Deciphering risk factors for blood stream infections, bacteria species and antimicrobial resistance profiles among children under five years of age in North-Western Tanzania: a multicentre study in a cascade of referral health care system

BACKGROUND

Blood stream infections (BSIs) cause a complex cascade of inflammatory events, resulting in significant morbidity and mortality in children in Tanzania. This study was designed to delineate circulating bacterial species, antimicrobial resistance (AMR) profiles and risk factors for BSIs and mortality among children in the cascade of referral health care facilities so as to guide comprehensive BSIs management.

METHODS

A multiple cross sectional analytical study was conducted between July 20, 2016 to October 04, 2017 involving 950 children less than five years of age in the North-western part of Tanzania. Children with clinical features suggestive of BSIs were included. Demographic, clinical and laboratory information on culture and antimicrobial susceptibility testing was collected from children; and analyzed using STATA version 13.0 software.

RESULTS

The prevalence of BSIs among children was 14.2% (95% CI: 12.1-16.6%), with specific prevalence in the district, regional and tertiary hospitals being 8.3, 6.4 and 20.0%, respectively. The most common bacterial pathogens isolated from 135 culture-positive children were Klebsiella pneumoniae (55, 40.4%), Staphylococcus aureus (23, 17.0%), and Escherichia coli (17, 12.6%). Multi-drug resistance (MDR) was higher in isolates from children at Bugando Medical Centre (BMC) tertiary hospital than isolates from district and regional hospitals [OR (95% CI): 6.36 (2.15-18.76); p = 0.001]. Independent risk factors for BSIs were neonatal period [OR (95% CI): 1.93 (1.07-3.48); p = 0.003] and admission at BMC [2.01 (1.08-3.74); p = 0.028)]. Approximately 6.6% (61/932) of children died, and risk factors for mortality were found to be children attending BMC [OR (95% CI): 4.95 (1.95-12.5); p = 0.001)], neonatal period [OR (95% CI): 2.25 (1.02-5.00); p = 0.045)], and children who had blood culture positive results [OR (95% CI): 1.95 (1.07-3.56); p = 0.028)].

CONCLUSIONS

The prevalence of BSIs (14.2%) in this multi-centre study is high and predominantly caused by the MDR K. pneumoniae. Priority interventional measures to combat BSIs and mortality, specifically among neonates at BMC are urgently recommended.

Is axillary ultrasound imaging necessary for all patients with breast cancer?

Better use selectively

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part II1

BACKGROUND

Chronic venous disease (CVD) is extremely common worldwide with prevalence increasing with age. It is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. In this retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany a holistic evaluation of varicose vein surgeries has been undertaken. Part I covered postoperative complications in relation to co-morbidities, co-medication and clinical presentation. Part II of this article presents now the hemodynamic results in relation to the perioperative evolution of CVI specific symptoms.

METHODS

Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed with regards to perioperative hemodynamics. Evolution of CVI symptomology was accessed postoperatively with the help of a questionnaire and patient records in the case of complication development. Venous hemodynamics was analysed in the whole patient population and with regards to complication subgroups: no events (NE), neglectable adverse events (NAE) and non-neglectable adverse events (NNAE).

RESULTS

Postoperatively, patients' CVI-symptoms like pain (p < 0.001), swelling (p < 0.001) and itching (p = 0.003) significantly improved. The venous refill time and venous pump capacity improved significantly after open vein surgery (p < 0.05). Regardless of the development of postoperative complications there was a significant improvement of venous function at 6 weeks- and one-year postoperative in follow-up (p < 0.05). Symptom regression was strongly correlated with hemodynamic improvement.

CONCLUSION

A significant improvement of patients' symptoms was achieved by means of open-surgery, regardless of postoperative complication development. This was in accordance with the improvement of venous hemodynamics. A strong correlation between symptom regression and improvement in venous hemodynamics could be proven.

Detection of Aliphatically Bridged Multi-Core Polycyclic Aromatic Hydrocarbons in Sooting Flames with Atmospheric-Sampling High-Resolution Tandem Mass Spectrometry

This paper provides experimental evidence for the chemical structures of aliphatically substituted and bridged polycyclic aromatic hydrocarbon (PAH) species in gas-physe combustion environments. The identification of these single- and multicore aromatic species, which have been hypothesized to be important in PAH growth and soot nucleation, was made possible through a combination of sampling gaseous constituents from an atmospheric pressure inverse coflow diffusion flame of ethylene and high-resolution tandem mass spectrometry (MS-MS). In these experiments, the flame-sampled components were ionized using a continuous VUV lamp at 10.0 eV and the ions were subsequently fragmented through collisions with Ar atoms in a collision-induced dissociation (CID) process. The resulting fragment ions, which were separated using a reflectron time-of-flight mass spectrometer, were used to extract structural information about the sampled aromatic compounds. The high-resolution mass spectra revealed the presence of alkylated single-core aromatic compounds and the fragment ions that were observed correspond to the loss of saturated and unsaturated units containing up to a total of 6 carbon atoms. Furthermore, the aromatic structures that form the foundational building blocks of the larger PAHs were identified to be smaller single-ring and pericondensed aromatic species with repetitive structural features. For demonstrative purposes, details are provided for the CID of molecular ions at masses 202 and 434. Insights into the role of the aliphatically substituted and bridged aromatics in the reaction network of PAH growth chemistry were obtained from spatially resolved measurements of the flame. The experimental results are consistent with a growth mechanism in which alkylated aromatics are oxidized to form pericondensed ring structures or react and recombine with other aromatics to form larger, potentially three-dimensional, aliphatically bridged multicore aromatic hydrocarbons.

Enabling liquid vapor analysis using synchrotron VUV single photon ionization mass spectrometry with a microfluidic interface

Vacuum ultraviolet (VUV) single photon ionization mass spectrometry (SPI-MS) is a vacuum-based technique typically used for the analysis of gas phase and solid samples, but not for liquids due to the challenge in introducing volatile liquids in a vacuum. Here we present the first demonstration of in situ liquid analysis by integrating the System for Analysis at the Liquid Vacuum Interface (SALVI) microfluidic reactor into VUV SPI-MS. Four representative volatile organic compound (VOC) solutions were used to illustrate the feasibility of liquid analysis. Our results show the accurate mass identification of the VOC molecules and the reliable determination of appearance energy that is consistent with ionization energy for gaseous species in the literature as reported. This work validates that the vacuum-compatible SALVI microfluidic interface can be utilized at the synchrotron beamline and enable the in situ study of gas-phase molecules evaporating off the surface of a liquid, which holds importance in the study of condensed matter chemistry.

Functional Relationships between Kinetic, Flow, and Geometrical Parameters in a High-Temperature Chemical Microreactor

Computational fluid dynamics (CFD) simulations and isothermal approximation were applied for the interpretation of experimental measurements of the C₁₀H₇Br pyrolysis efficiency in the high-temperature microreactor and of the pressure drop in the flow tube of the reactor. Applying isothermal approximation allows the derivation of analytical relationships between the kinetic, gas flow, and geometrical parameters of the microreactor, which, along with CFD simulations, accurately predict the experimental observations. On the basis of the obtained analytical relationships, a clear strategy for measuring rate coefficients of (pseudo) first-order bimolecular and unimolecular reactions using the microreactor was proposed. The pressure- and temperature-dependent rate coefficients for the C₁₀H₇Br pyrolysis calculated using variable reaction coordinate transition state theory were invoked to interpret the experimental data on the pyrolysis efficiency.

Anti-Phospholipid Antibody Syndrome with Subdural Hematoma: A Case Report

A 33-year-old man with anti-phospholipid antibody syndrome associated with Budd Chiari syndrome and subdural hematoma. He developed venous thrombosis in his hepatic vein (stenting done) when laboratory studies demonstrated prolongation of activated partial thromboplastin time (APTT). Subdural hematoma demonstrated with Computed tomography (CT) of brain. Laboratory studies revealed thrombocytopenia, prolonged bleeding time and APTT, positive antinuclear antibody and positive test results for both lupus anticoagulant and an anti-cardiolipin antibody, namely antiphospholipid antibodies. Based on these findings, we consider that the tendency of this bleeding may have been due to antiphospholipid antibodies, attacking the platelet membranes and that the bridging veins in the subdural space may be the site at which the bleeding tendency easily appears. Antiphospholipid antibody syndrome accompanied by hemorrhagic complications had rarely been reported. We suggest that special attention should be given to hemorrhagic complications in patients with antiphospholipid antibody syndrome associated with fragility of the vessels and/or platelet dysfunction and on anticoagulant (warfarin).Pulse Vol.10 January-December 2017 p.25-28

Implementation of a 1-2 keV point-projection x-ray spectrometer on the National Ignition Facility

A point-projection soft X-ray Opacity Spectrometer (OpSpec) has been implemented to measure X-ray spectra from ∼1 to 2 keV on the National Ignition Facility (NIF). Measurement of such soft X-rays with open-aperture point-projection detectors is challenging because only very thin filters may be used to shield the detector from the hostile environment. OpSpec diffracts X-rays from 540 to 2100 eV off a potassium (or rubidium) acid phthalate (KAP or RbAP) crystal onto either image plates or, most recently, X-ray films. A "sacrificial front filter" strategy is used to prevent crystal damage, while 2 or 3 rear filters protect the data. Since May 2017, OpSpec has been recording X-ray transmission data for iron-magnesium plasmas on the NIF, at "Anchor 1" plasma conditions (temperature ∼150 eV, density ∼7 × 10²¹ e ^-/cm³). Upgrades improved OpSpec's performance on 6 NIF shots in August and December 2017, with reduced backgrounds and 100% data return using filter stacks as thin as 2.9 μm (total). Photometric noise is beginning to meet requirements, and further work will reduce systematic errors.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Protein C Deficiency Causing Recurrent Myocardial Infarction in a Young Male

Protein C is one of the most important factors that prevent blood from clotting. Protein C deficiency usually leads to venous thrombosis. We intend to report a male of 38 years admitted in coronary care unit of Dhaka Medical College Hospital, who suffered recurrent episodes of myocardial infarction, whose traditional risk factors were well controlled. Ultimately he was diagnosed with protein C deficiency, which is not commonly implicated in arterial thrombosis. Protein C deficiency can rarely cause severe life threatening arterial thrombosis, like myocardial infarction. Many more cases are reported in recent literature. It can happen sporadically. A high degree of suspicion should be maintained if traditional risk factors are absent in instances of arterial thrombosis, to look for protein C deficiency.

Practical consensus recommendation on when to do BRCA testing

BRCA-mutation associated breast cancer and to future cancer risks and sensitivity to systemic therapies. Now that rapid genetic testing for BRCA1 and BRCA2 mutations is available, BRCA mutation status can be considered when making treatment and prevention decisions for BRCA testing, BRCA mutation carriers with breast cancer. Expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

Practical consensus recommendations regarding the management of HER2 neu positive early breast cancer

Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations with regards to the use of these agents and the management of HER2 neu early breast cancer for the benefit of community oncologists.

Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds' hip fractures treated with DHS fixation?

INTRODUCTION

80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively.

METHODS

A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P < 0.05 was considered significant.

RESULTS

648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009).

CONCLUSION

There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K.

IMPLICATIONS

Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.

Ultrasound guided percutaneous nephrostomy: Experience at ahmadu bello university teaching hospital, Zaria

BACKGROUND

Obstructive uropathy is a common problem in urologic practice; temporary relief of obstruction in the upper tract poses a significant challenge. Ultrasound-guided percutaneous nephrostomy (PCN) is an option for upper tract drainage; compared to fluoroscopic guidance, it is readily available, affordable, and not associated with radiation exposure. We present our experience with ultrasound-guided PCN.

PATIENTS AND METHODS

We studied all patients who had ultrasound-guided PCN in our center between January 2013 and January 2017. Information obtained included the patients' demographics, clinical details, primary pathology, indications, outcome, and complications within 30 days. Relevant data were extracted and analyzed using descriptive statistics.

RESULTS

A total number of 35 PCNs were performed in 26 patients within the period of study. The median age was 44.5 years. There were 17 females and 9 males. About 88.2% of the females had ureteric obstruction from advanced carcinoma of the cervix while the predominant cause of obstruction in the males was advanced carcinoma of the bladder. Kidney access under ultrasound guidance required well dilated collecting systems for success and ease of puncture. The most common complication was hematuria, which resolved within 24-48 h in all patients uneventfully.

CONCLUSION

PCN is an important and common procedure for temporary relief of upper urinary tract obstruction. While fluoroscopic guidance provides superior image guidance, ultrasound guidance is comparatively reliable, albeit with a longer learning curve. Adequate training, careful patients selection, and patience are key to success.

RELATIONSHIP OF ELECTRICAL RESISTANCE OF VAGINAL MUCUS DURING OESTRUS WITH POST-AI PREGNANCY IN COWS

Accurate detection of oestrus is a common problem for farmers to do AI timely resulting in conception failure in cows. The objective of the present study was to know the electrical resistance of vaginal mucus (ERVM) during oestrus to determine the best time of AI for improvement of conception in cattle. A total of 28 cows were inseminated with frozen thawed semen after detection of ERVM with Draminski estrus detector at Kendua Upazila Livestock Office under Netrakona district of Bangladesh. Pregnancy was diagnosed by per rectal palpation of genital tract 8-10 weeks after insemination. The mean ERVM in pregnant cows was 208.5 ± 31.2 Ω (163.3 to 263.3 Ω) and the ERVM in non-pregnant cows was 214.4 ± 36.6 Ω (153.3 to 280.0 Ω). Moreover, the pregnancy rate was higher in cows (80.0 to 83.3%) when ERVM during oestrus varied from 150 to 220 Ω than that of 221 to 280 Ω counterpart (36.4%). The difference in pregnancy rates between groups was significant (P<0.05). The present study indicates that Dramniski electrical heat detector may be used for prediction of time for AI in cows of Bangladesh. Up to 220 Ω ERVM during oestrus is better for higher conception rate than that of more than 220 Ω counterparts. Further studies with high number of inseminated cows should be conducted before wide application of this electrical heat detector under field conditions in Bangladesh.

Rhodium-calix[4]pyrrole and rhodium-tetraphenyl porphyrin: preparation, surface grafting and their catalytic application in nitro-benzene reduction

Rhodium containing macromolecules calix[4]pyrrole (RhCP) and tetraphenyl porphyrin (RhTPP) were prepared, grafted on functionalized SBA-15 and demonstrated as promising catalysts for nitro-arene reduction.

UK Consensus on Normal Tissue Dose Constraints for Stereotactic Radiotherapy

Six UK studies investigating stereotactic ablative radiotherapy (SABR) are currently open. Many of these involve the treatment of oligometastatic disease at different locations in the body. Members of all the trial management groups collaborated to generate a consensus document on appropriate organ at risk dose constraints. Values from existing but older reviews were updated using data from current studies. It is hoped that this unified approach will facilitate standardised implementation of SABR across the UK and will allow meaningful toxicity comparisons between SABR studies and internationally.

Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation

Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered.

Design This is a case report.

Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital.

Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock.

Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support.

Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy.

Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.

High-intensity focused ultrasound in the treatment of breast fibroadenomata (HIFU-F trial)

BACKGROUND

High-intensity focussed ultrasound (HIFU) is a non-invasive ablative technique utilising the application of high frequency ultrasound (US) pressure waves to cause tissue necrosis. This emerging technology is currently limited by prolonged treatment times. The aim of the HIFU-F trial was to perform circumferential HIFU treatment as a means of shortening treatment times.

METHODS

A prospective trial was set up to treat 50 consecutive patients ≥18 years of age. Eligible patients possessed symptomatic fibroadenomata, visible on US. Patients ≥25 years of age required histological confirmation of the diagnosis. Primary outcome measures were reduction in treatment time, reduction in volume on US after 12 months and complication rates.

RESULTS

HIFU treatment was performed in 51 patients (53 treatments) with a mean age of 29.8 years (SD 7.2 years) and a diameter of 2.6 cm (SD 1.4 cm). Circumferential ablation reduced treatment times by an estimated 19.9 min (SD 25.1 min), which is a 29.4% (SD 15.2%) reduction compared with whole lesion ablation. Volume reduction of 43.2% (SD 35.4%; p < 0.005, paired t-test) was observed on US at 12 months post-treatment. Local complications completely resolved at 1 month apart from skin hyper-pigmentation, which persisted in nine cases at three months, six cases at 6 months and six at 12 months.

CONCLUSION

Circumferential HIFU treatment for breast fibroadenomata is feasible to reduce both lesion size and treatment time. HIFU is a non-invasive alternative technique for the treatment of breast fibroadenomata. ISRCTN registration: 76622747.