Transcutaneous Delivery of Dexamethasone Sodium Phosphate Via Microneedle-Assisted Iontophoretic Enhancement - A Potential Therapeutic Option for Inflammatory Disorders.

AIM: This study aimed to fabricate dexamethasone sodium phosphate loaded microneedle arrays (MNA) and investigate their efficiency in combination with iontophoresis for the treatment of hind paw oedema in rats. METHODS: Drug loaded polyvinyl alcohol, polyvinyl pyrrolidone and D-sorbitol-based MNA11 were fabricated by vacuum micromolding. Physicochemical, morphological, thermal, in-silico, in-vitro insertion ability (on parafilm) and drug release studies were performed. Ex-vivo permeation, in-vivo insertion and anti-inflammatory studies were performed in combination with iontophoresis. RESULTS: MNA11 displayed sharp-tipped projections and acceptable physicochemical features. Differential scanning calorimetry results indicated that drug loaded MNA11 were amorphous solids. Drug interacted with PVP and PVA predominately via hydrogen bonding. Parafilm displayed conspicuously engraved complementary structure of MNA11. Within 60 min, 91.50 ± 3.1% drug released from MNA11. A significantly higher i.e., 95.06 ± 2.5% permeation of drug was observed rapidly (within 60 min) from MNA11-iontophoresis combination than MNA11 i.e., 84.07 ± 3.5% within 240 min. Rat skin treated using MNA11 and MNA11-iontophoresis showed disruptions / microchannels in the epidermis without any damage to underlying anatomical structures. MNA11-iontophoresis combination led to significant reduction (83.02 ± 3.9%) in paw oedema as compared to MNA11 alone (72.55 ± 4.1%). CONCLUSION: MNA11-iontophoresis combination can act as a promising candidate to deliver drugs transcutaneously for treating inflammatory diseases.

A descriptive analysis of skin-only closure and Bogota bag techniques for achieving complete fascial closure in damage control abdominal surgery.

BACKGROUND: Temporary abdominal closure (TAC) techniques are essential in managing open abdomen cases, particularly in damage control surgery. Skin-only closure (SC) and Bogota bag closure (BBC) are commonly used methods for TAC, but their comparative effectiveness in achieving primary fascial closure (PFC) remains unclear. The objective of this study was to evaluate the rates of PFC between patients undergoing SC and BBC techniques for TAC in peritonitis or abdominal trauma cases at a tertiary care hospital. METHODS: A retrospective cross-sectional study was conducted at the Surgical A Unit of Hayatabad Medical Complex, Peshawar, from January 2022 to July 2023. Approval was obtained from the institutional review board, and patient consent was secured for data use. Patients undergoing temporary abdominal closure using either skin-only or Bogota bag techniques were included. Exclusions comprised patients younger than 15 or older than 75 years, those with multiple abdominal wall incisions, and those with prior abdominal surgeries. Data analysis utilized SPSS version 25. The study aimed to assess outcomes following damage control surgery, focusing on primary fascial closure rates and associated factors. Closure techniques (skin-only and Bogota bag) were chosen based on institutional protocols and clinical context. Indications for damage control surgery (DCS) included traumatic and non-traumatic emergencies. Intra-abdominal pressure (IAP) was measured using standardized methods. Patients were divided into SC and BBC groups for comparison. Criteria for reoperation and primary fascial closure were established, with timing and technique determined based on clinical assessment and multidisciplinary team collaboration. The decision to leave patients open during the index operation followed damage control surgery principles. RESULTS: A total of 193 patients were included in this study, with 59.0% undergoing skin-only closure (SC) and 41.0% receiving Bogota bag closure (BBC). Patients exhibited similar demographic characteristics across cohorts, with a majority being male (73.1%) and experiencing acute abdomen of non-traumatic origin (58.0%). Among the reasons for leaving the abdomen open, severe intra-abdominal sepsis affected 51.3% of patients, while 42.0% experienced hemodynamic instability. Patients who received SC had significantly higher rates of primary fascial closure (PFC) compared to BBC (85.1% vs. 65.8%, p = 0.04), with lower rates of fascial dehiscence (1.7% vs. 7.6%, p = 0.052) and wound infections (p = 0.010). Multivariate regression analysis showed SC was associated with a higher likelihood of achieving PFC compared to BBC (adjusted OR = 1.7, 95% CI: 1.3-3.8, p < 0.05). CONCLUSION: In patients with peritonitis or abdominal trauma, SC demonstrated higher rates of PFC compared to BBC for TAC in our study population. However, further studies are warranted to validate these results and explore the long-term outcomes associated with different TAC techniques.

Safety of glucose-6 phosphate dehydrogenase deficient donors in living right lobe liver donation.

BACKGROUND: The literature lacks data on World Health Organization (WHO) class II and III deficient liver donors who underwent right hepatectomy during living donor liver transplantation (LDLT). METHODS: In this prospective cohort study, we compared the perioperative outcomes of 15 glucose-6 phosphate dehydrogenase (G6PD) deficient living liver donors with a matched cohort of 39 nondeficient living liver donors undergoing right lobe donation. RESULTS: Out of 15 G6PD deficient donors, four (26.67%) donors had class II, and 11 (73.34%) had class III G6PD deficiency. The mean postoperative trough hemoglobin level was significantly lower in the deficient group than the nondeficient group (9.38 ± 1.59 g/dL vs. 10.27 ± .91 g/dL, p = .046). The mean peak indirect bilirubin level was significantly higher in the deficient group than the nondeficient group (2.22 ± 1.38 mg/dL vs. 1.40 ± .89 mg/dL, p = .047), and a similar trend was observed in total serum bilirubin (3.99 ± 2.57 mg/dL vs. 2.99 ± 1.46 mg/dL, p = .038). Biochemical evidence of hemolysis was found only in three (20%) deficient donors, but none of them needed a blood transfusion. No mortality was observed in either group. All other parameters, including demographics, operative parameters, graft characteristics, and hospital stay were comparable between both groups (p > .05). CONCLUSION: G6PD deficiency with WHO class II and above should not be considered a contraindication for right lobe donation.

Molecular Characterization of Bacterial Isolates from Soil Samples and Evaluation of their Antibacterial Potential against MDRS.

Some soil microbes, with their diverse inhabitance, biologically active metabolites, and endospore formation, gave them characteristic predominance and recognition among other microbial communities. The present study collected ten soil samples from green land, agricultural and marshy soil sites of Khyber Pakhtunkhwa, Pakistan. After culturing on described media, the bacterial isolates were identified through phenotypic, biochemical and phylogenetic analysis. Our phylogenetic analysis revealed three bacterial isolates, A6S7, A1S6, and A1S10, showing 99% nucleotides sequence similarity with Brevibacillus formosus, Bacillus Subtilis and Paenibacillus dendritiformis. The crude extract was prepared from bacterial isolates to assess the anti-bacterial potential against various targeted multidrug-resistant strains (MDRS), including Acinetobacter baumannii (ATCC 19606), Methicillin-resistant Staphylococcus aureus (MRSA) (BAA-1683), Klebsiella pneumoniae (ATCC 13883), Pseudomonas aeruginosa (BAA-2108), Staphylococcus aureus (ATCC 292013), Escherichia coli (ATCC25922) and Salmonella typhi (ATCC 14028). Our analysis revealed that all bacterial extracts possess activity against Gram-negative and Gram-positive bacteria at a concentration of 5 mg/mL, efficiently restricting the growth of E. coli compared with positive control ciprofloxacin. The study concluded that the identified species have the potential to produce antimicrobial compounds which can be used to control different microbial infections, especially MDRS. Moreover, the analysis of the bacterial extracts through GC-MS indicated the presence of different antimicrobial compounds such as propanoic acid, oxalic acid, phenol and hexadecanoic acid.

Effects of safety pattern, cabin ergonomics, and sleep on work-related stress and burnout of city and transit bus drivers in Lahore, Pakistan.

The health and working environment of bus drivers is compromised in low-middle-income countries like Pakistan which leads to burnout and excessive Road Traffic Crashes. Hence, this study delves into factors affecting their safe operations from health and work environment perspectives and measures their associated stress and Burnout level. In a study of four hundred and ninety-nine (499), 86% city and 14% transit bus drivers are surveyed through a questionnaire. Stress is estimated for city and transit bus drivers, using the Effort/Reward Imbalance Model (ERI) of Siegrist, and burnout is calculated using the Copenhagen Burnout Inventory (CBI). For the determination of important determinants, descriptive and regression analyses are conducted. Findings show that stress has emerged as a negative factor for the physical and psychological health of city and transit bus drivers. Results based on bus drivers' responses suggest that organisational awareness and emphasis on health and safety levels can significantly reduce driver stress and burnout. Practitioner Summary: This study explores burnout and work-related stress of bus drivers in Lahore (Pakistan). City and transit bus drivers were interviewed through a questionnaire, containing three sections, using different subjective ratings based upon their past reliability. Results indicate that stress in bus drivers emerged as a physical and psychological health-damaging factor.

A Case of Pulmonary Tumor Thrombotic Microangiopathy: A Rare and Fatal Phenomenon.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a pulmonary hypertensive arteriopathy thought to be caused by activation of the coagulation cascade at the surface of circulating tumor microemboli along with intimal proliferation in small pulmonary arteries in patients with metastatic carcinomas. The subsequent stenosis of the pulmonary vasculature leads to pulmonary hypertension (PH) and, cor pulmonale with eventual respiratory compromise leading to respiratory failure. PTTM is always a nearly fatal disease with most cases diagnosed postmortem. Most cases reported on this condition are from Japan where the incidence of gastric malignancy is relatively higher than other parts of the world. We report a case of a Caucasian man with a classic presentation of PTTM to help make physicians aware of this rare, rapidly progressive and usually fatal phenomenon.

A Unique Case of Community Acquired Proteus mirabilis Meningitis.

Proteus mirabilis, a gram-negative bacterium commonly known for causing urinary tract infections (UTI) can rarely present with central nervous system (CNS) infections. Proteus mirabilis CNS infections are usually encountered in the neonatal and infantile period and occasionally cause brain abscesses. It is an uncommon cause of adult CNS infection. We report the first case of a community-acquired Proteus mirabilis meningitis (PMM) in a patient with Proteus mirabilis UTI, urolithiasis, and bacteremia. Risk factors for gram-negative bacillary meningitis (GNBM) include extremes of age, cancer history, diabetes mellitus, UTI, and nosocomial exposure, with the latter being a more prominent cause of PMM. Compromise of the anatomical defense against CNS infections whether accidental or neurosurgical is another important cause, and approximately two-thirds of reported cases of PMM have occurred after neurosurgical procedures. PMM patients develop fever, altered consciousness, and have an acute clinical course. Antimicrobials that can be used for treatment include third-generation cephalosporins, ciprofloxacin, imipenem/ cilastatin, aztreonam, and intraventricular aminoglycosides. Despite appropriate antibiotic therapy outcomes are poor with severe neurological deficit and death commonly resulting. Nosocomial infections can be drug-resistant and multiple antibiotics should be started while awaiting culture results. Literature review reveals that treatment with intraventricular aminoglycosides when attempted has shown bacteriological cure indicating this can be an important treatment approach. Due to the acute clinical course and high morbidity and mortality, we recommend starting multiple antibiotics with different mechanisms of action as soon as the disease is suspected. Our patient was initially started on ceftriaxone, vancomycin, acyclovir, and ampicillin for UTI and meningoencephalitis. The antibiotics were later consolidated to cefepime based on blood, urine and, cerebrospinal fluid cultures growing pan-sensitive Proteus mirabilis. Her clinical condition continued to worsen and ciprofloxacin was added. However, due to the progressive decline in her condition, the family elected for inpatient hospice care and intraventricular aminoglycosides were not attempted.

Posttraumatic stress disorder and psycho-social impairment following snakebite in Northeastern Nigeria.

BACKGROUND: Snakebite is a major public health problem among impoverished rural populations causing considerable morbidity and mortality in West Africa. Despite the huge burden of snakebite in this region, psycho-social impairment following snakebite has not been evaluated. In this study, we assessed for features of posttraumatic stress disorder and psycho-social impairment among rural snakebite victims in Northeastern Nigeria. METHODS: Individuals with previous snakebite managed in our facility, defined as exposed to snakebite, and their matched relatives not exposed to snakebite were invited to participate in the study following community mobilization. A retrospective cohort study was conducted evaluating the presence of psycho-social functioning, posttraumatic stress disorder, quality of life, social disability, cognitive impairment, and psychological morbidity using standard tools administered by the investigators, trained nurses, and community health workers. RESULTS: The prevalence of features of posttraumatic stress disorder among those exposed to snakebite compared to those not exposed to snakebite was 43% and 28%, respectively (risk ratio = 1.53; 95% confidence interval: 1.04-2.24; p = 0.024). Subjects exposed to snakebite had significantly poorer quality of life score in the psychological and social domains (p < 0.05). Other psycho-social complications associated with snakebite were impaired family/school functioning and psychological morbidity. No difference in cognitive functioning was observed between the two groups. CONCLUSIONS: Snakebite is complicated by features of posttraumatic stress disorder, poor quality of life, and psycho-social impairments in northeastern Nigeria. Detection, monitoring, and appropriate management interventions should be provided and made more accessible to snakebite victims to ameliorate mental and psychological impairment.

Pleural and Pulmonary Tuberculosis in a Patient Presenting with a Massive Exudative Pleural Effusion: A Diagnostic Challenge.

Worldwide, Mycobacterium tuberculosis (MTB) is the leading cause of death due to a single infectious agent. According to the CDC, there were 9,025 reported new cases of active TB in the U.S. in 2018. There are various diagnostic modalities available to diagnose infection with MTB, whether it is latent or active. We present a diagnostically challenging case of pulmonary and pleural TB in a patient with known risk factors. It serves as a reminder of the high false negative rate of many of the tests for TB.

Ovarian dermoid cyst presenting with unusual complaint of hair coming out of the anal orifice - A case report.

Dermoid cyst of the ovary is a common benign condition. It is usually asymptomatic but can present with pain, mass, hormone related symptoms or paraneoplastic syndrome. Hair is a common morphological component of the dermoid cyst; however, it rarely manifests as a presenting complain. We report a case, who presented with the complaints of hair coming out through her anal orifice for a year. Ultrasound and computed tomography scan revealed a dermoid cyst of the right ovary adherent to the rectum. Surgical removal showed hair coming out of the cyst. Primary repair of the defect in rectal wall was performed which resulted in resolution of the symptoms.

Utility of Endoscopic Ultrasound in the Work Up for Solitary Hepatobiliary Neuroendocrine Lesions.

A 43-year-old woman, with an unremarkable past medical history, presented with a three-week history of generalized itching, jaundice, and abdominal pain. Initial workup showed amorphous, regionally invasive, and obstructing soft tissue mass in the region of the hepatic hilum. The middle third of the main bile duct was subsequently found to harbor a polypoid mass on endoscopic retrograde cholangiopancreatograph. Biopsy revealed nests of neoplastic cells that was subsequently identified as well-differentiated neuroendocrine tumor. A search for a possible primary neuroendocrine tumor was performed and included imaging of the chest, abdomen, and pelvis, a colonoscopy, capsule endoscopy, and an octreotide scan; however, no primary tumor outside of the liver was identified. Surgical debulking was performed, during which intraoperative exploration and ultrasound failed to reveal any extra-hepatic tumor sanctuaries. A few months later, patient underwent endoscopic ultrasound (EUS) for evaluation of recurrent abdominal pain which revealed a small lesion in the pancreas. It was unclear, however, whether it was primary or a metastatic lesion. This case represents a diagnostic challenge and emphasizes the potential utility of EUS in the preoperative work up for any presumable primary hepatobiliary neuroendocrine tumor.

Trends in utilization of hypofractionated whole breast irradiation (HF-WBI) in triple negative breast cancer (TNBC): a national cancer database (NCDB) analysis.

PURPOSE: We sought to identify trends over time with respect to the use of hypofractionated whole breast irradiation (HF-WBI) in women with triple negative breast cancer (TNBC) in the national cancer database (NCDB). METHODS: Trends in utilization of HF-WBI in women diagnosed with T1-2N0 TNBC in the NCDB between 2008 and 2013 were analyzed. Case-matched luminal A women were used for comparison. Variables included age, race, year of diagnosis, insurance status, income quartile, receipt of neoadjuvant chemotherapy, and institution (academic vs. community). Chi square, logistic regression, and multivariate analysis was performed. RESULTS: Utilization of HF-WBI among the 53,269 TNBC women identified steadily increased from 4.7% in 2008 to 14.0% in 2013 for women with TNBC compared to luminal A cancer whose utilization increased from 7.3 to 23.3% over the same time frame (p < 0.001). On univariate analysis, HF-WBI was associated with increasing age (p < 0.001), Medicare insurance (p < 0.001), race (p = 0.041), diagnosis after 2011 (p < 0.001), higher income quartile (p < 0.001), and treatment at academic institutions (p < 0.001). On multivariate analysis, age (p < 0.001, OR 1.038 per year), income quartile (p = 0.002, OR 1.061 per increase in quartile), treatment at an academic institution (p < 0.001, OR 1.78) significantly increased use of HF-WBI. CONCLUSIONS: Treatment at an academic center and year of diagnosis were most correlated with increased HF-WBI in T1-2N0 TNBC women in the NCDB from 2008 to 2013, followed by increasing age and income. Only 14% of T1-2N0 TNBC women received HF-WBI in 2013. Focus on increased utilization is needed for non-academic centers, lower income, and younger women.

Dedicated Afternoon Rounds for ICU Patients' Families and Family Satisfaction With Care.

OBJECTIVE: It was hypothesized that adding dedicated afternoon rounds for patients' families to supplement standard family support would improve overall family satisfaction with care in a neuroscience ICU. DESIGN: Pre- and postimplementation (pre-I and post-I) design. SETTING: Single academic neuroscience ICU. PATIENTS: Patients in the neuroscience ICU admitted for longer than 72 hours or made comfort measures only at any point during neuroscience ICU admission. INTERVENTION: The on-service attending intensivist and a neuroscience ICU nursing leader made bedside visits to families to address concerns during regularly scheduled, advertised times two afternoons each week. MEASUREMENTS AND MAIN RESULTS: One family member per patient during the pre-I and post-I periods was recruited to complete the Family Satisfaction in the ICU 24 instrument. Post-I respondents indicated whether they had participated in the afternoon rounds. For primary outcome, the mean pre-I and post-I composite Family Satisfaction in the ICU 24 scores (on a 100-point scale) were compared. A total of 146 pre-I (March 2013 to October 2014; capture rate, 51.6%) and 141 post-I surveys (October 2014 to December 2015; 47.2%) were collected. There was no difference in mean Family Satisfaction in the ICU 24 score between groups (pre-I, 89.2 ± 11.2; post-I, 87.4 ± 14.2; p = 0.6). In a secondary analysis, there was also no difference in mean Family Satisfaction in the ICU 24 score between the pre-I respondents and the 39.0% of post-I respondents who participated in family rounds. The mean Family Satisfaction in the ICU 24 score of the post-I respondents who reported no participation trended lower than the mean pre-I score, with fewer respondents in this group reporting complete satisfaction with emotional support (75% vs. 54%; p = 0.002), coordination of care (82% vs. 68%; p = 0.03), and frequency of communication by physicians (60% vs. 43%; p = 0.03). CONCLUSIONS: Dedicated afternoon rounds for families twice a week may not necessarily improve an ICU's overall family satisfaction. Increased dissatisfaction among families who do not or cannot participate is possible.

Localized Injection of Streptomycin, Kenacort and Lidocaine combination for Symptomatic Pain Management of Knee Osteoarthritis.

OBJECTIVE: To determine the frequency of reduction of pain in symptomatic knee osteoarthritis by using combination injections. METHODS: The experimental study was conducted from January 1, 2010, to December 31, 2016,at Al-Noor Surgery Hospital, Chakwal, Pakistan, and comprised patients suffering from symptomatic knee osteoarthritis. All patients were injected intra-articularly and peri-articularily with a combination of streptomycin, kenacort and lidocaine. The effects of this injection were recorded immediately after injection, after a month and after a year. Data was analyzed using SPSS 21. RESULTS: Of the 169 patients, there were 70(41.40%) males and 99(58.60%) females. The overall mean age and pain duration was 59.27±7.79 years and10.5±5.1 years respectively. No patient had pain immediately after the injection and after a month of follow-up. After a year, 145(86%) had a complete loss of pain compared to the baseline. Three (1.77%) patients required repetition of injection after a year. None of the patients suffered from septic arthritis or localised flare-ups and no one opted for knee joint arthoplasty. CONCLUSIONS: Combination of streptomycin, low-dose corticosteroids and lidocaine hadimmediate and prolonged effect in reducing pain in patients with knee osteoarthritis.

Shaving effects on percutaneous penetration: clinical implications.

CONTEXT: Human/animal shaving biology. OBJECTIVE: To assess the effect of shaving on percutaneous penetration and skin function. METHODS: We screened 500+publications in Pub Med, Scopus, Cochrane Library and pertinent journals out of which only 17 were deemed relevant. Terms for searches included shaving and skin, percutaneous penetration and shaving, skin absorption and shaving, absorption of dyes and shaving, skin penetration, effects of shaving and absorption, shave and dyes, axillary shaving and stratum corneum, shaving and breast cancer, shaving and infections, etc. RESULT: Shaving appears to have an exaggerated effect on percutaneous absorption; however, some studies do not support this evidence. CONCLUSION: Shaving enhances percutaneous penetration of some chemicals; however this effect is species and chemical specific. Further investigations of chemicals of varying physio-chemical properties are mandated before a generalized theory can be promulgated.

EPIDEMIOLOGY OF CHILDHOOD FRACTURES IN THE CITY OF KARACHI.

BACKGROUND: The epidemiology of paediatric fractures is crucial for developing preventive strategies, but when it comes to developing countries, the urban scenario has rarely been studied in the context of childhood trauma. This study aims to identify the epidemiology of paediatric injuries occurring in the largest and most populated city of Pakistan, Karachi, so that a comparison to data from the developed world can be made, and appropriate precautionary measures can be devised. METHODS: The data from 1,514 paediatric orthopaedic patients treated at the Accident and Emergency department of Jinnah Postgraduate Medical Centre, during the time frame ranging from January 2012 to January 2013 was studied. Survey forms were filled out by the residents on call. RESULTS: The patients' ages ranged from 2 months to 17 years, with males outnumbering females. The mean age of presentation was 8.8±4.6years. The number of fractures was maximal among children aged 5-11 years, after which it decreased in adolescents. Fractures of the radius and ulna were most common (16.9%), followed by the distal radius (14.6%) and humours (12.0%). Patients aged 0-2 years most commonly presented with a fracture of the femoral shaft. Falls on the same plane were responsible for the most fractures (44.2%), followed by falls from a height (21.5%) and road traffic accidents (26.7%).Incidence of fractures peaked in the summer months (p=0.007). CONCLUSION: Adequate precautionary measures and preventive programs need to be inculcated through legislation and a community based effort. In a developing nation however, unless the issues of ignorance, illiteracy and poverty are tackled by the authorities, they will continue to be a maior hindrance.