Standards Institute Protocols Research Articles

An Unusual High Prevalence of Cryptococcus (Naganishia) diffluens Colonization in Neonates Hospitalized in a Referral Neonatal Intensive Care Unit.

Although the Candida species continue to be the most frequent colonizer of neonatal skin, a clear increase of colonization due to rare yeast-like fungi has been reported. In this study, we report an unusual high prevalence of Cryptococcus diffluens colonization in neonates admitted to the neonatal intensive care unit (NICU) over a 1-month period. From January 2020 to June 2021, the study included all neonates who were admitted to the NICU of Bu Ali Sina Hospital at least 28 days old. Skin swabs from different anatomical areas were collected. Sampling was done 3 times/week. Each sample was inoculated into Sabouraud Dextrose Agar containing chloramphenicol and CHROMagar Candida, separately. The plates were incubated at 30 °C and 35 °C, respectively. Identification of the isolates was molecularly confirmed. In vitro antifungal susceptibility testing of the isolates was performed against different antifungal agents using the Clinical Laboratory Standards Institute protocol. Among 1026 samples collected from 78 neonates, 213 yeast isolates were recovered, of which the Candida species were the most common (77.5%), followed by C. diffluens (16.9%). During the study, 55 isolated yeasts were collected from December 26, 2020, to January 26, 2021, of which 65.5% were C. diffluens, while Candida spp. constituted 100% and 98.3% of the isolates before and after this period, respectively. The most frequent sources of C. diffluens were genital regions (27.8%). Of 36 C. diffluens isolates, 13.9%, 22.2%, 52.8%, and 83.3% were non-wild type to fluconazole, amphotericin B, itraconazole and 5-flucytosine, respectively. We reported for the first time an unusual high prevalence of C. diffluens colonization in neonates hospitalized in NICU. Our findings also showed the high minimum inhibitory concentration of amphotericin B and 5-flucytosine against C. diffluens.

Computed tomography predictors of increased transvenous lead extraction difficulty.

The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject. To identify CT characteristics associated with increased TLE difficulty. All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty. A total of 343 patients were analyzed. The mean age of the study population was 63.8±15.4 years; 71% were male. The mean lead dwell-in duration was 8.6±5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p=0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p<0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p<0.001, 95% CI: 1.89-7.35), respectively. In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures.

To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation. Retrospective pre-post study design. Single Level II Trauma Center. All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group. The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days. Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups. This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract PO4-20-05: An open label phase III randomized trial to evaluate the efficacy of Post-chemotherapy Axillary Conservation Surgery in breast cancer (PACS)

Abstract Background- Axillary lymph nodes (ALN) status is the most important prognostic factor in breast cancer. Traditionally, a complete axillary lymph node dissection (ALND) has been standard of care for those patients who have a positive node pre-chemotherapy. However, lately axillary conservation is paving its way in the post-chemotherapy setting as well to avoid significant morbidity of ALND. Most sentinel node biopsy studies have failed to achieve the desired false negative rate(FNR). (Boughey JC et al, JAMA. 2013 Oct; Kuehn T et al, Lancet Oncol. 2013; Boileau JF et al, J Clin Oncol. 2015 Jan).We previously reported a low FNR of low axillary sampling (LAS) in the post-chemotherapy setting. (Parmar et al, JCO-GO, 2021) We are conducting a phase III, randomised controlled trial of LAS versus complete ALND in post-chemotherapy negative (ypN0) axilla. Aims and objectives- The primary objective is to assess the non-inferiority of LAS in patients who are rendered ypN0 by pre-operative chemotherapy with disease-free survival as primary end point. The secondary objectives are comparing the morbidity of ALND (lymphedema, paraesthesia, and shoulder dysfunction) in the LAS and ALND arms, and to evaluate the impact on overall survival, local, regional, and distant recurrence free survival and quality of life. Trial design- This is a prospective, open label, randomised, phase III trial where histologically proven, non-metastatic, cT1-4,N0-2 breast cancer patients who are rendered ycN0 after pre-operative systemic chemotherapy are being accrued. Patients with prechemo N3 disease, inflammatory breast cancer, recurrent disease, pregnancy associated breast cancer are being excluded from the study. The chemotherapy regimens and surgical assessment is as per standard institutional protocols. After obtaining informed consent, patients undergo LAS during surgery and lymph nodes(LN) are sent for frozen section analysis. If any LN is found to be involved, a complete ALND is carried out. If the staging procedure is negative, then patients are randomised into 2 groups- observation v/s complete ALND. Stratification factors are T stage, N stage, Hormone receptor status, Her2 receptor status and number of chemotherapy cycles taken. Morbidity assessment is done with- Constans shoulder score, arm volumetry, paraesthesia assessment, and a QOL questionnaire- Self-reported Breast cancer Lymphedema Symptom Experience Index (BCLSEI). A baseline assessment pre-surgery is followed by 6 monthly morbidity assessments and regular oncologically relevant follow-up up to 5 years. A two-sided log-rank test with an overall sample size of 2316 with a 10% dropout rate (1158 in ALND and 1158 in LAS group) achieves 80% power at a 0.05 significance level to detect a hazard ratio of 1.16 (upper limit of non-inferiority) when the proportion surviving in the control group is 0.71. An interim analysis will be carried out at 25% events and conditional power will be calculated. If the conditional power is below 20%, then the study will be discontinued for futility. The study has been approved by Institutional Ethics Committee (CTRI/2022/07/044461) Expected Study and Results- We started accrual in February 2023 and have screened 63 and randomized 45 patients until now. Ours is a first large randomised prospective study in the post-chemotherapy axillary management setting which will help us understand the efficacy of axillary conservation surgery in patients who are node negative post neoadjuvant chemotherapy. In future, lesser morbid procedures than LAS like targeted axillary dissection can be tested in the same trial. However, LAS as a technique of axillary conservation suits resource constraints and high volume setting such as ours. Citation Format: Shalaka Joshi, Jessicka Shah, Pallavi Daphale, Rohini Hawaldar, Anuradha Daptardar, Ayushi Sahay, Tanuja Shet, Palak Popat, Tabassum Wadasadawala, Nita Nair, Vani Parmar, Bipin Bandre, Shabina Siddique, Vaibhav Vanmali, Sudeep Gupta, Rajendra Badwe. An open label phase III randomized trial to evaluate the efficacy of Post-chemotherapy Axillary Conservation Surgery in breast cancer (PACS) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-20-05.

Comparative study between Ketamine and Propofol versus Ketamine and Dexmedetomidine for Monitored Anaesthesia Care for Dilatation and Curettage surgeries in Daycare procedures

Introduction. Anaesthesia is frequently administered through Monitored Anaesthesia Care (MAC) utilising various combinations of anaesthetic drugs for moderately painful operations like Dilatation and Curettage (D&amp;C), which is preferably done as a daycare procedure. The hunt for improved drug combinations is always ongoing, and the pharmacological properties of the individual drugs are considered. In this regard, anaesthesiologists all over the world are quite fond of the combination of Ketamine and Propofol, which is also known as Ketofol. Recently, especially in situations involving MRI sedation, the combination of ketamine and dexmedetomidine (Dexket) has gained popularity. This study compares the combinations for MAC during D&amp;C surgeries in a daycare setting. Aim. The primary objective was to estimate the recovery times using either combination. Secondarily, we would also compare the duration of analgesia, the haemodynamics, and the side-effect profiles of the two combinations. Material and Methods. This study enrolled 60 patients posted for elective D&amp;C. According to standard institutional protocols, they were administered Ketofol(KP group) or Dexket(KD group), depending on the anaesthesia provider’s choice. The Ketofol group received Ketamine 1mg/kg and Propofol 1mg/kg with boluses of Ketamine 0.25mg/kg to maintain the depth of anaesthesia using Ramsay sedation score(RSS) &gt;3. KD group received Dexmedetomidine intravenously 1mic/kg over 10 minutes followed by ketamine 1mg/kg boluses of Ketamine 0.25mg/kg to maintain the adequate anaesthetic depth of RSS&gt;3. Results. The Recovery time in post-operative period was significantly prolonged in the KD group (mean 22.77 minutes) compared to the KP group (mean 17.8 minutes). The total duration of analgesia was also longer in the KD group (250 minutes vs 220 minutes in the KP group). It was seen that the hemodynamic variables (HR, SBP, DBP) were consistently higher in the KD group compared to the KP group. There was a significant difference in SBP, DBP, and MAP in the intraoperative period between the KP and KD groups till 4hr in the postoperative period. Conclusions. We conclude that a combination of Dexmedetomidine and Ketamine has longer recovery times and analgesia duration than a combination of Propofol and Ketamine. Side effects like postoperative nausea and vomiting are not significant. However, since the recovery times are comparatively longer in a daycare setting, dexmedetomidine and Ketamine may not be the preferred agents compared to the combination of Ketamine and Propofol in the context of a daycare setting.

Covid-19 Pneumonia Presenting as a ‘Typical Radiological Bronchopneumonia’ Pattern in Clinical-Radiological-Pathological Phenotype with Transient Hyperglycemia

Radiological phenotypes are radiological patterns or observable characteristics of COVID19 pneumonia. Various phenotypic classifications have been reported in literature. CT severity radiological phenotypes are widely used and universally accepted radiological phenotypic methods. Radiological CT severity phenotypic differentiation has documented very crucial role in initial assessment and during triaging of these cases in indoor and outdoor setting. Typical COVID-19 lung parenchymal involvement described as predominant ground glass opacities (GGOs) and consolidations in peripheral and subpleural portion of any lobe, predominantly involving lower lobes. Atypical Radiological patterns in COVID-19 has been documented as bronchopneumonia, multifocal consolidations, necrotizing pneumonia, cavitations with GGOs with or without consolidations. In present case report, 43-year male, presented with acute febrile respiratory illness with acute hypoxic respiratory failure documented as oxygen saturation of 80% at room air with tachypnea and respiratory distress. HRCT thorax was showing Pleural based, peripheral, central, multifocal patchy, confluent &amp; ill-defined GGOs and consolidations in bilateral lung fields in upper, middle and lower lobes. These typical radiological features suggestive of bronchopneumonia like radiological pattern which was very unusual for typical COVID-19 radiology. His laboratory parameters have shown abnormally raised inflammatory markers like CRP, Ferritin, LDH, D-Dimer and IL-6. Importantly, his random blood sugars were raised with abnormally raised HbA1c levels to label as diabetes mellitus. He was diagnosed with diabetes mellitus this time with COVID-19 illness without use of steroids. He was treated with standardized COVID-19 management institutional protocol with combination of low molecular weight heparin, methylprednisolone, remdesivir, meropenem and teicoplanin. Patient required BIPAP support with higher oxygen requirement with nasals canula for one week due to advanced radiological disease with more anatomical involvement. We have documented successful treatment outcome with use of rational treatment in timely by predicting disease severity with use of composite analysis of clinical, laboratory and radiological markers of illness. Transient hyperglycemia is known to occur and reported after COVID-19 illness due to virus induced inflammatory response and pancreatopathy with beta cell dysfunction. Transient hyperglycemia can be easily managed with insulin during hospitalization and oral anti-diabetic agents after discharge for few weeks. Dietary and lifestyle modification will help in majority with complete reversal of abnormally high sugar levels with restoration of normal HbA1c levels to non-diabetic range.

Prediction of Patient Outcomes in Locally Advanced Cervical Carcinoma Following Chemoradiotherapy-Comparative Effectiveness of Magnetic Resonance Imaging and 2-Deoxy-2-[18F]fluoro-D-glucose Imaging.

To evaluate the utility and comparative effectiveness of three five-point qualitative scoring systems for assessing response on PET-CT and MRI imaging individually and in combination, following curative-intent chemoradiotherapy (CRT) in locally advanced cervical cancer (LACC). Their performance in the prediction of subsequent patient outcomes was also assessed; Methods: Ninety-seven patients with histologically confirmed LACC treated with CRT using standard institutional protocols at a single centre who underwent PET-CT and MRI at staging and post treatment were identified retrospectively from an institutional database. The post-CRT imaging studies were independently reviewed, and response assessed using five-point scoring tools for T2WI, DWI, and FDG PET-CT. Patient characteristics, staging, treatment, and follow-up details including progression-free survival (PFS) and overall survival (OS) outcomes were collected. To compare diagnostic performance metrics, a two-proportion z-test was employed. A Kaplan-Meier analysis (Mantel-Cox log-rank) was performed. The T2WI (p < 0.00001, p < 0.00001) and DWI response scores (p < 0.00001, p = 0.0002) had higher specificity and accuracy than the PET-CT. The T2WI score had the highest positive predictive value (PPV), while the negative predictive value (NPV) was consistent across modalities. The combined MR scores maintained high NPV, PPV, specificity, and sensitivity, and the PET/MR consensus scores showed superior diagnostic accuracy and specificity compared to the PET-CT score alone (p = 0.02926, p = 0.0083). The Kaplan-Meier analysis revealed significant differences in the PFS based on the T2WI (p < 0.001), DWI (p < 0.001), combined MR (p = 0.003), and PET-CT/MR consensus scores (p < 0.001) and in the OS for the T2WI (p < 0.001), DWI (p < 0.001), and combined MR scores (p = 0.031) between responders and non-responders. Post-CRT response assessment using qualitative MR scoring and/or consensus PET-CT and MRI scoring was a better predictor of outcome compared to PET-CT assessment alone. This requires validation in a larger prospective study but offers the potential to help stratify patient follow-up in the future.

Continuous Analgesia through an Extrapleural Catheter: Ropivacaine Alone versus Ropivacaine with Fentanyl

Introduction: Thoracotomy incision causes severe debilitating pain. Local anesthetic infusion in extrapleural paravertebral space via a catheter is a good alternative for postoperative analgesia for such patients. The addition of fentanyl to the local anesthetic infusion may further augment the analgesic efficacy of this technique. The aim was to compare the analgesic efficacy of 0.375% ropivacaine with fentanyl and without fentanyl via extrapleural paravertebral catheter (EPVC) for continuous postoperative analgesia. Materials and Methods: This prospective comparative study included 40 patients aged 18–60 years belonging to the American Society of Anesthesiologists (ASA) Grade I, II, and III posted for thoracic surgery. All the patients received general anesthesia as per the standard institutional protocol, and intubation was done with an appropriate size double-lumen endotracheal tube after giving muscle relaxant. An extrapleural catheter was inserted by the surgeon under direct vision external to the parietal pleura just before thoracotomy closure. Patients were randomly allocated to receive an infusion of 0.375% ropivacaine at 0.15 ml/kg/h in Group R or 0.375% ropivacaine with fentanyl 2 mcg/ml at 0.15 ml/kg/h in Group R.F. The dose or rate of infusion was decreased after 2 days or chest drain removal as the pain subsided. Postoperatively, the pain was assessed using a Visual Analog Scale (VAS) at 1, 6, 12, 18, 24, 48, and 72 h after the surgery. Patients who complained of pain with a VAS score of more than or equal to 4 were given injection tramadol 1 mg/kg as rescue analgesic. The peak expiratory flow rates (PEFRs), hemodynamic parameters, and incidence of any adverse effect were compared between groups. Results: The analgesia duration was comparable in the two groups (3.46 h in Group R vs. 4.60 h in Group R.F, P = 0.091). The mean VAS score at rest as well as during cough was comparable between the two groups (P &gt; 0.05). There was no statistically significant difference in the mean PEFRs between the two groups. Conclusion: Fentanyl 2 μg/ml does not increase the duration of analgesia when combined with ropivacaine 0.375% for continuous EPVC infusion.

Cholescintigraphic evaluation of gallbladder contraction in correlation with serum thyrotropin and serum cholesterol

Background and aims: To study the effect of serum thyrotropin (Sr.TSH) and serum cholesterol on gallbladder contraction by cholescintigraphy. Methods: This is a prospective cross-sectional study comprising 77 patients for evaluation of gallbladder function in patients with biliary pain. All of them underwent 99mTc- Mebrofenin fatty meal cholescintigraphy following a standard institutional protocol apart from regular investigations. Dynamic images were acquired for 90 minutes with a standardised fatty meal given at the 60th minute. Gallbladder emptying kinetics was determined with Gallbladder Ejection Fraction (GBEF) calculated at 30 minutes post-meal. Relevant statistical methods were applied for interpretation. Results: The mean of GBEF was 60.82% ± 16.65% and the mean of Sr.TSH was 3.72 ± 3.88 mIU/ml, there was a negative correlation between GBEF and Sr.TSH (Pearson correlation coefficient r = -0.535, p &lt; 0.05). The mean serum cholesterol was 180.61 ± 46.34 mg/dl, there was a negative correlation between GBEF and serum cholesterol (Pearson’s correlation coefficient r = -0.685, p &lt; 0.05). The mean GBEF in euthyroid and hypothyroid patients were 65.04% ± 15.04% and 47.27% ± 15.93% respectively (P &lt; 0.05). Conclusion: Hypothyroidism is one of the key factors affecting gallbladder contractility and should not be overlooked in the management of functional gallbladder disorders. Cholescintigraphy can accurately assess gallbladder function qualitatively and quantitatively, and it can help (aid) physicians in diagnosing and decision-making on the management of biliary pain in hypothyroidism.

Incidence and risk factors for acute kidney injury in children with congenital heart disease undergoing cardiac surgery in a tertiary care center.

Objective: To determine the incidence and risk factors associated with acute kidney injury (AKI) in children with congenital heart diseases (CHDs) who underwent cardiac surgery in a tertiary care center. Study Design: Cross-sectional study. Setting: Paediatric Cardiac Intensive Care Unit (PCICU) of National Institute of Cardiovascular diseases, Karachi, Pakistan. Period: November 2022 to May 2023. Material &amp; Methods: We included patients of both genders and any age who underwent open or closed heart surgery for congenital heart defects. All patients undergoing CHD repairs were monitored for the total duration of PCICU stay. The development of AKI was labeled as per RIFLE criteria, and management thereafter was performed as per standard institutional protocols. Results: In a total of 93 patients with CHD, there were 50 (53.8%) males and 43 (46.2%) females. The mean age was 9.71±9.14 year ranging between 3 months to 60 years. There were 6 (6.5%) patients who developed AKI post-surgery. Overall, mortality was noted in 7 (7.5%) patients. Cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were significantly higher among patients who developed post-surgery AKI (&lt;0.001). Moreover, post-surgery AKI was significantly associated with intra-operative hypotension (p&lt;0.001), post-operative hypotension (p&lt;0.001), and post-operative sepsis (p&lt;0.001). It was also found that AKI had significant association with higher post-operative inotropic scores (p&lt;0.001), prolonged duration of mechanical ventilation (p&lt;0.001), and length of PCICU stay (p&lt;0.001). Mortality had significant association with AKI (33.3% vs. 5.7%, p=0.013). Conclusion: We noted the incidence of AKI among patient who underwent cardiac repairs to be 6.5%. CPB time and ACC time were significantly higher among patients who developed post-surgery AKI. Post-surgery AKI was significantly associated with intra-operative hypotension, post-operative hypotension, and post-operative sepsis. Mortality was significant high among cases that had AKI.

Detection of Antimicrobial Susceptibility Pattern and Molecular Detection of Resistance Genes in Klebsiella pneumoniae Isolated from Urine Samples of Suspected UTI Patients Attending Public Hospitals in Nasarawa South Senatorial District, Nasarawa State, Nigeria

Aims: The aim of the current study was to determine antimicrobial susceptibility patterns and the incidence of resistance genes (β-lactamase-encoded genes) among clinical isolates of K. pneumoniae.&#x0D; Study Design: Investigative.&#x0D; Place and Duration of Study: Department of Microbiology, Nasarawa State University, Keffi, between November 2022 and July 2023.&#x0D; Methodology: A total of 375 clinical samples were randomly collected from patients and isolation and identification was done using standard microbiological methods. The antibiotic susceptibility testing for the isolates was carried out in accordance with the Clinical and Laboratory Standards Institute protocol. The detection of extended-spectrum beta-lactamase (ESBL) production in K. pneumoniae isolates was carried out using double disc synergy test. In addition, molecular detection of ESBL genes was carried out using Polymerase Chain Reaction (PCR) method.&#x0D; Results: The overall incidence rate of K. pneumoniae in the 375 clinical samples from Nasarawa South Senatorial District was 38 (10.13%). Resistance was high to ampicillin (94.74%) and amoxicillin-clavulanic acid (73.6%) but low to cefotaxime (13.16%), ceftriaxone (18.42%), ceftazidime and cefoxitin (23.60%) and gentamicin (28.94%). Most of the isolates were multi-drug resistant (MDR; 81.5%) and none was Pan Drug resistant. All 15 isolates jointly resistant to cefotaxime and/or ceftazidime and ciprofloxacin 100.0% were ESBL producers, distributed as follows: blaCTX-M-1 7(46.6%); blaCTX-M-34(26.6%); blaSHV 6(40.0%); blaTEM6 (40.0%); and blaOXA 5(33.3%).&#x0D; Conclusion: K. pneumoniae isolated from the urine of patients attending public hospitals in Nasarawa South were less resistant to cefotaxime, ceftazidime, gentamicin, ceftriaxone, and cefoxitin in the study location. This implies that the antibiotics are useful in the treatment of infection caused by K. pneumoniae. Also, ESBL-positive K. pneumoniae isolates harbored ESBL genes, with blaCTX-M as the most common.

A-076 Abbott Alinity ci System Automated Sample Interference Indices for Immunoassays

Abstract Background The Alinity ci system Sample Interference Indices (HIL) provides a more accurate and consistent method for interpretation of interferents than time consuming visual interpretation. The Alinity c system uses specific wavelength pairs and an algorithm to provide a Sample Interference Index that can correlate with sample interference due to hemolysis, bilirubin and turbidity present in serum/plasma samples. Using just a single aspiration from a sample, the individual or all 3 indices can be selected to be reported. These values in combination with assay specific endogenous interference can be used to determine the potential for HIL interference in the Alinity i immunoassays. Methods The HIL methodology will be reviewed and discussed. The study followed Clinical and Laboratory Standards Institute (CLSI) protocol EP7-A2. Interferences were studied up to concentrations of 1000 mg/dL for hemoglobin, 30 mg/dL for bilirubin (unconjugated) and 1000 mg/dL for triglycerides in serum. Serial dilutions of the sample pools were analyzed in replicates of 4 on the Alinity c system. A cumulative summary was compiled of the Hemolysis, Icterus and Lipemia indices for 100 Alinity immunoassays. Results Using known concentrations of hemoglobin, bilirubin and Intralipid, the Abbott Semi-Quantitative Index (concentration range in mg/dL) and Qualitative Index (Blank, 1+, 2+, 3+ 4+) were confirmed on the Alinity c system. Correlation studies show a linear relationship (r = 1.0) of the indices with increasing concentration of analyte. An easy-to-use guide was created that combines the HIL Qualitative and Quantitative Index scores with the assay specific interference results to provide a guide to potential interferents for the Alinity i immunoassays. This guide provides background information on the causes of HIL interferences, conversion factors from Conventional to SI units and denotes the specific concentrations of interferents which could lead to an over or under estimation in the presence of hemoglobin, bilirubin and/or lipemia. In addition, the effects of the influence of two or more HIL interferents on assay reported results is discussed. The majority (96%) of the 100 immunoassays had no significant interference using samples with elevated H, I or L index values. The remaining 3 assays showed slight interference. Conclusion The Alinity ci system provides a simple and automated procedure for determining the sample indices (HIL) for patient specimens. These HIL values in combination with assay specific endogenous interference results can be used to determine the potential for HIL interference in the Alinity i immunoassays to avoid misdiagnosis.

A-072 An All-Purpose Particle Enhanced Immunoturbidimetric Assay for the Comparable, Instrument-Independent Monitoring of Procalcitonin in the Management of Sepsis

Abstract Introduction Sepsis is a life-threatening organ dysfunction caused by a dysregulated host immune response to infection. It is a global health concern and a leading cause of death worldwide, affecting an estimate of 48.9 million people every year. Procalcitonin (PCT) revealed to be an indispensable parameter for the management of sepsis. However, recent analysis of EQA survey results suggested crucial deviations of PCT measurements in Germany and studies by the IFCC Working Group on standardization of PCT stated the need for a higher-order reference measurement procedure.Here we present the evaluation of the all-purpose particle enhanced immunoturbidimetric assay (PETIA) of DiaSys, which can be easily applied to every high-throughput clinical chemistry analyzer. The high diversity of applications and datasets match current diagnostic and regulative needs (IVDR). Procalcitonin FS enables the equivalent and instrument-independent monitoring of PCT in the management of sepsis. Methodology Evaluation of Procalcitonin FS was performed on seven clinical chemistry analyzer platforms (Jeol BioMajesty® JCA-BM6010/C, DiaSys respons®920 and respons®940, Roche cobas c501, Abbott Architect c8000 and Alinity c, Beckman Olympus AU680). Measurements were performed according to Clinical and Laboratory Standards Institute (CLSI) protocols. Results The onboard stability reaches 8 weeks (with chimney) on BioMajesty® JCA-BM6010/C, 20 days on respons®920 and respons®940, 21 weeks on cobas c501, 9 weeks on Architect, 12 weeks on Olympus AU680 and 13 weeks on Alinity c. The calibration stability is 4 weeks (with chimney) on BioMajesty® JCA-BM6010/C, 2 weeks (with chimney) on respons®920 and respons®940, 21 weeks on cobas c501, 3 weeks on Architect, 5 weeks on Olympus AU680 and 10 weeks on Alinity c. The intra-assay precision (CV%) ranges from ≤4.57% on respons®920 up to ≤7.19% on respons®940. The Total Precision (CV%) ranges from ≤3.99% on cobas c501 up to ≤9.62% on Olympus AU680. LOB ranges from 0.07 ng/mL on BioMajesty® JCA-BM6010/C up to 0.130 ng/mL on Olympus AU680. LOQ ranges from 0.20 ng/mL on Architect up to 0.277 ng/mL on Olympus AU680. The reagent displayed a linear recovery up to 50 ng/mL and no prozone effect was detected up to 1000 ng/mL on all seven analyzers. The Passing &amp; Bablok regression vs the reference test showed an excellent comparability/alignment between the methods (slope ≤1.11, intercept ≤0.156 ng/mL, R ≥ 0.986). Conclusion Evaluation work proves that DiaSys PETIA reagent Procalcitonin FS shows excellent performance on all seven clinical chemistry analyzers. In addition, the high comparability between the seven analyzers enables the reliable and instrument-independent monitoring of PCT in the management of sepsis, and thus offering a solution to the current landscape of deviating PCT measurement results.

B-281 Analytical Validation of the Mindray High Sensitivity Cardiac Troponin I Assay

Abstract Background According to recent global guidelines for patients presenting with ischemia, high sensitivity cardiac troponin I and T (hs-cTn) are the preferred biomarkers for the diagnosis and risk assessment of acute myocardial infarction (MI) and myocardial injury. The purpose of our study was to perform an analytical validation study of the Mindray hs-cTnI assay. Methods Analytical studies were designed according to Clinical and Laboratory Standards Institute protocols (CLSI). We used one reagent lot and one CL1200i chemiluminescence Immunoassay Analyzer (Mindray Bio Medical Electronics Co., Shenzhen, China). Following the CLSI EP17 A2 document, the limit of blank (LoB) and limit of detection (LoD) were assessed following analysis of a) Mindray controls without cTnI concentrations added for the LoB and b) 4 lithium heparin (LiHep) fresh samples with low cTnI concentrations, for 3 days for LoB and LoD, with 5 replicates per day (60 replicates per study). For the precision study, according to the CLSI EP15-A3 protocol, we used 12 LiHep fresh samples, measured for 10 days, with 2 runs per day (separated by a minimal time of 2 h) and in replicates of 3 (n = 720). For the 12 samples for the precision study, 7 were chosen with hs-cTnI concentrations close to the manufacturer sex-specific 99th percentile upper reference limits (URL; 31 ng/L for males and 15 ng/L for females). The CLSI EP06 protocol was followed to study linearity, using 9 fresh LiHep samples analyzed the same day in replicates of 7 (n = 63). A blank sample between every sample was used to avoid carryover. Our analytical specification for linearity was an allowable deviation &amp;lt;10%. Analyses were performed with Analyze it for Excel (Method Validation edition, version 6.15). Results Using both parametrical and non-parametrical analyses, LoB was &amp;lt;0.1 ng/L, with a relative light unit (RLU) of 5394. LoD was 0.1 ng/L according to the parametrical analysis. Regarding imprecision, for samples ranging from cTnI concentrations of 1 to 106 ng/L, repeatability had a coefficient of variation (%CV) from 1.15% to 3.83%, and within-laboratory imprecision ranging from 1.69% to 5.03%. Using samples with hs-cTnI concentrations close to the manufacture’s sex-specific upper reference limits (9–36 ng/L), the repeatability and within-laboratory precision was 1.27%–1.61% and 1.92%–2.52%, respectively. The measuring interval for the linearity study ranged from 1.1 to 30 772 ng/L. All analytical parameters met CLSI limits of acceptable performance. No carry over was detected. Conclusion Our analytical observations of the Mindray hs-cTnI assay demonstrate excellent LoB, LoD, imprecision and linearity, that were in alignment of with the manufacturer’s claims and published guidelines for hs-cTnI.

In vitro sensitivity of Malassezia furfur isolates from HIV-positive and negative patients to antifungal agents

Malassezia is a lipophilic and lipid-dependent yeast genus belonging to the skin microbiota of humans and other animals. However, due to dysbiosis processes or other factors in the host, this yeast can cause different pathologies, ranging from skin diseases, such as seborrheic dermatitis, to fungemia. Isolation of Malassezia furfur has been reported in HIV-positive patients with or without skin lesions. Due to its opportunistic nature and its variable resistance to antifungal compounds, it is relevant to know the Malassezia sensitivity profiles. To determine the sensitivity to different antifungal agents, of clinical isolates of M. furfur obtained from HIV-positive or negative patients, with or without seborrheic dermatitis. Assessment of isolates sensitivity to itraconazole, voriconazole, fluconazole, and amphotericin B was performed by two techniques: (1) Broth microdilution using Clinical and Laboratory Standards Institute (CLSI) protocol M27-A3 with modifications; and (2) agar tests using Etest®. Isolates obtained from HIV patients showed an increase in the minimum inhibitory concentration of fluconazole, voriconazole, and amphotericin B, compared with those of non-HIV patients. Itraconazole was the antifungal with the lowest minimum inhibitory concentration (MIC) in most isolates. We observed differences in the sensitivity profiles of M. furfur isolates according to the context of the patient. High MIC of antifungals like fluconazole, commonly used for treating pathologies caused by Malassezia, were identified.

The spectrum of measles in COVID-19 pandemic; An observational study in children.

Objective: To assess the spectrum of measles during COVID-19 era among children. Study Design: Cohort study. Setting: Department of Pediatric, Dr. Ziauddin University Hospital, Kemari Karachi. Period: February 2019 to February 2021. Material &amp; Methods: Clinically diagnosed measles children of either gender aged between 3 months to 5 years admitted to our tertiary care center in the 2 years marked period of the study were analyzed. Measles was labeled as the presence of high grade fever (&gt;104 0F) and maculopapular rash. Medical history was noted and clinical examination was performed in all children. Necessary laboratory investigations like complete blood count and chest X-rays (CXR) were evaluated. All patients were treated as per standard institutional protocols. Outcomes were noted in terms of successful discharge or expiry. Results: In a total of 88 children, 55 (62.5%) were male. The mean age was 1.61±1.12 years while 49 (55.7%) children were aged ≤ 1 year. Twenty four (27.3%) children were fully vaccinated appropriate to their age. Fever and rash were found among all children (100%) while respiratory distress and coryza were reported by 82 (93.2%) and 51 (58.0%) children respectively. Overall duration of hospitalization was 7.02±2.32 days. Mortality was reported in 11 (12.5%) children while 76 (86.4%) children were successfully discharged. Development of acute respiratory distress (p=0.0011) and shock (p&lt;0.0001) proved to have significant association with mortality. Conclusion: Mortality was relatively high among children with measles during the COVID-19 pandemic era. During hospitalization, most frequent complications were pneumonia, and eye and/or mouth related complications. Development of acute respiratory distress and shock proved to have significant association with mortality.

Isolation and Antibiotic Resistance of Staphylococcus aureus Isolated from Nosocomial Sources

Methicillin resistance Staphylococcus aureus have been reported worldwide to emerge mostly in developing and developed countries. This study aimed at isolated and antibiotic resistance from nosocomial sources in Dalhatu Araf specialist Hospital, Lafia, Nigeria. A total of (200) samples were collected from February 2021 to May 2021 from different Nosocomial sources such as door handles, seat handles, surgical equipment and stretchers and Staphylococcus aureus was isolated and identified using standard microbiological method. The Antibiotic susceptibility test for the isolates were carried out and interpreted in accordance with Clinical and Laboratory Standard Institute (CLSI) protocol. The occurrence of Staphylococcus aureus from the samples was 50 (25%). The highest occurrence of Staphylococcus aureus is from seat handle swab with (32%) and the lowest occurrence is (18%) from surgical equipments. The Antibiotic resistance of Staphylococcus aureus showed that the isolates were more resistant to oxacillin.

Water Quality Analysis and The Occurrence of Antibiotic-Resistant Bacteria (ARB) From Satow Waterfall in Bau, Malaysian Borneo

Water quality monitoring of a particular river is crucially important to determine if the river water meets the requirement for its designated uses. Therefore, an assessment of the physiochemical water quality at Satow Waterfall, Sarawak, and the prevalence of antibiotic-resistant bacteria (ARB) was conducted to corroborate the safety of the water from the waterfall. A total of 42 water samples were collected at the subsurface water of the upstream, midstream, and downstream on two sampling trips in June 2021 (dry season) and December 2021 (wet season), with six months intervals. The water quality index (WQI) of the sampling stations ranged from 92.60 to 95, classifying the water under Class I. However, the water is microbiologically polluted, with the highest coliform count of 2.59 × 105 CFU/mL recorded at the middle stream during the wet season, which has surpassed the regulatory standard set by the Malaysian Department of Environment (DOE). A total of 54 bacterial isolates were chosen as representatives and identified by 16S rRNA sequencing, which confirmed the existence of 21 bacterial genera. All identified isolates were tested against 15 antibiotics of various classes employing the Clinical and Laboratory Standards Institute (CLSI) protocols. The antibiotic susceptibility test (AST) demonstrated substantial resistance to sulfamethoxazole (48%) and erythromycin (48%), as well as high susceptibility to chloramphenicol (84%), levofloxacin (60%) and ofloxacin (60%). The Multiple Antibiotic Resistance Index (MARI) evaluations demonstrated the MARI varied from 0-0.60, with 33% of the isolates having a MARI greater than 0.2. In this study, the occurrence of ARB in a water environment where there is an undisclosed source of antibiotic utilization is still inevitable, highlighting the necessity to constantly monitor the water quality and the pervasiveness of ARB in recreational water.

Analytical performance of the Enhanced Liver Fibrosis (ELF) Test on the Atellica IM Analyzer

BackgroundThe Enhanced Liver Fibrosis (ELFTM) Test comprises 3 direct serum markers of fibrosis—hyaluronic acid (HA), amino-terminal pro-peptide of type III procollagen (PIIINP), and tissue inhibitor of matrix metalloproteinase 1 (TIMP-1)—whose results are combined in an algorithm to generate the ELF score. Outside the U.S., the ELF Test and score are CE marked for assessment of liver fibrosis severity in patients with signs, symptoms, or risk factors of chronic liver disease to support diagnosis of fibrosis staging or prognosis for likelihood of progression to cirrhosis and liver-related clinical events. In the U.S., the FDA granted de novo marketing authorization to aid prognostic evaluation of disease progression (to cirrhosis and liver-related clinical events) in nonalcoholic steatohepatitis patients with advanced liver fibrosis. We describe the analytical performance of the ELF analytes and score on the Atellica® IM Analyzer. MethodsClinical and Laboratory Standards Institute protocols were followed for detection capability (limits of blank [LoB], detection [LoD], and quantitation [LoQ]), precision, interference, linearity, hook effect, and ELF reference interval. ResultsAll parameters met predetermined requirements: HA (LoB 1.00 ng/mL, LoD 2.00 ng/mL, LoQ 3.00 ng/mL); PIIINP (LoB 0.50 ng/mL, LoD 0.75 ng/mL, LoQ 1.00 ng/mL); TIMP-1 (LoB 3.0 ng/mL, LoD 4.0 ng/mL, LoQ 5.0 ng/mL). Across the 3 assays, repeatability was ≤5.4% CV; within-lab precision was ≤8.5% CV. ELF score repeatability was ≤0.6% CV, within-lab precision ≤1.3% CV, and reproducibility ≤1.1% CV. Good correlation was obtained between the Atellica IM ELF and ADVIA Centaur ELF Tests (y = 1.01x − 0.22, r = 0.997). Assays were linear across analytical measuring ranges. ConclusionsAnalytical performance validation results for the ELF Test and ELF score were excellent making the test acceptable for routine clinical use.

Changes in the preoperative ocular surface flora with an increase in patient age: A surveillance analysis of bacterial diversity and resistance to fluoroquinolone.

This study analyzed the relationship between patient age and the prevalence and fluoroquinolone susceptibility of gram-positive cocci from the ocular surface flora before ophthalmic surgery. This surveillance study included scraped samples from the conjunctival sac of 8923 eyes of 5490 patients (70.0 ± 13.7years) without ocular infection before ophthalmologic surgery between August 2018 and December 2020. A review of microbiological records regarding patient age was used to determine the number of isolates and gram-positive species obtained, as well as their fluoroquinolone susceptibility. Fluoroquinolone susceptibility was determined using the Clinical and Laboratory Standards Institute protocols of broth microdilution. Statistical analysis was performed using a generalized additive model and a log-linear model. In total, 9,894 bacterial isolates obtained from scraped samples from the patients were analyzed. The detected species were Staphylococcus epidermidis (31.0%), Staphylococcus aureus (6.1%), Staphylococcus lugdunensis (3.9%), Enterococcus faecalis (5.8%), Corynebacterium species (31.7%), and Cutibacterium acnes (7.5%) and others. The number of species isolated from the ocular surface was increased at the rate of 1.018 per 10years of age (p < 0.0001). S. epidermidis, S. lugdunensis, E. faecalis, and Corynebacterium species were isolated more often with an increase in patient age. The levofloxacin resistance ratio of methicillin-sensitive S. epidermidis and Corynebacterium species increased at the rate of 1.204 and 1.087 respectively with a 10-year increase in age (both p < 0.0001). Gram-positive bacteria in the ocular surface flora (OSF) exhibited gradual changes in diversity and fluoroquinolone resistance with an increase in patient age. It is important to monitor the OSF of the patients before ophthalmologic surgery to prevent refractory ocular postoperative infection.