Nosocomial Infection Among Burn Patients Admitted to a Tertiary Care Hospital of Bangladesh: A Cross-Sectional Study

Nosocomial infection is a major challenge for the appropriate management of burns. The present study aimed to investigate incidence, risk factors, and causative organisms of nosocomial infection in burn patients of Khulna, Bangladesh. This cross-sectional study was conducted among patients admitted to the Burn and Plastic Surgery Department of Khulna Medical College Hospital (KMCH) from January to December 2020. Relevant data were collected from the patients' hospital records. Samples of wound swabs and blood were collected and cultured in the microbiology laboratory of KMCH. Logistic regression models were used to determine risk factors for infective complications in burn patients. All statistical analyses were carried out using SPSS version 26.0. A total of 100 burn patients were included. Mean age was 29.2 years with a male-female ratio of 1.3:1. Flame burns were most prevalent among the patients (41%), followed by scald (23%) and electric burns (15%). Almost 40% patients had full thickness burn. The incidence of nosocomial infection was 42% (wound infection 33% and septicemia 9%). Total body surface area of burn >40% (OR 7.56, 95% CI 2.89-19.81), full thickness burn (OR 34.40, 95% CI 3.25-97.14) and prolonged hospital stay (aOR 1.31, 95% CI 1.15-1.51) were significant risk factors for nosocomial infection. Staphylococcus aureus was the most commonly isolated organism (45%), followed by Streptococcus (24%), Pseudomonas aeruginosa (19%) and Escherichia coli (12%). As the epidemiology of nosocomial infection is not the same in different health facilities, a facility-based comprehensive burn management protocol considering the local epidemiology and causative organisms of burn wound infection is crucial for the prevention and management of nosocomial infections in burn patients.

Treatment Burden for Pediatric Eosinophilic Esophagitis: A Cross-Sectional Survey of Carers

OBJECTIVE

To investigate treatment burden and impact on health-related quality of life (HRQoL) for children with eosinophilic esophagitis (EoE) and their carers.

METHODS

An Australian cross-sectional online survey of carers of children aged 18 years and under with EoE between September 2018 to February 2019.

RESULTS

Of 181 complete responses, more than half of carers experienced reduced HRQoL since their child's diagnosis. Reported mean out-of-pocket expenditure for healthcare utilization (practitioner visits and treatment) was AUD$3064.3 annually. Backwards stepwise linear regression models showed that reduced ability to manage on income and missing more than one workday in the previous 30 days were significant predictors of lower carer HRQoL. Ability to manage on the current income described as "difficult some of the time," "difficult all of the time," and "impossible" were associated with lower child HRQoL. When compared with EoE diagnosis between 13 and 23 months of age, diagnosis between 2 and 4 years was a significant predictor of lowered child HRQoL.

CONCLUSIONS

Pediatric EoE in Australia leads to high treatment burden for carers. Changes in carer employment and income manageability can negatively impact carer psychosocial wellbeing. Carers of children with EoE need to be informed about available financial and social support to reduce treatment-related burden and improve the quality of life of both the carer and child.

Efficacy and safety of vitamin C in the management of acute respiratory infection and disease: A rapid review

BRIEF OVERVIEW

Current evidence from published systematic reviews indicate that oral intake of vitamin C may assist with symptoms of acute viral respiratory infections (ARI) by reducing fever and chills, relieving chest pain and assist in reducing symptoms of common cold-induced asthma. Intravenous (IV) vitamin C administration may reduce the need for vasopressor support and the duration of mechanical ventilations in critically ill patients in hospital. COVID-19 has similar signs and symptoms of ARI. Further studies involving patients with COVID-19, either through administration of oral vitamin C in mild cases or IV vitamin C in critical cases, would be advantageous to examine if it is safe and efficacious.

VERDICT

Oral vitamin C may assist with the symptoms of acute respiratory viral infections (ARI) and common cold-induced asthma but no studies have been identified justifying oral vitamin C for the prevention or treatment of coronavirus infections including COVID-19. When taken at onset of ARI, oral vitamin C may reduce the duration of symptoms including fever, chest pain, chills and bodily aches and pains. It may also reduce the incidence of hospital admission and duration of hospital stays. For individuals admitted to hospital with community-acquired pneumonia, vitamin C may improve respiratory function in more severe cases. No major adverse events nor interactions were reported by either method of administration. However, there is an absence of high quality, contemporary clinical research examining this topic. Current evidence suggests further studies are needed to better understand the value of both oral and IV vitamin C for ARI, including COVID-19.

The effects of N-acetyl cysteine on acute viral respiratory infections in humans: A rapid review

Current evidence suggests that N-Acetyl Cysteine (NAC) administration may help improve outcomes in people with acute respiratory distress syndrome and acute lung injury – conditions that closely resemble the signs and symptoms of COVID-19. Few mild and transient adverse events were reported in published randomised-controlled trials, indicating that NAC may be reasonably safe. These findings suggest that NAC may complement the management of COVID-19 infection, particularly when administered intravenously within an intensive care unit (ICU) environment.

Verdict

Current evidence suggests that N-Acetyl Cysteine (NAC) administration may help improve outcomes in people with acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) – conditions that closely resemble the signs and symptoms of COVID-19. In this rapid review, NAC was predominately administered intravenously to patients with ARDS or ALI, who were at risk of or requiring mechanical ventilation, and were admitted to a hospital intensive care unit. Findings indicated that NAC administration may assist in improving markers of inflammation or oxidation, systemic oxygenation, the need for / duration of ventilation, rate of patient recovery and clinical improvement score. The effects of NAC on patient length of stay, CT/x-ray images, mortality rate and pulmonary complications were inconclusive.

Few mild and transient adverse events were noted, indicating that NAC may be safe for use in acute respiratory distress syndrome or acute lung injury. Based on the evidence identified, and the similar symptomatic profiles of ARDS/ALI and COVID-19, the findings suggest that NAC may be used to complement the management of COVID-19 infection within an acute care setting. The safety and efficacy of orally administered NAC for the management of milder forms of COVID-19 infection within the community setting, remains uncertain. The current research evidence suggests NAC warrants further research for acute respiratory viral infections, including COVID-19.

The effect of Echinacea spp. on the prevention or treatment of COVID-19 and other respiratory tract infections in humans: A rapid review

Brief overview

Current evidence suggests that Echinacea supplementation may decrease the duration and severity of acute respiratory tract infections; however, no studies using Echinacea in the prevention or treatment of conditions similar to COVID-19 have been identified. Few adverse events were reported, suggesting that this herbal therapy is reasonably safe. Because Echinacea can increase immune function, there is a concern that it could worsen over-activation of the immune system in cytokine storm; however, clinical trials show that Echinacea decreases levels of immune molecules involved in cytokine storm.

Verdict

Echinacea supplementation may assist with the symptoms of acute respiratory infections (ARI) and the common cold, particularly when administered at the first sign of infection; however, no studies using Echinacea in the prevention or treatment of conditions similar to COVID-19 have been identified. Previous studies have reported that Echinacea may decrease the severity and/or duration of ARI when taken at the onset of symptoms. The studies reporting benefit used E. purpurea or a combination of E. purpurea and E. angustifolia containing standardized amounts of active constituents.Few adverse events from the use of Echinacea were reported, suggesting that this herbal therapy is reasonably safe. No human trials could be located reporting evidence of cytokine storm when Echinacea was used for up to 4 months.When assessing all human trials which reported changes in cytokine levels in response to Echinacea supplementation, the results were largely consistent with a decrease in the pro-inflammatory cytokines that play a role in the progression of cytokine storm and Acute Respiratory Distress Syndrome (ARDS), factors that play a significant role in the death of COVID-19 patients. While there is currently no research on the therapeutic effects of Echinacea in the management of cytokine storm, this evidence suggests that further research is warranted.

The effect of quercetin on the prevention or treatment of COVID-19 and other respiratory tract infections in humans: A rapid review

Brief overview

There is currently insufficient evidence to recommend quercetin supplementation as a therapy for the treatment or prevention of COVID-19. Three human clinical trials with low risk of bias suggest that oral quercetin may have a beneficial effect on the incidence and duration of respiratory tract infections in certain populations; however, further research is needed.

Verdict

Current evidence on the efficacy of quercetin supplementation in the treatment and prevention of COVID-19 is insufficient for its clinical recommendation at this time. Quercetin exhibits both immunomodulatory and antimicrobial effects in preclinical studies; however, only three human clinical trials, each with a low risk of bias rating, were identified in this rapid review. One study reported a decrease in incidence of upper respiratory tract infections following a competitive athletic event. A larger community clinical trial reported a benefit in older, athletic adults only.

Health Service Use and Treatment Choices for Pediatric Eosinophilic Esophagitis: Findings From a Cross-Sectional Survey of Australian Carers

Objectives: The incidence and the prevalence of eosinophilic esophagitis (EoE) are increasing, and healthcare utilization among children with EoE is high. This study provides novel insights into the health services and the treatments, including complementary medicines (CMs), used by carers to manage their children's EoE as well as the carers' beliefs and attitudes toward these treatments. Methods: A national cross-sectional online survey was conducted in Australia between September 2018 and February 2019. The survey included questions about health service and treatment utilization, health insurance and government support, health-related quality of life of children with EoE and their carers, views and attitudes toward CM use, and perceived efficacy of treatment. Results: The survey was completed by 181 carers (96.6% of whom were mothers) of EoE children. Most children (91.2%, n = 165) had seen a medical doctor for their EoE, and almost half had consulted with a CM practitioner (40.3%, n = 73). Pharmaceuticals (n = 156, 86.2%) were the most commonly used treatment option, followed by dietary changes (n = 142, 78.5%), CM products (n = 109, 60.2%), and CM therapies (n = 42, 23.2%). Most children received care from numerous practitioners on multiple occasions, indicating a substantial financial and treatment-related burden. Conclusions: A variety of practitioners are involved in the care of children with EoE, and a high rate of CM use warrants further attention to ensure that appropriate treatment is provided. Carer involvement and guidance, combined with individual practitioner expertise, referrals, and collaboration between providers, is essential to successfully navigate this complex disease and provide adequate care for these patients.

Double blind, randomised, placebo-controlled trial to evaluate the efficacy of esomeprazole to treat early onset pre-eclampsia (PIE Trial): a study protocol

INTRODUCTION

Pre-eclampsia is a major complication of pregnancy, globally responsible for 60 000 maternal deaths per year, and far greater numbers of fetal losses. There is no definitive treatment other than delivery. A drug that can quench the disease process could be useful to treat early onset pre-eclampsia, as it could allow pregnancies to safely continue to a gestation where fetal outcomes are significantly improved. We have generated preclinical data to show esomeprazole, a proton pump inhibitor used for gastric reflux, has potent biological effects that makes it a worthwhile therapeutic candidate. Esomeprazole potently decreases soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin secretion from placenta and endothelial cells, and has biological actions to mitigate endothelial dysfunction and oxidative stress.

METHODS AND ANALYSIS

We propose undertaking a phase II, double blind, randomised controlled clinical trial to examine whether administering 40 mg esomeprazole daily may prolong gestation in women with early onset pre-eclampsia. We will recruit 120 women (gestational age of 26+0 to 31+6 weeks) who will be randomised to receive either esomeprazole or an identical placebo. The primary outcome will be the number of days from randomisation to delivery. Secondary outcomes include maternal, fetal and neonatal composite and individual outcomes. Maternal outcomes include maternal death, eclampsia, pulmonary oedema, severe renal impairment, cerebral vascular events and liver haematoma or rupture. Neonatal outcomes include neonatal death within 6 weeks after the due date, intraventricular haemorrhage, necrotising enterocolitis and bronchopulmonary dysplasia. We will examine whether esomeprazole can decrease serum sFlt-1 and soluble endoglin levels and we will record the safety of esomeprazole in these pregnancies.

ETHICS AND DISSEMINATION

This study has ethical approval (Protocol V.2.4, M14/09/038, Federal Wide assurance Number 00001372, IRB0005239), and is registered with NHREC (ID 3649) and the Pan African Clinical Trial Registry (PACTR201504000771349). Data will be presented at international conferences and published in peer-reviewed journals.

155. UNDERSTANDING THE CROSSTALK IN THE HUMAN UTERINE CAVITY: ROLES FOR SOLUBLE MEDIATORS DURING EMBRYO IMPLANTATION

Embryo implantation requires synchronized dialogue between a receptive endometrium and an activated blastocyst via locally produced soluble mediators. During the mid-secretory (MS) phase of the menstrual cycle there is increased glandular secretion into the uterine lumen. These secretions contain important mediators that modulate the endometrium and support the conceptus during implantation. Analysis of the composition of uterine fluid across the menstrual cycle and in fertile and infertile women will, therefore, provide new insights into uterine receptivity. We hypothesized that multiplex platform analysis of human uterine lavages would identify soluble mediators important for the establishment of pregnancy in humans. Lavages were collected (by flushing the uterine cavity with 5mL of saline) from fertile and infertile women during the MS phase and from fertile women during the mid-proliferative (MP) phase of the menstrual cycle. Comparison of lavages from the three cohorts was performed using quantitative MilliplexTM Luminex® cytokine/chemokine assays containing 42-analytes. Luminex analysis detected a number of cytokines in uterine fluid, revealing 8 soluble mediators previously unknown in the endometrium and present in human uterine fluid including, PDGF-AA, TNFβ, sIL-2Rα, Flt-3 ligand, sCD40L, IL-7, IFNα2 and GRO. Furthermore comparison of the three cohorts revealed VEGF levels were significantly higher in the fertile (MS) fluid when compared to infertile. Functional studies demonstrated that rhVEGF treatment significantly increased the adhesive properties in cells present at the maternal-fetal interface. These findings suggest VEGF plays a role in regulating embryo implantation. Furthermore identifying the soluble mediators in uterine fluid may provide potential markers of endometrial receptivity, insight into the unique microenvironment essential for pregnancy and a profile of maternal factors that influence the implanting blastocyst.

532. SOLUBLE MEDIATORS IN THE HUMAN UTERINE CAVITY: POTENTIAL ROLES IN EMBRYO IMPLANTATION

Embryo implantation requires synchronized dialogue between a receptive endometrium and an activated blastocyst via locally produced soluble mediators. During the mid-secretory (MS) phase of the menstrual cycle there is increased glandular secretion into the uterine lumen. These secretions likely contain important mediators that modulate the endometrium and support the conceptus during implantation. Previously we identified that several chemokines were maximally produced during the MS phase by endometrial glandular epithelium (GE) (1, 2) and the presence of chemokine receptors on GE and human trophoblast (3). Furthermore recombinant human chemokines and endometrial epithelial cell-conditioned media stimulated trophoblast migration; this was attenuated by neutralizing specific chemokines (3). Chemokines also regulate a variety of adhesion and ECM molecules on trophoblast (4). Thus chemokines have important roles during embryo implantation. We hypothesized that chemokines are secreted into the uterine cavity and may act on the implanting blastocyst and the endometrium. This study aimed to identify chemokines in uterine fluid (collected by flushing the uterine cavity with 5mls of saline) from fertile women during the proliferative (non-receptive; n=4) and MS (receptive; n=4) phases of the cycle, and from women with unexplained infertility during the MS phase (n=4). Uterine fluid was analyzed using quantitative MilliplexTM Luminex® 42-plex cytokine/chemokine assays revealing the presence of IL-8, CCL2, CCL4, CCL7, CCL11, CCL22 and CX3CL1 in uterine fluid from all women. Importantly chemokine profiles were altered with both cycle phase and fertility; for example CCL4 and CCL22 levels were lower in the infertile cohort, where as CCL2 levels were higher in uterine fluid collected during the proliferative phase. Identifying the soluble mediators in human uterine fluid may provide potential markers of endometrial receptivity, insight into the unique microenvironment essential for pregnancy and a profile of maternal factors that influence the implanting blastocyst.

A molecular study of EBV DNA and p53 mutations in nasopharyngeal carcinoma of Saudi Arab patients

Tumor biopsies obtained from 25 Saudi Arab patients with nasopharyngeal carcinoma (NPC) were examined for the presence of Epstein-Barr virus (EBV) DNA detected by the polymerase chain reaction (PCR) and for the incidence of p53 mutations screened by a combination of PCR, single strand conformation polymorphism (SSCP) and PCR-restriction fragment length polymorphism (PCR-RFLP). DNA sequencing was carried out to confirm the occurrence of p53 mutation. While 92% of the tumor specimens were found to carry EBV DNA, only 1/25 showed the incidence of a homozygous mutation at codon 248 of the p53 gene. The data showed that despite a high association of EBV infection with Saudi NPC, the frequency of p53 mutations was very low. Our results are consistent with the worldwide observation of infrequent p53 mutations in NPC.

Effect of diabetic state and related disorders on the urinary excretion of magnesium and zinc in patients

We examined the urinary excretion of magnesium and zinc in 175 diabetics [19 insulin-dependent (type I) and 156 insulin-independent (type II)] and in 160 control subjects of the same origin by determining the ratio of the concentration of each of these metals to that of creatinine (creat). Electrothermal atomic absorption spectrophotometry was used for analyzing Mg and Zn in urine. There was no significant difference in the urinary excretion of Mg between the control group [mean (SEM) = 362.6 (15.1) mmole of Mg/mole of creat] and the overall [350.2 (15.7) mmole Mg/mole creat], type I [368.4 (45.0) mmole Mg/mole creat], or type II [347.9 (16.7) mmole Mg/mole creat] diabetics regardless of the disorders associated with diabetes (cardiovascular diseases, neuropathy, retinopathy, infections, and hepatic disease). In contrast, diabetics of both types [2.67 (0.14) mmole Zn/mole creat] with or without a diabetes associated disorder excreted significantly (p = 0.031 to 0.0000) more Zn than did the control subjects [1.76 (0.09) mmole Zn/mole creat]. There was positive correlation between hemoglobin A1c and urinary loss of Mg (p = 0.013) or Zn (p = 0.0241) in patients with type II diabetes. From these data, it appears that of the two elements examined only Zn is associated with higher urinary loss in diabetic state. The discrepancy between our results and those of previous studies for Mg may be ascribed to dissimilarities in the diet habits and metabolism of Mg among diabetics of different geographical origins.

Urinary excretion of chromium, copper, and manganese in diabetes mellitus and associated disorders

The urinary excretion of chromium, copper and manganese was determined in 185 diabetics and in an equal number of control subjects by measuring the concentration of each of these metals using electrothermal atomic spectrophotometry and dividing the values by the urinary concentration of creatinine (creat) in each subject. The mean (SEM) values for the overall diabetics and the control group were 2.32 (0.17) and 2.62 (0.22) mumol Cr/mole of creat, 76.5 (5.5) and 73.9 (6.1) mumol Cu/mole of creat, and 3.56 (0.44) and 2.66 (0.3) mumol Mn/mole of creat, respectively. There was no correlation between the urinary excretion of any of the metals examined and age or sex of either group. While the cardiovascular or ophthalmologic diseases associated with diabetes did not influence the excretion of any of these metals, significantly higher urinary excretion of Cu was exhibited by diabetics with neuropathy (p < 0.0027) or infections (p < 0.014) than by those without. Also, diabetics with liver disorders or those who were not treated with insulin excreted significantly more Mn than did their diabetic counterparts.

Systemic administration of glycosaminoglycan polysulphate (arteparon) provides partial protection of articular cartilage from damage produced by meniscectomy in the canine

Bilateral medial meniscectomy was undertaken in 14 mature beagles. Another two underwent arthrotomy (sham-operated controls). One week after surgery, six of the meniscectomised animals were administered glycosaminoglycan polysulphate (Arteparon) (2 mg/kg) subcutaneously three times a week for 3 weeks, then twice weekly until killed 23 weeks later. Two months before death all animals were given Na2(35)SO4 (1.0 mCi/kg) intravenously. At autopsy, articular cartilage (AC) from the medial and lateral compartments, as well as from the femoral trochlear groove and femoral head, was sampled. Proteoglycans (PGs) were isolated by 4.0 M Guanidine hydrochloride (GuHCl) extraction of AC and purified by ultracentrifugation. The PG monomers were assayed for hexuronic acid, protein, and hexosamines (galactosamine/glucosamine), and their ability to aggregate. The results indicated that Arteparon provided some protective effect to AC in the meniscectomised compartment as demonstrated histologically by reduced surface fibrillation, diminished chondrocyte cloning, and maintenance of alcianophilia. The levels of PGs and hexuronate-protein ratios in medial AC of drug-treated meniscectomised animals were found to be comparable to sham controls, whereas these parameters in the nondrug-treated meniscectomized group were depressed.