Genotypic Frequency of Rh Cw Antigen in Blood Donors of Northern Pakistan

OBJECTIVE

To determine the genotypic frequency of Rh Cw antigen in blood donors of Northern Pakistan.

STUDY DESIGN

Descriptive cross-sectional study. Place and Duration of the Study: Department of Molecular Haematology, Armed Forces Institute of Transfusion (AFIT), Rawalpindi, Pakistan, from August 2022 to January 2023.

METHODOLOGY

Blood donors were randomly selected. Venous blood samples were taken in K3-EDTA anticoagulant tubes. ABO and Rh D grouping were performed conventionally. DNA for Rh Cw genotyping was extracted via Chelex TM, followed by PCR amplification using an ABI 2700 thermal cycler. Human growth hormone (HGH) acts as an internal control. Amplified products underwent Polyacrylamide gel Electrophoresis (PAGE).

RESULTS

There were 400 randomly chosen donors whose ages ranged from 26-35 years, with a predominantly male population (94.8%) of Punjabi origin (67.8%). The majority (87.3%) was RhD positive. Blood group B was the most prevalent (35%) in the studied population, followed by O (34.75%). Only 1.5% had Rh Cw antigen. Rh Cw was more prevalent in ABO-positive participants (87.25%) compared to ABO-negative (12.75%).

CONCLUSION

There was a 1.5% prevalence of Rh Cw antigen genotype in randomly selected Northern Pakistani blood donors. Rh Cw prevalence was higher in ABO-positive participants. Significant correlation (<0.05) existed between RhD and Cw antigens. Given the implications of anti-Cw antibody, including Cw antigen-positive cells in antibody screening is recommended.

KEY WORDS

Alloimmunisation, Blood donors, HDFN, Phenotype, Rh antigens, Transfusion.

Prevalence and Association of Transfusion-Transmissible Infections with Age of Blood Donors: A Regional Transfusion Centre Study in Northern Pakistan

OBJECTIVE

To evaluate the prevalence and association of Transfusion-Transmissible Infections (TTIs) with age of blood donors in a regional transfusion centre located in Northern Pakistan.

STUDY DESIGN

Descriptive study. Place and Duration of the Study: Armed Forces Institute of Transfusion, Rawalpindi, Pakistan, from January 2017 to December 2021.

METHODOLOGY

All blood donors who qualified institutional blood donation criteria were initially screened for HBsAg, Anti-HCV Ab, HIV antigen-antibody combination and syphilis by an automated chemiluminescent microparticle immunoassay analyzer (Architect Plus i 2000 SR, Abbott Diagnostics, Abbott Park, IL). Initially, all seronegative donor blood samples were subjected to nucleic acid amplification test (NAAT). All TTI-positive donors were immediately informed and counselled to consult the medical physicians for further treatment. Descriptive statistics and significance of association were determined.

RESULTS

The prevalence of TTIs among blood donors was calculated to be 3.33% among 308,767 donors. HCV (1.4%) was the most prevalent TTI followed by syphilis (0.9%), HBV (0.68%) and HIV (0.26%), respectively. TTIs were most prevalent in the 26 to 35-year-old group, accounting for 5,143 (50.0%) positive donors (p<0.05).

CONCLUSION

The prevalence of TTIs among blood donors was found to be 3.33%. HCV was the most common TTI, followed by syphilis, HBV, and HIV. The 26 to 35 year-old group had a significantly high prevalence of TTIs.

KEY WORDS

Transfusion-transmissible infections, Hepatitis B virus, Hepatitis C virus, Human immunodeficiency virus, Treponema pallidum, Syphilis, Automated chemiluminescent microparticle immunoassay analyzer, Nucleic acid amplification test.

Transfusion-associated Graft versus Host Disease: A Certain but Avoidable Cause of Death

Transfusion-associated graft versus host disease (TA-GvHD) is a rare complication of blood transfusion. It is a delayed transfusion reaction that usually presents from day 7 to day 14 following a transfusion. It can affect both immunocompromised as well as immunocompetent patients. In immunocompetent patients, the culprit is usually the transfusion from first-degree relatives. The recipient takes the donor cells as self while the donor takes the recipient cells as foreign and the lymphocytes in the donor blood start attacking the recipient cells leading to a cascade of catastrophic events that ultimately result in a condition called TA-GvHD. The condition is usually fatal in 90% of cases. Here, we present one such case in which the maternal blood transfused to an infant cost him his life within 12 days of transfusion. Key Words: Transfusion, Homozygous antigen, Heterozygous antigen, Graft versus host disease.

Bombay Blood Group: An Incidental Discovery in a Family

Bombay phenotype is an uncommon blood type. It is found in approximately 1 in 10,000 people in the Indian subcontinent and approximately 1 in 1,000,000 in Europe. The lack of the H antigen (foundation stone of the ABO blood system) on red blood cells (RBCs) and in secretions is the hallmark of this phenotype. Individuals lacking this antigen do not produce A or B antigens and appear as type O on routine blood grouping. Herein, we report an incidental discovery of a family with three members having Bombay phenotype on routine antenatal examination. Key Words: ABO blood group system, Bombay phenotype, Cross matching.

Extensively Drug-Resistant Typhoid Outbreak in Pakistan, Experience at a Tertiary Care Hospital in Lahore; A Tip of An Iceberg

Objective: To provide a laboratory-based surveillance report of typhoid fever cases diagnosed at a tertiary care hospital in Lahore during the ongoing outbreak. Study Design: Cross-sectional study. Place and Duration of Study: Department of Microbiology, Combined Military Hospital, Lahore Pakistan, from Mar 2018 to Jun 2019. Methodology: All positive blood culture samples that yielded the growth of Salmonella Typhi were included in the study. The samples were dealt with according to standard microbiological procedures. Antimicrobial susceptibility was performed using Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: During the study period, (377) Typhoidal Salmonellae were isolated, of which 327 (86.7%) were Salmonella Typhi and 50 (13.3%) were Paratyphi A. The percentage of XDR Salmonella isolates was 41.9%. Conclusion: Extensively drug-resistant typhoid fever cases reported in this study represent just the tip of an iceberg. Therefore, nationwide surveillance efforts must be undertaken along with implementing effective preventive measures.

429 Clinical Audit Ankle Fractures

Aim

Ankle fractures are common among adult age group with an incidence of 174 per 100000 per year and they pose serious problems in management of geriatric age group because of osteoporotic bone. Our aim of current clinical audit was to introduce changes in current clinical practice by recommendations according to Standard BOAST guidelines of management of Ankle Fractures.

Method

Clinical Audit was carried out in Department of Orthopedics Benazir Bhutto Hospital in Outdoor and Emergency in March 2021 in patients of age group 20–70 years taking 50 patients for pre- and post-audit assessment. Emergency, Outdoor Slips were evaluated according to Standards of Practice formulated. Then a presentation was given to medical staff on Guidelines of Ankle fractures management, and they were informed about the deficiencies in their documentation and management. Panaflexes of Guidelines were displayed in ER, ward and then re-evaluation was done after 4 weeks in April 2021 using proformas in which clinical notes, discharge certificates and emergency slips were used for data analysis and observing improvement.

Results

The results of asymmetric data were calculated by Fischer Exact Test and with a p-value of &lt;0.05 considered as significant. Results were very pleasing as they showed great improvements in documentation as well as management of patients in accordance with the set guidelines and protocols.

Conclusion

Clinical Audits should be carried out on regular basis in hospital settings as they help to improve the standards of care as well as proper documentation which has medico-legal importance.

Randomised controlled study of seroma rates after mastectomy with and without quilting the skin flap to pectoralis muscle

Aims

The aim of this study was to determine whether seroma formation was affected by reduction of the potential dead space with the flap fixation method and obliteration of the axillary region in patients with breast cancer who underwent either mastectomy and axillary lymph node dissection or sentinel lymph node biopsy. A total of 105 patients with breast cancer were divided into two groups according to wound closure patterns.

Patients and Methods

The operating time, postoperative pain and complications, time to drain removal, seroma formation, amount of fluid aspirated and number of aspirations were recorded prospectively.

Results

No significant difference was found between groups in the rates of seroma development (P = 0.7), complication rates (P = 0.6), time to drain removal (P = 0.5), length of hospital stay (P = 0.3) or numbers of aspiration (P = 0.7). The operating time for fixation was determined to be longer than that of the classic procedure (P = 0.02).

Conclusions

Reducing potential dead space with flap fixation and obliteration of the axillary region may be useful in decreasing the development of seroma in patients who have undergone mastectomy because of breast cancer. However, surgical technique must be careful, and appropriate patient follow-up must be conducted.

MAGNITUDE OF VANCOMYCIN RESISTANT ENTEROCOCCUS FECAL COLONIZATION AND BACTEREMIA IN PATIENTS WITH HEMATOLOGICAL DISEASES AT TERTIARY BONE MARROW TRANSPLANT CENTRE RAWALPINDI

Objective: To discover the frequency of vancomycin resistant enterococci (VRE) fecal colonization and subsequent bacteremia in patients with hematological diseases in a bone marrow transplant center. Study Design: Cross-sectional study. Place and Duration of Study: Department of Microbiology, Armed Forces Institute of Pathology (AFIP), in collaboration with Armed Forces Bone Marrow Transplant Center, Rawalpindi, from Jan 2016 to Dec 2019. Methodology: Stool specimens/anal swabs from all enrolled patients were collected aseptically and transported to the laboratory without delay. Blood cultures were collected aseptically from only those enrolled patients who developed signs and symptoms of bacteremia. Stool and blood cultures were processed as per standard microbiological protocols. Enterococci were identified to species level by colony morphology and biochemical tests. Modified Kirby Bauer disc diffusion method and VITEK-2 system (Version-8.01 bio Merieux, France) were used to perform antimicrobial sensitivity of each isolate. Results: A total number of 246 patients were studied. Among them, 67 (27%) patients had fecal colonization by vancomycin resistant enterococci. We report a statistically significant association of recent hospitalization, prolonged exposure to antimicrobial therapy, chemotherapy exposure and use of indwelling devices during the hospital stay with vancomycin resistant enterococci colonization. Vancomycin resistant enterococci bacteremia was detected in 57 (23%) patients. Among these 57 patients, 53 (93%) were vancomycin resistant enterococci colonizers. Vancomycin resistant enterococci colonization was significantly associated with vancomycin resistant enterococci bacteremia. Conclusion: A considerable burden of vancomycin resistant enterococci fecal colonization exists among patients with hematological diseases. vancomycin resistant enterococci colonization poses a considerable risk of vancomycin........

EVALUATION OF GERMICIDAL UV-C LIGHT FOR SURFACE DISINFECTION IN A TERTIARY CARE HOSPITAL

Objective: To check the efficacy of 36-Watt Ultraviolet-C tube light, in terms of distance and time against medically important microorganisms (Staphylococcus aureus, Escherichia coli, Pseudomonas aeroginosa, Candida albicans and Aspergillus species). Study Design: Quasi-experimental study. Place and Duration of Study: Pathology department, Combined Military Hospital, Lahore Pakistan, from Jun to Sep 2020. Methodology: ATCC control organisms of above mentioned bacteria, yeasts, and fungi were exposed to ultraviolet-C light for different times and distances to ascertain its germicidal effect. Two methods were selected, one in which micro-organisms inoculated plates were exposed to ultraviolet-C light and second in which McFarland suspensions of microorganisms were exposed before inoculation. Both the methods were compared. Observations were noted down after repeated performance of both the procedures. Results: An exposure time of 15 minutes, mean ± SD (13.8 ± 10.1) at 1-foot distance was proved ideal for all the tested bacteria, but yeasts and fungi required >30 minutes, mean ± SD (17.5 ± 13.5) to be killed. Moreover, distance and time of exposure were found out to be directly proportional irrespective of microbial load. Greater the distance longer the ultraviolet C exposure was required. Conclusion: Ultrviolet-C light 36-Watt can have efficient inactivation of bacterial, fungal and archaeal species up to 6 feet for >30 minutes exposure time. Ultraviolet-C light disinfection is best for areas like closed rooms, operation theatres, PCR Labs, and bio-safety cabinets keeping bio-safety guidelines in view.

Superficial Thrombophlebitis caused by Extensively Drug-resistant Salmonella Enterica Serovar Typhi

Salmonella enterica serovar typhi causes one of the most common blood stream infections, the typhoid fever. However, it can cause pyogenic infections involving different sites as well. Extensively drug resistant (XDR) strains of Salmonella typhi are resistant to all first line anti-typhoidal drugs (chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole) as well as ciprofloxacin and ceftriaxone. XDR-strains were first reported from Pakistan in 2016, and since then the strains have been spreading. These XDR Salmonella cases not only pose a therapeutic challenge but also predispose to complications as a result of prolonged illness and delayed treatment. Here, we report a case of superficial thrombophlebitis at intravenous cannula site in a 49-year male, who was being treated for XDR-typhoid fever. To the best of our knowledge, thrombophlebitis of a superficial vein is an unusual complication of Salmonella typhi, not previously reported in literature. Key Words: Bacteremia, Thrombophlebitis, Extensively drug-resistant, Typhoid fever, Salmonella typhi.

Catheter related recurrent blood stream infection caused by linezolid-resistant, methicillin resistant Staphylococcus haemolyticus; an emerging super bug

A 61 year male, admitted in Combined Military Hospital Rawlpindi on 12th March 2017, operated for diverticulitis became colonized with Staphylococcus haemolyticus. Patient suffered repeated septic episodes caused by the same organism during his stay in hospital. The strain was identified as methicillin resistant Staphylococcus haemolyticus (MRSH) also resistant to Linezolid by analytical profile index for Staphylococcus (API Staph) and VITEK 2 Gram positive cocci panel. The isolate was cultured from blood cultures, Central Venous Catheter (CVC) tip and skin swabs. Patient was successfully treated with injectable vancomycin and skin decolonization was acheived with chlorhexidine bath after which no episode of MRSH infection occurred. Patient had an uneventful recovery and was discharged on 21st June. His follow up visit showed clinical improvement.

Cerebral Abscess caused by Novel Species: Streptococcus Pluranimalium

Streptococcus pluranimalium, a gram-positive aerobic coccus, has been isolated primarily from several farm animals. The pathogenicity of this species is not well characterised either in animals or humans. As per the literature, cases of S. pluranimalium infection in humans have been reported only a handful of times. We report the case of cerebral abscess caused by S. pluranimalium in a patient who presented with weakness and confusion. The diagnosis of cerebral abscess was made on imaging supported by microbiological culture. Burr hole procedure for abscess drainage followed by an antibiotic regimen based on culture and sensitivity results contributed to a successful outcome. The bacteria were identified by analytical profile index for Streptococci (API Strep) and VITEK 2 gram-positive cocci panel. The case was successfully treated with vancomycin.

Native valve dual pathogen endocarditis caused by Burkholderia cepacia and Aspergillus flavus - a case report

Introduction

Infective endocarditis (IE) is an important clinical condition with significant morbidity and mortality among the affected population. A single etiological agent is identifiable in more than 90 % of the cases, however, polymicrobial endocarditis (PE) is a rare find, with a poor clinical outcome. Here we report a case of native valve dual pathogen endocarditis caused by Burkholderia cepacia and Aspergillus flavus in an immunocompetent individual. It is among unique occurrences of simultaneous bacterial and fungal etiology in IE.

Case presentation

A 30-year-old male was admitted to a cardiology institute with complaints of low grade intermittent fever and progressive shortness of breath for last two months. He was a known case of rheumatic heart disease and had suffered an episode of IE three years ago. On the basis of clinical presentation and the results of radiological investigations, a diagnosis of infective endocarditis was made. Paired blood samples for culture and sensitivity, sampled before the commencement of antimicrobial therapy, yielded growth of Burkholderia cepacia which was highly drug resistant. Sensitivity results-directed therapy consisting of tablet Trimethoprim–Sulfamethoxazole, two double-strength tablets 12 hourly, and Meropenem, 1 g IV every 8 h, was commenced. Despite mild relief of fever intensity, overall clinical condition did not improve and double valve replacement therapy was carried out. Excised valves were sent for microbiological analysis. Burkholderia cepacia was grown on tissue culture with a similar antibiogram to that previously reported from the blood culture of this patient. Direct microscopy of section of valvular tissue with 10 % KOH revealed abundant fungal hyphae. Patient serum galactomannan antigen assay was also positive. Histopathological examination of vegetations also revealed hyphae typical of species of the genus Aspergillus. The patient was successfully treated with meropenem, trimethoprim–sulfamethoxazole and voriconazole.

Conclusion

The hallmark of successful treatment in this case was exact identification of pathogens, antibiogram-directed therapy and good liaison between laboratory experts and treating clinicians.

Bacterial biofilm-based catheter-associated urinary tract infections: Causative pathogens and antibiotic resistance

BACKGROUND

We sought to determine the incidence of bacterial biofilm-based catheter-associated urinary tract infections, identify variables affecting biofilm formation, and identify etiologic bacterial pathogens and antibiotic-resistance patterns associated with biofilm-based catheter-associated urinary tract infections (CAUTIs) in our setup.

METHODS

Patients who developed at least 2 symptoms of urinary tract infection after at least 2 days of indwelling urinary catheters were included. Urine was collected aseptically from catheter tubing and processed per standard microbiologic practices. Bacterial pathogens were identified on the basis of gram staining, colony morphology, and biochemical reactions. The detection of the biofilm was done using the tube adherence method. Drug susceptibility testing was done using the Kirby-Bauer disc diffusion method.

FINDINGS

Biofilm was detected in 73.4% isolates, whereas 26.6% of isolates were nonbiofilm producers. Mean duration of catheterization after which biofilm was detected was 5.01 ± 1.31 days. A latex catheter was used in 69.5% of patients, whereas a silicone catheter was used in 30.4% of patients. Escherichia coli was found to be the most common pathogen isolated (52.3%), whereas Enterobacter cloacae exhibited the highest biofilm production (87.5%) among isolated pathogens. Among biofilm producers, the highest resistance was observed with ampicillin (100%). Fosfomycin exhibited the lowest resistance (17.2%). Significant association with biofilm was detected for gender, duration of catheterization, and type of catheter.

CONCLUSION

Biofilm-based CAUTI is an emerging problem. E coli was the most frequent isolate. High antibiotic resistance was observed in biofilm-producing strains. Using the variables affecting biofilm formation, tailored intervention strategies can be implemented to reduce biofilm-based CAUTIs.

Connecting quantum dots with enzymes: mediator-based approaches for the light-directed read-out of glucose and fructose oxidation

The combination of the biocatalytic features of enzymes with the unique physical properties of nanoparticles in a biohybrid system provides a promising approach for the development of advanced bioelectrocatalytic devices. This study describes the construction of photoelectrochemical signal chains based on CdSe/ZnS quantum dot (QD) modified gold electrodes as light switchable elements, and low molecular weight redox molecules for the combination with different biocatalysts. Photoelectrochemical and photoluminescence experiments verify that electron transfer can be achieved between the redox molecules hexacyanoferrate and ferrocene, and the QDs under illumination. Since for both redox mediators a concentration dependent photocurrent change has been found, light switchable enzymatic signal chains are built up with fructose dehydrogenase (FDH) and pyrroloquinoline quinone-dependent glucose dehydrogenase ((PQQ)GDH) for the detection of sugars. After immobilization of the enzymes at the QD electrode the biocatalytic oxidation of the substrates can be followed by conversion of the redox mediator in solution and subsequent detection at the QD electrode. Furthermore, (PQQ)GDH has been assembled together with ferrocenecarboxylic acid on top of the QD electrode for the construction of a funtional biohybrid architecture, showing that electron transfer can be realized from the enzyme over the redox mediator to the QDs and subsequently to the electrode in a completely immobilized fashion. The results obtained here do not only provide the basis for light-switchable biosensing and bioelectrocatalytic applications, but may also open the way for self-driven point-of-care systems by combination with solar cell approaches (power generation at the QD electrode by enzymatic substrate consumption).

A pro forma and review process for the assessment of standards of care in stillbirths

Stillbirth rates do not address deficiencies in care. We collected information on stillbirths from 2004 to 2009 using a standardised pro forma. A local panel used the pro forma to grade the level of care received by the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) categorisation. Comparison using kappa scores showed agreement between local and external multidisciplinary panels of similar referral patterns (n = 47, κ = 0.7), and that the categorisation was unaffected by the individual who fills out the pro forma (n = 17, κ = 0.5). There was less agreement between the local panel and adverse event review (n = 100, κ = 0.45). This report represents a validation of the pro forma and the review process for standard use in all units.

Determination of trimester specific reference intervals for thyroid hormones during pregnancy in Malaysian women

OBJECTIVE

To establish trimester specific reference intervals for thyroid hormones during pregnancy in Malaysian women.

STUDY DESIGN

Cross-sectional observational study performed in the Obstetric Clinic, University Malaya Medical Centre. A single blood sample from 626 women at various trimesters of pregnancy was analyzed for thyroid function. TSH, FT4, TT4, FT3 and TT3 values at each trimester of pregnancy were calculated.

RESULTS

From the TSH, FT4, TT4, FT3 and TT3 results, reference values based on mean +/- 2SD was calculated for the hormones at each trimester of pregnancy.

CONCLUSION

We calculated clinically relevant trimester-specific reference values for thyroid function tests through pregnancy to facilitate improved management of thyroid disease in pregnancy in our local population.

Ultrasonographic and biochemical evaluation of visceral obesity in obese women with non-alcoholic fatty liver disease

OBJECTIVE

Identification of specific origin of lipid accumulation in the liver of patients with non-alcoholic fatty liver disease (NAFLD) is the most important step in preventing this condition. Because liver steatosis, in the obese patients without any systemic disease, can be graded easily by ultrasonography (US), we aimed to demonstrate the degree of liver steatosis and abdominal fat distribution by US, furthermore evaluate biochemical, anthropometrical measurements, and define the possible relationship between these parameters in obese women with different grades of liver steatosis.

METHODS

In this controlled clinical study, according to US evaluation of liver steatosis, the patients were divided into four groups: control (no steatosis), mild, moderate and severe steatosis groups. Demographic, biochemical and anthropometric measurements were done. Insulin resistance was determined by using homeostasis model assessment (HOMA-IR). Liver steatosis and abdominal fat distributions were evaluated by US.

RESULTS

The subcutaneous and preperitoneal fat layer measurements did not show any significant difference between the groups. The visceral fat layer thickness was significantly higher in severe liver steatosis group compared to the control and steatosis groups. The highest serum fasting insulin, uric acid levels and HOMA-IR index were observed in the severe liver steatosis group. Visceral fat thickness was positively correlated with serum UA levels and HOMA-IR CONCLUSIONS: This study suggests that visceral adipose tissue, HOMA-IR and serum uric acid levels are the main determinants of NAFLD in obese patients.

Comparison of ultrasonographic and anthropometric methods to assess body fat in childhood obesity

BACKGROUND

Pattern of fat distribution rather than obesity is of importance for cardiovascular morbidity and mortality. The accurate measurement of total and regional fat mass requires sophisticated and often expensive methods that have limited applicability in the clinical setting.

OBJECTIVE

The aim of this study is to evaluate body fat distributions by ultrasound (US) as a gold standard method for measuring visceral, preperitoneal and subcutaneous fat layers and comparing with anthropometric results, and then to find the most reliable anthropometric measurement in childhood obesity.

MATERIALS AND METHODS

Study group of 51 obese children (21 F, 30 M) (mean age+/-s.d.: 11.5+/-2.6 years) and control group of 33 non-obese children (17 F, 16 M) (mean age+/-s.d.: 12.2+/-2.7 years) were recruited for this study. Anthropometric measurements as body mass index (BMI), waist circumference (WC), waist/hip ratio (WHR), triceps and subscapular skinfold thicknesses were taken from all the participants. Abdominal preperitoneal (P), subcutaneous (S) fat at their maximum (max) and minimum (min) thickness sites, visceral (V), triceps (TrUS) and subscapular (SsUS) fat thicknesses were also measured ultrasonographically.

RESULTS

In the obese group, BMI was significantly correlated with US measurements of fat thicknesses, except Pmin and SsUS, whereas in the control group, BMI was significantly correlated with all US fat measurements. The relation of US measurements with skinfold thickness and WC was more significant in the control than in the obese group. No relation between WHR and US fat thickness measurements was found in both groups. Multiple regression analysis, using V as the dependent variable and anthropometric parameters, gender and the group as the independent variables, revealed BMI was the best single predictor of V (R(2): 0.53).

CONCLUSION

This study suggests that the validity of the anthropometric skinfold thickness in the obese children is low. Despite the limitations reported in the literature, in our study, BMI provides the best estimate of body fat. WHR in children and adolescents is not a good index to show intra-abdominal fat deposition.

A national survey of obstetric anaesthetic handovers

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.

Malign cystic glucagonoma presented with diabetic ketoacidosis: case report with an update

A 44-year-old woman was diagnosed with type II diabetes in 1998 and 1 year later she developed necrolytic migratory erythema, which is a specific skin lesion of glucagonoma. During the clinical investigation, a nodular 6 cm mass in the distal pancreatic region and multiple cystic liver metastases were found. She was operated on, and glucagonoma was detected and the long-acting, repeatable, octreotide treatment was started. 3 years after resection of a pancreatic glucagonoma she presented to a hospital emergency department with diabetic ketoacidosis. Hepatic multiple cystic metastases were visualized by computed tomography. During hospitalization she developed severe pulmonary embolism and deep-venous thrombosis of the lower extremities. Indium-labeled octeotide scintigraphy showed multiple cystic lesions in the liver with additional lesions in the iliocecal region, which had not been visualized by computed tomography. Despite somatostatin therapy the tumor had expanded in the liver. Arterial chemoembolization was performed but 6 months later she died.

Impact of antibiotic usage on resistance in microorganisms; urinary tract infections with E-coli as a case in point

OBJECTIVES

In this study, we sought to establish a correlation between consumption of flouoroquinolones in our hospital and the emergence of ofloxacin resistant strains of E. coli in the urinary specimens. Data of all urinary samples, received at Aga Khan University Hospital between January 1995 and December 2002, was retrieved and analyzed. Specimens yielding E-coli as an isolate were included in this study.

METHODS

E. coli Isolates showing >103 colonies were identified using standard microbiological techniques. Antibiotic susceptibility of E. coli was tested using Kirby Bauer disc diffusion method. Antimicrobial usage data, obtained through hospital Pharmacy as unit utilized per year for Quinolones in different medical and surgical units was available only for the period of 1997- 2002.

RESULTS

Among 32,722 urinary specimens E. coli (53%) was the most frequent isolate. Steady increase in the number of ofloxacin resistant E. coli was noted, 24% in 1995 to 55% in 2002. Maximum quinolone resistant E. coli have been observed in Medical units, 41% in 1997 increasing to 70% in 2002, followed by Surgery units (35% to 54%) and Pediatrics (12 to 38%). Sharp increase in ofloxacin consumption in our hospital, 1997 (28613 units) to 2002 (96880 units) has been observed. Trends in quinolone resistance correlate significantly with utilization in the same period as shown by linear regression.

CONCLUSION

E. coli resistance against most antibiotics has been on a rise particularly for quinolones. The utilization of quinolones correlates with increasing resistance in our hospitalized patients.

Correlation of abdominal fat accumulation and liver steatosis: importance of ultrasonographic and anthropometric measurements

PURPOSE

This study has two objectives: (1) using ultrasound (US) as a tool for measuring subcutaneous (S) and intra-abdominal; preperitoneal (P) and visceral (V) fat thickness. (2) Assessing the relationship between selected anthropometrical variables and US-measured S, P and V fat also evaluating the contribution of abdominal fat accumulation in development of liver steatosis.

METHODS AND MATERIALS

Sixty-eight obese patients (aged 43.9+/-9.3 years) and 40 non-obese subjects (aged 34.03+/-9.0 years) were recruited to this study. Height, weight (W), waist (WC) and hip circumferences were measured. Body mass index (BMI) and waist to hip ratio (WHR) were calculated. A linear-array probe (7.5 MHz) was used to measure S and P. A convex-array probe (3.5 MHz) was used for measuring V and assessing liver fatty infiltration.

RESULTS

In 45 (66%) patients, there were diffuse liver fatty changes. Liver steatosis showed significant correlation with V (r=0.57), P (r=0.38) and S (r=0.37). It also correlated with W (r=0.52), BMI (r=0.6), WC (r=0.45) (P<0.0001). V positively correlated with BMI (r=0.62), W (r=0.55), WC (r=0.52) and WHR (r=0.33). P correlated with WC (r=0.29), WHR (r=0.36) and W (r=0.34), but not with BMI, height and age. A significant correlation was found between S and BMI (r=0.73), W (r=0.65), and WC (r=0.57) (P<0.0001).

CONCLUSION

Obese patients showed thicker S, P, and V. Liver steatosis correlates significantly with both anthropometrical data; BMI, WHR, WC, and W, and with abdominal V, P, and S fat. V fat can be used as a good predictor for the possibility of different metabolic disorders and liver disturbances as steastosis.

Magnetic resonance imaging with rectal Gd-DTPA: new tool for the diagnosis of perianal fistula

This study investigated the effectiveness of magnetic resonance imaging (MRI) with rectal administration of the enteral contrast agent gadolinium diethylene triamine pentaacetic acid (Gd-DTPA) in the diagnosis of recurrent perianal fistulae, assessing the number, anatomical extent, location, and signal intensities of various lesions. Fistulas were examined by MRI before and after rectal administration of Gd-DTPA in 50 patients (excluding fistulas due to inflammatory bowel disease). Surgical findings were compared with both pre- and postcontrast T1-weighted, T2-weighted, and short T1 inversion recovery (STIR) sequences. Of the 68 fistulous tracts detected surgically, precontrast imaging identified 16 by T1-weighted images (hypointense), 27 by T2-weighted images (hyperintense or iso- to weakly hyperintense), and 54 by STIR. Postcontrast imaging identified 29 by T1-weighted images, 58 by T2-weighted, and 54 by STIR. MRI with rectal administration of Gd-DTPA thus facilitates determination of fistula tracts, which are better resolved by precontrast STIR than by either precontrast T1- or T2-weighted images. Postcontrast T2-weighted images were substantially superior to T1-weighted. Both noncontrast STIR and postcontrast T2-weighted sequences were adequate for classifying fistulas in ano, but in complex recurrent anal fistula postcontrast T2-weighted images were more helpful.

Can magnetic resonance imaging predict the success of parturition in oxytocin-induced pregnant women?

The aim of this study was to assess whether magnetic resonance imaging could predict the outcome of attempted vaginal delivery in a group of pregnant women whose parturition had to be induced by oxytocin. The signal intensity and morphology alterations in the cervix of 21 full-term pregnant women were analyzed before the induction of parturition. T2-weighted gradient echo sequences were utilized and signal intensity in the cervix was measured from the anterior and posterior lips of the cervix. An index indicating the brightness range of the cervix was formulated to overcome the effects of the individual intensity changes. Imaging features including the signal intensity and the evidence of effacement were correlated with the actual type of delivery performed. Images were also assessed visually by two independent radiologists. Statistical analysis of brightness indexes that were considered to have a predictive value as an indicator for possible delivery was not significant. However, visually assessed signal intensity of the cervix correlated strongly with the type of delivery. Effacement itself was the most reliable parameter in predicting the progress of the delivery. In conclusion, MR imaging seems to be useful for predicting normal parturition in full-term pregnant women who need oxytocin induction. However, the presence of effacement seems to be a more reliable and practical parameter that will be preferred in that prediction.

Postoperative wound infections

A prospective study of postoperative wound infection was carried out over a two year period in Cumhuriyet University Medicine Faculty Hospital in Sivas, Turkey. Examination of wounds, with cultures of all suspicious wounds using standard bacteriological methods was performed. Of a total of 4146 surgical wounds, 188 (4.53%), became infected. High infection rates were noted after colon resection (32.1%), gastric and oesophageal operations (21.1%), cholesystectomy (17.2%), and splenectomy (10.2%). Low infection rates were noted after thyroidectomy, mastectomy, caesarean section and abdominal hysterectomy. The commonest causative organisms were coagulase-negative staphylococci 21.7%, Staphylococcus aureus 19.7%, Escherichia coli 19.7%, Enterobacter spp. 17.6%, and Pseudomonas spp. 10.7%.