Open Access Case Study

Use of Elores™ in Guiding Successful Treatment of Ventilator Associated Pneumonia Due to Multi Drug Resistant Acinetobacter baumannii and Klebsiella pneumoniae

Ashish Gupta, Sunny Rupal

Journal of Advances in Medicine and Medical Research, Page 1-6
DOI: 10.9734/BJMMR/2016/28546

Introduction: Increased antimicrobial resistance of Acinetobacter baumannii (A. baumannii) and Klebsiella pneumoniae (K. pneumoniae), is of great concern worldwide. Management of Ventilator associated pneumonia (VAP) due to MDR poses a challenge for clinicians.

Case Presentation: Here we are discussing a case of 47 year old male patient diagnosed with VAP due to A. baumannii and K. pneumoniae. Use of Elores™ (Ceftriaxone/Sulbactam/Disodium-edetate) as antibiotic for the treatment of VAP due to MDR pathogen K. pneumoniae and A. baumannii resulted in clinical cure of infection.

Conclusion: Elores™ can be considered as a safe and efficacious antibiotic to treat MDR gram negative pathogens in VAP.

Open Access Case Study

A Rare Case of IgA-mediated Autoimmune Hemolytic Anemia in a Young Adult

Majid Alameri, Abdullah Alnuaimi

Journal of Advances in Medicine and Medical Research, Page 1-5
DOI: 10.9734/BJMMR/2016/26583

A 21-year-old previously healthy male presented with unexplained intravascular hemolysis. Patient had anemia, elevated serum indirect bilirubin, elevated LDH, reticulocytosis, decreased haptoglobin and spherocytosis. Initial Laboratory investigations revealed a negative direct antiglobulin test (DAT), suggesting a Coombs-negative hemolytic anemia. Additional testing with monospecific anti-IgA was strongly positive. Autoimmune hemolytic anemia due to warm-reacting IgA autoantibodies is very rare and presents with "Coombs negative" autoimmune hemolytic anemia. A diagnosis of idiopathic IgA-only-associated warm AIHA was made after extensive investigations. Treatment included transfusion of multiple ABO/RH-D compatible typed red cell concentrates and administration of high-dose steroids. This case report will highlight the initial clinical presentation, panel of investigations for diagnosis; course of treatment and follow up with a brief literature review of the pathophysiologic mechanism and suggested treatment modalities for this rare IgA-induced warm AIHA.

Open Access Original Research Article

Effect of Anterıor and Posterıor Capsular Polıshıng on the Rate of Posterıor Capsule Opacıfıcatıon

Ali Kurt, Cagatay Caglar, Adem Gül, Kemal Türkyılmaz, Saıt Nafız Mutlu

Journal of Advances in Medicine and Medical Research, Page 1-7
DOI: 10.9734/BJMMR/2016/27704

Aim: To analyze whether anterior and posterior capsule polishing after lens cortex cleaning done by phacoemulsification has any effect on the rate of posterior capsule opacification (PCO).

Study Design: Randomized controlled trial.

Materials and Methods: A total of 587 with cataract who underwent uncomplicated phacoemulsification surgery were analyzed. The patients were divided into two groups. The anterior capsule and posterior capsule polishing procedure after lens cortex cleaning was carried out in 271 patients (Group 1) and not carried out in 316 patients (Group 2). The posterior capsule was evaluated by using the retroillumination technique on the biomicroscope by one ophthalmologist.

Results: The mean age was 65.33±13.90 (18-93) years in group 1 and 67.32±11.72 (22-95) years in group 2. PCO developed in 9 of 271 patients (3.3%) in group 1 and 39 of 316 patients (12.3%) in group 2. The difference was statistically significant (p<0.001). Comparison of the two groups for PCO development at the 6th nd 12th months revealed a statistically significant difference (p<0.001) with less PCO in group 1 at both time points. The mean follow-up duration was 29.72±2.7 (24-37) months.

Conclusion: Our study shows that the PCO rates showed a statistically significant decrease in patients who underwent anterior and posterior capsule polishing during cataract surgery. The combination of anterior capsule and posterior capsule polishing may significantly reduce the rate of PCO development.

Open Access Original Research Article

Detecting Human Papillomavirus 6 & 11 in a Set of Pakistani Population

Fauzia Perveen, Saeeda Baig, Farah Ahmad, Numan Majeed

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/BJMMR/2016/28578

Introduction: Human papillomavirus 6 &11, two clinically important low risk-HPV genotypes are known for genital warts, laryngeal papillomas and low-risk squamous intraepithelial lesions. Recent research has documented HPV 6 &11, cause of malignancies in oral cavity, pharynx, larynx etc. the frequency of which is also increasing in Pakistan. Therefore, it was hypothesized that HPV 6 & 11 might also be associated with oral malignancies in Pakistan.

Methodology: For this case control study a total of 266 subjects (133 cases and 133 controls), >18yrs, smokers and chewers were recruited. Diagnosed cases of Squamous Cell Carcinoma of the oral cavity, larynx and pharynx were included. Precancerous oral lesions were identified on the basis of Axell & Poulson criteria. According to their classification, subjects falling in grade 1 or above were considered as oral lesion cases. The subjects without any signs similar to grade 1 and without any lesions were controls. Detailed questionnaire was filled followed by oral sample collection. After DNA extraction conventional PCR for HPV was performed. Positive samples were further analyzed for HPV 6 &11 on Real time PCR.

Results: The 266 subjects (mean age cases-42.07±13.7; controls- 33.61±11.68 years) included 132 males [93 (69.9%) cases, 39 (29.3%) controls] and 134 females [40 (30.1%) cases, 94 (70.7%) controls]. Further division into six ethnic groups showed Urdu speaking as major group (40.6% cases and 38.3% controls). Main habit reported was Gutka (67; 25.18%). The most common (68; 95.77%) cancer was Squamous Cell Carcinoma with buccal mucosa (49; 69.01%) as the most common site. HPV was found in 21 (7.9%) cases only. Strong association of HPV with cases (P= 0.006) was found at confidence interval of 3.06-851.8 and odds ratio of 51.02. However none was positive for HPV 6&11. The HPV association was significant with betel quid addiction (P<0.0001). The most common (68; 95.77%) cancer observed was Squamous Cell Carcinoma of the oral cavity with buccal mucosa (49; 69.01%) as the most common site.

Conclusion: Since, HPV 6/11 was not detected we can conclude that there is no association between HPV 6/11 and tobacco use leading to oral lesions/cancers. Thus there is no definitive causative role of HPV 6&11 in oral carcinogenesis in our ethnically diversified population where use of chewable tobacco is very common among the masses.

Open Access Original Research Article

P53 and Ki67 Expression by Cervical Cancers in Ile-Ife, Nigeria

O. O. Odujoko, G. O. Omoniyi-Esan, A. O. Komolafe, Aremu Adegoke, B. J. Olasode

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/BJMMR/2016/21697

Background: Cervical cancer is the second most common cause of cancer deaths in females in Nigeria. The aim of this study is to determine the percentage of cervical cancers in Ile-Ife that express the p53 and Ki-67 protein and to compare the expression of the proteins with the different histological types of the tumour.

Methods: We retrospectively reviewed our data of histological results over the last twenty years and retrieved all the diagnosed cases of cervical cancers over this period. The haematoxylin and eosin slides were reviewed to confirm the diagnosis and also to confirm the histological variants. Immunohistochemistry for p53 and Ki-67 was done on selected blocks.

Results: A total of 149 cervical cancer cases were evaluated by immunohistochemistry. The age range at presentation of cervical cancer was 20-95 years (mean 56.6 years). The large cell non-keratinizing variant was the most common histological variant with a percentage of 57.7% followed by the keratinizing variant with a percentage of 29.5%. The basaloid variant was the least common with a percentage of 0.7%. Of all the 149 cases, 59.7% were positive for Ki67 while 40.3% were negative. Sixty-one percent of the cases were positive for p53 while 38.3% were negative. There was no significant association between the histological variants of cervical cancer and age distribution. The association between p53 and Ki-67 and the different histological variants was not found to be statistically significant, although most cases that were positive for both proteins were found to be the large cell non-keratinizing variant.

Conclusion: The expression patterns of p53 and Ki-67 by cervical cancer cases evaluated in Ile-Ife is similar to those obtained in other African countries. The relationship between histological variants and age groups as well as that between p53 and Ki-67 with the different histological variants of cervical cancer were found to be statistically insignificant.  More  studies  on  expression  of  these  proteins  are  needed  to  confirm  their importance in cervical carcinogenesis and prognosis.

Open Access Original Research Article

Prediction of Renal Injury Risk by Expressions of KIM-1 and NGAL in Type 2 Diabetic Nephropathy

V. V. Khot, K. S. Yadav

Journal of Advances in Medicine and Medical Research, Page 1-8
DOI: 10.9734/BJMMR/2016/28398

Background: About 10 to 40% Type 2 diabetes (T2DM) and 30% Type 1 diabetes (T1DM) suffer from kidney failure increases huge financial burden for care for patients [1]. Patients with uncontrolled diabetes prone to end-stage renal disease (ESRD) which required kidney transplantation, haemodialysis or peritoneal dialysis which adds psychological & financial burden. Early kidney injury can be prevented by evaluating gene expression (KIM1, NGAL) in T2DM with microalbuminuria.

Methodology: This study includes 241 subjects (118 male, 123 women, and age ranges 30-70 years, distributed in two groups; 30-45 years and 45-70 years) were included after screening for T2DM by measurement of blood glucose in fasting, post-prandial, glycosylated haemoglobin and micro albumin in urine. Subjects were randomised after written consent; subject examined by physician and enrolled as per inclusion/exclusion criteria. Categorization of subjects in three study groups were done on the basis of T2DM duration 3-5 years, Glycosylated haemoglobin level (HbA1c) ≥ 7.0% with fasting blood glucose ≥126 mg/dl) and micro albuminuria in study group. Equal numbers of age and sex matched healthy volunteers enrolled in control group. Blood samples were processed for other renal parameters &rt-PCR to check expressions of KIM1 and NGAL.

Results: In study groups all renal parameters are within normal range except albumin creatinine ratio (p<0.012) & e-GFR (p<0.000). Other parameters showed marginal significance within and between the groups. KIM-1 and NGAL showed high degree of significance (p<0.000).

Conclusion: Biochemical renal parameters are not enough to identify risk of DN even in microalbuminuria. Early detection of gene expressions of   KIM1 and NGAL may help to evaluate the status of kidney functions which help to prevent morbidity & mortality of kidney due to diabetic nephropathy. Extensive study in large population size was recommended.

Open Access Original Research Article

Neurologic Outcome after Asphyxial Cardiac Arrest in a Juvenile Porcine Model: Comparison of Epinephrine and Vasopressin, Alone or Combined with Nitroglycerin

Nektaria Lekka, Theofilos M. Kolettis, Giolanda Varvarousi, Theodoros Lappas, Sotirios Goulas, Georgios Agrogiannis, Ismene Dontas, Evaggelia Kouskouni, Despina Perrea, Nikolaos Kordalis, Theodoros Xanthos, Lila Papadimitriou

Journal of Advances in Medicine and Medical Research, Page 1-14
DOI: 10.9734/BJMMR/2016/27850

Aims: Hypoxemic encephalopathy is a devastating complication of asphyxial cardiac arrest in children, commonly occurring despite prompt resuscitation. Epinephrine, incorporated in present algorithms, may contribute to unfavorable outcome by causing excessive vasoconstriction, but the effects of alternative agents are unclear. Here, we compared the neurologic outcome after epinephrine with that after vasopressin (alone or combined with nitroglycerin) in a juvenile porcine model of asphyxia.

Study Design: Randomized experimental animal study.

Place and Duration of Study: Experimental surgery and surgical research department, of the Medical School, Athens University, from January 2013 to February 2016.

Methodology: Asphyxia was induced in 30 Landrace piglets (12-15 weeks of age) by occlusion of the endotracheal tube, leading to cardiac arrest. Four minutes thereafter, resuscitation was commenced with mechanical ventilation and chest compressions. The animals were randomized into three treatment groups, namely into epinephrine (E, n=10) vasopressin (VP, n=10) or vasopressin plus nitroglycerin (VP+NTG, n=10). Hemodynamic variables were measured at baseline and for 30 minutes after the onset of resuscitation. Neurological deficit and brain histological damage scores were assessed in survivors at 24 hours.  

Results: At baseline, hemodynamic variables did not differ between groups. The rates of restoration of spontaneous circulation (ROSC), followed by successful extubation, were comparable in the three groups, as were 24-hour survival rates. Mean aortic pressure and coronary perfusion pressure were higher in the VP and VP+NTG groups at the 5th minute of resuscitation, but lower than in the E group at the 30th minute. Neurological deficit and brain histological damage were improved after VP or VP+NTG, compared to that after E.

Conclusion: In this juvenile porcine model of asphyxial cardiac arrest, vasopressin (with or without nitroglycerin) yielded improved neurologic outcome, when compared to epinephrine, albeit similar ROSC and survival rates.

Open Access Original Research Article

Influence of the Disinfection Technique in Detail Reproduction and Dimensional Change of Plaster Casts Obtained from Different Alginate Impression Material Molds

Ricardo Danil Guiraldo, Sandrine Bittencourt Berger, Rodrigo Vieira Caixeta, Eloisa Helena Aranda Garcia de Souza, Murilo Baena Lopes, Alcides Gonini Júnior, Sandra Kiss Moura, Mário Alexandre Coelho Sinhoreti

Journal of Advances in Medicine and Medical Research, Page 1-8
DOI: 10.9734/BJMMR/2016/28035

The aim was to evaluate the detail reproduction and dimensional change of alginates after using different disinfection techniques. The molds of three alginate (Jeltrate Plus, Hydrogum 5 and Cavex ColorChange) were prepared at the top surface of the matrix where there was three parallel lines 20, 50, and 75 µm wide and 25 mm length between two vertical lines marked X and X′ with perforated metal tray. The molds were disinfected using a 0.2% peracetic acid solution by spraying or immersion or not disinfected. The alginate impressions were poured with dental stone obtaining plaster casts. The detail reproduction and dimensional change of plaster casts were measured on the 50 µm wide and 25 mm length line with an optical microscopy and compared with the matrix. The dimensional change date (%) was analyzed with two way ANOVA (factors, disinfection technique and material) and post-hoc comparison was conducted with Tukey’s test. The three alginates showed complete detail reproduction in the line of 50 µm. For the disinfection technique factor, models obtained from molds disinfected by the immersion technique differed significantly from models obtained from molds that were not disinfected. There is no difference in detail reproduction in plaster casts made from alginate molds, regardless of differences in disinfection technique or alginate used. There is a difference in dimensional accuracy in plaster casts made from alginate molds between molds disinfected by immersion and not disinfected; however, the difference found is not of clinical relevance.

Open Access Original Research Article

Maxillary and Mandibular Arch Perimeter Prediction Using Ramanujan's Equation for the Ellipse-In vitro Study

Rahul Aghera, Hina Desai, Padmaja Sharma, Nirav Dholakiya, Nishil Agrawal

Journal of Advances in Medicine and Medical Research, Page 1-9
DOI: 10.9734/BJMMR/2016/28868

Introduction: Arch expansion in the molar region or incisor proclination is an effective method to resolve arch length discrepancy. Predicting the change in arch perimeter by arch expansion in the molar region or incisor proclination is important in deciding during treatment planning if the removal of teeth will be required.

Purpose: The primary objective of this study was to determine if there is a mathematical correlation between Ramanujan's equation for the perimeter of an ellipse and the maxillary and mandibular arch perimeter. The secondary goal was to predict the gain in arch perimeter by arch expansion in molar region and incisor proclination using same equation for non-extraction cases.

Materials and Methods: 55 maxillary and 55 mandibular well-aligned diagnostic casts of untreated patients with class I molar relationships were used. Arch perimeter was measured using light wire and was compared with the calculated arch perimeter obtained by using Ramanujan’s equation.

Results: A strong correlation was found between measured and calculated arch perimeters with 1.5% error in maxillary arch and 1.7% error in mandibular arch. The average gain in arch perimeter by 1 mm molar expansion was 0.73 mm in maxilla and 0.74 mm in the mandibular arch. Average gain in arch perimeter by 1mm incisor proclination was 1.67 mm in maxilla and 1.65 mm in the mandible.

Conclusion: Ramanujan’s equation for an ellipse can be used to calculate the arch perimeter in the maxillary arch with a 1.5% chance of error and a 1.7% chance of error in mandibular arch. The equation can also be used to predict change in arch perimeter by molar expansion and incisor proclination.

Open Access Original Research Article

Achieving Economy of Scale in Critical Care, Planning Information Necessary to Support the Choice of Bed Numbers

Neeraj Beeknoo, Rodney P. Jones

Journal of Advances in Medicine and Medical Research, Page 1-15
DOI: 10.9734/BJMMR/2016/28736

Aims: To investigate the need for additional critical care beds, the potential for economy of scale in larger units, including ratios to support the choice of bed numbers.

Study Design: Time trend analysis and construction of useful ratios to assist planning.

Place and Duration of Study: Operational data for English NHS hospitals (2011 to 2016) obtained from NHS agencies. Analysis of critical care data at King’s College Hospital from April 2013 to February 2016.

Methodology: Analysis of time trends and/or calculation of averages and ratios of critical care beds per total hospital beds in different categories.

Results: In England, demand for critical care beds is growing at around 2.6% per annum. In 2015/16, the ratio of critical care beds to total hospital beds ranges from an average of 1:5 in tertiary/specialist hospitals to a minimum of 1:50 in general hospitals. Ratio of neonatal beds to maternity beds is around 1:5. Critical care units with more than 35 beds (adult, pediatric or neonatal) operate at around 85% annual average occupancy. Average monthly occupancy across the whole of England correlates with total monthly cancelled urgent operations.

Conclusion: Smaller units require far higher levels of flexibility in staffing and will suffer the unavoidable consequences of higher costs and the knock-on effects of periods of 100% occupancy. Smaller units must become part of a larger network in order to compensate for the higher volatility in CCU demand as size reduces.