Medical officer's perspectives and professional challenges in handling poisoning cases in rural India

Introduction: Poisoning is a significant public health problem in developing countries, more so in rural areas. Very little is known about the treatment available for poisoning cases in the context of rural health care provision in India. This study explores the perceptions of the primary health care medical officers regarding the management of poisoning cases. Material and Methods: A semistructured, self-designed survey form was used to interview the medical officers in Pune district. The interview focused on understanding rural hospital settings in terms of infrastructure, available facilities, and medical officers' perception of professional challenges in the management of poisoning cases. Results: Underreporting of poisoning cases in these primary health centers (PHCs) and transferring to higher hospitals without basic first aid provided was noted through interviews. Conclusion: Medical officers in rural PHCs lack the necessary training and knowledge required for the management of poisonings which is further worsened by lack of resources. There is a need to focus on poison management in continuous medical education. Training programs and education for medical officers are needs of the hour.

Molecular characterization of mycotoxin-producing Aspergillus parasiticus and sensitivity pattern to different disinfectants

Aims@#The study was aimed to isolate and characterize the mycotoxin-producing filamentous Aspergillus parasiticus from the feed samples. The sensitivity pattern of the isolates was assessed against different disinfectants.@*Methodology and results@#Fifty different feed samples were screened for A. parasiticus isolation. Isolates were subjected to macroscopic and microscopic characterization. Polymerase chain reaction was performed to confirm the isolates at the genomic level. Mycotoxin producing potential of the isolates was assessed by thin-layer chromatography (TLC). To quantify the toxins, high performance liquid (HPLC) was employed. The antifungal potential of disinfectants was determined by the well diffusion method followed by minimum inhibitory concentration (MIC) calculation. Out of twenty isolates of A. parasiticus, 11(55%) isolates were observed positive for toxin production. Three toxigenic isolates (AspP2, AspP4 and AspP8) were selected to evaluate their susceptibility against disinfectants by well diffusion method. AspP2 produced maximum (5.90 ng/mL) toxin, followed by AspP4 (3.11 ng/mL) and AspP8 (18.47 ng/mL). Terralin showed maximum fungicidal activity with 29.66 ± 8.08 mm zone of inhibition at 0.42 μg/mL MIC. Hypochlorite and Instru Star showed 99% disinfection with 30, 60 and 90 min contact time (6 mean log reduction) for all A. parasiticus isolates. Alpha Guard inhibited growth after 15 min contact time for all the isolates.@*Conclusion, significance and impact of study@#This study provides data indicating the contamination of feed samples with mycotoxin-producing A. parasiticus isolates and their sensitivity against commercially available disinfectants. Use of these disinfectants in appropriate concentrations and time could help prevent the contamination of food, feed and healthcare settings with the fungal species.

Biofuel production potential of indigenous isolates of Scenedesmus sp. from lake water in Pakistan

Aims@#This paper presents the report on biodiesel and biogas production at a laboratory scale from Scenedesmus strain.@*Methodology and results@#Previously isolated and identified Scenedesmus were grown in 10 Liter flask using BG-11 media at 16 h light and 8 h dark cycle. Oven-dried biomass (20 g) from 16-day-old culture of Scenedesmus was finely grounded and subjected to lipids extraction by chloroform-methanol-NaCl mixture. Microalgal lipids (6 mL) were subjected to transesterification by using NaOH leading to the production of 5 mL biodiesel and 4 mL of glycerin. Biodiesel was rich in methyl esters of linoleic acid, phosphorothioc acid and dodecanoic acid, as shown by gas chromatography-mass spectrometry (GC-MS) analysis. Oven-dried microalgae (2 g) without lipid extraction and leftover biomass (2 g) after lipid extraction were subject to biogas production through anaerobic digestion. Biogas (34, 27 and 19 mL) were recorded respectively in oven-dried whole biomass; lipid extracted biomass and control over a period of 15 days of anaerobic digestion.@*Conclusion, significance and impact of study@#It was concluded that water bodies are rich in diverse algae, especially Scenedesmus sp., and this algae can be cultured to produce biodiesel and biogas. But the lipid accumulation potential of microalgae requires special treatment and lipid extraction methods are not up to the mark, which is a major bottleneck in biofuel production from microalgae.

Global variation of COVID-19 mortality rates in the initial phase

Objectives@#Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused devastation in over 200 countries. Italy, Spain, and the United States (US) were most severely affected by the first wave of the pandemic. The reasons why some countries were more strongly affected than others remain unknown. We identified the most-affected and lessaffected countries and states and explored environmental, host, and infrastructure risk factors that may explain differences in the SARS-CoV-2 mortality burden. @*Methods@#We identified the top 10 countries/US states with the highest deaths per population until May 2020. For each of these 10 case countries/states, we identified 6 control countries/ states with a similar population size and at least 3 times fewer deaths per population. We extracted data for 30 risk factors from publicly available, trusted sources. We compared case and control countries/states using the non-parametric Wilcoxon rank-sum test, and conducted a secondary cluster analysis to explore the relationship between the number of cases per population and the number of deaths per population using a scalable EM (expectation– maximization) clustering algorithm. @*Results@#Statistically significant differences were found in 16 of 30 investigated risk factors, the most important of which were temperature, neonatal and under-5 mortality rates, the percentage of under-5 deaths due to acute respiratory infections (ARIs) and diarrhea, and tuberculosis incidence (p < 0.05) @*Conclusion@#Countries with a higher burden of baseline pediatric mortality rates, higher pediatric mortality from preventable diseases like diarrhea and ARI, and higher tuberculosis incidence had lower rates of coronavirus disease 2019-associated mortality, supporting the hygiene hypothesis.

Global variation of COVID-19 mortality rates in the initial phase

Objectives@#Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused devastation in over 200 countries. Italy, Spain, and the United States (US) were most severely affected by the first wave of the pandemic. The reasons why some countries were more strongly affected than others remain unknown. We identified the most-affected and lessaffected countries and states and explored environmental, host, and infrastructure risk factors that may explain differences in the SARS-CoV-2 mortality burden. @*Methods@#We identified the top 10 countries/US states with the highest deaths per population until May 2020. For each of these 10 case countries/states, we identified 6 control countries/ states with a similar population size and at least 3 times fewer deaths per population. We extracted data for 30 risk factors from publicly available, trusted sources. We compared case and control countries/states using the non-parametric Wilcoxon rank-sum test, and conducted a secondary cluster analysis to explore the relationship between the number of cases per population and the number of deaths per population using a scalable EM (expectation– maximization) clustering algorithm. @*Results@#Statistically significant differences were found in 16 of 30 investigated risk factors, the most important of which were temperature, neonatal and under-5 mortality rates, the percentage of under-5 deaths due to acute respiratory infections (ARIs) and diarrhea, and tuberculosis incidence (p < 0.05) @*Conclusion@#Countries with a higher burden of baseline pediatric mortality rates, higher pediatric mortality from preventable diseases like diarrhea and ARI, and higher tuberculosis incidence had lower rates of coronavirus disease 2019-associated mortality, supporting the hygiene hypothesis.

Quorum Sensing Interfering Strategies and Their Implications in the Management of Biofilm-Associated Bacterial Infections

Abstract The bacterial species employ various types of molecular communication systems recognized as quorum sensing for the synchronization of differential gene expression to regulate virulence traits and biofilm formation. A variety of quorum sensing inhibitors; molecules that interfere with quorum sensing among bacteria have been examined which can block the action of autoinducers. Moreover, the studies have scrutinized various enzymes for their quorum quenching activity resulting in the degradation of signaling molecules or blocking of gene expression. So far, the studies have found that these approaches are not only capable to reduce the pathogenicity and biofilm formation but also resulted in increased bacterial susceptibility to antibiotics and bacteriophages. The effectiveness of these strategies has been validated in different animal models and it seems that these practices will be transformed in near future to develop the medical devices including catheters, implants, and dressings for the prevention of bacterial infections. Although many of these approaches are still in the research stage, the increasing library of quorum quenching molecules and enzymes will open innovative perspectives for the development of antibacterial approaches which will extend the therapeutic arsenal against the pathogenic bacterial species.

Comparison of recurrence of low risk superficial bladder cancer in patients with and without single dose intravesical doxorubicin instillation

Introduction: Urinary bladder Cancer [UC] is second most common cancer among patients with genitourinary malignancies. Because of high recurrence rate the patients with Non-muscle-invasive bladder cancer [NMIBC] requires a lifelong surveillance. Doxorubicin has been shown to decrease recurrence rate on long term follow up. However, evidence on its efficacy on short term follow-up is limited. The purpose of the current study was to find out early recurrence rate after Doxorubicin treatment. If found low, this study will reduce the costs and hospital burden for patients needing Re-TURBT

Objective: The study objective was to compare the frequency of recurrence in patients with low risk superficial bladder cancer receiving a single dose intravesical Doxorubicin instillation with placebo

Study Design: Randomized Controlled Trial

Setting: Department of Urology, Khawaja M Safdar Medical College, Sialkot

Duration: One year from 10-03-16 to 09-03-2017

Methodology: 70 patients with Non-muscle-invasive bladder cancer were randomly allocated into 2 groups. Group-A received Doxorubicin treatment while Group-B received Placebo. Patients were followed after 3 months on cystoscopy. All the patients were informed about the procedure

Results: The mean age of the patients was 56.84+/-7.28 years and majority [n=58, 82.85%] of the patients were male and only 12 [17.14%] patients were female giving a male to female ratio of 4.38:1. The mean age of the patients in Group-A was 56.44+/-7.10 years while in Group-B it was 57.23+/-7.50 years. Among Group-A 80% patients were male and 20% were female while in Group-B 82.9% were male and 17.1% were female. However, the difference in term of age and gender was not significant statistically. On follow up at 3 months, 19 [27.14%] patients had recurrence while 51[72.85%] patients were clear of disease. The rate of recurrence was similar across different age groups and gender. Doxorubicin treatment was associated with decreased frequency of recurrence [18.6% vs. 35.7%; p=.023] as compared to Placebo

Conclusion: This comparative randomized control trial showed that intravesical Doxorubicin instillation within 6 hours of TURBT is effective in reducing recurrence in patients with NMIBC

Implementation of ventilator bundle in pediatric intensive care unit of a developing country

The aim of this study was to assess the frequency of VAP [ventilator associated pneumonia] after strict implementation of ventilator bundle in PICU. Medical records of all children [age 1 month - 16 years] were retrospectively reviewed, who were on mechanical ventilation [MV] for more than 48 hours and received all key components of "ventilator bundle" from January 2012 to December 2014. Out of 1050, 565 [54%] patients were enrolled. The mean age was 4.02 SD 4.29 years and 62 [69%] were male. The indications of MV were respiratory illness [54%], neurological illness [31%], shock [9%], and postoperative care [6%]. The mean duration of MV was 7.05 SD 5.4 days. Only 4 patients [0.7%] developed VAP. The incidence-density of VAP was 1.6 per 1000 ventilator days. The strict implementation of simple, inexpensive interventions [ventilator bundle] in care of mechanically ventilated children can decrease significantly VAP even in resource-limited country

Single incision laparoscopic cholecystectomy with conventional instruments and ports: initial experience at tertiary care public sector Hospital

Objective: To find out safety and feasibility of single incision laparoscopic cholecystectomy [SLIC] using conventional instruments

Methods: This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in order to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy

Results: Total no of cases were 50. The age ranged from 30-59 years [mean 35.20 years +/- 4.886.] There were 43[86%] females and 07[14%] males. The mean operating time was 80 minutes [range 50-120 +/- 16.020]. Four [8%] cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot's triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days [mean 1.08 +/- 0.274]

Conclusion: SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time

Ascites in patients on maintenance hemodialysis: causes, characteristics and predicting factors

Objective: To describe the causes, characteristics and factors associated with ascites in patients on maintenance hemodialysis

Study Design: Observational study

Place and Duration of Study: Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, from November 2007 to November 2014

Methodology: All patients on maintenance hemodialysis and age > 16 years with ascites were included. Frequencies and percentages were computed for different categorical variables. Chi-square or Fischer exact test were used to identify factors associated with ascites like frequency of hemodialysis, serum albumin and cardiac ejection fraction [EF]. Odds ratios were calculated for associated factors

Results: Ninety patients were included in this study; 55.5% were males. Median age was 33 years. Cause of ascites was nephrogenic in 77.8%, cardiac failure in 16.7%, hypothyroidism in 6.67%, liver cirrhosis in 4.4%, abdominal tuberculosis in 2.2%, and peritoneal carcinomatosis in 1.1% patients. The ascites was severe in 53.3% patients and severity was associated with serum albumin < 2.8 gm/dL [p=0.007] and cardiac EF < 40% [p=0.028]. The ascites was low serum ascites albumin gradient [SAAG], high protein type [LSHP] in 60% patients and associated with hemorrhage [p=0.040]. High SAAG, high protein [HSHP] ascites, found in 33.3%, was associated with cardiac EF < 40% [p=0.005] and portal hypertension [p=0.048]. High SAAG, low protein [HSLP] ascites, seen in 6.7%, was associated with portal hypertension [p=0.006]

Conclusion: The commonest cause of ascites in hemodialysis dependent patients is nephrogenic followed by cardiac failure. Low serum albumin and low cardiac EF predispose to severe forms of ascites

Mesh fixation vs. non-fixation in total extra peritoneal mesh hernioplasty

To compare mesh fixation with non-fixation and its effect on outcome. The interventional prospective study was conducted at the National Hospital and Medical Centre, Lahore from January 2007 to December 2008. After the two-year intervention period, the patients were followed up for 5 years. The selected patients were divided into two groups. In group 1, mesh fixation was performed with metal non-absorbable tackers and in group II no fixation of mesh was performed. Patients were followed up at 6, 12, 24 and 60 months. Of the 63 patients in the study, 32[50.7%] were in group I and 31[49.2% in group II. The Mean pain score in group I was 4.7 +/- 0.683 and 4.1 +/- 0.860 in group II [p< 0.001]. Urinary retention was more common in group 1 [p>0.05], while recurrence was more common in group II [p>0.05]. Pain was significantly less in the non-fixation group, while urinary retention and recurrence were not significantly increased. Non-fixation is a viable option for total extraperitoneal mesh hernioplasty and should be preferred over mesh fixation

Anatomical variations of sacral hiatus in dry human sacra

To observe anatomical variations of sacral hiatus in dry human sacra and its significance in caudal epidural block. An observational study. The study was conducted at Islamic International Medical College Rawalpindi from July 2011 to January2012. We studied 191 dry human sacra without discrimination of sex, geographical and ethnic group consideration. The bones were examined for various shapes of the sacral hiatus and level of apex and base of the sacral hiatus. Sacral cornua and median crest was also observed. The sacral hiatus were divided into six groups. [Group l-inverted U, group II- inverted V, group 111= irregular, group IV- M shape, group Vl-dumbbell shape]. SPSS 17 was used for the statistical analysis of the data. Out of 191 bones, inverted U shaped 76 [39%] and V shaped 56 [29%] sacral hiatus were most common and irregular 29 [15%] sacral hiatus was least common. Sacral cornua were prominent bilaterally in 83 [46.5%] bones while flat cornua were seen in 16 [9%]. The apex of hiatus was lying against 4th sacral vertebra in 129 [73%] bones while base of was present against 5th sacral segment in 183 [91%] of cases. The sacral hiatus has variations in shape. Inverted U shaped and inverted V shaped hiatus are most common shapes in dry human sacra. Sacral cornua are a reliable landmark in Caudal Epidural Block [CEB]

Learning preferences; teaching medical faculty

Introduction: This study has focused to know the learning preferences among faculty considering different methodologies and considering about CME to improve healthcare

Objectives: To identify the gaps in knowledge regarding CME in medical faculty of Lahore and to see the awareness of the CME among them

Study Design: This is a cross-sectional study of medical faculty in Lahore

Settings: Three hospitals in Lahore are included from both private/ public sectors. Period: It was conducted over a period of 2 months from JULY, 2014 to August, 2014

Methods: A questionnaire comprising of 21 questions was distributed at random for data collection among doctors having done post graduation

Results: Most of the faculty members who attended CME found it as useful tool for improving the knowledge and techniques for better patient care

Conclusions: Majority teachers are not interested in CME and do not participate and ask for some incentives

CVC related bacteremia; microbiologically confirmed, central venous catheter related bacteremia in intensive care unit pediatric patients

Objectives: To characterize clinically, epidemically and microbiologically the episodes of confirmed bacteremia associated with intravascular catheters of patients in the pediatric intensive care unit

Study Design: An analytical, prospective study

Setting: Intensive care unit of Pediatric Hospital José Luis Miranda"

Period: January 2003 to December 2007

Methods: 453 patients. Rates, density of incidence, risk factors, static's and mortality were determined and analyzed

Results: 96 patients developed bacteremia episodes and 90 [74%] had microbiological criteria. The risk factors associate were: to have multiple catheters, permanency with the catheter more than 7 days, parenteral feeding, prolonged mechanical ventilation, previous transfusions and surgical interventions. The isolations of coagulase negative staphylococci prevailed in 33 patients [36, 7%]. The previous demurrage to the insert of the catheter was of 4,0 +/- 9,4 days for the healthy ones and 11, 6 +/- 24,6 days in the sick persons [p = 0,000]; the definitive demurrage was of 56,1 +/- 62,4 days in the sick persons versus 24,6 +/- 31,7 days in the healthy ones [p = 0,000]. The mortality of the second group was superior [26%]

Conclusions: Multiple dependent and independent factors exist on which actions should be focused to prevent and to diminish the mortality by bacteremias associated with catheters in children admitted in intensive care units

Isolation and antibiotic susceptibility of E. coli from urinary tract infections in a tertiary care hospital

The study was conducted to isolate and determine the antibiotic resistance in E. coli from urinary tract infections in a tertiary care hospital, Lahore. Urine samples [n=500] were collected from patients with signs and symptoms of Urinary tract infections. Bacteria were isolated and identified by conventional biochemical profile. Antibiotic resistance pattern of E. coli against different antibiotic was determined by Kirby-Baur method. Bacterial etiological agent was isolated from 402 samples with highest prevalence of E. coli [321, 80%] followed by Staphylococcus aureus [9.4%], Proteus species [5.4%] and Pseudomonas species [5.2%]. The E. coli were highly resistant to penicillin [100%], amoxicillin [100%] and cefotaxime [89.7%], followed by intermediate level of resistance to ceftazidime [73.8%], cephradine [73.8%], tetracycline [69.4%], doxycycline [66.6%], augmentin [62.6%], gentamycin [59.8%], cefuroxime [58.2%], ciprofloxacin [54.2%], cefaclor [50%], aztreonam [44.8%], ceftriaxone [43.3%], imipenem [43.3%], and low level of resistance to streptomycin [30%], kanamycin [19.9%], tazocin [14%], amikacin [12.7%] and lowest to norfloxacin [11.2%]. Out of 321 E. coli isolates, 261 [81%] were declared as multiple drug resistant and 5 [1.5%] were extensive drug resistant. It is concluded that most of the urinary tract infections in human are caused by multiple drug resistant E. coli

Predictors of vaccination card retention in children 12-59 months old in Karachi, Pakistan

To determine the factors associated with retaining the vaccination card among care takers of 12-59 months old children in Karachi, Pakistan. This was an analytical cross-sectional study in Karachi. Households were randomly selected throughout a multistage cluster sampling technique. Data was collected for 504 children of 12- 59 months of age. Questionnaire was administered to caretakers to gather information regarding the children's vaccination status, socio-demographic characteristics and reviewing their vaccination cards. Statistical analysis was done by SPSS 19 using logistic regression. Among 462 vaccinated children, caretakers of 33% provided vaccination cards. Odds of card retention decrease if the caretaker has a large household i.e., >5 people sharing one room [AOR 0.277, 95% CI: 0.096, 0.797] and if the child is of four to five years of age [AOR 0.544, 95% CI: 0.305, 0.970]. Gender of the child, and the caretaker's education and access to electronic media were not significant predictors of vaccination card retention in our study. Our study showed that vaccination card retention for children 12-59 months of age was low [33%] in Karachi. There is a need to educate caretakers of young children regarding the importance of keeping vaccination card and to disseminate this information through healthcare providers. Improving vaccination card retention is one of the key measures which will help towards accurately estimating coverage and to inform health policy decisions

Transurethral cystolithotripsy for large vesical calculi

To assess efficacy and safety of transurethral cystolithotripsy in the management of large vesical calculi. Adult patients with large vesical calculi [>2.5cm] were selected for this prospective study. Patients with associated urethral stricture and big adenomas were excluded. Stone size was measured on ultrasound in the largest diameter. Patients were operated under spinal or general anaesthesia. Nephroscope with 28 fr sheath was used transurethrally along with 2 cm lithoclast probe. Initial fragmentation was achieved with Swiss lithoclast. Later bigger fragments were dealt with stone punch. In the end all fragments were evacuated with Ellick evacuator. Bladder was drained with Foley's catheter for 24 hours. TURP [transurethral resection of prostate] was done if required. Patients with bigger glands were excluded to restrict operating time. Patients were followed up for two weeks. Forty patients were selected. Mean age of the patients was 55 years [range 18-73 years]. There were 32 males [80%] and 8 females [20%]. Stone size was 4.72 +/- 2.52 cm with range of 2.5-7.0 cm. Five patients had multiple stones, four of them had associated neurogenic bladder. Procedure time ranged from 20-90 minutes [mean 45.8 minutes]. Complete fragmentation of calculi was achieved in all patients. Twelve patients underwent TURP under same anaesthesia. Time consumed on resection of prostate was not included in procedure time. There were no major complications. Transurethral cystolithotripsy is very effective and safe for large vesical calculi [>2.5cm]. It is time consuming but saves patients from hazards of open surgery.

Experience of laparoscopic cholecystectomy during a steep learning curve at a university hospital

Cholelithiasis is the most common disease of alimentary tract affecting the adult population globally and our country in particular is no exception to it as a cause of hospitalization. Surgical removal of gall bladder is the main stay of symptomatic cholelithiasis ensuring a permanent cure. The minimally invasive technique of laparoscopic cholecystectomy has gained wide acceptance as a Gold Standard treatment ever since its introduction. The purpose of this prospective observational study was to document our experience of laparoscopic Cholecystectomy during a learning curve in a single unit of a university hospital and compare it with other available data in the literature. Total 94 patients underwent laparoscopic cholecystectomy during the learning curve from Jan 2009 to Dec 2010 in the Department of Surgery Liaquat University Hospital Jamshoro. Mean age was 42 years with females [88.29%] preponderance. Majority of the cases were operated by consultants [85.10%] within 25-60 minutes. Postoperative hospital stay was 3 days with return to work in 7 days. Only 6 [6.38%] cases were converted to open technique. Intra-peritoneal drains and Foley's catheter were kept in selected cases only. Eleven patients [11.70%] had intra-operative complications including complete transaction of CBD in only one [1.06%] male patient. Five patients [5.31%] had postoperative complications with two patients having iatrogenic duodenal injury which was not identified during surgery and pseudo cyst pancreas. Four patients [4.25%] died due to multiple organ failure. We conclude that Laparoscopic Cholecystectomy is a gold standard procedure and should be learned on virtual simulated models before starting this procedure on human patients.