Analysis of carbapenem-resistant Acinetobacter from a tertiary care setting in North India.

Multidrug-resistant (MDR) Acinetobacter baumannii is a worldwide concern as cause of serious nosocomial infections. We analysed 140 non-duplicate Acinetobacter sp. isolates from hospitalised patients in a tertiary care centre; 87% were MDR and 20% (28/140) meropenem resistant. Metallo-β-lactamase was produced by 16 of these, detected by ethylene-diamine-tetra-acetic acid disc synergy test. AmpC β-lactamase and efflux pump were present in 17 and 4 of the meropenem-resistant Acinetobacter, respectively. 9/16 MBL-positive isolates carried genes for carbapenem resistance as shown by polymerase chain reaction.

Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking.

Background: In India, common morbidities among children under 3 years of age are fever, acute respiratory infections, diarrhea. Effective early management at the home level and health care-seeking behavior in case of appearance of danger signs are key strategies to prevent the occurrence of severe and life-threatening complications. Objectives: To find out the prevalence of acute child morbidities, their determinants and health-seeking behavior of the mothers of these children. Setting and Design: The cross-sectional study was carried out in Wardha district of central India. 0 Material and Methods: We interviewed 990 mothers of children below 3 years of age using 30-cluster sampling method. Nutritional status was defined by National Center for Health Statistics (NCHS) reference. Composite index of anthropometric failure (CIAF) was constructed. Hemoglobin concentration in each child was estimated using the 'filter paper cyanm ethemoglobin method.' Using World Health Organization guidelines, anemia was defined as hemoglobin concentration less than 110 g/L. Post-survey focus group discussions (FGDs) were undertaken to bridge gaps in information obtained from the survey. Statistical Analysis: The data was analyzed by using SPSS 12.0.1 software package. Chi-square was used to test the association, while odds ratios were calculated to measure the strength of association. Multiple logistic regression analysis was applied to derive the final model. Results: Anemia was detected in 80.3% of children, and 59.6% of children were undernourished as indicated by CIAF. The overall prevalence of acute morbidity was 59.9%. Children with mild anemia, moderate anemia and severe anemia had 1.52, 1.61 and 9.21 times higher risk of being morbid, respectively. Similarly, children with single, 2 and 3 anthropometric failures had 1.16, 1.29 and 2.27 times higher risk of being morbid, respectively. Out of 594 (60%) children with at least one of the acute morbidities, 520 (87.5%) sought health care, where majority (66.1%) received treatment from private clinics. The final model suggested that anemia and mother's poor educational status are predictors of childhood morbidity. Conclusions: Nutritional anemia and mother's poor educational status are the most important risk factors of acute childhood morbidity. There is need to revitalize existing health care delivery and child health programs in rural India with emphasis on immediate correction of nutritional anemia.

The 2006 Dengue Outbreak in Delhi, India.

Dengue is a worldwide condition spread throughout the tropical and subtropical zones between 30 degrees north and 40 degrees south. It is endemic in South East Asia, the pacific, East and West Africa, the Caribbean and the Americas. Dengue outbreaks are occurring almost every three yearly in Delhi for the last 12 years. The latest outbreak was in the year 2006, which started late in August, peaked in the month of October and lasted till late November. We describe here the clinical, hematological and biochemical data of 70 patients of dengue fever diagnosed as per WHO criteria in Lok Nayak Hospital, New Delhi during this outbreak. Hematological parameters were estimated by automated counter and dengue serology was done by capture ELISA technique. The results displayed widespread effect of dengue fever on hematological and biochemical profile. Some of our patients also had atypical dengue manifestations. These results suggest that dengue fever is a major public health problem which can lead to significant morbidity and can even be fatal at times. All efforts should be made to prevent it.

Evaluation of WHO haemoglobin colour scale & palmar pallor for screening of anaemia among children (6-35 months) in rural Wardha, India.

BACKGROUND & OBJECTIVE: Anaemia is a public health problem in India, particularly in women and children. Clinical diagnosis by health workers may be inaccurate. It is therefore important to evaluate simple methods for diagnosis of anaemia in rural set up with no or minimal laboratory facilities. We carried out this study to evaluate the performance of haemoglobin colour scale and palmar pallor against filter paper cyanmethaemoglobin method as screening methods for anaemia in children 6-35 months of age. METHODS: A total of 772 children between 6-35 months were studied from three primary health centres of Wardha district, central India, by house-to-house visit. The child was examined for presence of palmar pallor and haemoglobin estimated by haemoglobin colour scale (HCS) and filter paper cyanmethaemoglobin method independently by two persons. RESULTS: Haemoglobin colour scale had sensitivity of 89 per cent and specificity of 97 per cent in detecting anaemia in children. Pallor had sensitivity of 73 per cent and specificity of 98 per cent. The predictive values were 99 per cent and 69 per cent for positive and negative HCS result. Similarly, the predictive values were 99 and 48 per cent for positive and negative pallor result. Correct diagnosis of anaemia was 34 and 0.1 times common if HCS test result was positive (Hb < 110.0 g/l) and negative (Hb > 110.0 g/l) for anaemia. INTERPRETATION & CONCLUSION: HCS fulfills the requirement of field test for screening of anaemia in resource poor country. It also has acceptable precision and accuracy and hence can be used in national anaemia control programmes.

Epidemiological correlates of nutritional anemia among children (6-35 months) in rural Wardha, Central India.

Background and Objectives : Nutritional anemia is associated with impaired performance of a range of mental and physical functions in children, along with increased morbidity. Iron supplementation at a later age may not reverse the adverse effects. National Nutritional Anemia Control Program was launched in India in 1970, but it failed to make any impact. The present study was undertaken to find out prevalence of anemia and its correlates in rural Wardha in children 6-35 months of age. Materials and Methods : Seven hundred seventy-two children between 6 months and 35 months of age were studied for anemia by cluster-sampling method. The hemoglobin was estimated in the child by 'Filter paper cyanmethemoglobin method.' Pre-designed and pre-tested questionnaire was used to collect data on socio-demographic and other variables. Data was analyzed by SPSS 12.0.1. Results : Mean hemoglobin level was 98.5 +/- 12.9 gm/L. Prevalence of anemia was 80.3%. Only 1.3% children had severe anemia (hemoglobin < 70 gm/L). The univariate analysis showed that anemia is significantly associated with age of the child, education of mother and father, occupation of father, socioeconomic status, birth order and nutritional status as measured by weight for age. The final model suggested that only educational status of the mother, occupation of the father, birth order and nutritional status of the child were significantly associated with anemia. Interpretation and Conclusion : For short-term impact, appropriate nutritional interventions remain the only operational intervention as only the nutritional status (weight for age) is a modifiable factor. But for long-term sustained impact, policy makers need to focus on improving maternal education and reducing family size.

Utility of carotid intimal medial thickness as a screening tool for evaluation of coronary artery disease in pre-transplant end stage renal disease.

BACKGROUND: Coronary artery disease (CAD) is associated with a higher incidence of allograft failure and mortality in patients with end-stage renal disease (ESRD) following renal transplant. AIM: To evaluate the efficacy of using carotid intimal medial thickness (CIMT) to predict the presence of CAD in patients with ESRD, using coronary angiography (CAG) as the gold standard. MATERIALS AND METHODS: This prospective study enrolled consecutive patients with ESRD who underwent CAG as a part of pretransplant evaluation to rule out the presence of atherosclerotic CAD. An operator who was blinded with respect to the results of the CAG, measured carotid IMT in all patients prior to CAG and recorded it on videotape. Two independent observers blinded to the results of CAG measured carotid IMT offline to validate its predictive accuracy as a noninvasive test in predicting the presence or absence of CAD. Measurement of carotid IMT was done on USG B mode 7.5 MHZ probe [HP 5500 andover, Massachusetts]. Student's t-test was used for inter-group comparisons. Pearson correlation coefficient test was used to assess the relation between CAD and various risk factors and carotid IMT. Linear regression analysis was applied to identify independent factors determining presence of CAD. A P value < 0.05 was considered statistically significant. RESULTS: Mean CIMT was significantly higher in those with CAD as compared to those without [0.80+/- 0.06 vs.0.70+/-0.06 mm, P< 0.0001). Patients with CIMT> 0.75 mm were older and had more incidence of diabetes(78% vs. 47%; P=0.001). Only 4/53 (7%) of patients with CIMT< 0.75 mm had CAD, vs. 38/52 (73%) in those with CIMT >0.75 mm. The sensitivity and specificity of using CIMT > 0.75 as a predictor of CAD was 90.47%and 73% and its positive and negative predictive values were 0.73 and 0.92. On multivariate analysis, only CIMT was a significant predictor of CAD. CONCLUSION: Carotid IMT can be used to predict CAD in patients with ESRD. In the absence of other risk factors,patients with IMT< 0.75 mm may not need a pretransplant CAG.

Our experience with epidural steroid injections in management of low backpain and sciatica.

BACKGROUND: Low back pain and sciatica is a common clinical condition. It is a most common orthopaedic complaint in the Kaski region of Nepal. The reason for its increased incidence may be hilly terrain, difficult working and living environment of the region. The initial treatment of Low back pain is conservative. Epidural steroid injection is being slowly established as are liable mode of conservative management in many orthopaedic centres of the world. This is a preliminary report of on-going study of the use of epidural steroid in the management of low back pain cases coming to the orthopaedic department of Manipal Teaching Hospital. METHODS: Prospective clinical trial was carried out on the patients reporting with low back pain and sciatica not responding to other modes of conservative treatment. Pre and post injection evaluation was done clinically. The level of pain, improvement in physical signs and ability to do activities of daily living were noted. RESULTS: Fifty two patients were observed for the average duration of 2.87 months. Average duration of symptoms was for 10 months. After first epidural steroid injection 83% of patients reported relief on day one. In some cases the onset of analgesia was delayed. Four patients reported no relief after first injection. Fifteen patients were given two injections and four received three injections. The average duration between two injections was three weeks.Average duration of pain relief was 20 days. At the end of 3 months, good results were seen in 39%, fair in 33% and bad results in 27%. Overall 59% of patients were able to do activities of daily living. Three patients (5.76%)required operation for disc prolapse. Postoperatively two patients reported back with back pain. Most common complaint of patients after injection was pain at the injection site. No major complications were encountered. CONCLUSION: Epidural Steroid Injection is a safe and effective mode of treatment of Low Back Pain. It provides painfree period to enable the patient for physiotherapy which helps in early recovery.

TNFR2 gene polymorphism in coronary artery disease.

BACKGROUND: Recently atherosclerosis and coronary artery disease (CAD) are considered to be inflammatory diseases. The genetic polymorphism in inflammatory markers has been well studied and found to be associated with development of CAD. AIM: To study the association of biallelic polymorphism at position 196 in exon 6 of tumor necrosis factor 2 (TNFR2) gene and coronary artery disease. SETTINGS AND DESIGN: The study design was a prospective case control study conducted at a tertiary referral center mainly catering to the north Indian population. MATERIALS AND METHODS: One hundred and fifty angiographically proven patients with coronary artery disease and one hundred and fifty age matched controls were genotyped for TNFR2 gene by polymerase chain reaction followed by analysis of restriction fragment length polymorphism. STATISTICAL ANALYSIS: Genotype frequencies were compared in patients and controls by Chi-square test. Binary logistic regression analysis was used to examine the relationship between genotypes and disease, incorporating other variables into the model. RESULTS: The incidence of CAD in those with MM genotype was 65% and in those with RM genotype was 42%. Genotype frequency shows significant association of MM genotype with development of CAD (P < 0.001; odds ratio-2.585; 95% confidence interval 1.533-4.359). The association of TNFR2 genotype with CAD persisted on logistic regression analysis. CONCLUSION: MM genotype of TNFR2 gene is associated with development of CAD and RM genotype appears to be protective.

T1 and M1 polymorphism in glutathione S-transferase gene and coronary artery disease in North Indian population.

BACKGROUND: DNA damage has been found to play an important role in atherosclerosis and coronary artery disease. Genetic polymorphisms of the genes coding for enzymes involved in the metabolism of genotoxins result in different phenotypes with respect to their ability to detoxify these agents. In the present study the contribution of the polymorphism in the glutathione S-transferase gene to the development of coronary artery disease has been investigated. METHODS: One hundred and ninety seven angiographically proven patients with coronary artery disease and one hundred and ninety eight age-matched controls were genotyped for glutathione S- transferase polymorphism by polymerase chain reaction. Genotype frequencies were compared in patients and controls by Chi-square test. Binary logistic regression was used to examine the relationship between genotype and disease, incorporating other variables into the model. RESULTS: GSTT1 null genotype was significantly decreased in patients with coronary artery disease. No significant association was found with GSTM1 genotypes. No such association was seen with smokers. CONCLUSION: Null genotype of GSTT1 is protective against coronary artery disease in our population.

Absence of factor V Leiden (G1691A) mutation, FII G20210A allele in coronary artery disease in North India.

BACKGROUND: Interaction between various genetic and environmental factors is associated with coronary artery diseases (CADs). Factor V Leiden mutation (FVL) and FII G20210A polymorphism are two recently described genetic factors with a propensity towards venous thrombosis, however, with a doubtful role in coronary artery disease and myocardial infarction. AIM: Present study was conducted to assess the relationship of both these factors in coronary artery disease in population from North India. SETTING AND DESIGN: Case control study. MATERIAL AND METHODS: Two hundred angiographically proven coronary artery disease patients were studied to examine the association of Factor V Leiden mutation and FII G20210A mutation with coronary artery disease and myocardial infarction. Out of 200 patients, 51 had myocardial infarction. Two hundred controls were selected who were from north India and were also age and sex matched. RESULTS AND CONCLUSIONS: Our results indicate that both these polymorphisms were totally absent in our population, therefore, these variants cannot be considered as independent risk factors or as a predictor for CAD. However, there is a need to confirm the above findings on patients from different populations from different parts of the country as there are reports which show that the incidence of Factor V Leiden varies from 1.3 % to 10%.

Role of thrombolytic therapy for stuck prosthetic valves: a serial echocardiographic study.

BACKGROUND: Thrombotic occlusion of a prosthetic valve continues to be an uncommon but serious complication. Intravenous thrombolytic therapy has been proposed as an alternative to surgical treatment, but only in critically ill patients. METHODS AND RESULTS: Forty-one consecutive patients presenting with 48 episodes of prosthetic valve thrombosis (44 mitral and 4 aortic) were treated with thrombolytic therapy under serial echocardiographic guidance. There were 14 male and 27 female patients. The anticoagulation status was inadequate in 89.6% of episodes. Atrial fibrillation was present in 47.9% of episodes. The prostheses involved in these episodes were tilting disc in 45, bileaflet in 2, and ball and cage type in 1. The Sorin prosthetic valve was the most commonly involved. The time interval between valve replacement and thrombosis ranged from 1 month to 108 months (mean 20.4+/-20.6 months). Patients were in New York Heart Association functional class III in 47.9% and in class II in 43.9% of episodes. Thrombolytic agents used were streptokinase and urokinase in 44 and 4 episodes, respectively. The mean duration of thrombolytic therapy was 27.9+/-15.0 hours and the overall success rate was 87.5%. Patients developed peripheral embolism with almost complete recovery in 5 episodes while significant bleeding that required termination of thrombolytic therapy was observed in 2 episodes. Redo valve replacement was done in 3 episodes because these patients did not improve on thrombolytic therapy (all 3 cases were of recurrent prosthetic valve thrombosis and were found to have pannus peroperatively). Three patients died during thrombolytic therapy because of persistent heart failure. Six patients experienced a total of 13 epidoses of recurrent prosthetic valve thrombosis including index episodes (rethrombosis in 5, re-rethrombosis in 1). They were treated with repeated thrombolysis with a success rate of 76.92%. The mean duration of thrombolytic therapy in these episodes was 36.1+/-14.0 hours. CONCLUSIONS: In patients with prosthetic valve thrombosis, intravenous thrombolysis guided by echocardiography is a safe and effective method that may expand the indications for nonsurgical treatment of prosthetic valve thrombosis. By using serial echocardiography, the duration of thrombolytic therapy can be tailored to the patient's requirement for normalization of valve hemodynamics.

Vectorial efficacy of Phlebotomus argentipes in Kala-azar endemic foci of Bihar (India) under natural and artificial conditions.

Ability of Phlebotomus argentipes to acquire Leishmania donovani the causative agent of Indian Kala-azar was evaluated in the laboratory. Flies were fed artificially on infected blood suspensions, using a chick-skin-membrane feeding apparatus, and naturally on Leishmania donovani infected mice. In addition flies collected from different endemic areas were dissected and examined for natural infection. Flies fed on infected mice showed significantly higher feeding rate (14.4%, p < 0.01) compared to that of other experiments (9%, 8.75%) but the percentage of infection was very low (2.43%). No Chi-square comparison was made between infection rate and feeding rate because of low value in infection rate (less than 5). Flies dissected for natural infection showed only 0.1% infection. Not much difference was observed in the intensity of Leishmania donovani infection in the mid gut of sandflies examined from any of these experiments. These observations have confirmed that Phlebotomus argentipes has ability to acquire infection and it provides the final piece of evidence that Phlebotomus argentipes is the vector of Leishmania donovani in Bihar State.

Plasma lipoprotein(a) levels in patients with pulmonary arterial hypertension.

BACKGROUND: Pulmonary artery hypertension is a common sequelae of a variety of cardiac and lung diseases. Pathogenesis of primary and secondary pulmonary artery hypertension is still debatable. METHODS AND RESULTS: We studied the serum lipoprotein(a) levels in patients with primary (n=27) and secondary (n=19) pulmonary artery hypertension (Eisenmenger syndrome). The results were compared with age and sex matched controls (n=46). We also studied the frequency of high levels of lipoprotein(a) (> 30 mg/dl) in pulmonary artery hypertension. Mean lipoprotein(a) levels were significantly higher in the pulmonary artery hypertension group compared to age- and sex-matched controls (31.60+/-15.49 mg/dl v. 14.66+/-14.7; p=0.0001). All patients were classified into two groups on the basis of their lipoprotein(a) levels (<30 mg/dl and >30 mg/dl). There was a higher frequency of lipoprotein(a) >30 mg/dl in patients of pulmonary artery hypertension v. controls (52% v. 24%; p= <0.001). Younger age, higher functional class, more severe congestive heart failure, shorter duration of symptoms. and more cases of hemoptysis were observed in the group with lipoprotein(a) >30 mg/dl. CONCLUSIONS: High lipoprotein(a) may be a marker and be associated with a more adverse prognosis in severe pulmonary artery hypertension. Larger prospective studies are needed to establish lipoprotein(a) as a risk factor for the development of pulmonary artery hypertension.

Is axillary temperature an appropriate surrogate for core temperature?

The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports about its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6-14 years age) were compared using mercury-in-glass thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6 degree C (-0.3 degree C, 1.4 degrees C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6-14 years was observed to be 0.6 degree C (-0.4 degree C, 1.4 degrees C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.

Captopril for prevention of contrast-induced nephropathy in diabetic patients: a randomised study.

Contrast-induced nephrotoxicity is an important cause of hospital-acquired acute renal insufficiency. Different modalities have been used to prevent contrast induced-nephrotoxicity namely saline infusion, mannitol, furosemide, calcium channel blockers, atrial natriuretic factor and dopamine infusion with variable success. The possible role of medullary ischaemia mediated by renin angiotensin system in genesis of contrast-induced nephrotoxicity prompted us to investigate the role of captopril (a sulfhydryl group containing angiotensin-converting enzyme inhibitor) in its prevention. Seventy-one patients of diabetes mellitus undergoing coronary angiography were included in the study. Patients randomised to receive captopril, received the drug in a dose of 25 mg thrice a day for three days, starting one hour prior to angiography while the patients in the control group underwent angiography in a routine manner without receiving captopril. Following angiography, patients in the control group developed a significant increase in serum creatinine and blood urea nitrogen levels, as compared to those who received captopril. Contrast-induced nephrotoxicity (i.e. a rise of 0.5 mg/dL in serum creatinine) developed in 29 percent of the control group. Administration of captopril reduced the risk of development of contrast-induced nephrotoxicity by 79 percent. Glomerular filtration rate as measured by Tc DTPA renal scanning prior to and 24-72 hours following angiography demonstrated a mean fall of 9.6 ml/min in the control group while those in the captopril group had a mean increase of 13 ml/min in glomerular filtration rate. We conclude that abnormalities of renal perfusion possibly mediated by renin angiotensin system are responsible for development of contrast-induced nephrotoxicity. Administration of the angiotensin-converting enzyme inhibitor, captopril, offers protection against development of contrast-induced nephrotoxicity.