Current status of inpatient HIV care at a tertiary care center in Nepal

The success of the WHO's '3 by 5' programme will depend on the ability of developing countries to provide antiretroviral therapy. The purpose of this study was to determine the current status of HIV care at a major teaching hospital in eastern Nepal. A retrospective cohort study was conducted of admitted HIV-infected patients at BPKIHS between 1993 and 2003, evaluating reasons for admission and the care received. There were 2, 2, 2, 3, 5 and 18 admissions, respectively, from 1998 to 2003. Only 4 were female patients. Two were children, both admitted in the last y studied. 10 admissions (31% of the total) were for opportunistic infections (OIs). Seven patients were prescribed OI prophylaxis, with incorrect dosages in 6. Four patients were prescribed antiretroviral therapy, all in inappropriate dosages or combinations. 13 patients were rapidly discharged without further care as soon as a diagnosis of HIV was made. Hospital admissions of HIV-infected individuals are increasing rapidly. Important segments of the HIV-infected population such as women and children are not receiving medical services. Most admissions are not due to OIs. The care of HIV-infected patients even at a major tertiary care teaching hospital in Nepal is sub-optimal.     

Initial experience with double-balloon enteroscopy at a U.S. center

BACKGROUND: Double-balloon enteroscopy (DBE) allows direct visualization and intervention in the entire small intestine. Concerns include long procedure times and a long learning curve after training. OBJECTIVES: To analyze the initial experience of a single endoscopist when using DBE; assess resource utilization, safety, clinical utility, and the learning curve. DESIGN: Prospective study. SETTING: Tertiary-referral center. PATIENTS: A total of 137 consecutive patients with bleeding or other small-intestine disorders. MAIN OUTCOME MEASURES: Clinical impact at the time of DBE and changes in the procedure time and extent with experience. RESULTS: Two hundred DBE procedures were performed without major complications. For 115 oral DBEs, the mean (SD) procedure duration was 101 +/- 35 minutes and length of examined small intestine was 220 +/- 80 cm, with no significant change with experience. For 85 anal DBEs, the mean (SD) procedure duration was 96 +/- 33 minutes, and the length examined was 124 +/- 60 cm; the length examined increased with experience, but the duration did not decrease. The percentage of patients in which a DBE had a helpful clinical impact rose from 58% in the first 50 DBEs, to 86% in the last 50 of 200 DBEs. The total enteroscopy rose from 8% in the first 50 DBEs, to 63% in the last 50 of 200 DBEs. LIMITATIONS: No follow-up data on outcomes. CONCLUSIONS: DBEs required significant time and did not always allow for a total enteroscopy. DBEs were safe and helpful in the management of most patients. An experienced endoscopist may perform a safe and useful DBE after limited training, but the development of expertise may require more than 100 to 150 DBE procedures.     

Dropout from care among HIV-infected patients enrolled in care at a tertiary HIV care center in Chennai,India

Long-term follow-up of persons infected with HIV infection is essential to optimize clinical outcomes. However, limited data exist on the rates of dropout (DO) from HIV care and factors associated with DO especially from resource-limited settings. We conducted a retrospective analysis of the data available at YRGCARE, a private HIV care provider in south India that has registered over 15,000 HIV-infected persons since its inception in 1993. We included 7995 patients who registered for care between 1 January 2004 and 31 December 2009. A dropout was defined as a person who registered for care during this period and had not been seen in the clinic for >1 year. Logistic regression was used to examine factors associated with DO from clinical care. The median age of the patients registered for care was 34 years; 66% were male and 83% were married. The overall DO rate was 38.1 per 100 person-years – the majority of the DOs occurred within 6 months from registration. In multivariate analyses, patients who were enrolled in clinical studies/projects entitling them to free medications and retention staff (Odds Ratio [OR]: 0.65) or were on antiretroviral therapy (ART; OR: 0.37) or had a CD4 > 350 at the last visit (OR: 0.20) were significantly less likely to DO from clinical care. We observed a high rate of DO from clinical care at this tertiary HIV clinic in Chennai, India. Making ART available free of charge in the private sector and providing incentives/benefits for attending clinic visits as is routinely done in clinical trials might help improve retention.     

Corynebacterium jeikeium bacteremia at a tertiary care center

Summary During a six-year period 23 patients with isolation ofCorynebacterium jeikeium (formerly known asCorynebacterium group JK) from one or more blood cultures at a university hospital were identified. Cases occurred sporadically without time- or ward-related clustering. Review of the cases showed that most infections were nosocomial, that most of the patients had underlying malignant disease, had a chronic intravascular catheter implanted, had been pretreated with antibiotics, and were neutropenic at the time the blood cultures were drawn. Patients with only one versus those with more than one positive blood culture differed in some important aspects. Patients with only one positive blood culture were less likely to have acute leukemia, had significantly higher neutrophil counts and a shorter duration of preceding antibiotic treatment, and all had other probable causes of infection and fever. The mortality also appeared to be lower in these patients. Despite the possibility of increasing frequency of blood cultures positive forC. jeikeium, severe infections due to this organism continue to be largely confined to neutropenic patients with hematologic malignancy.

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Corynebacterium jeikeium-Bakteriämien an einem Universitätskrankenhaus

Zusammenfassung In einer Universitätsklinik wurde während eines Zeitraumes von sechs Jahren bei 23 PatientenCorynebacterium jeikeium aus Blutkulturen isoliert.C. jeikeium-Bakteriämien traten weder zeitlich noch örtlich gehäuft auf. Die retrospektive Analyse der Patientendaten zeigte, daß in den meisten Fällen eine maligne hämatologische Grunderkrankung mit Neutropenie vorlag, ein zentral-venöser Katheter implantiert und eine antibiotische Therapie vorausgegangen war. Die Patientenpopulation mit nur einer positiven Blutkultur unterschied sich in wichtigen Aspekten von derjenigen mit mehreren positiven Blutkulturen. So waren Patienten mit nur einer positiven Blutkultur seltener an akuter Leukämie erkrankt, hatten signifikant höhere neutrophile Granulozytenkonzentrationen im peripheren Blut und waren zuvor über einen kürzeren Zeitraum antibiotisch behandelt worden. Weiterhin fanden sich in dieser Patientengruppe in allen Fällen andere mögliche Ursachen der Fieberepisoden. Auch die Mortalität war deutlich geringer. Trotz des zunehmend häufigeren Nachweises vonCorynebacterium jeikeium in Blutkulturen bleiben schwere Infektionen durch diesen Erreger weiterhin meist auf die Patientenpopulation mit hämatologischer Grunderkrankung und Neutropenie beschränkt.

     

Caspofungin for invasive candidiasis at a tertiary care medical center

Background

Caspofungin is emerging as first-line therapy for invasive candidiasis. Data on the use of caspofungin for treatment for invasive candidiasis are limited to clinical trials and case reports. We report a single-center experience with 104 consecutive courses of caspofungin for the treatment of invasive candidiasis to evaluate a real-world performance of this drug.

Methods

A retrospective chart review of patients receiving caspofungin at a tertiary care medical center was performed. Patient information and microbiologic data were abstracted from patient charts and electronic medical records.

Results

Of 241 patients receiving caspofungin for all indications, 122 (51%) had proven invasive candidiasis. There were 104 treatment courses for candidiasis in 99 patients available for review. Bloodstream (66%) and abdominal infections (25%) were the most common sites of infection. Most infections were non-albicans (80/104, 77%; including patients infected with more than one species). Clinical cure rates at the end of therapy were 83% (57/69) for bloodstream infections and 84% (22/26) for abdominal infections. Caspofungin did not clear candidiasis in 14 episodes (microbiologic cure rate 75%, 42/56).

Conclusions

The clinical use of caspofungin has been successful in the treatment of invasive candidiasis, even in patients with prior antifungal exposure. In this unselected review, caspofungin performed similarly as in clinical trials, and clinicians should consider caspofungin as first-line therapy for invasive candidiasis, particularly non-albicans species.     

Prevalence of celiac disease in nutritional anemia at a tertiary care center

Background

While anemia occurs in 80 % to 90 % of patients with celiac disease (CD), it may be the sole manifestation of CD. The prevalence of CD in Indian patients with nutritional anemia is not known.

Patients and Methods

Adolescent and adult patients presenting with nutritional anemia were prospectively screened for CD using IgA anti-tissue transglutaminase antibody (anti-tTG Ab) followed, if positive, by upper gastrointestinal endoscopy and duodenal biopsy.

Results

Ninety-six patients [mean?±?SD age 32.1?±?13.1 years and median duration of anemia 11 months (range 1 to 144 months)] were screened. Of these patients, 80 had iron deficiency anemia, 11 had megaloblastic anemia, and 5 had dimorphic anemia. Seventy-three patients were on hematinics and 36.4 % had received blood transfusions. Nineteen had a history of chronic diarrhea and the mean?±?SD duration of diarrhea in them was 9.7?±?35.8 months. IgA anti-tTG Ab was positive in 13 patients, of whom 12 agreed to undergo duodenal biopsy. Ten patients had villous atrophy (Marsh grade 3a in three, 3b in one, and 3c in six) and two did not. Thus, 10 patients with nutritional anemia (iron deficiency 9, vitamin B₁₂ deficiency 1) were diagnosed to have CD. On multivariate logistic regression, age, duration of symptoms, and presence of diarrhea were found to be the predictors of CD. All the patients with CD were put on gluten-free diet and with iron and vitamin supplementations and showed a significant improvement in hemoglobin concentration.

Conclusions

CD screening should be included in the work up of otherwise unexplained nutritional anemia.     

Mycobacterium tuberculosis complex bacteremia among HIV and non-HIV patients in a Mexican tertiary care center

Objectives

To determine the factors associated with Mycobacterium tuberculosis complex-positive blood culture.

Profile of fatal visceral leishmaniasis at an Indian tertiary care center.

Visceral leishmaniasis is a highly morbid and incapacitating infection, which usually presents with prolonged fever, weight loss and hepato-splenomegaly. Despite the availability of effective treatment, the disease can have a high mortality even at referral centers. A case series of fatal visceral leishmaniasis, encountered during a prospective, two year period is presented. All the patients died due to multisystem organ failure. However, delayed diagnosis due to atypical manifestations was an important factor contributing to the fatal outcome of the patients. Instead of relying solely on the classical clinical features of visceral leishmaniasis, simple laboratory findings like pancytopenia, altered albumin/globulin ratio and appositive aldehyde and rK 39 dipstick tests can help in making an early diagnosis even in atypical cases, thereby reducing the mortality of visceral leishmaniasis.     

High retention in HIV care at a tertiary care centre in Toronto,Canada*

Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients’ median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues.     

Survey of alcohol-related cirrhosis at a tertiary care center in North East India

Background

Alcohol use is increasing in North East India and is important to estimate the influence of these changes in the epidemiology of alcohol related cirrhosis.

Methods

Among 1000 consecutive patients of cirrhosis, diagnosed by a combination of clinical, radiological and/or histopathological features, etiology was established by history of significant alcohol abuse, determining viral and autoimmune markers and by metabolic screening. Patients not confirmed to be cirrhotic were excluded from the study. All cases were studied to determine clinical features, complications, disease prognosis, and mortality. Alcoholic cirrhotics were then compared with nonalcohol etiology.

Results

72.2 % alcoholic cirrhosis were compared with 27.8 % patients of nonalcohol etiology and alcoholic cirrhotics were younger (45?+?9.4 years vs. 47.9?+?12.5 years), predominantly males (M/F ratio 37:1 vs. 1.8:1) with significantly high incidence of jaundice (38.5 % vs. 30.5 %), night blindness (14.4 % vs. 3.6 %), ascites (76.3 % vs. 69.1 %), upper gastrointestinal bleed (46.4 % vs. 34.5 %), and hepatic encephalopathy (24.1 % vs. 10.4 %). Biochemical parameters that were significantly higher in alcoholics were mean bilirubin (4.7?+?8.7 vs. 3.1?+?4.7 mg/dL), AST/ALT ratio (2.03 vs. 1.4), gamma-glutaryl transaminase levels (209.7?+?37.9 vs. 93.9?+?14 IU/mL), and serum ammonia (75.1?+?55.7 vs. 52.1?+?45.4 mg/dL). Mean model for end-stage liver disease, scores, and Child C disease was significantly higher in alcoholics (18.6?+?7.7 vs. 15.6?+?6.4) and (54.1 % vs. 37 %), respectively, representing advanced disease at presentation. Mortality within 1 month was significantly higher among alcoholic cirrhosis (9.8 % vs. 3.2 %).

Conclusion

Thus, alcoholic cirrhosis is of major concern in North East India as majority patients are in most productive age group and presented with advanced disease. Short-term mortality was high among alcoholic cirrhotics. Proper education and legislation are essential to mitigate the consequences of this disease.

     

Double balloon enteroscopy: a 3-year experience at a tertiary care center

Background/Aims: To evaluate the indications, diagnostic yield, therapeutic interventions, complications and safety of double balloon enteroscopy (DBE) in clinical practice. Methodology: The medical records of the patients who underwent DBE at the Turkiye Yuksek Ihtisas Hospital between October 2007 and January 2010 were examined to note the demographic data, indications for the examination, results of previous non-invasive small bowel imaging and endoscopic procedures and the results of DBE including findings, endoscopic interventions, complications and pathological reports. Results: A total of 139 procedures were performed in 118 patients. DBE was performed 81 times through mouth and 26 times through anus and additionally both approaches were used 16 times in the same patients. Panenteroscopy was successfully performed in 13 of 16 patients (87.5%) in whom it was attempted. The most common indication was obscure gastrointestinal bleeding (28.8%). DBE had an overall diagnostic and/or therapeutic contribution in 63 (53.4%) patients. The main pathologies detected on DBE were polyps (12.7%), infammation (10.7%) and vascular lesions (3.4%). Complications were recognized in four cases (3.4%) but no major complication occured. Conclusions: Our retrospective analysis showed that DBE is a useful, safe and well-tolerated method with a diagnostic and therapeutic impact for the management of small bowel diseases.     

Mucormycosis in hospitalized patients at a tertiary care center in Lebanon: a case series

Purpose

Mucormycosis (MCM) is a rare fungal infection affecting people with impaired immunity. Data related to MCM from Lebanon are scarce. The aim of this study is to shed light on the epidemiology, incidence, and outcome of patients with MCM hospitalized at a tertiary care center in Lebanon.

Methods

We conducted a retrospective chart review between Jan 1, 2008 and Jan 10, 2018. All patients with proven or probable MCM were included.

Results

A total of 20 patients were included. Their median age was 49 years and the majority were males. Comorbidities included mainly hematologic malignancy and diabetes mellitus. Most common sites of involvement were rhino-orbital and pulmonary, respectively. The number of MCM cases/10.000 hospital admissions increased significantly between 2008 and 2017 (0.47 vs. 1.18; P?<?0.05). A liposomal amphotericin B formulation alone or in combination with other antifungals was used as a first line agent in all patients. All-cause mortality was 60%; however, death was attributed to MCM in 20% of cases.

Conclusion

The incidence of MCM has significantly increased over the past 10 years at our institution, most likely due to the increasing patient population at risk. Understanding the epidemiology of MCM in our setting would help guide antifungal therapy.