Pagers and stethoscopes as vehicles of potential nosocomial pathogens in a tertiary care hospital in a developing country.

It has long been recognized that stethoscopes and other inanimate objects carry virulent micro-organisms that can cause nosocomial infections in susceptible patients. Among the frequently used items in hospitals are pagers and stethoscopes. The manner in which these items are used has the potential to cause colonization of bacteria and transfer of these bacteria to another person. This prospective study was performed in order to assess the colonization rates among randomly selected pagers and stethoscopes. We found that 15 (25%) pagers and 11 (27.5%) stethoscopes were contaminated. Enterococci (10%) were the most common isolates found followed by Staphylococci (8%) and Enterobacteriaceae (7%). There was no significant difference in the rates of colonization between shared and personal pagers (P = 0.16). Stethoscopes were more likely to be contaminated with Enterococci compared to pagers (P = 0.013, 95% confidence interval 1.3-52.9). Our findings confirm the need for protocols to prevent transmission of infection through inanimate objects.

Genotype phenotype correlation in Wilson's disease within families--a report on four south Indian families.

AIM: To study the genotype phenotype correlation in Wilson's disease (WD) patients within families. METHODS: We report four unrelated families from South India with nine members affected with WD. Phenotype was classified as per international consensus phenotypic classification of WD. DNA was extracted from peripheral blood and 21 exons of ATP7B gene and flanking introns were amplified by polymerase chain reaction (PCR). The PCR products were screened for mutations and the aberrant products noted on screening were sequenced. RESULTS: Four separate ATP7B mutations were found in the four families. ATP7B mutations were identical amongst affected members within each family. Three families had homozygous mutations of ATP7B gene while one family had compound heterozygous mutation, of which only one mutation was identified. We noted concordance between ATP7B gene mutation and Wilson's disease phenotype amongst members within each family. The age of onset of symptoms or of detection of asymptomatic disease, baseline serum ceruloplasmin and baseline urinary copper levels were also similar in affected members of each family. Minor differences in phenotype and baseline serum ceruloplasmin level were noted in one family. CONCLUSION: We report concordance between ATP7B mutation and WD phenotype within each family with > 1 member affected with WD. Homozygous ATP7B mutation was present in 3 of the 4 families studied. Our report supports allelic dominance as a determinant of WD phenotype. However, in one family with compound heterozygous mutation, there was a similar WD phenotype which suggests that there may be other factors determining the phenotype.

Significance of the hepatitis C virus (HCV) core antigen as an alternative plasma marker of active HCV infection.

PURPOSE: To evaluate the role of core antigen (Ortho trak-C assay) as a marker of active HCV infection in comparison to HCV RNA as detected by reverse transcription polymerase chain reaction (RT-PCR). METHODS: This evaluation was carried out during January 2000 to December 2003 in HCV infected individuals who were treatment naomicronve or were on anti-viral therapy. Additionally, sequential plasma samples from patients on clinical follow-up were included in this study. A total of 167 samples from 61 patients were tested by trak-C and RT-PCR. HCV RNA detection was achieved by a RT-PCR. Trak-C assay results were also compared in a limited proportion of these samples with known HCV viral load and genotype. RESULTS: Of 167 samples tested, 56.9% were RNA positive and 43.1% were RNA negative while 50.3% were trak-C positive and 49.7% were trak-C negative, yielding a sensitivity of 85.3% and a specificity of 95.8% for the trak-C assay (Kappa co-efficient = 0.8). The concentration of HCVcAg and HCV RNA showed significant correlation (n=38, r=0.334, P =0.04). The trak-C assay detected the most prevalent HCV genotypes in India without significant difference (P =0.335). The difference between mean absorbance values of HCV RNA positive samples compared to HCV RNA negative samples in the trak-C assay was highly significant (P < 0.000). Qualitative results of trak-C assay and RT-PCR were comparable in 93% of follow-up samples. CONCLUSIONS: Trak-C assay can be recommended for confirmation of HCV infection and follow-up in laboratories with resource-poor facilities.

ATP7B mutations in families in a predominantly Southern Indian cohort of Wilson's disease patients.

OBJECTIVE: To analyze ATP7B mutations in Wilson's disease (WD) patients from the Indian subcontinent and to correlate these with WD phenotype. METHODS: We studied 27 WD patients from 25 unrelated families. Twenty-two families were from three southern Indian states - Tamil Nadu andhra Pradesh and Kerala. We applied conformation- sensitive gel electrophoresis (CSGE) to screen for the mutations in patients and their families. PCR products exhibiting aberrant patterns in CSGE were subjected to direct DNA sequencing. As siblings affected by WD within a family share identical ATP7B genotype, we compared WD phenotype among affected siblings within families. RESULTS: ATP7B mutations were detected in 22 of the 25 probands -13 were homozygotes and 9 were compound heterozygotes. Eleven novel mutations were detected. Only two common mutations were found: G3182A in 4 (16%) and C813A in 3 (12%) probands. 'Hot spots' for ATP7B mutations were exons 18 and 13. Lack of common dominant mutations prevented correlation of individual ATP7B mutations with WD phenotype. Symptomatic WD in a live sibling was not found in any family. In 8 families, a sibling died of presumed WD - in 6 of these, WD phenotype was identical to that in the proband. CONCLUSIONS: We describe the spectrum of ATP7B mutations including 11 novel mutations in Indian WD patients and document lack of a single dominant mutation. Identical WD phenotype among siblings in only 6 of 8 families with >1 child affected by WD suggests that factors other than ATP7B mutations influence WD phenotype.

Tuberculosis among healthcare workers in a tertiary-care hospital in South India.

It is possible that tuberculosis is transmitted from patients to healthcare workers (HCWs). However, there are few data on this from developing countries. The object of this study was to document the incidence of tuberculosis among HCWs in the Christian Medical College (CMC), Vellore, India during a 10-year period (January 1992-December 2001). Data were collected from records maintained in the staff and students health services of CMC. A total of 125 cases were diagnosed during the period of study. The overall incidence of sputum positive cases was similar to that observed in the general population, during most years. However, it appears that focal outbreaks occur with transmission between HCWs. The chance of developing extra-pulmonary tuberculosis was higher in HCWs compared with the general population.

Hepatopulmonary syndrome: clinical perspectives.

Hepatopulmonary syndrome consists of a triad of chronic liver disease, pulmonary gas exchange abnormalities and pulmonary vascular dilatation in the absence of detectable cardiopulmonary disease. Patients usually present with symptoms of liver disease and the clinical recognition of this condition is a challenge. Newer non-invasive tests facilitate the diagnosis. Therapeutic strategies for this condition are still dismal. Liver transplantation is a possible curative option for a subgroup of patients with hepatopulmonary syndrome.

Toxic megacolon in a renal allograft recipient with cytomegalovirus colitis.

We report a 35-year-old man, a renal allograft recipient, who presented with toxic megacolon. Segmental biopsies from the colon were consistent with cytomegalovirus colitis. Serum polymerase chain reaction for cytomegalovirus DNA confirmed the diagnosis. He was treated with ganciclovir but, though his abdominal condition improved initially, he worsened later and succumbed to his illness.

Should health care workers in the tropics be immunized against varicella?

In tropical regions, chickenpox affects both adults and children. Therefore, healthcare workers in the tropics are vulnerable to hospital-acquired varicella infection and they may transmit infection to susceptible hospitalized individuals. Although the varicella vaccine is safe and effective, its cost is a deterrent to its use in routine immunization programmes. In order to assess whether vaccination of susceptible healthcare workers to prevent hospital-acquired transmission may be justified, we have documented the frequency of varicella among healthcare workers in our hospital. There were 96 admissions for varicella during the 1993-1997 period; staff and student nurses accounted for 76%. The peak season of admission was from February to April. The attack rate in staff and student nurses was 0.78 and 1.54 per 100 person-years, respectively. While community outbreaks of varicella occur in this region once in 4-5 years, hospital outbreaks of varicella occurred every year. This poses the risk of transmission to hospitalized patients, with serious consequences among immunocompromized individuals. Therefore, we recommend systematic selective vaccination of susceptible healthcare workers to break this cycle of annual varicella outbreaks among hospital personnel.

Impact of introduction of sharps containers and of education programmes on the pattern of needle stick injuries in a tertiary care centre in India.

Documentation of needlestick injuries was started in the Christian Medical College Hospital, Vellore in 1993. In 1995 large sharps containers were introduced, accompanied by an intensive education programme. Details of documented injuries from 1993 to 1999 were analysed using the Epi-Info software. A total of 347 injuries occurred, mainly due to improper disposal of needles, re-capping and carelessness during use. The percentage of injuries attributed to disposal fell from 69.2% in 1995 to 38.5% in 1996 (after the education programme). A further decrease was noted after the additional introduction of small sharps containers. In 1995, 73% of injuries involved housekeeping staff, this fell to 12% in 1998. Relatively simple interventions decreased the numbers of injuries, and we recommend that all healthcare institutions should have a system of documenting needlestick injuries, and take measures to decrease their incidence.

Vesical varix in cirrhosis of liver.

Vesical varices in portal hypertension are rare. We report a patient with portal hypertension who developed recurrent painless hematuria. Cystoscopy was normal. Doppler ultrasound and MR angiography showed a dilated paraumbilical vein within the falciform ligament coursing down to the urinary bladder wall and draining into the right internal iliac vein. He underwent liver transplantation for decompensated chronic liver disease. He is in good health and has not had further episodes of hematuria.

Spontaneous fungal peritonitis in patients with hepatitis B virus-related liver disease.

Spontaneous bacterial peritoneal infections is recognized as a very common complication of cirrhotic ascites, but isolation of fungus in pure culture from ascitic fluid is relatively rare, even more so in the human immunodeficiency virus (HIV)-negative or nonimmunocompromised hosts. We describe two patients of spontaneous fungal peritonitis where the isolate was Cryptococcus neoformans. Both cases suffered from hepatitis B virus (HBV) infection. The clinical and laboratory profiles of both patients were similar to those of conventional spontaneous bacterial peritonitis. We suggest that it would be prudent to heighten clinical suspicion for fungal peritonitis in such cases.

Preventing transmission of blood-borne pathogens to health care workers.

Health care workers are exposed to blood-borne pathogens, mainly the human immunodeficiency virus, hepatitis B virus and hepatitis C virus. Infection by these viruses leads to chronic or fatal illnesses which are expensive and difficult to treat. Individuals who harbour these viruses may be asymptomatic and hence all patients should be assumed to harbour a blood-borne pathogen. All health care workers should take adequate precautions (a set of guidelines termed 'universal precautions'). Methods of preventing transmission of blood-borne pathogens include vaccination against hepatitis B virus, following universal precautions and taking adequate post-exposure prophylaxis.