Progression to bacteremia in critical care patients colonized with methicillin-resistant Staphylococcus aureus expressing Panton–Valentine leukocidin

The role of Panton–Valentine leukocidin (PVL) in methicillin-resistant Staphylococcus aureus (MRSA) infections is unclear. PVL has been long associated with soft tissue infections and necrotizing pneumonia, but inconsistently with other site infections or mortality. The retrospective cohort study explores the association between PVL and bacteremia in colonized medical intensive care unit (ICU) patients with surveillance isolates and blood cultures. A total of 840 patients were screened by nasal swab, with 266 patients found to be colonized and 46 with bacteremia. Colonization by PVL⁺ MRSA increased the odds of bacteremia (odds ratio, 2.40; confidence interval, 1.23–4.57), and invasive infection developed earlier in these patients (relative risk, 0.44; confidence interval 0.25–0.85) compared to those colonized with PVL⁰ MRSA. PVL was not associated with infections at other sites, length of ICU stay, or mortality. PVL decreases the time to bacteremia in colonized patients but does not otherwise contribute to disease course or clinical outcome.     

Early and mid-term angiographic and clinical results after intracoronary duet stent placement.

The Duet stent (Guidant/Advanced Cardiovascular Systems) is a new stent with a corrugated ring design and very limited data on its short- and mid-term performance. Accordingly, in this study we sought to determine the early and mid-term clinical and angiographic outcomes in a moderate-sized series of 86 consecutive patients who underwent placement of 108 premounted Duet stents in 98 coronary lesions. Procedural success, accomplished in all patients, was accompanied by a significant reduction in lesion severity from 89% +/- 11% before to 5% +/- 3% diameter stenosis after the procedure (P = 0.0001) and a 0.9% incidence of subacute stent thrombosis. Angiographic restudy at 5.7 months in 89% of eligible patients revealed a binary in-stent restenosis rate of 26%. Coronary stenting with the new Duet stent confers a low risk of stent thrombosis and a favorable mid-term clinical and angiographic outcome despite the presence of a large proportion of patients at high risk of in-stent restenosis.     

Rapid species determination of Nocardia keratitis using pyrosequencing technology

PURPOSE: To describe a new technique, pyrosequencing, which allows for the rapid identification of Mycobacterium and Nocardia species. DESIGN: Interventional case report. METHODS: The medical records of a patient presenting with an infectious keratitis were reviewed. RESULTS: A case of Nocardia abscessus/arthrititis/asiatica keratitis was diagnosed in a young individual with the aid of pyrosequencing technology. Based on presumed antibiotic sensitivities, therapy with topical trimethoprim-sulfamethoxazole eyedrops was initiated, and the infection was cleared rapidly with minimal residual scarring. CONCLUSIONS: Pyrosequencing may be a useful tool in aiding the rapid diagnosis and treatment of ocular infections caused by slow-growing pathogens.     

Renal Transplantation: Experience at a Single Centre

Background

Renal transplantation program in the Armed Forces commenced in Feb 1991 and till date 245 patients have undergone renal transplantation at INHS Asvini. We describe our protocols for donor and recipient evaluation and immunosuppression. Methods: 245 patients received renal transplants during this period, 243 (99.2%) being from live donors. Most of them were started on triple immunosuppression comprising of cyclosporine, azathioprine and prednisolone. Newer drugs like mycophenolate, tacrolimus and sirolimus were administered in a select population.

Result

69 (28.1%) of them had at least one episode of acute rejection, most of which were steroid responsive and 13 (18.8%) of them required either anti CD3 monoclonal or anti-thymocyte globulin (ATG). Complete recovery with normal renal function occurred in 54 (78.2%) cases and 15 (21.7%) recovered with residual dysfunction with maximum serum creatinine being 2.1mg/dl. There were three (1.2%) cases of accelerated rejection during the first week of transplantation and one had graft rupture. All three lost their grafts. There were eight (3.2%) cases of acute tubular necrosis, who recovered completely within 8–14 days. Immediate infections included wound sepsis, lower respiratory tract infection, disseminated candidiasis and disseminated aspergillosis. Late infections included pulmonary tuberculosis, disseminated tuberculosis, cytomegalovirus infection and recurrent urinary tract infection. 28 (11.4%) patients developed post transplant diabetes mellitus. At the end of one year and five years, graft and patient survival were 97.2%, 93%, 80.9% and 85.7% respectively.

Conclusion

Our outcomes show that the transplantation is a viable mode of renal replacement therapy in patients of end stage kidney disease with a near normal rehabilitation.Key Words: Kidney, Transplantation, Immunosuppression, Complications     

Measuring domestic violence in human immunodeficiency virus-positive women

Background

Violence affects the lives of millions of women worldwide, in all socioeconomic classes. Violence and the fear of violence are emerging as important risk factor contributing to the vulnerability to human immunodeficiency virus (HIV) infection for women. The objective of the present cross sectional study is to compare the experiences of domestic violence between HIV-positive and HIV-negative married women seeking treatment in a tertiary care hospital.

Methods

The study is conducted in a tertiary care hospital in Pune on a randomly selected 150 married women (75 HIV-positive and 75 HIV-negative). Informed consent was obtained from all the women and also a trained counsellor was present during the process of data collection. The data was collected by interview method by taking precautions as laid down in the World Health Organization's ethical and safety recommendations for research on domestic violence and using modified conflict tactics scale (CTS). The definition of violence followed is as per the Declaration on the Elimination of Violence against Women, adopted by the United Nations General Assembly in 1993.

Results

The percentage of women reporting domestic violence is 44.7% (95% confidence interval [CI] = 36.84–52.68). The proportion of physical, emotional and sexual violence reported is 38% (95% CI = 30.49–45.96), 24% (95% CI = 17.67–31.31), and 14.7% (95% CI = 9.66–21.02), respectively. The odds of reporting violence of all forms is significantly higher among HIV-positive women than among HIV-negative women (P<0.05). Univariate and multivariate logistic regression is carried out to examine the possible predictors of domestic violence.

Conclusion

The findings suggest high proportion of HIV-positive women report violence then HIV-negative women which must be addressed through multilevel prevention approaches.     

Toxicity of Low-Dose Intermittent Isotretinoin in Recalcitrant Acne

Background

Isotretinoin, an oral retinoid, has been utilized to achieve long term remissions in cases of recalcitrant acne. In the conventional dosage schedule, the use of oral isotretinoin has been limited by the occurrence of biochemical abnormalities such as hypertriglyceridaemia and impaired liver function tests and radiological changes consistent with diffuse idiopathic skeletal hyperostosis. Low-dose intermittent regimen of oral isotretinoin has been evolved as a cost effective alternative to the conventional dosage regimen in cases of acne. This study addresses the issue of adverse effects of low-dose intermittent isotretinoin and the safety of this regimen.

Methods

A total of 60 cases of recalcitrant acne were included in the study. Baseline haematological, biochemical and radiological investigations were carried out. Low-dose intermittent isotretinoin was instituted in a dose of 0.5 mg/kg/day for one week in every four weeks for six months. The investigations were repeated at the end of six months therapy.

Result

High triglyceride levels occurred in 5% of cases whereas impaired liver function tests and skeletal hyperostosis of the spine were not observed in any case after low-dose intermittent isotretinoin.

Conclusion

The low-dose intermittent regimen in cases of acne may be utilized to limit the systemic toxicity of oral isotretinoin.Key Words: Recalcitrant acne, Isotretinoin, Low-dose intermittent regimen     

Local Anaesthesia for Fiberoptic Intubation : A Comparison of Three Techniques

Background

The successful conduct of fiberoptic aided intubation is dependent upon effective local anaesthesia. The aim of the study was to compare three different methods of anaesthetizing the airway.

Methods

60 adult patients (American Society of Anaesthesiologists status I-III and Mallampati class III & IV), scheduled for elective surgery, received sedation followed by spraying of the nares and posterior pharyngeal wall with 4% lignocaine. Thereafter the patients received 4 ml of 4% lignocaine either by transtracheal injection (n=20, group A), via intubating fiberscope (Pentax F1-10P2) using ‘spray as you go’ technique (n=20, group B) or by nebulizer (Devilbiss 5610W) 20 min before intubation, (n=20, group C). Patients were asked to score the procedure using visual analog scale (VAS) and severity scores. Episodes of coughing, choking, stridor, extra / total local anaesthetic used and intubation times were recorded. Patients were monitored continuously for vital parameters.

Results

Group B patients showed better VAS scores with shorter intubation times and had a lower incidence of coughing and choking. The endoscopists’ VAS scores also showed a preference for group B.

Conclusion

In conclusion the ‘spray as you go’ technique was safe, provided effective local anaesthesia and was preferred by both patients and endoscopists.Key Words: Awake intubation, Difficult airway, Fiberoptic intubation     

Dilated Cardiomyopathy with Short QT Interval: Is It a New Clinical Entity?

Short QT syndrome is a rare autosomal dominant channelopathy of structurally normal hearts characterized by atrial fibrillation, ventricular arrhythmias, and sudden cardiac death. We report a case having short QT, dilated ventricles, and severe ventricular dysfunction, an unreported association so far.