30-day mortality risk after major surgery

Pre-operative assessment of 30-day mortality risk after major surgery: the role of the quick sequential organ failure assessment: A retrospective observational study
BACKGROUND The quick Sequential Organ Failure Assessment (qSOFA) is intended for the assessment of the prognosis and risk of sepsis. It may also help predict the mortality risk of nonseptic patients. OBJECTIVE This study investigated the relationship between pre-operative qSOFA scores and 30-day mortality after major surgery. It also evaluated the predictive value of qSOFA scores combined with the American Society of Anesthesiologists (ASA) physical status and Charlson comorbidity index (CCI). DESIGN A retrospective observational study. SETTING Single tertiary academic hospital. PATIENTS Medical records of patients who underwent major surgery (estimated blood loss >500 ml; surgery time >2 h) between January 2010 and December 2017 were examined. MAIN OUTCOME MEASURES The qSOFA score was measured within 24 h before surgery, and its association with 30-day mortality was analysed using multivariable logistic regression. A receiver-operating characteristic curve analysis was used to investigate the predictive power of the pre-operative qSOFA scores combined with the ASA physical status and with CCI. RESULTS A total of 6336 patients were included in the final analysis, and 91 (1.4%) died within 30 days. The multivariable logistic regression analysis including all covariates indicated that 30-day mortality was 2.43-times higher for the score 1 group than for the score 0 group (P = 0.002), and it was 3.54-times higher for the score at least 2 group than for the score 0 group (P < 0.001). The area under the curve (AUC) of the pre-operative qSOFA, ASA physical status and CCI were 0.69, 0.55 and 0.57, respectively. When the pre-operative qSOFA score was combined with the ASA physical status or CCI, the AUCs were 0.73 and 0.72, respectively. CONCLUSION Higher pre-operative qSOFA scores within 24 h of surgery were associated with increased 30-day mortality. Pre-operative qSOFA scores have better predictive value for 30-day mortality when combined with the ASA physical status or CCI. Correspondence to Tak Kyu Oh, MD, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82 31 787 7499; fax: +82 31 787 4063; e-mail: airohtak@hotmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Spontaneous breathing through face mask and high-flow nasal oxygen

Comparison of pre-oxygenation using spontaneous breathing through face mask and high-flow nasal oxygen: A prospective randomised crossover controlled study in healthy volunteers
BACKGROUND High-flow nasal oxygen (HFNO) therapy has been proposed for pre-oxygenation before intubation, but the end-tidal fraction of oxygen (ETO2) obtained remains unknown. OBJECTIVE(S) To compare the ETO2 following a 3 min pre-oxygenation with HFNO and face mask. SETTING Operating room in a primary university hospital. DESIGN A prospective, randomised crossover study. PARTICIPANTS Fifty healthy volunteers. INTERVENTIONS Participants were randomly pre-oxygenated through spontaneous breathing 100% oxygen in a face mask and with HFNO (mouth closed, heated and humidified gas flow at 60 l min–1). In the face mask group, the ETO2 was measured continuously. In the HFNO group, the nasal cannula was quickly exchanged with a face mask while the subject held their breath at end inspiration and the ETO2 was measured after a deep expiration. The protocol ended when ETO2 reached 90% or otherwise at 6 min. MAIN OUTCOME MEASURES The primary endpoint was the ETO2 after 3 min of pre-oxygenation. Secondary endpoints were the proportion of participants with an ETO2 at least 90% and the time until the ETO2 at least 90%. RESULTS The ETO2 after 3 min of pre-oxygenation was 89 (2) % and 77 (12) % in the face mask and HFNO groups [difference 12% (95% confidence interval, 95% CI: 8 to 15]; P < 0.001), respectively. After 3 min of pre-oxygenation, 54 and 4% (P < 0.001) of volunteers had an ETO2 at least 90% in the face-mask and HFNO groups, respectively. After 6 min of pre-oxygenation, 96 and 46% (P < 0.001) of volunteers had an ETO2 at least 90% in the face-mask and HFNO groups, respectively. In the face mask group, the hazard ratio to achieve an ETO2 of 90% was 5.3 (95% CI: 3.2 to 8.9; P < 0.001). CONCLUSION Our study demonstrates that pre-oxygenation with HFNO is not a reliable method of pre-oxygenation before the induction of anaesthesia. TRIAL REGISTRATION clinical trial NCT03399695. Correspondence to Jean-Luc Hanouz, Service d'Anesthésie Réanimation (niveau 6), CHU de Caen, Av Côte de Nacre, 14033 CAEN Cedex, France E-mail: hanouz-jl@chu-caen.fr © 2019 European Society of Anaesthesiology

Presbycusis and vestibular activity

The relationship between presbycusis and vestibular activity
Gehan M S. Abd El-Salam

Journal of Medicine in Scientific Research 2018 1(4):245-249

Introduction Presbycusis or age-related sensorineural hearing loss (SNHL) is a complex disorder that results in a slow deterioration in auditory function. A considerably high number of these patients with presbycusis or age-related SNHL also experience dizziness and related vestibular symptoms. Although auditory and vestibular systems are distinct, they work just alike. So, there is a great relation among their functions. Once one is stimulated, the other experiences changes as well. Participants and methods This study comprised 40 adult patients (50&#8211;75 years) without any vestibular symptoms or diagnosed vestibular diseases. Audiological status was measured with auditory brainstem response (ABR). The vestibular system was assessed using videonystagmography test battery, sensory organization test, and vestibular evoked myogenic potential (VEMP). &#8216;Get up and go&#8217; test was used as a quick screening tool for detecting balance problems. Patients were divided into two groups: a study group (patients with SNHL) and a control group (patients without SNHL). ABR and VEMP results of the groups were calculated and compared. Results Absolute peak latencies of ABR waves I, III, and V were prolonged in the study group than the control group (P &#60; 0.0001). VEMP results showed that P13 and N23 latencies were prolonged in the study group when compared with the control group (P &#60; 0.0001). Conclusion Thorough full examination of the vestibular system, in conjunction with auditory functions in elderly persons, is recommended. This may help to discover their subclinical vestibular problem and guide physicians to design a suitable treatment plan that helps in decreasing risk of falls for aged persons. 

Iron-deficiency anemia on auditory function in school-aged children

Effects of iron-deficiency anemia on auditory function in school-aged children
Gehan M S. Abd El-Salam, Eman Soliman Abd El-Gaffar, Hala M Abd El-Samad

Journal of Medicine in Scientific Research 2018 1(4):239-244

Introduction Iron is important for proper myelination of spinal cord and white matter of cerebellar folds in brain and is a cofactor for a number of enzymes involved in neurotransmitter synthesis. Auditory brainstem evoked response (ABR) represents the progressive activation of different levels of the auditory pathway from the acoustic nerve (wave I) to the lateral lemniscuses (wave V). Otoacoustic emissions (OAEs) are sounds measured in the external ear canal that reflect movement of the outer hair cells in the cochlea. Patients and methods A total of 40 children, of both sexes, with age ranging from 6&#8211;12 years old, were selected for this study after a thorough clinical assessment to exclude any other pathological disorder other than anemia. They are compared with a control group that consisted of 20 normal children of the same age. After laboratory investigations, all children were examined by ABR and transient-evoked OAEs. The study group children were classified according to ABR results into study group 1, comprising anemic children with abnormal ABR results and study group 2, comprising anemic children with normal ABR results. Results ABR showed that absolute peak latencies of waves I, III, and V and interpeak latencies were prolonged; moreover, ABR waves I and V showed reduced amplitude in study group 1 than control group, and the difference is statistically significant. In contrast, there was no statistically significant difference between study group 2 and control group regarding ABR results. Transient-evoked OAEs results showed no statistically significant difference between anemic children and control group. Conclusion This study added to the evidences that iron-deficiency anemia is a risk factor for auditory function impairment. Further studies for the effect of timing, duration, and severity of iron deficiency on auditory functions are needed. Well-designed large-scale studies are needed to address the iron-deficiency anemia in health planning programs to put plans for control and prevention especially in developing countries. 

rivaroxaban and apixaban anticoagulant activity in whole blood

Modified ROTEM for the detection of rivaroxaban and apixaban anticoagulant activity in whole blood
BACKGROUND Rapid detection of the anticoagulant effect of oral factor Xa (FXa) inhibitors may be essential in several emergency clinical situations. Specific assays quantifying the drugs are performed in plasma and require a turnaround time that is too long to be useful in emergency situations. Rotational thromboelastometry (ROTEM) is a whole blood coagulation assay of blood viscoelasticity and could be of interest for FXa inhibitor detection in emergency. However, conventional ROTEM reagents only detect high amounts of inhibitors. OBJECTIVE The aim of this study was first to assess the effect of whole blood components on the viscoelastic measurement of the effects of FXa inhibitors, an second to evaluate whether a modified ROTEM, triggered with a low amount of tissue factor and a saturating amount of phospholipid vesicles, can reliably detect low levels of FXa inhibitor activity in whole blood. DESIGN Diagnostic test study. SETTINGS A university research laboratory. From November 2014 to April 2016. PATIENTS Sixty-six patients: 30 treated with rivaroxaban, 17 with apixaban and 19 without treatment. INTERVENTION ROTEM was triggered with 2.5 pmol l−1 of tissue factor and 10 μmol l−1 of phospholipid vesicles. MAIN OUTCOME MEASURES Modified ROTEM parameters were measured in different experimental conditions: platelet-poor plasma (PPP), platelet-rich plasma, PPP supplemented with fibrinogen and reconstituted whole blood with various haematocrit levels adjusted between 30 and 60%. Modified ROTEM was further validated using whole blood from patients who were either treated or not treated with FXa inhibitors. RESULTS Modified ROTEM allowed detection of as little as 25 ng ml−1 FXa inhibitors in PPP, with at least a 1.4-fold increase of the clotting time (P ≤ 0.02). Neither changes of fibrinogen concentration nor variations of platelet count or haematocrit precluded FXa inhibitor detection. A lengthened modified ROTEM clotting time of more than 197 s allowed detection of FXa inhibitor concentrations above 30 ng ml−1 in whole blood with 90% sensitivity and 85% specificity. CONCLUSION Modified ROTEM may be applicable in emergency situations for the detection of FXa inhibitors in whole blood. Correspondence to Charles M. Samama, MD, PhD, FCCP, Department of Anaesthesia and Intensive Care Medicine, Cochin University Hospital, 27 rue du Faubourg St Jacques, 75014 Paris, France Tel: +33 1 42 34 85 51/+33 6 62 14 86 64; fax: +33 1 58 41 14 15; e-mail: marc.samama@aphp.fr Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Laboratory

Urinary N-acetyl-beta-d-glucosaminidase levels in diabetic adults Eiya Bibiana Omozee, Enajit Ibiene Okaka, Andrew Efosa Edo, Leonard Fedinard Obika Journal of Laboratory Physicians 2019 11(1):1-4 Diabetes mellitus (DM) is known to be one of the most common causes of end-stage renal disease. The disease is usually not detected on time, because of the large functioning reserve of the kidney. Currently used markers (serum creatinine, creatinine clearance, urea, and electrolytes) remain relatively normal even when more than 50% of the renal nephron is not functioning. The aim of this study was to determine the level of urinary N-acetyl-beta-d-glucosaminidase (NAG) in diabetic adults in comparison with some currently used markers. A total of 56 diabetic patients between the ages of 23 and 63 were used for this study and 30 nondiabetic between the ages of 18 and 62 were used as control. The diabetic patients were classified into three groups based on how long they have been diagnosed: <2 years (25), 2–5 years (30), and >5 years (25). Spot midstream urine samples were collected into sterile containers, and blood samples were collected into plain tubes. All the analyses were done spectrophotometrically. Creatinine clearance was calculated using the Cockcroft–Gault Equation. There was a significant increase (P < 0.01) in NAG values of 2–5 years and above 5 years and control. The urinary microalbumin concentration of controls was significantly different (P < 0.05) only with those who have had DM for <2 years. Urinary creatinine concentration of control was significantly higher (P < 0.05) than values of all the diabetic groups. There was a significant increase (P < 0.01) in creatinine clearance of control group and those who have had DM for <2 years. It is thus concluded that urinary NAG can be used as an early marker in the diagnosis of diabetic nephropathy since urinary NAG increases first before the other markers analyzed in this current study begins to increase.

Clinical profile and determinants of short-term outcome of acute kidney injury: A hospital-based prospective study from Northeastern India Prasanta Kumar Bhattacharya, Akash Roy, Md. Jamil, Bhupen Barman, Subrahmanya V Murti, Patrick R Marak Journal of Laboratory Physicians 2019 11(1):5-10 CONTEXT: Acute kidney injury (AKI) is an outcome of multiple etiologies and is mostly reversible. Data on its incidence and outcome, particularly from India, are limited. AIMS: To study the etiology, clinical profile, and short-term prognosis in AKI. SETTINGS AND DESIGN: A hospital-based prospective observational study on AKI. SUBJECTS AND METHODS: Seventy-five AKI patients diagnosed by Acute Kidney Injury network criteria were selected. Patients with preexisting chronic kidney disease were excluded. STATISTICAL ANALYSIS USED: Data were compiled using the Statistical Package for the Social Sciences version 17. Regression analysis was done for determining the association of various variables for mortality. P < 0.05 was considered statistically significant. RESULTS: The mean age of patients was 41.09 ± 16.17 years with a male:female ratio of 1.42:1. Comorbidities were present in 37.3%, with diabetes mellitus (10.6%) and chronic liver disease (10.6%) being the most common. Fever was the most common (40%) presenting symptom, followed by oliguria (25.8%). Infection was the most common cause of AKI (56%), with sepsis in 26.7% followed by acute gastroenteritis in 17.3%. Pneumonia was the primary focus in 50% of cases with sepsis. Mean serum creatinine and urea at admission were 2.37 ± 0.90 and 92.44 ± 39.67 mg/dl, respectively. Serum creatinine rose progressively to 2.96 ± 1.18 and 3.26 ± 1.56 mg/dl at 24 and 48 h, respectively, since hospitalization. Majority of the cases (73.3%) were nonoliguric. Hemodialysis was necessary in 24% of cases. Mean hospital stay was 8.16 days. In-hospital mortality was 24%. Among survivors, 92.9% had complete renal recovery on discharge. Sepsis, need for hemodialysis, urea >100 mg/dl, and peak serum creatinine >3 mg/dl were contributors to mortality (P < 0.01). CONCLUSIONS: Infections, especially sepsis, were the most common cause of AKI. Hemodialysis was required in one-quarter of the patients. Sepsis, need for hemodialysis, and high creatinine were associated with a significantly higher mortality.

Serological evidence of human leptospirosis in patients with acute undifferentiated febrile illness from Uttarakhand, India: A pilot study Mohit Bhatia, Pradeep Kumar, Pratima Gupta, Puneet Kumar Gupta, Minakshi Dhar, Deepjyoti Kalita Journal of Laboratory Physicians 2019 11(1):11-16 CONTEXT: To the best of our knowledge, there are no reports of serological evidence of human leptospirosis from Uttarakhand state in India. AIMS: The aim of this study was to screen for serological evidence of leptospirosis in patients with acute undifferentiated febrile illness at a tertiary care teaching hospital in Uttarakhand. SETTINGS AND DESIGN: A pilot study was conducted from March to November 2017. SUBJECTS AND METHODS: Fifty-three adult patients who presented in Medicine outpatient Department with a history of fever of ≥7 up to 14 days duration with or without other associated symptoms such as a headache, rashes, myalgia, arthralgia, and conjunctival suffusion were enrolled in the study using convenience sampling technique. Blood samples of these patients were collected and subjected to peripheral smear examination for malaria parasites, dengue immunoglobulin M (IgM) immunochromatographic card test, IgM Typhidot, Leptospira and Scrub typhus IgM ELISA, respectively. Aerobic blood culture was performed in 24 cases. Relevant clinico-epidemiological details were obtained as per the pro forma formulated in accordance with the modified Faine's criteria. STATISTICAL ANALYSIS USED: Descriptive statistics. RESULTS: The study population consisted of 50.94% of males and 49.06% of females with a mean age ± standard deviation of 34.2 ± 15.2 years. Fifty febrile patients had additional symptoms of which myalgia was the most common (81.1%) followed by arthralgia (22.6%). Peripheral smears of all patients were negative for malaria parasites. Dengue and Typhidot IgM positivity was observed in two and eight patients, respectively. Six and five patients were tested positive by leptospira and scrub typhus IgM ELISA, respectively. Salmonella Typhi was isolated from blood sample of only one patient. Serum samples of two patients showed dual positivity. All six leptospira seropositive patients satisfied modified Faine's criteria. CONCLUSIONS: Leptospirosis is a seemingly unexplored infection in Uttarakhand and should be considered as a differential diagnosis in patients with acute undifferentiated febrile illness.

Detection of biofilm among uropathogenic Escherichia coli and its correlation with antibiotic resistance pattern Rashmi M Karigoudar, Mahesh H Karigoudar, Sanjay M Wavare, Smita S Mangalgi Journal of Laboratory Physicians 2019 11(1):17-22 BACKGROUND: Escherichia coli accounts for 70%–95% of urinary tract infections (UTIs). UTI is a serious health problem with respect to antibiotic resistance and biofilms formation being the prime cause for the antibiotic resistance. Biofilm can restrict the diffusion of substances and binding of antimicrobials. In this context, the present study is aimed to perform in vitro detection of biofilm formation among E. coli strains isolated from urine and to correlate their susceptibility pattern with biofilm formation. MATERIALS AND METHODS: A total of 100 E. coli strains isolated from patients suffering from UTI were included in the study. The identification of E. coli was performed by colony morphology, Gram staining, and standard biochemical tests. The detection of biofilm was carried out by Congo Red Agar (CRA) method, tube method (TM), and tissue culture plate (TCP) method. Antimicrobial sensitivity testing was performed by Kirby–Bauer disc diffusion method on Muller–Hinton agar plate. RESULTS: Of the 100 E. coli strains, 49 (49%) and 51 (51%) were from catheterized and noncatheterized patients, respectively. Biofilm production was positive by CRA, TM, and TCP method were 49 (49%), 55 (55%), and 69 (69%), respectively. Biofilm producers showed maximum resistance to co-trimoxazole (73.9%), gentamicin (94.2%), and imipenem (11.6%) when compared to nonbiofilm producers. Significant association was seen between resistance to antibiotic and biofilm formation with a P = 0.01 (<0.05). CONCLUSION: A greater understanding of biofilm detection in E. coli will help in the development of newer and more effective treatment. The detection of biofilm formation and antibiotic susceptibility pattern helps in choosing the correct antibiotic therapy.

Multidrug-resistant Acinetobacter septicemia in neonates: A study from a teaching hospital of Northern India Asifa Nazir Journal of Laboratory Physicians 2019 11(1):23-28 BACKGROUND: Acinetobacter species are typical nosocomial pathogens causing infections and high mortality, almost exclusively in compromised hospitalized patients. Acinetobacter sp. are intrinsically less susceptible to antibiotics and have propensity to acquire resistance. Multidrug-resistant (MDR) Acinetobacter sp. blood infection in the neonatal intensive care unit patients create a great problem in hospital settings. AIMS: A prospective data analysis was performed over a one year period of all neonates admitted with sepsis who developed Acinetobacter infection and their antibiotic susceptibility pattern was carried out. MATERIALS AND METHODS: Blood samples of infected neonates were collected aseptically and cases of Acinetobacter septicemia were identified. Speciation of Acinetobacter species was done. Various risk factors were identified and their drug-sensitivity test was performed. RESULTS: The incidence of neonatal septicemia due to Acinetobacter species was 13.7% (49/357). Predominant species isolated was Acinetobacter baumannii (98%). The major symptoms were lethargy and poor feeding. The major signs were tachypnea, intercostal retraction, and respiratory distress. The major fetal risk factors were low birth weight and prematurity. High degree of resistance was observed to the various antibiotics used. Majority of the isolates (95.9%) were MDR while 93.68% were resistant to carbapenems as well as extensively drug resistant. However, all the strains were sensitive to colistin. CONCLUSION: MDR Acinetobacter septicemia in neonatal patients is becoming alarmingly frequent and is associated with significant mortality and morbidity. Therefore, rational antibiotic use is mandatory along with an effective infection control policy in neonatal intensive care areas of each hospital to control Acinetobacter infection and improve outcome.

Volume, conductivity, and scatter parameters of leukocytes as early markers of sepsis and treatment response Parul Arora, Praveen Kumar Gupta, Raghavendra Lingaiah, Asok Kumar Mukhopadhyay Journal of Laboratory Physicians 2019 11(1):29-33 INTRODUCTION: Morphologic changes in the size and granularity of leukocytes seen in sepsis could be measured using the volume, conductivity, and scatter (VCS parameters) from the automated hematology analyzers. The objective of this study is to find the clinical usefulness of VCS parameters as possible indicators of sepsis and to determine the effect of treatment on these parameters. METHODS: This observational study was conducted in a tertiary level hospital in India. Hemogram and VCS parameters obtained from LH 750 (Beckman coulter, Fullerton, CA) from 134 proven blood culture-positive cases of sepsis were reviewed on the day of culture positivity (day 0), day 3, and day 7 were analyzed and compared with those of samples from otherwise healthy 100 participants. Statistical analysis of data was done, and cutoff value was established using receiver-operator characteristic curve. RESULTS: Out of 134 culture-positive cases, 55.2% (n = 74) Gram-negative and 44.8% (n = 60) Gram-positive bacteria were isolated. The mean neutrophil volume (MNV) and mean monocyte volume (MMV) were higher in the sepsis group compared to that of the control group (165.43 ± 18.21 vs. 140.59 ± 7.6, P = 0.001 for MNV and 179.8 ± 14.16 vs. 164.54 ± 9.6, P = 0.001 for MMV). A significant decrease in MNV and MMV was observed with the initiation of the treatment. Significant changes in scatter and conductivity parameters were also noticed. A cutoff value of 150.2 for MNV gave a sensitivity and specificity of 79.1% and 95%, respectively, with an area under the curve (AUC) of 92.3%. With a cutoff of 168.3, MMV had a sensitivity of 80.6% and specificity of 77.5%, AUC of 83%. CONCLUSION: VCS parameters such as MNV and MMV can be easily obtained by an automated hematology analyzer and could be used for early detection and therapeutic response in sepsis.

A 5-year surveillance on antimicrobial resistance of Acinetobacter isolates at a level-I trauma centre of India Minu Kumari, Priyam Batra, Rajesh Malhotra, Purva Mathur Journal of Laboratory Physicians 2019 11(1):34-38 INTRODUCTION: Acinetobacter spp. has emerged as a major cause of nosocomial outbreaks. Multiple antibiotic resistance is an important problem in Acinetobacter isolates in recent years. The aim of this study was to evaluate the rate of antimicrobial resistance and changes in resistance pattern over a period of 5 years (2012–2016) in Acinetobacter spp. isolated from trauma patients. MATERIALS AND METHODS: Acinetobacter spp. was identified by VITEK 2 and antibiotic susceptibility of isolates was investigated by disc-diffusion method and VITEK 2 automated system. Interpretation of susceptibility results was based on the Clinical and Laboratory Standards Institute guidelines. RESULTS: Out of the total 16,210 isolates obtained throughout the period of 5 years, Acinetobacter spp. accounted for 3744 (28.9%). Out of which, the species which was maximally isolated was Acinetobacter baumannii (98.5%), followed by Acinetobacter lwoffii (1.4%) and Acinetobacter hemolyticus (0.1%). The highest number of clinical isolates of Acinetobacter were recovered from neurosurgical ward (n = 1210), followed by the neurosurgical intensive care unit (ICU) (n = 1000) and surgical ICU (n = 948) and the most common sample of Acinetobacter isolation was from tracheal aspirate (37.1%), followed by wound swab (18.8%). The highest level of resistance was observed against ciprofloxacin (96%), followed by cefepime (95%), ceftazidime (95%), piperacillin (95%), and amikacin (92%). The trend of antibiotic resistance was found to be statistically significant (P < 0.001) for most of the antibiotics being tested such as amikacin and carbapenems. CONCLUSION: The high rate of antibiotic resistance of the Acinetobacter strains indicated that there is an urgent need for controlled antibiotic usage and appliance of hospital infection control measures.

Reconsidering azithromycin disc diffusion interpretive criteria for Salmonellae in view of azithromycin MIC creep among typhoidal and nontyphoidal salmonella Sadia Khan, Parvathy Kurup, Vivek Vinod, Raja Biswas, Gopala Krishna Pillai, Anil Kumar Journal of Laboratory Physicians 2019 11(1):39-44 PURPOSE: Enteric fever continues to be an important public health challenge for the developing world. With the emergence of fluoroquinolone resistance in Salmonellae spp. azithromycin is increasingly being used for oral treatment of enteric fever. We investigated the antibiotic susceptibility pattern of azithromycin in Salmonellae spp. isolates from a tertiary care hospital to detect emerging resistance. METHODS: The study assessed the reliability of disc diffusion as a screening test to detect azithromycin resistance by comparing it with the minimum inhibitory concentrations (MICs) of the drug in 100 Salmonellae spp. strains. The strains of Salmonellae spp. showing resistance to azithromycin were further investigated for resistance markers – mphA, mphB, and mef B genes. RESULTS: This study was conducted on 100 Salmonella enterica strains recovered from blood culture samples between 2013 and 2017. Among these isolates, 18 showed resistance to azithromycin by disc diffusion methodology with zones of inhibition <13 mm. MIC of 6 of these isolates were ≥32 mg/L. The mean MIC of azithromycin increased from 5 mg/L in 2013 to 24 mg/L in 2017. Azithromycin consumption as defined daily doses per 1000 patient days also showed an increase over the past 4 years. CONCLUSION: Azithromycin disc diffusion diameter interpretations as recommended by Clinical and Laboratory Standards Institute can mislabel a few sensitive strains as resistant. Azithromycin resistance is emerging in typhoidal and nontyphoidal Salmonella. MphA gene is associated with high MICs in nontyphoidal Salmonella spp.

Typing of Neisseria gonorrhoeae isolates by phenotypic and genotypic techniques in New Delhi, India Seema Sood, Neeraj Mahajan, Rajendra Singh, Sonu Kumari Agrawal, Trupti Shende, Arti Kapil, Hemanta K Kar, Vinod K Sharma Journal of Laboratory Physicians 2019 11(1):45-50 BACKGROUND: The objective of this study is to investigate gonococcal isolates using phenotypic and genotypic methods. METHODOLOGY: Sixty gonococcal isolates obtained were examined. Strains were divided into 9 resistant phenotypes: Chromosomally mediated penicillin-resistant Neisseria gonorrhoeae (CMRNGP), penicillinase-producing NG (PPNG), chromosomally mediated tetracycline-resistant NG (CMRNGT), TRNG, PPNG and TRNG, CMRNGPT, quinolone resistant NG (QRNG), Azithro R, and decreased susceptibility (DS) to ceftriaxone. These isolates were also subjected to auxotyping and NG-multi-antigen sequence typing (MAST). RESULTS: Of 60 isolates, 32 (53.33%) PPNG and only one was CMRNGP; 16 (26.66%) were CMRNGT, while 18 (30%) were TRNG. Both PPNG and TRNG found in 13 (21.66%) and none were CMRNGPT. QRNG was seen in 93.33%, 5% Azithromycin R, and 6.66% were DS to ceftriaxone. Based on auxotyping, 24 (40%) nonrequiring, 16 (26.66%) were proline requiring, 13 (21.66%) arginine requiring while 7 (11.66%) belonged to others. The most common ST was 6058 (32.5%). The discriminatory indices of antibiogram, auxotyping and NG-MAST were 0.77, 0.72, and 0.95, respectively. CONCLUSIONS: NG-MAST is the method of choice for epidemiological studies.

Correlation of vascular endothelial growth factor and vascular endothelial growth factor receptor-1 levels in serum and thyroid nodules with histopathological and radiological variables Gurkan Haytaoglu, Fatih Kuzu, Dilek Arpaci, Ayfer Altas, Murat Can, Figen Barut, Furuzan Kokturk, Sevil Uygun Ilikhan, Taner Bayraktaroglu Journal of Laboratory Physicians 2019 11(1):51-57 BACKGROUND/AIM: Vascular endothelial growth factor (VEGF) is a major cytokine in angiogenesis and has a role on aggressivity of various tumors. The expression of VEGF has been shown to increase in differential thyroid cancer. The aim of the study was to evaluate serum and intranodular VEGF (nVEGF) and VEGF receptor-1 (VEGFR-1) levels in patients with thyroid nodules and their relevance to ultrasonographic and pathological results. MATERIALS AND METHODS: A total of eighty patients were included in the study. Thyroid fine-needle aspiration biopsies were performed, and the levels of serum and nVEGF and VEGFR-1 were measured. Any possible correlations between serum and nVEGF, VEGFR-1, and biochemical/radiological variables were investigated. RESULTS: There were no significant differences between serum VEGF (sVEGF), nVEGF, sVEGFR-1, nVEGFR-1 levels, number of nodules, size of nodules, and benign and malignant ultrasonographic features. sVEGF and nVEGF were higher in malignant or suspicious nodules than that in benign nodules, but did not reach statistical significance (P > 0.05). sVEGFR-1 and nVEGFR-1 levels were higher in hyperthyroid patients than that in euthyroid patients (P < 0.05 and P = 0.003, respectively). nVEGFR-1 level was higher in hypothyroid patients than that in euthyroid patients (P = 0.016). sVEGF level was found to be higher in hyperactive nodules than that in others. Both sVEGFR-1 (P = 0.008) and nVEGF levels (P = 0.01) significantly increased with increasing age. nVEGFR-1 decreased with increasing body mass index (BMI) (P = 0.004). CONCLUSIONS: Our study showed the relationships of sVEGF, nVEGF, sVEGFR-1, and nVEGFR-1 levels with age, gender, BMI, and hyperthyroidism. To determine the role of VEGF/VEGFR-1 in thyroid nodules, further studies are required with a large number of patients.

Physical Medicine & Rehabilitation

Assessment of Usability and Task Load Demand Using a Robotic Assisted Transfer Device Compared to a Hoyer Advance for Dependent Wheelchair Transfers Objective Manual lifting can be burdensome for people who care for power wheelchair users. Though technologies used for dependent transfers are helpful, they have shortcomings of their own. This study compares the usability and task load demand of a novel robotic assisted transfer device to a clinical standard when performing dependent transfers. Design A cross-sectional study was conducted to assess caregivers (N=21) transferring a 56 kg mannequin with the Strong Arm and Hoyer Advance at three transfer locations. Feedback was gathered through qualitative surveys. Results Usability was significant in multiple areas important for transfers. Caregiver fatigue and discomfort intensity were reduced, and the Strong Arm was preferred at the three transfer locations. Device ease and efficiency favored Strong Arm at two stations as was discomfort frequency. Additionally, physical demand, frustration, and effort were significantly lower using Strong Arm compared to the Hoyer Advance. Conclusion Compared to the Hoyer, participants favored Strong Arm for transfer usability and task load demand. However, further Strong Arm developments are needed. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating the influence of social engagement on cognitive impairment and mobility outcomes within the Boston RISE cohort study OBJECTIVE We investigated the associations between mild cognitive impairment (MCI), social engagement (SE) and mobility. DESIGN We evaluated data from a cohort study of older adult primary care patients (N=430). Outcomes included self-reported function (Late-Life Function Instrument-LLFI) and performance based mobility (Short Physical Performance Battery score-SPPB). Linear regression models evaluated the association between MCI and mobility, MCI and SE, mobility measures and SE, and whether SE mediated the association between MCI status and mobility. RESULTS Participants with MCI had significantly lower mobility and lower SE as compared to those without MCI (LLFI: 53.5 vs. 56.9, p<.001; SPPB: 7.9 vs. 9.3, p<.001; SE score 44.9 vs. 49.0, p<.001). MCI was significantly associated with both LLFI and SPPB (LLFI β=-2.93, p= <.001; SPPB β=-1.26, p= <.001) and SE (β=-3.20, p= <.001). SE was significantly associated with both LLFI and SPPB (LLFI β=0.22; p= <.001; SPPB β=0.08; p= <.001). There was a positive association between SE and mobility (p-value <0.05). A mediator effect of SE was supported when evaluating the association between MCI and mobility. CONCLUSION Among older adult primary care patients at risk for mobility decline, higher levels of SE mitigate the association between MCI and mobility. Corresponding Author: Hannah Steere, MD, Spaulding Rehabilitation Hospital, 300 1st Ave, 2nd floor, Charlestown, MA, 02129, USA, Tel: 617-952-5243 | Fax: 617-952-5934 | Email: steere.hannah@gmail.com Author Disclosures: There are no competing interests or financial benefits to the authors to disclose. This work was supported by the National Institute on Aging (R01 AG032052-03), Eunice Kennedy Shriver National Institute of Child Health and Human Development (1K24HD070966-01), and the National Center for Research Resources in a grant to the Harvard Clinical and Translational Science Center (1 UL1 RR025758-01). The main results of this study have been presented as a poster presentation at the 2017 American Congress of Rehabilitation Medicine conference. This study has not been previously submitted to any journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise training guidelines for multiple sclerosis, stroke, and Parkinson's disease: Rapid review and synthesis The translation of knowledge from exercise training research into the clinical management of multiple sclerosis (MS), stroke, and Parkinson's disease (PD) requires evidence-based guidelines that are uniformly recognizable by healthcare practitioners and patients/clients with these diseases. This paper synthesized resources that reported aerobic and resistance training guidelines for people with MS, stroke, and PD. Systematic searches yielded 25 eligible resources from electronic databases and websites or textbooks of major organizations. Data were extracted (exercise frequency, intensity, time, and type) and synthesized into recommendations per disease. Exercise guidelines for MS consistently recommended 2-3 days/week of aerobic training (10-30 minutes at moderate-intensity) and 2-3 days/week of resistance training (1-3 sets between 8-15 repetition maximum (RM)). Exercise guidelines for stroke recommended 3-5 days/week of aerobic training (20-40 minutes at moderate-intensity) and 2-3 days/week of resistance training (1-3 sets between 8-15 repetitions between 30-50% 1-RM). Exercise guidelines for PD recommended 3-5 days/week of aerobic training (20-60 minutes at moderate-intensity), and 2-3 days/week of resistance training (1-3 sets of 8-12 repetitions between 40-50% of 1-RM). This harmonization of exercise guidelines provides a prescriptive basis for healthcare providers, exercise professionals, and people with these diseases regarding disease-specific exercise programming. Correspondence to: Yumi Kim, MS, University of Alabama at Birmingham/Lakeshore Foundation Research Collaborative, 4000 Ridgeway Drive, Birmingham, AL 35209, USA; email: yumikim@uab.edu Authorship: YK: Article selection/screening, data extraction/synthesis, writing, editing, BL: Data cross-check, exercise guideline summary, writing, editing, TM: Reviewing, editing, MT: Reviewing, editing, SP: Reviewing, editing, JH: Exercise guideline summary, reviewing, writing, editing, RM: Exercise guideline summary, reviewing, writing, editing All the authors approved and critically revised the manuscript. FUNDING: This work was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (grant number 90REGE0002-01-00). The National Institute on Disability, Independent Living, and Rehabilitation Research is a Centre within the Administration for Community Living, Department of Health and Human Services. The contents of this manuscript do not necessarily represent the policy of these groups and you should not assume endorsement by the US Federal Government. CONFLICT OF INTEREST: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Short History of Medical Expert Guidelines and How They Pertain to Tracheostomy Tubes and Physical Medicine and Rehabilitation Continuous noninvasive ventilatory support (CNVS) and mechanical insufflation exsufflation (MIE) have been used since 1953 to spare patients with ventilatory pump failure from ever requiring tracheostomy tubes for ventilatory support or secretion management. Today there are patients with spinal muscular atrophy type 1 who are 25 years old and CNVS dependent since 4 months or age, post-polio survivors CNVS dependent for 64 years, Duchenne muscular dystrophy patients over age 45 CNVS dependent for over 25 years, high level spinal cord injured patients CNVS dependent for over 20 years, and even lung disease patients dependent on CNVS. All these patients, although unweanable from ventilatory support and with little or no measurable vital capacity, can also be extubated to CNVS and MIE without resort to tracheotomies when necessary to continue CNVS. However, for various reasons, this is not cited in academic society expert guidelines. This article considers the extent of the damage being caused by this. This work was not funded. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Artificial Intelligence and Applications in PM&R Artificial intelligence methods are being applied broadly in society and increasingly in healthcare and research. Machine learning, a subset of artificial intelligence, represents the study of algorithms that improve automatically with experience. This article provides a basic overview of artificial intelligence, machine learning categories, common applications in the business sphere, advantages and disadvantages of utilizing this technology, and example applications in rehabilitation and other fields for contextual purposes. The study and implementation of machine learning and artificial intelligence can function to improve patient care and represents a burgeoning area of research. Correspondence: Dustin Anderson, MD. 12631 E 17th Ave, Aurora, CO 80045. dustin.anderson@ucdenver.edu Author Disclosures: None Competing Interests: None Funding or grants or equipment provided for the project from any source: None Financial benefits to the authors: None Details of any previous presentation of the research, manuscript, or abstract in any form: None Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Randomized Trial on Comparison of the Efficacy of Extracorporeal Shock Wave Therapy and Dry Needling in Myofascial Trigger Points Objectives To compare the efficacy of radial extracorporeal shock wave therapy (ESWT) and dry needling (DN) in the treatment of myofascial trigger points (MTrPs) in the upper trapezius muscle. Design A total of 65 patients with MTrPs were randomly divided into ESWT group (n=32) and DN group (n=33). Patients received 3 weeks of treatment at one-week intervals in both groups Visual analogue scale (VAS), pressure pain threshold (PPT), Neck Disability Index (NDI) and shear modulus were evaluated pre-treatment, immediately post the first therapy, 1-month and 3-month after the completion of the third therapy. Results Significant improvements of VAS, PPT, NDI scores were observed at all time points post-treatment (p<0.01) in both treatment groups. The shear modulus of MTrPs was reduced in both DN group (p<0.05) and ESWT group (p<0.01) immediately after the first treatment. Significant reductions in shear modulus were maintained up to 3-month post-treatment in both groups (p<0.01). There were no significant differences between the radial ESWT group and DN group. Conclusions The ESWT is as effective as DN for relieving pain, improving function and reducing shear modulus for patients with MTrPs following a series of three treatments. Shuo Luan and Zhi-min Zhu contributed equally to this work. Co-Corresponding authors: Chao Ma and Shaoling Wu are both corresponding authors of this article. All correspondence should be addressed to: Chao Ma, MD, PhD and Shaoling Wu, MD, PhD, Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital, No.107 Yanjiang West Road, Guangzhou, 510120, China Disclosures: This study was supported by a grant from National Natural Science Foundation of China (81771201, 81671088), Natural Science Foundation of Guangdong (2016A030311045), Guangzhou science and technology plan projects (201807010050) and Sun Yat-Sen Clinical Research Cultivating Program (SYS-C-201704). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Understanding measures of association: A primer with examples from rehabilitation research Understanding measures of associations, how they are calculated, what they mean, and how to compare them is an important part of understanding clinical and health research. The relative risk (RR) and odds ratio (OR) are the two most common used measures of association in medical research. The appropriate use of these statistics to estimate the association between treatment or risk factor and outcome in research studies depends on the methodology and design of the study. The aim of this article is to cover basics of odds ratio and relative risk as the most important measures for the association between an exposure and an outcome. We use a clinical scenario as an example of their uses and demonstrate their calculation. Corresponding author: Dinesh Kumbhare, MD, PhD, FRCPC, FAAPMR, 550 University Avenue, Suite 7-131, Toronto, Ontario M5G 2A2, dinesh.kumbhare@uhn.ca, Telephone: 416-597-3422 x 4612 Author Disclosures: All the authors report no conflict of interest for the completion of this manuscript. Also, no funding was received. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise-induced bilateral rectus femoris injury No abstract available

Minimal Clinically Important Difference of Shoulder Outcome Measures and Diagnoses: A Systematic Review Objective Patient-reported outcome scales determine response to treatment. The minimal clinically important difference (MCID) of these scales is a measure of responsiveness: the smallest change in a score associated with a clinically important change to the patient. This study sought to summarize the literature on MCID for the most commonly reported shoulder outcome scales. Design A literature search of PubMed and EMBASE databases identified 193 citations, twenty-seven of which met the inclusion/exclusion criteria. Results For rotator cuff tears, a MCID range of 9-26.9 was reported for American Shoulder and Elbow Surgeons (ASES), 8 or 10 for Constant, and 282.6-588.7 for the Western Ontario Rotator Cuff Index (WORC). For patients who underwent arthroplasty, a MCID range of 6.3-20.9 was reported for ASES, 5.7-9.4 for Constant, and 14.1-20.6 for the Shoulder Pain and Disability Index (SPADI). For proximal humeral fractures, a MCID range of 5.4-11.6 was reported for Constant and 8.1-13.0 for Disability of the Arm, Shoulder, and Hand (DASH). Conclusion A wide range of MCID values was reported for each patient population and instrument. In the future, a uniform outcome instrument and MCID will be useful to measure clinically meaningful change across practices and the spectrum of shoulder diagnoses. Corresponding Author: Nitin B. Jain, MD, MSPH, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, 2201 Children's Way, Suite 1318, Nashville, TN 37212, United States of America, Phone: (615) 936-8508; Fax: (615) 322-7454, Email: nitin.jain@vanderbilt.edu Source of Funding: Dr. Jain is/was supported by funding from NIAMS 1K23AR059199 and 1U34AR069201. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessing the Accuracy of Ultrasound Guided Needle Placement in Sacroiliac Joint Injections Objective The aim of this study was to assess the accuracy of ultrasound guided needle placement for sacroiliac joint injections. Design Institutional Review Board (IRB) approval was gained for a prospective cohort study of fifty patients (N=50). Study patients who were referred for sacroiliac joint injections for sacroiliac joint mediate pain, and met inclusion/exclusion criteria, were enrolled in the study. Each patient underwent needle placement with ultrasound guidance in the procedure suite. After the needle was placed with the ultrasound guidance, fluoroscopy was utilized to confirm correct placement via contrast injection confirming a sacroiliac joint arthrogram. The arthrogram was confirmed via the performing physician and radiologist. Results The placement of the needle with ultrasound guidance into the sacroiliac joint was confirmed successful in 96% (48/50) patients by fluoroscopic arthrogram. The two patients with unsuccessful arthrograms following initial placement of the needle with ultrasound were morbidly obese. There was intra-vascular uptake during the arthrogram of one patient who had a successful arthrogram. Conclusions Ultrasound-guided injection of the sacroiliac joint is successful and accurate upon confirmation of fluoroscopic arthrogram and should be utilized as an imaging modality for needle guidance. Correspondence: Arthur Jason De Luigi, DO, MHSA, 10825 N. 140th Way, Scottsdale, AZ 85259, 301793-2136, ajweege@yahoo.com Competing Interests-None for any author Funding or grants or equipment provided for the project from any source-None for any author Financial benefits to the authors-None to any author Details of any previous presentation of the research, manuscript, or abstract in any form: None Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.