Abstract:

ESKAPE pathogens Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, and Enterobacter species are currently the cause of majority of hospital infections globally and they also effectively “escape” the effects of antibacterial drugs. The UNSTOPPABLE SUCCESS of these SUPERBUGS will lead to UNWINNABLE WAR. It has been suggested that resistance by these organisms are due to mutations, modification of LPS. As the crisis of antibiotic resistance continues to grow, the latest IDSA(Infectious disease society of America) "Bad Bugs, No Drugs" report examines the trickle of new antibiotics in the research and development (R&D) pipeline and proposes steps to tackle the shortage. The aim of the study was to characterize the antimicrobial resistance in ESKAPE pathogens isolated from 430 culture positive clinical sample like urine, pus, blood, wound swab and sputum,. Antibiotic resistance was determined by VITEK 2 and manual Kirby Bauer method. MIC was determined by VITEK 2 and E Test according to Clinical and Laboratory Standards Institute (CLSI). ESKAPE pathogens account for 63%. Except for S. aureus multiple drug resistance (MDR) index of ESKAPE pathogens revealed an increasing trend. The statistical analysis was done for hospital acquired and community acquired MDR infections. Extended spectrum betalactamase (ESBL), Klebsiellaspp., carbapenem resistant, A. baumannii and P. aeruginosa were identified mainly in hospital acquired than in community acquired infections. In conclusion, ESKAPE pathogens are commonly identified in alarming frequency and knowledge of antimicrobial resistance will be aided for empirical treatment.

Keywords: Multi drug Resistant, ESKAPE pathogens, Infections, antibiotics.

References:

[1]. Abdul Ghafur1, Vidyalakshmi PR1, A Murali. Emergence of Pan-drug resistance amongst gram negative bacteria! The First case series from India, Journal of Microbiology and Infectious Diseases / (2014); 4 (3): 86-91 JMID doi: 10.5799/ahinjs

[2]. Anima Poudyal, Benjamin P. Howden In vitro pharmacodynamics of colistin against multidrug-resistant Klebsiella pneumonia new Journal of Antimicrobial Chemotherapy (2008) 62, 1311–1318 doi:10.1093/jac/dkn425 Advance Access publication 15 October (2008)

[3]. Azza Elemam, Joseph Rahimian, and William Mandell. Infection with Panresistant Klebsiella pneumoniae: A Report of 2 Cases and a Brief Review of the Literature Clin Infect Dis. (2009) 49 (2): 271-274. doi: 10.1086/600042

[4]. Brooke A. Napier,a, b Eileen M. Burd, c, f Sarah W. Satola, c, d, e Stephanie M. Cagle, c, e Susan M. Ray,c, e, i Patrick McGann, g Jan Pohl, h Emil P. Lesho, g David S. Weiss a, b, c Clinical Use of Colistin Induces Cross-Resistance to Host Antimicrobials in Acinetobacter baumannii (2013) 4 (3).

[5]. Chua SL, Yam JKH, Sze KS, Yang L (2016).”Selective labelling and eradication of antibiotic-tolerant bacterial populations in Pseudomonas aeruginosa biofilms". Nat Commun. 7:10750. doi:10.1038/ncomms10750. PMID 26892159.

[6]. Ching Jou Lim, Allen C. Cheng Prevalence of multidrug resistant organisms and risk factors for carriage in long-term care facilities: a nested case–control study. Antimicrob Chemother(2014); 69: 1972–1980 doi:10.1093/jac/dku077 Advance Access publication 7 April 2014

[7]. Rafael López-Rojas,a,c Michael J. McConnell,a,c Manuel Enrique Jiménez-Mejías, Colistin Resistance in a Clinical Acinetobacter baumannii Strain Appearing after Colistin Treatment: Effect on Virulence and Bacterial Fitness. Antimicrobial agents chemother (2013) sep; 57 (9). Federico Perez, Andrea M. Hujer, Kristine M. Hujer, Brooke K. Decker, Philip N. Rather, and Robert A. Bonomo. Global Challenge of Multidrug-Resistant Acinetobacter baumannii ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Oct. (2007), p. 3471–3484 Vol. 51, No. 10 0066-4804/07/$08.000 doi:10.1128/AAC.01464-06 Copyright © 2007, American Society for Microbiology.

[8]. Giske CG, Monnet DL, Cars O, Carmeli Y. Clinical and economic impact of common multidrug-resistant gram-negative bacilli. Antimicrob Agents Chemother (2009);52:813-21.

[9]. National Nosocomial Infections Surveillance System Report, data summary from January 1992 through June (2004) issued October 2004. Am J Infect Control 2004;32:470-85.

[10]. Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: no ESKAPE. J Infect Dis (2009);197:1079-81.

[11]. Spellberg B, Guidos R, Gilbert D The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis (2009);46:155-64.

Abstract:

Introduction: A high blood glucose is common in actually ill neurological patients, even in non-diabetics. A consensus regarding the cut-off blood glucose level that would be related to poor prognosis in children and adolescent with head trauma, which makes the comparison of different studies important. Objective: Prevalence of acute hyperglycemia and Glasgow coma scale (GCS) in Pediatric Traumatic brain injury in the Emergency Room. Method: Prospective cross-sectional study of pediatric head injury patients in the emergency room during one year period. The cut-off value of 150 mg/dL to define hyperglycemia was considered. Results: A total of 440 children were included and 65 had admission hyperglycemia. Hyperglycemia was present in 11% of mild head trauma cases; 35% of those with moderate head trauma and 54% of severe head trauma. In this study, observed that among children with higher blood glucose levels, 83% had abnormal findings on cranial computed tomography scans. The prevalence of hyperglycemia is higher in patients with severe head trauma, as well as in those with abnormal findings on CCT scans. Conclusion: Hyperglycemia was more prevalent in severe head trauma (GCS ≤8), regardless of etiology of trauma, mode of injury or multiple trauma in children with abnormal findings on head computed tomography scans.

Keywords: adolescents, children, head trauma, hyperglycemia, prevalence

References:

[1]. Bochicchio GV, Sung J, Joshi M. Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma (2005); 58; 921-924.

[2]. Bochicchio GV, Joshi M, Bochicchio KM. Early hyperglycemic control is important in critically injured trauma patients. J Trauma (2007); 63; 1353-1358.

[3]. Chiaretti A, De BR, Langer A. Prognostic implications of hyperglycaemia in paediatric head injury. Childs NervSyst (1998); 14:455-459.

[4]. Chiaretti A, Piastra M, Pulitano S. Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs NervSyst (2002); 18:129-136.

[5]. Cochran A, Scaife ER, Hansen KW, Downey EC. Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma (2003); 55: 1035-1038.

[6]. Durr JA, Hoffman WH, Sklar AH, Steinhart CM. Correlates of brain edema in uncontrolled IDDM. Diabetes (1992); 41; 627-632.

[7]. Epstein J, Breslow MJ. The stress response of critical illness. Crit Care Clin (1999); 15; 17-33. 20. Hirsch IB.

[8]. Jeremitsky E, Omert LA, Dunham CM, Wilberger J, Rodriguez A. The impact of hyperglycemia on patients with severe brain injury. J Trauma (2005); 58; 47-50.

[9]. Kuzuya T, Nakagawa S, Satoh J. Report of the Committee on the classification and diagnostic criteria of diabetes mellitus. Diabetes Res ClinPract (2002); 55:65-85.

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[11]. Lam AM, Winn HR, Cullen BF, Sundling N. Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg (1991); 75: 545-551.

[12]. Laird AM, Miller PR, Kilgo PD, Meredith JW, Chang MC. Relationship of early hyperglycemia to mortality in trauma patients. J Trauma (2004); 56; 1058-1062.

[13]. Marcoux KK. Management of increased intracranial pressure in the critically ill child with an acute neurological injury. AACN Clin Issues (2005); 16:212-231.

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[15]. Melo JR, Silva RA, Moreira ED Jr. [Characteristics of patients with head injury at Salvador City (Bahia--Brazil)]. Arq Neuropsiquiatr (2004); 62;711-714.

[16]. In-patient hyperglycemia--are we ready to treat it yet? J ClinEndocrinolMetab (2002);87; 975-977.

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[19]. Parejo P, Stahl N, Xu W, Reinstrup P, Ungerstedt U, Nordstrom CH. Cerebral energy metabolism during transient hyperglycemia in patients with severe brain trauma. Intensive Care Med (2003); 29; 544-550.

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Abstract:

Background: The incidence and spectrum of mortality and morbidity in Botswana are not well established. Mortality data can be provided through the hospital records and documentation.

Objectives: Based on the importance given to accident and emergency at princess marina hospital by both the leaders and the entire population in Botswana, it was opportune to conduct this study. The major objective is to establish some epidemiological markers of death in our facility and therefore to provide factors surrounding death and solutions to reduce mortality.

Methods: A retrospective study has been conducted, based on monthly mortality and morbidity report provided by different doctors within the department.

Results: 27361 patients were seen during the said period with about 111 deaths (0.41 %). A total number of 10041(36.7 %) patients were admitted to different wards for in-patients management. A couple of patients were brought in death after sudden collapse at home or being involved in road traffic accident. Roughly 9 patients died in accident and emergency each month with a mean of 2280 patients monthly attending the department. 56 % of patient died with an internal medicine condition. 51 % of died in accident and emergency were young adult on the range of 14 – 49 year old. No significance value concerning the difference in gender.

Conclusion: The study provided details and a preliminary answer to cause of death grossly. Despite of comorbidities and the high number of HIV patients at the age ranging between 14 and 49 year old, having a high percentage of patients adults dying in accident and emergency is alarming and suggestions had been given to shrink this number.

Keywords: mortality, morbidity, mortality and morbidity, princess marina hospital, accident and emergency department, brought in dead, died in casualty,

References:

[1] Brennan TA, Leape LL, Laird NM, et al. (1991) Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New Engl J Med 324:370–376

[2] “Canadian Institute for Health Information, HSMR: A New Approach for Measuring

[3] Deis JN, Smith KM, Warren MD, Throop PG, Hickson GB, and Joers BJ, et al. (2010) ‘Transforming the morbidity and mortality conference into an instrument for system wide improvement’. http://www.ahrq.gov/downloads/pub/ advances2/vol2/Advances-Deis_82.pdf. Accessed May 9, 2010

[4] D.L. Clarcke (2013) “using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a south African regional hospital”;

[5] Friedman JN, Pinard MS, Laxer RM. (2005) “The morbidity and mortality conference in university-affiliated pediatric departments in Canada”. J Pediatr; 146:1–2.

[6] Hospital Mortality Trends in Canada (Ottawa: CIHI, 2007)”.

[7] Jed D. Gonzalo, Julius J. Yang, Grace C. Huang (2012) ‘Systems-Based Content in Medical Morbidity and Mortality Conferences: A Decade of Change'.

[8] Juliet Higginson and al. (2012) “Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?” www.patientsafetyfirst.nhs.uk

[9] Kravet SJ, Howell E, Wright SM. (2006)‘Morbidity and mortality conference, grand rounds, and the ACGME’s core competencies’. J Gen Intern Med.; 21(11):1192–1194.

[10] ‘Making the Medical Morbidity, Mortality, and Improvement Conference Even Better’, J Oncol Pract May 1, 2015:e434-e436

[11] Morbidity and Mortality Revisited: Applying a New Quality Improvement Paradigm in Oncology Daniel G. Stover, and Jessica A. Zerillo, 2015

[12] Orlander JD, Fincke BG. (2003) Morbidity and mortality conference: a survey of academic internal medicine departments. J Gen Intern Med; 18:656–8.

[13] Orlander JD, Barber TW, Fincke BG. (2002) ‘the morbidity and mortality conference: the delicate nature of learning from error’. Acad Med.; 77(10):1001–1006.

[14] Pierluissi E, Fischer MA, Campbell AR, et al. (2003) Discussion of medical errors in morbidity and mortality conferences. JAMA; 290:2838–42.

[15] Steven J Kravet and Al. (2006) “morbidity and mortality conference, grand rounds, and the ACGME’s core competencies”, J. Gen Med;

[16] Schwarz D, Schwarz R, Gauchan B, et al. (2011) Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Qual Saf; 20:1082–8.

[17] Szostek JH, Wieland ML, Loertscher LL, Nelson DR, Wittich CM, McDonald FS, et al.(2010) ‘ A systems approach to morbidity and mortality conference’. Am J Med. ;123(7):663–668

[18] Wachter RM, Shojania KG, Saint S, et al. (2002) Learning from our mistakes: quality grand rounds, a new case-based series on medical errors and patient safety. Ann Intern Med; 136:850–2.

[19] Wachter RM, Pronovost PJ (2009) Balancing “no blame” with accountability in patient safety. New Engl J Med 361:1401–1406.

[20] Wachter RM, Pronovost PJ (2009) Balancing “no blame” with accountability in patient safety. New Engl J Med 361:1401–1406.

Abstract:

Introduction: Medical incident reporting is a key tool for improving patient safety in healthcare, hence improved quality of care. The better the knowledge, attitude and practice of this concept, the better the quality of care. The perceived knowledge, attitude and practice are still low in many Uganda healthcare facilities. Many of the healthcare providers have, therefore, limited their scope to maternal death audit and reporting or perinatal death reporting and to a greater extent Adverse Event Following Immunization (AEFI). This problem of perceived low knowledge, attitude and practice of incident reporting is coupled with the poor institutional culture to persistently and inadequate support healthcare professionals to report incidents. Medical incident reporting is, therefore, the single most powerful tool for developing and maintaining an awareness of risks in healthcare practice, hence a cornerstone to improved patient safety and improved quality of service delivery.

Objectives: The study objectives were as follow; to assess the level of knowledge about medical incident reporting among healthcare professionals, by April, 2016 and determine their attitude towards medical incident reporting. The researcher also set out to ascertain the practice and the extent to which medical incident reporting is practiced in Midigo Health Centre IV, as well as, establishing the factors affecting medical incident reporting in the said healthcare facility.

Methods: The study was a cross sectional study of knowledge, attitude and practice of medical incident reporting among Healthcare Professionals in Midigo health centre IV. It was both qualitative and quantitative; with a sample of 44healthcare professionals interviewed using structured questionnaires. The questionnaire was pre-tested. Analysis of result was done using computer packages called Statistical Package for Social Sciences (SPSS) and Microsoft excel. Ethical considerations in research were observed.

Results: The cadre of the respondents were; Medical officers – 4.5%, Clinical officers – 6.8%, Nurses – 43.2%, Midwives – 11.4%, Theatre staffs – 9.1%, Laboratory staffs – 6.8% and other staffs – 18.2%. The response rate was 100%. The level of knowledge about medical incident reporting among healthcare professionals in Midigo HC IV was at 84.1%, by April 2016. Much as there was no statistical significance between cadre of staffs and extent of knowledge, p-value >0.39, the only cadres that had excellent knowledge on medical incident reporting were nurses (75%) and clinical officers (25%). The rest of the staffs either had average knowledge or fair knowledge or no knowledge at all. The healthcare professionals had strong positive attitude towards medical incident reporting and this was at 97.7%. By April, 2016, the practice of medical incident reporting was at 72.6% with the majority of these respondents (up to 50%), having participated in reporting three times or more for the last 5years. The major factors that facilitated the respondents to report were; Strong positive feeling to participate and improve patient safety and respondents were knowledgeable (educated) about medical incident reporting. Other minor factors like ability of respondents to get feedback on reported incidents and strong institutional culture of reporting did not make strong contribution towards the practice of reporting. However, the major barriers were; respondents didn’t know where and how to report, coupled with weak institutional culture of reporting incidents. Surprisingly, fear of consequence of reporting did not in any way hinder any respondent from reporting. In other words, it was not a reason for them not to participate in medical incident reporting.

Conclusion: Medical incident reporting still remains a key tool in improving patient safety. The greater the practice of reporting, the better; as evident by the strong positive feeling towards medical incident reporting, in this research finding. Educating professionals on incident reporting and strong positive individual feeling to improve safety have remained the major factors facilitating medical incident reporting. Likewise, lack of knowledge on where and how to report, coupled with weak institutional culture of reporting have remained the major barriers to practicing medical incident reporting.

References:

Book

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[2.] Mahajan, R. P. (2010). Critical incident reporting and learning. British Journal of Anaesthesia,105 (1), 69–75. doi:10.1093/bja/aeq133

Project report

[3] Nabudere, H., Asiimwe, D. and Semakula, D. (2014). Improving patient safety for better quality of care. Regional East African Community Health (REACH) Policy Initiative

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[4] Anderson, J. E., Naonori, K., Rhiannon, W., and Anneliese, D. (2013). Can incident reporting improve safety? Healthcare practitioners‟ views of the effectiveness of incident reporting. International Journal for Quality in Health Care, 2013(25), 141–150. doi: 10.1093/intqhc/mzs081

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[6] Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O ‟Shaughnessy, J. and DeWit, M. (2006). Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care, 15, 39–43. doi: 10.1136/qshc.2004.012559

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[7] Omona, K. (2015). Patients and Health Workers' Engagement in Patient Safety in Healthcare in Kitgum General Hospital. South American Journal of Management, 1, 1-44.

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[8] Domenico, F., Paolo, R., Aida, B., Claudia, P., and Maria, P., (2012). Patient Safety and Medical Errors: Knowledge, Attitudes and Behavior among Italian Hospital Physicians. International journal for quality in healthcare, 2012, 1-8.

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[9] Jansma, J. D., Cordula, W., Reinier, W. t. K., & Arnold, B. B. (2011). Effects on incident reporting after educating residents in patient safety: a controlled study. BMC Health Services Research, 11:335. doi:10.1186/1472-6963-11-335

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London, UK: Wiley Blackwell.

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Abstract:

Background: The Global report from the World Health Organization (WHO), published in 2016, estimated that 422 million of the adult population lives with diabetes the number of diabetic patients has dramatically increased 4 times over in the adult population.

Methods: This is Interventional study, 648 of the participants of diabetes mellitus in out-patient diabetic clinic in hospital central Nampula, the participants taken according to inclusion and exclusion criteria, completed the pre-test at baseline and post-test after the second follow up session of education, during each session of education blood pressure, urea, creatinine were recorded. Education commenced with instruction in groups of each session followed by individual advice sessions for each patient with different specialists.

Results: The present study found that educational intervention of diabetes was highly effective to improve blood pressure from baseline mean of 131.02/71.73 mmHg second follow up 120.95/68.79 mmHg with standard deviation of baseline 24.35 mmHg/14.66 mmHgto second follow up 19.95 mmHg/11.33 mmHg, blood urea and serum creatinine significantly decreased from baseline in the second follow up (P <. 001). A post hoc Turkey test on blood pressure, blood urea and serum creatinine when compared with dependent variable fasting blood sugar found significantly (P=. 05) at baseline, at first follow up (P=. 005) and at second follow up (P=. 005).

Conclusion: The present study found that educational intervention was highly effective in controlling blood pressure, blood urea and creatinine among participants of diabetes mellitus.

Keywords: Diabetes Mellitus, blood pressure, blood urea and creatinine, effect education, control, and participants

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[14]. Moattari, M., Ghobadi, A., Beigi, P. and Pishdad, G. (2012) ‘Impact of self management on metabolic control indicators of diabetes patients’, Journal of Diabetes & Metabolic Disorders, 11 (1), p. 6. doi: 10.1186/2251-6581-11-6. In-text citations: (Moattari et al., 2012)

[15]. Mollaoğlu, M. and Beyazıt, E. (2009) ‘Influence of diabetic education on patient metabolic control’, Applied Nursing Research, 22 (3), pp. 183–190. doi: 10.1016/j.apnr.2007.12.003. In-text citations: (Mollaoğlu and Beyazıt, 2009)

[16]. MakkiAwouda, F., Elmukashfi, T. and Al-Tom, H. (2014) ‘Effects of health education of diabetic patient’s knowledge of diabetic health centers, Khartoum State, Sudan: 2007-2010’, Global journal of health science, 6 (2), pp. 221–6. In-text citations: (MakkiAwouda, Elmukashfi, and Al-Tom, 2014)

[17]. Merakou, K., Knithaki, A., Karageorgos, G. and Theodoridis, D. (2015) ‘Group patient education: Effectiveness of a brief intervention in people with type 2 diabetes mellitus in primary health care in Greece: A clinically controlled trial’, Health Education Research, 30 (2), pp. 223–232. doi: 10.1093/her/cyv001.In-text citations: (Merakou et al., 2015)

[18]. Mash, B., Levitt, N., Steyn, K., Zwarenstein, M. and Rollnick, S. (2012) ‘Effectiveness of a group diabetes education program in underserved communities in South Africa: Pragmatic cluster randomized control trial’, BMC Family Practice, 13 (1). doi: 10.1186/1471-2296-13-126. In-text citations: (Mash et al., 2012)

[19]. Mendes, G., Nogueira, J., Reis, C., Meiners, D. and Dullius, J. (2016) ‘Diabetes education program with emphasis on physical exercise promotes significant reduction in blood glucose, HbA1c and triglycerides in subjects with type 2 diabetes: A community-based quasi-experimental study’, The Journal of sports medicine and physical fitness., In-text citations: (Mendes et al., 2016)

[20]. Norris, S., Lau, J., Smith, S., Schmid, C. and Engelgau, M. (2002) ‘Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control’, Diabetes care., 25 (7), pp. 1159–71. In-text citations: (Norris et al., 2002)

[21]. Pereira, D.A., Ma, N., Costa, S.C., Luíza, A., Sousa, L., César, P., Jardim, V., Sanches, L. and Jardim, S. (2014) ‘Effect of an educational intervention on the metabolic control of people with type 2 diabetes’, Journal of Diabetes Nursing, 18. In-text citations: (Pereira et al., 2014)

[22]. Ricci-Cabello, I., Ruiz-Pérez, I., Rojas-García, A., Pastor, G., Rodríguez-Barranco, M. and Gonçalves, D.C. (2014)‘Characteristics and effectiveness of diabetes self-management educational programs targeted to racial/ethnic minority groups: A systematic review, meta-analysis and meta-regression’, BMC Endocrine Disorders, 14 (1), p. 60. doi: 10.1186/1472-6823-14-60. In-text citations (Ricci et al., 2014)

[23]. Retrieved August 29, 2016, from https://en.wikipedia.org/.../Geography_of_Mozambi. NDEP program overview. (2016, June 24). Retrieved August 29, 2016, from https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/about-ndep/ndep-overview/Pages/ndep-overview.aspxIn-line Citation:(“NDEP program overview,” 2016)

[24]. Salinero-Fort, M., Santa, C., Arrieta-Blanco, F., Abanades-Herranz, J., Martín-Madrazo, C., Rodés-Soldevila, B. and Burgos-Lunar, de (2011) ‘Effectiveness of PRECEDE model for health education on changes and level of control of HbA1c, blood pressure, lipids, and body mass index in patients with type 2 diabetes mellitus’, BMC public health., 11. In-text citations: (Salinero-Fort et al., 2011)

[25]. Tidy, C. (2014b) Diabetes education and self-management programs. Patient. Available at: http://patient.info/doctor/diabetes-education-and-self-management-programmes (Accessed: 14 August 2016). In-text citations: (Tidy, 2014b)

[26]. zareban, I., Niknami, S. and Rakhshani, F. (2013) ‘The effect of the self-efficacy education program on reducing blood sugar levels in patients with type 2 diabetes’, Health Education & Health Promotion, 1 (1), pp. 67–79. In-text citations: (zareban, Niknami, and Rakhshani, 2013) 

Abstract:

Background: This study is performed to evaluate the treatment of complex regional pain syndrome CRPS type 1 with radiofrequency thermo coagulation of stellate ganglion block and T2-T3 sympathetic block.

Material and methods: We performed diagnostic stellate ganglion block in all patient with CRPS TYPE 1 in one hand. Those patients reduce 50% in pain score e.g. VAS SCORE, was considered for RF stelleate ganglion block after 1 week and this is GROUP 1. Those patients reduce less than 50% pain score was considered for diagnostic T2-T3 sympathetic block after 1 week. Those patients reduce 50% in pain score e.g. VAS SCORE, was considered for RF T2-T3 sympathetic block after 1 week and this is GROUP 2. Pain intensity using a visual analog score also assessed usage of analgesic dosages before and after RF in both groups.

Results: Treatment produced a significant decrease in pain score, VAS value in both groups and significant reduce the dosages of analgesic drugs in both groups.

Conclusion: The study of these 17 patients shows that there is chance of inadequate pain relief after satisfactory stellate ganglion block because of KUNTZ’S nerve and giving T2-T3 sympathetic block among this gives good pain relief. Also RF in stellate ganglion and T2-T3 sympathetic ganglion block gives long term pain relief and decrease analgesic dosages and thus improves quality of life.

Keywords: Complex regional pain syndrome type 1, Stellate ganglion block, T2-T3 sympathetic block, RF-radiofrequency, VAS score, analgesic drugs

References:

[1.] Agarwal-Kozlowski K, Lorke DE, Habermann CR, Schulte am Esch J, Beck H. Intervetnional management of intractable sympathetically mediated pain by CT guided catheter implantation for block and neuroablation of thoracic sympathetic chain: technical approach and review of 322 procedures. Anaesthesia 2011, 66. Pages 699-708.

[2.] Boas RA. Sympathetic nerve blocks: in search of a role: Reg Anasth Pain Med. 1998 May-June;23(3): 292-305. Review.

[3.] Becker DE. Basic and clinical pharmacology of glucocorticosteroids. Anaesth Prog 2013 Spring; 60(1):25-31; Review.

[4.] Bonica JJ, editor: The Management of Pain. Philadelphia, Lea & Febiger, 1953 & 4^th edition 2010.

[5.] Bonica JJ SCOTT editor, 4th edition 2010

[6.] Day M. Sympathetic blocks: the evidence Pain Pract. 2008 Mar-Apr; 8(2):98-109.

[7.] Elias M. Cervical sympathetic and stellate ganglion blocks. Pain physician. 2000. Jul; 3(3):294-304.

[8.] Fischer SG, Zuurmond WW, Birklein F, Loer SA, Perez RS. Anti-inflammatory treatment of Complex Regional Pain Syndrome. Pain 2010 Nov; 151(2) 251-256.

[9.] Goebel A. Complex regional pain syndrome in adults. Rheumatology (oxford). 2011 oct; 50(10):1739-1750.

[10.] Hogan QH, Erickson S J, Haddox JD, Abram SE. The spread of solution during stellate ganglion block. Reg. Anaesth 1992:17:78-83.

[11.] Hogan QH, Taylor ML, Goldstein M, Steven R, Kettler R. Success rates in producing sympathetic blockade by paratracheal injection. Clin J pain 1994 Jun; 10(2) 139-145

[12.] Harden RN, Oaklander AL, Burton AW, Perez RS, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S; Reflex Sympathetic Dystrophy Syndrome Association, Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4^th edition. Pain Med. 2013 Feb; 14(2):180-229.

[13.] Kunzt A. Distribution of the sympathetic rami to the brachial plexus its relation to sympathectomy affecting the upper extremity. Arch Surg 1927:15:871-877.

[14.] Munts AG, van der Plas AA, Ferrari MD, Teeps-Twiss IM, Marinus J, Van Hilten JJ. Efficiency and safety of a single intrathecal methylprednisolone bolus in chronic complex regional pain syndrome. Eur J Pain. 2010 May;14(5):523-528.

[15.] O’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database Sys Rev. 2013 Apr 30;4:CD009416.

[16.] Raj PP, Lou L, Erdine S, Staats PS, Waldman SD: T2 & T3 sympathetic nerve block and nerolysis, ch 22, pp 132-137, in Radiographic Imaging for Regional Anaesthsia and Pain Management 2003.

[17.] Rmsaroop L, Partab P Singh B, Satyapal KS. Thoracic origine of a sympathetic supply to the upper limb: the ‘nerve of Kuntz’ revisited J Anat 2001:199:675-682.

[18.] Raj’s practicle management of pain 4th edition 2008

[19.] Shfali A, Broatch J, RAJA SN: Web-based epidemiological survey for CRPS-1 (poster). The American Society of anaesthesiologists, New Orleans, 2005.

[20.] Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sumpathetic block improves the treatment effect for upper extremities neropathic pain. Anesth Analg. 2011 Sept;113(3):605-609.

Abstract:

Background: Diagnosing and treating impalpable breast lesions is one of the greatest gains of screening and it is a game changer in winning against breast cancer. Screening must be complemented with availability of methods to handle impalpable lesions. At the least, impact of screening is considerably diminished and at worst, screening will be counter-productive or downright unethical if detected lesions cannot be diagnosed and treated, yet standard methods of handling impalpable lesions are not available or not sustainable in low-income centers.

Objective: To make screening effective by finding cheap and sustainable method of localizing, diagnosing and treating impalpable breast lesions.

Method: Intra-operative ultrasound (USS) directed biopsy of impalpable breast lesions was modified so that the localization and operative procedure can be dissociated and performed with limited facility; Under USS-guidance at the radiology department, hematoma was formed around impalpable lesions by injecting 3-4mls of patient’s own blood into them and incision placement was planned at the same time. Two to 3 days later, during open surgical procedure without intra operative USS-facility, the iatrogenic hematomas were found and excised. Primary measures of outcome were achievement of successful excision and histological diagnosis.

Result: Following walk-in screening, 5 impalpable breast lesions visible to mammography and ultrasound were included. All 5 were successfully localized and excised. Histological diagnosis was reached in all 5 lesions.

Conclusion: This small volume pilot experience demonstrated how impalpable lesions can be handled in poor resource centers. The HUGE method allows flexibility of scheduling and lowers dependence on high technology.

Keywords: Hematoma localization, Impalpable, breast lesion, low-income

References:

[1]. Adamczyk B, Murawa P. Preoperative localization of nonpalpable breast nodules-which method to choose? Reports of Practical Oncology and Radiotherapy. 2008:201-4.

[2]. Ahmad S, Ginawi AE, Sabbagh S. DEDICATED BREAST CANCER MANAGEMENT CENTRES WITH. FACILITIES FOR FULL IMAGE-GUIDED ASSESSMENT AND IMAGE-GUIDED SURGERY IN THE DEVELOPING AREAS OF PAKISTAN--A LONG OVERDUE NECESSITY. Journal of Ayub Medical College, Abbottabad : JAMC. 2015;27(1):251-4.

[3]. Agodirin O, Olatoke S, Rahman G, Adeoti M, Oyeyemi G, Durojaiye A, et al. How effective is the treatment of locally advanced and metastatic breast cancer in Developing centers; A retrospective review Ethiop J Health Sci. 2015;25(4):338-44.

[4]. Anyanwu SN, Egwuonwu OA, Ihekwoaba EC. Acceptance and adherence to treatment among breast cancer patients in Eastern Nigeria. Breast. 2011;20 Suppl 2:S51-3.

[5]. Alikhassi A, Ahmadinejad N, Sedighi N, Najafi M. Stereotactic breast core needlel biopsy in a tertiary breast center of tehran University of Medical sciences Arch Breast Cancer. 2015;2(1):21-6.

[6]. Agodirin SO, Ojemakinde OM, Bello TO, Oguntola AS, Aremu AA, Ojemakinde KO, et al. Ultrasound-guided wire localization of lesions detected on screening mammography in Osogbo, Nigeria and its impact on breast conservative surgery. Ann Afr Med. 2012;11(2):91-5.

[7]. Akanbi oO, A. Adeoti, M. Aderounmu, A. Idris, O. Abayomi, O. Delay presentation of breast cancer: A study among south western Nigerian women. International Journal of Current Research. 2015;7.

[8]. Blumencranz PW, Ellis D, Barlowe K. Use of hydrogel breast biopsy tissue markers reduces the need for wire localization. Ann Surg Oncol. 2014;21(10):3273-7.

[9]. Chan BK, Wiseberg-Firtell JA, Jois RH, Jensen K, Audisio RA. Localization techniques for guided surgical excision of non-palpable breast lesions. The Cochrane database of systematic reviews. 2015(12):Cd009206.

[10]. Egwuonwu O, Anyanwu S, Ihekwoaba E, Chianakwana G, Iloabachie I. Pattern of presentation and adherence to treatment in young breast cancer patients Orient Journal of Medicine. 2013;25(1-2):14-8.

[11]. Ko K, Han BK, Jang KM, Choe YH, Shin JH, Yang JH, et al. The value of ultrasound-guided tattooing localization of nonpalpable breast lesions. Korean Journal of Radiology. 2007;8(4):295-301.

[12]. Mascaro A, Farina M, Gigli R, Vitelli CE, Fortunato L. Recent advances in the surgical care of breast cancer patients. World J Surg Oncol. 2010;8:5.

[13]. Memon MA, Berstock DA. Ultrasound-guided excision of impalpable mass breast lesion. Annals of The Royal College of Surgeons of England. 1996;78(1):61-2.

[14]. Masroor I, Afzal S, Shafqat G, Rehman H. Usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically. International Journal of Women's Health. 2012;4:445-9.

[15]. Ogundiran TO, Ayandipo OO, Ademola AF, Adebamowo CA. Mastectomy for management of breast cancer in Ibadan, Nigeria. BMC Surgery. 2013;13:59.

[16]. Sule E. Breast conservation for T3/T4 Tumors in a developing country. wjpmr. 2016;2(4):39-42.

Abstract:

Introduction: Carcinoid tumours are neoplasms of neuroendocrine cells with varying symptoms and malignant potential. Cystic hepatic metastasis secondary to carcinoids is a rare entity. There are very few reports in literature (around four as of date) and all have been in relation to ileal carcinoid or post chemotherapy. Most of the carcinoids present with diarrhoea, flushing, pruritis. Severe anemia as presenting symptom is rare.

Case report: Herein we describe a 66 year old gentleman who presented with severe anemia and heart failure. An OGD (Oesophago gastro duodenal endoscopy) done as part of anemia work-up revealed multiple, duodenal, centrally umbilicated nodules. Histopathology and special stains (chromogranin & synaptophysin) confirmed it to be Grade 1 Neuroendocrine tumour (carcinoid) with a Ki-67 index of less than 2%. CECT abdomen showed two small cystic lesions, the largest one measuring 2x3cms. Anemia was corrected and patient improved symptomatically. He was placed on conservative management for Neuroendocrine tumours and is on regular follow up.

Discussion: In this case patient presented with severe anemia and heart failure. He had no other symptoms like flushing, diarrhoea. The rarity of this case is the presence of cystic hepatic metastasis and presentation with severe anemia. This is the first case reported in which a duodenal carcinoid is diagnosed during the workup for anemia. Here another interesting and rare feature is the presence of cystic hepatic metastasis which is quite unusual.

Case report: A 66 year old male, known case of CVA not on treatment, hypertensive on treatment admitted with history of progressive easy fatigability, progressive bilateral lower limb swelling, decreased appetite for 15 days. Patient denied history of diarrhea, vomiting, melena or hematochezia, diabetes, hypertension or cardiac problems .Physical examination revealed pallor, bilateral pitting pedal oedema, raised JVP, with pansystolic murmur at tricuspid area, S3 with bilateral basal crepitations and rhonchi with tender right hypochondrium. His initial workup revealed hemoglobin of 4.3gm/dl and peripheral blood smear showed microcytic hypochromic anaemia. Liver and kidney functions were within normal limits with a serum albumin of 3.4mg/dl. 2D ECHO revealed dilated RA, RV with a severe tricuspid regurgitation (TR) with PASP of 70 mmHg. LVEF 56%,No RWMA, mild MR & AR. Oesophago-gastro duodenoscopy(OGD) revealed multiple duodenal nodules with central umbilication in D1,D2,D3 with largest measuring 2x3 cm(?Carcinoid) and was biopsied for histopathological examination(HPE) (fig 1). Contrast enhanced computerised tomography(CE-CT) thorax and abdomen revealed enlarged liver(15.5cm) with two well defined non enhancing cystic lesions in segments 4A of liver (measuring 36x31x32 mm and 8x9x4 mm) and pyloric and duodenal wall thickening suggesting a possibility neoplastic etiology(fig 2). HPE (Fig 3) revealed well differentiated neuroendocrine tumor (WHO grade1) with EMA, synaptophysin, chromogranin positive and a Ki-67 index: of 2%. Patient transfused with three pint of packed RBC and was symptomatically better, In view of the low grade of the NETs patient is on regular follow up 

References:

Abstract:

Monkeypox disease is a zoonosis caused by monkeypox virus, a member of the genus orthopoxvirus, subfamily Chordopoxvirinae, family Poxviridae. It is a virus very similar to the smallpox virus. It is a disease that occurs in tropical Africa, in the Congo Basin. The Congo is the country where you meet the most cases of monkeypox. The disease was first identified in 1958 but the first cases were observed after the eradication of smallpox in 1977, the disease was confused with smallpox for several years (1).

References:

[1]. Aysegul N, Anne W, Sina B, Chris A. Reemergence of Monkeypox: Prevalence, Diagnostics, and Countermeasures. Clin Infect Dis. 2005 Dec 15;41(12):1765-71. Epub 2005 Nov 11

[2]. Foster SO, Brink EW, Hutchins DL, et al. Human monkeypox. Bull World Health Organization 1972;46:569-76.

[3]. Gentile M, Gelderblom HR. Rapid viral diagnosis: role of electron microscopy. New Microbiol 2005; 28:1-12.

[4]. Heymann DL, Szczeniowski M, Esteves K. Re-emergence of monkeypox in Africa: a review of the past six years. Br Med Bull 1998; 54:693-702

[5]. Jezek Z, Arita I, Mutombo M, Dunn C, Nakano JH, M. Szczeniowski Four generation of probable person to person transmission of human monkeypox. Am j Epidemiol 1986; 123:1004-12

[6]. Jezek Z, Fenner F. Human monkeypox. In: Melnick JL, ed. Monographs in virology ol. 17. Basel, Switzerland: Karger,1 988

[7]. Khodakevich L, Jezek Z, Messinger D. Monkeypox virus: ecology and public health significance. Bull World Health Organ 1988; 66:747-52.

[8]. Ladnyj ID, Ziegler P, Kima E. A human infection caused by monkeypox virus in Basankusu Territory, Democratic Republic of the Congo. Bull World Health Organ 1972;46:593-7.

[9]. Multistate outbreak of monkeypox-Illinois, Indiana, and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:537-40.

[10]. The global eradication of smallpox: final report of the global commission for the certification of smallpox eradication. Geneva, Switzerland: World Health Organization, 1980.

[11]. Inger K. Damon. Status of human monkeypox: clinical disease, epidemiology and research. Vaccine. Dec. 30 2011, 29 Suppl 4: D54-9. Epub 2011 Dec 18.

Abstract:

The process of individual spirit Union with the Supreme Being, or any practice that makes such union is expounded by Sage Patanjali. Here are 10 major concepts associated with Yoga which can be implemented for overall quality of our life style in real world (Fitness Health, 2016).

References:

[1]. Chinmayananda, S. (1995). The Holy Geeta from

https://books.google.co.in/books/about/The_Holy_Geeta.html?id=eVw_Rff7m7AC

[2]. Coghlan, D., & Miller, M.B. (2014). The Sage Encyclopedia of Action Reserach from http://www.ebook777.com/sage-encyclopedia-action-research/

[3]. Dalal, A.K., & Misra, G. (2012). New Directions in Health Psychology from

https://books.google.co.in/books?id=1l_lDAAAQBAJ&pg=PT215&lpg=PT215&dq=current+research+activities+Vasanas&source=bl&ots=b25a45RqHZ&sig=Vwf7iNXsBRwZizNEBp9kHAujmds&hl=en&sa=X&ved=0ahUKEwjj75OStI7QAhUKN48KHZFrCZQQ6AEIITAC#v=onepage&q=current%20research%20activities%20Vasanas&f=false

[4]. Elenjimettam, A. (1974). The Yoga Philosophy of Patanjali from

https://books.google.co.in/books?id=E8jWAAAAMAAJ

[5]. Fitness Health. (2016). Concepts of Yoga from

http://www.fitnesshealth101.com/fitness/yoga/concepts

[6]. Gupta, P. (2016). Wisdom of Kalam from

https://books.google.co.in/books?id=anhQihB4lKsC&pg=PA44&lpg=PA44&dq=wisdom+of+kalam&source=bl&ots=_ylGseTnKC&sig=_iZhXeQW2U9XKiT7QJzDc5zN3vU&hl=en&sa=X&sqi=2&ved=0ahUKEwjsl-yHuo_QAhXJuo8KHeufCkwQ6AEIUTAM#v=onepage&q=wisdom%20of%20kalam&f=false

[7]. Holloway, R. (2014). Towards Financial Self reliance from

https://books.google.co.in/books?id=y-pRAwAAQBAJ&pg=PP1&dq=Towards+financial+self+reliance&hl=en&sa=X&ved=0ahUKEwi96cLJmY_QAhWIM48KHXaYCSkQ6AEIGjAA#v=onepage&q=Towards%20financial%20self%20reliance&f=false

[8]. James, L. (2011). Philosophy: An introduction to the Art of wondering from

https://books.google.co.in/books/about/Philosophy_An_Introduction_to_the_Art_of.html?id=8vw9z_mnzH8C&redir_esc=y

[9]. James, J.D. (2010). McDonaldisation, Masala McGospel and Om Economics from

https://in.sagepub.com/en-in/sas/mcdonaldisation-masala-mcgospel-and-om-economics/book235557

[10]. Jayaram, V. (2015). What is Buddhi? From

http://www.hinduwebsite.com/hinduism/concepts/buddhi.asp

[11]. Kinnes, T. (2014). Kriya Research Findings from http://oaks.nvg.org/kresearch.html

[12]. Kramer, S. H. (2011). Karma Yoga and Practical Spirituality from

http://www.susankramer.com/KarmaYoga.html

[13]. Marques, J, & Dhiman, S. (2016). Leadership Today: Practices for Personal and Professional Performance

https://books.google.co.in/books?id=2LnmDAAAQBAJ&pg=PA91&lpg=PA91&dq=current+research+activities+Vivekam&source=bl&ots=QGphLJCmjj&sig=3fjFVTSOMo_gxRabNfcM0dZ6aEo&hl=en&sa=X&ved=0ahUKEwjGve6k9o7QAhUIL48KHUbXB1QQ6AEIKDAC#v=onepage&q=current%20research%20activities%20Vivekam&f=false

[14]. Nikhilanda, S. (2016). Restraining Mind through Abhyasa and Vairagya from

http://www.chinmayamission.com/restraining-mind-abhyasa-vairagya/#.WBhWOtIrLIU

[15]. Philips, S.H. (2009). Yoga, Karma, and Rebirth: A Brief History and Philosophy from

 http://www.jstor.org/stable/10.7312/phil14484

[16]. Ramesh, T.A. (2006). Dharma and the Modern World from

http://www.boloji.com/index.cfm?md=Content&sd=Articles&ArticleID=2583

[17]. Sivananda, S. (2010). Samskaras from http://sivanandaonline.org/public_html/?cmd=displaysection§ion_id=871

[18]. Sivananda, S. (2010). Vasanas from

http://sivanandaonline.org/public_html/?cmd=displaysection§ion_id=884&format=html

[19]. Sivananda, S. (2011). Kriya Yoga Sadhana from

http://sivanandaonline.org/public_html/?cmd=displaysection§ion_id=526&format=html

[20]. Sivananda, S. (2011). Jnana Yoga Sadhana from

http://sivanandaonline.org/public_html/?cmd=displaysection§ion_id=1225&format=html

[21]. Sivananda, S. (2011). True Renunciation from

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[22]. Trivedi, I. (2014). Impact of Manomaya kosh sadhana on Adolescent’s Mental Health from

http://www.jiarm.com/July2014/paper15812.pdf

[23]. Tiwari, M. (2012). Women’s Power to Heal: Through Inner Medicine from

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[24]. Venkateswara, R.K. (2015). Oneness in Science and Spirituality from

https://books.google.co.in/books?id=lrhcDQAAQBAJ&pg=PT69&lpg=PT69&dq=current+research+activities+Buddhi(knowledge)&source=bl&ots=p4dw294x5I&sig=x-snJZqJCjyB4hlSXBj3-46v5gQ&hl=en&sa=X&ved=0ahUKEwj4zK-N84zQAhXLL48KHdZSDLwQ6AEIPDAH#v=onepage&q=current%20research%20activities%20Buddhi(knowledge)&f=false

[25]. YOGA. (2016). Magazine of Bihar School of Yoga published in 1963 from

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[26]. Wisdomsdoor. (2016). Karma: Why does it exist? And How can you control it? From

http://www.wisdomsdoor.com/rc4/hrc4-05.php

[27]. Wikipedia. (2016). Dharma: from https://en.wikipedia.org/wiki/Dharma

Abstract:

Background: obstetric anaesthesia recommends that caesarean sections are done under regional anaesthesia, but there are conditions for which regional anaesthesia is contraindicated, so in those conditions general anaesthesia is the only choice.

For general anaesthesia thiopental 4-5mg/kg l and propofol 2,5mg/kg are both used for caesarean section.

Methods: we have reviewed articles from 1989 up to 2016 comparing the use of thiopental to propofol in caesarean sections.

Result: a total of 20 published articles and abstracts from 1989 up to 2016 were reviewed. These articles show that propofol was the best alternative drug for general anaesthesia induction in caesarean section and has few disadvantages according to the neonate Apgar score at one minute.

Conclusions: these articles reviewed show that propofol is currently the most commonly used induction agent and alternative for obstetric general anaesthesia and has better neonatal and maternal outcomes post operation than thiopental.

Keywords: propofol, obstetric anaesthesia, thiopental, caesarean section

References:

[1]. Arzu Mercan et al. A prospective, randomized comparison of the effects of thiopental and propofol on bispectral index during caesarean section till delivery of new-born. 2012.

[2]. Celleno D1 et al.1993 J Clin Anesth. 1993 Jul-Aug; 5(4):284-8.

[3]. Dr Tom Lupton &Dr Oliver Pratt. Tutorial on: Intravenous drugs used for the induction of anesthesia. 
Salford Royal Hospitals NHS Foundation Trust, Salford, UK (2003).

[4]. Dadras MM, Mahjoobifard M, Panahipoor A, &Dadras MA. Comparing propofol with sodium thiopental on neonatal Apgar score after elective cesarean section. Zahedan J Res Med Sci (ZJRMS) 2013; 15(4): 21-24.

[5]. Heather McKenzie et al. The pregnant patient: assessment and perioperative management...2015.

[6]. Mahjoobifard M et al. The comparison of propofol with thiopental as induction drug on neonatal Apgar during elective cesarean section. Zahedan J Res Med Sci (Zahedan Journal of Research in medical sciences) 2011; 13(4):35-39.

[7]. M. Valtonen et al. Comparison of propofol and thiopentone for induction of anesthesia for elective Caesarean section. 1989.

[8]. M. Mamidi, Shiva Prasad D. Propofol and Thiopentone as induction agents in obstetric anesthesia – A comparative study. IAIM, 2016; 3(4): 111-117.

[9]. Michael A et al. Propofol infusion for cesarean section. 1990; 37:5 pp514-20.

[10]. Perisa Golfam et al. The effect of propofol and thiopental on apgar score during caesarean section. 2009.

[11]. Rob Dyer. Update on general anesthesia for C/S. South African Journal of Anesthesia Analgesia 2011; 17(1).

[12]. South African guidelines for safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults: 2010.

[13]. Tiffany Sun Moon &Joshua Sappenfield Anaesthesia management and challenges in the pregnant patient. 2016; 6:89-94.

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