The use of botulinum toxin in the management of burns itching: preliminary results

Itching is a common and well recognised problem following burns. As the underlying pathways involved in burns itch have been identified, different pharmacological agents have been introduced to improve the effectiveness of management regimes. We present preliminary data from an on-going study in the use of botulinum toxin as a novel agent in the treatment of this problem.

METHOD

Patients with recalcitrant itching secondary to burns treated with Botox(©) were identified. Data pertaining to burn size, depth and management were recorded. The delay in the onset of the itch, its severity and the speed and duration of any improvement in symptoms were also noted.

RESULTS

10 patients were identified. 1 patient was excluded. Average follow-up was 11.3 months. All patients had deep partial thickness to full thickness burns. Eight patients underwent grafting. The average burn was 24% TBSA. 87.5% of patients rated their burns itch as being severe (>7 on the pain scale). Following the administration of Botox(©) this fell to 0 out of 10 at 4 weeks. The average duration of the symptom free period was nine months (range 3-18 months).

CONCLUSION

Botox(©) can successfully be used to treat burns itch that are resistant to conventional therapies.

Formulation development of a cream containing fennel extract: in vivo evaluation for anti-aging effects

This study was aimed to formulate and evaluate anti-aging effects of a topical cream (w/o emulsion) containig extract of Fennel (Foeniculum vulgare) versus its base. Formulation containing 4% concentrated extract of Foeniculum vulgare was developed by entrapping in the inner aqueous phase of w/o emulsion and base contained no extract. Both the base and formulation were stored under different storage conditions to predict their stability. The formulation and base were evaluated for effect on skin moisture and transepidermal water loss (TEWL). The base showed insignificant while the formulation showed significant effects on skin moisture and TEWL. The parameter volume and surface evaluation of living skin (SELS) parameters SEr, SEsc, SEsm, SEw were also evaluated and showed a significant (p < or = 0.05) decline. The texture parameter energy showed a significant increase proving that the formulation possesses potential anti-aging effects.

Patients with congenital atrial septal defects: effect of age at repair and defect size on pulmonary artery pressures prior to repair

BACKGROUND

Pulmonary arterial hypertension (PAH) is a major complication of atrial septal defect (ASD) and can be responsible for significant functional limitations and early mortality. Various factors have been shown to predispose ASD patients to the development of PAH. Our study aimed to determine the association between the size of the ASD, the age of the patient and the increase in pulmonary artery pressures.

METHODS

Data from 74 ASD patients was retrospectively reviewed, including the patients' presenting symptoms, vital parameters, comorbidities, as well as their preoperative diagnostic workup. Echocardiography findings were used to determine the type and size of the ASD, and pulmonary artery pressures were evaluated using tricuspid regurgitation velocity as assessed by echocardiography or based on cardiac catheterization data. All patients underwent ASD repair either surgically or via percutaneous repair. Univariate and multivariate linear regression was performed to analyze the effect of age and defect size on pulmonary artery pressures. Model adequacy check was also done for the final model. Postoperative morbidity/mortality was additionally evaluated.

RESULTS

The study sample comprised 44.6% males and 55.4% females. The most prominent presenting features were shortness of breath (70.3%), chest pain (43.2%), and palpitations (33.8%), and arterial hypertension was the commonest morbidity. Using multiple linear regression analysis, age and size of ASD were found to be independently associated with pulmonary artery pressure. We found that for every 1 mm increase in the size of the ASD, pulmonary artery systolic pressure (PASP) increased by 0.32 mmHg ( P ≤ 0.05). Similarly, with every increase of one year in age, pulmonary artery pressure increased by 0.24 mmHg (P ≤ 0.02). No significant postoperative complications were reported following both types of repair.

CONCLUSIONS

Our study concludes that ASD patients are at greater risk of developing PAH with increasing age and increasing ASD size. This can potentially help to determine which ASD patients are at greater risk and require urgent repair of their defects. The study also shows that early repair is best to prevent complications.

Vaginal carriage rate of group B Streptococcus in pregnant women and its transmission to neonates

BACKGROUND

Maternal vaginal colonisation with Group B Streptococcus (GBS, Streptococcus agalactiae) at the time of delivery can cause vertical transmission to the neonate. GBS is the leading cause of sepsis, meningitis and pneumonia in the infants. Asymptomatic colonisation of the vagina with GBS varies with the geographical location.

METHODS

This was a cross-sectional study conducted in 2009 at Benazir Bhutto Hospital, Rawalpindi, Pakistan. Lower vaginal swabs were obtained from 200 pregnant women at the time of admission in the Gynaecology and Obstetrics Department for term, normal vaginal delivery and swabs from the skin of abdomen and ear canals of their respective neonates immediately after delivery were collected. Swabs were inoculated on blood agar and incubated aerobically and on Group B Streptococcus agar (GBS agar) and incubated anaerobically in an anaerobic jar. Identification of GBS was made on the basis of colonial morphology (beta-haemolytic colonies on blood agar and orange pigmented colonies on GBS agar), Gram stain, catalase test and conformation was done by means of latex agglutination tests.

RESULTS

A GBS carriage rate of 8.5% among pregnant women before delivery and an acquisition rate of 53% on the abdominal skin and 18% in the ear canals by the neonates of colonised mothers were found.

CONCLUSIONS

GBS colonisation in pregnant women and its transmission to the neonates is present in our population so GBS infections in the prenatal and neonatal period might not be uncommon in Pakistan, so routine screening should be carried out.

Staphylococcal nasal carriage of health care workers

OBJECTIVE

To determine the frequency of staphylococcal nasal carriage of health care workers (HCWs) and antimicrobial susceptibility profile of the isolates for appropriate decolonization therapy.

STUDY DESIGN

An observational study.

PLACE AND DURATION OF STUDY

The study was conducted at Holy Family Hospital, Rawalpindi, during the period from May 2007 to April 2008.

METHODOLOGY

Nasal swabs from anterior nares of HCWs were cultured and identified as Staphylococcus aureus, coagulasenegative staphylococci (CoNS), methicillin-resistant S. aureus (MRSA), methicillin-resistant CoNS (MRCoNS) by using standard methods. Antimicrobial susceptibility testing was performed on Muller Hinton Agar using disc diffusion method.

RESULTS

Of the 468 HCWs, 213 (45.5%) participants were men and 255 (54.5%) were women. Eighty five (18.2%) were nasal carriers of S. aureus, 07 (1.5%) for MRSA, 343 (73.3%) for CoNS and 10 (2.1%) for MRCoNS. The highest carriage rate for S. aureus was in midwives (30%) followed by maintenance staff (28.6%), security guards (25%), technicians (23.5%), staff nurses (22.7%) and < 20% in house physicians and nursing students. Carriage rate in HCWs from different departments was: surgical ICU (40%), gynaecology (34.9%), delivery room (30%), gynaecology operation rooms (25%), medicine (22.7%) and < 20% in pediatrics and surgery. All isolates were susceptible to vancomycin, imipenem and levofloxacin and > 90% of S. aureus and CoNS were susceptible to amikacin, gentamicin and fluoroquinolones tested.

CONCLUSION

Fluoroquinolones, preferably oral levofloxacin in combination with topical gentamicin ointment, in places like Pakistan where mupirocin is not routinely available, can be used for decolonization of nasal staphylococcal carriage.

Hospital acquired infections in a medical intensive care unit

OBJECTIVE

To determine the frequency of nosocomial infections and causative organisms in medical intensive care unit (ICU) patients and antimicrobial susceptibility pattern of the isolates.

STUDY DESIGN

A cross-sectional study.

PLACE AND DURATION OF STUDY

The Holy Family Hospital, Rawalpindi, during the period of May 2007 to April 2008.

METHODOLOGY

Clinical samples from patients having any signs of site-specific infections or fever appearing anytime after 48 hours of admission into ICU were collected. The samples were cultured onto suitable culture media and bacterial isolates were identified using standard biochemical methods. Antimicrobial susceptibility testing to conventional and newer antibiotics was performed on Mueller Hinton agar using disc diffusion method. Frequency percentages were determined.

RESULTS

Bacteria or Candida spp. were isolated from 269/440 (60.1%) samples. The most frequent site of infection was respiratory tract (47.95%) followed by urinary tract (25.3%). Pseudomonas (P.) aeruginosa, Klebsiella (K.) pneumoniae, Escherichia (E.) coli and Candida spp. were the commonest organisms. The isolation rate of Gram-positive bacteria was relatively low. Majority (> 50%) of the Gram-negative isolates were resistant to many of the antibiotics tested. Relatively low resistance was only observed against amikacin (21.3%) and imipenem (26.1%). Majority (> 60%) of Gram-negative isolates were resistant to cefotaxime, ceftriaxone and ceftazidime. The isolates showed high resistance to ofloxacin (65.9%) and ciprofloxacin (73.9%).

CONCLUSION

The high frequency of HAIs and antibiotic resistance rate, suggests that more strict infection control practices along with prescription of antibiotics after antibiotic susceptibility testing should be implemented to limit the emergence of antibiotic resistant organisms.

Is mechanical embolectomy performed in nonanesthetized patients effective?

BACKGROUND AND PURPOSE

In centers performing endovascular treatment for patients with AIS, there is variability in placing patients under general anesthesia. Nonanesthetized patients might move during the procedure leading to complications and prolonging the time to revascularization due to lack of cooperation. However, general anesthesia can lead to a delay of the procedure, an inability to assess the patient during the procedure, and fluctuations of blood pressure. Our center does not routinely either use general anesthesia or sedate patients. We report our experience with nonanesthetized patients undergoing emergent mechanical embolectomy.

MATERIALS AND METHODS

We performed a retrospective analysis of 66 consecutive patients enrolled in the MERCI Registry at our center from June 2007 to June 2009. A univariate statistical analysis was performed by using the Fisher exact test for categoric variables and the Student t test for continuous variables in comparing use of general anesthesia with nonanesthetized patient demographics, procedural times, procedural complications, good outcome, and mortality.

RESULTS

Nine patients (13.6%) were placed under general anesthesia, and 57 (86.4%) were awake. Higher baseline NIHSS scores and older age were statistically associated with general anesthesia. No significant difference occurred between groups in the time to groin puncture or procedural times. Revascularization rates were 77% for general anesthesia patients and 70% for nonanesthetized patients (P = .331). The nonanesthetized group had better outcomes, but we did not control these outcomes for other factors. Complications were much more frequent in the general anesthesia patients (22%) than in the nonanesthetized patients (3.5%) (P = .0288).

CONCLUSIONS

Performing mechanical embolectomy in nonanesthetized patients at our institution does not prolong procedure time, decrease revascularization rates, increase complication rates, or decrease good outcome. Mechanical embolectomy in nonanesthetized patients is effective and should be considered an option in the treatment of the patient with AIS.

In vitro ciprofloxacin resistance profiles among gram-negative bacteria isolated from clinical specimens in a teaching hospital

OBJECTIVE

To evaluate the trends of ciprofloxacin resistance pattern in commonly isolated gram-negative bacteria over time in a Saudi Arabian teaching hospital.

METHODS

A retrospective analysis was carried out for ciprofloxacin resistance patterns of 10089 isolates of gram-negative bacteria isolated from various clinical specimens submitted to microbiology laboratories at King Fahd Hospital of the University (KFHU), Alkhobar, Saudi Arabia during the period January 2002 to August 2005.

RESULTS

Increase in ciprofloxacin resistance rates in these isolates during the years 2002 and 2005 were as follows: Escherichia coli, 23.85 to 33.1%; Klebsiella pneumoniae, 15.93 to 27.55%; Enterobacter cloacae, 12.32 to 18.05%; Enterobacter aerogenes, 4.16 to 25.64%; Pseudomonas aeruginosa 17.05 to 39.53%, Pseudomonas spp., 20.58 to 58.77%; H. influenzae, 00.00% to 11.11% and H. aegyptius, 00.00% to 1.73%.

CONCLUSION

There was a gradual increase in resistance from year 2002 to 2005 in most of the gram negative isolates i.e. E. coli, K. pneumoniae, E. cloacae, E. aerogenes, P. aeruginosa and Pseudomonas spp showing that ciprofloxacin is no more a drug of choice for gram negative infections by these microbes.

Cutaneous sporotricosis

Sporotrichosis, a deep fungal infection caused by Sporothrix schenckii, is a rare disease. Infection acquired by traumatic implantation of fungus to the skin. Our patient a 40 years old woman presented with multiple erythematous, ulcerated, crusted nodules of different size and shape situated over the right little finger to upper arm along the course of the lymphatic in a linear fashion. Microscopic examination and culture of the discharge from the skin lesion was done. Sporothrix schenckii was detected on microscopic examination (Yeast form) and on culture (Mycelial form). The patient was treated with Itraconazole at a dose of 100 mg twice in a day for 6 months. She was clinically cured of the disease by 6 months and then the treatment was stopped. We do not commonly encounter sporotrichosis in our practice. We are therefore, prompted to report the case.

Production, characterization, in vitro and ex vivo studies of babchi oil-encapsulated nanostructured solid lipid carriers produced by a hot aqueous titration method

An aqueous dispersion of solid fat nanoparticles of babchi oil (BOSLN) was prepared by means of the hot water titration method. Surface morphology was determined by HR-TEM which revealed a fairly spherical shape of the formulations. Further they were evaluated for in vitro drug release characteristics and ex vivo skin permeation profile, zeta potential and particle diameter, rheological measures and droplet size distribution. Highest values for steady state flux (Jss), permeability coefficient (Kp) and enhancement ratio (Er) were observed for formulation, BOSLN3 comprised of oil [10% v/v; BO (3.33%), CAT (6.67%)], Tween 80 (9.25% v/v), transcutol-P (28.75% v/v) and distilled water (53% v/v). These results suggest that the studied SLN might be promising vehicles for babchi oil in the management of psoriasis.