A prospective study of risk factor profile & incidence of deep venous thrombosis among medically-ill hospitalized patients at a tertiary care hospital in northern India.

Background & objectives: Hospitalization for medical-illness is associated with an increased risk of deep venous thrombosis (DVT). However, there are no published data from India addressing at this issue. We sought to study the risk factor profile and the incidence of DVT among hospitalized medically-ill patients, a tertiary care hospital in northern India. Methods: All adults admitted to the medical wards and intensive care unit with level 1 or 2 mobility over a period of two years (July 2006 to July 2008) at the All India Institute of Medical Sciences hospital, New Delhi, were prospectively studied. Patients having DVT at admission or an anticipated hospital stay less than 48 h were excluded. The presence of clinical risk factors for DVT was recorded and laboratory evaluation was done for hypercoagulable state. A routine surveillance venous compression Doppler ultrasonography was performed 12 ± 8 days after hospital admission. Results: Of the 163 patients, 77 (47%) had more than one risk factor for DVT. Five (3%) patients developed DVT; none of them had symptomatic DVT. None of these patients received anticoagulation prior to the development of DVT. The mean age of those who developed DVT was 40 ± 13 (25-50) yr; two of five were male. The incidence rate of DVT was 2.7 per 1000 person-days of hospital stay [95% confidence interval (CI): 0.87 to 6.27]. None of the factors was found to be significantly associated with the risk of DVT. Interpretation & conclusions: In our setting, although many hospitalized medically-ill patients had risk factors for DVT, the absolute risk of DVT was low compared to the western population but clearly elevated compared to non hospitalized patients. Large studies from India are required to confirm our findings.

A clinical prediction rule to identify patients with tuberculosis at high risk for HIV co-infection.

Background & objective: Many patients presenting with tuberculosis (TB) have underlying human immunodeficiency virus (HIV) co-infection. Routine HIV testing, however, is not a component of the national TB control programme in India. We sought to derive and validate a clinical prediction rule, based on clinical and laboratory parameters, to identify patients at high risk for HIV co-infection among those treated for active TB. Methods: Case records of adult patients with active TB treated between 1997 and 2003 at the All India Institute of Medical Sciences hospital, New Delhi were retrospectively reviewed. The data set was randomly split into a training set and a testing set. First a clinical prediction rule was derived by multivariable logistic regression on the training set and was subsequently validated on the testing set. Results: The study group comprised 1074 patients [training set 711 (66%), HIV co-infected 66 (9%); testing set 363 (34%), HIV co-infected 30 (8%)]. In the training set, male gender [odds ratio (95% CI) 5.31(1.52- 18.61)], axillary lymphadenopathy [9.71 (3.24-29.10)], anaemia [7.56 (2.48-23.05)], hypoalbuminaemia [3.67(1.31-10.26)], and reduced triceps skinfold thickness [2.91(0.95-8.89)] were independently associated with HIV co-infection. In the testing set, presence of any two of these five features was 94 per cent (95% CI 84-100%) sensitive and 54 per cent (49-60%) specific for predicting HIV co-infection; negative predictive value was 99 per cent (98-100%). Area under the receiver-operating characteristic curve was 0.93 (0.86-1.0) in the testing set. Interpretation & conclusions: A simple clinical prediction rule based on clinical and laboratory parameters could be used to identify a subgroup of patients, among those treated for active TB in a hospital setting, for targeted HIV testing.

Use of non-invasive ventilation in a pregnant woman with acute respiratory distress syndrome due to pneumonia.

Utility of non-invasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS) is not proven. We report a case of a 28-year-old primigravida female with ARDS due to community-acquired severe pneumonia in whom non-invasive ventilation was instituted in an attempt to improve oxygenation and avoid intubation. This lead to an improvement in arterial oxygenation and reduction in respiratory rate of the patient and gradual disappearance of fetal distress.