Sanjeev Bhoi

Evaluation of susceptibility testing methods for polymyxin

BACKGROUND The widespread resistance in Gram-negative bacteria has necessitated evaluation of the use of older antimicrobials such as polymyxins. In the present study we evaluated the different susceptibility testing methods for polymyxins B and E against Gram-negative bacteria using the new Clinical and Laboratory Standards Institute (CLSI) guidelines. METHODS The susceptibility of 281 multidrug-resistant (MDR) Gram-negative bacteria (GNB) to polymyxin B was evaluated, comparing broth microdilution (BMD; reference method), agar dilution, E-test, and disk diffusion. Disk diffusion testing of polymyxin B was also performed against 723 MDR GNB. RESULTS Twenty-four of 281 (8.5%) isolates were found to be resistant to polymyxin B by the reference BMD method. The rates of very major errors for agar dilution and E-test (for polymyxin B) were 0.7% and 1%, respectively, and those for disk diffusion (for polymyxin B and polymyxin E) were 1% and 0.7%, respectively. For the 257 isolates found sensitive by reference BMD, the rates of major errors by agar dilution and E-test (for polymyxin B) were 2.4% and 0%, respectively, and those for disk diffusion (polymyxin B and polymyxin E) were 0% and 0.7%, respectively. Twenty-six (3.6%) of the 723 Gram-negative isolates were resistant to polymyxin B by disk diffusion. CONCLUSION The E-test and agar dilution methods showed good concordance with BMD. The disk diffusion method can be useful for initial screening in diagnostic laboratories.

To determine the accuracy of focused assessment with sonography for trauma done by nonradiologists and its comparative analysis with radiologists in emergency department of a level 1 trauma center of India

Background: Focused assessment with sonography for trauma (FAST) is an important skill during trauma resuscitation. Use of point of care ultrasound among the trauma team working in emergency care settings is lacking in India. Objective: To determine the accuracy of FAST done by nonradiologists (NR) when compared to radiologists during primary survey of trauma victims in the emergency department of a level 1 trauma center in India. Materials and Methods: A prospective study was done during primary survey of resuscitation of nonconsecutive patients in the resuscitation bay. The study subjects included NR such as one consultant emergency medicine, two medicine residents, one orthopedic resident and one surgery resident working as trauma team. These subjects underwent training at 3-day workshop on emergency sonography and performed 20 supervised positive and negative scans for free fluid. The FAST scans were first performed by NR and then by radiology residents (RR). The performers were blinded to each others sonography findings. Computed tomography (CT) and laparotomy findings were used as gold standard whichever was feasible. Results were compared between both the groups. Intraobserver variability among NR and RR were noted. Results: Out of 150 scans 144 scans were analyzed. Mean age of the patients was 28 [1-70] years. Out of 24 true positive patients 18 underwent CT scan and exploratory laparotomies were done in six patients. Sensitivity of FAST done by NR and RR were 100% and 95.6% and specificity was 97.5% in both groups. Positive predictive value among NR and RR were 88.8%, 88.46% and negative predictive value were 97.5% and 99.15%. Intraobserver performance variation ranged from 87 to 97%. Conclusion: FAST performed by NRs is accurate during initial trauma resuscitation in the emergency department of a level 1 trauma center in India.

Evaluation of an automated erythrocyte sedimentation rate analyzer as compared to the Westergren manual method in measurement of erythrocyte sedimentation rate

CONTEXT Monitor 100® (Electa Lab, Italy) is a newly developed automated method for measurement of erythrocyte sedimentation rate (ESR). AIMS The aim of our study was to compare the ESR values by Monitor 100® against the standard Westergren method. PATIENTS AND METHODS This cross-sectional study was conducted at a Level I trauma care center on 200 patients. The samples taken were as per the recommendations charted out by International Council for Standardization in Hematology (ICSH) for comparing automated and manual Westergrens method. STATISTICAL ANALYSIS USED Bland and Altman statistical analysis was applied for evaluating Monitor 100® against the conventional Westergren method. RESULTS The analysis revealed a low degree of agreement between the manual and automated methods especially for higher ESR values, mean difference -11.2 (95% limits of agreement, -46.3 to 23.9) and mean difference -13.4 (95% limits of agreement-58.9 to 32.1) for 1 and 2 hours, respectively. This discrepancy which is of clinical significance was less evident for ESR values in the normal range <25 mm/hour (-7.7 mean of difference; -18.9 to 3.5 limits of agreement). CONCLUSIONS The fully automated system Monitor 100® for ESR measurement tends to underestimate the manual ESR readings. Hence it is recommended that a correction factor be applied for the range of ESR values while using this equipment. Further studies and validation experiments would be required.

Cytokines, granulocyte-monocyte colony stimulating factor, interleukin-3 and erythropoietin: Can be a therapeutic option for the stimulation of hematopoietic progenitor cells in trauma-hemorrhagic shock?

Hemorrhagic shock (HS) is the major leading cause of death after trauma,[1] condition with a limited therapeutic option. Fluid, blood, and its component and stopping of bleeders have been the cornerstone of management since many decades. A Recent study showed that recombinant human activated protein C, interleukin-1 (IL-1) receptor antagonist, anti-tumor necrosis factors (TNF) or anti-lipopolysaccharides agents, or tight glycemia control were tested for treatment of HS. However, these treatments were not effective and sometimes dangerous.[1] Finfer et al. reported that resuscitation with fluids and blood products induces reperfusion ischemia due to the production of reactive oxygen species and activation of immune cells.[2] The excessive release of inflammatory cytokines contributes to the tissue damage. The present study has shown that HS-induced inflammation leads to drastic changes in active cytokine milieu. Pro- and anti-inflammatory cytokines (TNF-α, IL-6, IL-10, and IL-8) and monocyte chemoattractant protein-1 are thought to be an important role in immune dysfunction resulting multi-organ failure (MOF) and death.[3] It also causes hematopoietic progenitor cells (HPCs: Colony forming unit [CFU-E], burst forming unit [BFU-E], CFU-granulocyte-monocyte/macrophage [CFU-GM]) apoptosis which leads to MOF, following severe injuries and HS in human and animal models.[4,5]

Confirmation of endovenous placement of central catheter using the ultrasonographic “bubble test”

Insertion of central venous catheter (CVC) is the most common procedure to be performed in Intensive Care Units. Addition of ultrasonographic guidance to this procedure, which was initially performed blindly, has improved safety of this procedure. Confirmation of endovenous placement of CVC though, is tricky, as methods for confirmation are either operator dependent, time-consuming or not available at bedside. Prospective observational study was carried out to study feasibility of use of sonobubble test to confirm the presence of CVC within central vein. After insertion of CVC in the internal jugular, subclavian or axillary vein, a 10 ml bolus of shaken saline microbubble is injected through port of CVC, and opacification of right atrium is observed in xiphoid view on ultrasonography. The Sonobubble test was helpful for dynamic confirmation of endovenous placement of CVC and prevented complications such as arterial puncture and cannulation. We recommend its use following CVC insertion.

PTSD in post-road traffic accident patients requiring hospitalization in Indian subcontinent: A review on magnitude of the problem and management guidelines

Traumatic events after a road traffic accident (RTA) can be physical and/or psychological. Posttraumatic stress disorder (PTSD) is one of the major psychological conditions which affect accident victims. Psychological issues may not be addressed in the emergency department(ED) immediately. There have been reports about a mismatch between the timely referrals from ED to occupational or primary care services for these issues. If left untreated, there may be adverse effects on quality of life (QOL) and work productivity. Hospital expenses, loss of income, and loss of work could create a never ending cycle for financial difficulties and burden in trauma victims. The aim of our review is to address the magnitude of PTSD in post-RTA hospitalized patients in Indian subcontinent population. We also attempted to emphasis on few management guidelines. A comprehensive search was conducted on major databases with Medical Subject Headings (MeSH) term ‘PTSD or post-traumatic stress’ and Emergency department and vehicle or road or highway or automobile or car or truck or trauma and India. Out of 120 studies, a total of six studies met our inclusion criteria and were included in the review. Our interpretation of the problem is that; hospital expenditure due to trauma, time away from work during hospitalization, and reduction in work performance, are three major hits that can lead RTA victims to financial crisis. Proposed management guidelines are; establish a coordinated triage, implementing a screening tool in the ED, and provide psychological counseling.

Human-induced pluripotent stem cells derived hematopoietic progenitor cells for treatment of hematopoietic failure among trauma hemorrhagic shock patients

Hematopoietic failure (HF) has been observed in trauma hemorrhagic shock (T/HS) patients. Multiple factors are involved. Elevated serum levels of cytokines, catecholamine, granulocyte colony stimulating factor, peripheral blood hematopoietic progenitor cells (HPCs) and decreased expression of erythropoietin receptor are associated with HF among T/HS. HF leads to anaemia, susceptibility to infection, sepsis and multi-organ failure. There is a lack of molecular understanding of HF and its potential therapeutic strategies. Cell-based therapy has ability to modulate the production of inflammatory cytokines, vascular dysfunction, tissue damage and apoptosis. Human-induced pluripotent stem cells (iPSC) derived HPCs may have the ability to restore HF in T/HS. Autologous cell-based iPSC have great promises for various diseases such as Alzheimers disease, Parkinsons disease, cardiovascular disease, diabetes, amyotrophic lateral sclerosis, and spinal cord injury without ethical concerns. Similarly, treatment with iPSC derived hematopoietic stem cells can used for the treatment of HF among T/HS and may also improve the outcome. Here, we review the potential of human iPSC derived HSC to reversed HF following T/HS.

Does metabolic syndrome determine severity and disability of chronic low backache

Introduction: Obesity may be associated with more severe and disabling low backache (LBA) due to alteration in biomechanics, but there are no such studies from developing countries. Aims: We report the frequency of metabolic syndrome (MS) in chronic LBA (CLBA) and its association with severity and disability of CLBA. Subjects and Methods: Consecutive patients with CLBA attending to the neurology service from October 2015 to February 2016 were included in the study. Clinical and demographic parameters were recorded. Routine biochemical test was done. The severity of pain was assessed by a 0–10 Numeric Rating Scale (NRS) and disability by Oswestry Disability Index (ODI) version 2. Comparison of variables was done by Chi-square or independent t-test and correlation by Karl Pearson or Spearmans rank correlation test. Results: Seventy-none (39.3%) patients had MS as per the International Diabetic Federation (IDF) criteria and 68 (33.8%) as per the National Cholesterol Education Program Adult Treatment Panel III criteria. Abdominal obesity was the most common (171 [85.1%]) feature of MS. The patients with MS had longer duration of sitting work and did less frequently exercise. The NRS score (6.95 ± 1.06 vs. 6.65 ± 0.95; P = 0.04) and ODI score (54.91 ± 8.42 vs. 51.89 ± 8.54; P = 0.01) were higher in CLBA patients with MS compared to those without MS. Conclusion: About 40% patients with CLBA have metabolic syndrome, and they have more severe pain and disability.

Expression of p38 mitogen-activated protein kinases, glycogen synthase kinase, c-Jun NH2-terminal kinase, extracellular signal-regulated kinase signaling: Can it be used as molecular markers among trauma-hemorrhagic shock patients?

p38MAPK signaling pathway leads to the multi-organ injury caused by ischemia-reperfusion in animal models. Increased expression of p38MAPK is seen in ischemia-reperfusion models of kidney, liver, vascular and myocardial cells, and lung.[7] Yang et al. showed that in HS rats, MAPK’s signaling pathways indirectly regulate vascular activity.[8] A recent study reported that nuclear factor-kappa B is one of the key players that are involved in the regulation of hypoxic inflammation after HS following resuscitation (H/R).[9,10] McCloskey investigated that the activation of JNK in the liver as an early response to tissue hypoxia soon after the initiation of hemorrhage.[11] A recent study has shown that GSK-3β inhibitor modulates the inflammatory response to stress and may be protective in condition with sepsis inflammation and shock.[12] Multiple signaling pathways including the Akt pathway regulates GSK-3, inactivates it by causing Ser9 phosphorylation. There is a consistent decline in the activation of Akt pathway during the hemorrhage and resuscitation. This indicates an excessive activation of GSK-3β, which leads to both inflammation and tissue injury.[13]

General Management of Trauma

Trauma affects the productive youth of the country and is a major cause of death and disability in the first four decades of life. Improvement and organization of trauma care services are a cost-effective way of improving patient outcome. Proper organization of these systems reduces the time between injury and the definitive care, thereby reducing the morbidity and mortality.