Multivariate Analysis of Effective Dose and Size-Specific Dose Estimates for Thorax and Abdominal Computed Tomography.

The study aimed to compute the effective dose (E) and size-specific dose estimate (SSDE) of routine adult patients undergoing thorax and abdominal computed tomography (CT) imaging and to present their multivariate analysis. All adult thorax and abdominal CT examinations conducted from March 2022 to June 2022 were prospectively included in this study. The Water Equivalent Diameter (Dw) and SSDE of all the examinations were computed from CT dose index volume (CTDIvol) and Dose length product (DLP) displayed on the dose report in the CT console. The multivariate statistical analysis was performed to investigate the correlation of SSDE and E on CTDIvol, Dw area of the region of interest (ROI) (AreaROI), body mass index (BMI), conversion factor (fsize) and hounsfield (HUmean) number in the ROI at 95% level of significance (P < 0.05). The linear regression analysis was performed to investigate the dependence of SSDE and E on other parameters for both abdominal and thorax patients. A total number of 135 (Abdomen = 61 and Thorax = 74) measurements were performed. The mean value of effective dose for abdomen and thorax patients was found to be 7.17 ± 3.94 and 4.89 ± 2.16 mSv, respectively. The SSDE was observed to be 13.24 ± 3.61 and 13.04 ± 3.61 mGy for thorax and abdomen respectively. The multivariate analysis suggests that SSDE for abdominal CT is found significantly dependent on CTDIvol, Dw and fsize with P < 0.05 and E is found to be significantly dependent on DLP, AreaROI, Dw and fsize at 95% level of confidence for abdominal CT imaging. SSDE for thorax CT was found significantly dependent on BMI, CTDIvol, HUmean, Dw and fsize at 95% level of confidence. Furthermore, E was observed dependent on DLP at P < 0.05. The linear regression analysis also shows that E is strongly correlated with DLP (r = 1.0) for both thorax and abdominal CT, further the SSDE was observed strongly correlated with CTDIvol with r = 0.79 and r = 0.86 for abdomen and thorax CT respectively. A strong correlation was observed between BMI and for Dw abdominal CT imaging (r = 0.68). The mean value of SSDE for thorax is slightly greater than abdomen. The average value of effective dose for abdomen and thorax measurements was found to be 7.17 ± 3.94 and 4.89 ± 2.16 mSv and , correspondingly. SSDE for both abdomen and thorax CT is significantly dependent on CTDIvol, Dw and fsize at 95% level of confidence. The strong correlation was also observed E on DLP and SSDE on CTDIvol for both Abdomen and Thorax CT. The strong dependence of Dw on BMI (r = 0.68) is due to the excessive fat concentration around the stomach and abdomen.

Considerations in wound care of patients living with dementia.

The prevalence of wounds and comorbidities such as dementia increases with age. Given projected rises in population ageing and growth, the likelihood of encountering an overlap in these conditions in clinical practice has increased. Clinicians provide wound care for patients in a variety of settings, drawing on different evidence-based clinical guidelines. Most research into wound care has excluded patients with dementia. Therefore, the aim of this review is to provide safe strategies and methods of implementation in those patients living with dementia.

A time-series assessment of the productive and reproductive performance of Balochi sheep.

This study was carried out to find the environmental factors which have a significant effect on the productive and reproductive characteristics of the Balochi sheep. The study used data from 729 ewes and 71 rams for a period of 13 years (2003 to 2016) at the Sheep Research Center, Yet Abad, Balochistan, Pakistan. The productive characteristics considered for current study were weight, birth weight (BW), 90 days weight (3 MW), 180 days weight (6 MW), 270 days weight (9 MW), 365 days (12 MW), and 2 years weight (24 MW). Reproductive characteristics measured were ewe age at first service (AFS), service period (SP) of ewe, age at 1st lambing (AFL) of ewe, lambing interval (LI), and sex ratio. Restricted maximum likelihood (REML) assessments of different characteristics were analyzed for the Balochi sheep on the basis of location, birth year (YOB), season of birth (SOB), type of birth (TOB), and sex of lamb. The average means ± SE for BW, WW, 6 MW, 9 MW, 12 MW, and 24 MW, were 3.28 ± 0.83, 17.20 ± 2.04, 21.94 ± 1.60, 26.20 ± 2.87, 30.21 ± 3.58, and 37.11 ± 2.84 for ram and 2.56 ± 0.53, 15.69 ± 1.45, 19.57 ± 1.77, 24.07 ± 2.70, 27.46 ± 2.09, and 34.61 ± 2.32 for ewes respectively. The results of reproductive performance of the Balochi sheep age of ewe at the time of breeding, age at first service (AFS), service period (SP), age at first lambing (AFL), and lambing interval (LI) were 1078 ± 2.2, 579.61 ± 0.6, 206.25 ± 0.2, 731.67 ± 0.3, and 256.60 ± 0.3 days respectively. The twining and lambing rates were 10.12% and 86.78%, while the sex proportion for ram and ewes was 50.12:49.37. Area, sex, and TOB had a significant (p < 0.05) effect on weight while TOB (twinning rate) was higher in Balochi sheep. These conditions affected the productive and reproductive performance of the Balochi sheep. At Sheep Research Center, Yet Abad, Balochistan, Pakistan, performed fundamentally better in all qualities such as weight gain and reproductive performance. Supplements were given with feed to get maximum profit from the sheep of Yet Abad farm. The birth weight of males was higher than that of females and single conceived Balochi sheep were heavier than that of twins. Thus, it was concluded that the Balochi sheep can be improved with better management practices, feeding, and disease control.

Metatranscriptome sequencing identifies Escherichia are major contributors to pathogenic functions and biofilm formation in diabetes related foot osteomyelitis.

Osteomyelitis in the feet of persons with diabetes is clinically challenging and is associated with high rates of amputation. In this study RNA-sequencing was employed to explore microbial metatranscriptomes with a view to understand the relative activity and functions of the pathogen/s responsible for diabetes foot osteomyelitis (DFO). We obtained 25 intraoperative bone specimens from persons with confirmed DFO, observing that Escherichia spp. (7%), Streptomyces spp. (7%), Staphylococcus spp. (6%), Klebsiella spp. (5%) and Proteus spp. (5%) are the most active taxa on average. Data was then subset to examine functions associated with pathogenesis (virulence and toxins), biofilm formation and antimicrobial/multi-drug resistance. Analysis revealed Escherichia spp. are the most active taxa relative to pathogenic functions with K06218 (mRNA interferase relE), K03699 (membrane damaging toxin tlyC) and K03980 (putative peptidoglycan lipid II flippase murJ), K01114 (membrane damaging toxin plc) and K19168 (toxin cptA) being the most prevalent pathogenic associated transcripts. The most abundant transcripts associated with biofilm pathways included components of the biofilm EPS matrix including glycogen synthesis, cellulose synthesis, colonic acid synthesis and flagella synthesis. We further observed enrichment of a key enzyme involved in the biosynthesis of L-rhamnose (K01710 -dTDP-glucose 4,6-dehydratase rfbB, rmlB, rffG) which was present in all but four patients with DFO.

Listeria monocytogenes endograft infection after fenestrated endovascular aneurysm repair-a case report.

An extremely uncommon cause of endograft infections, Listeria monocytogenes graft infections are associated with high morbidity and mortality. Best managed with complete graft resection and long-term antibiotic therapy, we present a rare case of L. monocytogenes aortic graft infection managed successfully with direct sac drainage and lifelong suppressive antibiotic therapy.

Synergy in penicillin, cephalosporin, amphenicols, and aminoglycoside against MDR S. aureus isolated from Camel milk

Abstract This study investigated the synergy testing of penicillin, cephalosporin, amphenicols, and aminoglycoside in the camel milk (n=768 samples), subsequently used for isolation of MDR S. aureus targeting mecA gene. Antibiotic susceptibility of S. aureus showed >90% isolates were sensitive to ciprofloxacin and trimethoprim and resistant against oxacillin, ampicillin, and cefoxitin. Further, 50-85% of the S. aureus were sensitive to gentamicin, oxytetracycline, and chloramphenicol and resistant against cefotaxime, vancomycin, and cefixime. Minimum inhibitory concentration (MIC) of cefotaxime, (C) and ampicillin (A) in combination with gentamicin (G) was reduced by 99.34% and 70.46%, respectively, while with chloramphenicol (Ch), reduction was 57.49% and 60%, respectively. In addition, the Fractional Inhibitory Concentration Index (FICI) of G+A, Ch+C and Ch+G combinations showed synergy against 80%, 60%, and 30% of MDR S. aureus, respectively. Similarly, C+A and Ch+G displayed indifferent interaction against 70 % and 30% of isolates, respectively, while the later showed additive interaction against 10% of MDR S. aureus. Altogether, our results described effective combination of gentamicin and chloramphenicol with ampicillin and cefotaxime to combat MDR S. aureus

Repair of a late endoleak following complete proximal endograft fixation strut separation.

Introduced as an alternative endograft for those with unfavorable anatomy, bare metal suprarenal fixation barbs have been widely used for endovascular abdominal aortic repair. Type I endoleaks result in continued perfusion of the aneurysm sac and warrant prompt reintervention. We describe an unusual presentation and endovascular management of a late type IA endoleak secondary to complete separation of the suprarenal fixation struts in a Cook endograft after an uncomplicated, emergent infrarenal endovascular abdominal aortic repair 5 years earlier.

The role of nutrition in wound healing: an overview.

Wounds are a commonly encountered and complex entity in healthcare, and often require multidisciplinary involvement for their management. Wound care and healing are affected by a range of factors of which nutrition, a modifiable factor, plays an integral part. Familiarity with the phases of wound healing and the differing nutritional requirements at each stage is fundamental to managing wounds. Additionally, awareness of the signs of malnutrition, screening tools and educational resources for managing malnutrition in primary care settings are all vital to minimising malnutrition and its adverse effects on wound healing. This article reviews the phases of wound healing and the associated nutritional requirements required for optimal healing, the clinical signs of malnutrition and screening resources for identifying at-risk groups, as well as reviewing current guidelines for managing malnutrition in the inpatient and outpatient setting.

A systematic review of the effect of surgeon and hospital volume on survival in aortic, thoracic and fenestrated endovascular aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) is becoming a mainstay in vascular surgery, both in metropolitan and regional hospitals. This review aims to assess the impact of hospital and surgeon volume on perioperative mortality specific to this surgery type to support the use of this treatment modality extensively. METHODS: A literature search was performed on multiple dedicated medical databases using a detailed search strategy with terms focusing on hospital volume and EVARs. Inclusion and exclusion criteria were used to screen and evaluate suitable sources, focusing on operators and hospitals performing EVARs and the morbidity/mortality as outcomes. The results were then appraised using a PRISMA framework. RESULTS: We reviewed 45 articles. Twelve articles met inclusion criteria for complete review. There was no level 1 evidence, and only a single systematic review and meta-analysis. EVAR and thoracic EVAR perioperative mortality had no correlation with hospital volume. Limited evidence was presented for fenestrated EVAR, where a mortality risk based on hospital volume remains unanswered. Open procedures for aneurysm repair had perioperative mortality outcomes that grossly correlated with hospital volume, supporting their use in high-volume centers. CONCLUSIONS: With open aneurysm repairs having an increased mortality risk in low-volume centers, and endovascular treatment options gaining momentum, there is considerable support for the use of EVAR and thoracic EVAR in smaller regional centers safely and effectively. There is very limited evidence in the use of fenestrated EVAR, which remains unanswered, but presents a significant opportunity for research.

Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections.

AIMS: To utilise the 2019 International Working Group on the Diabetic Foot (IWGDF) - diabetic foot infection (DFI) guidelines as an audit tool for clinical practice in patients with diabetes attending a High-Risk Foot Service. METHODS: Data from 93 consecutive patients were collected over a 19-month period in patients attending a High-Risk Foot Service. The diagnosis and management of each patient in the sample were compared against the 2019 IWGDF DFI guidelines, grouped into four categories: Diagnosis, Microbiology, Treatment of soft tissue infection, and Surgical treatment and osteomyelitis. Deficits in performance were recorded using the recommendations as a benchmark standard. RESULTS: There were 109 DFI events. Nineteen (63%) of the recommendations were met, 7 (24%) were partially met, and four (13%) recommendations were not met. Fourteen of the sample had no documented requests for full blood counts. Tissue was obtained for culture in 32 (29%) of the sample. No percutaneous bone biopsies were performed. Only 13 (28%) patients had intraoperative bone specimens sent for culture and sensitivities, with no bone specimens sent for histopathology. Modification of antibiotic therapy following available culture results was low, occurring in 12 out of 63 possible occasions (19%). The duration of antibiotic regimens in PEDIS 2 infections and osteomyelitis was greater than that recommended. CONCLUSIONS: Utilising the IWGDF DFI guidelines to benchmark clinical practice is a useful tool to identify gaps in clinical performance or service delivery and may help to improve patient care.

Improving Abdominal Aortic Aneurysm (AAA) Screening Uptake through Patient Engagement-Analysis and Outcomes of Strategies to Improve Uptake at a Regional Program Level.

BACKGROUND: To identify areas of health inequality that adversely affect patient engagement at a regional level within the National Abdominal Aortic Aneurysm Screening Program (NAAASP). Patient-reported improvements to services were implemented and analysis of subsequent uptake undertaken. METHODS: A prospective study of 390 men who failed to attend their AAA screening invitation. Nonattendees were contacted by post and telephone. Patients were analyzed as per ethnicity, working status, and Index of Multiple Deprivation quintile. Patient-suggested improvements to the service were recorded, analyzed, and implemented. Uptake data were then collected for the subsequent two years. RESULTS: The Screening Management and Referral Tracking system used by NAAASP is 97% accurate in holding patient contact details, and nonattenders are four times more likely to respond to telephone contact. Reasons for failing to attend screening invitations include factors that can be addressed at a regional level such as: inconvenient timings/locations of screening clinics and a lack of awareness or understanding of what AAA screening means as well as language/literacy barriers. The incidence of AAAs in the nonattendee group was almost 3 times that of our general (attending) population. Afro-Caribbean men were disproportionately less likely to attend for screening. After implementing patient-suggested improvements to the service, screening uptake increased from 75.2% (2015-16 screening year) to 81.3% (2017-2018). CONCLUSIONS: To date, no other studies have gone on to assess the effectiveness of interventions targeted at reducing inequalities in NAAASP attendance, but we show an increase in local screening uptake of 6% in a 2-year period after implementing improvement strategies. This article adds to existing literature by confirming external factors such as social deprivation adversely influence screening uptake and that AAAs are more prevalent in socially deprived groups. It reinforces the importance of regional attempts to contact and engage nonattenders as they may be most at risk of developing AAAs.

Management of an inflammatory abdominal aortic aneurysm causing ureteric obstruction: a case report.

Inflammatory abdominal aortic aneurysms (IAAAs) are rare large-vessel pathology, with potentially life-threatening complications including obstructive uropathy secondary to retroperitoneal fibrosis. Comprising a small proportion of all AAA, their pathogenesis remains unknown, with the hypothesis of infective and immunological aetiologies circulating in current literature. Management principles of IAAAs aim at prevention of aortic rupture and include open-surgical or endovascular therapies. Due to their involvement of other structures, additional considerations are needed when approaching their management for optimal patient outcomes. We present the case of a 53-year-old otherwise healthy male with a large IAAA complicated by adjacent ureteric obstruction, successfully treated with ureteric stenting and delayed endovascular aortic aneurysm repair.

Upper limb phlegmasia cerulea dolens treated with single-session suction thrombectomy: a case report.

Phlegmasia cerulea dolens (PCD) of the lower limbs is a rare condition. PCD of the upper limbs is extremely uncommon, with only a select few cases documented in the literature. A complication of severe deep venous thrombosis, PCD, is characterized by the clinical triad of oedema, pain and limb cyanosis. Delays in treatment are associated with high rates of morbidity and mortality. We present a case of sudden-onset upper limb PCD in a 68-year-old man following haemodialysis through a long-term arteriovenous fistula. Prompt diagnosis and rapid initiation of intravenous anticoagulation followed by urgent single-session suction thrombectomy resulted in the successful restoration of vessel patency without any significant adverse sequelae on 3-month follow-up.

The management of malignant lower limb ulcers: clinical considerations.

Lower limb malignant ulcers are an uncommon finding, making diagnosis complex and their management costly. Yet, despite this, the increase in skin cancers over the past 30 years means that clinicians require an awareness and understanding of their existence, particularly in the primary care setting. Familiarity with common aetiologies and presentations is vital for prompt recognition, diagnosis and referral of wounds suspicious for malignancy. Lower limb malignant wounds often develop insidiously, with a wide variation in clinical presentation that overlaps between entities. Therefore, a fundamental algorithm for approaching lower limb ulcers that raise suspicion of malignancy should be possessed by all clinicians. This article reviews the clinical features of malignant wounds that should alert clinicians to the need for further evaluation, such as atypical location and appearance. The authors also highlight the various diagnostic and therapeutic modalities available and review current clinical guidelines for the referral and follow-up of suspicious lesions.

Acute bilateral renal vein thrombosis diagnosis and management: a case report.

Undifferentiated abdominal pain accounts for a significant proportion of emergency presentations and often presents as a diagnostic dilemma. Renal vein thrombosis (RVT) has many aetiologies including nephrotic syndrome, malignancy, trauma, infection and hypercoagulable states. RVT should be considered in cases of persistent abdominal pain where other, more common, pathologies have been excluded. We present the case of a 42-year-old male with a delayed diagnosis of bilateral RVT after presenting with multiple episodes of intractable abdominal pain and adverse sequelae of this condition. This case report aims to emphasize the importance of prompt RVT recognition and the utility of bedside emergency department (ED) investigations, which can guide initial differential diagnoses of abdominal pain, reduce the delay in diagnosis as well as limit unnecessary investigations.

Direct transarterial embolization via the deep circumflex iliac artery for a type II endoleak using a novel Onyx™ mixture.

Internal iliac artery aneurysms (IIAA) can be associated with abdominal aortic aneurysms. We describe a technique of successful transarterial embolization using a mixture of Onyx™ formulations in a 72-year-old with previous open and endovascular aneurysm repairs of his abdominal aorta and a residual large left IIAA causing a Type II endoleak. We demonstrate that utilization of the deep circumflex iliac artery is a safe and viable alternate route to treating IIAA when direct access is not achievable.

Different ambient management intervention techniques and their effect on milk production and physiological parameters of lactating NiliRavi buffaloes during hot dry summer of subtropical region.

In tropical countries, one of the major threats for diary animal production is climate change. Ambient management interventions are beneficial and are the dire need of animal production in tropics. Ambient management intervention and its effect on physiological performance of lactating NiliRavi buffaloes were investigated during the hot dry months (April to June) of Pakistan. Fifteen lactating NiliRavi water buffaloes of similar size, age, and same parity were randomly stratified into three groups, comprising of five animals in each group, designated as group S, SF, and SFS. Animals of group S (control) were kept just under the shade while the animals in group SF were provided shade plus fan, animals in group SFS were provided the shade, fan as well as sprinklers during the hot day hours between 10:00 AM to 6:00 PM. Shed conditions were same for all animals, isonitrogenous and isocaloric feed was provided to all animals. Milk production decreased with the increase in ambient temperature. Average dry matter intake in group S, SF, and SFS were 75%, 80%, and 90% of the total feed offered to the experimental animals, respectively. The mean rectal temperatures (°F) were 101.69, 101.19, and 100.85 in group S, SF, and SFS, respectively. Heat stress had pronounced effect on blood glucose level as indicated by the mean glucose concentration in group S and SFS being recorded at 78.04 mg/dl and 90.47 mg/dl, respectively. It is concluded that the buffaloes should be provided with sprinklers and fans to minimize heat load and maximize the production during hot dry season.