Glucose level in the bronchial aspirate as a marker of ventilator associated pneumonia in mechanically ventilated patients

Ventilator-associated pneumonia [VAP] is the leading cause of death amongst hospital-acquired infections. Despite this, the diagnosis of VAP remains challenging and there is a lack of diagnostic standardization. In humans, glucose concentrations are normally low in nasal and bronchial fluid, but are elevated by inflammation or hyperglycaemia. Exhaled breath condensate glucose was reported to be a potential marker of both infection and outcome in patients with acute respiratory distress syndrome [ARDS]. To study the signifcance of detecting glucose in bronchial aspirate in mechaniclly ventilated patients under tight glycemic control and using it as a follow up parameter in patients with VAP versus patients with community acquired pneumonia [CAP]. Also the present work aimed to describe the pattern of changes of C - reactive protein [CRP] in patients with VAP versus those with CAP. Forty patients were enrolled into the present study and were divided into 3 groups: Group I: Thirty critically ill patients requiring intubation and mechanical ventilation were followed up from admission and daily till they fulfilled criteria suggesting development of VAP. Group II: Ten patients with community acquired pneumonia [CAP]. Group III: Ten healthy volunteers constituting the control group. Patients were assessed using the following scoring systems: 1] Assessing the disease severity using the Acute Physiological And Chronic Health Evaluation scoring system [APACHE II] on the day of admission, 2] Daily assessment of disease severity using the Sequential Organ Failure Assessment [SOFA] score, and 3] the Clinical pulmonary infection score [CPIS]. All patients with CAP were evaluated by Pneumonia severity index [PSI] on admission. CRP was assessed on admission, on day 2 and on day 7. All patients were under tight glycemic control to abolish the effect of hyperglycemia on the bronchial aspirate glucose levels. Glucose measurements were performed simultaneously in the blood and bronchial aspirates. Bronchial aspirates were analyzed for glucose on the day of admission and daily. The present study demonstrated a correlation between the presence of glucose in the bronchial aspirates from mechanically ventilated patients and development of VAP. Glucose in the bronchial aspirates preceded the development of VAP in the first 48 hours of mechanical ventilation and steadily increased thereafter. This was later associated with infiltrates on the chest radiographs, increased levels of CRP, with significant CPIS score. In contrast the glucose level in the sputum from patients with CAP was high on admission then steadily decreased till discharge. There was no correlation between patient's blood glucose and the glucose level in the bronchial aspirate. In the present study CRP values in patients with CAP steadily decreased from admission till the patients were discharged. The mean CRP value in the mechanically ventilated patients at day one was statistically significant less than that in patients with CAP. While at the 7[th] day, the mean CRP value in patients with VAP was higher than that in patients with CAP. The mean CRP level in patients with VAP was higher in nonsurvivors than survivors. In critically ill patients kept under tight glycemic control, early detection of glucose in bronchial aspirates may improve the ability of clinicians to early recognize the onset of VAP. This technique is simple, rapid, and inexpensive and following it daily may serve as a marker for infection or clinical resolution. CRP levels in patients with CAP steadily decrease from time of admission till discharge, whereas in patients with VAP, CRP steadily increases from time of VAP development thereafter thus suggesting a role in following such patients as a prognostic marker

Treatment of hepatocellular carcinoma associated with cirrhosis by ultrasonograhic guided percutaneous ethanol injection

This study aimed to evaluate the short-term response to ultrasonographic guided percutaneous ethanol injection [PEI] for hepatocellular carcinoma [HCC] in cirrhotic patients. The study included 20 cirrhotic patients with HHC. Cases with severe liver impairment [Child's class C], severe bleeding tendency, impaired prothrombin concentration, thrombocytopenia, big tumors [more than 5 cm] or more than one tumor were excluded from the study. The patients were treated with percutaneous injection of ethanol 95% under guidance with ultrasound. The total amount of injected ethanol per session was between 5-20 ml. One to nine administrations were performed for each lesion according to its size. No serious complications occurred during or after treatment. The patients were followed up for 9-12 months. All lesions had post treatment sonographic structured changes of fibronecrotic echopattern. All patients were followed up by aspiration cytology at the end of treatment and at three and six months and yielded negative results for malignancy in all cases, except one who responded adequately to re-injection, with a significant reduction in the tumor size. Alpha fetoprotein level dropped significantly. No biochemical changes or untoward clinical sequelae were detected

Ulcerative colitis in upper Egypt

This study examined 858 patients suffering from low gastrointestinal symptoms in the Endoscopy Unit, Tropical Medicine Department, Assiut University, during the period from January 1995 till December 1996. Colonoscopy was done for all patients using CF-200S Olympus EVIS videoscope. The findings were consistent with ulcerative colitis [UC] in 67 patients [47 male and 20 females]. Their mean age was 37.8 years [range 11 - 80 years]. 16% of the patients were below 40 years. They had mild [40%] or moderate [54%] diseases activity. The lesions were confined to the rectum in 26 patients and to the rectosigmoid segment in 37 patients. In few patients [6%], the lesions extended to involve the left side of the colon. Mucosal mucins, CEA expression, IgA production and peanut agglutinin [PNA] lectin binding were evaluated in 31 patients with UC. Decreased mucosal mucin content was noticed in 71%. Sialomucins was predominated over sulfomucins in the mucosal glands in 55%. Mucosal CEA expression was detected in 90%. IgA was detected in lamina propria in all cases with variable staining intensity. PNA lectin binding was detected in 81% of cases

Tuberculin testing for typical and atypical mycobacteria in tuberculous patients in upper Egypt

This study included one hundred and sixteen tuberculous patients [all proved to have active tuberculosis of different forms] as well as twenty non-tuberculous persons served as controls. Both groups were subjected to dual skin testing using typical mycobacterial antigen [PPD-T] as well as five different atypical mycobacterial antigens. There were no significant differences between responders to [PPD-T]in both groups. The response to atypical antigens was higher in tuberculous lymphadenitis [47%] than pulmonary tuberculosis [30%]. The greatest response was to M. fortuitum and M. avium, while the response to M. gordonae was minimal. Positive skin testing for atypical mycobacteria was recorded in a high percentage among diseased and healthy persons. Its presence means previous exposure to the organisms rather than disease. Atypical mycobacterial infection might have a role in resistant cases of tuberculosis to anti-mycobacterial drug therapy. Bacterial cultures and identification of the organisms are recommended in the tuberculous patients

Colo-Rectal cancer in upper Egypt

This study included 1650 patients with lower gastrointestinal symptoms. The findings were consistent with colorectal cancer in 130 cases [72 males and 58 females]. Their mean age was 42.9 years [range 17 to 85 years]. The main presenting symptoms were gross bleeding [53.1%], abdominal pain [31.5%] and diarrhea [28.5%]. Most patients had more than one symptom or sign at the time of diagnosis. The lesions in 85% of the cases were within the reach of sigmoidoscopy. 93% of the tumors were adenocarcinomas and 7% were mucinous adenocarcinomas. In Upper Egypt, colorectal cancer was not considered the disease of elderly patients. Its occurrence at younger age [22% of cases below 30 years] should draw attention for further studies

Screening for brucella antibodies among farm workers in Assiut

This study was conducted on one hundred persons in brucellosis risky occupation, they were collected from two cattle farms and one sheep farm. The control group included thirty persons. Clinical data revealed that symptoms and signs were not specific for the disease which must be differentiated from other illnesses. SAT and RBT behaved the same, 21 out of 100 persons were positive by both tests. Titers in them were >/ 1/180 or more. Most of the cases were in the University station [eighteen cases] followed by Bani-Mur station [three cases] and no case in El-Hawatka station. This difference may reflect the protective measures applied in the three farms. It was concluded that brucellosis is not uncommon among the farm workers in Assiut. Health education of the workers is of great importance to minimize the transmission of the disease

Micro-determination of fluoride by means of metallic sodium fusion and using fluoride-sensitive electrode.

A simple and accurate method to determine the content of fluoride in non-volatile organofluoro compounds or in biological samples has been developed. The method includes the metallic sodium fusion followed by quantitative estimation of fluoride using fluoride-sensitive electrode.

Important micro'organisms associating chronic or recurrent diarrhoea in adults

The study included 100 patients presenting with diarrhoea for more than two weeks. Stool examination included fresh microscopic and bacteriologic examination. Isolation of Enterobacteriaceae was confirmed by API 20 E system. Coli test sera were used for identification of enteropathogenic strains of E. coli [EPEC] and Salmonella test sera for salmonella. Special culture for Yersinia entercolitica was done. Cytopathic effect of C. difficile toxin [B] was also detected. The isolated pathogenic organisms included EPEC in [36%], non-typhoidal salmonellae [10%], Staphylococcus aureus [2%] and C. difficile [6%]. Four cases with Yersinia enterocolitica [4%] were isolated. This organism was mainly described in cold weather especially among pork consumers

Helicobacter pylori associating upper gastro-intestinal diseases

Fifty patients with dyspeptic symptoms were studied for the presence of H. pylori organisms. They were subjected to UGI-Endoscopy. Biopsy specimens were taken from the pyloric antrum and first part of the duodenum and examined bacteriologically by Gram strain, urease test and cultures. In the 50 antral biopsies studied; H.pylori organisms were isolated by culture in 35 cases [70%]. In comparison with culture results; urease test revealed the presence of H. pylori in 33 cases [66%] with 94.3% sensitivity and 100% specificity. While Gram stain revealed the presence of H.pylori in 24 cases [48%] with 68.5% sensitivity and 100% specificity. According to endoscopic findings; H. pylori organisms were isolated in 35.7% of cases with normal gastro-duodenal mucosa; in 77.7% of cases with gastritis, in 75% of cases with duodenitis, in 94.44% of cases with duodenal ulcer and in 60% of cases with gastric ulcer. It was found that there was a significant association between H. pylori infection with both duodenal ulcers and gastritis

Ultrasonically guided percutaneous drainage of amoebic liver abscess

Fifteen patients with amoebic liver abscess were treated over two years. The diagnosis was in all cases verified by diagnostic aspiration. Twelve patients were treated by needle aspiration at three day intervals guided by ultrasonography and 3 patients were treated by surgical drainage. Anti amoebic drugs were given simultaneously with the chosen procedure to both groups. The patients were followed up with clinical examination and ultrasonography for a mean time of 3 months. During follow-up period, it was found that the group treated with aspiration drainage showed rapid clinical improvement and less hospitalization time in comparison with the surgically treated group. There were no complications from the US guided aspiration which was considered an integral part in the management of amoebic liver abscess

association between plasma lipids and gall stones in patients with ischaemic coronary heart disease

The study was conducted on seventy five patients and thirty controls. The patients were classified into three groups: Group I included patients with gall stones only, Group II included patients with coronary heart disease CHD only and Group III included those with both diseases. Serum levels of the following lipid fractions were estimated: Total cholesterol, phospholipids, tri-glycerides, high density lipoprotein cholesterol, HDL-phospholipids, low density lipo-protein cholesterol and LDL phospholipids. The results showed that the serum total cholesterol was significantly lower in the patients with gall stones compared to controls. The serum phospholipids revealed no difference between patients controls. On the other hand, the serum HDL-cholesterol was significantly lower in all patients than controls. HDL-phospholipids was also lower in the three patient groups in comparison with the controls but this difference is significant in patients with gall stones and in those with CHD. Lastly, the serum level of LDL-cholesterol is significantly higher in all patients than controls LDL phospholipids. The serum level of the LDL-ph was higher in the 3 groups of patients than controls but this difference was significant in Group I and Group III while it was highly significant in Group II compared to controls. The difference between the three groups of patients was insignificant. There is positive correlation in the patient groups and controls as regard the following lipid fractions: Total cholesterol versus phospholipids, total cholesterol versus triglycerides, HDL-cholesterol versus HDL-phospholipids and LDL-cholesterol versus LDL-phospholipids. We had observed that there was no significant difference between the 3 groups of patients in any of the estimated lipid fractions and also in the correlation between the above mentioned parameters, so, we can predict that the metabolic effect and the behaviour of both CHD gall stones are the same. Both the serum total cholesterol and the serum phospholipids have no longer been a determinant factors for either CHD or gall stone disease as thought before. However, the serum levels of the lipoproteins are the good predictive indicators for the development of both diseases

Selective per-operative cholangiography and scoring method for selection.

A prospective clinical study was undertaken over a period of 3 years on a series of 210 consecutive cases of gall stones to review a selective policy for per-operative cholangiography (PC). All patients had elective cholecystectomy and routine PC. A scoring method (SM) based on pre and per-operative surgical criteria was adopted to determine the necessity of PC before this was attempted. The study revealed that PC was indicated in 64 cases (30.5%) only. Of these 64 patients 20 had abnormal cholangiograms of which 18 proved positive on exploration. There were two false positive results (0.95%) of PC but no false negative result. Of 146 patients (69.5%) not clinically indicated for routine PC, 145 had normal cholangiograms and one had a small (5 mm diameter) silent stone (0.47%) in the Common Bile Duct (CBD). The scoring method failed to predict this case of silent stone. PC was technically unsatisfactory in 4 cases (1.9%). Thus by adopting the selective policy X-rays could have been avoided in 69.5% cases in which only a small silent stone would have been overlooked. However, this stone could have passed into the duodenum spontaneously or else it could have been removed by endoscopic sphincterotomy had it caused any symptoms. It is concluded that routine PC is not always necessary, a selective policy may be preferred and a scoring method may be used as a guide for selection of the cases.