Introduction: Multidrug resistance bacteria is alarming worldwide. A lot of research were done and are ongoing to search for the best, convenient and economically affordable ways to fight them. With the latest genome editing tool; Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) technology, this research was performed to develop a novel strategy to genetically modify the genome and inhibit the growth of Klebsiella pneumoniae (UPM ESBLKP1), an Extended Spectrum Beta Lactamases (ESBL) organism. Methods: A CRISPR-Cas9 vector was constructed together with guide RNAs designed specifically for the targeted uppP gene, a gene responsible for bacterial cell growth and protection. Results: The growth and cell wall integrity of the modified Klebsiella pneumoniae (ΔUPM ESBLKP1) were significantly inhibited and reduced, respectively. Interestingly, wild type Klebsiella pneumoniae showed a normal growth curve while modified strains showed a faster doubling rate when supplemented with Luria-Bertani media. In contrast, slower growth rate of modified strain was observed in the M9 minimal media. This explained the higher doubling rate of mutants on nutrient rich medium earlier is being related to gene recovery. They grew slowly in the minimal media as they were adapting to a new environment while recovering the uppP gene and surviving, proving the success of its gene modification. Conclusion: The developed CRISPR-gRNA system was able to modify the targeted Klebsiella pneumoniae gene hence providing an opportunity to develop a new drug for Klebsiella pneumoniae infection as an alternative to antibiotics.

Estimating Surgical Duration for Surgeries: Towards an Efficient Schedule of Operating Theatre Poor operation theatre (OT) scheduling is a common cause of case cancellation on the day of surgery. We analysed the accuracy of anaesthetists and surgeons in estimating the surgical time to complete an operation and investigated whether the estimated times was correlated with the actual surgical time. It was a prospective observational study with 369 elective cases from various surgical subspecialties which were performed within three months in a tertiary university hospital. Anaesthetists and surgeons were required to estimate the surgical time of the elective cases before the day of surgery. Their estimations were compared with the recorded actual surgical time. The primary outcome was the median time difference from the estimated surgical time. Anaesthetists accurately estimated surgical times of 82 cases (22%) and surgeons 59 cases (16%). Overall, anaesthetists overestimated the surgical time by 11 minutes of actual surgical times [interquartile range (IQR) -15 to 40 minutes]. Surgeons underestimated their surgical time by 15 minutes [IQR -60 to 20 minutes]. The median estimated surgical time difference between anaesthetists and surgeons was significantly different (p<0.0001). Among the surgical subspecialties, the longest overestimation by anaesthetists was up to 48 minutes in colorectal surgeries. The most underestimated median time difference by surgeons was 65 minutes, seen in upper gastrointestinal surgeries. A significant strong positive correlation existed between overall anaesthetists' estimated and actual surgical times (rs = 0.735, p<0.0001). At the same time, there was a weak correlation between surgeons’ overall estimation time upon booking and actual surgical times (rs = 0.492, p<0.0001). In conclusion, both the anaesthetists and surgeons were significantly inaccurate in estimating the duration of surgical procedures. Although the anaesthetists tended to overestimate it while surgeons underestimated it, their estimations correlated strongly with the actual surgical times, whereas surgeons’ estimations were weakly correlated

Introduction: Effective post-operative analgesia is a major factor in functional outcome after total knee arthroplasty (TKA). To reduce post-operative pain and expedite recovery, peripheral nerve blocks, such as the femoral nerve block (FNB) have been used as an adjunct to the analgesic regime. We assessed whether the addition of a FNB to continuous epidural analgesia (CEA) would improve pain control after TKA. Materials and Methods: A prospective, randomised, controlled study was conducted on 58 patients undergoing TKA and randomised into two groups. The CEA+FNB Group received a single-shot FNB of 30 ml 0.5% bupivacaine using a nerve stimulator technique. The CEA Group acted as a control group and did not receive FNB. Patients in both groups then received combined spinal-epidural anaesthesia for the surgery. Post-operative epidural infusion with 0.1% bupivacaine and 2 μg/ml of fentanyl, at 6 ml/hr was continued up to 48 hours post-operatively. Visual analogue scale (VAS) scores, motor blockade, requirement of rescue analgesia and patient satisfaction were recorded. : Results: VAS scores were not significantly different between the CEA+FNB and CEA groups during rest (3 vs. 2) and flexion (5 vs. 6) on postoperative day-1 and during rest (1 vs. 2) and flexion (4 vs. 4) on postoperative day-2. There was no significant difference in rescue analgesia required, the volume of epidural infusion, motor blockade or patient satisfaction between both groups. Conclusion We concluded that the addition of FNB to epidural infusion did not improve analgesia after TKA.

Introduction: Pulmonary aspiration of gastric contents is a potentially life threatening complication of general anaesthesia especially in high risk patients undergoing emergency anaesthesia. Classically,ranitidine has been used to reduce gastric pH and volume. Esomeprazole, the S-isomer of omeprazole, is a newer generation proton pump inhibitor whose effect on gastric pH and volume in emergency surgeries has not been determined. Materials and Methods: This was a prospective, randomised, double blind study to compare the effect of intravenous esomeprazole and ranitidine on gastric pH and volume in patients undergoing emergency appendicectomy. Following induction of anaesthesia, seventy patients of American Society of Anesthesiologists physical status I or II had their gastric contents aspirated via a nasogastric tube. They were then randomised to receive either intravenous esomeprazole 40 mg or intravenous ranitidine 50 mg. A second aspiration of gastric contents was done three hours later. The pH and volume of gastric contents of both aspirations were recorded. Results: Both intravenous esomeprazole and ranitidine significantly reduced the gastric fluid acidity (p=0.001) and volume (p=0.001). There were no significant differences measured between the two groups in terms of gastric fluid pH (p=0.86) and gastric fluid volume (p=0.14) after administration of study drugs. Conclusion Esomeprazole and ranitidine given intravenously were both comparable in reducing the volume and acidity of gastric secretions in patients undergoing emergency appendicectomy.