Peripheral arterial blood pressure versus central arterial blood pressure monitoring in critically ill patient safter Cardio-pulmonary Bypass

Objective: To determine the accuracy of peripheral [radial] arterial access as compared to central [femoral] arterial access for measurement of invasive blood pressure [IBP] in critically ill patients after cardiopulmonary bypass

Methods: Sixty patients [60] who required high inotropic/vasopressor support on weaning from cardio-pulmonary bypass and weaned off in 2nd attempt were included in this study. The duration of this study was from June 2015 to August 2016. Radial and femoral arterial access was achieved in all patients for simultaneous measurement of blood pressure. Arterial pressures were noted after 5, 15 and 30 minutes of weaning from cardiopulmonary bypass for both radial and femoral artery simultaneously

Results: Mean age of study patients was 56.48+/-11.17 years. 85% patients were male. There was significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressures between the radial artery and femoral artery cannulation. Mean arterial pressures were significantly high in femoral artery as compared to the radial artery. The mean arterial pressures after five minutes of weaning using central access were 76.28+/-10.21 mmHg versus 64.15+/-6.76 mmHg in peripheral arterial access [p-value <0.001]. Similarly we also found significant difference in mean arterial pressures after 15 minutes of weaning from cardiopulmonary bypass 78.70+/-10.12 mmHg in central access versus 72.03+/-6.76 mmHg using peripheral arterial access [p-value <0.001]. The difference in arterial pressures were less marked as compared to the previous differences after 30 minutes of weaning from cardiopulmonary bypass as compared to the earlier readings [p-value 0.001]

Conclusion: Peripheral arterial pressures are unreliable in critically ill patients after cardiopulmonary bypass receiving high dose of inotropic drugs. Central arterial access should be used in these patients to get accurate estimates of patients' blood pressure in early periods after cardiopulmonary bypass

Myocardial protection with glucose-insulin-potassiuminfusion during adult cardiac surgery

Background and Objective: Recent meta-analysis reports have called for more randomized trials to evaluate the effectiveness of GIK solution in patients of cardiac surgery. So this study was conducted to evaluate the effectiveness of Glucose-insulin-potassium [GIK] solutions in non-diabetic patients undergoing coronary artery bypass grafting

Methods: A total number of one hundred and sixty [160] patients were randomized into two equal groups; GIK Group and non-GIK group. In GIK group, 5% dextrose containing 70 IU/L regular insulin and 70 meq/L of potassium was administered. The infusion was started at a rate of 30 ml/hour after induction of anesthesia and before the start of cardiopulmonary bypass. The infusion was started again after removal of aortic cross clamp and was continued for six hours after the operation

Results: In early post-operative period, peak CKMB levels were high in non-GIK group 48.50+/-19.79 IU/L versus 33.40+/-14.69 IU/L in GIK group [p-value <0.001]. There was no statistically significant difference in requirements of inotropic support between the groups. The mean duration of inotropic support in GIK group was only 5.50+/-6.88 hours in GIK group and 8.64+/-7.74 hours in non-GIK group [p-value 0.008]. Mean ventilation time in GIK group was 5.06+/-2.39 hours versus 6.55+/-3.58 hours in non-GIK group [p-value 0.002]. Similarly, ICU stay period was also shorter in GIK group [p-value 0.01]. We did not found any detrimental effect of GIK infusion on non-cardiac complications e.g. renal, pulmonary and neurologic complications

Conclusion: Glucose-insulin-potassium [GIK] infusion has a beneficial role in myocardial protection and is associated with better post-operative outcomes without increasing the risk of non-cardiac complications

Sternal wound infection following CABG: a review of 1121 patients

To know incidence of sternal wound infection, microbacteria involved and associated risk factors so as practical steps should be made before hand to counter theses problems. Case series study. This study was conducted at Ch. Pervaiz Ellahi, Institute of Cardiology, Multan from 2012-2014. Microbiological testing was conducted under supervision of a consultat microbiologist attached to the hospitals performing cardiac surgery. Infections were classified as in-hospital SSIs if occurring during the hospital stay, or post-discharge. Infections were recorded as sternal or harvest site infections. Associated Potential risk factors were recorded. A proforma was filled which was approved by hospital ethical committee. Over the study period, 1121 patients had CABG. Predominantly patients were male [mostly in age range of 50-76 with median age of 63 years]. ASA score of 3 was recorded in majority of patients. The majority of patients were recorded as having an ASA score of 3 or 4, a clean wound, and antibiotic prophylaxis administered. Antibiotic prophylaxis in almost all cases.97 patients had sternal site infections, with one half of the cases detected in-hospital and the other half post-discharge. Gram-positive bacteria were detected in 56% of cases having infections. 43% had Gram-negative bacteria and fungi [e.g. Candida albicans] 1 case. The incidence of MRSA is increasing and to counter these we had to adopt methods

Prevalence of methicillin-resistant staphylococcus aureus [MRSA] in intensive care unit of CPEIC, Multan

We undertook a study to determine the prevalence of MRSA colonization on admission to our intensive care unit [ICU] and the incidence of MRSA colonization in the ICU. Case series study. This study was conducted in ICUs in Chaudhry Pervaiz Ellahi Institute of Cardiology, Multan from January 2012, to December 2012. We included 1230 patients in which 766 were CABG and remaining 464 were for some congenital heart disesase. All patients were screened within 24 hours after ICU admission. For the intact skin specimen, a single swab was used to sample 4 different sites [the axilla and groin on both sides]. Sternotomywound were sampled also. Pre-moistened swabs were used to collect nasal and skin samples. Swabs were plated on Chapman agar alone. Data were analysed by using spss 11. Descriptive analysis were done along with p value. There were 1230 admissions to the ICU during the study. MRSA was isolated from 80 [6.8%] of 1,185 admission swabs taken, from 42 [7%] of 596 admission swabs where patients had both admission and discharge swabs taken, and from the discharge swabs of 63 [11.4%] of 554 remaining patients who had negative admission swabs. This study confirmed that there is a significant rate of acquisition of MRSA in our ICU. It also raised concerns about trauma patients being at increased risk compared with other patients. We are in the process of conducting a cohort study to assess risk factors for the acquisition of MRSA among trauma patients

Current status and future trends in the diagnosis and treatment of drug-susceptible and multidrug-resistant tuberculosis

The global burden of tuberculosis [TB] is still large. The increasing incidence of drug-resistant, multidrug-resistant [MDR] [resistant to at least rifampicin and isoniazid], and extensively drug-resistant [XDR] [additionally resistant to a fluoroquinolone and kanamycin/amikacin/capreomycin] strains of Mycobacterium tuberculosis and the association of active disease with human immunodeficiency virus coinfection pose a major threat to TB control efforts. The rapid detection of M. tuberculosis strains and drug susceptibility testing [DST] for anti-TB drugs ensure the provision of effective treatment. Rapid molecular diagnostic and DST methods have been developed recently. Treatment of drug-susceptible TB is effective in >/= 95% of disease cases; however, supervised therapy for >/= 6 months is challenging. Non-adherence to treatment often results in the evolution of drug-resistant strains of M. tuberculosis due to mutations in the genes encoding drug targets. Sequential accumulation of mutations results in the evolution of MDR and XDR strains of M. tuberculosis. Effective treatment of MDR-TB involves therapy with 5-7 less effective, expensive, and toxic second-line and third-line drugs for >/= 24 months and is difficult in most developing countries. XDR-TB is generally an untreatable disease in developing countries. Some currently existing drugs and several new drugs with novel modes of action are in various stages of development to shorten the treatment duration of drug-susceptible TB and to improve the outcome of MDR-TB and XDR-TB.

Acute haematogenous osteomyelitis of femur in a neonate with ‘bone within bone’ appearance: a case report.

Acute osteomyelitis in infants, which was known for high mortality and morbidity in the pre-antibiotic era can be managed conservatively by intravenous antibiotics and supportive therapy if the condition is detected and treatment started early in the course of the disease. Infantile osteomyelitis is separate entity from the one seen in older children in terms of vascular anatomy, pathogenesis, radiological changes and natural history. We present a neonate with acute haematogenous osteomyelitis of femur with preceding respiratory tract infection that was managed conservatively without surgical intervention despite severe radiographic changes. The child recovered without any residual deformity and final radiographs did not show any trace of the disease though early radiographs had exuberant involucrum formation and sequestration of entire diaphysis giving it a “bone within bone” appearance. Infants have excellent capacity of re-sorption of sequestrum and remodelling of involucrum such that no trace of disease is left in the adulthood.

Non-culture-based diagnostic methods for the diagnosis of invasive candidiasis: are they helpful to clinicians?

Invasive candidiasis in immune-compromised patients is associated with high attributable mortality. Early detection of candidemia and accurate identification of Candida species are essential pre-requisites for improved prognosis. Since clinical presentation is non-specific and blood culture-based methods lack sensitivity, detection of immunological and molecular markers has provided an alternative for early diagnosis of invasive candidiasis. Serial estimations of these biomarkers have also proved useful to initiate pre-emptive therapy in suspected patients before clinical signs appear and to monitor response to therapy. Antigen-based methods include detection of beta-D-glucan [panfungal marker] and Candida mannan [genus-specific marker]. Detection of both, Candida mannan and anti-mannan antibodies has higher sensitivity. While false positive / negative results remain a problem, these markers provide a useful adjunct to the diagnosis if performed in select patient population. Recent advances have also been made in nucleic acid-based detection methods. A commercial real-time PCR assay [Light Cycler Septi Fast] for detection of clinically important Candida spp. in blood specimens within six hours is now available. Molecular methods have also resulted in speciesspecific identification of yeast isolates within an hour. While these advances aid in early and specific diagnosis of candidemia and invasive candidiasis, further evaluation of these approaches in different clinical settings is also needed

New approaches in the diagnosis and treatment of susceptible, multidrug-resistant and extensively drug resistant tuberculosis

Tuberculosis [TB] is killing nearly two million people worldwide every year. The current global burden of TB is mainly due to the expanding human immunodeficiency virus infection and its association with active TB disease and increasing resistance of Mycobacterium tuberculosis strains to most-effective [first-line] anti-TB drugs. Incomplete/ improper treatment of TB patients leads to evolution of drug-resistant M. tuberculosis strains as a result of chromosomal mutations in genes encoding drug targets. Sequential accumulation of mutations in target genes generate multidrug-resistant [resistant atleast to rifampin and isoniazid] M. tuberculosis [MDR-TB] and extensively drug-resistant [additionally resistant to fluoroquinolones and an injectable anti-TB agent] M. tuberculosis [XDR-TB] strains. While proper treatment of susceptible TB has > 95% cure rate, effective treatment of MDR-TB is difficult in developing countries as it is heavily dependent on rapid diagnosis, supervised aggressive therapy with several [5 - 6] expensive, toxic and less efficacious drugs for 18 - 24 months and regular monitoring for bacteriological and clinical improvement. Treatment of XDR-TB is far more difficult even in developed countries. Several anti-TB drugs with novel mechanism of action are under clinical development, which may shorten treatment duration of susceptible TB to around three months and also help in effective treatment of MDR-TB / XDR-TB

Diagnosis of endocarditis caused by Mycobacterium abscessus

We report a fatal case of native valve endocarditis due to Mycobacterium abscessus in a hemodialysis patient. The diagnosis was based on culture isolation of acid-fast bacilli from peripheral blood and a permanent catheter tip, and their identification as M abscessus by a reverse hybridization-based assay and direct DNA sequencing of the 16S-23S internal transcribed spacer region. Rapid diagnosis and combination therapy are essential to minimize mortality due to this pathogen. Although combination therapy was started with clarithromycin and tigecycline, the patient refused to take clarithromycin due to severe abdominal pain. The patient became afebrile after therapy with tigecycline alone although bacteremia persisted. He was discharged against medical advice and readmitted three months later for persistent fever. His blood cultures again yielded M abscessus and a transesophageal echocardiogram showed two mobile vegetations. The patient was noncompliant with therapy and died due to cardiac arrest and multiorgan failure. This report shows that M abscessus should also be considered in the differential diagnosis of infective endocarditis in hemodialysis patients

Antituberculosis drug induced hepatitis

To study the incidence of drug induced hepatitis due to antituberculosis therapy. Descriptive study. Department of Internal medicine, Isra University Hospital Hyderabad, from January 2004 to December 2004. Medical records of all patients treated with antituberculosis therapy were ret rospectively reviewed. 215 patients were treated and 18 [8.4%] patients developed hepatitis. Rifctmpicin caused hepatitis in 2 [0.9%] patients. Isoniazid caused hepatitis in 11 [5.4%] cases. In 5 [2.3%] cases causative drug was unknown. In these cases, the patient died [four cases] or was lost to follow up [one case]. Among 215 treated cases, 4 patients [1.86%] died. Patients should be carefully monitored for the side effects of antituberculous sis chemotherapy

Phenotypic and molecular characterization of candida dubliniensis isolates from clinical specimens in Kuwait

This study was carried out to characterize Candida dubliniensis using phenotypic and molecular methods and to determine the occurrence of C. dubliniensis in clinical specimens in Kuwait. A total of 880 clinical specimens for isolation of fungi were processed according to standard procedures. Of these, 390 germ-tube-positive clinical isolates of Candida species were examined for rough colonies with hyphal fringes and chlamydospore production on simplified sunflower seed agar for their presumptive phenotypicidentification as C. dubliniensis. The identification of C. dubliniensis isolates was further confirmed by the Vitek 2 yeast identification system, semi-nested [sn] PCR amplification of high-copy rDNA and direct DNA sequencing of the internally transcribed spacer 2 [ITS2] region. Of the 390 isolates of Candida species investigated, 12 were identified as C. dubliniensis, giving an overall occurrence of 3%. All the C. dubliniensis isolates formed rough colonies with hyphal fringes and abundant chlamydospores on sunflower seed agar, did not assimilate trehalose, lactate and alpha -methyl-D-glucoside, and were isolated from human immunodeficiency virus [HIV]-negative patients. Four C. dubliniensis isolates utilized D-xylose. The species-specific primer derived from the ITS2 sequence of C. dubliniensis and used together with the panfungal reverse primer in the reamplification step of the snPCR specifically amplified rDNA from reference and clinical C. dubliniensis isolates and not from C. albicans or other Candida species. The identity of two representative isolates was confirmed by DNA sequencing of the ITS2 region. The identity of 12 C. dubliniensis isolates was first established by phenotypic characteristics and then by snPCR using species-specific primers derived from ITS2 sequences. The recovery of C. dubliniensis from HIV-negative patients from Kuwait reinforces the existing view that this novel yeast species has a worldwide distribution and its occurrence is not restricted to any particular immunocompromised population

Molecular fingerprinting of multidrug-resistant mycobacterium tuberculosis strains in Beirut reveals genetic diversity and father to daughter transmission

The typing of six consecutive multidrug-resistant Mycobacterium tuberculosis strains isolated from patients with tuberculosis [TB] at the American University of Beirut Medical Center, was performed by touchdown double-repetitive-element [DRE]-PCR. The isolates exhibited four distinct patterns in DRE-PCR with three isolates exhibiting unique patterns and three isolates yielded similar DNA fragment patterns [cluster pattern]. Only two of the three cluster isolates exhibited identical patterns as revealed by restriction fragment length polymorphism [RFLP] targeting specific mutations in the rpoB and katG genes that confer resistance to rifampin and isoniazid, respectively. A direct epidemiological linkage for the two isolates exhibiting genotypic relatedness was also established as the isolates were recovered from a 33-year-old man and his 8-year-old daughter. The data show that transmission of multidrug-resistant M. tuberculosis strains is contributing to the emergence of drug-resistant TB in Beirut. Combining DRE-PCR with RFLP at the rpo B and katG genes could provide a powerful means for investigating the spread of multidrug-resistant M. tuberculosis strains in Lebanon

Molecular diagnosis of drug-resistant tuberculosis

The worldwide emergence and spread of multidrug- resistant [MDR] strains of Mycobacterium tuberculosis has adverse effects on tuberculosis [TB] control programs. The goal of this paper is to describe the advances made in the understanding of the molecular basis of M. tuberculosis resistance to first-line anti-TB drugs, and to discuss the potential of molecular methods in early diagnosis of drug-resistant TB. Molecular methods such as DNA sequencing, polymerase chain reaction, DNA hybridization and restriction fragment length polymorphism have been used to identify/detect mutations in gene-encoding proteins or rRNA which are targets for the first-line anti-TB drugs. High level resistance to rifampin [RIF], isoniazid [INH], pyrazinamide [PZA], ethambutol [EMB], and streptomycin [STR] is caused by mutations in rpoB, katG, pncA, embB and rpsL/rrs genes, respectively. The most common mutations conferring high level resistance to RIF, INH, EMB and STR have been identified in rpoB, katG, embB and rpsLgenes, respectively. Molecular methods to detect the most frequent mutations in the gene encoding functions that are targets for first-line anti-TB drugs have provided encouraging results for early diagnosis of MDR-TB