim

We undertook CCM in a cohort of patients admitted to HMC with a clinical and radiological diagnosis of stroke.

Methods

17 stroke patients (age: 53.13 ± 9.09, years) and 15 age-matched healthy control participants (age: 55.30 ± 8.98, years) underwent corneal nerve assessment using CCM (Heidelberg HRT III) to quantify corneal nerve fiber density (CNFD)(no./mm²), corneal nerve fiber branch density (CNFBD)(no./mm²), corneal nerve fiber nerve length (CNFL)(mm/mm²) and corneal nerve fiber tortuosity (TC) and metabolic testing. Stroke patients underwent detailed neurological assessment to define the severity of the stroke using a National Institute of Health Stroke Scale (NIHSS), 3D Carotid Doppler and 3 Tesla MRI. Stroke patients were stratified into different groups for analysis: Normoglycemia (HbA1c <  5.7) (age: 57 ± 8.12, years, n = 5) v dysglycemia (HbA1c ≥  5.7), n = 12); neurological disability: NIHSS <  4 (n = 9) v NIHSS ≥  4 (n = 8), Pathology on MRI: <  10 silent infarcts n = 5 v > 10 silent infarcts (n = 4), patients with periventricular white matter hyperintensity (n = 11) v no periventricular white matter hyperintensity (n = 4).

Results

There was significant difference in HbA1c (8.51 ± 2.35; 5.72 ± 0.36, %, p <  0.001) between stroke patients with dysglycemia and healthy control participants and patients with dysglycemia compared to normoglycemia (8.51 ± 2.35; 5.18 ± 0.35, %, p <  0.009). There was no difference in the total cholesterol (4.96 ± 1.62, 5.34 ± 0.80, mmol/L, p <  0.457), triglycerides (1.32 ± 0.35, 1.64 ± 0.48, mmol/L, p <  0.118), HDL (1.73 ± 1.57, 1.44 ± 0.47, mmol/L, p <  0.527), LDL (2.92 ± 1.42, 3.16 ± 0.69, mmol/L, p <  0.593), hypertension (hypertensive/normal tension, 1/11, 0/15, p <  0.255), height (172.00 ± 4.24, 169.24 ± 9.85, cm, p <  0.708) weight (88.50 ± 13.44, 81.51 ± 13.37, kg, p <  0.500) or BMI (30.00 ± 2.83, 28.47 ± 4.44, Kg/m2, p <  0.649) between stroke patients and control subjects. There was a significant reduction in CNFD (30.47 ± 5.76; 39.50 ± 8.49; p <  0.043) but no change in CNBD (117.50 ± 25.99; 100.54 ± 37.30; p <  0.365), CNFL (29.49 ± 2.65; 27.45 ± 5.56; p <  0.447) or CNFT (19.27 ± 5.07; 15.32 ± 3.94; p <  0.091) in the stroke patients with NGT as compared to the healthy control participants. There was a significant reduction in CNFD (30.17 ± 5.68; 39.06 ± 8.36; p <  0.004) and increase in CNBD (127.71 ± 34.09; 97.80 ± 37.49; p <  0.042) and CNFT (18.57 ± 4.36; 14.93 ± 4.08; p <  0.035) but no change in CNFL (27.06 ± 4.76; 26.97 ± 5.67; p <  0.965) in stroke patients with dysglycemia as compared to the healthy control participants. There was no difference in CNFD (30.17 ± 5.68; 30.47 ± 5.76; p <  0.921), CNBD (127.71 ± 34.09; 117.50 ± 25.99; p <  0.559), CNFT (18.57 ± 4.36; 19.27 ± 5.07; p <  0.777) or CNFL (27.06 ± 4.76; 29.49 ± 2.65; p <  0.306) between stroke patients with and without dysglycemia. There was no significant difference in CNFD (30.36 ± 5.26; 30.14 ± 6.17; p <  0.941), CNBD (123.46 ± 32.58; 126.12 ± 32.37; p <  0.869), CNFT (19.26 ± 5.30; 18.22 ± 3.48; p <  0.645) or CNFL (27.05 ± 4.38; 28.60 ± 4.38; p <  0.479) in stroke patients with NIHSS <  4 compared to NIHSS ≥  4. There was no significant difference in CNFD (30.52 ± 5.27; 32.16 ± 7.73; p <  0.715), CNBD (120.00 ± 39.76; 134.96 ± 43.98; p <  0.609), CNFT (15.71 ± 2.55; 17.61 ± 4.59; p <  0.453) or CNFL (26.54 ± 5.43; 28.43 ± 4.90; p <  0.606) in stroke patients with silent infarcts <  10 vs ≥  10. There was no significant difference in CNFD (30.18 ± 5.15; 30.08 ± 6.00; p <  0.973), CNBD (127.20 ± 28.08; 121.35 ± 45.78; p <  0.766), CNFT (20.36 ± 4.53; 15.15 ± 2.56; p <  0.051) or CNFL (28.91 ± 2.95; 25.50 ± 5.67; p <  0.144) in stroke patients with white matter ischemia compared to stroke patients without white matter ischemia.

Conclusion

Corneal confocal microscopy identifies greater corneal nerve fibre abnormalities in patients admitted with stroke, which is present in patients with and without dysglycemia. It may therefore reflect the consequence of vascular risk factors independent of glycemic status. However, the extent of corneal nerve fibre pathology does not differ in relation to the severity of neurological disability or extent of pathology on MRI. Larger, longitudinal follow up studies are required to determine the prognostic ability and utility of CCM as a surrogate imaging biomarker for stratifying patients at risk of stroke.

References

1. Petropoulos IN, Alam U, Fadavi H, Asghar O, Green P, Ponirakis G, et al. Corneal nerve loss detected with corneal confocal microscopy is symmetrical and related to the severity of diabetic polyneuropathy. Diabetes care. 2013;36(11):3646–51.

2. Petropoulos IN, Manzoor T, Morgan P, Fadavi H, Asghar O, Alam U, et al. Repeatability of in vivo corneal confocal microscopy to quantify corneal nerve morphology. Cornea. 2013;32(5):e83–e9.

3. Petropoulos IN, Alam U, Fadavi H, Marshall A, Asghar O, Dabbah MA, et al. Rapid automated diagnosis of diabetic peripheral neuropathy with in vivo corneal confocal microscopy. Investigative ophthalmology & visual science. 2014;55(4):2071–8.

4. Asghar O, Petropoulos IN, Alam U, Jones W, Jeziorska M, Marshall A, et al. Corneal confocal microscopy detects neuropathy in subjects with impaired glucose tolerance. Diabetes care. 2014;37(9):2643–6.

5. Tavakoli M, Kallinikos P, Iqbal A, Herbert A, Fadavi H, Efron N, et al. Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. Diabetic medicine: a journal of the British Diabetic Association. 2011;28(10):1261–7.

6. Azmi S, Ferdousi M, Petropoulos IN, Ponirakis G, Alam U, Fadavi H, et al. Corneal Confocal Microscopy Identifies Small-Fiber Neuropathy in Subjects With Impaired Glucose Tolerance Who Develop Type 2 Diabetes. Diabetes care. 2015;38(8):1502–8.

7. Tavakoli M, Ferdousi M, Petropoulos IN, Morris J, Pritchard N, Zhivov A, et al. Normative values for corneal nerve morphology assessed using corneal confocal microscopy: A multinational normative data set. Diabetes care. 2015;38(5):838–43.

8. Dabbah M, Graham J, Petropoulos I, Tavakoli M, Malik R. Automatic analysis of diabetic peripheral neuropathy using multi-scale quantitative morphology of nerve fibres in corneal confocal microscopy imaging. Medical image analysis. 2011;15(5):738–47.

Background

Road Traffic Injuries (RTIs) are the leading cause of death in Qatar1, but the epidemiology of these injuries in the infant (0–1 years) and toddler (2–4 years) [IAT] population has not been reported. This study aimed to document and analyze the epidemiology of RTIs in IATs of Qatar and make recommendations for targeted and age-specific recommendations to improve road safety for this population.

Methods

A retrospective analysis of data on child RTIs and RTI deaths admitted to the Hamad Medical Corporation [HMC] Trauma Center or Mortuary in Doha, Qatar, from 2008–2014, was conducted. Temporal trends in the nature of RTI's and RTI deaths, road user types and mortality rates were calculated and analyzed for the years that age-group population size was available.

Results

There were 189 severe RTIs and 15 RTI deaths during the study period. Males made up 80% of the injured and 60% of fatalities. The average age of the injured was 3 years and for fatalities was 2.8 years. Pedestrians [53%] and unrestrained passengers [43%] made up the majority of the injured. There have been steady declines in severe RTI and RTI death rates from 2008 to 2012 [25.9 to 22.2 RTIs per 100,000 and 0.9 to 4.0 RTI deaths per 100,000], but these rates are still two times higher than those for IAT in other high-income countries [HICs] like the United States and Germany2.

Conclusions

RTIs and RTI death rates in IAT in Qatar have been declining but proven programs for improved safety of child pedestrians and passengers must be implemented if it is to approximate those in other HICs. This includes programs around child restraint use and improving pedestrian environments and practices/supervision for IAT.

Background

Patient counseling is a term used in the field of pharmacy to describe the communication that takes place between a pharmacist and a patient in regards to his or her medication therapy. Patient counseling is deemed to be the professional responsibility of pharmacists. Patients require education on the proper use of medications to improve therapeutic outcomes and avoid treatment failure. 1 Pharmacists are in an excellent position to provide this type of education and counseling to patients, and are readily accessible to the public as a first point of contact for patients with medical inquiries. 2 Several studies have shown that counseling provided by pharmacists can prevent medication related problems, improve patient compliance with medications, and contribute to positive therapeutic outcomes. 3, 4 Patient counseling practices among Arab countries are not clearly identified in literature or mandated by governing authorities or agencies. The reason may be the low expectation by the public of the pharmacist who for so long had confined their role to filling and selling medications. Many studies have identified various aspects such as the busyness of the pharmacies and the education, age, and attitude of the pharmacists as barriers for the provision of counseling. 4 The assessment of these barriers in addition to patient characteristics will assist in further evaluating and understanding pharmacist's counseling practices in community pharmacies. Since patient counseling is an essential element of patient care, investigating the current state of patient counseling practices in Qatar is necessary. One of the methods that help to gain an accurate assessment of pharmacist's counseling practices is to observe pharmacists in their natural environment without prior knowledge to the minimize the Hawthorne effect. 5 Therefore, to lessen the potential Hawthorne effect (change in someone's behavior due to the knowledge that s/he is being observed), this research project will utilize simulated patients (also known as mystery shopper) to examine the counseling practices of community pharmacists in Qatar. The objectives of this research project are to evaluate the quality of patient counseling practices by community pharmacists in Qatar and to determine if an association exists between the content of patient counseling and the characteristics of community pharmacists, patients, and community pharmacies.

Methods

This is an observational cross sectional study to evaluate the community pharmacist's counseling practices in Qatar using simulated patients. Two patient scenarios were created to assess the counseling provided by the pharmacist to the patients with diabetes and asthma. Two simulated patients of Arab decent fluent in Arabic and two simulated patients of non-Arab decent fluent in English were recruited for this study. Each simulated patient was randomly assigned to either the diabetes or asthma scenario. Each simulated patient entered the community pharmacy and observed the number of customers to assess for busyness of the pharmacy. The simulated patient then asked to speak to the pharmacist and requested their assigned medication. Prompting questions were initiated by the patient after each pharmacist was provided with the opportunity to counseling the patient. The simulated patient then purchased the medication to authenticate the interaction and left the pharmacy. Immediately following the interaction, the simulated patient completed a form that assessed the pharmacist's counseling ability. Once completed, the simulated patient returned to the same the pharmacist to explain the purpose of the study. Consent was obtained from the pharmacist and a survey written in English or Arabic was administered only to those who provided consent. The written survey included questions related to pharmacist demographics (gender, age, native language, pharmacy degree received, country of pharmacy education, graduation year, and practice experience), pharmacist's perception on patient counseling (barriers and importance), and pharmacy characteristics (number of staff, availability of a counseling area, and busyness of the pharmacy).

Results

One hundred and twenty-nine pharmacists consented to participate in this study. The majority of pharmacists were young male pharmacists with at least 2 years of practice experience in Qatar. Most pharmacists have received their pharmacy degree from India and Egypt. Most of the community pharmacies had one pharmacist per shift and no private patient counseling area. In the diabetes scenario (n = 64), the male simulated patient received significantly better counseling from the pharmacist when compared to the female simulated patient. The pharmacist's knowledge regarding diabetes was considered poor with over 60% of pharmacists referring the patient to the physician. For the asthma scenario (n = 65), the male simulated patient received significantly better counseling from the pharmacist compared to the female simulated patients. Only 6% of the pharmacists were able to properly demonstrate the correct inhaler technique to patients. However, more than 50% of the pharmacists were are able educate the simulated patient on the role of the asthma medications. Overall, the pharmacist's gender, age, native language, pharmacy degree, country of pharmacy education, and years of practice experience did not seem to have an effect on the quality of counseling provided to patients. Better counseling was provided by the community pharmacists to the simulated patients when the pharmacy was not busy. Not having a private counseling area in the pharmacy was a significant barrier leading to lower counseling practices among community pharmacists. Some other barriers related to patient counseling identified by pharmacist include time, no access to patient medication records, and patients not interested in the counseling provided by the pharmacist.

Conclusion

The findings from this study suggest the current counseling practices among community pharmacists in Qatar is substandard. Development of continuing education programs for practicing pharmacists to enhance their communication skills and knowledge to improve counseling practices is strongly advocated. These educational programs will need to be tailored to meet the needs of the pharmacists to address the fundamental communication skills that each pharmacist should possess for practice. In addition, pharmacy laws and regulations need to be updated to meet the changes in the pharmacy profession from dispensing to a patient centered care focus. Community pharmacies need to be equipped with a counseling area, mandatory drug information resources, and the ability to maintain medication profiles for each patient. Pharmacy regulations should also consider mandating all pharmacists to provide counseling for each patient.

References

Resnik DB et al. The conflict between ethics and business in community pharmacy: what about patient counseling? Journal of Business Ethics 2000;28:179–186.

Taylor J. OTC counseling: review of pharmacist performance. Medscape Pharmacists [serial online] 2001 Aug [cited 2009 Dec 21]; 2(2). Available from URL: http://www.medscape.com.

American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Hosp Phar 1997;54:431–4.

Svarstad BL, Bultman DC, Mount JK. Patient counseling provided in community pharmacies: Effects of state regulation, pharmacist age, and busyness. J Am Pharm Assoc 2004;44:22–29.

Puspitasari HP, et al. A review of counseling practices on prescription medicines in community pharmacies. Res Soc Admin Pharm 2009;5:197–210.

Background

Peripheral intravenous catheters (PIVs) are invasive catheters that may endure risks of clinical complications affecting health care outcomes and patient satisfaction. Patients requiring frequent PIV insertions due to an extended length of stay of one week or more would undergo multiple PIV pricks during their course of hospitalization. The combined factors of multiple PIV insertions and extended hospital stay make chronic patients especially at a higher risk for phlebitis and subsequently infection No studies in the literature review discussed the phlebitis rates and risks when toxic medications were infused using a peripheral catheter. The aim of this study was to determine the pattern and incidence of PIV complications among patients admitted to a tertiary care military health care facility in central region of Kingdom of Saudi Arabia. This was achieved through the following objectives: (1) Estimation of the cumulative incidence and incidence density for major PIV complications (catheter occlusion, dislodgment, infiltration, and phlebitis) during a period of 1 month, (2) Identification of significant risk factors for PIV complications such as patient related characteristics (gender, age, co-morbidities) or catheter related characteristics (catheter size, dressing, site of insertion, type of infusion, dwell times), and (3) Determination of the time line for the occurrence of various PIV complications.

Methods

An observational prospective cohort study investigated PIV pattern and complications among 359 adults with 842 PIV catheters, admitted to various wards at KAMC with a total of 2505 catheter days. Data on patient characteristics (age, gender, and health complaints) and PIV characteristics (Catheter size, duration, insertion site, nature of PIV infusate, and type of dressing) was collected. PIV catheters-related clinical outcomes (Pain, Phlebitis, leaking and others) were recorded on 12–hour intervals, using the Visual Inspection Phlebitis (VIP) scale. Phlebitis was defined as the presence of two or more signs of pain, tenderness, warmth, erythema, swelling, or a palpable cord, with or without purulent drainage from the catheter insertion site. Infusion Phlebitis scale can range from (0), indicating no symptoms of phlebitis, to (5), with signs of purulent drainage, redness, and a palpable cord greater than 3 inches. Infiltration was defined as permeation of intravenous fluid into the interstitial compartment, causing swelling of the tissue around the site of the catheter. All PIV catheters were changed for a score of 2 or more, determined by the presence of a cold/warmth skin region around the insertion site, pain, redness, and/or edema extending from 1 to 2 inches above the PIV site. Incidence density (DI) and cumulative incidence (CI) of complications were calculated. Regression analyses were applied to determine the significant predictors of complications. Significance limits were set at P < 0.05.

Results

One half of all patients were 65 years and above, with no significant sex difference. The majority of patients (76.88%) had medical chief admission complaints, whereas (51.53%) were admitted in cardiac wards. Complicated catheters were found in 141(39.3%) patients, with 273 complications (32.4/100 catheters), 190 complicated catheters (CI =  22.56/100 catheters & DI =  75.84/1000 catheter days). Phlebitis ranked first among complications, with a CI of (17.58%), followed by pain (7.60%), leaking (3.92%) and dislodgement (2.38%), and extravasations and occlusion (0.48% each). When the analysis was based on failure per 1000 device days, and after adjusting for all possible confounders, female gender remained as a significant predictor of higher incidence of overall complications (p = 0.00001), phlebitis (p = 0.000003) as well as other complications (p = 0.0.0003). Insertion in fore/upper arm was a significant predictor of both phlebitis (0.024) and other complications (0.049), while medical infusion was a significant predictor of phlebitis (0.02) and overall complications (0.006).

Conclusion

Incidence of complications in this study is comparable with figures in previous studies, however, better insertion techniques may be sought to lower the incidences of PIV complications, thus extending their onset beyond day 3. Changing catheters is recommended when clinically indicated rather than routinely post 72 hours of insertion which in return minimizes the frequency of insertions per patient and subsequently complications.

Network querying algorithms provide computational means to identify conserved network modules in large-scale biological networks that are similar to known functional modules, such as pathways or molecular complexes. Two main challenges for network querying algorithms are the high computational complexity of detecting potential isomorphisms between graphs and ensuring the biological significance of the query results. In this work, we propose a novel network querying algorithm that can enhance the biological significance of the query results through the use of a context-sensitive random walk (CSRW) model. In order to identify conserved subnetwork regions in the target network that are similar to a given query network, the algorithm estimates the node correspondence between the query and the target networks based on the CSRW model. Inspired by the pair hidden Markov model (pair-HMM) that has been widely used in comparative sequence analysis, the CSRW model can effectively capture the similarities between graphs by explicitly accounting for potentially inserted and deleted network nodes. Based on the estimated CSRW node correspondence scores, our algorithm first identifies high-scoring regions (referred to as the seed networks) in the target network that bear considerable similarity with (part of) the query. The seed networks are further extended by maximally minimizing the network conductance, which can effectively identify nearby nodes (e.g., proteins) that may share similar functions with other nodes in the current seed. Finally, the query result is pruned by removing irrelevant nodes based on an extension reward score, thereby improving the consistency of the final query result. Through extensive numerical simulations based on 938 real biological complexes, we show that our proposed algorithm yields accurate query results with enhanced biological significance.

References

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Sharan, R., Ulitsky, I., Shamir, R.: Network-based prediction of protein function. Mol. Syst. Biol. 3, 88 (2007).

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Jeong, H., Yoon, B.-J.: Effective Estimation of node-to-node correspondence between different graphs. IEEE Signal Processing Letters 22, 661–665 (2015).

Jeong, H., Yoon,B.-J.: Accurate multiple network alignment through context-sensitive random walk. BMC Systems Biology 9, S7 (2015).

Kelley, B.P., Yuan, B., Lewitter, F., Sharan, R., Stockwell, B.R., Ideker, T.: Path BLAST: a tool for alignment of protein interaction networks. Nucleic Acids Res. 32, W83–W88 (2004).

Shlomi, T., Segal, D., Ruppin, E., Sharan, R.: QPath: a method for querying pathways in a protein- protein interaction network. BMC Bioinformatics 7, 199 (2006).

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Introduction

The frequent outbreaks of novel or emerging infectious diseases are alarming. There is a need for urgent and appropriate intervention that can be adapted quickly for such diseases. Middle East respiratory syndrome coronavirus (MERS-CoV) previously known as novel CoV is a viral infection that causes severe acute respiratory illness. MERS-CoV is a respiratory pathogen and contagious that is contracted via close contact with infected subject. It appears to have been transmitted from camels to humans, recent studies have revealed an association among the virus found in humans and that found in camels (Drosten, et al., 2014). The epidemic that started in 2012 in the Kingdom of Saudi Arabia has spread to many countries, mostly in the Middle East and North Africa, and more recently South Korea. The new epidemic started when the virus crossed from an infected individual who had recently traveled to the Middle East and subsequently began spreading between people via direct contact while in some cases the infection crossed from animal to human. This has exposed the general populace and especially the healthcare workers to greater risk. Similar to the reaction during other infection outbreaks, such as SARS and Ebola virus, many countries have issued travel restrictions and advisories to the affected countries because of fear of international spread of the disease. The rate at which the outbreak is evolving cannot be overemphasized and the geographical extension of its spread is widening. Neighborhoods constitute a key determinant of socioeconomic disparities and health habits, and therefore there is a high risk that people at geographical proximity to the infection are particularly vulnerable. Additionally, people with preexisting chronic medical conditions are more prone to being infected by the illness or developing a severe case resulting in fatality (Assiri, et al., 2013). Strong links between healthcare facilities and the outbreak of the disease has been found in Jeddah, where the majority of patients were in contact with other patients or health care facilities (Oboho, et al., 2015). Elsewhere, the transmission of MERS-CoV in household contacts revealed that an outcome of approximately 5% as the rate of secondary transmission occurred at home (Assiri, et al., 2013). In spite of the many research conducted on MERS-CoV, very few have investigated the effect of ecological factors on the transmission of the disease. Moreover, very little is known on the possibility of airborne transmission of the virus and discussion is still on going on this issue. Airborne transmission of the pathogen may also occur through dust and movement of people, equipment and animals within infected countries which may contribute to the spread of the virus. Additionally, the effect of alternating temperature highs and lows may imply seasonality that could alter the transmission and survivability of the virus. Objectives During infectious disease outbreaks, transmission of disease may form networks of infected individuals because of the way virus crossed from infected individual to susceptible individual. See figure 1a for a subset of the infection network for MERS disease used in this study. The infected individuals may form network of individuals connected by source of infection (contact) as direct or indirection connection. The study intends to (1) explore and investigate the relationship between the intensity of the disease in a given region and environmental variables, (2) We sought to evaluate the risk factors of and trends in mortality as a result of MERS-CoV infection in a large cohort of patients between June 6, 2012 and May 19, 2015. Use covariate adjustment to correctly assess the disease-risk factor associated with the survival outcome, (3) It also aims to understand the dynamic pattern of the disease over different temporal and spatial scales. A functional spatial time series method of estimating the death rate in the outbreaks will be formulated. Spatial time series analysis of disease outbreaks are versatile tools for studying and understanding transmission and spread of a disease and may be useful in the different frontiers of its upsurge and in the possibility of its containment or eradication. And lastly, (3) a flexible dependence model that reflect the relationship among infected individuals in the same network.

Figure 1: (Top) Network for subset of the MERS data. The numbers represent the identification number of the patient while the arrow represents the infection direction. (Bottom) Showing the patients that were infected by patient 27.

Figure 2: Number of patients infected by each main contact (patient ID). Preliminary Exploratory Analysis This study is based on a retrospective analysis of the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in the Arabian Peninsula between June 6, 2012 and May 19, 2015.

Table 1 presents the summary of data used in this study. Of the 958 cases recorded during the study period more than 90% (866) of the disease incidence occurred in the Kingdom of Saudi Arabia while Kuwait has the least incidence of 3. Seventeen percent of those infected with MERS disease were heath care worker. The fatality for the disease is about 0.35 among the total population. The mean age of the infected persons was 50.22 ± 18.37 years, with large percentage (55%) reported that they had some kind of comorbidity. Spatial analyses of disease outbreaks are versatile tools for studying and understanding transmission and spread of a disease.

Figure 3 shows the spread of MERS disease across the Arabian Peninsula within the study period. Majority of the disease incidence occurred in KSA and closed countries.

Table 1. Summary of the MERS data Country No. of Patients No. of Male/female No. with comorbidity Age at incidence % of HCW % fatal Mean/median mean SD KSA 866 565/284 469 49.66/50 49.66 ± 18.54 153 302 UAE 70 50/18 49 54/56 54 ± 15.33 9 30 Qatar 12 9/3 5 59.1/58 59.1 ± 15.99 1 3 Kuwait 3 1/2 3 54/43 54 ± 27.22 0 1 Oman 7 7/0 2 56.28/60 56.28 ± 17.54 1 3 Total 958 632/307 528 50.22/50.5 50.22 ± 18.37 164 339

Hearing loss is a common sensory deficit that can affect all levels of society. The two age groups where hearing loss is most likely to be identified is in newborns and in the elderly. Newborn screens have been very effective in finding individuals affected by hearing loss. The general hearing loss incidence in newborns is 0.2%, with roughly 50% of all cases being hereditary. A recent study in Qatar found that the incidence of hearing loss in newborns was as high as 5.2% 1, 25 times higher than the general global incidence. Much of this increase can be attributed to hereditary forms of hearing loss, as the rate of consanguinity in Qatar is high 1,2. The elderly are the other population group where hearing loss is often identified. Globally, the hearing loss incidence for people over 50 is around 40%, with men showing a higher incidence than women 3,4. In Qatar, 66% of the Qatari population over the age of 50 suffers hearing loss, compared to ∼35% for the non-Qatari populations 5. The gender distribution of hearing loss within the Qatari population is also different from the global trend, with the incidence being 75% for women and 59% percent for men5. Therefore, the incidence of hearing loss is dramatically higher in the Qatari population than it is globally, and presents an important health issue that should be addressed. We have previously shown that the outer nuclear membrane protein Nesprin 4 is essential for hearing in humans and in mice. Nesprin 4 is expressed in the sensory outer hair cells (OHCs) of the cochlea and is important for the proper nuclear positioning and survival of these cells. In the absence of functional Nesprin 4, the nuclei are apically mispositioned and the OHCs die. OHCs act as cochlear amplifiers, augmenting sound signals by up to 100-fold6. This amplification is achieved, at least in part, through electromotility, a somatic cell motility that causes cell length changes in response to depolarization or hyperpolarization of the cell. Electromotility is mediated by SLC26A5/prestin, a membrane protein enriched in the lateral membranes of OHCs7. Prestin-mediated electromotility develops postnatally in mice, with full activity occurring at 12–14 days after birth. We observed that the majority of OHCs in mice lacking Nesprin 4 die around this time and predicted that the mislocalized nucleus was incompatible with electromotility. To test this hypothesis we generated double-null mice for Nesprin 4 and prestin and examined the fate of OHCs in these animals. We found that loss of prestin rescues the loss of OHCs in Nesprin 4-null animals, indicating that while a mispositioned nucleus is incompatible with electromotility, it does not affect cell viability independent of mechanical stress. Others have previously shown that animals heterozygous for the prestin allele exhibit a reduced electromotility. We predicted that a reduction in electromotility should yield a partial rescue of OHCs in Nesprin 4-null animals. When we examine the Nesprin 4-null/prestin heterozygous animals, we did indeed observe a partial rescue of OHCs. Together, these results indicate that proper nuclear positioning mediated by Nesprin 4 in OHCs is essential for these cells to survive the mechanical stress of electromotility.

References

1. Bener, A., EIHakeem, A. A. M. & Abdulhadi, K. Is there any association between consanguinity and hearing loss. Int J Pediatr Otorhinolaryngol 69, 327–333 (2005).

2. Girotto, G. et al. Consanguinity and Hereditary Hearing Loss in Qatar. Hum Hered 77, 175–182 (2014).

3. Roberts, A. Sensorineural Hearing Loss. Synopsis of Causation, Ministry of Defence 1–30 (2008).

4. Action on Hearing Loss. at < http://www.actiononhearingloss.org.uk/your-hearing/about-deafness-and-hearing-loss/statistics.aspx>

5. Bener, A., Salahaldin, A. H., Darwish, S. M., Al-Hamaq, A. & Gansan, L. Association between hearing loss and type 2 diabetes mellitus in elderly people in a newly developed society. Biomed Res 19, 187–195 (2008).

6. Liberman, M. C. et al. Prestin is required for electromotility of the outer hair cell and for the cochlear amplifier. Nature 419, 300–304 (2002).

7. Dallos, P. & Fakler, B. PRESTIN, A NEW TYPE OF MOTOR PROTEIN. Nat Rev Mol Cell Biol 3, 104–111 (2002).

The aortic arch and its branches form during the third week of embryogenesis, which involves a complex process. Abnormalities of the arch branching pattern arise by persistence of segments of arches that normally disappear or the disappearance of segments of arches that normally remain, or both [1]. The most common human aortic arch branching pattern has the innominate artery, the left common carotid artery and the left subclavian artery all as separate branches (Fig. 1). The most common variant branching pattern involves the left common carotid artery arising in a common origin with the innominate artery (Fig. 2), and the next most common the similar left common carotid artery originating from the innominate artery itself (Fig. 3). A true bovine arch involves a single common brachiocephalic trunk arising from the arch which then splits into the right subclavian artery, a bicarotid trunk and a left subclavian artery (Fig. 4), and is actually extremely uncommon in humans [2]. Originally the variations of the arch branching patterns were made by post-mortem studies [3], but, more recently large imaging studies have been performed [4,5] confirming that approximately 70% of people have a normal branching pattern with 20% having a common origin of the innominate artery and left common carotid artery (as in Fig. 2) [4,5], but these studies were performed without reference to the anatomy of the aortic valve (bicuspid versus tricuspid). Bicuspid aortic valve (BAV) is the commonest congenital cardiac malformation with 1–2% of the population being affected [6], and is associated with other cardiac anomalies, especially coarctation [6]. BAV is also associated with dilatation of the ascending aorta which is thought to be related to intrinsic pathological properties of the aortic wall and altered flow dynamics through the abnormal valve [7,8], with increased risk of aortic dissection compared to tricuspid aortic valve (TAV) patients [9,10]. As BAV is a common congenital anomaly and the variants of the aortic branching pattern are developmental in origin we decided to see if the frequency of arch variants in BAV and TAV patients differed, as this has not previously been looked at. We examined Computerised Tomographic aortograms (CT) and echocardiograms of BAV and TAV patients to assess the aortic arch branching pattern and any possible association with the valve morphology.

Materials and Methods

An established BAV patient database at the Heart Hospital, Doha, Qatar was used to retrieve patients. All BAV patients with CT scans of the aorta were examined. During the same period (September 2011–2014) 200 CT aortograms were performed in the Radiology department of the Heart Hospital and from these TAV patients were selected for comparison. Basic demographic data were collected for all the patients. This study was approved by the Institutional Review Board with waiver of consent as all tests had been preformed previously. Aortic images, obtained with Multidetector CT aortic angiography (MDCT) using dual source 128 multi slice CT, were further processed by the reporting consultant radiologist for three-dimensional reconstructions to obtain volume rendered images and maximum intensity projections for assessment of the aortic arch branching variation. Echocardiograms of both the BAV and TAV patients were examined to confirm valve anatomy, (images assessed by an echocardiography trained cardiologist, not just reading reports).

Results

Results of the 129 BAV patients in the BAV database 28 had ‘readable’ (branch pattern could be clearly discerned) CT scans. Fifty-seven (double the number of BAV patients) CT aortograms were selected from the radiology archive (first 57 that were ‘readable’ from September 2011 that had also undergone echocardiography). The sex and ethnic distributions are shown in Tables 1 and 2. Eighty-five patients’ images were assessed with 28 BAV and 57 TAV. All 85 patients had their echocardiographic images re-examined to verify BAV or TAV morphology. For BAV the aortic branching patterns were: 86% normal (24/28) and 14% abnormal branching patterns (4/28), and for TAV: 70% normal (40/57) and 30% abnormal branching patterns (17/57). The BAV patients abnormal patterns were all the left common carotid artery common origin with innominate artery (as in Fig. 2), whereas the TAV patients had 16 of the type left common carotid artery common origin with innominate artery (as in Fig. 2) and one left common carotid arising from the innominate artery (as in Fig. 3). There were no true bovine variants in our group. Other anomalies found in our group include 1 coarctation (BAV patient) and 1 dissection (BAV patient). The valve morphology was discernable in 42 (49%) of the 85 CT scans.

Discussion/Conclusions

Bicuspid aortic valve has previously been quoted as having a related aortopathy, but is this embryological or functional (related to intrinsic wall properties) in origin? [7,8]. If in fact BAV patients have fewer arch variations it may support the idea that the aortopathy is related to functional changes in the wall rather than embryological origins (excluding coarctation). In our group it does not appear to affect the embryological development of the branches of the aortic arch and we actually appear to have fewer arch variants in the BAV group. Although this is a small study our TAV group had similar percentages of normal (70%) and abnormal (30%) arch variants as the reported literature [1,2,4,5]. Our BAV group is small and we will expand it further in the future but the results at this stage suggest no increase, in fact a possible decrease in arch variants compared to the TAV patients. Despite this it would not be possible to exclude an embryologically based pathological change to the aorta in BAV patients. Some racial variations have been reported but these studies were done many years ago and involved post-mortem analysis [3], and suggested that arch branching variants were more common in African Americans (about 50%) [3], but these studies would be difficult to repeat due to widespread racial mixing nowadays and could only be looked at in isolated communities with a single racial group. In Qatar 60% of the population is originally from the Asian Indian Subcontinent so there may in fact be a greater prevalence of Bicuspid valves in the MENA region patients and also Arch Variants appear to be more common in the MENA region patients. The two large radiological studies that have looked at the aortic arch anatomy showed that approximately 70% of patients had normal configuration of the arch vessels and 20% had a common origin of the innominate artery and left common carotid artery [7,8], but these studies were performed without reference to the anatomy of the aortic valve. This is the first study in the literature to look at the arch branching variants when consideration of the aortic valve morphology (BAV versus TAV) is taken into account. Although there is little physiological significance in the majority of patients, these variations may have an impact if endovascular or surgical procedures are planned in the region of the arch. BAV patients have been shown to have ascending and arch dilatation [7–11] and are more likely to require intervention than TAV patients (due to concomitant valve dysfunction), so knowing the arch anatomy will become more important. We will continue to expand our numbers as this is a relatively small study.

Acknowledgement

Mr Mohammed Abdulsamad for diagrams. Conflicts of interest, disclosures: none declared by any author.

Table 1: Sex and Ethnicity for tricuspid valves. Tricuspid Male Female Ethnicity Numbers Normal (n = 40) 36 4 Africa 0 Asian Indian Subcontinent 15 Asian Oriental 3 Caucasian 3 MENA Region 19 Arch Variant (n = 17) 15 2 Africa 1 Asian Indian Subcontinent 5 Asian Oriental 2 Caucasian 0 MENA Region 9

Table 2: Sex and Ethnicity for bicuspid valves. Bicuspid Male Female Ethnicity Numbers Normal (n = 24) 24 0 Africa 1 Asian Indian Subcontinent 7 Asian Oriental 3 MENA Region 13 Arch Variant (n = 4) 4 0 Africa Asian Indian Subcontinent 2 Asian Oriental MENA Region 2

References

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[2] Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS. Bovine aortic arch variant in humans: clarification of a common misnomer. American Journal of Neuroradiol 2006;27:1541–42.

[3] De Garis CF, Black IH, Riemenschneider EA. Patterns of the aortic arch in American white and negro stocks, with comparative notes on certain other mammals. J Anat 1933;67:599–618.

[4] Jakanani GC, Adair W. Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clinical Radiology 2010;65:481–487.

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[7] Mahadevia R, Barker AJ, Schnell S, Entezari P, Kansal P, Fedak PW, Malaisrie SC, McCarthy P, Collins J, Carr J, Markl M. Bicuspid aortic cusp fusion morphology alters aortic three-dimensional outflow patterns, wall shear stress, and expression or aortopathy. Circ 2014;129(6):673–82.

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Figure Legends

Figure 1: the most common human aortic arch branching pattern with the innominate artery (IA), the left common carotid artery (LCA) and the left subclavian artery (LSA) arising as separate branches from the arch. Other branches shown are right subclavian artery (RSA), right common carotid artery (RCA), right vertebral artery (RVA) and left vertebral artery (LVA).

Figure 2: the left common carotid artery arising from a common origin with the innominate artery. Incidental finding on the central image - left vertebral artery arising from the arch, directly after the common origin vessel.

Figure 3: the left common carotid artery originating from the innominate artery itself.

Figure 4: the true bovine arch involving a single common brachiocephalic trunk arising from the arch which then splits into the right subclavian, a bicarotid trunk and a left subclavian artery.

Table 1: Sex and Ethnicity for tricuspid valves.

Table 2: Sex and Ethnicity for bicuspid valves.

Background & Objectives

Epilepsy is a neurological disorder that is associated with repeated episodes of seizures. In epilepsy, the normal pattern of neural activity is disturbed, causing the patient to experience various symptoms ranging from staring blanking for a few seconds to long periods of vigorous convulsions and unconsciousness. In many patients, the injuries they endure are a direct result of the confusion, loss of muscle control, and unconsciousness caused by the seizure. These injuries include fractures, head injuries, and burns. In an attempt to mitigate such risks, extensive research has been dedicated to developing a device that can detect or predict the onset of seizure episodes. The clinical behavior of an epileptic seizure is preceded and then accompanied by electroencephalographic alterations. As a result, electroencephalography (EEG) is the most common tool to measure these alterations. EEG measures the voltage fluctuations resulting from ionic current flows within the neurons of the brain. Research has demonstrated that epileptic seizures are caused by disturbances in the electrical activity between neurons in the brain. In the healthy brain, neurons fire in an asynchronous manner, relaying messages from one neural network to the other. However, in the epileptic brain, the complex interactions between neuronal networks are characterized by the evolution of synchronization between them. Excessive neuronal synchronization leads to a hyper-synchronous state that triggers the onset of a seizure. Extensive research has been dedicated to the detection of the earliest signs of electrographic changes associated with a seizure using either scalp or inter-cranial EEG. A device that has the ability to detect the electrographic onset of a seizure (seizure onset detector) will enable epileptic patients to lead a more normal and secure life, and will help them to avoid injuries due to the sudden nature of the seizure. At its most basic form, a seizure onset detector (SOD) is comprised of two major components, the feature extraction unit and the classification unit. In the feature extraction unit, relevant features are extracted from the multi-channel EEG and are fed into a classification unit where the features are classified as seizure or non-seizure in nature.

Methods

In this research, we present a novel patient-specific epileptic seizure onset detector using scalp EEG where we aim to exploit the benefits of integrating EEG channel selection and feature enhancement to improve the SOD's performance. Hence, we propose a detector architecture that is composed of five stages, namely, EEG channel selection, feature enhancement, spatial averaging, feature extraction, and classification. Assuming the collected scalp-EEG data contains M-channels, the channel selection stage chooses the N EEG channels that contain the most relevant electrographic seizure information. This stage is important because it reduces the detector's computational burden and omits the need to evaluate channels that have invaluable information, which may deterioted the detector's performance. The main goal of the feature enhancement stage is to emphasize the seizure EEG relative to the non-seizure EEG (background EEG). For this, a differentiation and exponentiation approach is adopted. Following the feature enhancement stage, the next stage is spatial averaging. In this stage, the N selected channels with enhanced features are averaged so that a single EEG vector is obtained. The main idea of this stage is to reduce the number of features extracted from the EEG channels to further decrease the computational complexity. The onset of a seizure is usually associated with rhythmic activity composed of multiple frequency components. Therefore, to utilize the information contained in the EEG, features are extracted from each frequency sub-band separately. A multi-resolution wavelet decomposition is used to extract relevant frequency components from the EEG. From this point, the energy from each frequency EEG sub-component is calculated as the EEG feature. The last stage of our detection is the classification and detection stage. A support vector machine (SVM) is used to classify EEG epochs as seizure or non-seizure.

Results

The data used to evaluate the proposed detector is from a publicly available database consisting of EEG recordings from pediatric subjects with intractable seizures, collected at the Children's Hospital Boston. The subjects have been monitored for up to several days following withdrawal of anti-seizure medication in order to characterize their seizures and assess their candidacy for surgical intervention. The proposed detector was tested on six of these patients, where a leave-one-out cross-validation testing scheme is adopted for each patient. In the leave-one-out cross-validation testing scheme, the SVM is given a training set that includes the seizure and non-seizure epochs from all but one of the subject's recordings. The detector then attempts to detect the seizure from the excluded recording using the learned knowledge from the training set. This process is repeated until all recordings have been tested. To test the effectiveness of our proposed detector, the energy difference between pre-seizure and seizure states are calculated for a detector that only implements spatial averaging, a detector that implements a feature enhancement stage with no channel selection, and our proposed detector. It is found that the energy difference when feature enhancement is used is higher than when no feature enhancement is implemented in the detector. The energy difference is further enhanced for the case when the detector implements both feature enhancement and channel selection. The performance of the detector is compared to a benchmark detector that uses only feature enhancement. Our proposed detector achieves a detection latency of 4 seconds, which is closely aligned with the electrographic seizure onset time that an expert has visually determined. Furthermore, the proposed detector achieves a sensitivity of 87.5% whereas the benchmark detector achieves a sensitivity level of 80.6%.

Conclusion

Our research proposes a novel architecture for an epileptic seizure onset detector. The combination of the channel selection and feature enhancement stages has led to an improved detection performance. An increase in the energy difference between seizure and pre-seizure states is observed when the proposed detection is implemented, versus implementing the detection system without any form of channel selection. The proposed system also performed better in terms of false alarm rate and sensitivity.

Background

Maternal health refers to the health of women pre-pregnancy, during pregnancy, childbirth and postpartum. Pregnancy is a state of altered physiology and medication use during this period is remarkably challenging. For various reasons medication use during pregnancy cannot be completely avoided however, due to altered drug pharmacokinetics and crossing of placenta many of these drugs could significantly still harm the growing fetus. Pharmacists are medication experts with great knowledge of pharmacology, pharmacokinetics and are trained to apply evidence based clinical knowledge. Although pharmacists are having great potential to modify and optimize drug therapy in pregnancy, current evidence demonstrates they do not actively provide this care and are least interested in doing so.

Objective

The primary objective of the study was to determine the knowledge, perception, attitude and experience of pharmacist in Qatar regarding risk benefits ratio, concerns, advice, and source of information about drug use in pregnancy and secondary objective aimed to correlate knowledge with different variables.

Methods

A prospective cross sectional questionnaire based study was conducted by Women's Hospital pharmacy department for 3 months in 2010 (June – August). A 23-item self-completed anonymous questionnaire was distributed to 400 licensed pharmacists in Qatar including community pharmacists, hospital pharmacists, Primary Health Centers (PHC) and pharmacists working in polyclinics. Five pharmacists from women's hospital were selected to distribute and collect the questionnaire. A convenient sampling technique was used. All licensed pharmacist were included while pharmacy technicians were excluded. Pilot study was conducted on 30 pharmacists (16 community and 14 hospital pharmacists), were almost consistent in terms of answering, except for two questions (concerning knowledge and pharmacists confidence levels while dealing with physicians) which were modified accordingly. The questionnaire was classified into 4 sections: 1) Section 1, about their practice 2) Section 2, about knowledge and perception of medication use in pregnancy 3) Section 3, about pharmacist's level of confidence while dealing with patient and physician 4) Section 4, about source of drug information and certain general statements regarding their beliefs Data was analyzed by SPSS version 17. Descriptive statistics was applied for all the collected variables. Knowledge level of each respondent is determined by ranking their answers based on a scale developed with maximum 28 scores. To see association between Knowledge levels and variables, χ² test was used. P value 0.05 was considered as statistical significant. The study conformed to the ethical principles of Hamad Medical Corporation Research center. Descriptive statistics was applied for all the collected variables.

Results

An overall response rate of 51.75% (207/400) was obtained, and majority (54.1%) of whom were males. The highest percentages of respondents were practicing hospital pharmacists (46.8%), followed by community pharmacist (35.3%) whereas only 13% responded from primary healthcare centers. Most of them had a bachelors' degree (95.7%) in pharmacy. More than 50% of pharmacists responded to have no continuous education or received any CE points in last 12 months. 66% of these respondents reasoned work related issues (time, workload) for not attending these educational activities. 86% of the respondents were aware of the risk and benefits associated with the medication use in pregnancy. Majority (64.7%) of pharmacist possessed ‘average knowledge levels’, 34.3% with ‘good knowledge’ very few (1%) had ‘very good knowledge’. Only 33.3% were comfortable giving advices/counselling to pregnant women. Approximately 89% (strongly agree 39.6% and agree 49.8%) respondents believed they were competent enough to inform pregnant population about their medication where as 1.5% disagreed (strongly disagree 0.5% plus 1% disagree) and around 9% being unsure. Respondents with experience of 5 years and above had better knowledge levels than others. There was a significant positive association between respondents having Continuous Educational activities and their knowledge levels. Respondents who were very comfortable and somewhat comfortable (69.4%) were more knowledgeable than those uncomfortable and somewhat uncomfortable (10.6%). Knowledge of respondents who contacted prescribers with an alternative medication was 79.6% compared to ones who contacted prescribers without an alternative 8.3%. Respondents who agreed and strongly agreed that they were confident enough to advice both physicians (87%) and pregnant patients (91.3%) were more knowledgeable than others.

Conclusion

Our study provided a baseline data regarding knowledge, perception and experience of pharmacist in Qatar regarding drug use in pregnancy. With majority of respondents lacking educational activities, there is an urgent need to stress on the importance of continuous pharmacy education tailored to meet the requirements of specialized areas. Pharmacist should be aware of medications used during pregnancy and should be familiar regarding risks and benefits of the medication used and to provide appropriate drug related information to pregnant women and healthcare professionals taking care of pregnant women.

Calreticulin is a molecular chaperone responsible for proper protein folding in the endoplasmic reticulum (ER), and supports assembly of protein oligomers. Calreticulin also plays a role in quality control of protein expression in the ER. Calreticulin is a ubiquitous protein that shows high levels of expression in fetal cardiomyocytes. Both knockout and over-expression of Calreticulin in the mouse embryos is lethal arguing for an important role for this protein in survival and importantly for tight regulation of its expression in that regard to support physiological functions. Interestingly, over-expression of constitutively active Calreticulin only in the hearts of Calreticulin-null mice, rescues the lethal phenotype. Collectively these results argue for an important role for Calreticulin in the development and differentiation of cardiac myocytes. The exact mechanism by which Calreticulin affects cardiac development remains unclear. Previous studies on Calreticulin knockout cells showed inhibition of IP3– dependent Ca2+ release, suggesting a role for Calreticulin in Ca2+ homeostasis. Ca2+ is a ubiquitous second messenger that can be either release from intracellular Ca2+ stores or flows into the cell from the extracellular space through multiple Ca2+ influx pathways at the cell membrane. Ca2+ release occurs through either the IP3-receptor (IP3R) or the ryanodine receptor depending on the cell type. An important Ca2+ influx pathway at the cell membrane is the store-operated Ca2+ entry pathway (SOCE). SOCE is activated in response to the depletion of intracellular Ca2+ store following Ca2+ release. SOCE is mediated by two primary molecules, stim1 and Orai1. stim1 is an ER resident membrane protein with lumenal EF-hands that allows it to sense ER Ca2+ levels. Upon store depletion stim1 clusters and moves close to the cell membrane where it binds to and activates Orai1. Orai1 is a four trans-membrane pass Ca2+ channel that is gated by direct coupling to stim1. Both Orai1 and Stim1 were shown to be expressed in cardiomyocytes and required for cardiomyocyte SOCE. SOCE is important in cardiomyocyte biology and was shown to regulate normal and hypertrophic postnatal cardiac growth. Moreover, studies in zebra fish suggest an important role of Orai1 in regulating cardiac function, linking Orai1-mediated calcium signaling to cardiomyocyte function. Ca2+ influx through SOCE has been shown to activate the transcription factor, nuclear factor of activated T-cells (NFAT), by enhancing its translocation from the cytoplasm to the nucleus, leading to specific induction of gene expression. NFAT activation occurs downstream of the activation of the Ca2+-dependent phosphatase calcineurin. This nuclear import of NFAT was shown to be impaired in Calreticulin knockout cells. This supports a role for Calreticulin in the Ca2+/calcineurin/NF-AT transcription pathway. Here we use Calreticulin knockout MEF cells to study the effect of the absence of Calreticulin on SOCE. We specifically focus on Orai1, and study its subcellular localization and function in Calreticulin knockout MEFs as compared to wild type MEFs. We used specific Ca2+ imaging assays to asses SOCE function. Our Calcium imaging data show no difference in SOCE between wild-type and Calreticulin knockout MEF cells. We further studied the membrane trafficking and plasma membrane localization of YFP-tagged Orai1 in knockout MEF cells. Calreticulin knockout cells show higher proliferation rate than wildtype cells in culture, which will be further investigated by MTT and CFSE labeling. Our results suggest that the lethal phenotype in Calreticulin-null mice is not due to improper folding of Orai1, but can be related to the change of calcium homeostasis in the absence of Calreticulin.

The study includes the isolation and extraction of some active molecules like (flavonoid and total poly phenolic) and plant insulin (Glucokinin) from leaves and flowers of B. variegate L. belonging to the family Leguminosae which cultivated in Iraq. Also the study employed an in vivo evaluation of Bauhinia leaves (petroleum ether and methanol extract) and methanol extract and flowers extraction in mice at concentrations (200 and 400 mg/kg) for (LM1 and LM2) and (200 mg/kg) for F given intra peritoneal for 10 days after inducing diabetes mellitus type 2 by alloxan (200 mg/1 kg body weight). The serum was isolated from blood by cardiac puncture for the biochemical tests, including glucose, cholesterol (ch), Triglyceride (TG), high density lipoprotein (HDL), low density lipoprotein (LDL) and very low density lipoprotein (VLDL). At day 10 the animal was killed and the liver and pancreas were kept in 10% formalin for preparation of histopathological sections. We concluded that the Plant insulin (Glucokinin) may be responsible for some of the actions at plant extracts for their antidiabetic properties. From the observations, it was concluded that the reduction of blood glucose levels in diabetic rats were found to be dose dependent and also dependent on duration of action. So it might be useful in the treatment of diabetes without toxicity.

Keywords

Bauhinia variegata, Antidiabetic activity, Hyperglycemia, Hypolipidemic

Introduction

Blood cultures are commonly performed in hospitals daily as it is employed to detect infections that are spreading through the bloodstream (eg; bacteremia, septicemia). This is possible because the bloodstream is usually a sterile environment. Positive blood cultures indicate either bacteremia, or false positive blood cultures from contamination with bacterial skin flora through improper technique. False positive blood cultures are associated with unnecessary hospitalization and/or extended length of stay with consequent financial burden. False positive blood culture rates in Emergency Departments (ED) are often twice as high as on the medical wards. We present the results of an intervention – ANTT (Aseptic Non-touch technique) to decrease false Positive blood culture rates at Hamad General Hospital during the period from Nov 2014 through Nov 2015.

Aim

The HGH Microbiology lab indicator showed that our blood culture contamination rate has been consistently higher than the international benchmark, thereby we aim to reduce it in the critical area of ED BY 50% by the end of July 2015 and at least 90% by end of February 2016.

Methods

A pilot area was chosen in the Emergency Dept. to do a study for 44 weeks after which blood culture kits (previously trolleys & trays were used) containing sterile gloves, masks, and blood culture supplies were introduced into the Critical area of ED-HGH in August 2015. Training included- new instructions to have two staff members present when drawing blood cultures (Preceptor-preceptee methodology) there by prohibiting drawing blood cultures from pre-existing lines and proper follow-up of every step. False positive blood culture rates were measured in the weeks preceding and the weeks following, this intervention.

Results

In the 8 weeks following the intervention, the average false positive blood culture contamination rate in HGH ED reached 1.9%–(which was the benchmark) out of 318 blood culture samples. In the 6 months preceding, the blood culture contamination rates ranged from 4% to 1.5% each month.Conclusion:Blood culture kits and educational training on proper technique resulted in significant reduction (> 60%) in the false positive blood culture rate in the Critical areas of ED-HGH. Studies at other institutions have suggested that reducing the false positive blood culture rate could decrease costs by preventing unnecessary hospitalizations and administration of unnecessary antibiotics, as well as helping to prevent the development of multi-drug resistant organisms.

Background

Chronic myeloid leukemia is characterized by the reciprocal chromosomal translocation t(9;22)(q34;q11), leading to the formation of the Philadelphia chromosome. This encodes the constitutively active Bcr-Abl tyrosine kinase, which profoundly affects proliferation, apoptosis, and cell adhesion signaling pathways. Despite remarkable success in controlling CML at chronic phase by Bcr-Abl tyrosine kinase inhibitors (TKIs), a significant proportion of CML patients treated with TKIs develop drug resistance. Therefore, there is an urgent need for more potent and safer therapies against CML cells for the efficient management of CML.Proteasome inhibitors are attractive cancer therapeutic agents because they can regulate apoptosis-related proteins. Bortezomib also known as bortezomib, a proteasome inhibitor that has been approved by the food and Drug Administration for treatment of patients with multiple myeloma, and many clinical trials are ongoing to examine to the efficacy of bortezomib for the treatment of other malignancies. Bortezomib has been shown to induce apoptosis and inhibit cell growth of many cancer cells. In current study, we determine whether bortezomib induces cell death/apoptosis in CML.

Material and Methods

Reagents

Bortezomib and antibodies against caspase-3, caspase-9, PARP, p27, GAPDH were obtained from Santa Cruz Biotechnology Inc (USA). Antibodies against SKP2 and caspase-8 were obtained from Cell Signaling Technology, Inc USA) Arsenic trioxide (As2O3) and cyclohexamide were purchased from Sigma. Chronic myelogenous leukemia cells (CML) cell lines: K562, LAMA and AR230 cell lines were cultured in RPMI 1640 medium supplemented with 10? (v/v) fetal bovine serum (FBS), 100 U/ml penicillin, 100 U/ml streptomycin at 37°C in an humidified atmosphere containing 5? CO2. Proliferation assays: 104 cells were incubated in triplicate in a 96-well plate in the presence or absence of indicated test doses of Bortezomib in a final volume of 0.20 ml for 24 hour. The ability of Bortezomib to suppress cell growth was determined by MTT cell proliferation assays.

Apoptosis

CML cell lines were treated with bortezomib in different conditions as indicated in each experiment for 24 hours. Apoptosis was determined by flow cytometry using Annexin V (Molecular probes, Eugene, OR), PI staining for cell cycle analysis and DNA laddering using an apoptotic kit (Roche, Indianapolis, IN).

JC1 staining

1 × 106 cells were treated with different doses of bortezomib for 24 hours and stained with 10 mMol JC1 (Alexis corp., San Diego, CA) and measured by flow cytometry.

Western blot

Equal amounts of protein were separated by SDS-PAGE, transferred to PVDF membranes and probed with specific antibodies. Cytochrome c release from mitochondria: 20 μg of proteins from the cytosolic fraction were analyzed by immunoblotting with a specific antibody.

Results

Our data showed that proteasome inhibitor bortezomib decreased cell viability as well as induced apoptosis in a dose-dependent manner in a panel of CML cell lines. S-phase kinase-associated protein 2 (SKP2) is an F-box protein that targets cell cycle regulators including cyclin-dependent kinase inhibitor p27Kip1 via ubiquitin-mediated degradation. SKP2 is overexpressed in CML cells, and Bortezomib treatment of these cells resulted in down-regulation of SKP2 and stabilization of p27Kip1. Furthermore, bortezomib-treatment of CML cells led to the loss of mitochondrial membrane potential with the subsequent release of cytochrome c from mitochondria into the cytosol. Cytochrome c release caused activation of caspase-3 followed by polyadenosin-5-diphosphate-ribose polymerase (PARP) cleavage. Finally, we assessed effects on leukemic progenitors (CFU-L) using clonogenic assays in methylcellulose. The treatment of CML cells with bortezomib resulted in inhibition of CFU-L colony growth of leukemic precursors in the CML cell lines. We also provide evidence that co-treatment of chronic CML cells with bortezomib and arsenic trioxide (As2O3) potentiated the inhibition of cell viability. In addition clonogenic assays in methylcellulose demonstrate potent suppressive effects of the combination of these agents on primitive leukemic progenitors derived from CML cells.

Conclusion

Altogether, our results suggest that bortezomib-mediated downregulation SKP2-induced efficient apoptosis in CML cells and exhibited antileukemic effects. Furthermore, co-treatment of CML cells with bortezomib and As2O3 potentiated anti-cancer effects. These data suggests that proteasome-ubiquitin pathway may be a potential target for therapeutic intervention for treatment of CML.

Keywords

Proteasome Pathway, CML, Apoptosis

Introduction

Accumulating evidence suggests that adipose tissue is a dynamic organ that undergoes expansion and contraction in response to energy demands and obesity-associated tissue injury. The dynamic nature of the adipose tissue is achieved via changes in both size and number of mature adipocytes through adipocyte hypertrophy and preadipocytes proliferation and differentiation respectively. These changes are mediated through various growth factors and cytokines secreted by cells within the adipose tissues (Spalding et al. 2008). Hypertrophied adipocytes secrete cytokines such as IL-6 that can trigger macrophage infiltration and secretion of IL-1β, TNFα and IL-8 (Bjorntorp 1974; Kobashi et al. 2009), causing impairment of preadipocytes differentiation and induction of insulin resistance (Gustafson et al. 2007; Veilleux et al. 2009). TNFα-stimulates HGF release from fibroblasts and monocytes within the adipose tissue serving as a potent mitogenic factor (Bell et al. 2008). Mature adipocytes secrete IGF-I that plays a major role in preadipocyte differentiation (Bluher et al. 2005). Other growth factors such as VEGF were suggested to regulate the balance between osteoblast and adipocyte differentiation from pre-preadipocytes (mesenchymal stem cells) (Liu et al. 2012). Preadipocytes exhibit unique depot-specific characteristics that persist in expanded in vitro such as different size, lipoprotein binding, fatty acid transfer, protein secretion and response to insulin and lipolytic agents (Tchkonia et al. 2013). Cultured human abdominal subcutaneous preadipocytes (SC) accumulate more fat and exhibit a greater expression of adipogenic transcription factor than omental preadipocytes (OM) (Tchkonia et al. 2005). SC adipocytes serve as the first optimal fat storage choice (Tchkonia et al. 2013). Obesity causes impairment in SC fat storing capacity as a result of reduction in the number of differentiating preadipocytes and hypertrophy of mature adipocytes (Isakson et al. 2009; Spalding et al. 2008). This leads to expansion of visceral fat, including OM depot, with ectopic fat accumulation in the liver, skeletal muscle and heart (Okuno et al. 1998; Tchkonia et al. 2010). Visceral and ectopic fat accumulation results in further augmentation of insulin resistance in these tissues (Petersen and Shulman 2006), which is associated with a depot-dependent (OM > SC) IL-6 release in vivo and ex vivo (Fried et al. 1998; Mohamed-Ali et al. 1997).

Methods

In this study we compared the secretion of IL-6, IL-1β, TNFα and IL-8 in 15 paired subcutaneous (SC) and omental (OM) preadipocytes cultures expanded from stromal-vascular fraction (SVF), isolated from morbidly obese patients (8 males and 7 females) undergoing weight reduction surgery at Hamad Medical Corporation (HMC). We further evaluated the effect of IGF-1, HGF and VEGF on preadipocytes proliferation and differentiation in paired SC and OM preadipocytes cultures isolated from 3 randomly selected female subjects matched for age and BMI. For this purpose, SVF-derived cells (passage 1–2) were grown in stromal medium overnight then incubated in differentiation medium for 7 days, followed by 12 days in maintenance medium as previously described (Lee et al. 2012). Accumulated levels of secreted IL-6, IL-1β, TNFα and IL-8 in the last four days of differentiation were measured in media supernatants using Inflammatory Cytokine Human Magnetic 5-Plex (Life Technologies) according to manufacturer's instructions and assessed by Luminex Flexmap 3D using xPONENT® software. For experiments investigating the effect of growth factors on preadipocytes proliferation and differentiation, cells were grown as above in the absence or presence of 200 ng/ml IGF-1, 100 ng/ml HGF or 50 ng/ml VEGF for the entire differentiation and maintenance periods (once every 3–4 days). To assess proliferation and differentiation capacity, cells were fixed with 4% formalin for 10 min, stained with DAPI and subsequently with Lipidtox (Life Technologies) for 20 min. Total number of nuclei (DAPI, indicator of proliferation) and differentiated adipocytes (Lipidtox positive cells) were scored in 20 fields per well by ArrayScan XTI (Thermo Scientific) using automated spot detection module. Differentiation capacity was assessed by calculating the ratio of Lipidtox positive cells/total number of stained nuclei and presented as a percentage (adipogenic capacity). All protocols were approved by Institutional Research Boards of ADLQ and HMC (SCH-ADL-070, SCH-JOINT-111).

Results

Levels of secreted IL-6, IL-1β and IL-8 were significantly higher in OM preadipocytes compared to their SC-derived counterparts (Fig. 1), whereas secreted TNFα levels were below the level of detection. Compared to their age and BMI matched males counterpart, SC preadipocytes from females exhibited significantly higher levels of secreted IL-6 by 49.2% (p = 0.05) (Table 1) with no significant differences in other measured cytokines in either tissue. Treatment of SC and OM preadipocytes with IGF1, HGF and VEGF increased subcutaneous preadipocytes proliferation by 20% (n = 3, p ≤ 0.01) but had no significant effect on omental preadipocytes (Fig. 2). In contrast, IGF1 increased omental preadipocyte differentiation by 50% (p = 0.02), whereas neither HGF nor VEGF exhibited significant effect on subcutaneous or omental preadipocytes differentiation (Fig. 3).

Discussion and Conclusion

Our data suggest that elevated levels of secreted IL-6, IL-1β and IL-8 in OM compared to SC expanded cultures confirm the greater inflammatory nature of OM-expanded in vitro cultures shown previously in vivo and ex vivo (Fain 2006; Fried et al. 1998; Maury et al. 2007). The greater IL-6 secretion in female SC preadipocytes may suggest a role of sex steroid hormones (estrogen and androgen), but mechanisms for depot-specific differences remain poorly understood (Lee et al. 2013). Previous data has shown that preadipocytes are potent sources of growth factors such as VEGF, HGF, and IGF-1 in response to inflammatory mediators via a p38 MAPK-dependent mechanism (Wang et al. 2006). Investigation of the function of these growth factors on proliferation and differentiation of SC and OM expanded cultures confirmed the mitogenic nature of all these growth factors in SC but not in OM preadipocytes, while only IGF-1 enhanced differentiation of OM preadipocytes. These depot-specific differences in preadipocyte proliferation and differentiation in response to various mitogenic and adipogenic factors may be explained by their different cellular composition and physiological role (Lee et al. 2013). The molecular mechanisms underlying these differences and their impact on metabolic syndrome remain elusive. The contribution of secreted cytokines and growth factors on depot-specific differences and metabolic complications associated with central obesity may shed some light on these mechanisms.

Acknowledgment

This research was sponsored by Qatar National Research Fund (QNRF), Grant number NPRP6-235-1-048.

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Objective

To evaluate the concordance of Pap smear, Colposcopy and histopathology in patients with cervical intraepithelial neoplasia (CIN) in a local tertiary care hospital.

Design

Retrospective descriptive study.

Materials and methods

All patient with CIN undergoing LLETZ during the period from January 2007 to July 2013 were included in the study. Case records were reviewed regarding demographics and clinical data, Pap smear reports, colposcopy findings and histopathology (HPR) reports following colposcopically directed cervical biopsy (CDB) and that following Large Loop excision of Transformation zone (LLETZ).

Results

patients with CIN undergoing LLETZ were included. Agreement between Pap smear and HPR was 96.2% with sensitivity of 80.6% and specificity of 60%. Agreement between CDB and HPR was 86.4% for high grade and only 33.3% for low grade lesions. Level of concordance of Pap smear with CDB was 96.2% for high grade and only 50% for low grade lesions.

Main Outcome Measures

Agreement between Pap smear, colposcopy, CBD and HPR.

Conclusion

Pap smear and CDB are complimentary to each other, and each cannot be used independently. LLETZ improves the yield of high grade lesions and detecs minimally invasive cancer which could be missed by CDB.