Measurement of adult antimicrobial drug use in tertiary care hospital using defined daily dose and days of therapy.

Widespread overuse and inappropriate use of antimicrobial drugs continues to fuel an increase in antimicrobial resistance and leads to consequent treatment complications and increased healthcare costs. In the present study we aimed to describe antimicrobial drug consumption and predictors and to identify potential targets for antimicrobial stewardship. This was a prospective observational study conducted at adult medicine wards of tertiary care teaching hospital over the period of five months. Antimicrobial drug consumption was measured using days of therapy per 1000 patient days and defined daily dose per 1000 patient days. Additionally, predictors of multiple antimicrobial prescribing were also analyzed. Seven hundred thirty patients were screened and 550 enrolled, receiving 1,512 courses of antimicrobial therapy, mainly intravenously (66%). Most frequently prescribed agents were artesunate (13%), ceftriaxone (11%) and metronidazole (10.5%). Overall consumption was 1,533 days of therapy per 1000 patient days and was mainly attributed to antibiotics (98.3%) for empirical therapy (50%). Median days of antimicrobial drugs prescribing were 3 (inter quartile range 2-5). Most commonly consumed antimicrobials were ceftriaxone (31%, 248.8 g) and artesunate (26%, 29 g). Antimicrobials contributed to 72.5% expense of the total incurred. Multivariate analysis reveals that younger patients (≥45 years) (odds ratio: 1.59, 95% CI 1.14-2.21) were more likely and absence of comorbidities (odds ratio: 0.58, 95% CI 0.42-0.79) and shorter hospital stay (≥6 days)(odds ratio: 0.44, 95% CI 0.32-0.60) were associated with less likelihood of prescribing multiple antimicrobial drugs. Estimating antimicrobial drugs use by defined daily dose method will remain open to criticism because the prescribed dosage is not often in agreement with the "usual" daily dose, which depends on location of and susceptibility of pathogenic organisms and metabolic status of the patient.

Long-term exposure to nonylphenol affects insulin signaling in the liver of adult male rats.

In the present study, we sought to investigate the long-term effects of nonylphenol (NP) on insulin signaling and glucose metabolism in liver. Furthermore, reactive oxygen species (ROS) in liver was evaluated as it is known to induce insulin resistance. Rats were administered NP by oral gavage at the doses of 15, 150 and 1500 µg/ kg body weight per day for 45 days. Hydrogen peroxide (H(2)O(2)) generation and lipid peroxidation were increased, and the activities of antioxidant enzymes were decreased in the liver of NP-treated rats. NP increased the plasma glucose and insulin levels and altered the enzymes of carbohydrate metabolism. Decrease in the protein levels of insulin signaling molecules insulin receptor (IR), IR substrate (IRS)-1, IRS-2 and phosphatidylinositol-3-kinase were observed with parallel increase in H(2)O(2) levels in the liver of NP-treated rats. These results suggest that NP downregulates insulin signaling in liver, which could be due to ROS production and oxidative damage.

Effects of corticosterone and 2,3,7,8-tetrachloro- dibenzo-p-dioxin on epididymal antioxidant system in adult rats.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), an endocrine disruptor, causes epididymal toxicity by inducing oxidative stress. Glucocorticoids have been found to influence TCDD action in vitro and in vivo. The present experiments were set up to analyze the effects of TCDD on rat epididymal antioxidant system under the influence of increased corticosterone level. Adult male Wistar/NIN rats (70-80 days old) numbering 24 (six per group) were used in the study. Corticosterone (3 mg/kg body weight per day) or TCDD (100 ng/kg body weight per day) were administered or coadministered to rats for 15 days. Treatment with corticosterone or TCDD decreased the levels of serum testosterone significantly. In caput, corpus, and cauda fractions, administration of corticosterone or TCDD increased the levels of lipid peroxidation and hydrogen peroxide and decreased the activities of superoxide dismutase and catalase significantly. Coadministration of corticosterone and TCDD to rats decreased the levels of serum testosterone significantly as compared with rats treated with TCDD alone. In caput, corpus, and cauda fractions, the levels of lipid peroxidation and hydrogen peroxide were increased and activities of superoxide dismutase and catalase were decreased significantly as compared with rats treated with TCDD alone. Stress, characterized by increased glucocorticoid levels and activity, may enhance TCDD-induced epididymal toxicity.

Bacterial endocarditis treated with intramuscular teicoplanin.

Right-sided endocarditis caused by Staphylococcus aureus in parenteral drug abusers is potentially life-threatening, more so in the presence of pulmonary embolisation, and a course of parental antibiotics is required for at least four weeks. A combination of intravenous cloxacillin and aminoglycosides has proven efficacious for more than 90 percent of the patients. Intravenous vancomycin can also be used in cases of penicillin allergy or methicillin-resistant staphylococci. Intravenous teicoplanin, a glycopeptide with a similar antimicrobial profile to vancomycin, has been used with a somewhat lesser degree of success in these cases and is not recommended as first line therapy. We describe a 37-year-old man, a parenteral drug user, who had right-sided endocarditis, where in the absence of other alternatives, teicoplanin had to be administered intramuscularly and not intravenously.

[Work outcome evaluation of cardiac surgery patients after rehabilitation training]. / Valutazione dell'outcome ripresa occupazionale di pazienti riabilitati cardioperati.

The aim of this study was to investigate the incidence of job resumption and the influence of clinical, psychological and functional factors in patients who underwent cardiac surgery. 859 patients were evaluated (mean age 66 +/- 9, 72% M, 28% F, 75% retired, 7% housewives and 18% still working) following admission in a Cardiac Rehabilitation Center; within 5 days of cardiac surgery. Six months after surgery, 80% of the patients resumed their previous occupation. The variables which positively influenced the latter were: a) left ventricular ejection fraction > 35% (p = 0.002), average-high education (p = 0.002), younger patients (p = 0.032), absence of complications during the 6 months post-surgery (p = 0.001), having attended frequent educational programs during the rehabilitation period (p = 0.022), a precise knowledge of the illness (p = 0.001), lack of depression (p =0.0001) and anxiety (p = 0.0001). Our data confirm, in accordance with the recent guidelines, the importance of a rehabilitative intervention which comprises physical, educational and psychological support.

Type II lepra reaction: an unusual presentation.

Ulcers with maculo-papular rash are an unusual presenting feature of leprosy. They occur as result of neuropathy, type-2 lepra reaction or Lucio's phenomenon. The hall mark of type-2 reaction is erythema nodosum. Very rarely it manifests as ulcerative skin lesions. We describe one such unusual case of a young male who presented with multiple ulcers and maculo-papular rash over the legs, chest and abdomen. In addition to this, he had fever, heart murmur, pulmonary infiltrates, neuropathy, and deranged liver function. A clinical differential diagnosis of infective endocarditis and systemic nectrozing vasculitis was made. Skin biopsy showed dense inflammation with lepra bacilli consistent with type-2 lepra reaction.

Ageing and circadian variation in cardiovascular events.

INTRODUCTION: Circadian variation in cardiovascular events is well recognised in vascular events. This study aims to observe any significant difference in circadian variability in geriatric patients when compared to their younger counterparts. METHODS: This prospective study was conducted at medical emergency at the Government Medical College and Hospital, Chandigarh, India. All the patients attending medical emergency with symptoms suggestive of coronary artery disease were included. The time of occurrence of first symptom and subsequent symptoms was noted. Electrocardiography, cardiac enzymes and echocardiography were performed to establish the diagnosis of acute coronary syndrome. The 24-hour day was divided into 12 equal parts of two hours each. For the final analysis, the two-hour periods were grouped into six equal periods of four hours each and four quarters of six hours each. RESULTS: We studied 559 patients, out of whom 459 were 65 years old or younger, and 100 patients were older than 65 years old. 459 patients had 498 episodes in all. 100 patients above the age of 65 years had 104 episodes. Both the groups had peaking of acute myocardial infarction in the early morning hours with patients older than 65 years of age having a slightly early peak. However, there was considerable variability for peaking of unstable angina and non-Q myocardial infarction. In patients older than 65 years, early morning peaking of events was noted whereas in 65 years or younger, the peaking of events was noted in the evening hours. CONCLUSION: Circadian variability exists in occurrence of acute coronary events and is variable in geriatric patients when compared to their younger counterparts.

Accurate blood pressure recording: is it difficult?

BACKGROUND: Blood pressure (BP) measurement is a routine procedure but errors are frequently committed during BP recording. AIMS AND SETTINGS: The aim of the study was to look at the prevalent practices in the institute regarding BP recording. The study was conducted in the Medicine Department at Government Medical College, Chandigarh, a teaching institute for MBBS students. METHODS: A prospective, observational study was performed amongst the 80 doctors in a tertiary care hospital. All of them were observed by a single observer during the act of BP recording. The observer was well versed with the guidelines issued by British Hypertension Society (BHS) and the deviations from the standard set of guidelines issued by BHS were noted. The errors were defined as deviations from these guidelines. STATISTICAL METHODS: The results were recorded as percentage of doctors committing these errors. RESULTS: In our study, 90% used mercury type sphygmomanometer. Zero error of the apparatus, hand dominance was not noted by any one. Every one used the standard BP cuff for recording BP. 70% of them did not let the patient rest before recording BP. 80% did not remove the clothing from the arm. None of them recorded BP in both arms. In out patient setting, 80% recorded blood pressure in sitting position and 14% in supine position. In all the patients where BP was recorded in sitting position BP apparatus was below the level of heart and 20% did not have their arm supported. 60% did not use palpatory method for noticing systolic BP and 70% did not raise pressure 30-40 mm Hg above the systolic level before checking the BP by auscultation. 80% lowered the BP at a rate of more than 2 mm/s and 60% rounded off the BP to nearest 5-10 mm Hg. 70% recorded BP only once and 90% of the rest re inflated the cuff without completely deflating and allowing rest before a second reading was obtained. CONCLUSION: The practice of recording BP in our hospital varies from the standard guidelines issued by the BHS.

Effect of piperine on the epididymis of adult male rats.

AIM: To study the effect of piperine on the epididymal antioxidant system of adult male rats. METHODS: Adult male rats were orally administered piperine at doses of 1 mg/kg, 10 mg/kg and 100 mg/kg body weight each day for 30 consecutive days. Twenty-four hours after the last treatment, the rats were weighed and killed with ether and the epididymis was dissected from the bodies. Sperm collected from the cauda region of the epididymis was used for the assessment of its count, motility and viability. Caput, corpus and cauda regions of the epididymis were separated and homogenized separately to obtain 10 % homogenates. The supernatants were used for the assays of sialic acid, superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase, lipid peroxidation and hydrogen peroxide generation. RESULTS: Body weight of the piperine-treated rats remained unchanged. The weights of the caput, corpus and cauda regions of the epididymis significantly decreased at dose of 100 mg/kg. Epididymal sperm count and motility decreased at 10 mg/kg and 100 mg/kg, and sperm viability decreased significantly at 100 mg/kg. Sialic acid levels in the epididymis decreased significantly at 100 mg/kg while significant decrease in the cauda region alone was observed at 10 mg/kg. A significant decline in the activities of superoxide dismutase, catalase, glutathione peroxidase and glutathione reductase, along with an increase in hydrogen peroxide generation and lipid peroxidation were observed at 10 mg/kg and 100 mg/kg. CONCLUSION: Piperine caused a decrease in the activity of antioxidant enzymes and sialic acid levels in the epididymis and thereby increased reactive oxygen species levels that could damage the epididymal environment and sperm function.

Acute respiratory failure due to hypokalaemic muscular paralysis from renal tubular acidosis.

We report a case of hypokalaemic quadriplegia with acute respiratory failure and life-threatening cardiac arrhythmias in a 26-year-old woman who was diagnosed to have distal renal tubular acidosis. She had persistent metabolic acidosis with severe hypokalaemia and required mechanical ventilation and potassium replacement. The anaesthetic implications of renal tubular acidosis are also discussed.

Metastasis to thyroid from lung carcinoma.

Metastasis to thyroid gland are rare. The primary sites which metastasize to thyroid gland include the breast, lung, kidney and stomach. Among lung cancer metastasizing to the thyroid, adenocarcinomas are the commonest followed by squamous, small cell and large cell carcinomas. The bronchioloalveolar carcinoma has not been reported to metastasize to the thyroid. In this case report we document this rare occurrence.

Wasp sting induced neurological manifestations.

Wasp stings generally cause local reactions like pain, wheal, flare, edema and swelling, which are generally self-limiting. Multiple stings can lead to vomiting, diarrhea, generalized edema, dyspnea, hypotension, collapse, renal failure or death. Unusually, they may cause serum sickness, vasculitis, neuritis or encephalitis. We report a case of a 40 year old male who developed focal neurological deficit 10 hours following a wasp sting, which was confirmed to be ponto-cerebellar infarction on MRI scan, and recovered within five days.

Left atrial myxoma presenting as pseudobulbar palsy.

A case of left atrial (LA) myxoma presenting as pseudobulbar palsy, due to multiple cerebral infarcts, without any cardiac manifestations, is presented. LA myxoma is rare cause of embolization to CNS causing ischemic infarcts. Due to multiple CNS infarcts patient can present with varied clinical picture and pseudobulbar palsy is not a very common presentation. It was a real diagnostic dilemma before LA myxoma was diagnosed on echocardiography.

Circadian pattern in cerebro vascular disorders.

Over the last decade, various studies have been reported to evaluate the circadian pattern of cardiovascular and cerebro-vascular diseases. The data from Indian population is lacking. We undertook this prospective observational study to evaluate the circadian variation in disorders like cerebro-vascular accidents and transient ischemic attacks. Total of 146 patients (events) were studied. Only 10 patients had TIA's. 55% had hemorrhage and 45% had infarction. The 24 hours period was divided into 6 equal portions of 4 hours each. The maximum events were seen between 4 am to 8 am and 12 noon to 4 pm (23.28%) each. Minimum events were seen between 12 midnight to 4 am 14/146 - 9.58%). The circadian variation in occurrence of cerebro-vascular disorders was present with two equal peaks.

Central nervous system complications in renal transplant recipients in a tropical environment.

Renal transplant recipients are at risk of developing various infectious and non-infectious complications affecting the central nervous system (CNS). There is paucity of data regarding the spectrum of CNS complications and the epidemiology of infective agents varies according to geographical location. We retrospectively studied the spectrum of CNS complications seen in 792 renal allograft recipients followed up at this tertiary care centre in north India over a 19-year period. Autopsy findings of 78 allograft recipients who died in the hospital were also reviewed and included. The brain was examined in 22 of these patients. Overall, 79 (10%) patients developed some form of CNS dysfunction with a mortality rate of 60.8%. CNS infections occurred in 31 renal allograft recipients (3.9% of total) and accounted for the largest group (39.2%). Fungi were the commonest etiological agents (21 patients) and were associated with a 70% mortality, with cryptococcal meningitis occurring in 12, mucormycosis in six, aspergillosis in one, and other unusual fungal infections in the remaining two patients. All patients with mucormycosis had a fatal outcome. The second largest group comprised of patients with non-uremic encephalopathies (23 patients, 29.1%) with metabolic encephalopathy occurring in 13, toxic encephalopathy in nine and hypertensive encephalopathy in one patient) and was associated with an overall mortality rate of 60.9%. Cerebrovascular accidents occurred in 12 patients (15.2%) and were associated with a mortality of 91.7%. Other CNS complications included treatment related complications in four (5.1%), primary CNS lymphomas in three (3.8%), and miscellaneous complications in six patients (7.6%). Patients with non-cryptococcal fungal infections of the CNS, hepatic and toxic encephalopathy and those with cerebrovascular accidents had the worst outcome. There was no relationship between the development of infection or stroke and the type of maintenance immunosuppression used. We conclude that complications involving the CNS occur in 10% of all renal transplant recipients and are associated a with high mortality, warranting early diagnosis and aggressive treatment.

Circadian pattern of cardiovascular and cerebrovascular diseases in geriatric population.

OBJECTIVES: Over last 13 years various studies have been done to evaluate the circadian pattern in cardiovascular and cerebrovascular diseases in adults and the existence of such variation in Indian population also has been demonstrated. The data on this variation in geriatric patients does not exist. METHODS: We undertook this prospective observational study at Government Medical College and Hospital, Chandigarh to evaluate the circadian variation in disorders like acute myocardial infarction (AMI), unstable angina (USA), non Q wave MI (non QMI), cerebrovascular accidents (strokes, both ischemic and hemorrhagic) and transient ischemic attacks (TIA). OBSERVATIONS: We studied 158 patients (56.98% males and 43.02% females), mean age was 69 +/- 4 years. 34.17% each had AMI and CVA, 22.78% and USA and 7.59% had NON Q MI, only two patients in our study group had TIAs. We divided 24 hours into four equal quarters each for analysis. RESULTS: We observed that maximum episodes were seen during the period between 6 am till 12 noon 58/158 (36.71%) and a second peak was seen during 6 pm and 12 midnight when 40/158 events were recorded (25.31%). The least number of episodes were seen during the period between 12 midnight till 6 am 22/158 (13.92%). Similar peaking of events was noted for acute myocardial infarction but only one peak was seen for unstable angina. For cerebrovascular accidents two similar peaks were noted between 6 am till 12 noon and 12 noon till 6 pm. CONCLUSIONS: Our study population (geriatric patients) shows the presence of a definitive circadian variation with two comparable peaks. One during the morning hours (6 am-12 noon) and another peak between 6 pm and 12 midnight in patients having acute coronary diseases. In cerebrovascular accidents patients too, similar peaks were noted between 6 am till 12 noon and 12 noon till 6 pm.

Isolated bilateral renal aspergillosis: an unusual presentation in an immunocompetent host.

A 35 year old apparently immunocompetent farmer developed isolated bilateral renal aspergillosis. He presented with acute renal failure due to granulomatous interstitial nephritis and had bilateral renal abscesses on CT scan. Diagnosis came from renal histology and was confirmed on serology. The patient responded quite satisfactorily to single agent antifungal chemotherapy with IV amphotericin B.