Inappropriate Administration Research Articles

Trauma-related wound infections among patients admitted to emergency teaching hospital in Duhok province, Iraq.

Wound infection is one of the universal challenges for patients who visit the hospital after trauma and undergo surgery and/or during their admission. Trauma could be due to Road Traffic Accidents (RTA), violence, or Falling from High (FFH). There is tangible evidence of the scope and the danger of hospital-acquired infections, which are far more common and deadly than many people comprehend. 280 samples were collected from 140 injured persons, who attended the Emergency Teaching Hospital in Duhok, Iraq from September 2021 to April 2022. 140 samples were collected on the patients' arrival and 140 samples after admission and treatment. The isolated bacteria were manually diagnosed, and then VITEK®2 compact system was performed for confirmation. 27 microbial species were identified. The common bacterial species detected on patients' arrival were Staphylococcus epidermidis 22 (19.6%), Escherichia coli 16 (14.3%), Staphylococcus aureus 14 (12.5%), Staphylococcus lentus 10 (8.9%) and Stenotrophomonas maltophilia 6(5.4%). On the 2nd samples, which were collected after patients' admission, the species were Staphylococcus aureus 35(31.3%), Escherichia coli 13(11.6%), Pseudomonas aeruginosa 12 (10.7%), Staphylococcus epidermidis 10 (8.9%), Acinetobacter baumannii and Klebsiella pneumonia were 8 (7.1%) each. The bacteria that contaminate wounds at the accident time led to serious problems after the admission as they cause wound infection with inappropriate antibiotic administration. It is established that there are differences between the bacterial species detected before and after admission in this study with p = 0.004. Furthermore, it has been demonstrated that some species that are isolated prior to the admission of patients turn hostile afterward.

Effect of a pharmacist-based toxicology consult service on appropriate use of intravenous N-acetylcysteine for acetaminophen toxicity: A retrospective cohort study.

Incorporating clinical pharmacists on the medical team has been associated with fewer medication errors and increased error interception. Due to the logistical complexities of the intravenous (IV) N-acetylcysteine (NAC) regimen for acetaminophen toxicity, many opportunities for medication errors exist. A pharmacist-based toxicology consultation service was implemented at our institution, allowing pharmacists to formally aid in the management of toxicology patients throughout their hospital admission, including those with acetaminophen toxicity. The purpose of this study was to evaluate the effect of a house-wide pharmacist-based toxicology consult service on errors associated with IV NAC treatment for patients admitted with acetaminophen toxicity. A retrospective, pre-post cohort study was conducted on patients who received IV NAC for acetaminophen toxicity. The intervention evaluated was the implementation of a pharmacist-based toxicology consult service, known as the pharmacy toxicology team. The primary end point was the incidence of an error associated with IV NAC. An error was defined as the composite of inappropriate dose, administration rate, initiation, continuation, or discontinuation. Eighty-four patients were included; 30 patients in the pregroup, and 54 patients in the postgroup. Fewer patients experienced an error in the postgroup compared to the pregroup (30% vs 63%, P = 0.003). The implementation of this unique pharmacist-based toxicology consult service was associated with fewer patients experiencing an error related to IV NAC therapy for acetaminophen toxicity. Application of this data may aid in the justification for development of clinical pharmacist-based toxicology consult services at other institutions.

Transfusion-related adverse reactions: An update from a district hospital in Ghana

Background: Transfusion therapy is indispensable for effective emergency medicine practice. However, in resource-poor settings transfusion therapy is suspected to be practiced in a manner that may be contributory to morbidity and mortality among blood recipients. Yet, there exists a wide information gap, with respect to incidence of transfusion-related adverse reactions secondary to inappropriate blood prescription.
 Objective: This study assessed incidence of transfusion-related adverse reactions in a district hospital in Ghana.
 Materials and Methods: A hospital-based cross-sectional study was conducted from December 2020 to January 2021. Patients attending a district hospital in Kumasi, Ghana who were prescribed blood transfusion were recruited into the study after oral/written consent. Patients’ demographic data, blood components and units of blood requested as well as the ward of patients were recorded. Records of patient’s full blood count (FBC), body temperature, blood pressure and transfusion-related adverse reactions were extracted from their medical folders.
 Results: Out of 200 patients, 169 were transfused with whole blood while 31 patients received packed red cells. Majority (48%) of the patients were transfused with ≤1 unit whereas 10% received 3 units of blood. Anaemia (Hb = 6.13 g/dl) and leukocytosis (WBC = 13.83 x 103/µL) were observed in the haematological parameters in which the MCV and lymphocyte count differed significantly in males compared to females. The overall incidence of transfusion-related adverse reactions was 47.5%. Of the 169 patients who received whole blood, more than half (53.8%) experienced more than one of the transfusion-related adverse reactions that were monitored. Finally, patients within the ages of 19-29 years had the highest incidence of transfusion reaction (30.5%) and overall, the number of units administered was significantly associated with the incidence of transfusion reaction (p<0.011). Conclusion: Transfusion-related adverse reaction was common at the study setting. This could be attributed to inappropriate administration of blood and blood products. Strict adherence to World Health Organization recommendations on transfusion therapy needs to be encouraged and supervised in the study setting>< 0.011)
 Conclusion: Transfusion-related adverse reaction was common at the study setting. This could be attributed to inappropriate administration of blood and blood products. Strict adherence to World Health Organization recommendations on transfusion therapy needs to be encouraged and supervised in the study setting.

A cross-sectional survey among parents to report challenges and barriers in the administration of medicines to children in United Arab Emirates.

Background: Lack of knowledge among parents can result in inappropriate administration practices. After analyzing different studies among children, there was no data on challenges and barriers in the administration of medicines among children in this region because of the diverse environmental issues and challenges in the UAE. The objective of this study was to determine the reported administration practices of parents and challenges and barriers in the administration of medicines among children in UAE. Methods: A questionnaire-based survey was conducted. A convenience sampling technique was used to collect the data. An online Raosoft® sample size calculator was applied (n = 248). The inclusion criteria were parents who had a child under 10 years of age and gave consent to participate in this study. Children with vision problems, cognitive/physical disabilities, and caregivers other than parents were excluded from this study. Results: The study reported response rate of 73.2%. The mean ± S.D age of the parents in years was 35.5 ± 7.8, and the mean ± S.D of children aged years was 2.60 ± 1.54. 26.2% of parents reported treatment failure due to oral medicine administration. A total of 22.2% of parents reported that they gave medicines in doses higher than prescribed by the doctor to treat their children more quickly. Similarly, a total of 64.5% of the parents reported self-medication without consultation from a healthcare provider. Conclusions: The study concluded that there were inappropriate medicine administration practices among parents. Parents reported administration of higher doses to treat their children quickly.

Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection

Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.

Perceptions, attitudes, and practices of a Belgian teaching hospital's physicians, pharmacists, and nurses regarding antibiotic use and resistance: survey towards targeted actions for Antimicrobial Stewardship

ObjectivesThis study aimed to identify barriers to the proper use of antibiotics by healthcare professionals and to help the hospital Antimicrobial Stewardship develop suitable actions for the staff.MethodsIn a Belgian teaching hospital, a survey was conducted among physicians, pharmacists, and nurses involved in antibiotherapy. Questions from the 2019 European Center for Disease Prevention and Control (ECDC) survey were analyzed based on components of the COM-B model (capabilities, opportunities, and motivations). First, collected data were reviewed with the Ethnos software to analyze the different COM-B model components. For statistical analyses, responses were grouped into three clear-cut answers in a Fisher’s exact test.ResultsOverall, 400 staff members were included. We found that our professions, combined, have a good perception of antibiotic resistance (97.8%). For capabilities, however, only 77.2% state that they have sufficient knowledge, with 91.3%, 71.5%, and 63.0% for physicians, nurses, and pharmacists, respectively. For opportunities (access to resources, information, and training), it is observed that 72.2% report having easy access to the guidelines they need to manage infections. In comparison, for 64.2% of the respondents, this information changed their opinion on the useless or inappropriate prescription, administration, and delivery of antibiotics. For 55.0%, this information has enabled them to change their practices. Finally, for motivations, 92.8% of respondents state that they know about the link between their practices and the emergence and spread of antibiotic resistance. However, only 65.0% of participants say they have a role in managing antibiotic resistance. We found that 5 out of 8 questions are significantly dependent on the profession: 2 inquiries related to capability, 1 to opportunity, and 2 to motivation.ConclusionWe found that responses to the ECDC questionnaire are related to the profession. While some topics are universal/cross-functional, others must be explicitly tailored to each professional category. Information is useless if not accessible. Communication and provision of documents are thus paramount.

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital.

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

A study of serum electrolyte imbalances and its impact in children of 4 months to 5 years of age group presenting with acute gastroenteritis

Background: Fluid and electrolyte derangement are the immediate causes that increases the mortality in diarrhea. The present study was carried out among children of 4 months to 5 years with dehydration due to acute diarrhea to determine the serum electrolyte profile. Methods: A hospital based cross sectional study was carried out in department of pediatrics, RIMS during a period of two years (sept 2019-Aug 2021). Results: A total of 195 patients of 4 months to 5 years of age group presented with acute gastroenteritis were included in the study, among them hyponatreamia was the most frequent electrolyte abnormality noted (37.4%). Most (65.5%) of hyponatremic patients in our study took dilute ORS whereas majority (64.2%) of patients who took appropriate ORS had normal serum sodium levels. Frequency and duration of diarrhea, dehydration status and inappropriate ORS were significant risk factors for serum electrolyte and acid base imbalances. Conclusions: Electrolyte abnormalities were significantly associated with frequency and duration of diarrhea, dehydration status and inappropriate ORS administration. Hence, timely recognition and management of electrolyte abnormalities and appropriate ORS administration improves outcome in acute gastroenteritis related dehydration in children.

The Role of COVID-19 in Antibiotic Resistance in Pediatric Population

There is data on the irrational use of antimicrobial drugs in pediatric population during the COVID-19 pandemic. This could lead to potential development of antibiotic resistance and increased morbidity and mortality among this vulnerable population group. The aim of this review is to study the role of COVID-19 in antimicrobial drugs administration and antibiotic resistance development, as well as to determine a set of measures for its prevention. Recent studies results have shown that COVID-19 pandemic had both direct and indirect impact on antibiotic resistance development in pediatric population. The COVID-19 outbreak has revealed weaknesses in health systems around the world. Antibiotics administration in patients with coronavirus infection during this period exceeded the number of cases with bacterial co-infection or other diseases. Thus, it indicates irrational antibiotic treatment. There were cases of inappropriate antibiotics administration during the crisis caused by the COVID-19 pandemic even in regions with long-term rational antibiotic treatment programs. One of the most viable methods to combat antibiotic resistance is to improve approaches in health care and to increase preparedness to infectious outbreaks. Increasing clinical competence of medical workers, accessibility of medical facilities, permanent supply of high-quality and cheap antibiotics, vaccines, reducing COVID-19 testing time, and adequate administration of antibacterial agents are the measures that can prevent diseases caused by drug resistance. All stakeholders (health authorities, regulating authorities, politicians, scientific community, pharmaceutical companies) have to collaborate and achieve results to implement all the mentioned above protection measures.

Evaluation of Proton Pump Inhibitors Prescribing Among Hospitalized Patients: A Cross-Sectional Study.

Proton pump inhibitors (PPIs) are the most effective agents for managing acid-related disorders. However, inappropriate prescribing of PPIs is becoming an issue of concern. This study aimed to assess the appropriate utilization of PPIs in terms of indication, dose, frequency, and route of administration during admission and discharge. Furthermore, direct costs associated with inappropriate PPI use were calculated. A descriptive cross-sectional study was conducted at the internal medicine department of a tertiary hospital in Palestine from January 1, 2021, to June 30, 2021. The medical records of patients aged 18 years or older, hospitalized for 48 hours or more, and receiving oral or intravenous (IV) PPIs during their stay were collected and evaluated for the appropriateness of PPIs prescribed according to clinical guidelines. Of 262 patients, 80.2% had an appropriate indication for prophylaxis (67.6%) or treatment (12.6%). A total of 230 patients were prescribed IV pantoprazole.182 (79.1%) had an appropriate indication, whereas 122/182 (67%) received IV PPI instead of oral without an appropriate indication. Of the 32 patients who received 20 mg of oral omeprazole, 28 (87.5%) had an appropriate indication, dose, and route of administration, whereas 16/28 (57.1%) had an inappropriate frequency. At discharge, 32.5% of patients were discharged with unnecessary PPI prescriptions. The total direct cost of inappropriate PPI Indications and route of administration in 188 patients over six months was $1518. This study showed that most patients received a PPI for an appropriate indication with the correct dose. However, a high prevalence of inappropriate IV pantoprazole administration was observed, resulting in the highest costs, demonstrating the importance of correctly ordering IV medications. Adherence to clinical guidelines, such as those of the American College of Gastroenterology (ACG), will improve the appropriateness of PPI prescribing, prevent complications, and reduce healthcare costs.

Monitoring Level of Hypnosis using Stationary Wavelet Transform and Singular Value Decomposition Entropy with Feedforward Neural Network.

Classifying the patient's depth of anesthesia (LoH) level into a few distinct states may lead to inappropriate drug administration. To tackle the problem, this paper presents a robust and computationally efficient framework that predicts a continuous LoH index scale from 0-100 in addition to the LoH state. This paper proposes a novel approach for accurate LoH estimation based on Stationary Wavelet Transform (SWT) and fractal features. The deep learning model adopts an optimized temporal, fractal, and spectral feature set to identify the patient sedation level irrespective of age and the type of anesthetic agent. This feature set is then fed into a multilayer perceptron network (MLP), a class of feed-forward neural networks. A comparative analysis of regression and classification is made to measure the performance of the chosen features on the neural network architecture. The proposed LoH classifier outperforms the state-of-the-art LoH prediction algorithms with the highest accuracy of 97.1% while utilizing minimized feature set and MLP classifier. Moreover, for the first time, the LoH regressor achieves the highest performance metrics (R2 = 0.9, MAE = 1.5) as compared to previous work. This study is very helpful for developing highly accurate monitoring for LoH which is important for intraoperative and postoperative patients' health.

Flow rate accuracy of infusion devices within healthcare settings: a systematic review.

One in five patients admitted to the hospital treated with intravenous (IV) fluid therapy suffer complications due to inappropriate administration. Errors have been reported in 13-84% of the preparation and administration of IV medications. The safe delivery of IV fluids requires precise rate administration. This systematic review aims to determine the accuracy of infusion sets and devices and examine the factors that affect the flow rate accuracy of devices. Six databases (CINAHL, MEDLINE PubMed, EMBASE, Web of Science and Cochrane Database of systematic reviews) were systematically searched. Search terms included infusion pumps, infusion devices, flow rate accuracy, fluid administration rate, gravity-led infusion set and fluid balance. Studies were included if they examined infusion devices' flow rate accuracy and drop rates for fluids or non-oncological drugs. Findings were tabulated and synthesised qualitatively. The quality of the studies was examined based on the design of the studies due to their heterogeneity. Eight studies were included: Four studies were conducted on human subjects in the hospital environment; studies recruited 182 participants between the ages of 18 and 94 years. Two studies examined flow rate accuracy in recruited patients across 509 observations and 2387 drip hours. No trials prospectively assessed the accuracy of infusion pumps in the clinical domain, and no studies were reported on patient safety outcomes. Four studies examined the impact of mechanical and physiological factors on the flow rate accuracies of infusion devices. Height and back pressure simulated vibrating conditions, the viscosity of IV fluid and the positions of patients were reported to have a significant impact on infusion volume and flow rates of infusion devices. Additionally, giving sets that vary from the manufacturer's specifications are reported to increase error percent by 10-20%. Infusion devices are an important source of error in administering IV fluids. Yet, there needs to be more prospective trial data to support their clinical accuracy and the impact on patient outcomes. Future flow variability and accuracy studies should capture their impact on patient safety and clinical outcomes.

A cross-sectional survey among parents to report challenges and barriers in the administration of drugs to children.

Background: Lack of knowledge among parents can result in inappropriate administration practices. After analyzing different studies among children, there was no data on challenges and barriers in the administration of drugs among children in this region because of the diverse environmental issues and challenges in the UAE. The objective of this study was to determine the reported administration practices of parents and challenges and barriers in the administration of drugs among children in UAE. Methods: A questionnaire-based survey was conducted. A convenience sampling technique was used to collect the data. An online Raosoft® sample size calculator was applied (n = 248). The inclusion criteria were parents who had a child under 10 years of age and gave consent to participate in this study. Children with vision problems, cognitive/physical disabilities, and caregivers other than parents were excluded from this study. Results: The study reported response rate of 73.2%. The mean ± S.D age of the parents in years was 35.5 ± 7.8, and the mean ± S.D of children aged years was 2.60 ± 1.54. The majority of parents (83.9%) completing the survey were mothers and resided in the city (97.2%). When the children did not like taking tablet drugs 41.9% used multiple practices and 26.2% of parents reported treatment failure due to oral drug administration. Around 47.6% of those who were interviewed reported that their children had swallowing problems during the administration of oral medication. A total of 22.2% of parents reported that they gave drugs in doses higher than prescribed by the doctor to treat their children more quickly. Similarly, a total of 64.5% of the parents reported self-medication without consultation from a healthcare provider. Conclusions: The study concluded that there were inappropriate drug administration practices among parents. Parents reported administration of higher doses to treat their children quickly.

Pyoderma Gangrenosum Affecting the Dorsal Hand: A Case Report.

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis characterized by an ulcerative lesion with a violaceous border. Most frequently, these lesions present in the lower extremity and are associated with underlying immune-mediated comorbidities. Infrequently, these lesions may present in the upper extremity, which presents difficult challenges for upper extremity surgeons as the lesions are frequently misdiagnosed as an infectious process. This often leads to inappropriate surgical debridement and antibiotic administration. Local trauma to the lesion can lead to a process of pathergy and worsening of the lesion. Here, we report on a case of cutaneous pyoderma gangrenosum affecting the dorsal hand, originally misidentified as an atypical infection with subsequent unsuccessful surgical debridement. After involvement of a multidisciplinary team, appropriate diagnosis was made, and treatment with local immunosuppressive agents achieved resolution of the lesion.

The Rationality of Antibiotic Prescription in Acute Upper Respiratory Infection Patients in Baun Puskesmas, Kupang Regency in 2020

Acute upper respiratory tract infection is an infectious disease caused by microorganisms, one of which is bacteria, so antibiotics are given. Rational use of antibiotics can provide benefits for recovery and does not provide harm that can cause problems or threats to the patient's health. Inappropriate administration of antibiotics can harm patients, one of which is antibiotic resistance. The purpose of this study was to obtain an overview of the rationale for prescribing antibiotics in patients with acute upper respiratory tract infections at the Baun Health Center, Kupang Regency, in 2020. This study was conducted using a descriptive non-experimental study with retrospective medical record data collection and guidelines from PERMENKES No. .5 of 2014 concerning Clinical Practice Guidelines for Doctors in Primary Health Care Facilities and KMK HK.02.02/MENKES/514/2015 concerning Clinical Practice Guidelines for Doctors in First Level Health Care Facilities to determine the accuracy of indications, drug accuracy, patient accuracy, and accuracy dose. The results showed 100% correct indication, 90.3% right drug, 100% right patient, 65% right dose, and 55.3% rational use of antibiotics. Keywords: Acute upper respiratory tract infection, antibiotics, rationality, right indication, right drug, right patient, right dose.

Drug-related problems identified at a Japanese community pharmacy: a cross-sectional study

Abstract Objectives This study aimed to identify drug-related problems (DRPs) using data regarding the communication of pharmacists with prescribers over the phone at a community pharmacy. Furthermore, we elucidated the frequency of the sources of information for detecting each DRP and evaluated the decisions made by the prescribers for each DRP. Methods This cross-sectional study was conducted at a community pharmacy in Fukuoka Prefecture, Japan. We anonymously collected data obtained by pharmacists through contacting prescribers over the phone relating to any problems or doubts found in prescriptions between April 2016 and March 2019. We classified the data and identified DRPs. We elucidated the frequency of sources of information for detecting each DRP using descriptive analyses and evaluated prescribers’ decisions regarding each DRP via multivariate Poisson regression analyses. Key findings Of the 95 023 prescriptions, 5073 DRPs were identified (5073/95 023 = 5.34%). The most frequent DRP was inappropriate dosage and administration (1349/5073 = 26.59%), followed by non-adherence (1272/5073 = 25.07%) and incorrect prescription periods (889/5073 = 17.52%). Patient interviews were the most frequent sources of information for detecting following DRPs: non-adherence (1057/1272 = 83.10%), untreated indication (590/631 = 93.50%) and adverse drug reactions (80/107 = 74.77%). Most of the DRPs were resolved by making changes to the prescriptions (4571/5073 = 90.10%). Conclusions Inappropriate dosage and administration and non-adherence issues were the most frequent DRPs in a Japanese community pharmacy. Patient interviews were an important source of information for detecting DRPs. Further research is warranted to address the impact of DRPs on patient safety.

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why.

Purpose of ReviewThere is global increase in the incidence of mucormycosis. However, a sudden increase in the COVID-associated mucormycosis (CAM) was noted, particularly in India, during the second wave of the COVID-19 pandemic. The interplay of factors involved in the pathogenesis is complex. In this review, the influence of pre-existing disease, exaggerated risk factors, altered milieu due to COVID-19 itself and the consequences of its treatment on the host pathogen interactions leading to the disease and morphology of the fungus will be highlighted.Recent FindingsHyperglycemia, acidosis, available free iron, lowered host defenses, and the fungal virulence factors promote the growth of Mucorales. There is a high background prevalence of diabetes mellitus (DM) in India. Uncontrolled or undiagnosed DM, COVID-19 itself, and inappropriate administration of corticosteroids in high doses and for prolonged periods result in hyperglycemia. Diabetic ketoacidosis (DKA) and metabolic acidosis due to hypoxia or renal failure contribute to acidic pH and dissociate bound iron from serum proteins. The host defenses are lowered due to COVID-19-induced immune dysregulation, hyperglycemia itself, and administration of corticosteroids and immune suppressants for the treatment of COVID-19. The altered metabolic milieu in the local microenvironment of nose and paranasal sinuses (PNS) promotes specific interaction of glucose-regulated protein-78 (GRP-78) on host cells with spore coat protein homologue (CotH 3) on Mucorales resulting in rhino-orbito-cerebral mucormycosis (ROCM) as the predominant clinical form in CAM. The pathology is extensive soft tissue involvement with angioinvasion and perineural invasion. Melanized hyphae and sporangia were seen on histopathology, which is unique to CAM. While many factors favor the growth of Mucorales in CAM, hyperglycemia, hyperferritinemia, and administration of hyperbaric oxygen result in reactive oxygen species (ROS) and inadequate humidification results in dehydration. Melanization is possibly the adaptive and protective mechanism of Mucorales to escape the unfavorable conditions due to the treatment of COVID-19.SummaryHigh background prevalence of DM, inappropriate administration of corticosteroids and immune dysregulation due to COVID-19 favor the growth of Mucorales in CAM. Melanization of Mucorales hyphae and sporangia on histopathology probably represent adaptive and protective mechanism due to the treatment with hyperbaric oxygen with inadequate humidification as well as the metabolic alterations.

Whole-genome sequencing-based characteristics of Escherichia coli Rize-53 isolate from Turkey.

Urinary tract infections (UTIs) are one of the most common infectious diseases. Inappropriate and excessive administration of antibiotics has led to the increased antibiotic resistance in the pathogens that cause UTIs. This work focused on identifying genetic determinants of antibiotic resistance in a clinical isolate of UTI-causing Escherichia coli. A clinical isolate of E. coli resistant to β-lactam, tetracycline and aminoglycoside antibiotics was analyzed using whole-genome sequencing (WGS) to identify genes that contribute to its resistance. The clinical isolate was obtained from a urine sample of a UTI patient in Turkey and identified via 16S rDNA sequencing. Antimicrobial susceptibility test was performed for 17 antibiotics using VITEK® 2 and the results were confirmed using minimum inhibitory concentration assay. Whole-genome sequencing of the isolate was performed using Illumina sequencing and analyzed with bioinformatic tools for multilocus sequence typing, replicon types, virulence factors, and antimicrobial resistance genes. Whole-genome datum was submitted to the National Center for Biotechnology Information (NCBI; accession No. JAKSGM000000000). The isolate was only found to be resistant to piperacillin in the β-lactam class of antibiotics. While the isolate was also resistant to aminoglycoside and tetracycline antibiotics, it was sensitive to other antibiotics tested. Ten antibiotic resistance genes were identified in the genome of the isolate: blaOXA-1, blaOXA-2, aac(6')-II, aac(6')-Ib-cr, tetB, catB3, qacE, sitABCD, mdfA, and sul-2. Clonal subtype (ST) and serotype of the isolate were identified as ST2141 and O107/H39, respectively. Plasmid replicon typing was used to identify 5 plasmid types in the genome of E. coli Rize-53 (Col(BS512), IncC, IncIA, IncFIB(AP1918), and IncFII(pRSB107)); however, none of the resistance genes were encoded on the plasmid. Genetic determinants of resistance to tetracycline, β-lactam and aminoglycoside antibiotics were identified using WGS in a uropathogenic E. coli from ST2141 lineage and O107:H39 serotype, isolated in Turkey.

Recognition and diagnosis of acute type A aortic dissection in a large Belgian referral center – can we do better?

Background: Acute type A aortic dissection (ATAAD) has a poor prognosis unless promptly diagnosed and surgically treated. As ATAAD is relatively rare and clinical presentation may mimic other pathologies, diagnosis can be challenging. Objectives: The aim of this study is to evaluate the difficulties in diagnosing ATAAD. Methods: A monocentric, retrospective analysis was conducted of all patients undergoing surgical repair for acute type A aortic dissection in our hospital (a large Belgian referral center) between the 1st of January 2016 and the 31st of December 2020. Data were collected regarding patient’s demographics i.e. age and gender, time of first medical contact, referral from other hospitals, presenting symptoms, initial diagnosis, inappropriate antiplatelet or antithrombotic therapy, time to the correct diagnosis, time to initiate surgical repair, and one- year mortality. Results: Thirty-three patients were included. We found that a correct initial diagnosis was only made in twelve percent of patients with ATAAD. In twenty-one percent of patients, misdiagnoses led to inappropriate administration of antiplatelet or antithrombotic drugs pre-operatively. There was a difference in time from first medical contact to initiation of surgical repair between referred and non-referred patients. This time interval tended to be shorter in the latter group. Conclusions: The main finding of this analysis is the delayed diagnosis of ATAAD in the majority of patients. This trend is slightly higher in patients referred from other hospitals. To improve outcome in ATAAD, efforts should be made to increase awareness for the presenting symptoms, and appropriate diagnostic imaging should be performed in a timely manner.

Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study.

The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired. We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM-). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission. Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM-, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360-0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM-, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM-, 28.7%; P = .87; 95% CI, -0.046 to 0.054). Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.