Acute kidney injury is an independent predictor of in-hospital mortality in a general medical ward: A retrospective study from a tertiary care centre in south India.

BACKGROUND & OBJECTIVES: : Acute kidney injury (AKI) has been identified as an independent risk factor for mortality in intensive care units. This retrospective study was conducted to determine the effect of AKI on in-hospital mortality in a general medical ward of a tertiary care hospital and risk factors for mortality in patients with AKI. METHODS: : Demographic and clinical details, and outcome data were collected from case records of patients. In all hospitalized patients, factors associated with increased in-hospital mortality, such as AKI, inotrope requirement, mechanical ventilation and primary disease were compared between patients who died during their hospital stay and those who were discharged alive. Among the hospitalized patients, who had AKI, likely predictors of in-hospital mortality were compared between dead and alive patients at discharge. Factors that were significant in univariate analysis were tested by multivariate regression analysis to identify those that independently predicted poor outcomes. RESULTS: : Of the 1150 patients admitted in a general medical ward in a year, 220 patients were identified to have AKI. In-hospital mortality rate among patients with AKI was 19.09 per cent as compared to 1.8 per cent without AKI [adjusted odds ratio (OR) 5.7 (95% CI: 1.56-20.74)]. The presence of AKI was an independent risk factor for death, with an adjusted OR of 6.0 [95% CI: 1.67-21.6]. Among patients with AKI, the presence of haematological malignancy, adjusted OR 25.86 (95% CI: 1.81-369.58), requirement of inotrope, adjusted OR 126.5 (95% CI: 19.39-825.93) and serum creatinine at admission (P<0.001) were found to be independent predictors of death. The presence of underlying chronic kidney disease and hospital-acquired AKI were not found to have an association with mortality. INTERPRETATION & CONCLUSIONS: : The study showed the in-hospital mortality rate among patients with AKI in a general medical ward was 19.09 per cent. The occurrence of AKI was an independent risk factor for death, with haematological malignancy, use of vasopressors and higher serum creatinine at admission, significantly associated with death among patients with AKI. Large prospective studies need to be done to better understand the outcomes in AKI and the ways to present and manage AKI.

The Efficiency of WhatsApp in Teleconsultation of Finger Vascularity in Hand Surgery.

Background Teleconsultation over the smartphone is now widely used in modern medicine in the management of burns, flap cover, upper extremity trauma, and in the assessment of the feasibility of reimplantation in amputated fingers. The development of the WhatsApp application has enhanced the smartphone's efficiency remarkably to transmit images in clinical and academic settings with its failsafe and encrypted technology. In hand surgery, a teleconsultation technology must communicate details of finger vascularity effectively. However, there is a paucity of evidence on the functionality of these modern teleconsultation technologies in Hand Surgery. Here, the authors have estimated the efficiency of the WhatsApp teleconsultation in the assessment of finger vascularity. Materials and Methods In two phases, the authors transmitted clinical photographs of vascular and avascular fingers to experienced hand surgeons over the WhatsApp and asked them to assess the finger vascularity. The efficiency of the WhatsApp teleconsultation in assessing the details of finger vascularity was estimated from their responses. Results Despite 81.06% of the hand surgeons rating the vascular fingers on the transmitted photographs correctly, only 44.95% detected the avascular digits accurately; that is, 55.05% of the surgeons failed to diagnose the avascularity of fingers. This suggests serious implications in a clinical setting. The intra- and the inter-rater reliability values were 0.232 and 0.6086 (with 95% confidence interval), respectively, which indicated poor reliability of the WhatsApp teleconsultation regarding the assessment of finger vascularity. Conclusion The authors, therefore, conclude that WhatsApp is inadequate in teleconsultation given the value of vascularity details of the fingers in making a diagnosis in hand surgery.

Continuous infusion versus intermittent bolus doses of fentanyl for analgesia and sedation in neonates: an open-label randomised controlled trial.

OBJECTIVE: Adequate data on fentanyl pharmacokinetics in neonates are lacking. The study was performed to compare serum concentrations and clinical outcome between continuous infusion (CI) and intermittent bolus (IB) doses of fentanyl for analgesia and sedation in neonates. METHODS: In this open-label randomised controlled trial, neonates requiring 24-48 hours of mechanical ventilation and fentanyl administration were recruited. In CI regimen, 1 mcg/kg loading dose was followed by 1 mcg/kg/hour infusion. In IB regimen, 1mcg/kg/dose was administered every 4 hours.Maximum six blood samples were collected in 48 hours from each baby at prespecified time points for estimating serum fentanyl concentration. Secondary outcomes were pain scores (Neonatal Infant Pain Scale and Neonatal Pain, Agitation and Sedation Scale for acute and ongoing pain, respectively) and incidence of adverse effects of fentanyl. RESULTS: 100 neonates were recruited, 53 in CI and 47 in IB group. In CI regimen, median (IQR) serum fentanyl concentration was 0.42 (0.35, 0.46) to 0.61 (0.47, 0.89) ng/mL throughout the infusion period. In IB regimen, median (IQR) peak concentration ranged from 2.21 (1.82, 3.55) to 3.61 (2.91, 4.51) ng/mL and trough concentration 0.41 (0.33, 0.48) to 0.97 (0.56, 1.25) ng/mL for various doses.Median (IQR) peak concentration (Cmax, 3.06 (1.09, 4.50) vs 0.78 (0.49, 1.73) ng/mL; p<0.001) was significantly higher and area under concentration-time curve (AUC0-24, 19.6 (10.4, 33.5) vs 13.2 (10.8, 22.6) µg·hour/L; p=0.12) was higher (though not statistically significant) in IB than CI regimen. Pain scores and adverse effects were comparable between the two regimens. CONCLUSION: CI regimen of fentanyl produces steady serum concentrations, whereas IB regimen produces wide fluctuations in serum concentration with high-peak concentrations. A serum fentanyl concentration of 0.4-0.6 ng/mL produces adequate analgesia and sedation in neonates. TRIAL REGISTRATION NUMBER: CTRI/2014/11/005190.

Association between human leukocyte antigen-DRB1 and human leukocyte antigen-DQB1 alleles and pemphigus vulgaris in Indian patients: A case-control study.

BACKGROUND: HLA-DRB1*04, -DRB1*08, -DRB1*14, -DQB1*03 and -DQB1*05 are reported to have significant association with pemphigus vulgaris; however, this is partially dependent on ethnicity. This study was done to determine the HLA-DR and -DQ types prevalent in Indian patients with pemphigus vulgaris. METHODS: A prospective case-control study was done for a period of 9 months in Christian Medical College Vellore, India. HLA typing was done by PCR-SSOP method in 50 cases and 50 healthy controls. Allele frequencies in cases and controls were compared and odds ratios with 95% confidence interval were calculated. RESULTS: The mean age of the patients (29 females, 21 males) and that of controls (36 males, 14 females) were 41.3 ± 13.65 and 35.42 ± 11.09 years, respectively. HLA-DRB1*14 was present in 47 patients and 18 controls (OR, 27.85; 95% CI, 7.57-102.42) and HLA-DQB1*05 was seen in 47 patients and 24 controls (OR, 16.97; 95% CI, 4.66-61.80). The haplotype DRB1*14, DQB1*05 was present in 44 patients and 14 controls (OR, 18.86; 95% CI, 6.58-54.05). DRB1*15 was present in 7 cases and 16 controls (OR, 0.35; 95% CI, 0.13-0.94) and DQB1*06 was present in 8 cases and 19 controls (OR, 0.31; 95% CI, 0.12-0.80). HLA-DQB1*03 was associated with significantly higher pemphigus disease area index scores. LIMITATIONS: The main limitations were that the numbers studied were small as the study was conducted at a single center, and the haplotype analysis was limited only to the proband. PDAI scores could have been influenced by prior treatment. CONCLUSION: There was a significant association between HLA-DRB1*14 and HLA-DQB1*05 and pemphigus vulgaris in our patients. A negative association was seen with DRB1*15 and DQB1*06.

C-reactive protein gene polymorphisms (rs1205) in Asian Indian patients with Takayasu arteritis: Associations and phenotype correlations.

BACKGROUND/PURPOSE: Normal C-reactive protein (CRP) in active Takayasu arteritis (TA) is a dilemma. We attempted to validate our pilot study finding of rs1205 in CRP gene being protective against TA. METHODS: Genomic DNA of 104 patients and 185 sex-matched healthy controls were genotyped for rs1205 by Taqman assay. Clinical details, demography, angiographic and activity scores (Indian Takayasu arteritis score 2010) were recorded prospectively at baseline and during follow-up visits for 12 months. Minor allele frequency (MAF) and genotype distribution between patients and controls as well as patient subgroups were compared using χ2 test with Bonferroni correction (pc ) and logistic regression was performed to determine independent associations. RESULTS: The majority of patients (n = 84) and controls (n = 166) were females. MAF of T allele of rs1205 was less frequent in patients (27%) as compared to controls (37.6%), P = 0.013, pc = 0.026 with an odds ratio of 0.632 irrespective of gender. Frequency of CC genotype was higher in cases (53.8%) than controls (37.3%), P = 0.006, pc = 0.018. A dominant model of genotype-phenotype association revealed CC to be associated with more frequent coronary arterial and ascending aorta involvement than the other genotypes clubbed together (P = 0.01 and P = 0.014, respectively). Blunted CRP response seems to be less frequent in patients with CC genotype (P = 0.064). CONCLUSION: T allele of rs1205 in CRP gene was less frequent in TA. CC genotype was associated with involvement of coronary arteries and ascending aorta. CC genotype was less commonly associated with blunted CRP response (CT + TT > CC).

Contrast Enhanced Computed Tomographic Study on the Prevalence of Duodenal Diverticulum in Indian Population.

INTRODUCTION: Duodenal diverticulum (DD) is the second most common diverticulum, yet its incidence varies widely from 1-22% based on the mode of investigation. Computed Tomography (CT) of abdomen is the preferred modality to diagnose acute abdomen including those of complications of DD. Moreover, the prevalence of DD in Indian population is not yet been studied using CT. AIM: The current study aim to look for the prevalence of DD in Indian population using Contrast Enhanced Computed Tomography (CECT) abdomen. MATERIALS AND METHODS: A retrospective study was done to assess the presence of DD using the CECT abdomen of 565 patients. The number, size, location, wall thickness and the contents of the diverticulum were noted. The data obtained was analysed using SPSS version 17.0. The mean, percentage of frequency of each variable and the association of DD with pancreatitis, cholelithiasis and colonic diverticulum were also looked for. Frequencies and percentages were calculated for all categorical variables. Spearman's rho correlation was done for age, diameter and content of DD. RESULTS: The prevalence of DD in Indian population was 8.3% with the mean diameter of 17.13mm+7.26. The prevalence increased with age with no sex predilection. 89.3% were solitary and 10.64% were multiple. It was predominantly seen in the second part of duodenum (90.38%) and juxtapapillary type was the commonest. As the diameter of DD increased, fluid became its content. No significant association was observed between the presence of DD with pancreatitis, cholelithiasis or colonic diverticulum. A case of periampullary carcinoma arising from DD, a rare entity is being reported in this study. CONCLUSION: The prevalence of DD in Indian population is high compared to western population. DD has been attributed to the cases of acute abdomen and fluid alone as a content of DD with an incidence of 1.92% can be mistaken for a cystic neoplasm of pancreas. Rarely, a periampullary carcinoma can also arise from the wall of the pre-existing DD. This knowledge should be emphasised upon by the radiologist, surgeons and gastroenterologist who will be dealing with cases of acute abdomen and periampullary carcinoma.

Association between stigma, depression and quality of life of people living with HIV/AIDS (PLHA) in South India - a community based cross sectional study.

BACKGROUND: India has around 2.27 million adults living with HIV/AIDS who face several challenges in the medical management of their disease. Stigma, discrimination and psychosocial issues are prevalent. The objective of the study was to determine the prevalence of severe stigma and to study the association between this, depression and the quality of life (QOL) of people living with HIV/AIDS (PLHA) in Tamil Nadu. METHODS: This was a community based cross sectional study carried out in seven districts of Tamil Nadu, India, among 400 PLHA in the year 2009. The following scales were used for stigma, depression and quality of life, Berger scale, Major Depression Inventory (MDI) scale and the WHO BREF scale. Both Stigma and QOL were classified as none, moderate or severe/poor based on the tertile cut off values of the scale scores. Depression was classified as none, mild, moderate and severe. Logistic regression analyses were performed to study the risk factors. RESULTS: Twenty seven per cent of PLHA had experienced severe forms of stigma. These were severe forms of personalized stigma (28.8%), negative self-image (30.3%), perceived public attitude (18.2%) and disclosure concerns (26%). PLHA experiencing severe depression were 12% and those experiencing poor quality of life were 34%. Poor QOL reported in the physical, psychological, social and environmental domains was 42.5%, 40%, 51.2% and 34% respectively. PLHA who had severe personalized stigma and negative self-image had 3.4 (1.6-7.0) and 2.1 (1.0-4.1) times higher risk of severe depression respectively (p < .001). PLHA who had severe depression had experienced 2.7(1.1-7.7) times significantly poorer QOL. CONCLUSIONS: Severe forms of stigma were equivalently prevalent among all the categories of PLHA. However, PLHA who had experienced severe depression had only developed poor QOL. A high level of social support was associated with a high level of QOL.