Role of Bedside Ultrasonography in Assessment of Diaphragm Function as a Predictor of Success of Weaning in Mechanically Ventilated Patients / 결핵및호흡기질환

Background@#Weaning failure is common in mechanically ventilated patients, and if ultrasound can predict weaning outcome remains controversial. The purpose of this study was to evaluate the diaphragmatic function (thickness and excursion) measured by ultrasound as a predictor of the extubation outcome. @*Methods@#We included 62 mechanically ventilated patients from the chest intensive care unit in this study. Sixty-two patients who successfully passed the spontaneous breathing trial (SBT) were enrolled. The transthoracic ultrasound of the diaphragm was performed during an SBT to the assess diaphragmatic function (excursion and thickness), and they were classified into the successful extubation group and the failed extubation group. @*Results@#There was a statistically significant increase in the successful extubation group in the diaphragmatic excursion and thickness fraction (p<0.001), a statistically significant negative correlation between the diaphragmatic function and the duration of the mechanical ventilation, and a statistically significant negative correlation between the diaphragmatic excursion and the Acute Physiology and Chronic Health Evaluation II. The diaphragmatic excursion cutoff value predictive of weaning was 1.25 cm, with a specificity of 82.1% and a sensitivity of 97.1% respectively, and the diaphragmatic thickness cut-off value predictive of weaning was 21.5%, with a specificity of 60.7% and a sensitivity of 91.2%, respectively. @*Conclusion@#The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

In vitro antimicrobial synergy studies of carbapenem-resistant Acinetobacter baumannii isolated from intensive care units of a tertiary care hospital in Egypt

The increasing prevalence of multidrug-resistant and pan drug-resistant Acinetobacter baumannii as a cause of nosocomial infections has led to the need for the reassessment of novel combinations of antibiotics as our only current viable option for handling such infections until a new therapeutic option becomes available. Two of the most commonly used methods for testing antimicrobial synergy are the Time-kill assay method and the E-test method, and these were the methods used in this study. Antibiotic combinations tested in this study were azithromycin and polymyxin, tobramycin and polymyxin, polymyxin and rifampicin, and tobramycin and rifampicin. The azithromycin and polymyxin combination showed synergy, while the rifampicin and polymyxin combination showed antagonism. The synergy was achieved at lower MIC values than using each of the single agents alone against the same isolates. Synergy testing results varied according to the method used, and it is difficult to establish which method is more accurate. The use of these lower MIC values as a guide to determine effective therapeutic doses used in combination therapy can help to decrease the emergence of resistance and can also minimize the side effects associated with using a single agent at a higher dose. Further research is still required to predict in vivo efficacy of such combinations

Multi-drug resistance 1 genetic polymorphisms gene expression and prediction of chemotherapy response in breast cancer Egyptian patients

Although anthracycline-based chemotherapy is a crucial treatment for breast cancer, its outcome is limited by the multidrug resistance MDR. Overexpression of P-glycoprotein [Pgp] a transmembrane active efflux transporter of various drugs and carcinogenic substrate, may result in MDR. The impact of MDR1 polymorphisms on MDR1 expression and risk of breast cancer, and whether it can alter chemotherapeutic agents response in breast cancer is unclear. The present work studied the relevance between MDR1 C3435T, C1236T, G2677T/A polymorphisms and MDR1 gene expression and susceptibility to breast carcinoma as well as sensitivity to anthracyine-based chemotherapy in Egyptian females with breast cancer [BC]. We determined mRNA levels of MDR1 in breast tumor specimens [n=190] by real-time rt-PCR. Blood samples from BC female patients and healthy controls were obtained for genotyping. ARMS-PCR assay was used for detection of C3435T, C1236T and G2677T/A Polymorphisms. This study revealed that C3435 TT patients showed a significant decrease in MDR1 mRNA level compared -with CC genotypes. No association was found between the MDR1 C1236T, G2677T/A polymorphisms and MDR1 mRNA expression. The frequency of C3435 TT genotype and T allele were significantlyhigher in BC patients compared to the controls [P < 0.05]. C3435 TT and C3435 CT had odds ratio [p-value] 5.6 [0.001] and 2.28 [0.01] for response to anthracycline-based chemotherapy, respectively, compared to CC genotype. No statistically significant differences were observed between patients and control regarding the allelic and genotypic frequencies of MDR1 C1236T, G2677T/A polymorphisms as well as no correlation was detected to the response rate to anthracycline-based chemotherapy. Our results suggested that C3435T, but not C1236T or G2677T/A, was associated with changes in MDR1 gene expression and hence alters the response after anthracyclin based chemotherapy

Prevalence and antimicrobial susceptibility patterns of bloodstream isolates at Jordan hospital intensive care unit: three years experience

To identify the most common species isolated from blood in a nosocomial setting and to assess the patterns of antimicrobials susceptibility of these isolates. In addition, to add to the regional antibiogram data that is ever changing, and to monitor highly resistant pathogens that are spreading in the region. This study was conducted at Jordan Hospital Intensive Care Unit over three years period [January 2006-December 2008]. Bloodstream isolates were utilized as a model to study susceptibility patterns, for that BSPs are less liable for contamination. All isolated micro-organisms were cultured in an automated culture machine [VersaTek] and antimicrobials susceptibility testing was precessed through [Viteck 1]. Identified isolates and antimicrobial susceptibility data were uploaded into Microsoft Excel Sheet. The most common Bloodstream isolates were coagulase-negative Staphylococci [38.1%], E.coli [12.4%], S. aureus [9.8%], Acinetobacter spp. [8.7%], Serratia spp. [8.2%] and Klebsiella spp. [6.1%]. Gram-negative isolates showed high prevalence of Extended-spectrum p-lactamse-producers [19.3%] distributed; E. coli [47.0%] isolates, Klebsiella [29.4%] and Serratia spp. [23.5%]. Escherichia coli isolates was 96% susceptible to Imipenem, Amikacin and Pipracillin/Tazobactam [PIP/TAZ], 59% susceptible to Ceftazidime and 57% susceptible to Cefepime. Pseudomonas aeruginosa was 67% susceptible to antipseudomonal P-lactams but 33% to Ciprofloxacin. Klebsiella and Serratia marscecence isolates were all susceptible to Imipenem and Amikacin. Acinetobacter was 24% Imipenem-susceptible. Nineteen S. aureus were isolated with 12 Methicillin-Resistant S. aureus [63%]. Methicillin resistant contributed to [31%] among 74 CoNS blood stream isolates. Enterococci were all susceptible to Vancomycin, teicoplanin, but 50% susceptible to Amoxicillin/Clavulanate. Coagulase-negative Staphylococci bloodstream isolates were dominating at Jordan Hospital Incentive Care Unit for the years [2006-2008]. Methicillin Resistance Staphlococcus Aureus were high in prevalence among Staphylococcus aureus bloodstream isolates; in addition, Extended-Spectrum 6-Lactamse producers among gram-negative isolates were also high. These findings may help shedding some light on the region antibiogram, and initial empiric therapy for septic patients the in Intensive Care Unit settings

Prevalence of respiratory syncytial virus in Egyptian pediatric patients suffering from pneumonia

Background and study aim: Respiratory syncytial virus [RSV] is one of the major causes of viral respiratory tract disease in young children and infants. In children less than one year-old, it was the principal cause of bronchiolitis and pneumonia and, a common cause of hospitalization in young children. We aim to study the prevalence of RSV and its subtypes in pediatric patients suffering from pneumonia and broncho-pneumonia with the evaluation of routinely used method for diagnosis

Patients and Method: This study included 68 patients, attended the pediatric hospital, faculty of medicine-Cairo University at the period between 2007-2008, who exhibited lower respiratory tract symptoms in the form of pneumonia and bronchopneumonia. They were subjected to clinical examination, chest X-ray examination. Nasopharyngeal aspirate [NPA] samples were taken and sent to National Cancer Institute for microbiological, virological and molecular examinations

Results: High prevalence of RSV 85% [58/68] was detected, of these, 21% [12/58] were group A, 36% [21/58] were group B, and 43% [25/58] were subtype A and B. Highly affected children were from 2-3 months [44.8%] and rate of infection decreased as age increasing. RSV infection was statistically significant with some clinical findings and radiological findings

Conclusion: RSV is an important etiological agent causing pneumonia and bronchopneumonia in infancy. RT-PCR for NPA was a good method in detecting virus and may provide important information in establishing the etiology and improving management of the patients

Predictive value of ischaemia modified albumin [IMA] in patients with acute coronary syndromes [ACS]

Establishing a diagnosis of acute coronary syndrome in the clinical setting remains a challenging task. The advent of testing for cardiac biomarkers such as myoglobin, creatine kinase [CK-MB], and the troponins has facilitated this process. Unfortunately, although these blood markers are extremely sensitive for the identification of patients with myocardial necrosis, their ability to identify patients with acute coronary ischaemia remains limited. During myocardial ischaemia, several changes occur in the amino terminus of ischaemia, several changes occur in the aminot terminus of albumin. Therefore, if reliable, an assay measuring IMA might represent a promising marker for early identification of patients with myocardial ischaemia. To assess the role of IMA and its predictive value for early diagnosis of patients with acute coronary syndromes. Seventy three patients with suspected ACS attending the emergency department at Assiut university hospital were included in addition to -sex and age matched -20 healthy control subjects. All patients were presented within 6h of the typical chest pain episode with negative troponin and normal serum albumin levels. Any patient with liver diseases, renal failure, anaemia, malignancy, acute infections, peripheral vascular diseases, cerebral ischaemia and physical exercise within the last 48 hours was excluded. Full history, clinical examination and standard 12 lead ECG, laboratory investigations including CPK, IMA, CRP, lipogram, kidney and liver functions were done. Twenty two patients were diagnosed as non ischaemic chest pain [NICP] and 51 cases as ACS. CPK and troponin levels were normal in all groups at presentations but 6 hours later CPK levels were significantly higher in ACS patients if compared with NICP or control groups [p<0.000]. on the other hand, IMA levels were statistically significantly high in ACS group only [p<0.000] with a good negative predictive value to diagnose NICP [86.3%]. Moreover, IMA levels were statistically significantly higher in patients finally diagnosed as unstable angina [UA] than those who diagnosed as non ST elevation myocardial infarction [NSTEMI] [p<0.04] meanwhile, it is insignificantly higher than that in STEMI patients. The sensitivity of IMA to predict ACS cases [94.1%] was higher than that of ECG [78.4%] and CPK at presentation [14.7%] and after 6 hours [54.7%]. On the other hand, the specificity of IMA, ECG, CPK at presentation and 6 hours later [86.4%, 90.9%, 86.4% and 97% respectively]. IMA can be used at the emergency setting to exclude the diagnosis of ADS. Moreover, the use of IMA as a diagnostic biomarker in addition to standard markers of myocardial injury is very useful for the evaluation of patients with suspected ACS

Effects of open heart surgery on intra ocular pressure [IOP]

The intra ocular pressure in both eyes of 23 patients undergoing open heart surgery, was measured by Schiotz indentation tonometer before, during and after the surgery until it returned to the pre operative levels. It was observed that a marked and rapid drop of the IOP occurs during the operation time, reaching its minimum during the cardio-pulmonary by-pass [[PB] period, then it gradually rises to its normal pre operative levels in 69.5% of cases [16 out of 23] at the end of the first post operative day, in 91% of cases [21 out of 23] at the end of the second post operative day and in all cases [100% of cases] at the end of the third post operative day. The possible explanations for such changes were discussed in view of the anaesthetic agents, techniques and associated hemodynamic parameters

Coeliac plexus block as a sole technique of pain relief in visceral pain

Evaluation of the role of Coeliac plexus block by using neurolytic agent 50% alcohol in relieving upper intra-abdominal pain due to cancer was studied in 23 patients in the National Cancer Institute. The patients were subjected to bilateral Coeliac plexus block using 50% alcohol 20-50 ml for each side in the prone position according to the patient's built. The technique eliminated visceral vasospasm and provided complete pain relief form transient pain in the back the site of injections no other complications were recorded

Local analgesia versus general anesthesia in emergency tracheotomy operations

This study was carried out on 60 patients submitted to emergency tracheostomy operation for variable etiology. Patients were divided into two groups. In group I, operation was performed under general anesthesia after successful intubation using oxygen halothane. In group II, operation was performed under local analgesia using lignocaine 2%. Pulse rate, systolic blood pressure, respiratory rate, blood gases and pH of the blood, loss, time interval between the start of the procedure operative and immediate postoperative complications, if any, were recorded. The study revealed that tracheostomy operation is best performed under general anesthesia with an endotracheal tube. Local analgesia is only justifiable when it is impossible to introduce tube before hand or when experienced anesthetist is not available

Pathogenesis and control of painful conditions in advanced breast cancer

This work was carried out on 42 females patients referred to the pain clinic at the National Cancer Institute, Cairo University complaining of pain 19 monthes to 4 years after radical mastectomy. Pain complaints took one or more of the following forma: Heavy painfull arm [26%], post-mastectomy pain [19%], back pain due to metastasis in vertebrebral column [12%], Epigastric and right hypochondrial pain due to liver metastasis [12%], joint pain in the hip [7%] and shoulder [15%], herpes zoster [7%], rib metastasis [5%], and sciatic or ulnar neuralgias [7%]. Medical treatment in the form of oral simple analgesics containing a combination of paracetomal and dextropropoxyphene given 6 hours together with amitroptyline were given to all patients. Anticonvalsants were added for neuralgias, antibiotics for infections, corticosteroids for bone metastasis and diuretics for odema. Medical treatment could control 47% of cases according to a verbal rating score T.E.N.S. when added, was found usefull in only 10% of cases for a limited period. Simple invasive treatments were applied for 53% of cases. Local marcaine steroid block was usefull in bony metastasis. Stellate ganglion block was tried successfully in 7 out of 9 cases of heavy painful arms, while thoracic epidural using marcaine could releif the pain of herpes zoster. Subarachnoid chemical rhizotomy using phenol was only needed in 6% of cases. Painfull conditions in advanced cases of cancer breast took various clinical forms, needing multiple lines of treatment, but medical control proved to be beneficial