Blood ordering and utilization in patients undergoing elective general surgery procedures in a tertiary care hospital: A prospective audit

BACKGROUND Blood ordering is commonly done for patients undergoing major elective surgery. Excessive order of the blood for elective surgery leads to wastage of resources, time and workforce. Auditing preoperative blood ordering decreases the cost of medical care by avoiding unnecessary cross-match without compromising patient safety. METHODS For this hospital-based audit, we collected data prospectively from July 2017 to June 2018 regarding the transfusion and transfusion indices, namely cross-match-totransfusion ratio (C/T ratio), transfusion probability (T%), transfusion index (TI) and maximum surgical blood ordering schedule (MSBOS) for elective surgeries done in the Department of Surgery. RESULTS A total of 1151 patients were included in the study. A total of 160 units of blood were issued of which only 138 were transfused to 116 patients. Seventy-one procedures were included in the study. The C/T ratio was less than 2.5 for 16 procedures, T% was >50% for 9 procedures and MSBOS was more than 0.5 for 16 procedures. CONCLUSION Cross-matching is overused for elective surgical procedures. Only 16 of the 71 procedures had an ideal C/T ratio. Group and screen policy can be adopted for most of the commonly performed procedures, and cross-matching of blood may not be needed.

Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: A prospective randomized controlled study.

Introduction: Incidence of junctional ectopic tachycardia (JET) after repair of tetralogy of Fallot (TOF) is 5.6–14%. Dexmeditomidine is a α-2 adrenoceptor agonist modulates the release of catecholamine, resulting in bradycardia and hypotension. These effects are being explored as a therapeutic option for the prevention of perioperative tachyarrhythmia. We undertook this study to examine possible preventive effects of dexmedetomidine on postoperative JET and its impact on the duration of ventilation time and length of Intensive Care Unit stay. Methods: After obtaining approval from the hospitals ethics committee and written informed consent from parents, this quasi-randomized trial was initiated. Of 94 patients, 47 patients received dexmedetomidine (dexmedetomidine group) and 47 patients did not receive the drug (control group). Results: Dexmedetomidine group had more number of complex variants like TOF with an absent pulmonary valve or pulmonary atresia (P = 0.041). Hematocrit on cardiopulmonary bypass (CPB), heart rate while coming off from CPB and inotrope score was significantly low in the dexmedetomidine group compared to control group. The incidence of JET was significantly low in dexmedetomidine group (P = 0.040) compared to control group. Conclusions: Dexmedetomidine may have a potential benefit of preventing perioperative JET.

The big Cs of the informed consent form: compliance and comprehension.

The informed consent process is a shield which protects subjects from harms that may be caused by a scientific enquiry. Only a competent participant with a complete understanding of the trial can give informed consent. Although the content of a valid informed consent form (ICF) has been established, the Drugs and Cosmetics (First Amendment) Rules, 2013 have stipulated that ICFs must fulfil the requirements of Appendix V of Schedule Y. We considered 50 ICFs and analysed whether they complied with Appendix V. Our analysis reveals a gloomy picture, with 70% of the ICFs deviating from the requirements of the law. We have identified the elements most commonly overlooked in the ICFs analysed. We recommend certain points which must be incorporated into ICFs to help participants better understand the trial. Our findings indicate that adequate action needs to be taken to ensure the protection of the rights of research participants.

Electrophysiological changes in acute guillain-barre syndrome.

Aim: To study the various electrophysiological changes in the motor conduction, sensory conduction and F wave latencies of acute Guillain-Barre Syndrome patients. Methods: Sixteen patients with acute GBS were included in this study. They were subjected to various nerve conduction studies (NCS) following standardized procedures. The mean values obtained for the various nerve conduction parameters were compared against the corresponding standardized values using Student’s t-test. P value less that 0.05 was considered significant. Results: The results of NCS in GBS patients were as follows: 1.The motor nerve conduction velocity was significantly lower and the motor nerve conduction latency was significantly prolonged. 2. The sensory nerve action potential conduction velocity and amplitude remained normal in most of these individuals. 3. F wave latency was significantly prolonged. Conclusion: Acute Guillain-Barre Syndrome patients manifest with abnormal motor nerve conduction parameters and F wave latency. Electrophysiological studies would help the researchers to diagnose the disease at an early stage.

Comparison of disc diffusion & E test methods with agar dilution for antimicrobial susceptibility testing of Haemophilus influenzae.

BACKGROUND & OBJECTIVES: Reliable methods of detection of antimicrobial resistance are of paramount importance in the treatment and management of infections caused by Haemophilus influenzae. The objective of the present study was to compare and evaluate the performance of disc diffusion and E test (Epsilometer test) with agar dilution method for antimicrobial susceptibility testing of H. influenzae. METHODS: A total of 46 isolates of H. influenzae from various invasive sites were included as test strains. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion method for ampicillin, chloramphenicol, trimethoprim-sulphamethoxazole (TMP-SMZ) and cefotaxime. Minimum Inhibitory Concentration (MIC) determination was performed by E test and agar dilution for the same set of antimicrobials. All tests were performed on Haemophilus test medium (HTM). RESULTS: Disc diffusion showed a very major (2%) and minor (4%) interpretative error with TMP-SMZ and minor interpretative errors to ampicillin (13%) and chloramphenicol (24%) when compared to agar dilution method. E test produced only minor interpretative errors to chloramphenicol (7%) and TMP-SMZ (2%) and no interpretative errors with ampicillin and cefotaxime as against agar dilution. E test showed good agreement with agar dilution for each of the antimicrobial tested. INTERPRETATION & CONCLUSION: Disc diffusion test may be used as a preliminary screen for susceptibility testing of H. influenzae. E test is simple, easy to perform and a reliable method for determination of resistance in H. influenzae. However its cost and limited availability in India may limit its use. The reference agar dilution method can be used reliably in routine susceptibility testing of H. influenzae.

Comparison of IgM capture ELISA with a commercial rapid immunochromatographic card test & IgM microwell ELISA for the detection of antibodies to dengue viruses.

BACKGROUND & OBJECTIVES: There is a need for a reliable test for the early diagnosis of dengue fever (DF), which is now active in many parts of India especially in the post monsoon months. This study evaluated two commercial tests with an assay available from a national laboratory in India to obtain information and to make a comparison among the three tests as to which will be the most suited for the detection of IgM antibodies to dengue virus. METHODS: An IgM capture ELISA (National Institute of Virology, Pune, India) was compared with two commercial tests, the PanBio Rapid Immunochromatographic Card Test (Brisbane, Australia) and the PanBio Microwell IgM ELISA for the detection of IgM antibodies to dengue virus. We tested 154 samples from individuals with febrile illnesses having DF--like symptoms. RESULTS: The NIV IgM capture ELISA (MAC-ELISA) showed a high positivity rate (38.9%) as compared to the PanBio Rapid (22.7%) and the PanBio IgM ELISA (20.7%). The true prevalence of disease, sensitivity and specificity of the three tests were estimated using 2LC latent class models using expectation-maximization (EM) algorithm. The NIV MAC-ELISA showed a high sensitivity (96%) as compared to PanBio Rapid (73%) and PanBio IgM ELISA (72%). A subset of 68 samples (of the 154 tested) were analyzed by the NIV MAC-ELISA for IgM antibodies additionally to Japanese encephalitis (JE) and West Nile (WN) of which 31 samples showed positivity to either one, two or all three flaviviruses. Out of the 8 samples which were positive for dengue IgM alone by the NIV MAC-ELISA, only 2 (25%) each were picked up by the other 2 tests. While out of 7 samples positive for IgM to all three flaviviruses IgM by the NIV MAC-ELISA, 5 (71%) were picked up by the other 2 tests. Of the 5 that were picked up by the PanBio tests, 3 had the highest absorbance values to WN by the NIV MAC-ELISA, indicating cross reactivity by PanBio tests. INTERPRETATION & CONCLUSION: The MAC-ELISA though a 3 day procedure, would be a valuable screening test for the detection of IgM to dengue in routine diagnostic laboratories because of its high sensitivity and specificity rates. The test uses specific viral antigens to detect IgM antibodies not only to dengue but also to JE and West Nile as a result of which IgM antibodies to all the 3 commonly encountered flaviviruses can be detected in a single run. It also has the advantage in that depending on the strength of the antibody units obtained to a specific flaviviral antigen, presumptive diagnosis as to which particular arboviral infection has occurred can be made in conjunction with clinical presentation.

Pre-transplant risk factors for renal allograft dysfunction at one year in Indian patients.

BACKGROUND: Only a few patients with end-stage renal disease in the Indian subcontinent receive optimal treatment. Of these only a minority can afford a second renal transplant. Awareness of modifiable pre-transplant risk factors that influence allograft function is crucial before embarking on the first transplant. There are no reports from the Asian subcontinent describing the pre-transplant risk factors. METHODS: We studied the effect of donor age, gender, and relation with the recipient, patient age, gender, HLA matching, native kidney disease and immunosuppression on one-year allograft function using data from 1177 consecutive primary living related donor renal transplants at the Christian Medical College Hospital, Vellore. We performed a univariate followed by a multivariate analysis using a logistic regression model to calculate the odds ratio for the effect of the above factors on two levels of graft function (serum creatinine > 1.4 mg/dl and > 2 mg/dl) at one year. RESULTS: On univariate analysis, older donors, women donors, mother being the donor, men recipients, < 1 HLA antigen match, cyclosporine-based immunosuppression and patient age between 16 and 40 years were associated with serum creatinine levels > 1.4 mg/dl at one year. Multivariate analysis showed that donor-related factors, namely mother as donor, older donors, and a < or = 1 HLA antigen match, were risk factors for graft dysfunction (serum creatinine level > 1.4 mg/dl) at one year. Recipient-related risk factors were male patients and those between the age of 16 and 40 years. CONCLUSION: In patients undergoing living related donor renal transplants from large extended families, a younger haplomatched donor, for instance, a brother, is a better choice than an older haplomatched donor, for instance, the mother, particularly in young male recipients at a higher risk of renal dysfunction.

Clinical manifestations and survival pattern of Wilson's disease.

BACKGROUND: Wilson's disease usually presents in childhood. Early recognition and treatment is crucial to retard the progression of this disease, which can be debilitating, if not fatal. We analysed the clinical manifestations and survival pattern of patients admitted at our centre from 1993 to 1996. METHODS: Hospital records of patients were reviewed to obtain the clinical manifestations. The survival status of patients was determined by a prospective follow up. The Kaplan-Meier survival curve and univariate Cox proportional hazards model were used to determine the survival pattern and risk for death in Wilson's disease. RESULTS: A total of 60 patients were studied. The median age at onset of symptoms was 12 years (range 5-52 years). The log rank test showed a significant difference in the mean (SD) survival between patients who presented with hepatic [87.36 (15.26) months] and neurological symptoms [114.33 (9.14) months]. Cox proportional hazards analysis showed a hazard ratio of 4.9 for patients with a hepatic presentation compared to those with neurological presentation. CONCLUSION: The presentation of Wilson's disease is not limited to the paediatric age group. Patients with a hepatic presentation had a five-fold higher risk of mortality when compared to those with a neurological presentation.

Guillain Barre syndrome-electrodiagnostic features and therapeutic observations.

Thirty seven patients with Guillain Barre syndrome were studied. The most common electrophysiologic abnormalities were delayed or absent Median nerve F wave (93.3%), increase in posterior tibial nerve distal latency (91.9%) and delayed or absent posterior tibial nerve F waves (83.9%). Slowing of nerve conduction was associated with the F wave abnormality and distal latency prolongation in most cases. There was no definite relationship between the results of electrophysiological studies and the clinical grade. 15 patients were treated with steroids, 10 with plasmapheresis, 8 with both steroids and plasmapheresis and 3 with immunoglobulins. There was a greater degree of improvement in patients treated with plasmapheresis.

Do neonates with meconium aspiration syndrome require antibiotics?

A randomized clinical trial was conducted to evaluate the utility of antibiotics in the routine management of Meconium Aspiration Syndrome (MAS). Neonates diagnosed to have MAS were randomly allocated to either the antibiotic group (n = 20) receiving gentamicin for 7 days, or the control group (n = 20), receiving no antibiotic. All infants were given identical supportive care. The two groups were comparable with respect to birth weight, gestation, sex distribution, mode of delivery, Apgar scores, and initial clinical and radiological severity of the illness. Results showed that the mean duration and the severity of respiratory distress at 24 hours and 48 hours were similar in the two groups. No secondary infection was documented in either group. A single death occurred in the antibiotic group. It is concluded that empirical use of antibiotics in the routine management of meconium aspiration syndrome is of no benefit.

Measles associated diarrhea and pneumonia in south India.

A prospective study was undertaken from April 1988 to April 1989, to assess the diarrheal and respiratory complications of measles. Standard definitions were used for the cases, Measles Associated Diarrhea (MAD) and Measles Related Pneumonia (MRP). Children with diarrhea not related to measles were recruited for comparison for MAD. There was a total of 454 cases, measles 53 (11.7%), measles associated diarrhea (MAD) 113 (24.9%), measles related pneumonia (MRP) 186 (41.0%) and MAD with MRP 102 (22.5%). Children under 10 months and 24 months were 11% and 51.5%, respectively. Altogether 215/401 (53.6%) and 288/401 (71.8%) had diarrhea and pneumonia. Children who had been measles vaccinated were 8.4%. The overall case fatality was 4.2%. Case fatality in pneumonia was 1.1%. There was no statistically significant difference between the MAD and diarrhea in relation to religion, water supply, the method of excreta disposal, nutritional status and immunization status other than measles vaccination. There was significant difference in the nature of stools between the two groups, the stools of MAD were more of dysenteric in nature (p < 0.005). Vitamin A deficiency as evidenced by eye signs, was significantly more in MAD than in diarrhea (p < 0.001). It is recommended that Vitamin-A be given to all children with measles, complication due to diarrhea be promptly and adequately treated and to consider measles vaccination earlier than 9 months.

Peptide mapping reveals differences in the non-glycosylated domains of cystic fibrosis and normal tracheobronchial mucins.

Tracheobronchial mucins from lung mucus secretions of healthy individuals and from patients with cystic fibrosis (CF) were purified according to a protocol established in our laboratory. Following digestion of the purified, reduced-alkylated mucin (free of 118 kDa and 70 kDa components) with trypsin-L-1-tosylamido-2-phenylethyl chloromethyl ketone, three fractions (TR-1, TR-2 and TR-3) were observed upon chromatography on a Superose 6 column using FPLC. TR-1 (glycosylated fraction) contained all of the carbohydrate, while TR-2 and TR-3 fractions had no detectable sugars. Comparison of the amino acid composition of TR-1 fractions from normal and CF individuals revealed no significant differences, while the TR-2 fractions from these mucins showed noticeable differences. Peptide mapping of TR-2 fractions from normal and CF mucins was performed on a C18 reverse phase column using FPLC. The peptide maps of normal mucins were markedly different from CF mucins. A greater number of peptides were seen in the TR-2 fractions of normal mucins when compared to CF mucin TR-2 fractions. In addition, normal TR-2 fractions appeared to be comprised of more hydrophobic peptides when compared to CF TR-2 fractions. These data provide evidence of possible structural differences in the non-glycosylated regions of CF and non-CF mucins, since the TR-2 fractions are essentially derived from the T-domains in the "naked" stretches of the mucin polypeptide backbone.

Immobilization of amyloglucosidase.

Enzymatic hydrolysis of starch for the production of glucose syrups of various compositions has assumed considerable commercial significance due to the extensive application of these syrups in food and beverage industries. Hydrolysis of starch to glucose involves liquefaction of the gelatinized starch with acid or thermostable alpha-amylase followed by saccharification to glucose by amyloglucosidase. Large scale saccharification of liquefied starch to glucose using soluble enzyme is time consuming and requires 48-72 hr at pH 4.5 and 55-60 degrees C. Since, by replacing soluble amyloglucosidase with immobilized enzyme, it is possible to reduce the conversion time, several methods have been tried to obtain a highly active and stable immobilized preparation capable of converting high concentrations of liquefied starch to glucose. However, till today, immobilized amyloglucosidase has not found industrial application as no immobilized system has shown high temperature stability and conversion efficiency comparable to that of the soluble enzyme.