In vitro activity of ceftazidime-avibactam against clinical isolates of Enterobacterales and Pseudomonas aeruginosa collected in Malaysia: Results from the ATLAS Programme, 2013 to 2019.

INTRODUCTION: There has been a steady rise in antimicrobial resistance among common pathogens in Malaysia. This study aims to determine the in vitro antimicrobial activities of ceftazidime-avibactam and its comparators against clinical isolates of Enterobacterales and Pseudomonas aeruginosa collected in Malaysia from 2013 to 2019, and to determine the rates of resistance among these isolates. MATERIALS AND METHODS: In this retrospective study, four participating study centres located in East (N = 1) and West (N = 3) Malaysia contributed to the collection of clinical isolates of Enterobacterales and P. aeruginosa from 2013 to 2019. Antimicrobial minimum inhibitory concentrations (MICs) and percentage susceptibilities were interpreted according to Clinical Laboratory Standards Institute (CLSI) breakpoints, except for tigecycline and colistin, which utilised the United States Food and Drug Administration (US FDA) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints, respectively. RESULTS: A total of 1,073 isolates of Enterobacterales and 332 isolates of P. aeruginosa were collected in Malaysia from the four centres. Among Enterobacterales isolates, the highest percentages of susceptibility were seen with ceftazidimeavibactam (99.2%), meropenem (98.9%), and tigecycline (96.9%). Whereas P. aeruginosa isolates demonstrated the highest susceptibilities to colistin (95.6%), followed by ceftazidime-avibactam (93.1%) and cefepime (87.1%). All metallo-ß-lactamase (MBL)-negative isolates of Enterobacterales, including ceftazidime-nonsusceptible, meropenem-nonsusceptible, and colistin-resistant phenotypes, were susceptible to ceftazidime-avibactam. Furthermore, ceftazidime-avibactam demonstrated the highest percentage of susceptibility (97.1%) against multidrug-resistant (MDR) isolates of Enterobacterales. CONCLUSION: Ceftazidime-avibactam exhibited potent in vitro activity against clinical isolates of Enterobacterales and P. aeruginosa collected in Malaysia from 2013 to 2019. The results of this study show that ceftazidime-avibactam should be considered in the treatment of indicated infections caused by susceptible strains of aerobic Gramnegative pathogens and is a valuable alternative to carbapenems.

Clinical characteristics of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV2) patients in Hospital Tengku Ampuan Afzan.

BACKGROUND: The COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aims to describe the clinical characteristics of COVID-19 patients admitted to Hospital Tengku Ampuan Afzan (HTAA), Pahang, Malaysia and to identify the clinical and laboratory markers for severe disease, complications and virologic clearance according to clinical staging. METHODS: This was a single-centre, retrospective, descriptive study. All COVID-19 patients admitted to HTAA from March 9 to April 15, 2020, were included in the study. Patients were categorised according to clinical staging. Data obtained from the medical report includes baseline characteristics of patients, comorbidities, presenting symptoms, laboratory findings, treatments, complications, and outcomes. RESULTS: Of the total of 247 patients hospitalised, the majority consisted at clinical-stage 1 (43%) and stage 2 (39%) disease. Older patients, diabetes mellitus, hypertension, cardiovascular diseases, and chronic kidney disease were found more common among patients with severe disease. Fever was uncommon and the majority had normal haemoglobin levels, white cell counts, and platelet counts. C-reactive protein (CRP) was found statistically significant to predict pneumonia or hypoxia at a cut-off value of 14mg/L (sensitivity 73.8%, specificity 91.3%) and 50mg/L (sensitivity 100%, specificity 96.4%) respectively. Pneumonia was mostly diagnosed radiologically using chest radiography, especially among clinical stage 3. Acute kidney injury (AKI) was a significant complication, with 31% of clinical stage 3 and above developed AKI and 44% of them requiring haemodialysis. Median virologic clearance time was 15 days from onset of illness, and asymptomatic patients had longer clearance time. CONCLUSION: COVID-19 presented with a wide spectrum of clinical patterns. CRP was a valuable predictor of severe disease. In this study risk and severity of acute kidney injury were found to be higher. A longer duration of virologic clearance was observed among the asymptomatic patients.

Does the UK undergraduate medical curriculum prepare students in Oral and Maxillofacial Surgery? A scoping review.

Oral and Maxillofacial Surgery (OMFS) is one of 10 surgical specialties recognised by the General Medical Council (GMC). The GMC states that newly qualified doctors should be familiar with a wide range of specialties and should refer patients appropriately. However, inadequate awareness of and exposure to OMFS in UK medical schools have been widely reported. Two independent investigators conducted a scoping review of all published articles that have evaluated the preparation of students in OMFS in UK undergraduate medical curricula. Our inclusion criteria were UK studies, articles published since inception, OMFS education, and relevance for undergraduate medical students. Data were extracted in accordance with recommendations by the National Health Service (NHS) Centre for Reviews and Dissemination. These were then analysed by qualitative synthesis. Our initial search yielded a total of 351 articles. Following application of the exclusion criteria according to PRISMA guidelines, 11 articles were included in the final analysis. Four main themes were identified: exposure to OMFS in the medical school curriculum, knowledge of OMFS conditions, knowledge of OMFS career progression, and ability to refer OMFS conditions appropriately. A consistent finding was that most medical students felt that they had insufficient exposure to and awareness of the specialty. All the papers recommended the need for change in the existing undergraduate medical curriculum. This review shows an overwhelming need for further development of OMFS in undergraduate medical curricula in the UK. However, there is insufficient primary research to show how best to achieve this. We propose that future research should focus on improvements in the quality of the current teaching methods and the adoption of new innovations to inspire and educate future doctors.

Current innovations in otolaryngology medical education in the UK: a systematic literature review.

OBJECTIVE: Recent studies have indicated a lack of ENT training at the undergraduate and post-graduate levels. This study aimed to review the impact of recent educational innovations in improving ENT training for medical students and junior doctors in the UK. METHODS: Three independent investigators conducted a literature search of published articles on ENT education. Included studies were analysed using qualitative synthesis methods. RESULTS: An initial search yielded 2008 articles; 44 underwent full-text evaluation and 5 were included for final analysis. Most included studies demonstrated benefits for students when compared to existing teaching standards in terms of objective assessment (knowledge and skills gained) or subjective assessment (confidence and preference) following implemented educational innovations. CONCLUSION: This study identified educational innovations developed in the past 15 years to enhance the teaching of core ENT competencies. More research is needed to establish their impact on the state of ENT medical education in the UK.

Leptospirosis in pregnancy: A lesson in subtlety.

INTRODUCTION: Leptospirosis is a zoonotic disease caused by spirochaete of the genus Leptospira. Human infection occurs after exposure to water or soil contaminated by urine from an infected animal. Most patients manifest as self-limited systemic illness. However 10% of patients manifest as severe disease associated with high fatality. The disease affects mostly men, cases involving pregnant women are uncommon. We presented a case of leptospirosis in a pregnant woman leading to mortality of both mother and foetus. CASE REPORT: A 28-year-old woman at 18 weeks of gestation, had shortness of breath and collapsed. She was brought unconscious to the emergency department and died shortly after arrival. A week prior to this, she had presented to the same hospital with pain on both thighs. Examination of the patient and ultrasound of the foetus revealed normal findings. Post mortem examination revealed hepatosplenomegaly and congested lungs; no jaundice, meningeal inflammation or cardiac abnormalities was evident. Histopathology examination of the lungs revealed pulmonary haemorrhages and oedema. Multiple infarcts were seen in the spleen and the kidneys showed foci of acute tubular necrosis. Laboratory investigations revealed Leptospira IgM antibody and PCR for leptospira were positive. This case illustrates the subtleness of clinical presentation of leptospirosis. The diagnosis was obscure even at post-mortem and was only suspected following histopathological examination, leading to further investigations. CONCLUSION: Leptospirosis may have a subtle presentation and a high index of suspicion for this infection is required for early identification of the disease.

A sudden paediatric death due to hand, foot and mouth disease: the importance of vigilance.

BACKGROUND: Hand, foot and mouth disease (HFMD) is caused by enteroviruses such as Coxsackie virus A16 (CVA16) and Enterovirus 71 (EV71). The diagnostic hallmarks are oral ulcers and maculo-papular or vesicular rash on the hands and feet. Severe form of this disease can lead to death due to neurological and cardiopulmonary complications. This case report aims to describe a fatal case of HFMD with minimal oral and skin manifestations. CASE REPORT: A four-year-old girl was brought to a hospital after suddenly becoming unresponsive at home. She had a history of fever and lethargy for three days prior to her demise. The patient, and f ive other children in her neighbourhood had been diagnosed to have HFMD at a local health clinic; the other children had recovered without complications. RESULTS: Autopsy revealed a few punctate, sub-epidermal vesicles measuring 1 to 2 mm on the palm of her right hand and sole of the right foot, visible only with a magnifying glass. Internal examination revealed prominent nodularity at the oro- and hypopharynxes. The lungs were markedly congested and oedematous. Histopathology of the lung showed marked oedema and haemorrhage with mild pneumonic changes. Oedema with increase in macroglia and astrocytic proliferation were seen in the cerebral tissue, but no lymphocytic infiltration was evident. Enterovirus EV71 was detected by polymerase chain reaction in samples from the lung, cerebrospinal fluid and serum. The cause of death was given as HFMD complicated by pneumonia. CONCLUSION: Fatal HFMD may have minimal signs. A complete history, careful physical examination and relevant investigations lead to a diagnosis at post mortem examination. Awareness of the subtle signs and rapid deterioration associated with a fatal case of HFMD is a challenge to clinicians who encounter these cases.

Development of multidrug resistance type I Cmdr1 expression in chicken embryonic gonads.

A primary role of P-glycoprotein (P-gp), encoded by the multidrug resistance type I gene, is to protect against naturally occurring xenotoxics. Recently, the preferential expression of chicken multidrug resistance type I (Cmdr1) was identified in the embryonic gonads during the early periods of development. Here we investigated the expression of Cmdr1 and P-gp in the gonads during embryogenesis, and compared to that in the ovarian follicles of domestic hens (Gallus gallus). As revealed by immunohistochemistry, P-gp was highly expressed in theca cells of mature follicles, whereas the expression was low in immature follicles. Immunohistochemical analysis showed that expression of Cmdr1-type P-gp was very low in embryonic gonads. Cmdr1 mRNA was undetectable in the gonads of 5-day embryos (E5) by RT-PCR, whereas Cmdr1 mRNA was significantly detectable in the developing gonads at E9 and E21. In the testicular tissues, germ cells were distributed along developing seminiferous cords as identified by a specific marker gene, whereas Cmdr1-type P-gp positive cells were observed evenly on testicular tissues. Collectively, it is concluded that Cmdr1 expression is initiated in the chicken ovary and testis after sexual differentiation, but expression of Cmdr1-type P-gp is very low through embryogenesis.

Effects of phosphate, prostaglandins, arachidonic acid and arginine vasotocin on oviposition and pigment secretion from the shell gland in Japanese quail.

1. Phosphate solution, prostaglandin F2alpha and E2, arachidonic acid and arginine vasotocin were injected intrauterinely or intravenously into laying quail hens 6 h before expected oviposition. Following injections, induced ovipositions and secretions of pigment from their shell glands were observed. 2. The effects of intrauterine injection with prostaglandins, which induced oviposition and pigment secretion, were not inhibited by pre-injection of indomethacin. 3. Indomethacin completely inhibited the inducing effects on oviposition and pigment secretion of intrauterine injections with phosphate solution and arachidonic acid. 4. Intravenous injection with arginine vasotocin or prostaglandins also induced oviposition and pigment secretion; indomethacin, however, only inhibited pigment secretion. 5. It is concluded that the effects of prostaglandins on pigment secretion from the shell gland were demonstrated experimentally.

An investigation of respiration while wearing back belts.

The research was conducted to evaluate the frequency of respiration during a repetitive lifting task when abdominal compression occurs from wearing a back belt. Three back belts were evaluated in this study: a nylon back belt, an inflatable back belt and an elastic vest. Analysis of the data revealed that the frequency of respiration increased while wearing the back belts at rest and while performing a repetitive lifting task. A statistically significant increase in the frequency of respiration was found while wearing the nylon back belt during the lifting task.

The effects of sex steroid hormones on the pigment accumulation in the shell gland of Japanese quail.

Effects of sex steroid hormones on the accumulation of the superficial pigment of the eggshell in the quail shell gland were investigated. In Experiment 1, 10 or 20 mg/100 g BW of aminoglutethimide (AG) was injected s.c. into laying quail hens 10 h before the expected ovulation. Thirty percent of the hens that received 10 mg/100 g BW and 87% of the hens that received 20 mg/100 g BW failed to ovulate. They had significantly (P < .01) lower concentrations of preovulatory plasma progesterone (P) than the control hens and showed significantly (P < .05) low concentrations of plasma estradiol-17 beta (E) and small amounts of the pigment in their shell glands after oviposition of the preceding egg. In Experiment 2, AG (20 mg/100 g BW) was administered s.c. to quail hens 10 h before the expected ovulation, followed by the administration of P (.05, .1, or .2 mg/100 g BW), E (.1, .2, or 1.0 mg/100 g BW), or testosterone (T) (.5 mg/100 g BW). Significant increases in the accumulated pigment 18 h after oviposition of the preceding egg were found when P was injected. However, administration of E and T had no influence on pigment accumulation. These results suggested that P might affect the accumulation of pigment in the quail shell gland.

[Cisplatin, vinblastine, and bleomycin combination chemotherapy in a stage IV pure endodermal sinus tumor of the ovary--a case report of a long-term survival].

Discussed is a case of a stage IV pure endodermal sinus tumor (EST) of the ovary that was treated with a PVB protocol following cytoreductive surgery. The serum alpha-fetoprotein (AFP) dosage before treatment was 83,546 ng/ml, and a complete clinical response was achieved with the disappearance of pleural effusions, ascites, and normalization of the serum AFP. A second-look laparotomy was substituted by serial AFP determinations and the patient remained free of disease for two years. Recently, complete remissions and long term survivals of patients with a stage I-II disease have been reported, though a prolonged or a complete remission of a stage IV EST of the ovary is still a rarity.