BIOCHEMISTRY

1. Organisms that produce commercial enzymes

2. Significance of enzyme in metabolic pathway
3. Principles of enzyme reaction
4. Mechanism of enzyme reaction
5. Pro-enzymes? & its advantages
6. Enzyme & co-enzyme which specifically act on DNA molecules in biotechnological
7. Enzymes in immune system
8. Enzymes as drug or antibiotics
To survive, bacteria developed antibiotic resistance mechanism
Enzyme as drug have 2 important features that distinguish them from all other type of drug
1. Enzyme often bind and act on their target with great affinity and specificity
2. Enzyme are catalytic and convert multiple target molecules to desired products

These 2 enzyme make enzyme specific and potent drug can accomplish therapeutic biochemistry in body
that small molecules cannot

9. Enzyme as marker for disease and diagnosis & pathology

Alkaline phosphatase
Creatine kinase
Alanine aminotrasnferase
Aspartate aminotrasnferase
Sorbitol dehydrogenase
Lactate dehydrogenase
Cholinesterase
Amylase
Lipase
Glutamyltransferase
Trypsin
Glutathione peroxidase
10. Enzyme application in immunoassay procedures (ELISA & EMIT)
Horseradish peroxidase
Alkaline phosphatase
-galactosidase

11. Enzymes acted as therapeutic agents

a) Streptokinase (from streptococcus)
clearing blood clots that occur in the lower extremities

activates the fibrinolytic proenzyme plasminogen that is normally present in plasma

activated enzyme is plasmin serine protease like trypsin that attacks fibrin, cleaving it into several
soluble componneys

b) asparaginase
therapy for adult leukemia
tumor cells have nutritional requirement for asparagines and must scavenge it from host plasma
asparaginase administration host plasma level of asparagine is decreases results in depressinf the
viability of tumor
c) u-plasminogen activator (urokinase)
from human urine
infused to blood stream of patient at risk from a pulmonary embolism
stimulate cascade system responsible for production of active plasmin, a proteolytic enzyme which
digest fibrin
d) lasaparaginase tx of several type of leukemia
e) immobilized enzyme as component of artificial kidney machines to remove urea & other waste
products from body

MICROBIOLOGY
1. Major foodborne pathogens that responsible for foodborne dx
Giardia
Campylobacter,
Salmonella..
2. Who are the vulnerable groups?
a) Individual with pathological immunosuppression/acquired immune-deficiency syndrome,
People with primary immunodeficiencies are prone to foodborne infections
For example, recurrent or chronic diarrhoea was reported in 118/252 patients (47%) with common
variable immunodeficiency with hypogammaglobulinemia in France; the pathogens detected most

frequently were Giardia, Campylobacter, and Salmonella

In the United States, nontyphoidal salmonellas were the main cause of bacteraemia in a group of
patients with chronic granulomatous disease

b) transplant recipients, cx patients,

The risk of infection in transplant recipients arises from the immunosuppressive treatment to

prevent tissue or organ rejection, and prophylactic antimicrobial treatment is given

In cancer patients chemotherapy and radiotherapy affect bone marrow cells and the gastrointestinal

mucosa, causing myelosuppression and mucositis

Neutropenia and concomitant steroid treatment also increase susceptibility to infection.
Although transplant patients are susceptible to Listeria monocytogenes, the reported incidence of

listeriosis and other foodborne pathogens is low, but they can cause high mortality
This low incidence may be due, in part, to the prophylactic use of trimethoprimsulphamethoxazole
(TMP-SMX) against Pneumocystis jiroveci pneumonia, but which also inhibits L. monocytogenes and

Toxoplasma gondii.
Cancer patients also show increased susceptibility to L. monocytogenes
Two patients with oral cancer developed listeriosis after eating large quantities of soft cheese to

counteract severe mouth soreness

Salmonella gastroenteritis is rare in transplant patients, but leads to bacteraemia in 20%30% of

cases, compared with 3%4% in nontransplant recipients.

Subsequent metastatic infection is common, and in patients aged over 50 years, cardiovascular sites

tend to be affected.
Salmonella and Campylobacter gastroenteritis are more common in patients with hematological

malignancies than those without a malignancy

Cryptosporidium and Giardia are the most common parasitic infections in transplant patients,

particularly in endemic regions

Cryptosporidium causes prolonged watery diarrhoea, malabsorption, nausea, and vomiting in

transplant recipients, which may be life-threatening, and the organism is difficult to eradicate
Patients with leukemia and other hematological malignancies also seem to be at increased risk of

cryptosporidiosis
Toxoplasma is a rare infection that can occur after heart, heart/lung, hematopoietic stem cell

(HST), and solid organ transplants (SOT), causing high mortality

Cases are often reported when prophylactic treatment with TMPSMX is discontinued because of ill-

effects.
Toxoplasmosis is also a risk for cancer patients in general
Sources of infection are consumption of undercooked meat, raw sheep or goat milk, contaminated
vegetables or raw oysters, clams, or mussels, contact with contaminated cat feces, or environmental
contamination

Toxoplasmosis can arise from allograft infection, reactivation that commonly results in encephalitis

or disseminated infection, or primary infection

Reactivation of latent infection with T. gondii in immunocompromised people emphasizes the need for

primary prevention.
Norovirus (NoV) infection, which is often foodborne or waterborne, poses a higher risk of severe

consequences in immunosuppressed patients, causing chronic gastroenteritis

Hepatitis E infection in immunocompromised organ transplant patients, which can result from

consumption of insufficiently cooked game or pork meat, can lead to chronic hepatitis
Aspergillus and Candida cause important invasive infections in transplant patients
Saccharomyces cerevisiae can cause invasive disease, particularly in transplant and cancer patients
There are reports of serious infection of immunocompromised patients with S. boulardii, a subtype
of S. cerevisiae used as a probiotic

c) immune system dx, impairment of immune system (rheumatoid, SLE)

Antiinflammatory and immunosuppressive corticosteroids are used to treat several autoimmune

diseases and have many dose-dependent effects on innate and acquired immunity
Chronic use of steroids to treat rheumatoid arthritis (RA) increases the risk of infection by L.
monocytogenes, Salmonella spp., and other Enterobacteriaceae, Brucella spp. Cryptosporidium and T.

gondii
Listeriosis is often associated with older age and concomitant use of immunosuppressants such as

methotrexate (MTX), a corticosteroid and a biological agent

Listeria endocarditis occurred in a psoriatic arthritis patient treated with the biological agent

infliximab who admitted eating soft cheeses

Consumption of soft cheese made with unpasteurized milk resulted in L. monocytogenes bacteremia in
an ankylosing spondylitis patient treated with infliximab, whereas eating partly cooked eggs from a
local farm was followed by Salmonella joint infection in an RA patient treated with infliximab,

prednisolone, and MTX

A patient with RA treated with MTX, prednisolone, and infliximab, who traveled to India and
consumed raw vegetables, experienced acute S. paratyphi gastroenteritis followed by bacteremia and

soft tissue infection

The risk of infection and death in systemic lupus erythematosus (SLE) patients is increased by

treatment with corticosteroids and other immunosuppressive agents

Bacteria, particularly Salmonella, are important causes of infections
L. monocytogenes infection is rare but causes severe symptoms, often mistaken for SLE flares
reported that 2.87% of their SLE patients in Colombia contracted listeriosis, and linked this to the

use of unpasteurized milk. T. gondii infection is rare but causes severe symptoms
In 83 SLE patients with major infections, the most frequently identified pathogens (43/83 cases)
were Escherichia coli, Staphylococcus aureus, M. tuberculosis, and Streptococcus pneumoniae,

followed by Salmonella
Treatment with prednisone increased the risk of infection, whereas antimalarials had a protective
effect.

d) pregnant women, neonates,

Important foodborne pathogens for pregnant women are L. monocytogenes and T. gondii
L. monocytogenes infection in pregnant women is often mild, with fever or flu-like illness, but can
cause fetal loss, stillbirth, or birth of a severely infected infant

Transplacental infection gives rise to early-onset illness in the neonate resulting in bacteraemia,
respiratory distress, fever, neurologic abnormalities, and, less frequently, disseminated granulomas

in multiple internal organs.

Late onset illness results from infection during passage through the birth canal or after delivery and

usually presents as meningitis

Congenital infection with T. gondii usually occurs when a pregnant woman is newly infected, but can
follow infection just before pregnancy or result from reactivation of an infection acquired before

pregnancy
Infection in pregnancy is usually asymptomatic but occasionally causes lymphadenopathy.
The risk of congenital infection between weeks 10 and 24 of pregnancy is low, but the symptoms can

be severe, including spontaneous abortion.

Infection of the fetus in weeks 2640 of pregnancy results in subclinical disease that can cause
symptoms later in life, because the organism survives in tissue cysts that persist, particularly in

neural and muscle tissue and in the eye.

The immune system in neonates and very young infants is not fully developed
Unlike most adults, infants are susceptible to infection by spores of Clostridium botulinum, which can
germinate and colonize the infant colon producing botulinum neurotoxin and leading to infant

botulism.
In healthy adults, the intestinal microflora stops growth from ingested C. botulinum spores, but in

infants the microflora is unable to prevent growth.

Most cases of infant botulism occur before the age of 1 year
Honey is the source of spores in some cases of infant botulism and so warnings are issued in several
countries, including the United Kingdom, United States, and Italy, that honey should not be given to

infants < 1 year old.

Other possible sources are soil and dust, but in many cases of infant botulism the source is unknown.
Rarely, C. botulinum or a neurotoxin-forming strain of C. butyricum can become established in the

adult intestineadult intestinal botulism.

This can occur if competing bacteria in the normal intestinal microflora are suppressed by antibiotic

treatment, or as a result of intestinal tract malformation

Infant formula or follow-on formula contaminated with Cronobacter sakazakii (Enterobacter

sakazakii) or Salmonella has caused serious infection in infants

C. sakazakii can be isolated from many sources, including foods, and may lead to meningitis,

bacteraemia, urinary tract infections, and wound infections.

There are also several reports of C. sakazakii infection in immunocompromised adults

e) elderly
Age-related deterioration of the immune system and comorbidity result in increased susceptibility to

infections
In elderly people with chronic gastritis, stomach acid production declines; gastrointestinal motility

decreases, increasing the gastrointestinal transit time and leading to constipation

The elderly are susceptible to various infections, including listeriosis, Campylobacter and Salmonella

bacteraemia, and focal infections, such as aortic infections, secondary to salmonella gastroenteritis
Recent increases in listeriosis in France, Germany, and England and Wales have mainly affected the

elderly and those with malignancies

Elderly people are also the group most likely to die after infection with Shiga-toxin-producing

Escherichia coli O157

Norovirus infection is generally considered to be mild, but there were an average of 80 deaths/ year
in people aged over 65 attributable to norovirus in England and Wales in 20012006

f) malnourished people
Malnutrition is a major factor increasing susceptibility to infection worldwide

Although malnutrition often refers to macronutrients, micronutrient deficiencies are also important

and common in older adults. W

while malnutrition is most widespread in low-income countries, it also occurs in hospital patients and
homeless people in high-income countries

3. Reason for vulnerability: often arises due to immune suppression, other reason??
a) Diabetes:
Diabetes can increase the risk of infection
Poor glycaemic control is associated with impaired neutrophil function
Controlling blood glucose appears to rectify some immune defects.
During a nosocomial Salmonella Enteritidis outbreak, in which raw eggs were used in a hospitalprepared mayonnaise, patients with diabetes who required insulin or oral hypoglycaemics were at
increased risk, perhaps through a combination of reduced gastric acidity and impaired intestinal
motility due to autonomic neuropathy.
Salmonellosis and campylobacteriosis are three and four times more common, respectively, in
patients with diabetes than in the general population, and patients with diabetes are about 25 times
more likely to develop listeriosis than healthy, nondiabetics (
b) Inflammatory bowel disease:
Immunosuppressants, including MTX, azathioprine/6-mecaptopurine, cyclosporine, steroids, and
biological therapies such as infliximab, used to treat inflammatory bowel disease (IBD), increase
susceptibility to infection, particularly when two or more drugs are used
Foodborne infections associated with immunosuppressant therapy in IBD patients include Salmonella,
L. monocytogenes, and T. gondii
For example, a man with Crohns disease receiving infliximab treatment died from listeriosis after
eating a contaminated chicken salad from a retail store
c) Multiple sclerosis:
The treatments for multiple sclerosis, including steroids and immunosuppressive drugs, might be

expected to increase susceptibility to foodborne infection.

There appear to be few reports of such infection, but a case of central nervous system
toxoplasmosis and a case of ocular toxoplasmosis have been reported in patients treated with the
monoclonal antibody natalizumab

d) Immunosuppressant therapies that increase the risk of foodborne disease

Several therapies, developed to cure or control some of the diseases described above, can also
increase patients foodborne disease risks.
Chronic use of steroids increases the risk of infection.
Purine analogs such as fludarabine, used in the treatment of cancer, increase the risk of Listeria and
mycobacteria infections
Treating chronic myeloid leukemia patients with the tyrosine kinase inhibitor imatinib mesylate has
caused monocytopenia, leading to L. monocytogenes meningitis
Alemtuzumab is a monoclonal antibody directed against the CD52 antigen on the surface of a range
of cells, including T and B lymphocytes.
It is used to treat patients with lymphoid malignancies and transplant patients, many of whom are at
increased risk because of prior treatment with other agents.
A range of infections has been reported after alemtuzumab treatment, including toxoplasmosis and
listeriosis, and the use of P. jiroveci prophylaxis is advised
Tumor necrosis factor-a (TNF-a) is an essential component of the host immune response. Treatment
of RA or IBD patients with TNF-a inhibitors, particularly infliximab (often combined with other
immunosuppressant agents), is associated with an increased risk of infection by a range of
microorganisms, including Mycobacterium tuberculosis, L. monocytogenes, Salmonella, Toxoplasma,
and Brucella

Treatment may cause reactivation of latent infection with M. tuberculosis, M. bovis, T. gondii, and
Brucella spp.
Tuberculosis occurred in two patients (one with RA and one with Crohns disease) treated with
infliximab, because of reactivation of M. bovis
In each patient a tuberculin test before treatment was negative; both patients probably drank
unpasteurized milk many years previously.

e) People with acquired immune-deficiency syndrome

Human immunodeficiency virus type 1 (HIV-1) infection causes chronic progressive immunodeficiency
through reducing CD4+ T-cell lymphocytes
Foodborne organisms causing diarrhea in people with HIV include nontyphoidal Salmonella and Giardia
and, less commonly, Shigella, Campylobacter, Microsporidium, Cryptosporidium, Isospora, and
Cyclospora
Patients with acquired immune-deficiency syndrome (AIDS) are also at greater risk of invasive
listeriosis than the general population, although widespread TMP-SMX prophylaxis and dietary
recommendations probably decreased listeriosis in parts of the United States
CD4 counts below 200/lL are associated with toxoplasmosis encephalitis, and diarrhea caused by
Cryptosporidium, which can be severe
Where antiretroviral treatment is available, with the attendant recovery of CD4 count, dramatic
reductions in toxoplasmosis have been seen. People with advanced HIV are particularly susceptible to
recurrent, invasive salmonellosis and occasionally to Salmonella meningitis
f) People with defects of iron metabolism, cirrhosis, or other liver diseases
Conditions that increase iron availability in the body, including multiple transfusions of whole blood or
erythrocytes in excess, liver dysfunction, alcohol-induced cirrhosis, hemochromatosis, and
thalassemia, can stimulate growth of several foodborne pathogens, including Bacillus, Clostridium,
Listeria, Campylobacter, Salmonella, Shigella, Vibrio, Yersinia, and Toxoplasma
Bacterial infection is a major complication and an important cause of death in patients with liver
cirrhosis because of defects caused in the immune response, in bacterial translocation, and in the
reticulo-endothelial system.
For example, Vibrio vulnificus septicemia after eating raw or undercooked seafood or following wound
infection occurs mainly in patients with liver diseases such as cirrhosis or hepatitis, elevated serum
iron levels, or immunodeficiency
Cirrhosis increases the risk of nontyphoidal Salmonella bacteraemia, and hepatitis E virus can cause a
high rate of mortality in people with chronic liver disease
g) People with reduced stomach acidity.
Stomach pH in fasting, healthy people is usually between pH 1.5 and pH 2 and serves as a barrier to
foodborne pathogens.
When food enters the stomach there is a transient rise in pH ( >pH 6.0), which gradually declines as
the stomach empties, depending on the nature of the food
Proton pump inhibitors are the most effective agents for suppressing acid production and can
prevent the intragastric pH from falling below pH 4 for a high percentage of time
There is evidence that patients with hypochlorhydria or achlorhydria, or who have been treated with
proton pump inhibitors or H2 receptor antagonists are more susceptible to Campylobacter, E. coli
O157, L. monocytogenes, Salmonella, Shigella, and Vibrio cholerae than healthy
Proton pump inhibitors are available increasingly without prescription, so that people can selfmedicate without realizing that this might mean an increased risk of foodborne disease.
h) People using antidiarrhoeal medication.
The diarrhea caused by enteropathogens helps to eliminate organisms during intestinal infections.
As well as masking dehydration, antidiarrheal agents can increase the severity of infections.
For example, in an outbreak of foodborne Clostridium perfringens in the United States in 2001,
three elderly patients developed severe bowel necrosis and two died

The symptoms were attributed in part to drug-induced constipation and fecal impaction, resulting in
prolonged exposure of colonic tissue to C. perfringens toxins.
Similarly, antidiarrheals are not recommended in children with E. coli O157 infection since they
appear to increase the risk of serious complications such as hemolytic uremic syndrome

4. Other host factors: age contributes to increase infection susceptibiiity

Age-related deterioration of the immune system and comorbidity result in increased susceptibility to

infections
In elderly people with chronic gastritis, stomach acid production declines; gastrointestinal motility

decreases, increasing the gastrointestinal transit time and leading to constipation

The elderly are susceptible to various infections, including listeriosis, Campylobacter and Salmonella

bacteraemia, and focal infections, such as aortic infections, secondary to salmonella gastroenteritis
Recent increases in listeriosis in France, Germany, and England and Wales have mainly affected the

elderly and those with malignancies

Elderly people are also the group most likely to die after infection with Shiga-toxin-producing

Escherichia coli O157

Norovirus infection is generally considered to be mild, but there were an average of 80 deaths/ year in
people aged over 65 attributable to norovirus in England and Wales in 20012006

5. Susceptibility of clostridium botulinum infection in neonates and new bor infants compared to adult
people
The immune system in neonates and very young infants is not fully developed
Unlike most adults, infants are susceptible to infection by spores of Clostridium botulinum, which can

germinate and colonize the infant colon producing botulinum neurotoxin and leading to infant botulism.
In healthy adults, the intestinal microflora stops growth from ingested C. botulinum spores, but in

infants the microflora is unable to prevent growth.

Most cases of infant botulism occur before the age of 1 year
Honey is the source of spores in some cases of infant botulism and so warnings are issued in several
countries, including the United Kingdom, United States, and Italy, that honey should not be given to

infants < 1 year old.

Other possible sources are soil and dust, but in many cases of infant botulism the source is unknown.
Rarely, C. botulinum or a neurotoxin-forming strain of C. butyricum can become established in the adult

intestineadult intestinal botulism.

This can occur if competing bacteria in the normal intestinal microflora are suppressed by antibiotic

treatment, or as a result of intestinal tract malformation

Infant formula or follow-on formula contaminated with Cronobacter sakazakii (Enterobacter sakazakii)

or Salmonella has caused serious infection in infants

C. sakazakii can be isolated from many sources, including foods, and may lead to meningitis, bacteraemia,

urinary tract infections, and wound infections.

There are also several reports of C. sakazakii infection in immunocompromised adults

6. Prevention strategis or recommendation to control foodborne infection to vulnerable groups in the

community:
a) food safety management
Suppliers of food, including water and beverages, to hospitals, nursing homes, elderly-care homes,
schools, and daycare centers for children aged nine or less, and to vulnerable people in the
community should have in place a food safety management system based on Hazard Analysis Critical

Control Point principles

The U.S. Food Code (FDA, 2009) contains special requirements for food establishments serving
highly susceptible populations.

b) low microbial diet

Low microbial diets avoid foods that are more likely to contain pathogenic microorganisms, including

certain uncooked foods with a high microbial load, and substitute safer alternative foods.
Such diets are recommended by some hospitals for high-risk
A low microbial diet is recommended for HST patients before engraftment
Autologous HST recipients are advised to remain on this diet for 3 months, whereas allogenic
recipients should remain on this diet until all immunosuppressive drugs are discontinued and the

patient is able to receive live virus vaccines.

These recommendations can be extrapolated to SOT patients
After SOT opportunistic infection remains a risk throughout a patients life, particularly if graftversus-host disease develops, requiring increased dosage of immunosuppressant drugs, so life-long

attention to safe food handling is recommended

A low microbial diet (neutropenic diet) may be suggested if a patients absolute neutrophil count is
It has been stated that evidence of the effectiveness of low microbial diets is lacking, partly

because in studies evaluating low microbial diets other interventions have also been used
But since immunosuppressed people are susceptible to infection from many sources, it is difficult to
envisage an ethical study to prevent foodborne infection that would not include other interventions

alongside a low microbial diet.

In a survey of mainly European blood and marrow transplant centers, the nature and use of low

microbial diets was highly variable

It is clear, however, that certain ready-to-eat foods carry a risk of infection with foodborne
pathogens

c) avoid high-risk foods

The FSIS/USDA (2010) has published the following brochures or fact sheets, which give advice for
vulnerable people:
1. Food Safety for Older Adults
2. Food Safety for People with Cancer
3. Food Safety for People with Diabetes
4. Food Safety for People with HIV/AIDS
5. Food Safety for Transplant Recipients
6. Protect Your Baby and Yourself from Listeriosis

Each of the food safety brochures contains guidelines on selecting lower-risk foods and advice on
purchasing, storing, and cooking foods.
Higher risk
Raw or undercooked meat or poultry

Lower risk
Meat or poultry cooked to a safe internal
temperature (Tip: use a food thermometer to check

Any raw or undercooked fish,

the internal temperature)

Smoked fish and precooked seafood heated to 165_F

Refrigerated, smoked fish, Precooked

seafood such as shrimp or crab
Unpasteurized milk
Foods that contain raw/undercooked
eggs such as Caesar salad dressings,
Homemade raw cookie dough,
Homemade eggnog

(74_C),
Canned fish and seafood,
Seafood cooked to 145_F (63_C)
Pasteurized milk
At home: Use pasteurized eggs/egg products when
preparing recipes that call for raw or undercooked

eggs.
When eating out: Ask if pasteurized eggs were used
(Tip: Most premade foods from grocery stores, such
as Caesar dressing, premade cookie dough, or

Raw sprouts (alfalfa, bean or any other

packaged eggnog, are made with pasteurized eggs)

Cooked sprouts

sprouts)
Unwashed fresh vegetables, including

Washed fresh vegetables, including salads

lettuce/salads
Soft cheeses made from unpasteurized

Hard cheeses, Processed cheeses, Cream cheese,

milk,

Mozzarella, Soft cheeses that are clearly labeled

such as Feta, Brie, Camembert, Blue-

made from pasteurized milk

veined cheese, Queso fresco

Hot dogs and luncheon meats that have

Hot dogs, luncheon meats, and deli meats reheated

not been reheated

to steaming hot or 165_F (74_C) (Tip: Your need to

reheat hot dogs, deli meats, and luncheon meats
before eating them because the bacterium Listeria

Unpasteurized, refrigerated pates or

monocytogenes grows at refrigerated temperatures.)

Canned pa tes or meat spreads

meat spreads

Other workers have recommended that patients being treated with TNF-a inhibitors should be
advised about specific high-risk foods to avoid

d) safe water and ice

U.K. guidelines state that persons whose T-cell function is compromised or who have specific T-cell
deficiencies should boil and cool their drinking water, from whatever source, to reduce the risk of

Cryptosporidium infection
ice cubes should be produced from boiled and cooled water
patients recovering from HST are advised to boil tap water for at least 1 min. to avoid the risk of

Cryptosporidium infection
end-line water filtration was the best way to produce drinking water for immunocompromised
patients, provided that there are robust protocols to ensure that filter cartridges are changed at

appropriate times.
Bottled natural water should be free from parasites and pathogenic organisms, but noncarbonated,
bottled water may contain high numbers of bacteria. It has been implicated in nosocomial infection

and should not be given to severely neutropenic patients;

water dispensers should not be used by severely neutropenic patients
Ice prepared in ice-making machines may also be a source of infection, and appropriate maintenance
is essential.

e) safe infant formula

For high-risk infants (preterm, low birth weight, immunocompromised) the safest option is to use

ready-to-feed liquid formula, which is sterile.

When reconstituting and storing powdered infant formula, special precautions and good hygiene are

important.
In particular, bottles should first be treated in boiling water, infant formula should be reconstituted
in boiling water cooled to not less than 70_C, and reconstituted formula should be stored below 5_C
in a refrigerator

f) antimicrobial prphylaxis
Antimicrobial prophylaxis is recommended during treatment of many vulnerable groups.
Currently, TMP-SMX is used in many transplant centers for varying durations (3 months to as long as
a lifetime) primarily to prevent Pneumocystis pneumonia, and this combination is also effective
against L. monocytogenes and T.
The great majority of L. monocytogenes isolates from clinical and food sources were susceptible to
TMP-SMX, but a very few isolates were resistant

Alternative prophylactic agents against Pneumocystis may have less activity against L. monocytogenes
Prophylaxis with TMP-SMX also appears to reduce the incidence of Salmonella infections after
transplant, but resistance has occurred in some Salmonella species
Listeria and Pneumocystis infections are more frequent in chronic lymphocytic leukemia patients
treated concurrently with fludarabine and corticosteroids, and TMP-SMX prophylaxis should be
considered for these patients
Patients with lymphoid cancers treated with the biological agent alemtuzumab, often following other
immunosuppressants, may show increased susceptibility to infections, including those by T. gondii and
L. monocytogenes
Prophylaxis with TMP-SMX and other agents was recommended routinely.
A range of antimicrobials is used in treatment of cancers, but increased rates of bacterial
resistance have occurred. It has been suggested that antimicrobial prophylaxis should be limited to
high-risk patients with severe neutropenia expected to last > 1014 days
Although adding prophylactic ampicillin or TMP-SMX to standard antibacterial regimens for patients
receiving TNF-a inhibitors has been suggested, in practice TNF-a inhibitors are often used in
conjunction with MTX, which increases the risk of hematological toxicity when given with
trimethoprim or cotrimoxazole
Similarly, penicillins increase the risk of toxicity when given with MTX, so using these antibacterials
in patients on MTX could create problems.
The development of resistance in microorganisms, and possible changes in practice regarding the use
of antimicrobials emphasize that reliance on treatment with antimicrobials is not a substitute for
avoiding high-risk foods to protect vulnerable groups from foodborne illness.

TOXICOLOGY
1. Major sources of lead exposure
Lead enters the biological system through the air, water, and dust.
Fine particles of lead, having diameter less than 5 nm are directly absorbed by lungs.
Inorganic lead is absorbed by the gastrointestinal tract, and organic lead is absorbed by the skin
2. Enter biological system through water, air, dust
Lead enters the biological system through the air, water, and dust.
Fine particles of lead, having diameter less than 5 nm are directly absorbed by lungs.
Inorganic lead is absorbed by the gastrointestinal tract, and organic lead is absorbed by the skin
drinking water provides a significant pathway for biological lead exposure.
lead seldom occurs naturally in water supplies like lakes and rivers, contamination is often associated
with the presence of lead in service pipes, solders, pipe-fittings and galvanized iron (GI) pipes.
3. Modern usage of lead: batteries, paint, water pipe, cosmetics, low cost toy
In modern times, lead has been used extensively in lead-acid batteries, water pipes, paints, ammunition,
cosmetics, alternate and folk medicines and even some low-cost toys.
4. Half life lead in blood, brain, bone
In the blood, lead has a half-life of 35 days,
In the bones, lead has a half-life of 17-20 years
2 year half-life in the brain.
5. Effect of chronic exposure of lead in children & adult
At this stage, lead decreases iron absorption thus disrupting heme development.
The inhibited production of heme may eventually lead to anemia,
hypertension may also result.
In children especially these subclinical effects have profound implications on their development.
Prior to birth lead can be transferred via the placenta (as there is no placental barrier for lead)
If an inadequate calcium intake exists, then lead will be released from the bones and transported to the
developing child.
Lead exposure at this stage can cause severe mental defects.
increased lead levels with lowered IQs and abnormal social habits.
even at low doses, lead can affect a childs IQ
lead levels of 10g/dL a childs IQ is reduced by up to 6 points
abnormal social habits including aggression, impulsiveness and lethargy occur at greater rates among
children exposed to lead.
Blood lead levels [have] an obvious negative correlation with the development quotients of child adaptive
behaviour, gross motor performance, fine motor movements, language development and individual social
behavior
clinical effects such as wrist drop, anemia and hypertension occur, however these only usually become
evident at blood lead levels at or above 60g/dL.
6. mechanism of lead toxicity in children & adult
Once ingested, lead proceeds to the gut, where it is absorbed.
On the cellular level, lead causes a buildup and then release of calcium in the mitochondria, which when

sustained for a long enough time leads to apoptosis, or programmed cell death [
Lead has the ability to substitute calcium, a common ion in bodily functions like muscle contraction and

nerve interaction.
Under this guise, lead readily crosses the blood brain barrier where it accumulates to a high degree.
Possibly in an effort to prevent the neuronal mitochondria from exposure, the lead is sequestered in
the non-mitochondrial areas of the astroglia

In effect, these areas of high lead content become reservoirs- areas of continuous exposure.
Lead in the brain has been associated with deleterious effects regarding neurotransmitter storage,
release and receptors [3].

7. Safety lead exposure level

accepted level of 0.01 mg/L
in blood <10mg/dL
8. Clinical symptoms of high blood lead levels in children social behavior, language, motor development
9. Limitation of available lead toxicity treatments
Expensive
Unable to fully reverse the effects of lead poisoning

CAM
1. Basis use of CAM: theory, belief, experience, culture, from previous generation
to improve the health and well-being of people
2. Use of herbal medicine for tx of various ailments during pregnancy: increasingly popular in Msia
S. Fatimah (Anastatica hierochuntica L.)
Minyak Selusuh (Coconut Oil)
Unidentified Herbs
Halia (Zingiber officinale)
Bawang Merah (Allium ascalonicum)
Bawang Putih (Allium sativum)
Serai (Cymbopogon citratus)
Kunyit (Curruma longa)
Manjakani (Croton caudatus)
Inai (Lawsonia inermis)
Sirih (Piper betle L)
Jarum Mas (Striga asiatica)
Pegaga (Centella asiatica L.)
Sepang (Caesalpinia sappan)
Homeopathy
3. Why high prevalence of herbal medicine utilization by pregnant Malays women
due to the strong believes that these herbs are safe
herbal products do not contain harmful chemicals and are free of side effects when compared to
commercially available pharmaceutical drug
to treat pregnancy related illness and to encourage healthy pregnancies and overall well-being.
herbal remedies facilitate labor
Anastatica hierochuntica L. promotes faster delivery, thus suggesting that this herbal medicine has
effects that caninduce and expedite labor and also open the womans cervix
herbal medicines as being safe and effective because herbs are natural substance
do not contain any dangerous chemicals
the practice of using medicinal herbs has been going on for many generations
4. Major concerns raised by health professionals on the usage of herbal medicine during pregnancy
pharmacological active component in herbal medicines is a possibility of potential harm to the fetus.
essential to determine the mineral elements in herbal medicines and to establish the levels of some
metallic elements in commonly used herbal medicines because, at elevated levels, these metals could be
dangerous and toxic
health care providers need to be aware of the common herbal medicines consumed by pregnant women
and need to be proactive with pregnant women who consider using herbal medicine.
They also need to be cognizant with the evidence base study regarding dosage and dosage forms, as well
as the potential benefits or harmful side effects of herbal medicines.
Information obtained could provide benefits in treating or preventing illness, including relevant
supporting evidence that is more conclusive in antenatal care and practices.
Knowledge of the elemental content in herbal medicines is very important since many trace elements
play significant roles in the formation of active constituents responsible for the curative properties in
human
health care professionals should at least be aware of the trends in herbal medicine utilization during
pregnancy so that they may educate themselves on herbal modes of action and avoid potentially
dangerous interactions in their patients.

5. Most common reasons for the use of herbal medicine during pregnancy
Facilitate labor
Promote health status
Traditional practice
Relieve common discomfort during pregnancy
Keep warm 17
Sexual pleasure
Restore youth
Prevent whitish discharge
Promote fetal physical health and intelligence
6. Basic flow of research & analysis on identification of element present in plant extract of a particular
herbal medicine

branches, flowers, and

grounded powder forms

digital stereomicroscope
images were taken

cyclically dehydrated
through a series of
ethanol washes (75%,
95%, and 100%) for 15
minutes each with 3
changes

preparations were
prepared for coating
within the sputter coater

preparations were
transferred into
specimen plate and
redried in a critical point
dryer for about half an
hour

preparations were then

removed from the ethanol
and dried via
hexamethyldisilazane
evaporative technique for
10 minutes

Elemental analysis using

Energy Dispersive X-Ray
(EDX) attached to the
VPSEM

Minimal three EDX

spectrums were acquired

SPORTS SCIENCE
1. What is doping?
Use of an expedient (substance or method) which is potentially harmful to athletes health and/or capable
of enhancing their performance or the presence in the athletes body of a prohibited substance or evidence
of the use thereof or evidence of the use of a prohibited method
2. Rationale of the usage of the hormone as performance enhancing drug
ln a normal individual, any loss of erythrocytes, such as by bleeding or haemolysis, decreases delivery of

oxygen to the tissues

When this tissue hypoxia is sensed by cells in the kidney and liver capable of producing EPO, they

produce and secrete EPO into the plasma

EPO is carried to the bone marrow, where it binds to specific cell surface receptors on its target cells

the CFU-E, pro-erythroblasts, and basophilic erythroblasts

The binding of EPO by these cells increases their ability to survive and reach the reticulocyte stage and

thereby contribute to the population of circulating erythrocytes.

The increased numbers of circulating erythrocytes in turn deliver more oxygen to the tissues.
This increased oxygen delivery is sensed by the EPO producing cells, which then reduce EPO production
so that the normal steady state number of erythrocytes is restored.

3. Major categories of performance enhancer

Anabolic agents (exogenous anabolic androgenic steroids, endogenous anabolic androgenic steroids)
Hormones & related substances (i.e. EPO, hGH, insulin like growth factors)
Agents with anti-estrogenic activity (anastrozole, letrozole)
Diuretics (furosemide, hydrochlorothiazide)
Stimulants (amphetamines, ephedrine, cocaine )
Canabinoids (marijuana, hashish)
Glucocorticoseroids (allowed externally but not internally)
4. Mechanisms of performance enhancer
Anabolic agents regulates building blocks (protein) for growth of body composition & masculinizing

characteristics
Hormones & related substances - (ex: growth hormone increases in tostesterone to grow faster & to

add additional muscle mass

Diuretics - to quickly lose weight & to reduce the concentration of other banned substances
Stimulants - example : amphetamine - increase alertness & aggressiveness & reduce fatigue

5. Life-threatening conditions of excessive usage of EPO by athletes

Excessive use of EPO leads to increase of hematocrit & hypertension & may arise even more dangerous

levels, likely due to dehydration, in athletes during & after training & competition
Potentially life-threatening thrombosis has occurred in the setting of dehydration & elevated
hematocrit (increased blood viscosity, sluggish blood flow in the small vessels of critical organs &
pulmonary emboli, stroke & death)

6. Life-threatening conditions of excessive usage of steroid by athletes

7. Adverse effect of EPO misuse in athletes

Excessive use of EPO leads to increase of hematocrit & hypertension & may arise even more dangerous

levels, likely due to dehydration, in athletes during & after training & competition
Potentially life-threatening thrombosis has occurred in the setting of dehydration & elevated
hematocrit (increased blood viscosity, sluggish blood flow in the small vessels of critical organs &
pulmonary emboli, stroke & death)

8. Adverse effect of steroid misuse in athletes

high blood cholesterol levels/ high blood pressure
Severe acne
thinning of hair & baldness
fluid retention
liver disorder/hepatotoxicity
sexual & reproductive disorders
MALE : atrophy of testicles, loss of sexual drive, decreased sperm production, breast & prostate

enlargement, sterility
FEMALE : menstrual irregularities, infertility, masculinizing effects such as facial hair, deepening
of voice, diminished breast size

Physiological effects :
Mood swing
Impaired judgment
Depression
Nervousness
Extreme irritability
Delusions
Hostility & aggression

9. Major issues related w/ detection of EPO misuse in sports

Two philosophies were developed for the detection of rHuEPO misuse in sports.
1. The first one was based on the detection of indirect blood markers
2. second one was based on the direct detection of rHuEPO in urine

The promotion of secondary blood markers was mainly on the basis that they could be used to detect
rHuEPO injected a long time ago (more than a week ago), and also that they could be used to detect all
kinds of erythropoietic stimulator such as erythropoietin alfa, beta, omega, and delta, and darbepoetin
alfa and mimetic peptides.
secondary blood markers could eventually be used to identify athletes who ceased using rHuEPO or
other erythropoietic stimulators.
In the meantime, scientists were working on the direct detection of rHuEPO in blood or urine.
This latter method had the advantage of identifying the drug itself (or metabolites), but had the
disadvantage of being expensive, little sensitive, and delicate to perform