892 Emergency General Surgical Practice at a District General Hospital during COVID-19 Pandemic: Implementing Royal College of Surgeons Guidance

Introduction

COVID-19 pandemic had a significant impact on surgical practice across NHS. RCS released guidance on altering surgical practise during the pandemic to deliver safe surgical care in March, 2020. We present an audit conducted at a DGH comparing practice of emergency general surgery (EGS) with RCS guidance at the peak of COVID-19 pandemic.

Method

Consecutive patients undergoing EGS from 1^st April to 15^th May,2020. Data of demographics, ASA grade, comorbidities, type of surgery, hospital stay, informed COVID-19 pneumonia consent, complications and 30-day mortality were collected. Pre- and post-operative COVID-19 status was determined.

Results

Forty-four (n = 44) patients, mean age 47.5 and IQR (26-69). Male (55.8%) and females (44.2%). Preoperative COVID19 status was confirmed in around 79.1% patients. All (100%) patients who underwent CT imaging preoperatively had CT chest performed. Informed consent for COVID19 pneumonia was taken in 4.7% patients. 30-day mortality risk was 7% and complications risk was 4.7%. RR of 30-day mortality in preoperative COVID19 status positive patients was RR = 0.92 (CI 0.85-1.01) and for complications was RR = 0.95 (CI 0.88-1.02).

Conclusions

RCS guidance on managing and altering practice in EGS during COVID-19 pandemic is reliable, implementable, and measurable in a DGH setting. Simple improvements in consent process can achieve full compliance with RCS guidelines.

In vitro evaluation of antimicrobial effect of miswak against common oral pathogens

BACKGROUND AND OBJECTIVE

Miswak is a natural tooth cleaning tool which is being used in many parts of the world since ancient times. It is known to be useful in prevention of dental caries. But still it is not used as frequently as other oral hygiene tools. This research was designed to scientifically establish antimicrobial effect of miswak in vitro against common oral pathogens.

METHODS

This was a cross-sectional study involving 100 health care workers. This research was carried out in Microbiology section of Dow Diagnostic Research & Reference Laboratory. A questionnaire was designed to test oral hygiene habits of study subjects. Oral swabs were taken and microorganisms were identified by standard bacteriological methods. Test material included four different types of miswaks i.e. (1) root of the peelu (Salvadora persica) tree (in packing) (2) root of the peelu tree (without packing) (3) stem of the peelu tree & (4) stem of the neem (Azadirechta indica) tree. These miswaks were tested against three different types of microorganisms isolated from oral swabs: Staphylococcus aureus, Streptococcus mutans & Candida albicans by agar diffusion method. Inhibition zone was measured after 24 hrs of incubation at 37(o)C.

RESULTS

Among the miswaks used, root of the peelu tree in both packing and without packing exhibited strong antimicrobial effect against all three tested microorganisms. However miswak taken from the stem of the peelu and neem tree did not show any antimicrobial activity against all three types of the tested microorganisms.

CONCLUSION

Miswak taken from the root of the peelu tree exhibited antimicrobial activity against all the common oral pathogens and could be a good oral hygiene tool in combating dental caries.

Efficacy of newly formulated ointment containing 20% active antimicrobial honey in treatment of burn wound infections

BACKGROUND

Honey has been familiar to possess antimicrobial potential to clear infection against burn wound infecting bacteria since ancient times. The objective of the study was to evaluate the efficacy of the newly formulated honey ointment during the treatment of burn wound infections. The Experimental (Non comparative) study was conducted at outpatient department of Dermatology, Fauji Foundation Hospital, Rawalpindi from November 2009 to October 2010.

METHODS

The antimicrobial activity of different Pakistani floral sources (Acacia nilotica species indica, Zizyphus, Helianthus annuus and Carisa opaca) honey samples were investigated by disc diffusion method against freshly isolated burn wounds infecting bacteria. Ointment containing 20% active antimicrobial honey was formulated as a sovereign remedy. A total number of twenty patients with second degree of burn wounds on different parts of the body were studied. A thin layer of honey ointment on gauze was applied to the wounds two to three times a day up to the complete healing.

RESULTS

During microbiological study, Pakistani honey samples were discovered to exhibit a very promising antimicrobial activity against all the wound infecting microorganisms tested. Clinical trials demonstrated that the topical application of honey ointment have significant control of infections arising form pathogenic bacteria and up to 100% healing results were observed in all burn wound cases within mean healing time for the duration of 8.15 (3-18) days time period.

CONCLUSION

Newly formulated ointment containing 20% active antimicrobial honey is more effective and low-cost alternative preparation for the treatment of burn wound infections.

Smoking is associated with increased lesion volumes and brain atrophy in multiple sclerosis

BACKGROUND

Cigarette smoking has been linked to higher susceptibility and increased risk of progressive multiple sclerosis (MS). The effects of smoking on MRI characteristics of patients with MS have not been evaluated.

OBJECTIVES

To compare the MRI characteristics in cigarette smoker and nonsmoker patients with MS.

METHODS

We studied 368 consecutive patients with MS (age 44.0 +/-SD 10.2 years, disease duration 12.1 +/- 9.1 years) comprising 240 never-smokers and 128 (34.8%) ever-smokers (currently active and former smokers). The average number of packs per day smoked (+/-SD) was 0.95 +/- 0.65, and the mean duration of smoking was 18.0 +/- 9.5 years. All patients obtained full clinical and quantitative MRI evaluation. MRI measures included T1, T2, and gadolinium contrast-enhancing (CE) lesion volumes (LVs) and measures of central, global, and tissue-specific brain atrophy. The associations between smoking status and MRI measurements were assessed in regression analysis.

RESULTS

Smoking was associated with increased Expanded Disability Status Scale (EDSS) scores (p = 0.004). The median EDSS scores (interquartile range) in the ever-smoker group and the active-smoker group were both 3.0 (2.0), compared with 2.5 (2.5) in never-smokers. There were adverse associations between smoking and the lesion measures including increased number of CE lesions (p < 0.001), T2 LV (p = 0.009), and T1 LV (p = 0.003). Smoking was associated with decreased brain parenchymal fraction (p = 0.047) and with increases in the lateral ventricle volume (p = 0.001) and third ventricle width (p = 0.023).

CONCLUSIONS

Smoking is associated with increased blood-brain barrier disruption, higher lesion volumes, and greater atrophy in multiple sclerosis.

Pharmacokinetic study of cephradine in Pakistani healthy male volunteers

To observe and discuss the difference in the pharmacokinetics of cephradine in Pakistani population with the reported data of other ethnic origins. A Single group pharmacokinetic study was conducted having six healthy male volunteers of 20-24 years of age. Blood samples were collected at appropriate times up to 7 hours. Plasma concentrations of cephradine was determined by HPLC technique and pharmacokinetic parameters were determined by both compartmental and noncompartmental methods using Kinetica ver 4.4.1 and Winnonlin ver 5.01. Peak plasma concentration was 11.49+/-1.73 microg/ ml achieved at 0.76+/-0.12 hr, after the administration of 250 mg cephradine to fasting volunteers. Area under the serum concentration-time curve was found to be 16.4+/-1.71 g.hr/ ml. Absorption, distribution, disposition and elimination half lives were calculated as 0.183 +/- 0.038 hr, 0.248 +/- 0.143 hr, 2.126 +/- 0.341 hr and 0.441+/-0.193 hr respectively where as the volume of central compartment and total body clearance were found to be 9.65+/-3.78 L and 15.4+/-1.89 L/hr. The plasma concentration time curves showed the absorption rate constant was 3.968 +/- 0.05 hr(-1), disposition rate constant was 0.333+/-0.05 hr(-1), distribution rate constant was 3.64+/-2.18 hr(-1) and elimination rate constant was 1.738+/-0.468 hr(-1). The value of micro-constants i.e. K(12) (central to peripheral compartment) and K(21) (peripheral to central compartment) were found to be 1.529+/- 1.499 hr(-1) and 0.704 +/- 0.44 hr(-1) respectively, where as MRT and AUMC were calculated as 2.04+/-0.09 hr and 35.92+/-1.86 hr(2) microg/ ml. The findings showed that the results of Pakistani subjects are slightly different when compared with the reported data of other ethnic origin.

Paediatric nosocomial infections: resistance pattern of clinical isolates

Hospital acquired infections are transmitted to patients by hospital personnel and other patients, or they may arise from patient's own endogenous flora. Children are one of the most susceptible subjects associated in the hospital-acquired infections and have a higher prevalence rate for infections. This problem is at its extremes in developing countries like Pakistan where in most of cases the severity depends on the hygienic conditions of the Hospitals and lack or lapse of infection control measures. To have a surveillance type of data in this regard, one hundred and twenty four isolates of Pseudomonas aeruginosa/Pseudomonas species, Staphylococcus aureus (MRSA/MSSA) and Klebsiella species, that are commonest among the nosocomial infection causing organisms, were collected from pediatric hospital settings in Karachi. A study of incidence and resistance pattern by Kirby Baur disc diffusion method, with selected antimicrobials, was carried out. These isolates were resistant against most antimicrobials tested. Drugs like mmipenem, meropenem, amikacin, vancomycin (especially in MRSA or BRSA), Fucidic acid (for burns and other infections) and some of the 3rd generation cephalosporins were found quite effective.

Resistance pattern of different aminoglycosides against Gram positive and Gram negative clinical isolates of Karachi

Microbial resistance to majority of the available antimicrobial agent is a serious and global problem. Due to heavy and discriminate usage of antibiotics, high prevalence of drug-resistant bacteria in the indigenous fecal flora, poor standards of sanitation, lack of education and prevalence of malnutrition. This problem is at its extreme in developing countries like Pakistan. For this various Aminoglycosides were tested against different Gram positive and Gram negative isolates. The results showed that these isolates were resistant against most of these antibiotics with increase in MIC's. In Aminoglycoside group Tobramycin was the most effective agent against Staph. aureus and E. coli with MIC90s of 1 microg/ml and 2 microg/ml, while against Klebsiella and P. aeruginosa its activity was moderate to low. Amikacin showed highest activity against P. aeruginosa, E. coli and Klebsiella species with MIC90s of 4 microg/ml and 8 microg/ml. Kanamycin and Streptomycin were not active against the tested isolates.

Comparative antimicrobial evaluation of Cephalosporins and Quinolones in common paediatric infections

More than 90% of world's children are born each year in the developing world. Each year 12.9 million children die. Twenty eight percent of death are caused by pneumonia, 23% by diarrheal disease and 16% by vaccine-preventable diseases. Thirty-five thousand die each day, most from common and preventable problems. Health and illness are the result of a complex dynamic of environmental, social, political and economic factors. Bacterial resistance to antimicrobial agents is a continuing serious problem in the treatment of infections. Although this problem was recognized shortly after the commercial introduction of antimicrobial agents, it means that resistance is now emerging at a more rapid rate than ever before. To start with, during the present study an effort has been made to accomplish this task, 84 clinical isolates of Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa were collected from different hospitals in Karachi. An in vitro study of these isolates was carried out by Agar dilution method using eleven antimicrobial agents and their combination (Lorian, 1991). Among Cephalosporins, third generation Cephalosporin, Cefotaxime was highly effective against Gram positive and Gram negative bacteria. Cefotaxime was active against Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa. 1.19% isolates of Staphylococcus aureus, 19% isolates of Escherichia coli and 10% isolates of Pseudomonas aeruginosa were resistant against Cefotaxime. In Quinolone group, Ofloxacin was highly active against Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa. Whereas 28% isolates of Staphylococcus aureus, 26% isolates of Escherichia coli and 11% isolates of Pseudomonas aeruginosa were resistant to Ofloxacin. Twenty six percent isolates of Staphylococcus aureus and 58% isolates Escherichia coli were resistant against Ciprofloxacin.

Antimicrobial activity of Penicillins in common paediatric infections

Pediatric bacterial infections are very rapidly growing in developing countries. Bacterial resistance to antimicrobial agents is a serious problem in the treatment of Pediatric bacterial infection. One of the most effective ways to control antibiotic resistance, is the development of surveillance programs. For this purpose isolates were collected from paediatric wards of different hospitals. The result shows that isolates were highly resistant against majority of selected antibiotics with increase in the MIC's. In Penicillin group, the most effective agent is Amoxicillin and Clavulanic acid, more than 90% isolates of Staphylococcus aureus were susceptible while other agents, as Cloxacillin, Ampicillin and Amoxicillin alone shows moderate activity against Staphylococcus aureus and Escherichia coli.

The impact of pulmonary infections on the survival of lung cancer patients

To determine the impact of pulmonary infections on survival in patients with lung cancer, a retrospective review of the records of 121 such patients treated at Howard University Hospital in Washington, DC, was done. There were 77 men and 44 women; 118 were black. The mean age was 63.5 years. Forty-three patients had squamous cell carcinoma, 31 had adenocarcinoma, 18 had large cell carcinoma, 19 had small cell carcinoma, and ten were unclassified. The stages were as follows: two patients in Stage 0, 15 in Stage I, seven in Stage II, 45 in Stage III, and 44 in Stage IV. Eight patients could not be staged at diagnosis. Eighty-five patients (70%) had documented infections; 37 had single episodes; and 48 had more than one. The five most common organisms recovered were alpha/gamma streptococci, Staphylococcus aureus, Klebsiella pneumoniae, Enterobacter aerogenes, and Pseudomonas aeruginosa. The median survival of all infected patients was 4.2 months which was significantly shorter than that of uninfected patients who had a median survival of 12.9 months (P less than 0.05). When Stage III patients were analyzed separately, infected patients lived a median of 5.8 months and uninfected patients, 13.4 months (P less than 0.05). This study indicated that pulmonary infections frequently occur in patients with lung cancer and suggested that they may adversely affect survival.

Anti-T antibody in malignant melanoma patients. Influence of response and survival following chemotherapy--changes in serum levels following C parvum, BCG immunization

The level of anti-T antibodies directed towards the precursor T antigen of the MN blood group system was measured in the sera of 55 patients with disseminated melanoma, before and during chemoimmunotherapy. The anti-T titer was subnormal in patients before therapy; patients who responded to therapy had significantly higher titers than did nonresponders in sera taken before therapy, at regression/progression of disease, and during the last pulse of treatment. Higher pretreatment titers were associated with a significntly longer survival time. A single infusion of Corynebacterium parvum was given to 14 other melanoma patients and significant elevation of preimmunization titers was observed on days 14, 21, and 28 after infusion; Bacillus Calmette-Guerin, vaccination of 9 patients did not significantly alter the anti-T titer. The expression of the normally cryptic T antigen on melanoma cells would absorb naturally circulating anti-T antibodies. Less dense expression of T antigen on melanoma cells that were responsive to therapy, i.e., less "malignant," would explain the better prognosis for patients with higher titers. The increase in anti-T antibodies following administration of C parvum but not of BCG is of possible clinical relevance when C parvum is used as an immunotherapeutic agent.

Myelofibrosis in chronic granulocytic leukaemia

Serial trephine biopsies were performed in 45 cases of chronic granulocytic leukaemia (CGL) in order to determine the frequency and significance of secondary myelofibrosis in the evolution of the disease. Histological changes were graded 1-5b, ranging from no increase in reticulin to dense osteomyelosclerosis. Many cases showed a progressive increase from Grade 1 to Grade 3, and accelerated disease, or blast crisis, often supervened when Grade 3 changes were present. However, a significant number of cases showed Grade 4 and 5 changes, which were indistinguishable histologically from those found in agnogenic myeloid metaplasia (AMM) (idiopathic myelofibrosis), at the time of diagnosis. These patients did not always show a rapidly fatal course and may be considered as an example of 'transitional myeloproliferative disorder', with features intermediate between CGL and AMM.