Efforts to improve diagnosis of bacteraemia by reducing blood culture contamination in an emergency department: Strategies and outcome

Objective: To assess the strategies and outcome for reducing blood culture contamination in order to improve the diagnosis of bacteraemia.Methods: The interventional study was conducted at a tertiary care hospital in Karachi from January 1, 2013, to December 31, 2016. The blood culture contamination data related to the first year of the study was taken as the baseline pre-intervention data. Strategies were planned as intervention for improvement by consolidating training and education in the form of dedicated lectures, practising on mannequins and developing in-house video, replacing povidone with 2% chlorhexidine preparation spray plus 70% isopropyl alcohol swabs and inducting dedicated phlebotomy team whose only responsibility was blood sample collection and minimising the probability of error.Results: In 2013, there were 8868 samples; 7402 in 2014; 6897 in 2015; and 9756 samples in 2016. The contamination rate in 2013 was 8% which went down to 7.75% in 2014, 4.25% in 2015 and 3.9% in 2016. The decline became statistically significant (p\u3c0.001) after implementing a dedicated phlebotomy team in the emergency department.Conclusions: Apart from teaching and training, the concept of blood culture collection kit with checklist and dedicated blood collection team was found to be vital in reducing blood culture contamination

Primary Soft Tissue Orbital Ewing’s Sarcoma Causing Unilateral Visual Loss: A Case Report

A case of primary Ewing's sarcoma of right orbit causing unilateral visual loss in a 3 year old female child is reported. The child presented with 1 year history of painless unilateral proptosis and loss of vision. Loss of vision due to primary Ewing's sarcoma in orbit is extremely rare and it should be considered as one of the differential diagnoses while dealing the patient with these sorts of clinical presentation

Microdiscectomy in Relieving Neurological Symptoms in Patients with Lumbar Disc Herniation

Introduction: Minimally invasive spine surgical approaches such as microdiscectomy have gained attention in recent years due to less tissue damage, speedy and acceptable neurological improvement with less complication.Objective: To assess efficacy of microdiscectomy in improving neurological status in patients with lumbar disc herniation.Material and Methods: A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean ± SD, Median (Range) and Frequency (percentage). Mc Neumer’s chi square test and paired t test were used to see association between pre-operative and post-operative Neurological status (MRC grade, sensory status, SLR) depending on their nature viz: qualitative or quantitative respectively in SPSS version 15 and hence efficacy of microdiscectomy was assessed.Results: Out of 70 patients 74% were male and 26% were females. Mean ± SD of patients was 37.6 ± 13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common characteri-stics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5-S1 level (96%) where Prolapse and extrusion were most common MRI findings. As compared to pre-operative (3.4) muscle power 1st and 42nd day power were respectively 4.0 and 4.7 (p = 0.001). Pre-operatively only 32 (45.7%) had normal sensation which improved to 38 (54.3%) and 51 (72.9%) respectively in 1st and 42nd day of surgery (p = 0.001). Pre-operative mean SLR improved to 98.6 degrees in 1st POD and continued to be the same till 42nd day (p = 0.001). All the MRC findings, sensory status and SLR values in each post-operative days were statistically significant with the baseline by paired t test (p = 0.001).Conclusion: Microdiscectomy is one of the effective procedures which can be adopted for symptomatic unilateral lumber disc herniation with significant improvement in Neurological statuses

Roles of Sociodemographic Characteristics in Determining Neurological Outcomes in Patients with Lumbar Disc Herniation after Microdiscectomy

Introduction: Socio-demographic characteristics like age, gender, occupation has important role in causation of lumbar disc herniation which may even affect their recovery after the surgery. We want to explore the difference in improvement in Neurological status in terms of difference in socio-demographic characteristics of patients.Objective: To find variation in improvement in Neurological status in post microdiscectomy lumbar disc herniation patient stratified in terms of socio-demographic characteristics.Material and Methods: A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean ± SD, Median (Range) and Frequency (percentage). Comparisons between categorical and continuous variables were done with the help of t test and one way ANOVA and comparison between both categorical variables was done with the help of chi square test in SPSS version 15.Results: Out of 70 patients 74% were male and 26% were females. Mean ± SD of patients was 37.6 ± 13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common charac-teristics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5-S1 level (96%) where Prolapse and extrusion were most common MRI findings. Improvement in motor power, sensory status was not dependent on any of socio-demographic characteristics. Improvement on SLR was associated with male genders on 1st (p = 0.03) as well as 7th, 21st and 42nd PODs (p = 0.001).Conclusion: Except gender in SLR value improvement, no other socio-demographic characteristics alter the improvement status in LDH patient after microdiscectomy

Spinal Tumours: - Experience at Mayo Hospital

Objective: Spinal tumours are mostly benign, having devastating effects on patients in terms of patient’s dis-ability, morbidity and mortality. Depending upon their site, size and growth potential, they have different clinical effects on the patients. We are presenting a case series of 138 patients managed in neurosurgery department Mayo hospital from Nov 2011 to Sept 2014.metastatic bony spinal lesions were not included in this study . The objectives of my study are to determine: Types of spinal tumours treated in this setting. Common and differenti-ating clinical features among subjects, different locations of the same types and the role of microsurgery. Materials and Methods: It is a retrospective study. 55 Schawanomas, 34 Menengiomas, 15 Ependimomas, 06 Dermoids, 17 Astrocytomas, 07 Plasmacytomas, 02 Aneurysm bone cyst and 02 Teratomas were managed surgi-cally. Schwanoma and meningioma’s prevalence was more in cervical and dorsal areas. plasmacytomas mainly affected dorsal spine, astrocytomas and ependymomas hade different locations. Teratomas occupied conus medu-llaris. Multiple laminectomies and laminotomies were performed according to situation. Radical resections for intradural extramedullary and gross total debulking for intramedullary lesions, under high resolution Microscope was done. Post operative improvements and complications were noted. Results: A radical resection of these tumors results in a good long-term outcome, since the majority is histolo-gically benign. For intradural intramedullary tumours gross total debulking is more appropriate. Adjuvant radi-ation therapy should only be administered for the high grade or malignant tumor. Malignant tumors have a dismal outcome and surgery in these patients should be a conservative debulking. Open door laminotomies are preferable in intradural extramedulary lesions and does not cause post op spinal deformity. Conclusion: Radical surgery for spinal tumors with laminotomies gives good results in terms of patient’s func-tionality and spinal stability

Prognostic Indicators in Patients with Severe Head Injury: A 2 Year Retrospective Experience at Mayo Hospital, Lahore

Introduction: Traumatic brain injury (TBI) is an important public health care problem in the western world and equally being pandemic in the developing world. It is one of the most common causes of death in young adults and it can affect people’s lives enormously. Since many years the prognostic indicators of severe head injury had been field of research. Knowing the factors responsible for poor prognosis and preventing them outcome of severe head injury can be improved.Material and Methods: A retrospective study was conducted analyzing past records of the patients in department of Neurosurgery, Mayo Hospital from Nov 2011 to Nov 2013 with diagnosis of severe head injury (Glasgow Come Scale < 9). All patients except the patients with brain death, associated poly trauma, spinal injuries were excluded from the study. Total sample of 236 either managed conservatively or surgical and observed in Intensive care unit were study population. Prognosis was assessed with Glasgow Outcome Score (GOS) on or before (if patient expired before 30 days) 30 post admission day. Age, GCS, CT findings, Pupils were compared with GOS to find probable predictors of prognosis. GOS of less than 4 was regarded as poor prognosis. Categorical variables like GCS, pupils, CT findings were presented in the form of frequency (percentage) whereas continuous variables like age were presented in the form of mean ± SD and median (range). Association between GOS and probable prognostic indictors was seen by chi square test.Results: Out of 236 patients, 188 were male and 48 were female. Mean ± SD age of patient was 32.8 ± 14.6 years. Age group 15 – 45 years had maximum number of patients. Road traffic accident was major cause of severe head injury and majority had GCS 3 after resuscitation. More than half of the patient had bilaterally reactive pupils, 10% patient had post traumatic fits and half of the patients had features of base of skull fracture. 208 (8%) patient had abnormal CT findings. 30% patient on CT scan had closed cisterns and half of the patients has midline shift of 1.5 – 3 mm. More than 35% cases had surgical lesions over CT scan. Patients with age group < 15 years, GCS < 4, with closed cisterns, with surgical lesions and with midline shift of more than 3 mm had 30 day GOS < 4, which is regarded as poor prognostic marker.Conclusion: Prognosis in patient with severe head injury is determined by age, presenting post resuscitation GCS, mode of injury, CT findings and surgical lesions