Irrational Antibiotic Usage among Pediatric Patients in a Tertiary Care Hospital-A Point Prevalence Cross-Sectional Study

Background: Irrational practicing of antibiotic prescribing adds up to increased morbidity and mortality of pediatric patients, especially with infections such as pneumonia, meningitis, bronchitis, etc. Objective: To determine the prevalence of irrational usage of antibiotics among pediatric patients and its effect on them. Methods: A crosssectional observational study was conducted in a tertiary care hospital for a period of 6-months with 250 pediatric patients from various specializations. The exclusion was based on those with malnutrition, syndromes, congenital heart defects and other concomitant diseases including 80 patients. Medical and laboratory records were made use for the analysis. Results: Common age category of patients were from 0-12 months (57(22.8%)). Mean length of stay was about 6.3 (4; 1-40%). Blood culture reported Staphylococcus aureus (36.6%) to be the prominent organism. Cephalosporin (33.7%) was the commonly prescribed antibiotic class, with tetracycline (11.6%) commonly used as the prophylactic broad-spectrum antibiotic. The mortality rate due to irrational antibiotic prescription was about 37 [PR: 7.21 (1.75 to 22.59, p>0.005)]. Conclusion: Male gender was more liable to infections and mortality due to irrational antibiotic prescribing had been increased significantly in the population requiring monitoring and appropriate screening.

Maternal and Perinatal outcomes of oligohydramnios in a tertiary care hospital in Salem, Tamil Nadu, India

Background: Oligohydramnios is the term coined for a condition where the amount of liquor amnii is less than 200 ml at term. Using an ultrasonogram, oligohydramnios can be deliberated when the vertical pocket of liquor is less than 2 cm or when amniotic fluid index (AFI) is less than 5 cm. Oligohydramnios is reported to occur in 1 to 5% of total pregnancies. It has been associated with adverse maternal and foetal outcomes.Methods: This hospital-based follow-up study was conducted among 540 pregnant women at 37 weeks attending to the Department of Obstetrics and Gynaecology for a period of 1 year from January to December 2018. All included pregnant women were subjected to routine ultrasound examination and assessment of amniotic fluid volume using Amniotic fluid index.Results: The incidence of oligohydramnios was 17.04% (n=92) among the included women and 62% (n=57) among them were primigravida. Among those women diagnosed with Oligohydramnios, the caesarean section rate was 56.5% (n=52), the common indications for LSCS being fetal distress 44. 2% (n=23) and IUGR 34.6% (n=18). The oligohydramnios pregnancies had more associated post-dated deliveries (28.3%), pregnancy induced hypertension (10.9%) and gestational diabetes (8.7%). It was also associated with higher incidence of low birth weight (27.2%), NICU admissions (32.6%), congenital anomalies (3.3%) and fetal deaths (5.4%).Conclusions: The study showed that an amniotic fluid index of less than 5 at term was associated with adverse maternal and perinatal pregnancy outcomes emphasizing the importance of amniotic fluid volume surveillance during the antenatal period.

CagA and VacA genes of Helicobacter pylori and their clinical relevance

Context: Helicobacter pylori is associated with the development of a variety of gastroduodenal diseases which varies with ethnicity and the type of strains that infect the population. Aims: This study aims to evaluate the prevalence of H. pylori cagA and vacA genotypes in our region and to determine their relationship to the severity of the lesions that they cause. Settings and Design: This study was an observational cross-sectional study. Subjects and Methods: DNA was extracted from 165 gastric biopsies from patients evaluated for dyspepsia. PCR was used to detect cagA and vacA (s1, s2, m1, m2) genes of H. pylori. Statistical analysis of associations was performed between endoscopy findings and virulence genes. Statistical Analysis Used: Pearson Chi-square test and Fischer's exact test. Results: The prevalence of H. pylori infection was 37% and the dominant genotypes was vacA s1 cagA-positive strain (54.1%) in this study. The vacAs1 subtype was found in all patients with peptic ulcer disease (PUD). The entire normal study group had VacA s2 variant only. This clearly shows that vacA s1 is a significant virulence marker and patients harboring s1 strains are more prone to develop ulcers (P = 0.007). There was a significant association of cagA with s1 strain rather than s2. Variation in VacA m genotype did not seem to have any association with disease status. There was a statistically significant association between the presence of cagA gene and PUD rather than the nonulcer dyspepsia (P = 0.027). Conclusion: The predominant genotype in our population was cagA positive vacA s1, which was found to be significantly associated with patients with gastric diseases, especially PUD. VacA s1 can serve as a single best virulence marker of the disease manifestation.

A study of aetiology of portal hypertension in adults (including the elderly) at a tertiary centre in southern India.

Background & objectives: There are only a few studies on aetiology of portal hypertension among adults presenting to tertiary care centres in India; hence we conducted this study to assess the aetiological reasons for portal hypertension in adult patients attending a tertiary care centre in southern India. Methods: Causes of portal hypertension were studied in consecutive new adult patients with portal hypertension attending department of Hepatatology at a tertiary care centre in south India during July 2009 to July 2010. Results: A total of 583 adult patients (>18 yr old) were enrolled in the study. After non-invasive testing, commonest causes of portal hypertension were cryptogenic chronic liver disease (35%), chronic liver disease due to alcohol (29%), hepatitis B (17%) or hepatitis C (9%). Of the 203 patients with cryptogenic chronic liver disease, 39 had liver biopsy - amongst the latter, idiopathic non cirrhotic intrahepatic portal hypertension (NCIPH) was seen in 16 patients (41%), while five patients had cirrhosis due to non alcoholic fatty liver disease. Fifty six (10%) adult patients with portal hypertension had vascular liver disorders. Predominant causes of portal hypertension in elderly (>60 yrs; n=83) were cryptogenic chronic liver disease (54%) and alcohol related chronic liver disease (16%). Interpretation & conclusions: Cryptogenic chronic liver disease was the commonest cause of portal hypertension in adults, followed by alcohol or hepatitis B related chronic liver disease. Of patients with cryptogenic chronic liver disease who had liver biopsy, NCIPH was the commonest cause identified. Vascular liver disorders caused portal hypertension in 10 per cent of adult patients. Cryptogenic chronic liver disease was also the commonest cause in elderly patients.

Severe and treatment resistant strongyloidiasis--indicator of HTLV-I infection.

The association between severe and persistent strongyloidiasis with human T cell lymphotropic virus type I (HTLV-1) infection is well documented in reports from HTLV-1 endemic regions like Japan and Jamaica. But there are no reports from non-endemic areas like India. We report a case of severe intestinal strongyloidiasis in a 45-year old Keralite man, living in Sikkim. Despite standard treatment with many courses of albendazole, his stool persistently showed Strongyloides stercoralis larvae. In the absence of other immunosuppressive conditions, human T cell lymphotropic virus type I infection was considered and determined positive. Subsequently, treatment with 2 courses of ivermectin achieved eradication of the infection. On follow-up, 3 years later, his stools again revealed Strongyloides stercoralis larvae.

Eosinophilic cholangiopathy - a report of two cases.

Eosinophilic cholangiopathy is an unusual and benign form of biliary disease characterized by peripheral blood eosinophilia and cholangitis. Dramatic response to steroids is the hallmark of the disease. We present two cases of eosinophilic cholangiopathy.

Isolated liver abscesses in melioidosis.

Melioidosis is a suppurative chronic infection caused by a gramnegative bacterium, Burkholderia pseudomallei. We report two patients who presented with isolated liver abscesses caused by this pathogen. Both patients presented with high-grade fever and abdominal pain. On examination they were toxic and had tender hepatomegaly. Investigations showed leucocytosis and a shift to the left. Early diagnosis of melioidosis was made by culture and growth of Burkholderia pseudomallei from aspirated pus from the abscesses and the patients were treated with ceftazidime and co-trimoxazole. Despite institution of antibiotics both the patients succumbed to their illness. Melioidosis is an emerging infection in the Indian subcontinent and can cause isolated liver abscesses.

Direct intrahepatic cavo-portal shunts in Budd-Chiari syndrome: Role of simultaneous fluoroscopy and trans-abdominal ultrasonography.

BACKGROUND: Transjugular intrahepatic porto-systemic shunt (TIPS) for Budd-Chiari syndrome (BCS) can be inserted from inferior vena cava or hepatic vein to portal vein. The former is performed when hepatic veins are not suitable and is technically more challenging. METHODS: In this retrospective study, 7 patients with chronic BCS needed cavo-portal shunt as hepatic veins were neither amenable to plasty nor provided access for TIPS placement. Simultaneous fluoroscopic and trans-abdominal ultrasound guidance was used at the time of portal vein puncture. RESULTS: Technical success and clinical improvement were obtained in all patients. Median 3 (range 1-4) attempts were needed to puncture the portal vein. There were no significant complications. Uncovered stents were used in six patients and stent occlusion was common, but could be managed by re-intervention. CONCLUSION: Cavo-portal shunt is an effective technique for patients with BCS uncontrolled by medical therapy. Additional trans-abdominal ultrasound in oblique parasagittal plane keeps the procedure safe.

Autoimmune pancreatitis--an uncommon type of chronic pancreatitis.

Autoimmune pancreatitis is a recently recognized clinical entity characterized by narrow strictured main pancreatic duct on ERCP, diffusely enlarged sausage-shaped pancreas on CT scan and MRI, seropositivity for antinuclear antibodies, hypergammaglobulinemia, and excellent response to steroids. We report a 25-year-old man and a 53-year-old man with this condition.

Pancreatico-pericardial fistula: a rare complication of chronic pancreatitis.

A 16-year-old boy presented with pericardial effusion, bilateral pleural effusion and mediastinal fluid collection. CT scan of abdomen revealed pancreatic calcification and a fistulous tract from a pseudocyst going along the inferior vena cava wall up to the pericardial cavity. After initial pericardiocentesis and pleurocentesis, lateral pancreatico-jejunostomy with Roux-en-Y loop was performed. The patient is well at 6 months follow up.

Giant splenic artery mycotic aneurysm presenting with massive hematemesis.

We report a 40-year-old man with rheumatic heart disease who presented with abdominal pain for three weeks and hematemesis for 24 hours. CT scan showed a large splenic artery aneurysm without evidence of pancreatitis. Mycotic aneurysm due to infective endocarditis was considered and confirmed by echocardiogram, which showed aortic and mitral valve regurgitation and vegetations. He was managed successfully with coil embolization of the aneurysm and antibiotics.