379 Improving Flow: A Quality Improvement Project on The Processing of Vascular Surgical Microbiology Samples

Aim

Tissue samples taken during vascular surgical operations are commonly sent for microbiological analysis, owing to the relatively high incidence and serious consequences of infection in these cases. Delays in obtaining results from these samples can hinder clinical management, leading to prolonged inpatient stay and adverse clinical outcomes. The aim of this audit was to identify causes for delay in obtaining microbiology results and to improve the service.

Method

A closed loop quality improvement project performed at a tertiary vascular centre in London. We initially identified all tissue microbiology samples sent from vascular surgical operations performed during April 2019 and record the time when samples reach microbiology laboratory and the time when results were made available. Re-audit data was collected in November 2019.

Results

Initial audit showed that on average, results were available for clinicians 9.1 days after the sample was taken and 7.3 days after the sample had reached the laboratory. Samples required an average of 44 hours to transit to the laboratory and notably there is delay if surgery is performed on Friday (71 hours). Additionally, one sample was missing. Following utilization of the urgent sample pathway and raising awareness amongst staff, re-audit data showed significant reduction in average time of transit (33 hours) with much reduced transit time on Friday (36 hours). Results were available 7.7 days following sample date, compared to 9.1 days before.

Conclusions

Utilization of existing pathway and staff training can reduce delays in microbiology sample processing. However, further analysis is necessary to ensure sustained improvement.

Education: A compassionate use of cefiderocol to treat osteomyelitis caused by an XDR Pseudomonas aeruginosa

We report a 59-year-old male with left leg osteomyelitis caused by an XDR Pseudomonas aeruginosa strain following a road traffic accident. Limited treatment options and adverse antimicrobial reaction led to consideration of cefiderocol together with appropriate surgical intervention. Improved bony remodelling over the tibia and fibula was observed with good bony alignment and no adverse features. Physiotherapy support was continued for 4 months following treatment, which resulted in good functional mobility, improved proprioception and full ability to bear weight. This case also adds to multiple reports that describe safe and successful use of cefiderocol to treat MDR, aerobic Gram-negative infections. The prescribing information for cefiderocol is available at: https://shionogi-eu-content.com/gb/fetcroja/pi.

Factors associated with successful completion of outpatient parenteral antibiotic therapy (OPAT): A 10-year review from a large West London service

Outpatient parenteral antibiotic therapy (OPAT) is an established antimicrobial delivery method in the UK. OPAT services differ nationwide, with a paucity of high-quality outcome data to enable benchmarking. A retrospective review of clinical outcomes and adverse events (AEs) of all patients treated during 2008-2017 was performed to identify factors associated with success and failure. Regression models were used to identify factors associated with OPAT success, and AEs were described for the study population using definitions recommended by BSAC. In the 10-year period, 2870 patient episodes resulted in 69 610 days of treatment, with a 91.7% rate of successful therapy completion and 92.0% of infections cured or improved. We encountered 196 AEs, including 1 case of Clostridium difficile-associated diarrhoea. AEs occurred in 10.9% of patient episodes. Adverse drug and line events occurred at a rate of 3.3 and 1.78 per 1000 treatment days, respectively. Rashes, blood dyscrasias and hepatitis were the most common drug AEs. The odds of OPAT success was greater for patients who spent more time (>14 days) on OPAT therapy (OR = 2.32; P < 0.01), utilised a peripheral line (OR = 1.83; P < 0.01), were treated in the clinic compared with self-administration (OR = 2.1; P < 0.02) and did not experience an AE (OR = 0.23; P < 0.01). In our setting, the odds of a successful OPAT episode were associated with longer treatment course, OPAT delivered via a peripheral line, administration in an OPAT clinic setting, and no adverse line or drug events.

Anti-viral therapy for prevention of perinatal HBV transmission: extending therapy beyond birth does not protect against post-partum flare

BACKGROUND

Antepartum anti-viral therapy (AVT) is often administered to prevent perinatal transmission of hepatitis B virus (HBV) infection. Little is known about the effect of AVT on post-partum flare rates and severity.

AIM

To examine whether extending AVT beyond birth influences the post-partum course.

METHODS

One hundred and one pregnancies in 91 women with HBV DNA levels ≥log 7 IU/mL were included. AVT (initially lamivudine, later tenofovir disoproxil fumarate) was commenced from 32 weeks gestation and stopped soon after birth and at 12 weeks post-partum. Outcomes according to post-partum treatment duration were examined: Group 1 = AVT ≤4 weeks (n = 44), Group 2 = AVT >4 weeks (n = 43), Group 3 = no AVT (n = 14).

RESULTS

The majority of women were HBeAg+ (97%), median age 29 years, baseline HBV DNA log 8.0 IU/mL and follow-up 48 weeks post-partum. Post-partum treatment duration was 2 weeks for Group 1 and 12 weeks for Group 2, P < 0.01. Flare rates were not significantly different: Group 1 = 22/44 (50%), Group 2 = 17/43 (40%) and Group 3 = 4/14 (29%), P = 0.32. Onset of flare was similar at 8/10/9 weeks post-partum for Groups 1/2/3 respectively, P = 0.34. The majority of flares spontaneously resolved. HBeAg seroconversion (n = 1/5/1 in Groups 1/2/3, P = 0.27) was not associated with treatment duration or the occurrence of a post-partum flare.

CONCLUSIONS

Post-partum flares are common and usually arise early after delivery. They are often mild in severity and most spontaneously resolve. Extending anti-viral therapy does not protect against post-partum flares or affect HBeAg seroconversion rates.

Salmonella mycotic thoracoabdominal aortic aneurysm associated with chronic lymphocytic leukemia

Non-typhoidal Salmonella infections typically cause self-limiting gastroenteritis. However, extraintestinal focal infections, including mycotic aneurysms of the aorta, can also occur. We present the case of a 71-year-old man with chronic lymphocytic leukemia (CLL) and a large type V thoracoabdominal mycotic aneurysm infected with Salmonella enteritidis, complicated by thoracolumbar spondylodiscitis, paravertebral collections, and epidural abscess. This is the first report of Salmonella aortitis in the setting of CLL, and the unusual extent of local infective invasion seen here with Salmonella enteritidis infection raises a suspicion of CLL-related immunosuppression as a direct predisposing factor. This case illustrates the need to consider the possibility of an immune defect, even in CLL patients with normal leukocyte counts. The underlying mechanisms are unclear, but are likely to involve defects in cell-mediated immunity, thought to be of particular importance in invasive infections with intracellular pathogens such as Salmonella spp.

Matching the numerator with an appropriate denominator to demonstrate low amputation incidence associated with a London hospital multidisciplinary diabetic foot clinic

AIMS

To establish a method to assess amputation incidence that addresses the problems matching a numerator with an appropriate denominator in London and to demonstrate low amputation incidence associated with the activity of our multidisciplinary diabetic foot clinic.

METHODS

Hospital-coded inpatient data was examined to derive the numerator: the number of non-traumatic amputations performed on subjects with diabetes each financial year where the Primary Care Trust commissioner code was our main local Primary Care Trust. Denominators were derived from the main local Primary Care Trust's Quality and Outcomes Framework data sets. Not all Primary Care Trust subjects with diabetes receive inpatient care at our hospital, so that the denominators were corrected for the hospital's percentage market share for the provision of inpatient diabetes care for the Primary Care Trust each financial year, derived from the Dr Foster database.

RESULTS

Between April 2004 and April 2009, 44 Primary Care Trust subjects with diabetes underwent 34 minor and 10 major amputations at the hospital. Although the Primary Care Trust populations with and without diabetes increased, the hospital's Primary Care Trust percentage market share decreased, so that overall denominators decreased. The mean annual incidence of minor, major and total amputations over the five financial years was 14.7, 4.2 and 18.9 per 10 000 subjects with diabetes,respectively, and 3.9, 1.1 and 5.0 per 100 000 of the general population, respectively.

CONCLUSIONS

We report for the first time amputation incidence in a London population. Acknowledging the limitations of accurately defining incidence in London, we demonstrate low amputation incidence associated with our multidisciplinary diabetic foot clinic.

Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging

AIMS

To assess efficacy of conservative management of neuropathic forefoot ulcers with underlying osteomyelitis in subjects with diabetes when magnetic resonance imaging (MRI) is used to confirm or establish diagnosis and to guide antibiotic duration.

METHODS

A retrospective cohort study over 6 years assessing rates of ulcer healing, relapse and amputation. Antibiotics were continued for 3-month cycles with interval MRI: if the lesion had healed and bone signal change resolved or improved, antibiotics were discontinued; if the lesion had not healed or there was no difference in bone signal change, antibiotics were continued for a further 3-month cycle; clinical or radiological deterioration resulted in endoluminal or open vascular surgical intervention where appropriate, or digital or more proximal amputation.

RESULTS

There were 53 episodes in 47 subjects (mean +/- sd age 62 +/- 13 years, duration of diabetes 19 +/- 13 years, glycated haemoglobin 8.4 +/- 1.6%; six with Type 1 diabetes and seven with end-stage renal failure). Successful healing without relapse was achieved in 40 episodes (75%) [median (range) duration of antibiotics 6 (3-12) months and follow-up post-cessation of antibiotics 15 (3-58) months]. Relapse occurred in six episodes (13%) at 31 (2-38) months post-cessation of antibiotics. There were one major (2%) and eight minor (15%) amputations. Five subjects have died (11%), all without foot ulcers.

CONCLUSIONS

High rates of healing and low rates of amputation were achieved. The use of MRI was associated with long courses of antibiotics, but particularly low relapse rate.

Harm reduction in the developing world

This paper examines harm reduction from the perspective of poor countries. In considering which elements of the broad approach are suitable for adaptation and adoption by poor countries, there is a need to examine critically the arguments put forth in support of it and which, if any, of these are supported by evidence. There are also significant indirect influences that the approach is likely to have on how drug use is understood and interpreted by wider society. The likely impact of these on areas other than simply services directed to drug users needs to be assessed. There are some features regarding harm caused by alcohol and other drug use that are specific to poor countries. Most important among these is that levels of use which are not deemed to be harmful in rich societies cause grave harm through diverting meagre resources away from survival needs in the poor world. Alcohol, as well as other drugs, tends in deprived settings to cause dependence and other problems much earlier in people's drinking careers and at much lower levels of consumption than in rich countries.

Hook wire localization procedure in biopsy and diagnosis of early breast cancers: Oman experience

INTRODUCTION

Between January 2000 and December 2005, a total of 30 cases of impalpable suspicious breast lesions (microcalcifications or impalpable lumps classified as BRADS IV and above) were biopsied after hook wire localization. This is a retrospective review of these cases.

RESULTS

One third of the suspicious lesions were malignant or pre-malignant. All these had further oncological treatment and follow up.

CONCLUSIONS

Hook wire localization biopsy remains an important tool for the diagnosis of impalpable lesions of the breast. The incidence of malignancy in our series was similar to the published international levels. Our series is small, so there is a need to review the data with bigger number.

Sentinel lymph node biopsy in the Sultanate of Oman

OBJECTIVE

To establish the feasibility of newly started sentinel lymph node (SLN) biopsy in our center at the Royal Hospital in the Sultanate of Oman.

METHODS

Twenty five patients with Breast cancer and melanoma were staged with sentinel lymph node (SLN) biopsy, followed by Axillary lymph Node Dissection (ALND). Axillary SLN were detected by injection of blue dye alone or with radioisotope. Intraoperatively, a gamma probe detector identified the isotope-labeled SLN. Two patients underwent preoperative lymphoscintigraphy. The SLNs were examined histologically by hematoxylin-eosin staining and, if negative by this method an immunohistochemical staining (IHC) was done.

RESULTS

The only failure to detect inguinal SLN was one case after neoadjuvant chemotherapy. Total detection rate of SLN was of 96%. Metastatic spread occurred in 11 patients of these 9 had other lymph node (LN) involved. Nine patients had no SLN involvement and no other LNs involved.

CONCLUSIONS

Ethically, according to the international recommendations and looking to the statistics of the Sultanate all clinical NO should have the choise of SLN biopsy prior to ALND.

Meckel Gruber syndrome--a single gene cause of recurrent neural tube defects

Meckel Gruber syndrome (MGS), an autosomal recessive disorder characterised by posterior encephalocoele, multicystic kidneys and post-axial polydactyly should be recognised by obstetricians and paediatricians to counsel parents regarding the 25% recurrence risk. We report a consanguineous family with MGS affecting three infants.

Which patients with hepatitis C develop liver complications?

To identify variables that are independent predictors of adverse outcomes in chronic hepatitis C, we analyzed a cohort of 455 patients followed for a median of 4.7 years. Associations were sought between demographic and behavioral factors, hepatitis C virus (HCV) genotype, liver histology and liver tests at entry, and development of liver complications, hepatocellular carcinoma (HCC), hepatic transplantation and liver-related death. Independent predictors were identified by multivariate analysis. The following were associated with a significantly higher rate of liver complications: age; birth in Asia, Europe, Mediterranean region, or Egypt; transmission by blood transfusion or sporadic cases; HCV genotypes 1b and 4 (compared with 1/1a); fibrosis stage 3 or 4 (cirrhosis); serum albumin; bilirubin; prothrombin time; and alpha-fetoprotein. However, the only independent predictors of liver-related complications were sporadic transmission (P <.001), advanced fibrosis (P =.004), and low albumin (P <.001). The corresponding independent risk factors for HCC were male gender (P =. 07), sporadic transmission (P <.001), and albumin (P <.001); bilirubin (P =.02) was an additional predictor of transplantation or liver-related death. It is concluded that only patients with advanced hepatic fibrosis or cirrhosis, are at risk of developing hepatic complications of chronic hepatitis C during 5-year follow-up. Among such patients, abnormalities in serum albumin, bilirubin, or prothrombin time indicate a high probability of complications. Patients without definite risk factors for HCV (sporadic cases) are at higher risk of complications, possibly because of interaction between older age, duration of infection, country of birth, and HCV genotypes 1b and 4.

RP59500 (Quinupristin/dalfopristin): three case reports of its use in infection due to Enterococcus faecium

We describe three cases of Enterococcus faecium sepsis arising in immunocompromised patients, severely ill with other conditions, who were treated with the new injectable streptogramin RP59500. There are still few reports of clinical experience with this drug. All had bacteriological resolution, with one patient recovering fully. Although two of the three patients died, this was due to underlying disease in one case and a gram-negative superinfection in another. Quinupristin/dalfopristin therapy was not associated with significant adverse effects in any of the patients.

TB or not TB?

These 3 cases illustrate what we believe to be unusual presentations of tuberculosis. In no case was there conclusive proof of infection with Mycobacterium tuberculosis using histological, microbiological or radiological techniques. All were treated empirically with anti-tuberculous medication, with complete recovery. With the re-emergence of tuberculosis, there may be a rise in such cases, and the importance of their recognition and empirical treatment is discussed.

Cytological diagnosis of Paget's disease of the nipple by scrape smears: a report of five cases

Five cases of mammary Paget's disease were diagnosed by nipple scrape cytology. The neoplastic material obtained was abundant in two cases, moderate in one, but in two, only a few cell aggregates feature in three cases and this, together with dense tumour cell cytoplasm and the background of keratinous debris, may impart a squamous-like appearance; however, three-dimensional cell aggregates, papillary-like groups, acinar-like collections, and some cells with vacuolated cytoplasm and eccentric nuclei allowed glandular differentiation to be inferred in three cases. In four cases a combination of clinical evaluation, and cytological findings of malignant cells compatible with Paget's disease was used so that mastectomy could proceed, and in one case there was frozen section confirmation of an underlying invasive carcinoma. In the single case in which it was performed, there was positive immunoperoxidase staining for c-erb B2 oncoprotein. Demonstration of this protein, CEA, or mucin, helps distinguish Paget's disease from melanoma or squamous cell carcinoma in-situ.

Reducing tobacco use in Sri Lanka

Tobacco use is steadily declining in wealthy countries, whereas it is increasing in poor countries. Approaches found successful in wealthy countries should be applied vigorously in Sri Lanka too. This requires sustained and active lobbying, especially by doctors. Some promising strategies are already being used in Sri Lanka which indicate that countries such as ours could develop appropriate local approaches in addition to those found useful in rich countries. These have evolved with little active support from the medical profession. If doctors actively complement these efforts, Sri Lanka could provide a model in successful smoking control for poor nations.

Intermittent supervised treatment of tuberculosis at Green Lane Hospital, 1987-8

AIMS

to assess the results of the first two years experience with intermittent supervised treatment of tuberculosis (IST) in Auckland, looking especially at practical problems.

METHOD

the hospital records of the 16 patients who received IST during 1987-8 were reviewed retrospectively, and public health nurses who administered the medications were questioned about problems that were encountered.

RESULTS

two-thirds of those who were given IST were Polynesian. In retrospect, the need for IST could have been anticipated in eight of the 12 patients (67%) who failed to comply with daily treatment. Five of the 16 IST patients presented major problems to the nurses supervising the twice weekly treatment. Poor motivation, itinerancy and alcohol abuse were the most common factors causing difficulty. IST was successfully completed in 13/16 patients (81%) and was abandoned in only one patient. Only two patients completed IST with a drug regimen for resistant organisms. Health nurse supervision resulted in improvements in understanding and attitude to tuberculosis, eventually enabling two patients to self medicate without supervision.

CONCLUSIONS

IST is a practical treatment method in New Zealand, permitting curative therapy in a group of tuberculosis patients who would otherwise create risks of drug resistance, disease reactivation and spreading the disease.

The clinical associations with hepatic steatosis: a retrospective study

Hepatic steatosis is a common liver biopsy finding. As a preamble to a study of nonA, nonB hepatitis we aimed to determine the clinical associations in patients who had hepatic steatosis on biopsy. All liver biopsies performed in the gastroenterology department at Auckland Hospital between 1986 and 1989 were reviewed for evidence of steatosis and the clinical associations analysed. Steatosis was present in 69 (43.7%) of 158 liver biopsy specimens with 35 being mild (47%), 29 moderate (45%) and five severe (7%). Excess alcohol intake was the probable aetiological association in 28 (45%), obesity in 17 (27%) and diabetes mellitus in seven (11%). No causal association could be identified in 17 (24%) and included three of the five cases with severe steatosis. There were no significant differences in clinical presentation, biochemistry or hepatic histopathology between alcoholic and nonalcoholic steatosis. Nonalcoholic steatosis appeared to be more benign with only one case of cirrhosis but further follow up is required to determine true prognosis.

Duodenal ulcer relapse after eradication of Helicobacter pylori

Thirty-six patients with healed duodenal ulcers, 27 infected with Helicobacter pylori and nine uninfected, were followed for up to 12 months to determine the rate of ulcer relapse. Eight patients withdrew over the follow up period. At one year, 15 of 20 (75%) infected patients and one of eight (13%) uninfected patients had relapsed, p less than 0.05. Eradication of H pylori favourably influences the natural history of duodenal ulcer recurrence. Significant patient morbidity may be prevented by using measures to eradicate H pylori during or after duodenal ulcer healing.

Acceptance of a psychiatric screening questionnaire by general practice attenders

The general health questionnaire (GHQ) is a self-reporting psychiatric screening questionnaire which has been tested and validated in a number of languages and cultural settings. The translated and validated 30 item GHQ was given to a selected sample of women between 15 and 49 years attending a suburban general practice, as a part of a study on emotional disorder. The acceptance of the questionnaire was high with a compliance of 91.5% from those who were invited to participate. The majority of respondents showed much interest and willingness in filling in the questionnaire.

Treating alcohol problems in Sri Lanka

Treatment in settings where facilities are limited poses many challenges. Attempts are being made to use untrained but committed people to help dependent persons maintain abstinence after withdrawal. This experience makes us question the need for highly trained specialized staff in helping in this task.

Behavior therapy in Sri Lanka

The development of behavior therapy in Sri Lanka is presented. Its beginnings in the decade of the 70s in the two medical schools in Colombo and Peradeniya and its current status are reviewed, and future prospects are discussed. The need for developing and expanding behavior therapy practice in the country, and possible directions in training, are commented on.

The ependyma of the saccular pineal gland in the non-eutherian mammal Trichosurus vulpecula. A scanning electron microscopic study

The pineal gland in the possum is represented by a thickening in the wall of the pineal recess. A superficial pineal body and a pineal stalk are characteristically lacking. The ependyma related to the gland is specialized but differs markedly from the lining in other circumventricular organs in form and in surface morphology. Two distinct topographic zones have been recognized. In the middle is a mass of cells which form a prominent knobby-surfaced central zone. These cells are characterized by the absence of cilia, the paucity of microvilli and blebs and the presence of processes which overlap adjacent cells. A surface pattern formed of cell outlines was lacking. it is suggested that the central zone is lined by pinealocytes, supporting cells and the processes of both cell types. Most of the central zone is surrounded by an intermediate zone of variable width. The latter region has been observed to possess a circumventricular organ-type surface morphology. It is sparsely ciliated, almost totally covered by a carpet of microvilli and it exhibits a variety of surface specializations. Supraependymal cells and various transitory supraependymal cell processes are also present. Outside the specialized ependyma is the peripheral zone which like the regular ventricular lining is densely ciliated. Supraependymal processes are found among the clusters of cilia, or rarely, on the surface of the ciliary bed. Season and sex related differences in surface ultrastructure were not observed.