Does the presence of Klebsiella pneumoniae carbapenemase and New Delhi metallo‑β‑lactamase‑1 genes in pathogens lead to fatal outcome.

Introduction: Infections due to multidrug‑resistant (MDR) pathogens are a medical challenge. There is considerable apprehension among clinicians regarding pathogens reported as carrying New Delhi metallo‑β‑lactamase‑1 (NDM) and Klebsiella pneumoniae carbapenemase (KPC) genes from their patients. In the face of extremely high rates of antimicrobial resistance, it is essential to gauge the clinical significance of isolation of pathogens carrying these genes from clinical samples. This study compares the outcome of patients infected with pathogens carrying NDM/KPC genes versus those without these genes. Methods: The study was conducted over a 1‑year period at a Level‑1 trauma centre. Hospital‑acquired infections were diagnosed on the basis of CDC’s criteria. The correlation of isolation of a multi‑resistant pathogen carrying KPC or NDM genes with the clinical outcome was ascertained. Results: A total of 276 consecutive patients admitted to the Intensive Care Units/wards of the JPNA Trauma Centre were included in this study. Of the 371 isolates recovered from these patients, 116 were from patients who had a fatal outcome. The difference in prevalence of blaNDM and blaKPC was not significant in any genera of Gram‑negative pathogens isolated from patients who survived versus those who had a fatal outcome. Conclusion: Isolation of MDR pathogens carrying NDM/KPC genes from clinical samples is not always a harbinger of a fatal outcome. Efforts should be made to prevent cross‑transmission of these pathogens.

Device-associated infections at a level-1 trauma centre of a developing Nation: Impact of automated surveillance, training and feedbacks.

Purpose: Device-associated infections constitute the majority of health care-associated infections (HAIs) in ICUs. Trauma patients are predisposed to acquire such infections due to various trauma-related factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the impact of an intensive surveillance on the rates and outcome of device-associated infections in trauma patients from a developing country and compares the rates with a previous pilot observation. Materials and Methods: The study was conducted at a level-1 trauma centre of India. Surveillance for ventilator-associated pneumonia (VAP), central line-associated blood stream infections (CLA-BSIs) and catheter-associated urinary tract infections (CA-UTIs) was done based on centre for disease control-National Healthcare Safety Network (CDC-NHSN) defi nitions. The impact of an intensive surveillance, education and awareness drive on the rates of infections over the study period, and compliance to preventive bundles and hand hygiene was assessed. Results: A total of 15,462 ventilator days, 12,207 central line days and 17,740 urinary catheter days were recorded in the study population. The overall rates of VAP, CLA-BSI and CA-UTI were respectively 17, 7.2 and 15.5/1000 device days. There was a signifi cant correlation between device days and the propensity to develop infections. Infections were the cause of death in 36.6% of fatal trauma cases. A signifi cantly higher rate of VAP, CLA-BSI and CA-UTIs was noted in fatal cases. The compliance to ventilator bundle, central line bundle, bladder bundle and hand hygiene were 74.5%, 86%, 79.3% and 64.6%, respectively. A high rate of multi-drug-resistance was observed in all pathogens. A gross reduction in the rates of all infections was observed over time during the study due to implementation of a stringent surveillance system, feedbacks and education. The compliance to hand hygiene and preventive bundles also increased over time. Conclusion: The automated surveillance was easy and useful for data entry and analysis. Surveillance had a signifi cant impact on reduction of HAIs and mortality in trauma patients.

Diagnosis of ventilator-associated pneumonia: Comparison between ante-mortem and post-mortem cultures in trauma patients.

Purpose: To evaluate the diagnostic utility of ante‑mortem tracheal aspirates for diagnosis of ventilator‑associated pneumonia (VAP). Trauma victims represent an otherwise healthy population, who are on multiple invasive life‑support devices, which predispose them to severe infections like VAP. The diagnosis of VAP is challenging, due to the difficulty in obtaining a representative sample from lungs. We studied the diagnostic utility of tracheal aspirates by comparing its results with the post‑mortem lung cultures. Materials and Methods: A total of 106 fatal trauma patients were included in the study. Lung samples and cardiac blood were taken for culture at the time of autopsy. The results of ante‑mortem and post‑mortem cultures were compared. Results: Septicemia was the cause of death in 51 (48%) of the fatal cases and VAP was identified in 36 (34%) cases. A total of 96 (90.5%) cases had pathogens isolated from lung samples. In 62 (58%) cases, the same organism was isolated from ante‑mortem and post‑mortem respiratory samples. Conclusions: Culture results of a properly collected tracheal aspirate should be taken into consideration along with Centre for Disease Control and Prevention (CDC’s) diagnostic criteria to maximise the diagnosis of VAP.

Mortality profile of patients with traumatic spinal injuries at a level I trauma care centre in India.

Background & objectives: There is no national spinal trauma registry available in India at present and the research on epidemiology of these injuries is also very limited. The purpose of this study was to describe the mortality profile of patients with spinal injuries brought to a level I trauma centre in India, and to understand the predictive factors which identify patients at an increased risk of spinal trauma mortality. Methods: Retrospective data were collected from computerized patients records and autopsy reports maintained in the department of Forensic Medicine. All the cases with spinal injuries whether in isolation or as a part of polytrauma were reviewed. A total of 341 such cases were identified between January 2008 to December 2011. The demographic data, type of trauma, duration of survival, body areas involved, level of spinal injury and associated injuries if any, were recorded. Results: There were 288 (84.45%) males and 53 (15.55%) females. Most victims (73%) were between 25 and 64 yr of age, followed by young adults between 16 and 24 yr (19.35%). Male: female ratio was 5.4:1. Fifty five per cent cases had spinal injuries in isolation. Injury to the cervical spine occurred in 259 (75.95%) patients, thoracic spine in 56 (16.42%) and thoraco-lumbar spine in 26 (7.62%) patients. The commonest cause of injury was high energy falls (44.28%), followed by road traffic accidents (41.93%). The majority of deaths (51.6%) occurred in the phase IV (secondary to tertiary complications of trauma, i.e. >1 wk). Forty patients died in phase I (brought dead or surviving <3 h), 55 in phase II (>3 to 24 h) and 70 in phase III (> 24 h to 7 days). Interpretation & conclusions: Our data suggest that there is an urgent need to take steps to prevent major injuries, strengthen the pre-hospital care, transportation network, treatment in specialized trauma care units and to improve injury surveillance and the quality of data collected which can guide prevention efforts to avoid loss of young active lives

Mortality due to septicemia at a level 1 Indian trauma care centre: An epidemiological analysis.

Trauma contributes to a signifi cant proportion of mortality and morbidity in the economically productive age group of 15-45 years. Infections are the second most important cause of death in trauma patients after head injury. Despite advances in trauma care, deaths due to septicemia are increasing. An epidemiological study of septicemia-related deaths were conducted at a level 1 Trauma Centre from January 2011 to December 2011. A total of 201 patients died due to suspected septicemia. The average age of the deceased trauma victims was 35.9 years and the median length of stay in hospital before death was 27 days. In our study, a high proportion of patients had grown pathogens in signifi cant counts from respiratory specimens (36%) and blood (23%) during ante-mortem period, which may have contributed to their fatal outcome. Infections are one of the most common and fatal complications following trauma and complicate the recovery of a signifi cant number of injured patients.

A preliminary molecular study on protein profile of vital organs: A new direction for post mortem interval determination.

Estimation of the postmortem interval (PMI) is one of the most important tasks in Forensic Medicine. Six autopsy organ tissues such as brain, lungs, heart, liver, pancreas and kidney were taken at the time of forensic autopsy. All the proteins present in the tissues were extracted and the protein profile was analyzed on the sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) starting from 0 day to 10th day after death. The protein profiles showed a consistent degradation pattern which was consistent and reproducible in all the samples with respect to the time interval. In conclusion, the protein profile of the vital body organs appears to be a useful method for estimating the post mortem interval up to 10th day. Advantage of this approach over others is that it can detect the post mortem interval over a long interval (0 - 10 days) with an easily detectable pattern of protein profile.

Sudden death due to aortic rupture while swimming: A case report.

An eleven year old, healthy boy with no past history of illness suddenly felt acute excruciating chest pain which was radiating to back, while he was swimming in a private swimming pool. He was immediately transferred to a hospital where he was declared dead on arrival. Autopsy and histopathological findings were suggestive of death was due to extensive advential haemorrhge due to inherent weakness in aortic wall.

Management of diabetic ketoacidosis in PICU.

OBJECTIVE: This study was undertaken to analyze the outcome of children with DKA treated with a modified protocol at a tertiary level teaching hospital PICU in Pune, Maharashatra. METHODS: We retrospectively analyzed case records of 12 patients (8 males and 4 females) with DKA (11 new and 1 readmission) admitted in our PICU from January 2005 to June 2006. Patients were managed according to a modified protocol (that is with less intensive biochemical monitoring when compared with standard book protocols). Laboratory parameters measured were blood glucose, urinary ketones, electrolytes, urea creatinine, arterial blood gas (ABG) and infectious screen. Treatment included fluid therapy and insulin infusion- 0.1 u/Kg short acting intravenously followed by 0.1 u/Kg/hr. No bicarbonate was administered as a bolus. RESULTS: Total fluid deficit was corrected slowly over a period of 36 hr. The median time to normalize ABG was 19 hr (5.3-39) while the median time for the urinary ketones to disappear was 1day (1-3). The child to nurse ratio was 1:2, there were 2 pediatric residents in house all 24 hr with an intensivist and pediatric endocrinologist on call. CONCLUSION: We have shown that when DKA is managed in a PICU setting using modified protocol, the outcome is good and complications such as brain edema can be prevented.

Fatal pulmonary oedema following laparoscopic chromopertubation.

The body of a 30-year-old woman was received for autopsy. The available medical case records mentioned that she had been married for the past 3 years and had had primary infertility. She had undergone a diagnostic-cum-operative laparoscopy under general anaesthesia in a private nursing home. On laparoscopy, the internal genital organs were normal except for a fimbrial cyst on each side. Chromopertubation was done using methylene blue dye along with diagnostic dilatation and curettage. The patient was extubated and shifted to the recovery room. About 15 minutes later she developed cyanosis and became unconscious. She died despite sustained efforts at resuscitation.

Mucolipidoses--II: A report of three cases.

Mucolipidoses II is a rare lysosomal storage disorder with autosomal recessive inheritance. There cases with typical clinical features in early infancy like coarse facial features, severe psychomotor retardation and joint contractures are being reported. All the cases had no mucopolysacchariduria. These cases had normal values of lysosomal enzymes in leucocytes but markedly increased values in serum thus confirming mucolipidoses II. Despite the fact that there is no specific treatment, genetic counselling and prenatal diagnosis is indicated.