Primary pyomyositis in North India: a clinical, microbiological, and outcome study

BACKGROUND/AIMS: Pyomyositis is an infective condition with primary involvement of the skeletal muscles. There is sparse recent literature on patients with pyomyositis. METHODS: This study was carried out at emergency services of a tertiary care center located in subtropical area of Indian subcontinent. RESULTS: Sixty-two patients of primary pyomyositis formed the study cohort. Mean age of occurrence was 29.9 ± 14.8 years. There were 54 men. Twelve patients had underlying medical diseases. Muscle pain was seen in all 62 patients. Forty-eight patients (77.4%) had the fever. Most common site of involvement was thigh muscles (n = 29, 46.8%). Forty-nine patients (79%) presented in the suppurative stage of illness. Patients with comorbidities were older (age: median 36 years [interquartile range (IQR), 25 to 47] vs. 24 years [IQR, 16 to 35], p = 0.024), had higher culture positivity with gram-negative organisms (8/9 [88.89%] vs. 6/29 [20.69%], p = 0.001). Importantly, higher number of these patients received inappropriate antibiotics initially. Patients with positive pus culture result had higher complication rate (32/38 [84.21%] vs. 10/18 [55.56%], p = 0.044). Six patients (9.7%) had in-hospital mortality. Lower first-day serum albumin, initial inappropriate antibiotic therapy, and advanced form of the disease at presentation were associated with increased in-hospital mortality. CONCLUSIONS: Primary pyomyositis is not an uncommon disease entity. Patients with comorbidities were more likely to receive initial inappropriate antibiotic therapy. Patients with positive pus culture report had the higher rate of complications. Lower first-day serum albumin, initial inappropriate antibiotic therapy and advanced form of the disease at presentation were associated with increased in-hospital mortality.

Prognostic significance of blood glucose levels and alterations among patients with aluminium phosphide poisoning

Objectives: This study aimed to assess the prognostic significance of blood glucose levels and blood glucose alterations [i.e. hyper- or hypoglycaemia] among patients with aluminium phosphide [AlP] poisoning

Methods: This prospective observational study was conducted at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2010 and June 2011. All patients presenting to the emergency department with a definitive history of AlP ingestion or symptoms compatible with AlP poisoning were included in the study. Blood glucose levels were recorded at presentation and every six hours thereafter. Alterations in blood glucose levels and other clinical and laboratory variables were subsequently compared between survivors and non-survivors

Results: A total of 116 patients with AlP poisoning were identified. Of these, 57 patients [49%] survived and 59 patients [51%] died. At presentation, the mean blood glucose levels of survivors and non-survivors were 119.9 +/- 35.7 mg/dL and 159.7 +/- 92.5 mg/dL, respectively [P <0.001]. In comparison to the survivors, non-survivors had significantly higher heart rates, total leukocyte counts, blood glucose level alterations and serum creatinine levels [P <0.050]. In addition, systolic blood pressure, Glasgow coma scale scores, arterial blood gas pH and bicarbonate values and duration of hospital stay was significantly lower compared to survivors [P <0.001]. However, neither blood glucose levels at admission nor blood glucose alterations correlated independently with mortality in a multivariate analysis

Conclusion: The role of blood glucose level alterations in predicting patient outcomes in AlP poisoning cases remains inconclusive. Further studies with larger sample sizes are required

Safety and efficacy of vitamin-based antioxidant therapy in patients with severe acute pancreatitis: a randomized controlled trial

Oxidative stress plays a major role in the pathogenesis of pancreatitis. Antioxidant therapy in the form of high-dose vitamin has been used for the treatment of severe acute pancreatitis with equivocal results. We wished to evaluate the efficacy and safety of antioxidant [vitamin A, vitamin C, vitamin E] therapy in patients with severe acute pancreatitis. Setting and design: This was a single-center, prospective, randomized, open-label with blinded endpoint assessment study of antioxidant therapy, conducted in the emergency department attached to our hospital. Thirty-nine patients with severe acute pancreatitis were randomly assigned to antioxidant treatment group [n=19] or a control group [n=20] within 96 hours of developing symptoms. Patients in the antioxidant group received antioxidants [vitamin A, vitamin E, vitamin C] in addition to the standard treatment provided to both the groups for a period of 14 days. The primary outcome variable was presence of organ dysfunction at day 7. The secondary outcome variables were length of hospital stay, multiorgan dysfunction [MODS] at day 7, recovery at the end of 4 weeks, complications, and mortality. The change in markers of oxidative stress from baseline was also measured. We demonstrated no significant difference in organ dysfunction [P=1.0], MODS [P=0.8], and length of hospital stay [P=0.29] between the two groups. All the patients survived in the antioxidant-treated group, whereas two patients died in the control group. The change in the levels of malondialdehyde, superoxide dismutase, and reduced glutathione were not significantly different in the two groups at day 7. Univariate analysis showed marginal benefit with antioxidant treatment [P=0.034] in patients with severe acute pancreatitis. This randomized study demonstrates that there is no significant benefit from antioxidant therapy in patients with established severe acute pancreatitis

effect of sedation during upper gastrointestinal endoscopy

We aimed to study whether sedation reduces discomfort during endoscopy and a comparison of longer-acting diazepam with shorter-acting midazolam. A prospective, randomized, single-blinded study was conducted at the Department of Medicine at Government Medical College and Hospital, Chandigarh, and was completed over a period of 6 months. The patients were randomized to receive either placebo or sedation with midazolam or diazepam before endoscopy. The endoscopist and the observer recording patient's/physician's responses were blinded to the drugs administered. Two hundred and fifty two consecutive patients undergoing diagnostic or therapeutic upper gastrointestinal endoscopy were recruited. The patient's discomfort and the physician's comfort during the procedure were recorded on a visual analogue scale rated from 1-10 with-in 10 minutes of the procedure by an independent observer. The Patient's discomfort ratings were further divided into 3 groups, comfortable [score, 1-3], satisfactory [score, 4-7] and uncomfortable [a score of >7]. Similarly the physician's ease of performing the procedure was also recorded on the same scale. This was again divided into 3 groups: easy [score, 1-3], satisfactory [score, 4-7] and difficult [a score of >7]. Out of the total of 252 patients, 82 patients received no sedation [group I], 85 received diazepam [group II] and 85 received midazolam [group III]. There was no statistical difference in the discomfort experienced by the patients during endoscopy when sedation was used [P=0.0754]. Out of 252 patients, 49 underwent endoscopic procedures. Nineteen patients were included in group I, 18 in group II and 12 in group III. Only 10 [20%] patients undergoing endoscopic procedures complained of significant discomfort, but there was no difference in the ones undergoing interventions with or without sedation [P=0.854]. The physicians were more comfortable in performing endoscopic procedure in sedated patients, however, the difference between patients in group II and group III was not statistically significant [P=0.0461]. Both diazepam and midazolam fared equally well in increasing physician's comfort [P=0.617]. There was no difference in the patient's discomfort with regard to the sedative used [midazolam or diazepam]. Although endoscopy was easy or satisfactory in the majority of patients in the unsedated as well as the sedated groups, more often the endoscopist found it difficult to do endoscopy on the unsedated patients

Role of neostigmine and polyvalent antivenom in Indian common krait [Bungarus caeruleus] bite

Bungarus caeruleus [Indian common krait] bite during monsoons is common in Northwest India. This study was undertaken to find the effectiveness of neostigmine and polyvalent antivenom in improving neuromuscular paralysis following bite. All the consecutive patients admitted between June 2007 and December 2008 with common krait bite, identified either from brought snake or circumstantial evidence were studied. Ten vials of polyvalent antivenom and three doses of 2.5 mg neostigmine at 30 min intervals after administration of 0.6 mg of atropine were administered I.V. and patients were assessed for any improvement in neuroparalysis. Seventy-two patients were admitted during the study period. All the patients except two came from rural areas and were brought between June and September. Sixty-two patients were bitten during the day while clearing bricks, cutting grass or walking. The mean time interval between bite and arrival to hospital was 4.5 h. None of the patients showed any improvement following treatment and all patients developed respiratory paralysis, requiring assisted ventilation. Seventy survived and two died. Neostigmine is ineffective in reversing or improving neuroparalytic features in patients with B. caeruleus bite even at higher dose than normally recommended