Incidence, bacteriology, and clinical outcome of ventilator-associated pneumonia at tertiary care hospital.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent Intensive Care Unit acquired infection. AIMS: The aim is to determine the incidence, bacteriology and factors affecting VAP and to determine the multi-drug resistant (MDR) pathogens. SETTINGS AND DESIGN: This was a prospective observational study conducted over a period of 1 year from April 1, 2011, to March 31, 2012. MATERIALS AND METHODS: The patients fulfilling criteria of VAP were included in this study. STATISTICAL ANALYSIS: This was performed using SPSS trial version 11.0 software (SPSS Inc., Chicago, Illinois, USA) and the values of P < 0.05 were considered statistically significant. RESULTS: Totally 74 (27.71%) patients were developed VAP. Of total 74 patients with VAP 53 (71.62%) were females and 21 (28.37%) were females (P < 0.0001). Total 13 (17.56%) patients had early-onset VAP and 61 (82.43%) had late-onset VAP (P < 0.0001). The overall incidence of VAP rate per 1000 ventilator days was 39.59. Total 126 bacterial isolates found in 74 patients with VAP. Predominant isolates were Gram-negative 52 (70.27%). Total 41 (55.40%) patients had polymicrobial VAP, and 33 (44.59%) had single isolate. Total 55 (43.65%) isolates were MDR organisms. Total 22 patients with VAP succumbed during treatment with overall case fatality rate of 29.72%. Of total 55 MDR isolates in VAP, 13 (26.63%) were Klebsiella spp., 11(20%) Pseudomonas aeruginosa, 14 (25.45%) Acinetobacter, 8 (14.54%) Escherichia coli, and 9 (16.36%) coagulase positive Staphylococcus aureus. Total 12 (21.41%) patients succumbed among MDR isolates. CONCLUSIONS: There was a high incidence of MDR pathogens in late-onset VAP. The Gram-negative organisms Klebsiella, PseudomonasE. coli and Acinetobacter were the most commonly isolated organisms with high mortality rates.

Clinical manifestations and outcome of patients with human immunodeficiency virus infection at tertiary care teaching hospital.

BACKGROUND: AIDS has become chronic illness which is well treated with antiretroviral therapy and management of opportunistic infections (OIs). AIMS AND OBJECTIVES: The study clinical profile and outcome of human immunodeficiency virus (HIV) seropositive patients. MATERIALS AND METHODS: This was retrospective observational study carried out over a period of 1 year (January 2011-December 2011). All HIV patients admitted in medicine ward, and ICU were enrolled. Statistical analysis was performed using SSPE statistical software trial version 11. The P< 0.05 was considered as statistically significant. RESULTS: Of total 111 patients with a diagnosis of HIV/AIDS, 75 (67.56%) were male and 36 (32.43%) were female patients. A total 52 (46.84%) patients presented with respiratory manifestations, of them 23 (44.23%) had pulmonary tuberculosis (TB), 6 (11.53%) had tubercular effusion, and 3 (5.76%) had Pneumocystis jirovecii pneumonia. Respiratory manifestations including pulmonary TB were the most common presentation (P< 0.001). Total 27 (24.32%) patients were presented with the neurological manifestation of them 8 (29.62%) had a cerebro-vascular accident, 5 (18.51%) had cryptococcal meningitis, 4 (14.81%) had tubercular meningitis, and 1 (3.70%) had progressive multifocal leukoencephalopathy. Total 12 (38.70%) had acute gastroenteritis 6 (19.35%) had oral candidiasis, 8 (25%) had general tonic clonic seizure and 7 (21.87%) had pyrexia of unknown origin, 6 (18.75%) had septicemia, 6 (18.75%) had acute renal failure, and 6 (94.11%) had anemia. A total 11 (9.90%) patients succumbed. CONCLUSIONS: Overall respiratory manifestations were the common presentation in a present cohort of HIV seropositive patients and TB was the most common OI and the cerebrovascular accident was the most common neurological manifestation.

Prevalence of obstructive airway disease by spirometric indices in non-smoker subjects with IHD and HTN.

BACKGROUND: Recent studies have found that there is a strong association between ischemic heart disease (IHD) and hypertension (HTN) with spirometric indices. AIMS: To study the prevalence of obstructive airway disease (OAD) in non-smoker subjects with IHD and HTN and to compare them with healthy population. SETTINGS AND DESIGN: This was a prospective, case-control, and observational study. SUBJECTS AND METHODS: A total of 100 patients (cases) (n = 100) admitted in medicine department were recruited for this study. Controls (n = 100) were apparently healthy age- and sex-matched without HTN and IHD, recruited from March 2007 to July 2008. All eligible subjects were subjected to spirometric examination on a turbine-based spirometer (MIR spirolab-II) according to ATS/ERS guidelines. Forced expiratory volume/forced vital capacity (FEV(1)/FVC) ratio <70% was used to make a diagnosis of OAD. STATISTICAL ANALYSIS USED: All analyses were carried out using Statistical Software Package for Social Sciences trial version (SPSS 10 version). RESULTS: Out of 100 cases, 18 were with FEV(1)/FVC ratio <70% (OAD) and 82 had >70% FEV(1)/FVC ratio. Out of 100 controls, 2 were with FEV(1)/FVC ratio <70% (OAD) and 98 had >70% FEV(1)/FVC ratio. Eleven patients out of 66 from the case population with HTN had FEV(1)/FVC ratio <70% (Odds ratio 8.044). Prevalence of OAD in the hypertensive individuals was 16.66%. Twelve patients out of 62 from the case population with IHD had FEV(1)/FVC ratio <70% (Odds ratio of 9.333). Prevalence of OAD in the IHD individuals was 19.35%. In multiple correlation results for case population, when pulmonary function test variables were correlated with various dependant (age) and independent variables [HTN, IHD, height, weight, body mass index (BMI)], they were significantly reduced (P = 0.00017). In multivariate analysis (MANOVA), spirometric variables like FEV(1), FEV(1)/FVC%, FVC, forced expiratory flow (FEF) 25-75%, and peak expiratory flow rate (PEFR) were compared with factors like IHD, HTN, and covariates like age and BMI. We found that systolic blood pressure (SBP; P = 0.005), diastolic blood pressure (DBP; P = 0.05), height (P = 0.05), weight (P = 0.042), and IHD (P = 0.0001) were strongly associated with reduced pulmonary functions like FEV(1), FEV(1)/FVC%, and FVC. The presence of IHD and HTN were independently associated with the presence of OAD. CONCLUSIONS: This study highlights the increased prevalence of OAD amongst patients with IHD and HTN. Patients with IHD and HTN should routinely undergo inexpensive investigations like spirometry to detect the presence of underlying OAD.

Diastolic dysfunction in asymptomatic type 2 diabetes mellitus with normal systolic function.

BACKGROUND: The incidence of heart failure in diabetic subjects is high even in the absence of hypertension and coronary artery disease. AIMS: The purpose of this study was to study the incidence of diastolic dysfunction in diabetic subjects and its relation to age, duration of diabetes mellitus (DM), Glycosylated hemoglobin (HbA1c) levels, obesity indices and diabetic microangiopathies. SETTINGS AND DESIGN: This was a case control prospective study conducted at the teaching hospital during a one year period. MATERIALS AND METHODS: A total of 127 subjects (case) with type 2 diabetes of more than five years duration were studied. Total 100 healthy subjects were included as the control group. Echocardiography was performed to assess left ventricular diastolic function. RESULTS: Out of the total 127 subjects, 69 (54.33%) from the case group had diastolic dysfunction, and 11% amongst 100 in the control group population showed the diastolic dysfunction (P < 0.001). Patients with a longer duration of DM (of 11 to 15 years) had a higher prevalence of diastolic dysfunction (P < 0.02). Subjects with high waist circumference and high waist to hip ratio had statistically significant diastolic dysfunction with 'P' =0.001 and 'P' = < 0.02 respectively. Subjects with HbA1c > 7.5% had a higher prevalence of diastolic dysfunction than subjects with HbA1c < 7.5% (P < 0.02). Diastolic dysfunction was present in majority of the subjects with autonomic neuropathy and retinopathy. CONCLUSIONS: Present study reveals high incidence of diastolic dysfunction in asymptomatic diabetic; subjects and, this finding was correlated with the duration of diabetes, HbA1c levels, obesity indices and diabetic microangiopathies. We conclude that early diagnosis and institution of treatment will reduce morbidity and improve the outcomes, and prevent future heart failure.

Isolated Non-compaction Cardiomyopathy Presented with Ventricular Tachycardia.

Non-compaction cardiomyopathy is a recently recognized disorder, based on an arrest in endomyocardial morphogenesis. The disease is characterized by heart failure (both diastolic and systolic), systemic emboli and ventricular arrhythmias. The diagnosis is established by two-dimensional echocardiography. Isolated left ventricular non-compaction cardiomyopathy (IVNC) is an exceedingly rare congenital cardiomyopathy. Only a few cases of this condition have been reported. It is characterized by prominent and excessive trabeculation in a ventricular wall segment, with deep intertrabecular spaces perfused from the ventricular cavity. Echocardiographic findings are important clues for the diagnosis. We report a case of isolated non-compaction of the left ventricular myocardium presented with ventricular tachycardia.

Cardiac tamponade in a patient with primary hypothyroidism.

Pericardial effusion is frequently found in patients with hypothyroidism, but it is rarely associated with cardiac tamponade. Hypothyroidism complicated by cardiac tamponade is rarely referenced in the medical literature. Here we report an unusual case of a 45-year-old female, who presented with breathlessness and was found to have hypothyroidism with large pericardial effusion with cardiac tamponade. Treatment included an emergency pericardiocentesis followed by thyroxine hormone replacement.

An unusual case of Weil's syndrome with paraparesis.

Leptospirosis is an important emerging zoonosis with a worldwide distribution that is characterized by a broad spectrum of clinical manifestations ranging from inapparent infection to fulminant disease. Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. The presentation of paraparesis in combination with Weil's syndrome is rare. Few cases were reported with leptospirosis and paraparesis in India and abroad. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens. Here we are reporting a case of Weil's syndrome with paraparesis in 28-year-old male patient who was critically ill due to severe hepatorenal dysfunction and hyperkalemia.

Extremely rare case of a rupture of the left sinus of Valsalva aneurysm into the main pulmonary artery.

We describe a case of ruptured aneurysm of the left coronary sinus of Valsalva diagnosed by transthoracic two-dimensional echocardiography. A very few cases with ruptured left sinus of Valsalva have been reported. We are reporting a rupture of the left sinus of Valsalva into the main pulmonary artery in a 40-year-old male diagnosed by transthoracic echocardiography.

Successful treatment of cerebral toxoplasmosis with cotrimoxazole.

Cerebral toxoplasmosis is an acquired immunodeficiency syndrome (AIDS)-related infection and is one of the causes of CNS mass lesions in AIDS. Toxoplasmosis is the most common cerebral mass lesion encountered in HIV-infected patients, and its incidence has increased markedly since the beginning of the AIDS epidemic. Cerebral toxoplasmosis is associated with high mortality and morbidity in patients with acquired immunocopromised state. We are reporting a case of cerebral toxoplasmosis presented with status epileptics and treated with cotrimoxazole. Refractory status epilepsy was controlled with intravenous levetiracetam, which has a unique drug profile.

Relation of anthropometric variables to coronary artery disease risk factors.

BACKGROUND AND OBJECTIVES: Anthropometric variables and their relation to conventional coronary artery disease (CAD) risk factors in railway employees have been inadequately studied in India. This cross-sectional survey was carried out in the Solapur division of the Central railway in the year 2004, to assess the anthropometric variables in railway employees and their relation to conventional CAD risk factors. MATERIALS AND METHODS: A total of 995 railway employees, with 872 males and 123 females participated in this cross-sectional study. All subjects underwent anthropometric measurements, fasting lipid profile, and blood sugar level. Various anthropometric indices were calculated for body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and abdominal volume index (AVI). Statistical analysis was done by EPI Info 6 statistical software. RESULTS: Compared to all other obesity indices, WHtR was most prevalent in both genders. High WHtR was present in 699 (80.16%) males and 103 (83.73%) females. Age ≥45 years, high systolic BP, high diastolic BP, low HDL, high triglyceride, and diabetes mellitus were positively correlated with high BMI, high WC, high WHR, high WHtR, and high AVI. High BMI, high WC, high WHR, high WHtR, and high AVI were negatively associated with physical inactivity. CONCLUSIONS: Over all, anthropometric variables in both genders were significantly deranged in subjects with coronary risk factors. Compared to all other anthropometric variables, WHtR was statistically significantly associated with a majority of coronary artery risk factors. Hence we recommend inclusion of WHtR as a parameter of obesity to predict coronary artery disease risk factor along with WC, WHR, and BMI in epidemiologic studies.

Central venous catheter-related bloodstream infections in the intensive care unit.

CONTEXT: Central venous catheter-related bloodstream infection (CRBSI) is associated with high rates of morbidity and mortality in critically ill patients. AIMS: This study was conducted to determine the incidence of central venous catheter-related infections (CRIs) and to identify the factors influencing it. So far, there are very few studies that have been conducted on CRBSI in the intensive care unit in India. SETTINGS AND DESIGN: This was a prospective, observational study carried out in the medical intensive care unit (MICU) over a period of 1 year from January to December 2004. MATERIALS AND METHODS: A total of 54 patients with indwelling central venous catheters of age group between 20 and 75 years were included. The catheters were cultured using the standard semiquantitative culture (SQC) method. Statistical analysis used SPSS-10 version statistical software. RESULTS: A total of 54 CVC catheters with 319 catheter days were included in this study. Of 54 patients with CVCs studied for bacteriology, 39 (72.22%) catheters showed negative SQCs and also negative blood cultures. A total of 15 (27.77%) catheters were positive on SQC, of which 10 (18.52%) were with catheter-associated infection and four (7.41%) were with catheter-associated bacteremia; the remaining one was a probable catheter-associated bacteremia. CRIs were high among catheters that were kept in situ for more than 3 days and emergency procedures where two or more attempts were required for catheterization (P < 0.05). In multivariate analysis of covariance duration of catheter in situ for >3 days, inexperienced venupucturist, more number of attempts and emergency CVC were associated with more incidence of CVCBSIs, with P <0.02. The duration of catheter in situ was negatively correlated (-0.53) and number of attempts required to put CVC was positively correlated (+0.39) with incidence of CVCBSIs. Sixty-five percent of the isolates belonged to the CONS group (13/20). Staphylococcus epidermidis showed maximum susceptibility to amikacin, doxycycline and amoxycillin with clavulanic acid and was susceptible to vancomycin (100%). Klebsiella pneumoniae was 100% susceptible to amikacin and ciprofloxacin. Escherichia coli was susceptible to amikacin and cefotaxime. CONCLUSIONS: The overall incidence of CRI was 27.77% (15/54). Catheter-associated BSIs were 47.31 per 1000 catheter-days. CRI was low in the catheters inserted by the experienced venipuncturists, elective procedure and CVC kept in situ for ≤3 days. S. epidermidis was the most common isolate.