Antimicrobial Resistance Patterns: Review of the Antibiogram of a Surgical Unit in a Public Tertiary Care Hospital of Pakistan.

Introduction Antimicrobial resistance (AMR) has become a challenge in modern-day medical practice. The pace at which microbes are becoming resistant to antibiotics is greater than the discovery of novel antimicrobial agents. There is a need to study these antimicrobial patterns and, for this purpose, antibiograms should be developed at the levels of wards and hospitals and studied to guide us better on how to choose suitable empirical therapy for our patients. Methods and materials A total of 286 reports were studied, which contained the culture and sensitivity data of all the patients admitted under the care of Surgical Unit-1 in Lahore General Hospital between April 1, 2019, and October 31, 2019. All the samples for culture and sensitivity were sent to the in-house laboratory of the hospital where the reporting was done by the pathology department. They were inoculated and then intubated, and gram staining was performed. Antibiotic resistance and susceptibility were measured by the disk diffusion method according to the Clinical and Laboratory standards institute (CSLI) guidelines. Results The most common isolated organism was Escherichia coli​​​​​​​ (E. coli) in 65 (24%) patients, the next most common was Acinetobacter species in 62 (23%), followed by Pseudomonas species 52(19%), Klebsiella species 32 (13%), Staphylococcus aureus 30 (11%), Coagulase-negative Staphylococci 20 (7%), Enterobacter species (2%), and Citrobacter species (1%). The antimicrobial susceptibility of E. coli was highest for aminoglycosides and carbapenems like amikacin (78%), meropenem (71%), and imipenem (63%). Acinetobacter was most sensitive to colistin (100%), amikacin (31%), meropenem (21%), and cefoperazone + sulbactam (21%). Pseudomonas was also most sensitive to colistin (93%) and after that amikacin (52%), meropenem (52%), and imipenem (44%). Klebsiella was most sensitive to colistin (86%), imipenem (60%), and aminoglycosides (50%). Among gram-positive organisms, Staphylococcus aureus was sensitive to linezolid (100%) and vancomycin (100%). Conclusion The vast majority of isolated organisms in this study were gram-negative bacteria, and most were showing high antimicrobial resistance. The antibiograms should be developed and regularly updated at every ward and hospital. There is a need to bring more awareness about the proper use of antimicrobials among healthcare workers, and antimicrobial stewardship programs can help in this matter.

Laparoscopic Curative Resection for Right-Sided Colonic Tumors: Initial Experience From a Specialized Cancer Hospital of a Developing Country.

Introduction Laparoscopic colonic resection is increasingly becoming popular worldwide and aims to provide curative resection in addition to the inherent benefits of laparoscopic surgery. The aim of this study was to evaluate the long-term outcomes of laparoscopic right hemicolectomy in a Pakistani cohort of patients. Methods and procedures We retrospectively analyzed the medical records of all patients who presented to our hospital with the diagnosis of right-sided colon carcinoma from January 2010 to December 2018 and underwent laparoscopic right or extended right hemicolectomy. Demographics, operative findings, histopathology report, and follow-up of patients were recorded and the analysis was performed on Statistical Packages for the Social Sciences (SPSS) Version 20 (IBM Corp, Armonk, NY). Results Seventy-five patients were included, 56 (74.7%) of whom were males and 19 (25.3%) were females. The median age was 52 years (range 25-82 years). The median hospital stay was five days (Range 3-13 days). The median blood loss was 70 milliliters and the mean operative time was 195.5±77.6 minutes. Laparoscopic extended right hemicolectomy was performed in 23 (16.67%) patients and standard right hemicolectomy in 52 (83.33%) patients. Most (72%) of the patients had a pathological T3 tumor, and the majority (61.3%) of the patients had no nodal involvement (pN0). The mean number of lymph nodes removed was 20+8. The median numbers of involved lymph nodes were 1.14+2.19. All the patients had R0 resection. Postoperatively, two patients had pelvic collection, and there was no 30-day mortality. Local recurrence occurred in four patients and distant metastases were observed in nine patients. The median follow-up in our study was 40.5±18.35 months. The median disease-free survival was 42±2.17 months and the median overall survival was 44±2.16 months. Conclusion Our experience with laparoscopic right colon resections has confirmed the safety and feasibility of the procedure.

Malignant Melanoma of the Female Genital Tract: Experience of an Oncology Center in Pakistan.

Introduction Malignant melanoma, which arises from melanocytes or pigment cells, is one of the most common forms of epithelial cancer. Cutaneous and noncutaneous melanomas differ clinically and genetically. Mucosal melanomas are rare. In the female genital tract, the most frequent location of melanoma is the vulva, whereas the vagina is seldom affected. The occult nature of their anatomical location contributes to the late presentation and late diagnosis of vaginal melanoma, resulting in an exceedingly poor patient prognosis. The present study describes the incidence, symptoms, management, and prognosis of women in Pakistan with malignant melanoma of the vulva, vagina, and cervix. Materials and methods The Hospital Information System of Shaukat Khanam Memorial Cancer Hospital and Research Center was searched electronically to identify patients diagnosed with malignant melanoma from January 1995 to December 2017. Patients with cutaneous malignant melanoma, multiple primary tumors, and metastases to the female genital tract from primary tumors located elsewhere were excluded. All included patients had been diagnosed with primary malignant melanoma of the female genital tract. Results The search of medical records identified 271 patients with malignant melanoma, of whom 13 had primary malignant melanomas of the female genital tract. Of these 13 patients, nine, three, and one had primary vaginal, vulvar, and cervical melanomas, respectively. Median age at presentation was 60 years (range, 30-70 years), with 10 patients being post-menopausal. The most common presentations were per-vaginal bleeding and per-vaginal discharge (five patients each). The mean duration of symptoms was 7.46 months. Seven patients underwent wide local excision. Six patients had nodular type malignant melanoma, two had superficial spreading type, and five were unclassified. Nine patients had pathological T4 disease, and two had pathological T3. Mean Breslow depth was 5.4 millimeters (mm), with 10 patients having tumor depth >4 mm. Eight patients were positive for the microscopic involvement of margins. The mean time to recurrence was 11.8 months (range, 1-24 months), and the mean time to metastasis was 17.6 months (range, 2-44 months). The median survival after surgery was 25 months (range, 2-75 months). Conclusion This study is the first to report the incidence, symptoms, management, and prognosis of patients in Pakistan with malignant melanoma of the female genital tract. Meta-analyses and prospective multicenter studies are needed.

Benefits of Outcomes of the Microscopic Examination of Anastomotic Donuts After Colorectal Resection for Oncological Purposes: A Medical Record-Based Study.

Objective  The objective of the study is to investigate the benefits of pathological assessment of donuts removed during coloanal anastomosis after anterior resection. Methodology During three years, 220 patients underwent circular stapled anastomosis. It is a retrospective study with convenient sampling. Involvement of donuts, the involvement of margins, length of donuts, and margins were primarily recorded. Ethical review approval was taken from the Institutional Review Board. Hospital electronic system was used to retrieve the data. Results Two hundred and twenty patients underwent circular end to end anastomosis (CEEA) stapled gun anastomosis. All had adenocarcinoma. Most of the patients had T3 disease (n=113). Low anterior resection was the most common procedure followed by anterior resection and sigmoid colectomy, respectively. We performed all rectal cancers anastomosis with a circular stapling gun. On histological analyses among 220 patients, only two patients were found to have a positive distal donut. No proximal donuts were positive. Both patients were also found to have positive distal margins. The mean length of the proximal donut was 1.79±0.45 cm. The mean length of the distal donut was 1.68±0.48 cm. Two distal margins and none of the proximal margins were positive for cancer. The mean length of the proximal margin was 8.69±4.48 cm. The mean length of the distal margin was 4.9±5.98 cm. Both patients had already received six months of pre-operative chemoradiotherapy and were not offered any additional treatment. Both patients were kept on close surveillance. Conclusion Routine analyses of the donuts after anterior resection has no impact on the management and outcome of the disease.

Diethylstilbestrol in the Treatment of Castration-resistant Prostate Cancer: A Lower-middle-income Country Experience.

INTRODUCTION:  Prostate cancer is the second most common cancer and the fifth leading cause of death worldwide. Its metastatic stage is associated with considerable morbidity and may lead to death. In Pakistan, given the high levels of economic constraint, patients with castration-resistant metastatic prostate cancer can be treated with cost-effective medications like diethylstilbestrol (DES). OBJECTIVES:  The goal of this study was to assess the efficacy and adverse effects of DES when used in patients with castration-resistant prostate cancer (CRPC). MATERIALS AND METHODS:  From January 2011 to December 2016, all medical records of patients with a diagnosis of prostate cancer resistant to the effects of castration presenting at Shaukat Khanum Cancer Hospital and Research Centre, Lahore, were reviewed. All patients were treated with DES (2.5 mg) initially, but the dose was increased for some patients to 5 mg in combination with aspirin (75 mg). The patients were followed clinically with prostate-specific antigen (PSA) value assessment. The PSA response to treatment, time to disease progression, and adverse events were recorded and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). RESULTS: A total of 91 patients were included in the study, and the mean patient age was 66 ± 8 years. The median baseline PSA was 150 ng/mL (range: 56-626 ng/mL), and the median Gleason's score was eight. A total of 90.1% of patients had metastatic disease at the time of diagnosis. Hormonal ablation was provided with bilateral orchiectomy for 71 patients (78.0%), and luteinizing hormone-releasing hormone (LHRH) analog was provided for 20 patients (22.0%). With this treatment, the median time to PSA progression was 597 days. After DES treatment was started, 78 patients (87.7%) showed a PSA response, and median time to progression was 212 days. In 24 patients (26.4%), the PSA response was maintained for more than a year. The PSA response was quantified as a good response (i.e., ≥50% PSA drop) or as a partial response (i.e., <50% PSA drop). The good PSA response was observed in 56 patients (61.5%) with a median time to progression of 273 days, and 22 patients (24.2%) had a partial response maintained for 109 days. Thirteen patients (14.3%) did not respond to DES treatment. The median percent change in PSA was -55.52% (range: -99.9 to +422). Thromboembolic complication was observed in eight patients (8.7%) patients while two patients suffered from liver toxicity. CONCLUSION:  DES is an effective, economical, and relatively safe drug in patients with CRPC.

Retrospective study of rare cutaneous malignant adnexal tumors of the head and neck in a tertiary care cancer hospital: a case series.

BACKGROUND: Adnexal tumors of the skin are a large and diverse group of benign and malignant neoplasms, which exhibit morphological differentiation toward one of the different types of adnexal epithelium present in normal skin and they pose a diagnostic challenge. The purpose of this study is to share our experience with these rare but aggressive tumors at a tertiary care cancer hospital in a developing country. A retrospective review of 11 patients diagnosed with rare adnexal tumors and their variants from January 2005 to December 2014, treated either surgically or non-surgically, was performed to describe the clinicopathological characteristics and outcome of the disease. CASE PRESENTATION: A total of 11 patients were diagnosed with adnexal carcinoma and its variants: a 34-year-old Sindhi man, a 59-year-old Punjabi woman, a 32-year-old woman from Khyber Pakhtunkhwa, a 43-year-old Punjabi woman, a 64-year-old Punjabi man, a 51-year-old man from Khyber Pakhtunkhwa, a 51-year-old Punjabi woman, a 74-year-old Punjabi woman, a 75-year-old Punjabi man, a 61-year-old man from Khyber Pakhtunkhwa, and a 53-year-old man from Khyber Pakhtunkhwa. The male to female ratio was 1.2:1. The histological variations were sebaceous differentiation (n = 4), microcystic adnexal carcinoma (n = 4), trichilemmal carcinoma (n = 1), pilomatrix carcinoma (n = 1), and hidradenocarcinoma (n = 1). The mean age at presentation was 54 years (range 32 to 75). The primary subsite of involvement was the scalp in nine patients followed by eyelids in two patients. Surgery was the primary treatment modality in almost all patients; postoperative radiotherapy (PORT) was offered to eight patients. The median dose of radiation was 45 Gy to the primary site. Indications for radiotherapy included close margins (n = 2), positive margins (n = 1), high grade histology (n = 4), and multifocal disease (n = 1). On follow-up, two patients presented with local, one regional and two patients developed distant metastasis. CONCLUSIONS: Adnexal carcinomas are rare tumors with diverse histological patterns and a tendency for locoregional and distant metastasis. Surgery should be the mainstay of treatment reserving radiotherapy for adjuvant, palliative, and re-treatment scenarios.