Clinical Pulmonary Infection Score to Diagnose Ventilator-associated Pneumonia in Children.

Background: There is a need to validate and suggest easy clinical method for diagnosis of ventilator-associated pneumonia (VAP) in developing countries. Objectives: To validate the use of simplified Clinical Pulmonary Infection Score (CPIS) for the diagnosis of VAP. Design: Prospective study. Setting: Pediatric intensive care unit of a tertiary care teaching hospital. Subjects: 30 children receiving mechanical ventilation for more than 48 hours and with simplified CPIS6. Methods: All patients underwent flexible bronchoscopy to obtain bronchoalveolar lavage which was analyzed quantitatively. Colony count 104cfu/mL was considered reference standard for definite VAP. Results: Of the five variables used for simplified CPIS, only patient’s temperature (P=0.013) and PaO2/ FiO2 ratio were significant (P<0.001) to differentiate the presence of definite VAP. Patients with definite VAP (BAL colony count 104cfu/mL) had CPIS of 8.4 while in no definite VAP group it was 6.4 (P= 0.007). CPIS of 8 was found to have sensitivity of 80%, specificity 80%, PPV 86.9%, NPV 70.5% and accuracy 80%. The area under Receiver operating characteristic curve of CPIS against reference standard was 0.81± 0.069 (P=0.001). Conclusion: Simplified CPIS is useful in patients on mechanical ventilation to diagnose ventilator- associated pneumonia.

Cell phones and tumor: still in no man's land.

The use of cell phones is increasing worldwide at a phenomenal pace. While cellular communication has dramatically influenced our lifestyle, its impact on human health has not been completely assessed. Widespread concern continues in the community about the deleterious effects of radiofrequency radiations (with which cell phones operate) on human tissues and the subsequent potential for carcinogenesis. A detailed survey of published studies researching this question was done in preparation of this manuscript. Included in the survey were case reports, in vitro studies, population based retrospective studies and other investigations. The database of indexed journals was searched for key words like 'cell phone', 'radiation', 'cancer' and 'radio waves'. Guidelines issued by the World Health Organization, federal and technical authorities, Institute of Electrical and Electronic Engineers and the International Commission for Non-Ionizing Radiation Protection were reviewed. The evaluation of current evidence provided by various studies to suggest the possible carcinogenic potential of radiofrequency radiation is inconclusive. This risk assumes significance in light of the burgeoning number of people who are continually exposed to the high frequency radiation from cell phones and towers that serve as receiving and transmitting stations. The aim of this review is to identify limitations in past studies, present available data for consideration, and identify gaps in the current knowledge base. This will provide impetus and direction for further research and allow informed decisions pertaining to cell phone use to be made.

Isolation and characterization of microsomal omega-6-desaturase gene (fad2-1) from soybean.

A genomic DNA sequence (fad2-1) encoding seed specific microsomal 0-6 desaturase was isolated from soybean (Glycine max. L cv. Pusa-9702). A positive genomic clone of 1852 nucleotides containing a single uninterrupted 3' end exonic region with an ORF of 1140 bp encoding a peptide of 379 amino acids, a complete 3' UTR of 206 bp and 86 bp of 5' UTR interrupted by a single intron of 420 bp was obtained on screening the sub-genomic library of soybean. Southern blots revealed at least two copies of the gene per haploid genome. Analysis of the translated product showed the presence of three histidine boxes, with the general sequence HXXXH and five probable transmembrane segments reported to be involved in substrate specificity.

Accurate blood pressure recording: is it difficult?

BACKGROUND: Blood pressure (BP) measurement is a routine procedure but errors are frequently committed during BP recording. AIMS AND SETTINGS: The aim of the study was to look at the prevalent practices in the institute regarding BP recording. The study was conducted in the Medicine Department at Government Medical College, Chandigarh, a teaching institute for MBBS students. METHODS: A prospective, observational study was performed amongst the 80 doctors in a tertiary care hospital. All of them were observed by a single observer during the act of BP recording. The observer was well versed with the guidelines issued by British Hypertension Society (BHS) and the deviations from the standard set of guidelines issued by BHS were noted. The errors were defined as deviations from these guidelines. STATISTICAL METHODS: The results were recorded as percentage of doctors committing these errors. RESULTS: In our study, 90% used mercury type sphygmomanometer. Zero error of the apparatus, hand dominance was not noted by any one. Every one used the standard BP cuff for recording BP. 70% of them did not let the patient rest before recording BP. 80% did not remove the clothing from the arm. None of them recorded BP in both arms. In out patient setting, 80% recorded blood pressure in sitting position and 14% in supine position. In all the patients where BP was recorded in sitting position BP apparatus was below the level of heart and 20% did not have their arm supported. 60% did not use palpatory method for noticing systolic BP and 70% did not raise pressure 30-40 mm Hg above the systolic level before checking the BP by auscultation. 80% lowered the BP at a rate of more than 2 mm/s and 60% rounded off the BP to nearest 5-10 mm Hg. 70% recorded BP only once and 90% of the rest re inflated the cuff without completely deflating and allowing rest before a second reading was obtained. Conclusion: The practice of recording BP in our hospital varies from the standard guidelines issued by the BHS.

A partial sequence of lipoxygenase gene from genomic DNA of aromatic rice (Oryza sativa L.).

Aromatic (Bas-370, PB-1) and non-aromatic (Pusa-677, Pusa-834) rice were selected for the characterization and for distribution of lipoxygenase (Lox) genes. Polymorphism was observed when genomic DNA of rice varieties was hybridized with a heterologous lipoxygenase probe. A distinct polymorphic fragment (approximately 1.2 kb) was found in Bas-370. Sub-genomic library of Bas-370 was constructed and screened with LoxA probe. The smallest putative clone (pBas-14) of approximately 1.2 kb was sequenced. Complete nucleotide and deduced amino acid sequence showed the clone was 1134 bp long and comprised of 378 amino acid residues. PCR amplification of genomic DNA from four rice varieties with a soybean Lox primer also showed a polymorphic fragment of size approximately 600 bp (amplicon) in aromatic varieties that was sequenced directly. Nucleotide sequence alignment between pBas-14 and amplicon concluded that the amplicon was a part of the insert pBas-14.

Unusual haematological alterations in rheumatoid arthritis.

Three cases of rheumatoid arthritis (RA), presenting with refractory anaemia, thrombocytopenia and peripheral lymphocytosis respectively, were observed. In all the cases haematological manifestations were unrelated to disease activity or drug toxicity. These patients were detected to have pure red cell aplasia (PRCA) (normocytic normochromic anaemia, reticulocytopenia and absence of erythroid precursors in the bone marrow), immune thrombocytopenia (IT) (absence of splenomegaly and presence of increased megakaryocytes in the bone marrow) and multiple myeloma (MM) (lytic lesions on skull, paraproteinaemia and bone marrow plasmacytosis) respectively. PRCA and IT responded to glucocorticoids. Association with these three haematological alterations has rarely been reported. Our report highlights the need to regularly monitor blood counts in patients with RA.

Helicobacter pylori and hepatic encephalopathy.

Several extra-intestinal diseases have been associated with Helicobacter pylori infection. Hepatic encephalopathy has been linked to H. pylori infection because of the ammonia produced by the organism in the stomach. H. pylori infection is commoner in cirrhotic patients with hepatic encephalopathy than in those without. Increased ammonia levels have been observed in the gastric juice and blood more commonly in cirrhotics with H. pylori infection than in those without. Though the amount of ammonia produced by H. pylori may be too small to contribute to hepatic encephalopathy, eradication of H. pylori has been shown to improve the blood ammonia levels and hepatic encephalopathy.

Decompressive shunts and hepatic encephalopathy.

Encephalopathy is a major complication of all decompressive procedures done to reduce portal pressure. There are two major groups of decompressive procedures: surgical portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS). Surgical decompressive shunts are of three types: total, partial and selective, depending on the amount of hepatopetal flow that is maintained in each of them. Encephalopathy with these shunts occurs because of reduction in hepatopetal flow. These shunts have failed to reduce mortality; in fact, some studies have shown an increase in mortality following shunts. TIPS has more or less replaced the need for surgical shunts, but their risk to cause encephalopathy is almost equivalent to that of selective shunts and in some series is even more. Lactulose, antibiotics and protein restriction can easily control severe encephalopathy as a consequence of decompressive shunts.

Autoimmune hemolytic anemia associated with benign ovarian cyst: a case report and review of literature.

A 28-years-old female presented with severe autoimmune hemolytic anemia (AIHA), warm antibody mediated, and right side tubo-ovarian (TO) mass. There was sub-optimal response to immunosuppressive therapy (IST). Eight months later she underwent ovarian cystectomy which resulted in complete remission of AIHA without the need for IST. Pathological examination of the TO mass revealed benign ovarian cyst. Our case highlights the need to search for ovarian cyst/mass in females presenting with AIHA. Since immunosuppressive therapy is usually ineffectual in AIHA associated with ovarian cyst, it may be appropriate to contemplate surgery before embarking on IST in such cases.

Efficacy of endoscopic wire guided biliary brushing in the evaluation of biliary strictures.

Endoscopic brush cytology is a valuable technique for the evaluation of biliary strictures. The sensitivity of this technique varies from 30% to 83%, however, it can have specificity of 100%. We retrospectively evaluated the usefulness of wire-guided biliary brush cytology in biliary strictures in our hospital over a 3 years period from 1997 to 2000. Brushings from 58 biliary strictures were obtained during endoscopic retrograde cholangiography. They were compared with histological proof obtained by surgical biopsy or percutaneous fine-needle aspiration cytology and/or clinical findings. These were reported as benign or malignant. Eleven patients were excluded due to incomplete data. Eighteen patients had benign brushings. Fourteen of the 29 patients in whom histological confirmation of malignancy brushings was obtained were also reported as malignant. The sensitivity of endoscopic brushings was 48.2%, specificity 100% and diagnostic accuracy 55.2%. No major complications were seen in our study group.

Metastasis to thyroid from lung carcinoma.

Metastasis to thyroid gland are rare. The primary sites which metastasize to thyroid gland include the breast, lung, kidney and stomach. Among lung cancer metastasizing to the thyroid, adenocarcinomas are the commonest followed by squamous, small cell and large cell carcinomas. The bronchioloalveolar carcinoma has not been reported to metastasize to the thyroid. In this case report we document this rare occurrence.

Circadian pattern in cerebro vascular disorders.

Over the last decade, various studies have been reported to evaluate the circadian pattern of cardiovascular and cerebro-vascular diseases. The data from Indian population is lacking. We undertook this prospective observational study to evaluate the circadian variation in disorders like cerebro-vascular accidents and transient ischemic attacks. Total of 146 patients (events) were studied. Only 10 patients had TIA's. 55% had hemorrhage and 45% had infarction. The 24 hours period was divided into 6 equal portions of 4 hours each. The maximum events were seen between 4 am to 8 am and 12 noon to 4 pm (23.28%) each. Minimum events were seen between 12 midnight to 4 am 14/146 - 9.58%). The circadian variation in occurrence of cerebro-vascular disorders was present with two equal peaks.

Wasp sting induced neurological manifestations.

Wasp stings generally cause local reactions like pain, wheal, flare, edema and swelling, which are generally self-limiting. Multiple stings can lead to vomiting, diarrhea, generalized edema, dyspnea, hypotension, collapse, renal failure or death. Unusually, they may cause serum sickness, vasculitis, neuritis or encephalitis. We report a case of a 40 year old male who developed focal neurological deficit 10 hours following a wasp sting, which was confirmed to be ponto-cerebellar infarction on MRI scan, and recovered within five days.

Adult onset celiac disease in north India.

INTRODUCTION: Informations on celiac disease among Indian adults is scarce. With the availability of improved and more accessible diagnostic tools for celiac disease, the disease is being more frequently recognized among the adults. Therefore, a retrospective analysis of duodenal biopsies were performed to identify adult celiac disease among Indian patients. MATERIAL AND METHODS: A retrospective analysis of the patients, who had villous atrophy on duodenal biopsy between February, 1997 to June 2001, was performed. The clinical presentation, laboratory parameters, treatment and follow up details of patients diagnosed as adult onset celiac disease were analysed. Diagnosis of celiac disease was established in these patients as per ESPGAN criteria. RESULTS: There were 68 duodenal biopsies during the study period. Thirteen (10 were under 15 years of age and 3 had followup biopsy) biopsies were excluded. Eleven (20%) out of 55 patients with villous atrophy in their duodenal biopsy satisfied the ESPGAN criteria for the diagnosis of celiac disease. The age at the time of diagnosis ranged from 15-56 years (mean 36.8 years). Male to female ratio was 5:6. Chronic diarrhea (99%) was the most common presentation followed by weight loss (88%) and anemia (66%). Only one patient had refractory iron deficiency anemia (11%). Histopathological examination showed, subtotal villous atrophy in 6 patients and partial villous atrophy in 5. Nine out of 11 patients had raised concentration of IgA antigliadin antibody. Two patients also had raised concentration of antiendomysial antibody. All of them showed favorable clinical response to Gluten free diet. CONCLUSION: Coeliac disease is considered rare in the tropics. Our study shows that this disease may not be as infrequent as is thought.

Left atrial myxoma presenting as pseudobulbar palsy.

A case of left atrial (LA) myxoma presenting as pseudobulbar palsy, due to multiple cerebral infarcts, without any cardiac manifestations, is presented. LA myxoma is rare cause of embolization to CNS causing ischemic infarcts. Due to multiple CNS infarcts patient can present with varied clinical picture and pseudobulbar palsy is not a very common presentation. It was a real diagnostic dilemma before LA myxoma was diagnosed on echocardiography.

Experience of surgical management of pseudo-aneurysms of branches of the coeliac axis in a North Indian Hospital.

BACKGROUND: Bleeding splanchnic artery pseudo-aneurysm is a rare but frequently fatal complication that can be successfully managed by angiographic embolization. However, certain patients because of hemodynamic instability, non-availability of technique or angiographic failure may require primary surgical intervention. METHOD: Retrospective review of 13 patients presenting with exsanguinating hemorrhage from ruptured pseudo-aneurysm arising from branches of coeliac axis, managed surgically in absence of angiographic embolization. RESULTS: Splenic artery was most commonly involved (n = 7) followed by hepatic (n = 3), gastroduodenal (n = 2) and left gastric artery (n = 1). The most common underlying aetiology was pancreatitis (n = 8, acute = 2; chronic = 6) followed by iatrogenic (n = 3), liver abscess (n = 1) and gastric ulcer (n = 1). Seven patients presented with upper gastrointestinal (GI) bleed, while 2 each with lower GI bleed, haemobilia and bleeding through tube drains. CT-scan accurately demonstrated the pseudo-aneurysm in 11 (84.6%) patients and additionally demonstrated the underlying pathology. The surgical management chiefly consisted of ligation of offending vessel and additional procedures directed at primary pathology. Overall, 77% patients had a favourable outcome while 23% died consequent to ongoing hemorrhage. CONCLUSION: Pseudo-aneurysm involving the branches of coeliac axis most commonly arises as a result of pancreatitis and affects splenic artery. CT-scan accurately demonstrates pseudo-aneurysm and associated pathology in majority of cases. Primary surgical management in the presence of hemodynamic instability and non-availability of angiographic embolization is a viable alternative.

Video game epilepsy.

Reflex epilepsy is the commonest form of epilepsy in which seizures are provoked by specific external stimulus. Photosensitive reflex epilepsy is provoked by environmental flicker stimuli. Video game epilepsy is considered to be its variant or a pattern sensitive epilepsy. The mean age of onset is around puberty and boys suffer more commonly as they are more inclined to play video games. Television set or computer screen is the commonest precipitants. The treatment remains the removal of the offending stimulus along with drug therapy. Long term prognosis in these patients is better as photosensitivity gradually declines with increasing age. We present two such case of epilepsy induced by video game.

ICU management of severe malaria.

Malaria is very common in India. First step in management of malaria is to establish the diagnosis. It is established by using traditional smear or method like dipstick antigen captures assay which is simpler, accurate and doesn't require expertise. Next step is to look for signs and symptoms, which help cases of severe malaria should be admitted in intensive care unit (ICU) and antimalarial chemotherapy should be started through parenteral route. Complications like coma, anemia, renal failure, pulmonary edema, disseminated intravascular coagulation are not very uncommon. These complications should be anticipated and treated in time. There is no role of corticosteroids, mannitol in the treatment of cerebral edema. Therapeutic monitoring of severe malaria should involve quantitative estimation of parasite load.