Clinical characteristics of imported malaria in Japan: analysis at a referral hospital

Imported malaria remains an important problem in Japan. We have reviewed the medical records of 170 cases of malaria in our hospital, which corresponds to 14.9% of the total cases in Japan. The predominant malarial species was Plasmodium falciparum (52.3%), and the most frequent area of acquisition was Africa (54.2%), followed by Asia (20.9%) and Oceania (19.6%). The most common reason for travel among Japanese patients was business. A significant proportion (22.2%) of vivax malaria cases experienced relapse despite standard primaquine therapy. Most primaquine failures were from Oceania. We also found that a substantial number of Japanese patients contracted malaria without chemoprophylaxis and consulted medical facilities with an unfavorably long delay from initial symptoms (median: 3.0 days). Direct education of travelers and travel companies, in addition to health care providers, is likely necessary to improve outcomes of imported malaria.     

Towards a rational malaria management at district hospital level: exploratory case series of febrile adult patients in a holoendemic area of Tanzania

One hundred and sixty eight febrile adult outpatients were investigated at St Francis Designated District Hospital in fakara, a holoendemic area in Tanzania. We wanted to assess the potential anamnestic and clinical risk indicators for malaria and to establish a rational strategy for malaria management. Blood slide investigations showed that 14% of all patients were positive for P. falciparum. All the positive cases were found during the rainy season. No reliable criteria for malaria were found in the history taking and physical examinations. Signs and symptoms of respiratory tract infection such as difficulties during breathing, sore throat, chest pain, cough, pathological findings in lung auscultation and combinations of these were negatively associated with malaria parasitaemia.The same was true for lymph node swelling and a clinical diagnosis other than malaria. Quality control of blood slide results from the hospital revealed a sensitivity of 55%, a specificity of 72%, and positive and negative predictive values of 24% and 91%. The main recommendations for malaria management in adults were to improve the quality of blood slide examinations and to use a different diagnostic strategy during the dry and rainy seasons. During the dry season blood slides of febrile adult patients should only be performed if there is a suspicion of malaria and antimalarial drugs should only be administered if blood slide results are positive. During the rainy season all febrile adults without obvious cause of fever other than malaria should be treated with antimalarials without previous blood slide examination.     

Epidemiology of nosocomial infections in medicine intensive care unit at a tertiary care hospital in northern India

This prospective observational study describes the rates of nosocomial infections (NI), the sites of infection, the pathogens involved, their antibiogram and the risk factors at a tertiary care hospital in northern India. In 62 of the 182 enrolled patients 95 episodes of NI were recorded (incidence rate 28.6/1000 person days): pneumonia (77%); urinary tract infection (24%) and blood stream infection (24%). All isolates of Acinetobacter, Pseudomonas and Klebsiella and 83.3% of Escherichia coli were resistant to the third generation cephalosporins. An increased duration of the time spent in intensive care units and days of intervention were associated with incident NI.     

Drug susceptibility of Mycobacterium tuberculosis in patients with AIDS at a tertiary care hospital in northern India

The study was done to determine the anti-tuberculosis drug resistance patterns of Mycobacterium tuberculosis (MTB) in AIDS patients. Fifty antiretroviral drug na?ve new AIDS patients with clinical evidence of pulmonary tuberculosis and no previous history of tuberculosis were recruited. Baseline CD4 counts and plasma viral loads (PVL) were measured by flow cytometry and RT-PCR, respectively. Sputum samples were obtained from each patient and subjected to Ziehl-Neelsen staining and cultured on Lowenstein-Jensen medium and using the BACTEC 460 system (B460). Antimicrobial susceptibilities were tested in all isolates using the B460 gystem. The occurrence of MTB was found to be more common with a PVL>4 log10 copies/ml (odds ratio: 4.6). Of 15 MTB isolates, 8 (53.3%) had single drug resistance, 4 (26.7%) had multidrug resistance (MDR) and 1 (6.7%) had resistance to three drugs (non-MDR). Two isolates (13.3%) were sensitive to all the four drugs. Resistance to first line anti-tuberculosis drugs was found to be higher among AIDS patients with MTB.     

Clinical profile of carcinoma stomach at a tertiary care hospital in south India.

Carcinoma of the stomach is an important cause of mortality due to cancer. Carcinoma of the stomach is common in the southern region of India. We conducted a retrospective study on the epidemiological, clinical and survival patterns among the patients with carcinoma of the stomach, attending our hospital from June 19, 1995 to 1st January 2003. All the patients had histopathological confirmation of malignancy. Patients with gastrooesophageal junction lesions were excluded. Surgery was performed with curative as well as palliative intent in suitable patients. Chemotherapy has been incorporated in to the combined modality treatment in our hospital since July 2000. Postoperative chemotherapy comprised commonly used intravenous chemotherapy regimens, while oral chemotherapy (etoposide) was given to patients with disease not amenable to surgery, and those having poor performance and nutritional status. Oral etoposide was given in a dose of 50 mg/day for 14 days, in a 28 day cycle. Quality of life was assessed in the oral chemotherapy group. Out of the 1749 cancer patients seen during the period, 151 had gastric malignancy (8.6%). The median age was 55 years (range 15-84 years). The male to female ratio was 4:1. Adenocarcinoma was found in 148 patients, 2 had stromal tumours and 1 had non-Hodgkin lymphoma. Stage disribution was as follows; stage 2-1 patient , stage 3a-25, stage3b-49, stage4-3 1, Metastatic-28. Staging was not completed in 17 patients. Eighty-nine patients underwent surgery. Fifty-nine patients (39%) did not have surgery. One patient underwent polypectomy. Curative gastrectomy was performed in 11 patients. Thirty-nine patients underwent palliative tumour resection. Palliative gastro-jejunostomy for relief of symptoms was performed in 26 patients and exploratory laparotomy alone was perforaied in 13. Thirty-eight patients received chemotherapy. Out of these, only 2 patients had prior complete resection of the tumour and 36 received palliative chemotherapy. Intravenous chemotherapy was given to 17 patients and oral chemotherapy to 19; All the patients who received oral etoposide did not experience any toxicity. Patients who received intravenous chemotherapy (n=17) had the following toxicities: grade 3 emesis in 4 (20%), discoloration of the skin and nails in 6(31%), alopecia in 8 (50%), grade 3 diarrhoea in 3 (15%) and neutropenic fever in 4 patients (20%). Median survival for the cohort was 10.4 months. Quality of life parameters, such as sleep, appetite, weight, pain, work and general sense of ill health showed improvement. In conclusion, 8.6% of all cancers at our hospital were due to cancer of stomach, in whom distal gastric tumor were more frequent and most were non-resectable. Median survival was 10.4 months. Oral etoposide was found to be safe, improved the quality of life and may play a role in the palliative management of advanced carcinoma of the stomach.     

Clinical profile and prevalence of rotavirus infection in children presented with acute diarrhea at tertiary care referral hospital at northern part of India

A prospective analysis of 90 clinically diagnosed cases with acute diarrhea over a period of one year was carried out to determine the prevalence of rotavirus infection in children between 2 months to 2 years of age. Enzyme Linked Immunosorbent Assay (ELISA) and Polyacrylamide Gel Electrophoresis (PAGE) were used for detection of rotavirus from stool sample. Fourteen (15.6%) of them were found to be positive for group A rotavirus, 9 (23%) cases were between 6 months to 1 year of age. Rotavirus excretion was highest (50%) when all three symptoms (diarrhea, vomiting and fever) occurred in the same child. A planned study for surveillance of rotavirus serotypes is required from this area.     

A longitudinal investigation of Plasmodium falciparum malaria in children in northern India

A group comprising 27 young children (1-4 y of age) suffering from uncomplicated falciparum malaria were studied to characterize the isolates and to measure humoral immune responses during acute infection and after recovery. Finger prick blood from each individual was collected on d 1. After treatment with chloroquine, a further blood sample was collected from each child on d 7, 30, 90 and 180 for assay of antibody responses to P. falciparum antigens. Isolates from individual patients were incubated in vitro for demonstration of rosette formation, assay of plasmodial growth rate and analysis of Pfcrt gene polymorphism. Out of 27 isolates of P. falciparum, 20 showed formation of rosettes in vitro. The growth rate at 96 h varied widely among the isolates. In Pfcrt gene analysis at 76-codon site, 14 showed wild-type Lys 76, 7 showed mutant type Thr 76 and 6 had mixed type. 14 children, all with anaemia on d 7, showed a positive direct antiglobulin test (DAT). Sera positive by ELISA IgG on d 90 also showed parasite growth inhibitory activity in vitro. Significant levels of IgG, IgG1 and IgG3 subclass antibodies against MSP1 were detected in 14 sera collected on d 90. On d 180, there was a decline in IgG and its subtypes. These findings suggest that a variability in isolates may occur in one and the same seasonal area, making children prone to infection. As a consequence, they develop antibodies during recovery phase from an acute attack, which remain in circulation for a period of 4-5 months. After that, a decline in antibody level may again make them susceptible to the disease. Prevalence of different serotypes in a small area may suggest the complexity of malaria transmission.     

Profile of hepatocellular carcinoma in a tertiary care hospital in Punjab in northern India

Purpose/Aim

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in all parts of the world. We analyzed the clinical presentation, etiology, and tumor characteristics of HCC presenting to our hospital.

Methods

All patients diagnosed to have HCC from September 2007 to August 2010 were prospectively enrolled. HCC was diagnosed according to EASL criteria—USG/CT/MRI of the abdomen and/or serum alpha-fetoprotein and/or histology (where indicated). Detailed clinical and laboratory parameters were noted. Barcelona Clinic Liver Cancer (BCLC) staging was done.

Results

One hundred and twenty-eight patients (22 females, mean±SD; age, 49.8?±?10.2 years) were diagnosed to have HCC. Underlying cirrhosis was present in 99.2 %. Hepatitis C virus infection, alone (21.9 %) or with alcohol (22.9 %) was the most common etiological factor, followed by alcohol alone; 33.6 % of the patients had more than one etiological factor. Most patients (83.5 %) presented with features of decompensated cirrhosis. HCC leading to decompensation of cirrhosis was the first presentation of the liver disease in nearly one third of the cases. Serum alpha-fetoprotein was >200 ng/mL in 67.2 % of the patients, while it was normal in 18.7 % of the patients. The mean±SD size of HCC was 5.3?±?2.9 cm. HCC was multicentric in 57 %, and portal vein thrombosis was present in 34.4 %. About 66 % of the patients belonged to BCLC stage C or D.

Conclusions

Hepatitis C virus infection was the most common cause of HCC in Punjab. One-third of the patients had multiple etiological factors and almost all had underlying cirrhosis and presented at advanced stage.     

A study on clinical profile of falciparum malaria in a tertiary care hospital in south India

Malaria continues to be a major problem in tropical countries. To study the clinical features and complications of malaria in a tertiary care hospital in south India, records of 183 patients were analysed. Among 86 patients with P. falciparum and mixed infection, 24 (28 per cent) had cerebral malaria and 32 (37 per cent) had hyperbilirubinemia. Twenty-three out of 32 (72 per cent) patients with jaundice had direct hyperbilirubinemia and elevated liver enzymes suggesting hepatocellular damage. Mortality of the order of 10 per cent was seen only in P. falciparum malaria. High incidence of hepatic involvement and hepatorenal failure were the unusual features observed in the study.     

Development of ARI case management at primary and secondary level in southern Vietnam.

In southern Vietnam it is not uncommon that children under 5 years of age die from pneumonia. Reduction of severity and mortality has to rely on proper case management by mothers and health workers on both grass root level and referral level. The responsibility of training of clinical skills of ARI case management in the southern provinces of Vietnam has been delegated to Pediatric Hospital N1 (PHN1) Ho Chi Minh City (HCMC) by Ministry of Health. A pilot project was carried out by the Danish-Vietnamese Study Group. The immediate objects were: to provide basic epidemiological information about ARI in southern Vietnam, to develop training modules and case management intervention modules at primary and secondary level in order to enable mothers, village workers, health post staff and district hospital emergency department staff to treat moderate and severe pneumonia and acute bronchitis in accordance with the WHO management guide for ARI and to evaluate the effect of those modules after implementation in a limited number of communes. The modules were developed at PHN1. Ten commune health stations were carefully selected. The purpose of the project and the conditions for taking part had been explained to the health workers. The doctors and other commune health workers from the 10 commune health stations and doctors from the connected district hospitals attended the training courses at PHN1, HCMC and also at the belonging provincial hospitals. Essential equipment was provided and a pharmacy with essential drugs established. The registered health statistics was collected yearly during on site visits. The local doctors and commune health workers gave seminars for mothers in the villages of the 10 project communes. The mothers' knowledge, attitude and practice (KAP) was tested in interviews before and two months after the seminars had taken place. The spread of KAP was measured by random interviews of mothers six month later. In the interviews information on social conditions was obtained. The mothers' KAP had risen by 25% two months after attending the seminars. A further increase of KAP by 5-10% within the untrained group appeared in a survey 4-6 months later. It was not possible to obtain reliable statistics on morbidity or mortality of ARI in the project area.     

Cataract surgery outcome at a rural eye care hospital in India

We report the final outcomes, based on final visual acuity, of patients who underwent cataract surgery at an outreach rural ophthalmology unit and document the details of the ophthalmic examination, type of surgery, intra- and postoperative complications and the final visual acuity. Of 208 eyes (198 patients), 81.3% had small incision cataract surgery and 18.7% had phacoemulsification. We believe that, with good planning and the proper utilization of available resources, it is possible to achieve a good visual outcome in the great majority of cases.     

Malaria transmission dynamics at a site in northern Ghana proposed for testing malaria vaccines

We studied the malaria transmission dynamics in Kassena Nankana district (KND), a site in northern Ghana proposed for testing malaria vaccines. Intensive mosquito sampling for 1 year using human landing catches in three micro-ecological sites (irrigated, lowland and rocky highland) yielded 18 228 mosquitoes. Anopheles gambiae s.l. and Anopheles funestus constituted 94.3% of the total collection with 76.8% captured from the irrigated communities. Other species collected but in relatively few numbers were Anopheles pharoensis (5.4%) and Anopheles rufipes (0.3%). Molecular analysis of 728 An. gambiae.s.l. identified Anopheles gambiae s.s. as the most dominant sibling species (97.7%) of the An. gambiae complex from the three ecological sites. Biting rates of the vectors (36.7 bites per man per night) were significantly higher (P<0.05) in the irrigated area than in the non-irrigated lowland (5.2) and rocky highlands (5.9). Plasmodium falciparum sporozoite rates of 7.2% (295/4075) and 7.1% (269/3773) were estimated for An. gambiae s.s. and An. funestus, respectively. Transmission was highly seasonal, and the heaviest transmission occurred from June to October. The intensity of transmission was higher for people in the irrigated communities than the non-irrigated ones. An overall annual entomological inoculation rate (EIR) of 418 infective bites was estimated in KND. There were micro-ecological variations in the EIRs, with values of 228 infective bites in the rocky highlands, 360 in the lowlands and 630 in the irrigated area. Approximately 60% of malaria transmission in KND occurred indoors during the second half of the night, peaking at daybreak between 04.00 and 06.00 hours. Vaccine trials could be conducted in this district, with timing dependent on the seasonal patterns and intensity of transmission taking into consideration the micro-geographical differences and vaccine trial objectives.     

Clinical and immunogenetic studies in rheumatoid arthritis from northern India

A total of 258 patients with classic rheumatoid arthritis seen over a 7-year period were included in this study. The majority of the patients had relatively mild disease at the time of presentation. The incidence of extraarticular manifestations such as subcutaneous nodules, vasculitis, amyloidosis and pulmonary involvement was low although one or two pulmonary function test parameters were abnormal in some. Seventy patients were tested for all three subclasses of rheumatoid factors - IgM, IgG and IgA. Of these, 23 patients had all three whilst four had only IgG. The 62 patients who had most typical and severe manifestations were typed for four major HLA loci A, B, C and DR. Of these 42 (67.7%) had DR4 antigen while DR3 antigen was detected in 14 (22.6%).