An observational study on the surgical antibiotic prophylaxis in the surgery ward of a tertiary care hospital

Background: Surgical site infection (SSI) is the most common postoperative complication and represents a significant burden in terms of patient morbidity, mortality and cost to health services around the world. Appropriate antibiotic prophylaxis helps in reducing the incidence of SSIs. Appropriate surgical prophylaxis is a multifactorial process that depends on proper case selection, antibiotic selection including dosing and route of administration and duration of therapy.Methods: A prospective observational study was conducted over 3 months on 200 operated patients in surgery ward of a tertiary hospital. Patient details like demography, type of surgery performed and antibiotics prescribed pre and post-surgical procedure was collected and analysed using Microsoft excel.Results: Out of 200 patients 32.5% (65) were females and 67.5% (135) were males. Total number of prophylactic antibiotics prescribed were 368. The most commonly prescribed group of antibiotics was cephalosporins (44.29%) followed by metronidazole (26.5%) and ofloxacin (9.48%). Among the cephalosporins the most commonly prescribed was cefuroxime in 82 patients (50.3%) and cefoperazone in 79 patients (48.46%). SSI developed in 3 out of 200 patients (1.5%).Conclusions: There is an urgent requirement to promote rational antibiotic prescribing among surgeons. The need of the hour is developing and implementing national guidelines for surgical prophylaxis by a multidisciplinary group of experts

Trichobezoars as a cause of intestinal obstruction in a young female

A bezoar is a mass found trapped in the gastrointestinal system, though it can occur in other locations. There are various types of bezoars including food boluses, lactobezoar, pharmacobezoar, phytobezoar, diospyrobezoar and trichobezoar. They are common in children and adolescents, and 90% of the patients are women. Complications may manifest as gastric outlet obstruction or bleeding and intestinal obstruction. CT is the preferred image modality for the evaluation of suspected trichobezoars in order to characterize the size, location, presence and level of obstruction and complications such as ischemia or perforation. Here authors present a case to stress the importance of considering trichobezoars as one of the causes for intestinal obstruction in young females.

FORMULATION OPTIMIZATION AND EVALUATION OF FLURBIPROFEN EMULGEL

Objective: The objective of the present study was to formulate flurbiprofen (FLB) emulgel, evaluation of the formulations and the selection of an optimized formulation through in vitro drug release and drug content studies. Flurbiprofen is a non-steroidal anti-inflammatory drug (NSAID) requiring frequent administration and its chronic intake can lead to systemic side effects like gastric irritation and GI bleeding. The development of a dermal drug delivery system can overcome these side effects. Methods: The emulgel formulations were produced using different combinations of oil and emulsifying agents. Carbopol 940 was used as a gelling agent. The prepared emulgels were evaluated for general appearance, pH, spreadability, extrudability, drug content, in vitro drug release, average globule size and viscosity. Results: Optimized formulation F7 showed a better in vitro drug release compared to the marketed gel preparation. The stability study for the optimized formulation was carried out at 25 °C/60 % RH for 3 mo and the emulgel was found to be stable concerning the physical appearance, pH and drug content. Conclusion: The study revolved around the formulation of emulgel containing Flurbiprofen for dermal delivery of the drug. Emulgel was formulated with the purpose to enhance the permeation of poorly water-soluble drug FLB. The study concluded that the optimized emulgel containing FLB exhibited better in vitro drug release profile compared to the marketed formulation

A phase 2, multicenter, open‐label study of sepantronium bromide (YM155) plus docetaxel in patients with stage III (unresectable) or stage IV melanoma

Survivin is a microtubule‐associated protein believed to be involved in preserving cell viability and regulating tumor cell mitosis, and it is overexpressed in many primary tumor types, including melanoma. YM155 is a first‐in‐class survivin suppressant. The purpose of this Phase 2 study was to evaluate the 6‐month progression‐free survival (PFS) rate in patients with unresectable Stage III or IV melanoma receiving a combination of YM155 plus docetaxel. The study had two parts: Part 1 established the dose of docetaxel that was tolerable in combination with YM155, and Part 2 evaluated the tolerable docetaxel dose (75 mg/m2) in combination with YM155 (5 mg/m2 per day continuous infusion over 168 h every 3 weeks). The primary endpoint was 6‐month PFS rate. Secondary endpoints were objective response rate (ORR), 1‐year overall survival (OS) rate, time from first response to progression, clinical benefit rate (CBR), and safety. Sixty‐four patients with metastatic melanoma were treated with docetaxel and YM155. Eight patients received an initial docetaxel dose of 100 mg/m2 and 56 patients received 75 mg/m2 of docetaxel. Six‐month PFS rate per Independent Review Committee (IRC) was 34.8% (n = 64; 95% CI, 21.3–48.6%), and per Investigator was 31.3% (n = 64; 95% CI, 19.5–43.9%). The best ORR (complete response [CR] + partial response [PR]) per IRC was 12.5% (8/64). The stable disease (SD) rate was 51.6% (33/64), leading to a CBR (CR + PR + SD) of 64.1% (41/64). Estimated probability of 1‐year survival was 56.3%. YM155 is a novel agent showing modest activity when combined with docetaxel for treating patients with melanoma. YM155 was generally well tolerated, but the predetermined primary efficacy endpoint (i.e., 6‐month PFS rate ≥20%) was not achieved.YM155 is a first‐in‐class agent that suppresses surviving. Though YM155 combined with docetaxel was generally well‐tolerated in this study, it showed limited efficacy in the treatment of metastatic melanoma.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111757/1/cam4363.pd

Sustainability in pediatric hospitals: An exploration at the intersection of quality improvement and implementation science

BACKGROUND: Although new evidence-based practices are frequently implemented in clinical settings, many are not sustained, limiting the intended impact. Within implementation science, there is a gap in understanding sustainability. Pediatric healthcare settings have a robust history of quality improvement (QI), which includes a focus on continuation of change efforts. QI capability and sustainability capacity, therefore, serve as a useful concept for connecting the broader fields of QI and implementation science to provide insights on improving care. This study addresses these gaps in understanding of sustainability in pediatric settings and its relationship to QI. METHODS: This is a cross-sectional observational study conducted within pediatric academic medical centers in the United States. Clinicians surveyed worked with one of three evidence-based clinical programs: perioperative antimicrobial stewardship prescribing, early mobility in the intensive care unit, and massive blood transfusion administration. Participants completed two assessments: (1) the Clinical Sustainability Assessment Tool (CSAT) and (2) a 19-question assessment that included demographics and validation questions, specifically a subset of questions from the RESULTS: A total of 181 individuals from three different programs and 30 sites were included in the final analyses. QI capability scores were assessed as a single construct (5-point Likert scale), with an average response of 4.16 (higher scores indicate greater QI capability). The overall CSAT score (7-point Likert scale) was the highest for massive transfusion programs (5.51, SD = 0.91), followed by early mobility (5.25, SD = 0.92) and perioperative antibiotic prescribing (4.91, SD = 1.07). Mixed-effects modeling illustrated that after controlling for person and setting level variables, higher perceptions of QI capabilities were significantly related to overall clinical sustainability. CONCLUSION: Organizations and programs with higher QI capabilities had a higher sustainability capacity, even when controlling for differences at the individual and intervention levels. Organizational factors that enable evidence-based interventions should be further studied, especially as they relate to sustainability. Issues to be considered by practitioners when planning for sustainability include bedside provider perceptions, intervention achievability, frequency of delivery, and organizational influences

Mobilization practices in critically ill children: a European point prevalence study (EU PARK-PICU)

Early mobilization of adults receiving intensive care improves health outcomes, yet little is known about mobilization practices in paediatric intensive care units (PICUs). We aimed to determine the prevalence of and factors associated with physical rehabilitation in PICUs across Europe. A 2-day, cross-sectional, multicentre point prevalence study was conducted in May and November 2018. The primary outcome was the prevalence of physical therapy (PT)- or occupational therapy (OT)-provided mobility. Clinical data and data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥72 h. Data of 456 children admitted to one of 38 participating PICUs from 15 European countries were collected (456 patient days); 70% were under 3 years of age. The point prevalence of PT- and/or OT-provided mobility activities was 39% (179/456) (95% CI 34.7-43.9%) during the patient days, with significant differences between European regions. Nurses were involved in 72% (924/1283) of the mobility events; in the remaining 28%, PT/OT, physicians, family members, or other professionals were involved. Of the factors studied, family presence was most strongly positively associated with out-of-bed mobilization (aOR 7.83, 95% CI 3.09-19.79). Invasive mechanical ventilation with an endotracheal tube was negatively associated with out-of-bed mobility (aOR 0.28, 95% CI 0.12-0.68). Patients were completely immobile on 25% (115/456) of patient days. Barriers to mobilization were reported on 38% of patient days. The most common reported patient-related barriers were cardiovascular instability (n = 47, 10%), oversedation (n = 39, 9%), and medical contraindication (n = 37, 8%). Potential safety events occurred in 6% of all documented mobilization events. Therapists are infrequently consulted for mobilization of critically ill children in European PICUs. This study highlights the need for a systematic and interdisciplinary mobilization approach for critically ill children

Fast relaxation in a fragile liquid under pressure

The incoherent dynamic structure factor of ortho-terphenyl has been measured by neutron time-of-flight and backscattering technique in the pressure range from 0.1 MPa to 240 MPa for temperatures between 301 K and 335 K. Tagged-particle correlations in the compressed liquid decay in two steps. The alpha-relaxation lineshape is independent of pressure, and the relaxation time proportional to viscosity. A kink in the amplitude f_Q(P) reveals the onset of beta relaxation. The beta-relaxation regime can be described by the mode-coupling scaling function; amplitudes and time scales allow a consistent determination of the critical pressure P_c(T). alpha and beta relaxation depend in the same way on the thermodynamic state; close to the mode-coupling cross-over, this dependence can be parametrised by an effective coupling Gamma ~ n*T**{-1/4}.Comment: 4 Pages of RevTeX, 4 figures (submitted to Physical Review Letters

The mean-squared displacement of a molecule moving in a glassy system

The mean-squared displacement (MSD) of a hard sphere and of a dumbbell molecule consisting of two fused hard spheres immersed in a dense hard-sphere system is calculated within the mode-coupling theory for ideal liquid-glass transitions. It is proven that the velocity correlator, which is the second time derivative of the MSD, is the negative of a completely monotone function for times within the structural-relaxation regime. The MSD is found to exhibit a large time interval for structural relaxation prior to the onset of the $\alpha$-process which cannot be described by the asymptotic formulas for the mode-coupling-theory-bifurcation dynamics. The $\alpha$-process for molecules with a large elongation is shown to exhibit an anomalously wide cross-over interval between the end of the von-Schweidler decay and the beginning of normal diffusion. The diffusivity of the molecule is predicted to vary non-monotonically as function of its elongation.Comment: 18 pages, 12 figures, Phys. Rev. E, in prin

Ipilimumab administration for advanced melanoma in patients with pre-existing Hepatitis B or C infection: a multicenter, retrospective case series

Ipilimumab is a fully human, monoclonal antibody directed against Cytotoxic T Lymphocyte Antigen-4 (CTLA-4) that has demonstrated a survival benefit and durable disease control in patients with advanced melanoma. Ipilimumab is associated with potentially serious immune-related adverse events, including autoimmune hepatitis. Because clinical trials of ipilimumab excluded patients with pre-existing hepatitis B or C infection, there is a paucity of data on the safety of ipilimumab administration to that patient population. Here, we report the largest case series to date of patients with hepatitis B or C who received ipilimumab for advanced melanoma. Two of the nine patients described in this case series experienced fluctuations in their liver function tests (LFTs) and were subsequently treated with corticosteroids. Although this is a small series, the rate of hepatotoxicity appears similar to what has been seen in the general population treated with ipilimumab, and the ability to administer ipilimumab did not appear to be affected by concomitant hepatitis B or C infection. The use of ipilimumab in patients with metastatic melanoma who have pre-existing hepatitis can be considered among other therapeutic options

Impact of a Multifaceted Early Mobility Intervention for Critically Ill Children - the PICU Up! Trial: Study Protocol for a Multicenter Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND: Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery. METHODS: The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial\u27s primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery. DISCUSSION: This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04989790. Registered on August 4, 2021