Incidence of vancomycin resistant enterococci colonization in Zagazig University pediatric ICU

Background: Multidrug resistant [MDR] bacteria inside hospitals are a major health problem which prolongs the hospital stay, increases the treatment costs and worsen the prognosis of patients. Vancomycin resistant enterococci [VRE] represent a group of MDR bacteria which came into the spotlight in the last decades. In Egypt, the problem is not well estimated especially in pediatric settings

Objectives: The objective of this work was to estimate the rate of VRE colonization inside Pediatric intensive care units [PICU] of Zagazig University Hospitals

Methodology: A total of 168 children admitted to PICU were surveyed for nasal and perirectal colonization by VRE. Phenotypic identification of the genus was performed and further species identification was done using PCR technique. VanA and VanB resistance genes were screened using specific primers for each

Results:Among the 168 children investigated, 47 [27.98%] were colonized by enterococci; 41 rectal and 6 nasal colonization. Only 7 isolates [14.9%] were identified as vancomycin resistant. The overall VRE colonization rate was 4.17% among the PICU children investigated. The colonization rate was significantly higher among children exceeded 7 days of hospital stay inside PICU. Thirty one [65.96%] isolates were identified as E. fecalis and 10 [21.28%] were identified as E. faecium. Six isolates [12.76%] were not identified by PCR reaction. VanA gene was detected in 4 of the VRE isolates while none of the isolates revealed VanB gene product

Conclusion: Generally the incidence of VRE colonization in the current study is considered low in comparison to other groups of MDR bacteria and to other geographic distribution

Spinal versus general anesthesia for Cesarean section in patients with sickle cell anemia / 대한마취과학회지

BACKGROUND: Sickle cell anemia (SCA) increases the rate of maternal and fetal complications. This pilot study was designed to compare the maternal and fetal outcomes of spinal versus general anesthesia (GA) for parturients with SCA undergoing cesarean delivery. METHODS: Forty parturients with known SCA scheduled for elective Cesarean delivery were randomized into spinal anesthesia (n = 20) and GA groups (n = 20). Perioperative hemodynamic parameters were recorded. Postpartum complications were followed up. Opioid consumption was calculated. Blood loss during surgery and the number of patients who received intraoperative or postpartum blood transfusion were recorded. Patient satisfaction with the type of anesthesia was assessed. The Apgar score at 1 and 5 min, neonatal admission to the intensive care unit, and mortality were also recorded. RESULTS: Blood loss was significantly higher in the GA than spinal group (P = 0.01). However, the number of patients who received an intraoperative or postpartum blood transfusion was statistically insignificant. Significantly more patients developed intraoperative hypotension and bradycardia in the spinal than GA group. Opioid use during the first 24 h was significantly higher in the GA than spinal group (P < 0.0001). More patients had vaso-occlusive crisis in the GA than spinal group without statistical significance (P = 0.4). There was one case of acute chest syndrome in the GA group. No significant differences were observed in postoperative nausea and/or vomiting, patient satisfaction, or hospital length of stay. Neonatal Apgar scores were significantly better in the spinal than GA group at 1 and 5 min (P = 0.006 and P = 0.009, respectively). Neonatal intensive care admission was not significantly different between the two groups, and there was no neonatal mortality. CONCLUSIONS: Spinal anesthesia may have advantages over GA in parturients with SCA undergoing Cesarean delivery.

Fetal responses to epidural analgesia as evidenced by doppler indices

This study was designed to evaluate tile maternal effects of epidural analgesia by different local anesthetics and their impact on placenta and fetal blood flow. Depending on the type of local anesthetics used, sixty full-term parturients were randomly allocated into 3 equal groups in a randomized blind study; Group [1] received Bupivacaine [0.1 25%], Group [2] received Ropivacaine [0.2%] and, Group [3] received Levobupivacaine [0.125%]. Epidural fentanyl [100 micro g] was added to all groups. Safety was assessed by recording the mothers characters and vital signs as well as tile fetal Doppler indices while efficacy was assessed by measuring severity of pain, onset and duration of analgesia, and the motor blockade. Doppler velocimetry studies for fetus included monitoring of Umbilical Artery Pulsitility Indices [UAPI] and Middle Cerebral Artery Pulsitility indices [MCAPI]. Parturient in all groups were comparable. Pulse rate and arterial blood pressure were significantly decreased in all groups after analgesia. but remained within normal ranges. The pain score, had significant reduction in all groups with best results observed in Group 3. The onset of analgesia was relatively rapid in Group 2 followed by Group 3 then Group 1. The duration of analgesia was prolonged in Group 1 followed by Group 3 and then Group 2. There was no incidence of motor block except in 5 parturient [20%] in Group 1 UAPI was significantly decreased in the three studied groups after epidural analgesia. But, during uterine contraction, there was slight elevation in the UAPI in all groups. The best improvement in placental perfusion was observed in Group 3, then Group 1, and the least was Group 2. On the other hand, MCAPI was significantly increased in all groups after epidural analgesia. But, during uterine contraction, there was slight decrease in the MCAPI in the three groups. The best improvement in MCAPI was observed in Group 3, then Group 1, and the least was Group 2. All local anesthetics produced excellent analgesia during labor. The Doppler indices were improved in the three groups with the best results in levobupivacaine group

Comparison between ambulatory blood pressure measurements and office BP for diagnosis of gestational hypertension and prediction of the oatconie of pregnancy

With the objective to assess the prognostic value of office values as compared with ambulatory monitoring in pregnancy, we analyzed 2430 blood pressure series systematically sampled from 403 untreated pregnant women for 48 consecutive hours every 4 weeks from the first visit to the hospital until delivery. Women were divided into 5 groups: detected" gestational hypertension, women with office blood pressures >140/90 mm Hg after 20 weeks of gestation and hyperbaric index [area of blood pressure excess above the upper limit of a time-specified tolerance interval] consistently above the threshold for diagnosing hypertension in pregnancy; "undetected gestational hypertension, office values <140/90 mm Hg but hyperbaric index above the threshold for diagnosis; normotension, both office values and hyperbaric index below the thresholds for diagnosis; white coat hypertension, women with recorded diagnosis of gestational hypertension but hyperbaric index consistently below the threshold for diagnosis; and preeclampsia, defined as gestational hypertension and proteinuria. Results indicate small and nonsignificant differences in 24-hour mean of ambulatory pressures between 'detected' and "undetected' gestational hypertension at all stages of pregnancy, in contrast with highly significant differences between these two groups and normotensive pregnancies. Average office blood pressure values were similar for preectampsia, "detected," and "undetected" gestational hypertension. The hyperbaric index was, however, significantly higher for women with preeclampsia after 20 weeks of gestation as compared with all other groups and higher for women with either 'detected" or "undetected" gestational hypertension as compared with normotensive pregnant women. The incidence of preterm delivery and intrauterine growth retardation were similar for "detected" and 'undetected" gestational hypertension but significantly lower for normotensive women. In pregnancy, the hyperbaric index derived from ambulatory monitoring is markedly superior to office measurements for diagnosis of what should he truly considered gestational hypertension, as well as for prediction of the outcome of pregnancy

Planned cesarean section versus planned vaginal birth in vertex-nonvertex twin pregnancies: maternal and neonatal outcomes

Over 97% of all multiple pregnancies are twin pregnancies and 35% of twins present as cephalic/noncephalic at birth. The approach to the delivery of cephalic/noncephalic twins is controversial. The purpose of this study is to compare between planned cesarean section [CS] and planned vaginal birth [VB] for delivery of vertex-nonvertex twins in terms of perinatal/ neonatal mortality and morbidity and maternal morbidity. The study is a randomized controlled trial [RCT], included 120 women with twin pregnancies and within gestational age groups [32-38 weeks] with twin A in cephalic presentation, they were randomized to either planned CS group [n = 60] or planned VB group [n = 60]. The study was carried out in Assiut University Hospital, Assiut, Egypt, through the period from October 2003 to August 2005. No perinatal death was reported in twins A born in the CS group compared to 2 perinatal deaths [3.3%] in the VB group. However, 4 perinatal deaths [6.7%] were reported in twins B born in CS group compared to 14 perinatal deaths [23.3%] in the VB group. Neonatal resuscitation, birth trauma, respiratory and cerebral complications were higher among twins born in VB group than those in CS group. Maternal morbidity as birth canal trauma, pos-partum hemorrhage, urinary incontinence and fecal/flatal incontinence were higher among women delivered by planned VB than those delivered by planned CS. The conclusion of the present study is that planned CS at 38 weeks gestation for delivery of vertex-nonvertex twins may be better than planned VB. A multicentre RCT with large sample size is needed to test this suggestion

Risk of acute otitis media in relation to acute bronchiolitis in children

A prospective study was carried out to evaluate the prevalence and the etiology of acute otitis media [AOM] In children with acute bronchiolitis. Also to determine whether AOM occurring with acute bronchiolitis "Which mainly due to respiratory syncytial virus [RSV]" is accompanied with another pathogens "which usually found in the middle ear aspirate [MEA]" or not. Thirty-six children with acute bronchiolitis aged 3 to 18 months that were admitted to pediatrics department, El-Minia University Hospital during the period from September 2005 to December 2005 were included In this study. In patients with AOM at entry or developed AOM within 14 days, Gram-stained smears, bacterial cultures, and enzyme-linked immunosorbent assay [ELISA] were performed on middle-ear aspirates to detect the presence of bacterial pathogens and RSV respectively. Twenty children [55.6%] with acute bronchiolitis had AOM at entry or developed AOM within 14 days, 9 patients [25%] had developed otitis media with effusion, and only 7 patients [19.4%] remained free of both AOM and otitis media with effusion, throughout the 2-weeks observation period. Of 27 middle-ear aspirates [13 unilateral and 7 bilateral], bacterial pathogens were isolated in 23 [85%] [10 bacteria alone "37%" and 13 mixed bacteria and RSV "48%"], RSV was identified in 15 [55.5%] of middle ear aspirates [mixed with bacteria in 13 and RSV alone in 2 cases [7.5%]], so RSV was identified in 15 of 20 patients [75%] with AOM. Streptococcus pneumoniae was isolated in 11 middle ear aspirates, Haemophilus influenza in 6, Moraxella catarrhalis in 4, Staphylococcus aureus in 2, Streptococcus pyogenes in one aspirate and Pseudomonas aeruginosa in one aspirate only. Of 20 cases of AOM, 15 [75%] responded clinically to usual dose of antibiotic [Amoxicillin and clavulanic acid and/or Cefotaxime]. Finally we concluded that bacterial AOM is a complication In most children with acute bronchiolitis. Streptococcus pneumoniae and Haemophilus influenza were the commonest organisms isolated from middle ear aspirate. RSV is identified in most cases of acute otitis media [75%] and mixed with bacterial pathogens. Accordingly, in patients with acute bronchiolitis and associated AOM, antimicrobial treatment is indicated

Hepatitis c virus infection associated anticardiolipin antibodies and recurrent hemodialysis arteriovenous fistula thrombosis: true association or mere coincidence

Background: vascular access thrombosis in patients on maintenance hemodialysis [HD] is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular HD and positive titers of anticardiolipin antibodies [ACAs]. ACAs are commonly found in patients with chronic hepatitis C viral [HCV] infection but their pathogen etic role and the mechanisms that stimulate their production have not yet been clarified. In HCV infection, ACAs are generally cofactor independent and may represent an epiphenomenon of the infection. Some studies, however, have found an increased incidence of thrombotic disorders in patients with chronic HCV infection who manifest ACAs positivity suggesting that the presence of these autoantibodies may predispose to thrombosis in specific HCV-infected patients

Aim of the work: this study was designed to evaluate the prevalence of ACAs associated with chronic HCV infection in chronic HD patients and its possible relation to recurrent arterio-venous fistula thrombosis [A VFT]

Patients and methods: eighty-four out of 97 patients undergoing chronic outpatient HD treatment in a single dialysis facility, who had a functional autologus A VF, were offered enrollment in the study. All baseline data collection occurred during December 2003, with follow-up through December 2005. Nonfasting pre-HD blood samples were collected for determination of serum levels of creatinine, glucose, albumin, and total cholesterol, and blood urea nitrogen levels. Fractional clearance index for urea [Kt/v] was calculated monthly. Standardized enzyme-linked immunosorbent assay [ELISA] was considered positive [medium to high titre] for lgG ACA with any value > 40 units. High sensitivity C reactive protein [hs-CRP] was measured by latex-enhanced turbidometry. Antibodies to HCV [HCV ab] were investigated using lnnotest TM HCV Ab IV ELISA 3rd generation. Vascular access failure was defined as loss of bruit or thrill and/or sudden cessation of function of the A VF rendering HD impossible. By the end of follow up period [median of 16 months], data were collected and statistically analyzed

Results: thirty four/84 [41%] patients experienced recurrent AVFT during follow-up versus 50/84 [59%] who did not. Higher mean baseline lgG-ACAs levels [i.e > 40 units] were noticed in those patients who subsequently thrombosed their fistulae compared with who did not [22/34 [65%] versus 10/50 [20%], P<0.001]]. Correlation analyses revealed that the incidence of recurrent A VFT were associated with HCV positivity 30/34 [88%], P =0.04] as well as plasma serum levels of hs CRP 21/34 [62%], P = 0.03], but not with age, gender,· serum albumin, months on dialysis, creatinine, current smoking, hypertension, hypercholesterolemia, or the Kt/v .The prevalence of HCV positivity was 65/84 [77.4%]. The incidence of recurrent AVFT was found to be higher among the group of patients having ACA+ve and HCV +Ve 19/34 [56%] compared with who had no recurrent AVFT within the same group of patients 8/50 [16%] [P<0.001]

Conclusion: from this study, it can be concluded that a possible relationship does exist between chronic HCV infection associated ACAs and recurrent AVFT in chronic HD patients. Whether this is a true association or a mere coincidence remains to be determined. This is a single-center study with a limited number of patients and should be confirmed by other mutlicenter prospective controlled trials with larger numbers of patients

Follow up for brucellosis patients; clinical, serological and blood culture assessment

Brucellosis is a zoonotic disease that has a worldwide distribution, and it remains as a major source of disease for both humans and domestics animals particularly in the Mediterranean region

Study hypothesis: one of the main characteristics of brucellosis is its marked tendency to relapse in spite of proper management. Since almost 90% of the relapses occur during the first 6 months following conclusion of treatment, strict follow up is necessary during this period in order to detect any relapses as soon as possible and to provide adequate therapy

Aim of the study: evaluation of the impact of continued occupational exposure of the already diagnosed Brucella cases

Subject and method: in our study we followed up 66 Brucella sero-positive workers from El-Minia slaughterhouses during their first 12 months post treatment. The study showed a high suspicion of relapse or re-infection in nearly one third of cases [20 cases]. Further work up was done for those cases to document the exact active brucellosis in general clinical practice

Result: our finding confirmed that programs for post treatment follow up of patients with brucellosis should include the appropriate clinical examination together with blood culture and serological tests. The high index of suspicion for relapse based on clinical examination was further confirmed to be positive on serological testing and by PCR assays, which indicated positive active brucellosis in 8 cases out of these suspicious twenty cases. However, blood cultures failed to prove brucellosis in three cases out of these cases diagnosed by PCR

Recommendation: we recommend that proper treatment of brucellosis must be followed by post treatment continuous follow up for at least one year as a preventive measure for relapses

Studies on deep fungal infections in cancer patients

This study included one hundred and ten tumour cases [tested group]. Also, twenty non tumor cases [control group]. All were subjected to four samples taken from each case, blood, sputum, urine and stool for isolation of possible fungi. The tested group was divided into 3 sub-groups according to the type of tumour. Group I. Haematological tumours [8 cases], Group II Lymphoproliferative tumours [10 cases] and Group III Solid organ tumours [84 tumours]. The most prevalent type of fungi was found in Group III. Most infections occur in respiratory tract infection. The fungal in these cases accounts for 12 types of fungi followed by, gastrointestinal fungal infections which accounts for 10 types of fungi and then to urinary tract fungal infections which accounts for 5 types of fungi. The most prevalent fungi in respiratory tract infections were C. albicans. Which was isolated from 52 cases of 84 cases with a percentage of 62%. In gastrointestinal infections were 36 cases of a total 86 positive cases with a percentage of 42%. The infected control cases were in 6 cases of 20' positive cases [30%]. In urinary tract infections 12 cases of 24 positive cases with a percentage of [50%] while; control cases were negative. The following most prevalent fungi in respiratory-tract infections was C.pseudotropicalis. It was isolated from 16 cases of 84 cases with a percentage of [19%]. Gastrointestinal infections were 20 cases of a total 86 positive cases with a percentage of [23%]. In urinary tract infections 6 cases of 24 positive cases with a percentage of [25%]. C.tropicalis infection of respiratory tract was in 12 cases of a total 84 with a percentage of [14%] and in gastrointestinal infections was 12 cases of a total 86 cases with a percentage of [14%]. Asp. Niger represent 9.5% [8/84] of respiratory tract infections while; control cases accounts for 20%. In gastrointestinal infections, Asp. Niger represent [2.4%] while controls was 2 of 20 positive cases [10%]. The same fungus represent 8.3%' [2/24] in urinary tract infections. Negative control cases in urinary tract infections

Proliferation of liver cells chronic liver disease: a study of liver in biopsies using immunohistochemical localization of prolifrating cell nuclear antigen

A significant proportion of chronic liver disease [CLD], consisting of chronic hepatitis and liver cirrhosis, results from chronic subclinical infection by hepatitis B and C viruses, HBV and HCV[1]. This chronic hepatitis [CH] is a forerunner of liver cirrhosis [LC] and may further progress to hepatocellular carcinoma[2-3]. The association of cirrhosis with hepatocellular carcinoma [HCC] is also well documented[4]. The exact mechanism of viral hepatocarcinogenesis is yet to be clearly defined[5]. Possibly the persistent liver cell necrosis and the resultant irregular regeneration[6]. The proliferative rate of regenerating hepatocytes may be an important pathogenetic and prognostic factor in chronic liver disease[7]. A number of markers have been used in the assessment of the proliferative status of cells, like bromodeoxyuridine[8], Ki-67[9] and DNA polymerase alpha[10]. Techniques utilizing these markers are complex, however, and require fresh or snap frozen tissue, except for Ki-67, which can be used on paraffin sections. Proliferating cell nuclear antigen [PCNA], an accessory protein of DNA polymerase delta, is one of the best markers for evaluating cell proliferation in studies on retrospective material, since the antigen can be localized in routine formalin-fixed paraffin-embedded tissue[7, 11-14]. Limited reports are available on the proliferation kinetics of normal human livers, though in recent years several studies reported on hepatocytic proliferation rates in acute and chronic liver diseases. Normal hepatocytes are generally quiescent and divide very slowly[15-17] High proliferative rates have been reported in hepatocellular carcinoma, cirrhosis and acute hepatic failure[11, 18-22]. Nakamura et al., [7] have shown that there is no significant difference in PCNA-labeling indices between chronic viral hepatitis types B and C. With increasing knowledge of the biology of hepatitis C virus infection, information on hepatocytic proliferation kinetics is emerging now. In a recent study on the prevalence of HBV- and HCV-associated chronic liver diseases in liver biopsy material over the last decade, we observed a steady rise of HCV-associated diseases and a decline in HBV-associated ones[23]. Chronicity of HCV infection leads to CH and LC much more frequently than chronic infection by other hepatitis viruses[24], and the former infection shows a higher degree of association with hepatocellular carcinoma in several parts of the world[25]. Therefore, we considered it worthwhile to examine for hepatocytic proliferation using PCNA-labeling in our material of chronic liver diseases and to note any differences between hepatitis B- and C-associated diseases

Cytokines' profile in fulminant hepatic failure: effect of hepatocyte transplantation

We used a previously described animal model of fulminant hepatic failure [FHF] to study the effect of hepatocyte transplantation [HcTx] on the cytokine profile. Three groups of Sprague Dawley rats were used. Group I [n=30] received intrasplenic HcTx. Group II [n=12] received intrasplenic injection of saline. Two days later, both groups underwent surgically induced FHF. Group III [n=30] underwent sham operation. Six animals of each group were euthanized preoperatively and on postoperative days 1, 7, 14 and 28 to study plasma cytokines; hepatocyte growth factor [HGF] and transforming growth factor beta one [TGF-beta 1]. Preoperatively, and after hepatocyte transplantation, Group I had a higher level of hepatocyte growth factor [HGF] than Groups II and III. On postoperative day 1, Group I had low levels of HGF and TGF-beta 1 and Group lI had the highest levels among the three groups. No animals in Group II survived beyond day 3 postoperatively. On day 14, HGF showed a rise in Group I as compared with Group III. HcTx has modified the level of cytokines in favor of liver regeneration in FHF rats

Up-regulation of the tumor suppressor gene P53 and WAF1 gene by IP6 in HPG2 human hepatocellular carcinoma cell line

Inositol hexaphosphate [InsP6 or IP6] is a naturally occurring polyphosphorylated carbohydrate that is present in substantial amounts in almost all plant and mammalian cells. It was recently recognized to possess multiple biological functions. IP6 exerts its effects on the body by controlling cell division. It reduces the rate of cellular proliferation, both in vivo and in vitro, and has exhibited an ability to reduce DNA synthesis and also causes differentiation of various cell lines, including HT-29 human colon carcinoma cell. We hypothesize that the tumor suppressor genes such as p53 and WAF1 may be involved in mediating the antineoplastic action of IP6. p53 acts as a molecular policeman preventing propagation of genetically damaged cells; it causes the cells to arrest in the G1 phase of cell cycle, and regulates the level of p21 wafl which acts as a growth inhibitor. We therefore investigated the effects of IP6 on the expression of p53 and WAF1/p21 in HP-G2 human hepatocellular carcinoma by immunocytochemistry. Our immunocytochemical studies with anti p53 antibodies [wild type-PAb246 and Pab 1620] and anti p21 wafl [EA10] antibodies demonstrated an increased level of p53 and p21 wafl after 3 and 6 days of treatment with 3.3 and 5 mM and 8 mM IP6. This increase was dose-dependent and a definite time-dependent increase was not observed. These data demonstrate that IP6 up-regulates the expression of the tumor suppressor gene p53 and p21waf1 gene and their modulation may be one of the mechanisms of the antineoplastic action of IP6 since loss of p53 function enhances cancer cells resistance to chemotherapeutic agents, the stimulating function of IP6 on p53 makes it an attractive adjuvant chemotherapeutic agent as well

study of acute bacterial conjuntivitis in children in Minia governorate

This study included 180 children [60 as healthy control group and 120 as study group]. In this study the incidence of acute bacterial conjunctivitis was higher in children living in rural areas [66.7%] than in those living in urban areas [33.3%]. In the study group, the results revealed variable pathogenic organisms of different percentages including Streptococcus aureus [44.1%], Haemophilus influenzae [25%], Streptococcus pneumoniae [22.5%], Diphtheroids [8.5%], Moraxella catarrhalis [3.4%], Streptococcus pyogenes [2.5%], and Peptostreptococcus [2.5%]. Mixed cultures were obtained in 8.5%. The incidence of Staphylococcus aureus was higher in children at school age than children at preschool age. Haemophilus influenzae was the commonest organism in children at preschool age. The commonest bacterial flora found in the conjunctiva were Staphylococcus epidermidis and viridans streptocci. Factors influencing the prevalence of microbiologic agents in patients with conjunctivitis include geographic location, season, age and associated concurrent illness. There was some degree of seasonal variations as regards Haemophilus influenzae and Streptococcus pneumoniae. Antibiotic showed the high susceptibility of most of the organism to the used fluoroquinolones and chloramphenicol