Molecular characterization of extended-spectrum β-lactamase-producing Escherichia coli isolated from postpartum uterine infection in dairy cattle in India

BACKGROUND AND AIM

Selection and dissemination of plasmid-encoded extended-spectrum β-lactamase (ESBL) among Enterobacteriaceae confers resistance to beta-lactam antibiotics. The purpose of this study was to determine the prevalence and molecular characteristics of ESBL-producing organisms isolated from dairy cattle with a uterine infection.

MATERIALS AND METHODS

Bacterial isolates (n=62) were characterized by biochemical test for genus and species determination. Antimicrobial susceptibility tests were performed by Kirby-Bauer disk diffusion method using panel of antibiotics for initial screening of ESBL organism. Phenotypic confirmation of ESBL-suspected strains was done by combination disk method and double-disk method. Multiplex polymerase chain reaction (PCR) was carried out for phylogrouping of Escherichia coli isolates as well as for genotyping ESBL genes. Enterobacterial repetitive intergenic consensus-PCR method was used for genotypic characterization of isolates.

RESULTS

Antibiotic susceptibility profile of E. coli (n=40) isolates showed high rates of resistance for ampicillin (95.0%), cefpodoxime (97.5%), cefotaxime (87.5%), and ceftriaxone (70%). However, low rates of resistance were observed for cefoxitin (25%), amoxicillin/clavulanic acid (20%), ceftazidime (17.5%), gentamicin (10%), and ertapenem (7.5%). A total of 39/40 E. coli isolates were confirmed as ESBL with Epsilometer test as well as the genotypic method and 28 (70%) of them were multidrug-resistant. Genotype blaCTX-M was observed as a predominant beta-lactamase type with the preponderance of CTX-M Group 1. The following combinations were observed: blaTEM + blaCTX-M in 15 (36.2%) isolates, blaTEM /blaSHV in 8 (5.2%) isolates, and blaCTX-M /blaSHV in 6 (5.2%) isolates. The phylogenetic grouping of E. coli strains revealed the highest prevalence for B1 (22.0%) followed by A (20%).

CONCLUSION

This report shows a high frequency of ESBL E. coli from cattle with postpartum uterine infections. These isolates showed reduced susceptibility to common antibiotics used for the treatment of uterine infections greater affecting the therapeutic outcome.

Biomarkers in intensive care: C-reactive protein and procalcitonin

With the current advances in medicine, we all can experience a paradigm shift of medicine from art to science. Everyone wish their practice to be more accurate and objective rather than being experience based and subjective. We have seen massive developments towards the goal of practicing medicine with precision and uniformity. One such advancement is seen in the form of ‘biomarkers’. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processor, pathogenic processor or pharmacological responses to a therapeutic intervention. Everyday new biomarkers are being found and the pace has been accelerated with rapid progress in the fields of biochemistry, microgenetics and laboratory tool manufacturing. C-reactive protein and procalcitonin are two important biomarkers, described in this nar-rative review, which are in extensive use in intensive care setting. Received: 31 Oct 2018Reviewed & Corrected: 4 Nov 2018,Accepted: 10 Nov 2018 Citation: Agrawal J, Sharma CK. Biomarkers in intensive care: C-reactive protein and procalcitonin. Anaesth Pain & Intensive Care 2018;22 Suppl 1:S118-S123

Human papillomavirus/p16 positive head and neck cancer in India: Prevalence, clinical impact, and influence of tobacco use

BACKGROUND

Limited data are available on the prevalence and prognostic significance of human papillomavirus (HPV) in squamous cell carcinoma of head and neck (SCCHN) in the Indian population.

AIM

The present study aimed to determine the prevalence of HPV and p16 in an Indian cohort of SCCHN and assess their correlation and influence of tobacco use on patient outcomes.

MATERIALS AND METHODS

The p16 and HPV status of 170 patients of SCCHN treated with curative chemoradiotherapy was determined using immunohistochemistry and polymerase chain reaction, respectively, and further correlated with their demographic characteristics. In addition, genotyping of HPV-positive samples was performed. Survival outcomes were analyzed and compared for both p16 positive (p16 +ve) and p16 negative (p16 -ve) population. The influence of tobacco use on outcomes was assessed.

RESULTS

p16 expression was observed in 20% (34/170) cases whereas HPV positivity was detected in 39.4% (67/170) of SCCHN patients with HPV16 being the most common (91%) subtype. About 73.5% patients were p16 +ve among the tobacco users in this cohort (83.5%). Interestingly, p16 positivity was significantly associated with nonusers of tobacco (P = 0.02) and younger females (P = 0.06). The p16 +ve and p16 -ve groups did not exhibit a significant difference in the 5-year cause-specific survival (CSS) (79% vs. 72.2%), disease-free survival (DFS) (78.3% vs. 68.3%, P = 0.5), and locoregional control (LRC) (82.2% vs. 71.5%, P = 0.4). However, the outcome analyses in tobacco nonusers revealed a definite large improvement in CSS (P = 0.08) and a trend toward improvement in DFS (P = 0.15) and LRC (P = 0.11) in the p16 +ve versus the p16 -ve groups.

CONCLUSION

The low prevalence of p16 positivity (20%) and dual HPV and p16 positivity (38.8%) in the studied Indian cohort indicates the low utility of p16 as a surrogate for HPV in the background of high tobacco burden. The outcomes are largely improved in a small subset of SCCHN cases comprising p16 +ve tobacco nonusers.

Skin involvement and ipsilateral nodal metastasis as a predictor of contralateral nodal metastasis in buccal mucosa cancers

CONTEXT

In view of low incidence of contralateral nodal metastasis and increase in the morbidity, the opposite neck is not routinely addressed. However, contralateral nodal metastasis is seen frequently in a certain group of patients. Identifying those factors associated with higher chances of contralateral nodal metastasis may help in optimizing the treatment.

AIMS

The aim of this study was to identify prognostic factors associated with contralateral nodal metastasis in cases of buccal mucosa cancers.

SETTINGS AND DESIGN

A retrospective audit of 125 patients with squamous cell carcinoma of buccal mucosa at a tertiary cancer center.

SUBJECTS AND METHODS

Those cases in which lesions were reaching or crossing midline were included in this study. All cases underwent surgery as primary modality of treatment and had bilateral neck dissection.

STATISTICAL ANALYSIS USED

Chi-square test is used for evaluating the variables predicting contralateral nodal metastasis. Finally, a multivariate analysis was performed using binomial logistic regression to identify those variables that were independently associated with the risk of contralateral nodal metastasis.

RESULTS

Among 125 patients, 53 cases were node negative. Ipsilateral nodal metastasis was seen in 44/125 (35.2%) patients, 26/125 (20.8%) had bilateral neck node metastasis, and 2/125 (1.6%) had isolated contralateral nodal metastasis. Among these 28 patients with contralateral nodal metastasis, 26 patients had ipsilateral nodal metastasis. Ipsilateral nodal metastasis and skin involvement were independently predictive of contralateral nodal metastasis.

CONCLUSIONS

Contralateral nodal metastasis in the absence of ipsilateral nodal metastasis is very rare and frozen section of ipsilateral neck dissection specimen can be an important pointer for addressing contralateral neck.

Recurrence Risk of Febrile Seizures in Children

BACKGROUND

Identifying children with febrile seizure who are at risk for recurrence is important so that special attention can be given to them. The objective of this study was to identify the risk factors for recurrence of febrile seizures in children.

METHODS

This prospective hospital based study was conducted from July 2013 to August 2014 'among children of 6 months to 6 years of age at Bishweshwar Prasad Koirala Institute of Health Sciences (BPKIHS), Nepal. Children meeting the selection criteria were enrolled in study. Clinical, investigation, treatment and outcome parameters were analyzed.

RESULTS

A total of 92 children with febrile seizure were enrolled in study. Males accounted for 70% and females 30%. Simple febrile seizure was present in 48% and complex febrile seizures were seen in 52%. Recurrence of seizure was seen in one third of cases. Loss of consciousness was most common post-ictal phenomenon followed by confusion and lethargy. Upper respiratory infection was the most common precipitating factor. Generalized Tonic Clonic Seizure was the most common seizure type present in 79% of cases. Significant risk factors for recurrence occurred in males (p=0.088), age less than 1 year (p=0.003). Most of the recurrence occurred within one year of first seizure.

CONCLUSIONS

Febrile Seizure is common in males. Almost one third of children with febrile seizure are at risk for recurrence. The significant risk factors for recurrences are male gender and age <1year.

Adaptive Particle Swarm Optimizer with Varying Acceleration Coefficients for Finding the Most Stable Conformer of Small Molecules

A novel parameter automation strategy for Particle Swarm Optimization called APSO (Adaptive PSO) is proposed. The algorithm is designed to efficiently control the local search and convergence to the global optimum solution. Parameters c1 controls the impact of the cognitive component on the particle trajectory and c2 controls the impact of the social component. Instead of fixing the value of c1 and c2 , this paper updates the value of these acceleration coefficients by considering time variation of evaluation function along with varying inertia weight factor in PSO. Here the maximum and minimum value of evaluation function is use to gradually decrease and increase the value of c1 and c2 respectively. Molecular energy minimization is one of the most challenging unsolved problems and it can be formulated as a global optimization problem. The aim of the present paper is to investigate the effect of newly developed APSO on the highly complex molecular potential energy function and to check the efficiency of the proposed algorithm to find the global minimum of the function under consideration. The proposed algorithm APSO is therefore applied in two cases: Firstly, for the minimization of a potential energy of small molecules with up to 100 degrees of freedom and finally for finding the global minimum energy conformation of 1,2,3-trichloro-1-flouro-propane molecule based on a realistic potential energy function. The computational results of all the cases show that the proposed method performs significantly better than the other algorithms.

Outcome of Twin Deliveries at a Tertiary Care Centre of Eastern Nepal

BACKGROUND

Twins, compared to singletons, have higher perinatal mortality and morbidity. The aim of this study was to describe the twinning rate, epidemiological variables and hospital outcome of twin deliveries and to find out ways of better management of twins in our part.

METHODS

A retrospective evaluation of the outcome of 92 twin pregnancies during one year study period (1st January 2014 to 31st December 2014) was conducted at BPKIHS. Twins delivered within the institution were included but cases less than 28 weeks gestation were excluded. Maternal and neonatal data were retrieved and analysed.

RESULTS

The twinning rate was 9.2/1000 (92/10,031). The mean birth weight was 1636.30 ±339.21 grams and mean gestational age 34.31±2.67 weeks(28 - 40 weeks). One hundred eighty-two babies (98.9%) were low birth weight (LBW) while 32.1% were small for gestational age (SGA). There was mild, moderate and severe growth discordance in 63 (68.5%)22 (23.9%)and 7 (7.6%) respectively. Three (3.26%) of 92 pairs had twin-to-twin transfusion syndrome. The hospital mortality rate was 10.87% (20/184) and 69 (37.5%) babies had complications. The clinical causes of death were hyaline membrane disease in 7 (3.3%), severe birth asphyxia in 5 (2.7%), congenital malformations in 3(1.6%) and sepsis in 3 (1.6%) babies.

CONCLUSIONS

Twin deliveries are common in this hospital and have poor hospital outcome with more complications and mortality. Hence there is a need for further studies with long term follow-ups to plan for better management of twins in our part.

Unsafe Abortion: Changing Pattern of an Avoidable Tragedy

Aims: The study was done to analyze current trend of unsafe abortion.Methods: It was a prospective study where all the abortion related admissions from January 2009 to December 2011, in Obstetrics and Gynaecology unit at B.P. Koirala Institute of Health Sciences were analyzed. Sixty-six women with diagnosis of unsafe abortion were enrolled in the study. Cases of unsafe abortion were identified and classified using the classification developed by The South African National Incomplete Abortion Study conducted in 1994. Morbidity pattern was compared among the patients using the above classification system.Results: There were 66 cases of unsafe abortion admitted in three years. Most common mode of unsafe abortion was by taking different types of oral drugs in various doses prescribed by medical shops, in 65.2% of women.  Most common clinical presentation was heavy vaginal bleeding in 77% of women. After evaluation, commonest diagnosis made was incomplete abortion in 56.1% of women. In 57.6% of women, unsafe abortion was of low grade. In previous similar study done at the same centre, 16 (22.8%) of unsafe abortions were of low grade, 17 (24.2%) were of moderate grade and 37 (52.8%) were of high grade.Conclusions:  Unsafe abortion is still a significant medical and social problem. The mode of unsafe abortion, presentation and morbidity has changed significantly in recent years. However the morbidity pattern of unsafe abortion is going towards low grade.

Intrathecal nalbuphine as an adjuvant to subarachnoid block: What is the most effective dose?

BACKGROUND

Nalbuphine has been used intrathecally as an adjuvant in previous studies, but none clearly state the most effective dose of nalbuphine. The purpose of our study was to establish the effectiveness of intrathecal nalbuphine as an adjuvant, compare three different doses and determine the optimum dose with prolonged analgesic effect and minimal side-effects.

MATERIALS AND METHODS

In this prospective, randomized, double-blinded, controlled study, 100 ASA I and II patients undergoing lower limb orthopedic surgery under subarachnoid block (SAB), were randomly allocated to four groups: A, B, C and D, to receive 0.5 ml normal saline (NS) or 0.2, 0.4 and 0.8 mg nalbuphine made up to 0.5 ml with NS added to 0.5% hyperbaric bupivacaine 12.5 mg (total volume 3 ml), respectively. The onset of sensory and motor blockade, two-segment regression time of sensory blockade, duration of motor blockade and analgesia, visual analogue scale (VAS) pain score and side-effects were compared between the groups.

RESULTS

Two-segment regression time of sensory blockade and duration of effective analgesia was prolonged in groups C (0.4 mg nalbuphine) and D (0.8 mg nalbuphine) (P<0.05), and the incidence of side-effects was significantly higher in group D (P<0.05) compared with the other groups.

CONCLUSION

Nalbuphine used intrathecally is a useful adjuvant in SAB and, in a dose of 0.4 mg, prolongs postoperative analgesia without increased side-effects.

Comparative study of post operative wound infection following emergency lower segment caesarean section with and without the topical use of fusidic acid

The study was undertaken to see the infection rate of wound following emergency caesarean section with and without the use of topical fusidic acid. The study was carried out at Himal Hospital from April 2006 to Jan. 2008. A total of 70 child bearing patients who underwent emergency caesarean sections were included. All of the patients were given absorbable subcuticular stitches. Out of the 70 patients, 35 patients had topical fusidic acid immediately after subcuticular stitches followed by dry dressing. The other 35 patients had simple dressing with povidone- iodine. Six patients (17.1%) out of the 35 patients who had dressing with povidone-iodine developed wound infection at the surgical site and only 1 patient (2.8%) out of the 35 patients with fusidic acid developed wound infection. The use of fusidic acid reduced the infection rate by six times. The relation of fusidic acid to wound infection was statistically significant (p = 0.0460).

Iridoschisis associated with lens subluxation

The etiopathogenesis of iridoschisis is unclear, although age-related degeneration and angle-closure glaucoma are its most common associations. We report the case of a 50-year-old man with lens subluxation (familial) in 1 eye and ipsilateral iridoschisis. The inferotemporal edge of the lens was directed anteriorly, pushing the iris forward; this led to iridoschisis and shallowing of the anterior chamber. The patient had bilateral angle-closure glaucoma. A subluxated lens rubbing against the iris may be a mechanical precipitating factor in the development of iridoschisis.

Unilateral frosted branch angiitis with vitreous haemorrhage

Idiopathic retinal frosted branch angiitis is a rare bilateral condition and presents with an acute reduction of vision. Unilateral affection is rare. We report an unusual case of unilateral frosted branch angiitis where the patient developed total vitreous haemorrhage.

Complete capsular bag distension syndrome

After conventional extracapsular cataract extraction and in-the-bag intr aocular lens (IOL) implantation 3 years previously, the partially cut su perior one-third of the anterior capsulotomy flap resealed in the eye of a 55-year-old woman. With the integrity of the capsular bag restored, it distended fully; the IOL was in the center and milky fluid accumulated inside. A neodymium:YAG laser was used to drain the milky fluid and di srupt the opacified anterior and posterior capsules, restoring vision.